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Cyber security encompasses a broad range of practices, tools and concepts related closely to those of information and operational technology security. Cyber security is distinctive in its inclusion of the offensive use of information technology to attack adversaries. Use of the term cyber security as a key challenge and a synonym for information security or IT security misleads customers and security practitioners and obscures critical differences between these disciplines. Recommendation for security leaders is that they should use the term cyber security to designate only security practices related to the defensive actions involving or relying upon information technology and/or operational technology environments and systems. Cyber defense is a computer network defense mechanism which includes response to actions and critical infrastructure protection and information assurance for organizations, government entities and other possible networks [3]. In this paper, we investigate how cyber security and cyber defense may lead to cyber resilience with the novel model of cyber resilience designed and presented. Furthermore, within the same model authors investigate actions for cyber security and cyber defense in conditions of increasing challenge of cyber-attacks and the limited capabilities to respond to this threat describing the process of creation, performance and future of EU Cyber Rapid Response Teams (abbr. CRRT) and Mutual Assistance in Cyber Security, introducing novel approach to cyber security and cyber defense at the EU level.

BACKGROUND: Rapid Response Teams (RRTs) have been employed by multiple hospital systems to enhance patient care and safety. However, processes to document Rapid Response Events (RRE) are often varied among providers and teams, which can lead to suboptimal communication of recommendations to both the primary medical team and family. METHODS: A pre-intervention chart review was conducted from January-March 2018 and revealed sub-optimal baseline documentation following RREs. A literature review and survey of RRT team members led to the creation of a standardized document with an EPIC(™) SmartPhrase which included six key elements of RRE documentation: physical exam, intervention performed, response to intervention, plan of care, communication with care team and communication with family. A post-intervention chart review was completed from April-June 2019 to assess improvements in documentation with the use of this SmartPhrase. RESULTS: There were 23 RRE activations in the post-intervention period, of which 60.8% were due to respiratory distress. The documentation of the six key elements improved (p

Background We describe the clinical course of medical and surgical patients who received naloxone on general hospital wards for suspected opioid-induced respiratory depression (OIRD). Methods From May 2018 through October 2020, patients who received naloxone on hospital wards were identified and their records reviewed for incidence and clinical course. Results There were 86,030 medical and 106,807 surgical admissions. Naloxone was administered to 99 (incidence 11.5 [95% confidence interval 9.4–14.0] per 10,000 admissions) medical and 63 (5.9 [95% confidence interval 4.5–7.5]) surgical patients (P Conclusion Medical inpatients are more likely to suffer OIRD than are surgical inpatients despite lower opioid doses. Definitive OIRD was confirmed in 77% of patients because of immediate naloxone response, whereas 23% of patients did not respond, and this subset was more likely to need a higher level of care and had a higher 30-day mortality rate. Careful monitoring of mental and respiratory variables is necessary when opiates are used in hospital.

Background and objectives The addition of a pharmacist to rapid response teams (RRT) has been shown to improve adherence to advanced cardiac life support protocols and to decrease mortality. A quality improvement study was initiated at a single center to evaluate the addition of a pharmacist to the RRT during cardiopulmonary arrest. Methods Data were prospectively collected on pharmacy response time and interventions performed. In addition, a pre- and post-intervention survey of the interprofessional medical emergency response improvement team (MERIT) was performed to assess the perception of pharmacist involvement. Results From April to November 2019, the pharmacists responded to 19 RRT activations for cardiopulmonary arrest. An average of 29.8 minutes were spent at each event and an average of 5.5 interventions per event were made. The most common intervention made by pharmacists was medication procurement (54 interventions), followed by providing drug information (14 interventions). Pharmacists also ensured medication reimbursement (13 interventions). The majority of the MERIT strongly agreed or agreed that the addition of a pharmacist to RRT activations improved teamwork (83.1%), decreased medication turnaround time (84.6%), decreased medication errors (66.7%), and may have prevented a poor outcome (71.8%) in the post-implementation survey. Conclusion Overall, pharmacists demonstrated value as a member of the RRT during cardiopulmonary arrest. The addition of a pharmacist was well received by interprofessional members of the MERIT.

Introduction and objectives In a Danish Hospital, 70% of all activations of the rapid response team (RRT) in 2016 were related to adult patients with respiratory insufficiency. The most frequent RRT intervention was continuous positive airway pressure (CPAP). However, there was no systematic follow-up and patients could not receive CPAP outside of daytime hours. The aim of the study was to implement and evaluate a CPAP intervention to improve healthcare. Patients and methods A quality inter-professional intervention project was conducted. The interventions consisted of: theoretical and practical education in respiratory insufficiency (including use of CPAP) of nurses and physicians from the general wards, physiotherapists and staff from the RRT; development of an instruction leaflet and video; an update of the existing guidelines. The interventions entailed patients being able to receive CPAP a minimum of 3 times for 5–10 min within a 24-h period. All RRT activations were registered and compared in a before–after evaluation of the intervention. Additionally, all staff groups received an electronic questionnaire after implementation. Results After implementation, respiratory insufficiency was still the highest primary course for RRT activation. The use of CPAP increased, and the number of patients needing a transfer to the intensive care unit decreased. The response rate for the questionnaire was 44% (203 out of 465), and staff experienced new competences, improved inter-professional cooperation and improved healthcare. However, a substantial number of staff did not feel sufficiently trained or that the intervention was well-implemented. Conclusion The intervention entailed new competences for the staff, as well as improved system performance, inter-professional cooperation and healthcare. However, there is a need for continuous focus on the intervention.

Work stress is the pressure of the mind of work that is felt when the demands faced exceed the strength contained in the worker. During the current COVID-19 pandemic, the workload of health workers has become very high compared to normal conditions, the ongoing emergency caused by Covid-19 has put health services under strong pressure. This study aims to determine the factors that cause work stress in the Barru District Health Office's fast-moving team. The research method used is quantitative with an analytical approach to cross-sectional study design, with a total sample of 65 people from the Covid-19 rapid response team taken by total sampling. used univariate and bivariate analysis using test Chi square. The results of the study found that there was something that affected work stress, namely the workload of the health department's fast-moving team during the COVID-19 pandemic handling Covid-19 (p = 0.010). While other variables did not affect work stress, namely the effect of work (p = 0.000), the influence of interpersonal relationships (p = 0.010), and the effect of work professionalism (p = 0.000) on the health service rapid movement team during the pandemic-19. The conclusion of this study is that there are those that affect work stress, namely the workload of the fast-moving team handling Covid-19, while the variables that do not affect work stress are the influence of work, the influence of interpersonal relationships, and the influence of work professionalism, on the fast-moving team handling Covid-19 It is recommended that the Barru District Health Office harmonize the work atmosphere at the Barru District Health Office, through activities in outdoor and outbound order to be able to maintain group and interpersonal relationships, and make rules that bind the fast-moving team to deal with Covid-19, especially the office. Barru Regency's health is related to additional tasks under certain conditions so that the leadership gives sanctions to the fast-moving team who do not work professionally in dealing with the covid-19 outbreak. Keywords: Work stress, and the Covid-19 Handling Team.

