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The Centers for Disease Control and Prevention (CDC) Global Rapid Response Team (GRRT) was launched in June 2015 to strengthen the capacity for international response and to provide an agency-wide roster of qualified surge-staff members who can deploy on short notice and for long durations. To assess GRRT performance and inform future needs for CDC and partners using rapid response teams, we analyzed trends and characteristics of GRRT responses and responders, for deployments of at least 1 day during October 1, 2018, through March 31, 2019. One hundred twenty deployments occurred during the study period, corresponding to 2645 person-days. The median deployment duration was 19 days (interquartile range, 5-30 days). Most deployments were related to emergency response (n = 2367 person-days, 90%); outbreaks of disease accounted for almost all deployment time (n = 2419 person-days, 99%). Most deployments were to Africa (n = 1417 person-days, 54%), and epidemiologists were the most commonly deployed technical advisors (n = 1217 person-days, 46%). This case study provides useful information for assessing program performance, prioritizing resource allocation, informing future needs, and sharing lessons learned with other programs managing rapid response teams. GRRT has an important role in advancing the global health security agenda and should continuously be assessed and adjusted to new needs. [ABSTRACT FROM AUTHOR]

Objective: To determine the effect of a clinical triggers program in the Emergency Department (ED) setting that utilized predetermined abnormal vital signs to activate a rapid assessment by an emergency physician led multidisciplinary team. Methods: A retrospective, separate sample, pre-post intervention study following implementation of an ED triggers program. Abnormal vital sign criteria that warranted a trigger response included: heart rate 130 beats/min, respiratory rate 30 respirations/min, systolic blood pressure

A high index of suspicion is needed in pediatric patients with neurological symptoms being the sole presenting manifestation, to diagnose infection with the Human Immunodeficiency Vims (HIV). This is a write up of two such cases who were admitted to the pediatric intensive care unit with neurological manifestations. A 6 year old previously healthy child, who initially presented with intermittent drowsiness and fluctuation in blood pressure, later during hospital stay, developed progressive motor, cognitive, visual and language difficulties. Investigations revealed the child to be HIV positive and magnetic resonance imaging (MRI) findings were consistent with progressive multifocal leucoencephalopathy. A 12 yr old child had stroke initially (for which extensive work up had been done) and later, after 8 months presented with the same complaints along with severe pneumonia. He succumbed to severe opportunistic infections. That he was HIV positive, had not been detected during the first admission as left sided weakness was the only presenting manifestation.

Background: The epidemiology and predictability of in-hospital cardiac arrests (IHCAs) in hospitals with established medical emergency teams (METs) is underinvestigated., Objectives: We categorised IHCAs into three categories: "possible suboptimal end-of-life planning" (possible SELP), "potentially predictable", or "sudden and unexpected" using age, Charlson Comorbidity Index, place of residence, functional independence, along with documented vital signs, K + and HCO 3 in the period prior to the IHCA. We also described the differences in characteristics and outcomes amongst these three categories of IHCAs., Methods: This was a prospective observational study (1st July 2017 to 9th August 2018) of adult (18 years) IHCA patients in wards of seven Australian hospitals with well-established METs., Results: Amongst 152 IHCA patients, 145 had complete data. The number (%) classified as possible SELP, potentially predictable, and sudden and unexpected IHCA was 50 (34.5%), 52 (35.8%), and 43 (29.7%), respectively. Amongst the 52 potentially predictable patients, six (11.5%) had missing vital signs in the preceding 6 hr, 18 (34.6%) breached MET criteria in the prior 24 hr but received no MET call, and 6 (11.5%) had a MET call but remained on the ward. Abnormal K + and HCO 3 was present in 15 of 51 (29.5%) and 13 of 51 (25.5%) of such patients, respectively. The 43 sudden and unexpected IHCA patients were mostly (97.6%) functionally independent and had the lowest median Charlson Comorbidity Index. In-hospital mortality for IHCAs classified as possible SELP, potentially predictable, and sudden and unexpected was 76.0%, 61.5%, and 44.2%, respectively (p = 0.007). Only four of 12 (33.3%) possible SELP survivors had a good functional outcome., Conclusions: In seven Australian hospitals with mature METs, only one-third of IHCAs were sudden and unexpected. Improving end-of-life care in elderly comorbid patients and enhancing the response to objective signs of deterioration may further reduce IHCAs in the Australian context., (Crown Copyright © 2023. Published by Elsevier Ltd. All rights reserved.)

