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Objective: Determine the prolonged effect of rapid response team (RRT) implementation on failure to rescue (FTR)., Design: Longitudinal study of institutional performance with control charts and Bayesian change point (BCP) analysis., Setting: Two academic hospitals in Midwest, USA., Participants: All inpatients discharged between 1 September 2005 and 31 December 2010., Intervention: Implementation of an RRT serving the Mayo Clinic Rochester system was phased in for all inpatient services beginning in September 2006 and was completed in February 2008., Main Outcome Measure: Modified version of the AHRQ FTR measure, which identifies hospital mortalities among medical and surgical patients with specified in-hospital complications., Results: A decrease in FTR, as well as an increase in the unplanned ICU transfer rate, occurred in the second-year post-RRT implementation coinciding with an increase in RRT calls per month. No significant decreases were observed pre- and post-implementation for cardiopulmonary resuscitation events or overall mortality. A significant decrease in mortality among non-ICU discharges was identified by control charts, although this finding was not detected by BCP or pre- vs. post-analyses., Conclusions: Reduction in the FTR rate was associated with a substantial increase in the number of RRT calls. Effects of RRT may not be seen until RRT calls reach a sufficient threshold. FTR rate may be better at capturing the effect of RRT implementation than the rate of cardiac arrests. These results support prior reports that short-term studies may underestimate the impact of RRT systems, and support the need for ongoing monitoring and assessment of outcomes to facilitate best resource utilization.

Background: There are few comparisons among the most recent versions of the major adult ICU prognostic systems (APACHE [Acute Physiology and Chronic Health Evaluation] IV, Simplified Acute Physiology Score [SAPS] 3, Mortality Probability Model [MPM]0III). Only MPM0III includes resuscitation status as a predictor., Methods: We assessed the discrimination, calibration, and overall performance of the models in 2,596 patients in three ICUs at our tertiary referral center in 2006. For APACHE and SAPS, the analyses were repeated with and without inclusion of resuscitation status as a predictor variable., Results: Of the 2,596 patients studied, 283 (10.9%) died before hospital discharge. The areas under the curve (95% CI) of the models for prediction of hospital mortality were 0.868 (0.854-0.880), 0.861 (0.847-0.874), 0.801 (0.785-0.816), and 0.721 (0.704-0.738) for APACHE III, APACHE IV, SAPS 3, and MPM0III, respectively. The Hosmer-Lemeshow statistics for the models were 33.7, 31.0, 36.6, and 21.8 for APACHE III, APACHE IV, SAPS 3, and MPM0III, respectively. Each of the Hosmer-Lemeshow statistics generated P values < .05, indicating poor calibration. Brier scores for the models were 0.0771, 0.0749, 0.0890, and 0.0932, respectively. There were no significant differences between the discriminative ability or the calibration of APACHE or SAPS with and without “do not resuscitate” status., Conclusions: APACHE III and IV had similar discriminatory capability and both were better than SAPS 3, which was better than MPM0III. The calibrations of the models studied were poor. Overall, models with more predictor variables performed better than those with fewer. The addition of resuscitation status did not improve APACHE III or IV or SAPS 3 prediction.

Background: The prehospital resuscitation of the exsanguinating patient with trauma is time and resource dependent. Rural trauma care magnifies these factors because transportation time to definitive care is increased. To address the early resuscitation needs and trauma-induced coagulopathy in the exsanguinating patient with trauma an aeromedical prehospital thawed plasma-first transfusion protocol was used., Methods: Retrospective review of trauma and flight registries between February 1, 2009, and May 31, 2011, was performed. The study population included all patients with traumatic injury transported by rotary wing aircraft who met criteria for massive transfusion protocol, Results: A total of 59 patients identified over 28 months met criteria for initiation of aeromedical initiation of prehospital blood product resuscitation. Nine patients received thawed plasma-first protocol compared with 50 controls. The prehospital plasma group was more commonly on warfarin (22 vs. 2%, p = 0.036) and had a greater degree of coagulopathy measured by international normalized ratio at baseline (2.6 vs. 1.5, p = 0.004) and trauma center arrival (1.6 vs. 1.3, p < 0.001). The prehospital plasma group had a predicted mortality nearly three times greater than controls based on Trauma and Injury Severity Score (0.24 vs. 0.66, p = 0.005). The use of prehospital plasma resuscitation led to a plasma-red blood cell ratio that more closely approximated a 1:1 resuscitation en route (1.3:1.0 vs. not applicable, p < 0.001), at 30 minutes (1.3:1.0 vs. 0.14:1.0, p < 0.001), at 6 hours (0.95:1.0 vs. 0.42:1.0, p < 0.001), and at 24 hours (1.0:1.0 vs. 0.45:1.0, p < 0.001). An equivalent amount of packed red blood cells were transfused between the groups. Despite more significant hypotension, less crystalloid was used in the prehospital thawed plasma group, through 24 hours after injury (6.3 vs. 16.4 L, p = 0.001)., Conclusion: Use of plasma-first resuscitation in the helicopter system creates a field ready, mobile blood bank, allowing early resuscitation of the patient demonstrating need for massive transfusion. There was early treatment of trauma-induced coagulopathy. Although there was not a survival benefit demonstrated, there was resultant damage control resuscitation extending to 24 hours in the plasma-first cohort.