Background many patients brought to emergency departments (EDs) following an emergency medical services (EMS) call have non-urgent needs that could be treated elsewhere. Older people are particularly vulnerable to adverse events while attending the ED. Alternative care pathway models can reduce ED crowding and improve outcomes. Internationally, there is no consensus on which model is recommended. Aim the aim of this study is to investigate the impact of the Pathfinder model on ED conveyance rates and patient safety. Methods the Pathfinder service is a collaboration between the National Ambulance Service and Beaumont Hospital Occupational Therapy and Physiotherapy Departments. It is supported by the Government of Ireland’s Sláintecare Integration fund. This is a retrospective cohort study of the Pathfinder service over a 5-month period. Results one-hundred and seventy-eight patients were responded to by the Pathfinder ‘Rapid Response Team’. Average age was 79.6 years (standard deviation 7.6), median clinical frailty score was 6 (interquartile range: 5–6). Sixty-four percent remained at home following initial review. None re-presented to the ED within 24 hours, and 10% re-presented within 7 days. The majority (67%) of patients required follow-up by the Pathfinder ‘Follow-Up Team’ and/or another community-based service. Feedback demonstrates 99% patient satisfaction with the service. Conclusion the Pathfinder service is a safe alternative to ED conveyance for older people following an EMS call. It is the first model of this kind to be evaluated in Ireland. The overwhelmingly positive feedback confirms that older people want this service. This model could expand, with local adaptation, nationally and internationally.

The pandemic of Coronavirus Disease 2019 (COVID-19) has now affected the entire globe which was first surfaced in China in December 2019. In absence of effective therapy to manage COVID-19, repurposed therapies were being used to manage the condition. In view of an urgent need for definitive therapy, multiple repurposed drugs, and investigational drug candidates are being tried in clinical trials which may lead to the emergence of unknown short term and long term adverse drug reactions (ADRs), and hence it is crucial to assess the safety of the tried therapeutic interventions. The lag in the pharmacovigilance activities in the midst of this pandemic fosters under-reporting of ADRs. Difficulty in causality assessment due to factors like wide variations in clinical presentation, concomitant use of multiple drugs, associated comorbidities, drug-drug and drug-disease interaction which forestalls the appropriate causality assessment. Hydroxychloroquine, a repurposed antimalarial drug has been a part of hue and cry at present because of its in-question safety in patients with cardiac disorders. National and International Drug monitoring centers have stressed upon reporting of ADRs and to boost up the process and come up with various recommendations. We can overcome these issues by working cohesively, motivating HCPs and patients to report ADRs electronically, and by setting up dedicated pharmacovigilance rapid response team to tackle the issues at the earliest.

Aim We aimed to evaluate neurological profiles of patients with in-hospital cardiac arrest (IHCA) from early time points to long-term follow-up periods. Methods For this prospective cohort study, we established a neurological rapid response team, and serially evaluated the neurological status of patients with IHCA from the initial resuscitation to 12 months after the onset of IHCA. The primary outcome was good neurological status defined as a Clinical Performance Category score of 1–2 at 12 months after IHCA. The secondary outcomes included the awakening and neurological recovery during the first week, the survival and neurological status at hospital discharge, and the survival at 12 months. Results A total of 291 adult patients with IHCA were included. On the first day and during the first week after IHCA, the awakening was achieved in 61 (21.0 %) and 119 patients (40.9 %), respectively; and neurological recovery in 12 (4.1 %) and 46 patients (15.8 %), respectively. Epileptic seizures developed in 9.7 % following restoration of spontaneous circulation. At hospital discharge, 106 patients (36.4 %) had survived; among them, 63.2 % showed good neurological status. At 12 months, 63 (21.6 %) patients survived; among them, 81.7 % showed good neurological status (17.0 % among all patients with IHCA). Of patients without awakening during the first 3 and 7 days, 2.7 % and 1.2 % showed good neurological status at 12 months, respectively. Conclusions Among patients with IHCA, awakening and neurological recovery were remarkable throughout the first week. Survival and good neurological status were substantial at 12 months after IHCA.

Rapid Response Systems (RRSs) have significantly evolved since they were introduced in the early 1990s. Today, in many healthcare institutions, Rapid Response Teams (RRTs) are activated at the first sign of clinical deterioration to provide appropriate expertise and resources to prevent negative patient outcomes. Interventional radiology departments around the world perform a wide range of procedures, both simple and complex. These procedures, although medically necessary, are performed with known risks and can be further complicated by the patient’s comorbidities. When complications and emergencies occur, activating a Rapid Response Team allows for the necessary medical, surgical, nursing, and pharmaceutical management of the patient and ensures proper escalation and transfer of care. This article presents three clinical case studies of patients that underwent routine interventional radiology procedures but ultimately experienced clinical deterioration causing the activation of the Rapid Response System. Complications are explored, radiology nursing care considerations are reviewed, and the history, benefits, and application of Rapid Response Systems are discussed.

Background The NSW Clinical Excellence commission introduced the 'Between the Flags' programme, in response to the death of a young patient, as a system-wide approach for early detection and management of the deteriorating patient in all NSW hospitals. The impact of BTF implementation on the 35 larger hospitals with intensive care units (ICU) has not been reported previously. Aim To assess the impact of 'Between the Flags' (BTF), a two-tier rapid response system across 35 hospitals with an ICU in NSW, on the incidence of in-hospital cardiac arrests and the incidence and outcome of patients admitted to an ICU following cardiac arrest and rapid response team activation. Methods This is a prospective observational study of the BTF registry (August 2010 to June 2016) and the Australian and New Zealand Intensive Care Society Adult Patient Database (January 2008 to December 2016) in 35 New South Wales public hospitals with an ICU. The primary outcome studied was the proportion of in-hospital cardiac arrests. Secondary outcomes included changes in the severity of illness and outcomes of cardiac arrest admissions to the ICU and changes in the volume of rapid response calls. Results The cardiac arrest rate per 1000 hospital admissions declined from 0.91 in the implementation period to 0.70. Propensity score analysis showed significant declines in ICU and hospital mortality and length of stay for cardiac arrest patients admitted to the ICU (all P Conclusions The BTF programme was associated with a significant reduction in cardiac arrests in hospitals and ICU admissions secondary to cardiac arrests in 35 NSW hospitals with an ICU.

Introduction:The efficacy of a specialized pediatric cardiac rapid response team is unknown. We hypothesized that a specialized cardiac rapid response team would facilitate team-wide communication between the cardiac stepdown unit and cardiac intensive care unit (ICU) teams and improve patient care.Materials and methods:A specialized pediatric cardiac rapid response team was implemented in June 2015. All pediatric cardiac rapid response team activations and outcomes from implementation through December 2018 were reviewed. Cardiac arrests and unplanned transfers to the cardiac ICU were indexed to 1000 patient-days to account for inpatient volume trends and evaluated over time.Results:There were 202 cardiac rapid response team activations in 108 unique patients during the study period. After implementation of the pediatric cardiac rapid response team, unplanned transfers from the cardiac stepdown unit to the cardiac ICU decreased from 16.8 to 7.1 transfers per 1000 patient days (p = 0.012). The stepdown unit cardiac arrest rate decreased from 1.2 to 0.0 arrests per 1000 patient-days (p = 0.015). There was one death on the cardiac stepdown unit in the 5 years since the implementation of the cardiac rapid response team, compared to four deaths in the previous 5 years.Conclusions:A reduction in unplanned cardiac ICU transfers, cardiac arrests, and mortality on the cardiac stepdown unit has been observed since the implementation of a specialized pediatric cardiac rapid response team. A specialized cardiac rapid response team may improve communication and empower the interdisciplinary care team to escalate care for patients experiencing clinical decline.