Background: Pre-medical emergency team (MET) calls are an increasingly common tier of Rapid Response Systems, but the epidemiology of patients who trigger a Pre-MET is not well understoof., Objectives: This study aims to examine the epidemiology and outcomes of patients who trigger a pre-MET activation and identify risk factors for further deterioration., Methods: This is a retrospective cohort study of pre-MET activations in a university-affiliated metropolitan hospital in Australia, between 13 April 2021 and 4 October 2021. A multivariable regression model was used to identify variables associated with further deterioration, defined as a MET call or Code Blue within 24 h of pre-MET activation., Results: From a total of 39 664 admissions, there were 7823 pre-MET activations (197.2 per 1000 admissions). Compared to inpatients that did not trigger a pre-MET, the patients were older (68.8 vs 53.8 years, p < 0.001), were more likely to be male (51.0 vs 47.6%, p < 0.001), had an emergency admission (70.1% vs 53.3%, p < 0.001), and were under a medical specialty (63.7 vs 54.9%, p < 0.001). They had a longer hospital length of stay (5.6 vs 0.4 d, p < 0.001) and higher in-hospital mortality (3.4% vs 1.0%, p < 0.001). A pre-MET was more likely to progress to a MET call or Code Blue if it was activated for fever, cardiovascular, neurological, renal, or respiratory criteria (p < 0.001), if the patient was under a paediatric team (p = 0.018), or if there had been a MET call or Code Blue prior to the pre-MET activation (p < 0.001)., Conclusion: Pre-MET activations affect almost 20% of hospital admissions and are associated with a higher risk of mortality. Certain characteristics may predict further deterioration to a MET call or Code Blue, suggesting the potential for early intervention via clinical decision support systems., Competing Interests: Conflicts of interest The authors have no conflicts of interest to declare., (Copyright © 2023 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Purpose: To evaluate the frequency of rapid response team (RRT) calls by time of day and their association with in-hospital mortality., Materials and Methods: This was a retrospective cohort study of all RRT calls at a tertiary teaching hospital in Porto Alegre, Brazil. Patients were categorized according to the time of initial RRT activation. Activations were classified as daytime (7:00-18:59) or nighttime (19:00-6:59). The primary outcome was in-hospital mortality rate. The secondary outcome was ICU admission within 48 h of RRT assessment., Results: During the study period, 4522 patients were included in the final analysis. Cardiovascular and respiratory changes were more common causes of nighttime activation, whereas neurological and laboratory changes were more common during the daytime. The in-hospital mortality rate was 23.9% (1081/4522). Nighttime RRT calls were not associated with worse outcomes than daytime calls. However, a decrease in the number of calls was observed during nursing handover periods (7:00, 13:00 and 19:00). Two time periods were associated with increased adjusted odds for mortality: 12:00-13:00 (adjusted OR 2.277; 95% CI 1.392-3.725) and 19:00-20:00 (adjusted OR 1.873; CI 1.873; 95% 1.099-3.190)., Conclusion: We found that nighttime RRT calls were not associated with worse outcomes than daytime RRT calls. However, a decrease in the number of calls and higher mortality was observed during nursing handover periods., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Rapid response teams (RRTs) respond to hospitalized patients with deterioration and help determine subsequent management, including ICU admission. In such patients with sepsis and septic shock, the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) clinical criteria have a potential role in detection, risk stratification, and prognostication; however, their accuracy in comparison with the systemic inflammatory response syndrome (SIRS)-based septic shock criteria is unknown. We sought to evaluate prognostic accuracy of the Sepsis-3 criteria for in-hospital mortality among infected hospitalized patients with acute deterioration.Methods: Prospectively collected registry data (2012-2016) from two hospitals, including consecutive hospitalized patients with suspected infection seen by the RRT. We compared the Sepsis-3 criteria with the SIRS-based criteria for prediction of in-hospital mortality.Results: Of 1,708 included patients, 418 (24.5%) met the Sepsis-3 septic shock criteria, whereas 545 (31.9%) met the SIRS-based septic shock criteria. Patients meeting the Sepsis-3 septic shock criteria had higher in-hospital mortality (40.9% vs 33.5%; P < .0001), ICU admission (99.5% vs 89.2%; P < .001), and discharge rates to long-term care (66.3% vs 53.7%; P < .0001) than patients meeting the SIRS-based septic shock criteria, respectively. Sensitivity and specificity of the quick Sequential (Sepsis-Related) Organ Failure Assessment were 64.9% and 92.2% for prediction of in-hospital mortality, whereas SIRS criteria had a sensitivity and specificity of 91.6% and 23.6%, respectively.Conclusions: Hospitalized patients with deterioration from suspected infection had higher risk of in-hospital mortality if they met the Sepsis-3 septic shock criteria than the SIRS-based septic shock criteria. Therefore, use of the Sepsis-3 criteria may be preferable in the prognostication and disposition of these patients who are critically ill. [ABSTRACT FROM AUTHOR]