Objective: This is a study of the influence of transthoracic impedance (TTI) on defibrillation, resuscitation and survival in patients with out-of-hospital cardiac arrest (OHCA), treated with a non-escalating impedance-compensating 150 J biphasic waveform defibrillator., Methods: Cardiac arrest data from two EMS systems were analyzed retrospectively. All witnessed arrests from patients who presented with a shockable rhythm and were treated initially by BLS personnel were included (n = 102). For each defibrillation and resuscitation outcome variable, we tested differences in mean TTI for successful versus unsuccessful outcome. The effect of call-to-shock time on overall outcome was also examined., Results: Initial shocks defibrillated 90% [83-95%] (95% confidence interval) of patients. Cumulative success with two shocks was 98% [93-100%] and with three shocks was 99% [95-100%]. TTI averaged 90 +/- 23 Omega. First-shock success, cumulative success through two shocks and cumulative success through the first-shock series were unrelated to TTI, as were BLS ROSC, pre-hospital ROSC, hospital admission and discharge. In contrast and consistent with previous findings, call-to-shock time was highly predictive of survival., Conclusions: High impedance patients were defibrillated by the biphasic waveform used in this study at high rates with a fixed energy of 150 J and without energy escalation. Rapid defibrillation rather than differences in patient impedance accounts for resuscitation success.

Objectives: Previous studies have shown that family members wish to be present during the resuscitation of a family member. No studies have addressed whether the patient would want family members present if he or she required resuscitation. The authors wanted to determine patients' preferences regarding family member presence during their own resuscitation., Methods: A seven-item survey was administered to a sample of patients and their family members older than 17 years of age on six randomly chosen shifts in an academic community hospital emergency department. Responses were analyzed using chi-square and t-tests. Subjective comments were also recorded., Results: A total of 266 subjects were asked to participate in the study; 200 subjects agreed to complete the survey. Most (72%) wanted a family member present. However, 21% did not wish any family member to be present. Positive responders (family present) tended to be younger (mean, 39.4 years; 95% confidence interval = 36.7 to 42.2) than negative responders (mean, 50.5 years; 95% confidence interval = 42.9 to 55.7; p < 0.001). Positive responders were also more likely to be nonwhite (chi2 = 6.29, p < 0.05). Gender, education, or health status was not associated with responder type. Of positive responders, 56% stated they wanted only certain members present, and these preferences were variable., Conclusions: Patients preferred to have family members present during their resuscitation. However, most of the positive responders wanted only certain members present, and approximately one in five patients, who tended to be older and white, did not want any family present. This study does not support an open policy of allowing family members into a resuscitation without prior knowledge of the patient's preferences.

Objective: To elucidate the critical care experience of emergency medicine faculty and delineate changing patterns of practice., Method: A retrospective review of the resuscitation room dictations for all patients treated in the emergency department resuscitation room by one emergency medicine physician from July 1, 1985, to June 30, 1997, was performed., Results: A total of 1,325 cases were reviewed. The number of cases of arrhythmia (p < 0.01) and medical cardiac arrest (p < 0.01) significantly decreased over time, while the number of cases involving firearm injury (p < 0.01) increased. The percentage of trauma cases steadily rose from 38.5% in year 1 to 50.2% (p < 0.01) in year 12. Significant decreases in the rate of arterial line placement (p < 0.01), central line placement (p < 0.01), nasotracheal intubation (p < 0.01), and thoracotomy (p < 0.05) have occurred. Significant increases were seen in cardiac ultrasound examination (p < 0.01), rapid sequence induction for intubation (p < 0.01), and the use of paralytic medications (p < 0.01)., Conclusion: Significant changes have occurred in the type of case and rate of utilization of various diagnostic and therapeutic procedures.

The implantable cardioverter-defibrillator (ICD) increases survival of patients who receive the device. However, candidacy rates have not been calculated for a defined population, and the potential effect of the device on the survival of all patients with heart disease has not been estimated. To make these calculations, medical records were reviewed for 1976 to 1988 in a population demographically similar to the white population of the United States. Definite and possible candidates were identified on the basis of American Heart Association/American College of Cardiology guidelines. Candidacy rates ranged from 3.3/100,000 (counting only definite candidates for the entire period) to 8.7/100,000 (counting definite and possible candidates after 1980). Extrapolated to the 1990 U.S. population, estimates ranged from 8,207 to 21,637 new candidates each year. During an average follow-up of 5 years, half of all deaths among candidates had the potential to be delayed by an ICD. In a similar population that has a death rate from heart disease of approximately 280/100,000, 0.6 to 1.6% of subjects have the potential to have their deaths delayed to some extent by an ICD.