A 63-year-old obese male was admitted with acute respiratory failure secondary to COVID-19. Day 13 the patient decompensated, lapsing into a critical stage of severe acute respiratory distress syndrome, requiring immediate prone positioning. The Rapid Response Team managed the emergency intervention for intubation but was unable to establish central access with the patient in the prone position. A consult to the Vascular Access Team succeeded in establishing central catheter placement with an ultrasound-guided mid-thigh superficial femoral 55-centimeter triple lumen catheter. The terminal tip of the catheter was confirmed in the mid portion of the inferior vena cava.

Purpose: We sought to evaluate if incorporating an early warning system (EWS), the Visensia Safety Index (VSI) and the National Early Warning Systems 2 (NEWS2), may lead to earlier identification of rapid response team (RRT) patients. Methods: This was a retrospective study (2015-2018) of patients experiencing RRT activation within a tertiary care network. We evaluated the proportion of patients with an EWS alert prior to RRT activation and their associated outcomes (primary: hospital mortality). Results: There were 6,346 RRT activations over the study period. Of these, 2042 (50.8%) patients would have had a VSI alert prior to RRT activation, with a median advanced time of 3.6 (IQR 0.5-12.8) hours, compared to 2351 (58.4%) patients and 9.8 (IQR 2.0-18.7) hours for NEWS2. Patients with a potential alert prior to RRT activation had an increased odds of mortality for both VSI (OR 1.2, 95%CI 1.1-1.3) and NEWS2 (OR 2.7, 95% CI 2.4-3.1). Prognostic accuracy for hospital mortality was similar between groups. Conclusion: Utilization of an EWS by an RRT has potential to provide earlier recognition of deterioration and mortality risk among hospitalized inpatients.

Background Decompensating patients require expeditious and focused care at the bedside. This can be particularly challenging when there are multiple layers of providers, each with differing specialisation, experience and autonomy. We examined the impact of our intensivist-driven hospital-wide rapid response team (RRT) at our 1171-bed quaternary care centre. Design Single-centre retrospective cohort study. Methods RRT service was implemented to assess, manage and triage acutely ill patients outside the intensive care unit (ICU). Criteria for consultation and workflow were established. The 24/7 team was led by an intensivist and included nurse practitioners and respiratory therapists. Over 3 years, we reviewed the impact of the RRT on patient outcomes and critical care support beyond the ICU. Results Over 3 years, the RRT received 31 392 consults for 12 122 individual patients averaging 30 consults over 24 hours. 58.9% of the calls received were for sepsis alerts/risk of decompensation and 41.1% of the consults were for reasons of acute decompensation. Among patients that were seen by the RRT, over the course of their hospital stay, 14% were upgraded to a step-down unit, 18% were upgraded to the ICU and 68% completed care without requiring any escalation. The average mortality rate for patients seen by the RRT service during their hospital stay was 11.3% with an average 30-day readmission rate of 16.5% and average hospital length of stay 16 days without significant variation between the 3 years. Conclusions Intensivist-led RRT ensured consistent high value care. Early intervention and consistent supervision enabled timely and efficient delivery of critical care services.

Introduction : Hospitalized patients are at risk of unrecognized clinical deterioration that may lead to adverse events.Context : Rapid Response Teams (RRTs) exist around the world as a strategy to improve patient safety.Objective : To explore how RRTs work, their characteristics, impacts, and methods of implementation.Design : Literature review.Method : Consultation of the databases CINAHL, MEDLINE, PUBMED, COCHRANE library, SCOPUS, and PROQUEST Dissertations and Theses. Keywords : “health care team” and “rapid response team”.Results : 121 articles were included. The collected data were divided into five categories : 1) composition and operation of RRTs, 2) benefits and limitations of RRTs, 3) perceptions of RRTs by health care teams, organizations, and patients, 4) implementation strategies, and 5) facilitators and barriers to implementation.Discussion : Although there are many articles related to RRTs, it appears that : 1) few studies analyze the difference in outcomes in hospitalized patients related to the composition of RRTs, 2) few studies describe how RRTs should work, 3) more studies are needed on the impacts of RRTs on hospitalized patients, 4) organizations’ and patients’ perceptions of RRTs are not well studied, and 5) more studies are needed on the best way to implement an RRT.Conclusion : The results show that there is a lack of studies on the difference in outcomes in hospitalized patients related to the composition of RRTs, on how RRTs should work, on the impacts of RRTs on hospitalized patients, on organizations’ and patients’ perceptions of RRTs, and on the factors that influence the success or failure of the implementation of an RRT.

Objective The objective of this review is to identify and understand how a family support role has been delivered in rapid response teams in hospital settings. Introduction A family support role in a hospital rapid response team is a designated position that is responsible for supporting the family members of people being medically attended to during a hospital rapid response. Support may include the provision of guidance to the family regarding a hospital procedure, support whilst witnessing the rapid response, or assisting the family to process their emotional response. This review will assist in identifying the ways in which the family support role is delivered in rapid response teams within a hospital environment. Inclusion criteria Family support must be delivered by a person who has a designated family support role within a rapid response team in a hospital setting. Studies will not be limited to geographical location, gender, or culture. Studies are not limited to year of publication or methodological design. Methods Databases will include MEDLINE (Ovid), Embase (Ovid), CINAHL, and Cochrane. Gray literature will be searched with predetermined search criteria. Two independent authors will be used to screen articles and perform data extraction on a predetermined data extraction form. A narrative Summary of Findings is planned, alongside a presentation of the data in diagrammatic or tabular form.

Background: New nurses report a sense of being unprepared and low levels of self-confidence. Simulation-based education is frequently used as a strategy to address this low level of confidence and to improve patient safety by providing high-fidelity training in a safe environment. Purpose: The purpose of this DNP scholarly project was to assess if new nurses’ participation in high-fidelity simulation-based training increased self-confidence and nurse-initiated activation of the Rapid Response Team (RRT) when caring for the deteriorating patient. Methods: A quality improvement (QI) design using the FOCUS PDSA framework was the basis for implementation. The target population was new nurses on two units at a Level One Trauma Center. New nurses participated in a 70-minute high-fidelity simulation (HFS), developed and validated over 10 years through multiple PDSA cycles, of a deteriorating patient. Two measures were used in this project. The change in new nurse self-confidence was measured by Grundy’s C-Scale, and the change in the percentage of staff-initiated RRT calls vs auto-triggered was calculated three months after simulation participation. Results: Twelve nurses participated in the simulation. All showed an improvement in self-confidence from pre-simulation to immediately post-simulation measurement. Using a Wilcoxon signed-rank paired data test, participants’ confidence scores on all five items of the C-scale showed a statistically significant improvement from pre- to immediately post-intervention as well as five months later. The difference in the percentage of staff-initiated RRT calls three months post-simulation was increased on Unit B, while Unit A showed a decline in staff-initiated RRT calls when compared to auto-triggered RRT calls. Discussion: This QI project’s simulation intervention was effective in increasing self-confidence scores between pre- and immediately post-intervention. Five months post-intervention, this increase was sustained. However, how this increased self-confidence by the new nurses was translated into practice when activating RRT calls cannot be interpreted by this data as many factors could have influenced RRT call patterns in the pre-and post-simulation period. Though a small test of change, the evidence in the literature review and these results do suggest that inclusion of HFS should be considered to be embedded into the existing Nurse Residency Program. This would allow an opportunity to use HFS to build self-confidence in the care of the deteriorating patient over time of a defined cohort of participants to evaluate the benefits of HFS on new-nurse self-confidence and activation of RRT in an academic medical center.