Aim: Study the incidence and reasons behind in-hospital cardiac arrests (IHCAs) after rapid response team (RRT) reviews.Methods: We conducted a matched case-control study at Tampere University Hospital, Finland. Data on adult patients who were triaged to remain on general ward after first (index) RRT review without treatment limitations but who suffered an IHCA within the following 48 h were prospectively collected for 5.3 years. These cases were matched (age ±3 years, sex, surgical/medical ward, admission year) at a 1:4 ratio to controls (no ICHA after RRT review).Results: Of 2653 index RRT reviews, 17 patients suffered an IHCA on general ward within the 48 h after review. Their 30-day mortality rate was 88%. The incidence was 6.3/1000 index RRT reviews or 4.6/100,000 hospital admissions. Patients who suffered an IHCA within 48 h after RRT review were more likely to have a preceding ICU admission, and their median national early warning scores (NEWSs) at the end of the index RRT reviews (=last NEWSs) were higher than those of the controls. Higher last NEWS was the only factor associated with ICHA after RRT review (OR 1.22, 95% CI 1.00-1.49, p = 0.048) in a conditional multivariable regression model.Conclusions: IHCA within 48 h after an index RRT review on general ward is a rare event with poor prognosis. It is independently associated with higher NEWS at the end of the index RRT review. Careful consideration is stressed, when patients with high NEWS are left on ward after RRT reviews. [ABSTRACT FROM AUTHOR]

ABSTRACT: UK prescribing legislation changes made in 2006 and 2012 enabled appropriately qualified nurses to prescribe any licensed medication, and all controlled drugs in schedule 2–5 of the Misuse of Drugs Regulations 2001, for any medical condition within their clinical competence. Critical Care Outreach nurses who are independent nurse prescribers are ideally placed to ensure that acutely ill patients receive treatment without delay. The perceived challenge was how Critical Care Outreach nurses would be able to safely prescribe for a diverse patient group. This study informs this developing area of nurse prescribing in critical care practice. The aims of the audit were to: identify which medications were prescribed; develop a critical care outreach formulary; identify the frequency, timing and number of prescribing decisions being made; identify if prescribing practice changed over the years and provide information for our continuing professional development. This article reports on data collected from a 5‐year retrospective audit; of prescribing activity undertaken by nine independent nurse prescribers working in a 24/7 Critical Care Outreach team of a 600‐bedded district general hospital in the UK. In total, 8216 medication items were prescribed, with an average of 2·6 prescribed per shift. The most commonly prescribed items were intravenous fluids and analgesia, which were mostly prescribed at night and weekends. The audit has shown that Critical Care Outreach nurse prescribing is feasible in a whole hospital patient population. The majority of prescribing occurred after 16:00 and at night. Further research would be beneficial, particularly looking at patient outcomes following reviews from prescribing critical care outreach nurses. The audit is one of the only long‐term studies that describes prescribing practice in Critical Care Outreach teams in the UK. [ABSTRACT FROM AUTHOR]