Aim The efficiency of rapid response teams (RRTs) is decreased by delays in activation of RRT (afferent limb failure, ALF). We categorized ALF by organ systems and investigated correlations with the vital signs subsequently observed by the RRT and associations with mortality. Methods International, multicentre, retrospective cohort study including adult RRT patients without treatment limitations in 2017–2018 in one Australian and two Finnish tertiary hospitals. Results A total of 5,568 RRT patients’ first RRT activations were included. In 927 patients (17%) ALF was present within 4 h before the RRT call, most commonly for respiratory criteria (419 patients, 7.5%). In 3516 patients (63%) overall, and in 756 (82%) of ALF patients, the RRT observed abnormal vital signs upon arrival. The organ-specific ALF corresponded to the RRT observations in 52% of cases for respiratory criteria, in 60% for haemodynamic criteria, in 55% for neurological criteria and in 52% of cases for multiple organ criteria. Only ALF for respiratory criteria was associated with increased hospital mortality (OR 1.71, 95% CI 1.29–2.27), whereas all, except haemodynamic, criteria at the time of RRT review were associated with increased hospital mortality. Conclusions Vital signs were rarely normal upon RRT arrival in patients with ALF, while organ-specific ALF corresponded to subsequent RRT observations in just over half of cases. Our results suggest that systems mandating timely responses to abnormal respiratory criteria in particular may have potential to improve deteriorating patient outcomes.

The purpose of this study is to evaluate the value and efficacy of rapid response teams (RRTs) for different triggering events in total hip arthroplasty (THA) patients.A retrospective review of all RRT events at a single, tertiary referral center from 2014 to 2016 was performed. Inclusion criteria were defined as patients18 years old that underwent primary or revision THA. Information queried included demographics, primary reason for RRT, Charlson Comorbidity Index (CCI), underlying etiology, whether any changes in management occurred, and whether the patient was uptriaged.In total, 168 RRTs were called on 153 hip arthroplasty patients (mean age 65.2 ± 14.1 years; mean body mass index 32.3 ± 4.8, 66% female). Length of stay in RRT for primary and revision THA was 3.4 and 6.2 days, respectively. This was significantly longer than the length of stay for primary THA patients (2.4 days, P.001) and revision THA patients (4.6 days, P = .005) that did not require an RRT. There were no mortalities. RRTs for hypotension/presyncope (11%) and for syncope (11%) resulted in significantly fewer changes in management (P.01) than tachycardia (77%), hypoxia (57%), AMS (79%), and other (47%). RRTs for hypotension/presyncope (28%), syncope (15%), and hypoxia (30%) resulted in significantly fewer patients being uptriaged (P.001) than tachycardia (81%). Hypotension/presyncope was found to be significantly more commonly due to volume depletion (67%) (P.001) than other etiologies. Hypoxia was significantly more commonly due to atelectasis (57%) and opioids/oversedation (30.4%) (P = .037). AMS/delirium was also significantly more commonly caused by opioids/over-sedation (71%) (P.001).In patients undergoing THA, RRTs for hypotension/presyncopal symptoms and syncope were significantly less likely to result in changes in management or uptriaging compared to tachycardia. The most common etiologies were potentially preventable, including volume depletion and opioid use.

Behavioral emergencies endanger hospital staff and patients. The objective of this study was to identify patient characteristics that could be used to predict and prevent these incidents.We analyzed a one-year consecutive series of behavioral emergencies that triggered the rapid response team at a general hospital, comparing study patients with controls who did not trigger a rapid response. Standard parametric or nonparametric tests, as appropriate, were used to compare the 2 groups in univariate analyses, and multivariable logistic regression analysis was used to identify the best combination of variables for stratifying the risk of such an event.There were 109 behavioral emergencies involving 83 patients. Comparison of patients who did (n = 83) or did not (n = 22,849) trigger a rapid response revealed marked differences between the two groups with respect to age, sex, and the prevalence of psychiatric comorbidities and various conditions that can diminish cognitive function. Substance use disorder was the most frequent principal diagnosis in the study group, accounting for 10.8% (9/83) of study patients vs. 0.6% (132/22849) of controls (p 0.0001). The presence of a condition that can impair cognition (substance intoxication and withdrawal, epilepsy, cerebrovascular disease, traumatic brain injury, delirium, dementia) was associated with a 13-fold increase in the risk of a behavioral disturbance (95% CI, 8 to 22-fold).Brief cognitive assessment of patients susceptible to cognitive impairment, along with diligent prophylaxis and management of substance withdrawal and delirium, may facilitate prevention of behavioral emergencies.

An ageing population, government funding cuts and pressures on local authorities to provide services that meet the needs of elderly people, particularly those with complex needs, has resulted in challenges for service providers and service users. This study examined the impact on service users and other stakeholders of rapid response services for elderly and vulnerable residents living in social housing in north-east England. The housing provider has a rapid response team for residents as part of its organisational infrastructure. This includes a 24/7 emergency response service combined with a telecare service, funded by the local authority for vulnerable clients with complex needs and self-funded by others. The study utilised semi-structured qualitative interviews to collect data. Participants included service users, commissioners, service providers, adult social care and family carers. Thematic analysis was used to identify key issues. Service users reported feeling safer and more confident knowing someone would be there at times of need. Family carers reported improvements in their own health and well-being, as they no longer felt on call all the time. The number of requests for ambulances as a consequence of falls was reported to have reduced by the rapid response team. Vulnerable people with electronic monitoring/telecare support were able to remain in their own home for longer, reducing the need for residential funding by the local authority. The partnership between the housing association and the local authority resulted in a service able to respond to changing needs as well as identifying deterioration in residents' health status. In conclusion, the use of a combined rapid response and telecare service resulted in elderly people remaining independent in their homes for longer, which improved their reported quality of life and relieved stress on carers and pressures on other service providers.

Capillary refill time (CRT) is easy, quick to perform and when prolonged in critical illness, correlates with progression of organ failure and mortality. It is utilized in our hospital's early warning score (EWS) as one of 11 parameters. We sought to define CRT's value in predicting patient outcomes, compared to the remaining EWS elements.Five-year prospective observational study of 6480 consecutive Rapid Response Team (RRT) patients. CRT measured at the index finger was considered prolonged if time to previous-color return was3 s. We analyzed the odds ratio of normal vs prolonged-CRT, compared to the other EWS variables, to individual and combined outcomes of mortality, cardiac arrest and higher-level of care transfer.Twenty-percent (N = 1329) of RRT-patients had prolonged-CRT (vs normal-CRT), were twice as likely to die (36% vs 17.8%, p .001), more likely to experience the combined outcome (72.1% vs 54.2%, p .001) and had longer hospital length of stays, 15.3 (SD 0.3) vs 13.5 days (SD 0.5) (p .001). Multivariable logistic regression for mortality ranked CRT second to hypoxia among all 11 variables evaluated (p 001).This is the first time CRT has been evaluated in RRT patients. Its measurement is easy to perform and proves useful as an assessment of adult patients at-risk for clinical decline. Its prolongation in our population was an independent predictor of mortality and the combined outcome. This study and others suggest that CRT should be considered further as a fundamental assessment of patients at-risk for clinical decline.

Background/aims The quick Sepsis-related Organ Failure Assessment (qSOFA) is a newly developed risk stratification tool, which has been presented along with a new sepsis definition, to classify infected patients outside of the intensive care unit (ICU). We evaluated the clinical usefulness of qSOFA for predicting adverse outcomes in sepsis patients with liver cirrhosis. Methods We performed a retrospective cohort study to assess the utility of qSOFA in sepsis patients with liver cirrhosis for whom medical emergency teams (METs) were activated in general wards at an academic tertiary care hospital between March 2008 and December 2015. qSOFA, Systemic inflammatory response syndrome (SIRS), modified early warning score (MEWS), and sequential (sepsis-related) organ failure assessment (SOFA) scores were calculated according to data at MET activation. Results Of 188 patients, 69 (36.7%) had a qSOFA score of 0 or 1 point and 119 (63.3%) had ≥ 2 points. The areas under the receiver operating characteristic curve (AUROC) for ICU transfer on the SOFA (AUROC, 0.691; 95% confidence interval [CI], 0.615 to 0.767) or MEWS (AUROC, 0.663; 95% CI, 0.586 to 0.739) were significantly higher compared to those for qSOFA (AUROC, 0.589; 95% CI, 0.507 to 0.671) or SIRS (AUROC, 0.533; 95% CI, 0.451 to 0.616). Conclusion Our findings suggest that qSOFA score may have limited utility in predicting adverse outcomes in sepsis patients with liver cirrhosis at MET activation. Either MEWS or another screening tool is needed for detecting early sepsis in these patients.

All clinical nurses need to be prepared to recognize deterioration in a patient's clinical status and activate the rapid response team when appropriate. This article explores the clinical nurse's role in recognizing and responding to deterioration in a patient's condition with a focus on hospital-based nurses practicing on a medical-surgical unit.

Airway management challenges encompass the anticipated (eg, airway pathology, history of difficult intubation, bleeding) and the unanticipated. Challenging airway situations also occur in patients with existing in situ tracheostomy tubes and laryngectomy stomas or in intubated patients around the time of planned or unplanned extubation. Preparedness to handle difficult airway scenarios requires a structured approach to patient assessment, identification, and planning. Preparedness also necessitates an organized, disseminated, and predefined process to deliver appropriate resources efficiently to the bedside in an emergency at any time of day. Specialized equipment, multidisciplinary expertise, clinical algorithms, effective communication, and teamwork are critical components of an effective response system. A structured multidisciplinary airway rapid response team that includes both an anesthesiologist and a surgeon is one model to effect such as system.

OBJECTIVES To evaluate the effect of providing early attending physician involvement via telemedicine to improve the decision process of rapid response teams. DESIGN Quasi-experimental; three pairs of control/intervention months: June/July; August/October; November/December. SETTING Single-center, urban, quaternary academic children's hospital with three-member rapid response team: critical care fellow or nurse practitioner, nurse, respiratory therapist. Baseline practice: rapid response team leader reviewed each evaluation with an ICU attending physician within 2 hours after return to ICU. SUBJECTS 1) Patients evaluated by rapid response team, 2) rapid response team members. INTERVENTIONS Implementation of a smartphone-based telemedicine platform to facilitate early co-assessment and disposition planning between the rapid response team at the patient's bedside and the attending in the ICU. MEASUREMENTS AND MAIN RESULTS As a marker of efficiency, the primary provider outcome was time the rapid response team spent per patient encounter outside the ICU prior to disposition determination. The primary patient outcome was percentage of patients requiring intubation or vasopressors within 60 minutes of ICU transfer. There were three pairs of intervention/removal months. In the first 2 pairs, the intervention was associated with the rapid response team spending less time on rapid response team calls (June/July: point estimate -5.24 min per call; p < 0.01; August/October: point estimate -3.34 min per call; p < 0.01). During the first of the three pairs, patients were significantly less likely to require intubation or vasopressors within 60 minutes of ICU transfer (adjusted odds ratio, 0.66; 95 CI, 0.51-0.84; p < 0.01). CONCLUSIONS Early in the study, more rapid ICU attending involvement via telemedicine was associated with rapid response team providers spending less time outside the ICU, and among patients transferred to the ICU, a significant decrease in likelihood of patients requiring vasopressors or intubation within the first 60 minutes of transfer. These findings provide evidence that early ICU attending involvement via telemedicine can improve efficiency of rapid response team evaluations.

Background Although diagnostic error (DE) is a significant problem, it remains challenging for clinicians to identify it reliably and to recognize its contribution to the clinical trajectory of their patients. The purpose of this work was to evaluate the reliability of real-time electronic health record (EHR) reviews using a search strategy for the identification of DE as a contributor to the rapid response team (RRT) activation. Objectives Early and accurate recognition of critical illness is of paramount importance. The objective of this study was to test the feasibility and reliability of prospective, real-time EHR reviews as a means of identification of DE. Methods We conducted this prospective observational study in June 2019 and included consecutive adult patients experiencing their first RRT activation. An EHR search strategy and a standard operating procedure were refined based on the literature and expert clinician inputs. Two physician-investigators independently reviewed eligible patient EHRs for the evidence of DE within 24 hours after RRT activation. In cases of disagreement, a secondary review of the EHR using a taxonomy approach was applied. The reviewers categorized patient experience of DE as Yes/No/Uncertain. Results We reviewed 112 patient records. DE was identified in 15% of cases by both reviewers. Kappa agreement with the initial review was 0.23 and with the secondary review 0.65. No evidence of DE was detected in 60% of patients. In 25% of cases, the reviewers could not determine whether DE was present or absent. Conclusion EHR review is of limited value in the real-time identification of DE in hospitalized patients. Alternative approaches are needed for research and quality improvement efforts in this field.

INTRODUCTION: The Rapid Response System for recognising and responding to clinically deteriorating patients has been progressively implemented in acute care hospitals across the globe. This study sought to review the implementation of this system in acute public hospitals in Singapore. METHODS: A cross-sectional study using a face-to-face survey questionnaire was conducted. RESULTS: Five out of seven invited hospitals completed the questionnaire and rated the Rapid Response System as either high priority or essential, and indicated its importance over other patient safety indicators. Sensitivity and specificity of the triggering criteria and non-adherence to the escalation protocol were highlighted issues. Only two hospitals had a dedicated response team for providing emergency help to deteriorating ward patients. Limited manpower resources, unclear roles between the primary and response teams, and the potential deskilling of ward staff were reported barriers that inhibited the uptake of a response team. All hospitals had a committee that oversaw its system operation, provided training to ward staff, and used information technology to support the implementation. CONCLUSION: A variety of approaches have been taken to support the system of recognising and responding to clinical deterioration. This calls for a national approach to enable the standardisation of clinical processes, sharing of educational resources and multi-site evaluation.

Acute kidney injury (AKI) is a common complication in critically ill patients in the intensive settings with increased risks of short- and long-term complications and mortality. AKI is also associated with an increased length of stay in intensive care units (ICU) and worse kidney function recovery at hospital discharge. The management of AKI is one of the major challenges for nephrologists and intensivists overall for its early diagnosis. The current KDIGO criteria used to define AKI include the serum creatinine and urinary output that are neither sensitive nor specific markers of kidney function, since they can be altered only after hours from the kidney injury. In order to allow an early AKI detection, in the last years, several studies focused on the identification of new biomarkers. Among all these markers, urinary insulin-like growth factor-binding protein (IGFBP-7) and tissue inhibitor of metalloproteinase (TIMP-2) have been proven as the best-performing and have been proposed as a predictive tool for the AKI detection in the critical settings in order to perform an early diagnosis. Patients undergoing major surgery, cardiac surgery, those with hemodynamic instability or those with sepsis are believed to be the top priority patient populations for the biomarker test. In this view, the urinary [TIMP-2] x [IGFBP-7] becomes an important tool for the early detection of patients at high risk for AKI and its integration with the local ICU experience has to provide a multidisciplinary management of AKI with the institution of a rapid response team in order to assess patients and customize AKI management.

Surgical comanagement (SCM), in which surgeons and hospitalists share responsibility of care for surgical patients, has been increasingly utilized. In August 2012, we implemented SCM in Orthopedic and Neurosurgery services in which the same Internal Medicine hospitalists are dedicated year round to each of these surgical services to proactively prevent and manage medical conditions. In this article, we evaluate if SCM was associated with continued improvement in patient outcomes between 2012 and 2018 in Orthopedic and Neurosurgery services at our institution. We conducted regression analysis on 26,380 discharges to assess yearly change in our outcomes. Since 2012, the odds of patients with ≥1 medical complication decreased by 3.8% per year (P = .01), the estimated length of stay decreased by 0.3 days per year (P < .0001), and the odds of rapid response team calls decreased by 12.2% per year (P = .001). Estimated average direct cost savings were $3,424 per discharge.

Aims and objectives To examine the relationship between resuscitation status and (i) patient characteristics; (ii) transfer characteristics; and (iii) patient outcomes following an emergency inter-hospital transfer from a subacute to an acute care hospital. Background Patients who experience emergency inter-hospital transfers from subacute to acute care hospitals have high rates of acute care readmission (81%) and in-hospital mortality (15%). Design This prospective, exploratory cohort study was a subanalysis of data from a larger case-time-control study in five Health Services in Victoria, Australia. There were 603 transfers in 557 patients between August 2015 and October 2016. The study was conducted in accordance with the STrengthening the Reporting of OBservational studies in Epidemiology guidelines. Methods Data were extracted by medical record audit. Three resuscitation categories (full resuscitation; limitation of medical treatment (LOMT) orders; or not-for-cardiopulmonary resuscitation (CPR) orders) were compared using chi-square or Kruskal-Wallis tests. Stratified multivariable proportional hazard Cox regression models were used to account for health service clustering effect. Findings Resuscitation status was 63.5% full resuscitation; 23.1% LOMT order; and 13.4% not-for-CPR. Compared to patients for full resuscitation, patients with not-for-CPR or LOMT orders were more likely to have rapid response team calls during acute care readmission or to die during hospitalisation. Patients who were not-for-CPR were less likely to be readmitted to acute care and more likely to return to subacute care. Conclusions Two-thirds of patients in subacute care who experienced an emergency inter-hospital transfer were for full resuscitation. Although the proportion of patients with LOMT and not-for-CPR orders increased after transfer, there were deficiencies in the documentation of resuscitation status and planning for clinical deterioration for subacute care patients. Relevance to clinical practice As many subacute care patients experience clinical deterioration, patient preferences for care need to be discussed and documented early in the subacute care admission.

Rapid response teams (RRT) have become an expected component in response to acute clinical deterioration of patients outside of the intensive care unit. Even with this support, many RRTs are not activated despite a high level of nursing concern that patients are decompensating. Bedside nurses may be discouraged from appropriately activating RRT due to fear of reprimand. Instituting a proactive, dedicated RRT of nurse practitioners who developed relationships and improved communication with nurses led to an increase in RRT activations for general nursing concern. Early recognition of acute clinical change allowed for prompt intervention by the RRT and decreased intensive care unit transfers.

Background The utilization of a rapid response team (RRT) has influenced the clinical outcomes of patients in the general ward. However, the characteristics of RRT-screened patients who are transferred to the intensive care unit (ICU) are unknown. Therefore, the present study aimed to evaluate these factors. Methods We conducted a retrospective study using patient data from a tertiary medical center in Republic of Korea between January 2016 and December 2017. Multivariate logistic regression analyses were performed to assess the factors associated with the risk of in-hospital mortality. Results A total of 1,096 patients were included: 389 patients were transferred to the ICU, and 707 patients stayed in the ward. Patients in the ICU group were more likely to be admitted for medical reasons, hepatobiliary disease, and high heart rate. More interventions were performed, hospital stays were longer, and the 28-day and in-hospital mortality rates were higher in the ICU group than in the ward group. Multivariate logistic regression analyses showed that risk factors affecting ICU admission were higher Sequential Organ Failure Assessment (SOFA) score, National Early Warning Score (NEWS), platelet count, and lactate level. ICU transfer was not associated with in-hospital mortality. Conclusions Among RRT-screened patients, those with higher SOFA score, NEWS, and lactate level were more likely to be transferred to the ICU. Therefore, these patients should be closely monitored and considered for ICU transfer.

Introduction Chicago’s COVID-19 Rapid Response Team (CRRT) is a decentralized, interprofessional group of nurses, residents, students, and faculty who provide free COVID-19 testing for those living or working in congregate settings (i.e., shelters, long term care facilities, prisons and encampments) due to their increased risk. Individuals within these vulnerable populations regularly experience stigma, a lack of privacy, and healthcare discrimination as they are often in low-income and underserved communities. The CRRT tests in settings that are necessarily large (cafeterias, meeting areas, gymnasiums, recreation rooms), and provide little physical privacy. Regardless of patient circumstances, respecting patient dignity is a professional standard of care, and patient privacy is consistent with that standard. Methods Guided by trauma-informed care techniques, emancipatory nursing practice, and cultural safety methodology, student members of the CRRT initiated a project focused on expanding physical privacy protection for those undergoing COVID-19 testing. Conclusion Though the introduction of a portable privacy screen started as an initiative to safeguard the dignity for underserved populations, this call to action implores current and future health care providers to prioritize the ethical treatment of those most vulnerable by advocating for patient dignity and privacy.

The Critical Care Resource Nurse Team (CCRNT) evolved from our traditional Rapid Response Team (RRT). The CCRNT is a unique paradigm created using the conceptual framework of the American Association of Critical Care Nursing Synergy Model for Patient Care. The goal of the CCRNT is to help align nurse competencies with patient needs. This team was seen as a much-needed strong clinical support by nursing leadership as large numbers of inexperienced new graduate registered nurses were hired and senior experienced nurses were leaving the workforce. The CCRNT supports 24/7 RRT, Code Blue, Code Stroke, Emergency Airway Response Team, Early Warning System, Medical Emergency Team, simulation team training, and bedside nurse support and mentoring. Coverage expanded from inpatient medical/surgical areas to all areas of the medical center and included hospital-wide initiatives. The focus for the CCRNT changed to a system-wide nursing and patient safety model to improve practice and intervene in near-miss events. This model improved communication between disciplines, provided critical surveillance of at-risk patients, supported patient safety with a significant decrease in patient mortality, and offered a 24/7 expert critical care nurse resource team for staff.

BACKGROUND AND OBJECTIVES Pediatric rapid response teams (RRTs) enhance patient safety, reduce cardiorespiratory arrests outside the PICU, and detect deteriorating patients before decompensation. RRT performance may be affected by failures in communication, poor team dynamics, and poor shared decision-making. We aimed to describe factors associated with team performance using direct observation of pediatric RRTs. METHODS Our team directly observed 73 in situ RRT activations, collected field notes of qualitative data, and analyzed the data using conventional content analysis. To assess accuracy of coding, 20% of the coded observations were reassessed for interrater reliability. The codes influencing team performance were categorized as enhancers or threats to RRT teamwork and organized under themes. We constructed a framework of the codes and themes, organized along a spectrum of orderly versus chaotic RRTs. RESULTS Three themes influencing RRT performance were teamwork, leadership, and patient and family factors, with underlying codes that enhanced or threatened RRT performance. Novel factors that were found to threaten team performance included indecision, disruptive behavior, changing leadership, and family or patient distress. Our framework delineating features of orderly and chaotic RRTs may be used to inform training and design of RRTs to optimize performance. CONCLUSIONS Observations of in situ RRT activations in a pediatric hospital both verified previously described characteristics of RRTs and identified new characteristics of team function. Our proposed framework for understanding these enhancers and threats may be used to inform future interventions to improve RRT performance.

IntroductionAcute physiological deterioration is a major contributor to in-hospital morbidity and mortality. Early detection and intervention of deteriorating patients is key to improving patient outcomes. Prior research has demonstrated the effectiveness of Early Warning Systems and other algorithmic approaches in automatically identifying these patients from passively monitoring vital signs.MethodsIn this work, we conduct a prospective pilot study of clinical deployment of the Mayo Clinic Bedside Patient Rescue (BPR) system using an escalating alerting logic enabled by machine learning. Among four units where the BPR system was deployed, time to response and time to intervention for deteriorating patients were significantly reduced relative to matched control units.ResultsIn pilot units, time to response decreased by 35.4% (from 63.2 minutes to 40.8 minutes) and time to intervention decreased by 48.5% (from 106.3 minutes to 55.9 minutes). No significant differences were observed in counterbalance metrics of mortality, ICU transfer rate, and Rapid Response Team activation rate. Furthermore, the automated alerting system was well-received by clinicians participating in the pilot study, as assessed by survey.DiscussionThese results demonstrate a successful clinical deployment of a practice-changing machine learning alert system with demonstrable impact on improving patient care.

BackgroundTimely recognition of the deteriorating inpatient remains challenging. Wearable monitoring systems (WMS) may augment current monitoring practices. However, there are many barriers to implementation in the hospital environment, and evidence describing the clinical impact of WMS on deterioration detection and patient outcome remains unclear.ObjectiveTo assess the impact of vital-sign monitoring on detection of deterioration and related clinical outcomes in hospitalised patients using WMS, in comparison with standard care.MethodsA systematic search was conducted in August 2020 using MEDLINE, Embase, CINAHL, Cochrane Database of Systematic Reviews, CENTRAL, Health Technology Assessment databases and grey literature. Studies comparing the use of WMS against standard care for deterioration detection and related clinical outcomes in hospitalised patients were included. Deterioration related outcomes (primary) included unplanned intensive care admissions, rapid response team or cardiac arrest activation, total and major complications rate. Other clinical outcomes (secondary) included in-hospital mortality and hospital length of stay. Exploratory outcomes included alerting system parameters and clinical trial registry information.ResultsOf 8706 citations, 10 studies with different designs met the inclusion criteria, of which 7 were included in the meta-analyses. Overall study quality was moderate. The meta-analysis indicated that the WMS, when compared with standard care, was not associated with significant reductions in intensive care transfers (risk ratio, RR 0.87; 95% confidence interval, CI 0.66–1.15), rapid response or cardiac arrest team activation (RR 0.84; 95% CI 0.69–1.01), total (RR 0.77; 95% CI 0.44–1.32) and major (RR 0.55; 95% CI 0.24–1.30) complications prevalence. There was also no statistically significant association with reduced mortality (RR 0.48; 95% CI 0.18–1.29) and hospital length of stay (mean difference, MD − 0.09; 95% CI − 0.43 to 0.44).ConclusionThis systematic review indicates that there is no current evidence that implementation of WMS impacts early deterioration detection and associated clinical outcomes, as differing design/quality of available studies and diversity of outcome measures make it difficult to reach a definite conclusion. Our narrative findings suggested that alarms should be adjusted to minimise false alarms and promote rapid clinical action in response to deterioration.PROSPERO Registration number:CRD42020188633.

Background:The utilization of a Rapid response team (RRT) has influenced patient’s clinical outcomes in the general ward. However, characteristics of RRT-screened patients admitted in the ward or transferred to the intensive care unit (ICU) is unknown. Therefore, this study aimed to evaluate these factors.Methods:We conducted a retrospective study using patient’s data in a tertiary medical center in Korea between January 2016 and December 2017. Results: Total 1,096 patients were included; 389 patients were transferred to the ICU, and 707 patients stayed in the ward. The ICU group was more likely to be admitted for medical reasons, hepatobiliary disease, and high heart rate. More interventions were performed, hospital stays were longer, and 28-day and in-hospital mortality were higher in the ICU group. Multivariate logistic regression analyses showed that the risk factors affecting ICU admission were Sequential Organ Failure Assessment (SOFA) score, and National Early Warning Score (NEWS), platelet and lactate level. Transfer to the ICU was not associated with in-hospital mortality.Conclusions: Among RRT-activated patients, those with higher SOFA, NEWS scores, and lactate levels were more likely to transfer to the ICU. Therefore, these patients should be closely monitored and considered for ICU transfer.

BACKGROUND Approximately one third of Rapid Response Teams (RRT) involve end of life care (EOLC) issues. Intensive care unit (ICU) registrar experience in such calls is under-investigated. AIM To evaluate the proportion of RRT calls triaged as relating to EOLC issues, issues around communication regarding prognostication, registrar self-reported moral distress, and associations between RRT EOLC classification and patient outcomes. METHODS Prospective observational study of RRT calls in a tertiary referrals hospital between December 2016 and January 2017 using a standardised case report form and data from an electronic RRT database. RESULTS There were 401 RRT calls in the study period, and data were available for 270 calls (67%), of which 72%, 10%, and 18% were triaged as "obviously not EOLC call", "obvious EOLC call", and "uncertain EOLC call", respectively. Most discussions regarding prognostication occurred between registrars, and more than half were with a covering doctor (55%). Consensus on prognostication was achieved in 93% cases. Registrars reported distress in 19% of calls that obviously related to EOLC and 22% of calls that were uncertain, compared to

Rapid response teams (RRTs) became embedded in US hospitals following the launch of the 100,000Lives Campaign in 2004 by the Institute for HealthcareImprovement and the introduction of RRTs as one ofsix initiatives to improve the quality of patient care.The use of RRTs also allows hospitals to meet a JointCommission requirement to implement a mechanismthat enables staff members to obtain help from expertswhen their patients’ conditions are deteriorating.Thisarticle reviews performance data from an AcademicMedical Center and recent rapid response literature.

A rural community hospital provided a pilot patient deterioration simulation education for new graduate nurses in an attempt to advance the utilization of an existing rapid response team. Pre- and post-intervention self-confidence scores demonstrated a large effect size and a clinically significant eta squared value (.48). The participants successfully completed most of the simulation competencies. This pilot project supports further studies exploring new graduate nurses' self-confidence levels and competency performance with patient deterioration simulation education.

Objectives To characterize the rapid response team activations, and the patients receiving them, in the American Heart Association-sponsored Get With The Guidelines Resuscitation-Medical Emergency Team cohort between 2005 and 2015. Design Retrospective multicenter cohort study. Setting Three hundred sixty U.S. hospitals. Patients Consecutive adult patients experiencing rapid response team activation. Interventions Rapid response team activation. Measurements and main results The cohort included 402,023 rapid response team activations from 347,401 unique healthcare encounters. Respiratory triggers (38.0%) and cardiac triggers (37.4%) were most common. The most frequent interventions-pulse oximetry (66.5%), other monitoring (59.6%), and supplemental oxygen (62.0%)-were noninvasive. Fluids were the most common medication ordered (19.3%), but new antibiotic orders were rare (1.2%). More than 10% of rapid response teams resulted in code status changes. Hospital mortality was over 14% and increased with subsequent rapid response activations. Conclusions Although patients requiring rapid response team activation have high inpatient mortality, most rapid response team activations involve relatively few interventions, which may limit these teams' ability to improve patient outcomes.

Introduction During rapid response team (RRT) management of haemodynamic instability (HI), continuous non-invasive haemodynamic monitoring may provide supplemental physiological information. Objectives To continuously and non-invasively obtain the cardiac index (CI) and mean arterial pressure (MAP) in patients with HI at baseline and during RRT management using the ClearSight™ device. Methods We performed a prospective observational study in adult patients managed by the RRT for tachycardia or hypotension or both. We assessed changes from baseline in heart rate (HR), MAP, CI, stroke volume index (SVI) and systemic vascular resistance index (SVRI) (i) at 5-minutely intervals up to 20 min, and (ii) over the entire 20-min period. We analysed patients by RRT trigger (tachycardia/hypotension) and intervention (fluid bolus therapy [FBT]/ no FBT). Results We successfully recorded the CI in 47 of 50 (94%) patients. RRT reviews triggered by hypotension rather than tachycardia had a lower baseline HR (−45.4 bpm, p = Conclusions Continuous non-invasive measurement of haemodynamics during RRT management for HI was possible for 20 min. Patients with hypotension rather than tachycardia had lower baseline HR, MAP and CI values. There was a statistically significant but small increase in MAP at the 15–20 min time-block and overall, for both the tachycardia and FBT groups.

OBJECTIVES: To validate a scale to assess pediatric providers’ resuscitation and escalation of care self-efficacy and assess which provider characteristics and experiences may contribute to self-efficacy. METHODS: Cross-sectional cohort study performed at an academic children’s hospital. Pediatric nurses, respiratory therapists, and residents completed the Generalized Self-Efficacy Scale (GSES) and Pediatric Resuscitation Self-Efficacy Scale (PRSES) as well as a survey assessing their experiences with pediatric escalation of care. RESULTS: Four hundred participants completed the GSES and PRSES. A total of 338 completed the survey, including 262 nurses, 51 respiratory therapists, and 25 residents. Cronbach α for the PRSES was 0.905. A factor analysis revealed 2 factors within the scale, with items grouped on the basis of expertise required. Multiple logistic regression analyses controlling for GSES score, number of code blue events participated, number of code blue events activated, number of rapid response team events participated, number of rapid response team response events called, performance on a knowledge assessment of appropriate escalation of care, and years of experience demonstrated that PRSES performance was significantly associated with GSES scores and number of escalation of care events (code blue and rapid response) previously participated in (R2 = 0.29, P < .001). CONCLUSIONS: The PRSES can be used to assess pediatric providers’ pediatric resuscitation self-efficacy and could be used to evaluate pediatric escalation of care interventions. Pediatric resuscitation self-efficacy is significantly associated with number of previous escalation of care experiences. In future studies, researchers should focus on assessing the impact of increased exposures to escalation of care, potentially via mock codes, to accelerate the acquisition of resuscitation self-efficacy.

Background Operationalization of the rapid response team (RRT) and its quality champion (QC) nurses at a community hospital is unique and provides benefits not entirely captured by analysis of mortality data. Purpose The purpose was to determine the perceived benefits of the RRT at the facility and behaviors and activities observed during actual RRT responses. Also examined was the timeliness of the RRT calls. Methods This was a mixed-method study including qualitative (interviews, focus groups, and surveys) and quantitative (retrospective chart reviews) data collection. Results Themes included teaching/education, foster development of critical thinking skills, expertise/resource, communication/facilitation/go-between, safety net/security, validation, and advocate/foster collaboration. RRT calls were made quickly after clinical deterioration. Conclusions Benefits of the RRT-QC registered nurse were extensive. Observations showed support, education, and teamwork in an effort to improve outcomes and support clinicians.

Objective To determine if a hospital-wide symptom-based alcohol withdrawal protocol may result in significant clinical improvements to patient outcomes, safety, and hospital efficiency. Methods Retrospective/prospective cohort study between January 1, 2016 and December 31, 2016 (pre-protocol), and between March 1, 2017 and August 7, July 2017 (post-protocol). Pre-protocol patients were identified retrospectively using International Classification of Diseases, 10th revision codes (F10.1, F10.2, and Z71.4). Post-protocol patients were identified by the use of a unique alcohol withdrawal order set in their electronic medical record. The primary endpoint was average length of stay. Secondary outcomes included death, escalation of care as defined as requiring intensive care unit (ICU) consultation or the rapid response team, average ICU length of stay, respiratory failure, average benzodiazepine usage, and incidence of seizures. Results The study included 276 patients in the pre-protocol group and 145 patients in the post-protocol group. There was a significant reduction found in the primary endpoint of average length of stay (7.15 ± 6.5 days vs 5.7 ± 5.6 days; P=.02). There was a significant reduction in the average benzodiazepine use, use of adjunctive medications, need for ICU consultation or rapid response team, respiratory failure, average ICU length of stay, use of neurologic imaging, and the need for lumbar puncture. Conclusion Implementation of a Clinical Institute Withdrawal Assessment for Alcohol, Revised–based alcohol withdrawal protocol may significantly improve quality of care, patient safety, and treatment effectiveness in a large, mixed medical/surgical, urban community-based academic medical center.