Rapid response systems (RRS) in hospitals in Australia and New Zealand (ANZ) have been present for more than 20 years but governance of the efferent limb-the rapid response team (RRT)-has not been previously reported in detail. The objectives of this study were to describe current governance arrangements for RRTs within ANZ and contrast those against expected implementation, using the Australian Commission for Safety and Quality in Health Care National Standard 9 (S9) as a benchmark. Assessment focused on S9 subclauses 9.1.1 (governance and oversight), 9.1.2 (RRT implementation), 9.2.3 (data collection and dissemination), 9.2.4 (quality improvement), 9.5.2 (call reviews), 9.6.1 and 9.6.2 (basic and advanced life support [ALS] skill set). We identified public and private hospitals across ANZ from government-maintained registers. Those reasonably expected to have an RRT were contacted and invited to participate. Responses were obtained via an online anonymised questionnaire. Three hundred and forty-two hospitals were contacted, of whom 284 (83.0%) responded. Two hundred and thirty-two hospitals submitted data, and the other 52 declined to participate or did not have an RRT. In hospitals with an intensive care unit (ICU), intensivist attendance at RRT calls occurred less often outside office hours (odds ratio, OR, 0.49, 95% confidence interval, CI, 0.32 to 0.75]). Where intensivists were not on the RRT, consultation with them about calls also occurred less often outside office hours (OR 0.39, 95% CI 0.22 to 0.66). Consultation with patients' admitting specialists occurred more often during office hours versus out of hours RRT calls and in private versus public hospitals. The presence of ICU staff on the RRT decreased the likelihood of admitting specialists being consulted about RRT calls (OR 0.66, 95% CI 0.47 to 0.93). Most hospitals maintained databases of RRT calls and regularly audited RRT activity (92% and 90% respectively). However, most (63.7%) did not make that information available beyond their hospital or local network. We concluded that the majority of hospitals in the ANZ region had governance mechanisms for their RRT. However, there was a notable lack of consistency, especially around specialist involvement and audit processes. Although some findings from this study are reassuring, there is still potential for improvement. Further development of guidelines and the establishment of a regional RRS database may assist with achieving this. [ABSTRACT FROM AUTHOR]

Hintergrund: Ungeplante Aufnahmen oder Rückverlegungen auf die Intensivstation haben einen negativen Einfluss auf das Behandlungsergebnis und stellen eine Klinik vor medizinische, logistische und ökonomische Herausforderungen.Fragestellung: Wie häufig sind und warum kommt es zu Rückverlegungen auf die Intensivstation, was gibt es für Strategien und Empfehlungen, sie zu vermeiden.Material und Methode: Analyse und Diskussion der Studienlage und der Empfehlungen von Fachgesellschaften national und international.Ergebnisse: Viele Studien belegen, dass die Rückverlegung auf eine Intensivstation ein unabhängiger Einflussfaktor auf eine schlechte Prognose für den Patienten ist. Verschiedene Faktoren erhöhen die Wahrscheinlichkeit für eine Rückverlegung. Strukturelle Änderungen auf der Normalstation, auf der Intensivstation und bei der innerklinischen Notfallversorgung konnten in einigen Studien die Rückverlegungsrate und/oder das Patientenoutcome im jeweiligen Krankenhaus dramatisch verbessern, jedoch blieb in anderen Studien ein positiver Effekt aus.Schlussfolgerung: Für die optimale Patientensicherheit muss eine Klinik jederzeit eine hochwertige Übergabe und Überleitung von der Intensivstation auf die Normalstation gewährleisten. Instabile Patienten auf der Normalstation müssen frühzeitig erkannt und behandelt werden, jedoch ist der Effekt durch ein standardisiertes Einsatzteam umstritten. [ABSTRACT FROM AUTHOR]

Objectives: To assess whether a national standard for improving care of deteriorating patients affected ICU admissions following cardiac arrests from hospital wards. Design: Retrospective study assessing changes from baseline (January 1, 2008, to June 30, 2010), rollout (July 1, 2010, to December 31, 2012), and after (January 1, 2013, to 31 December 31, 2014) national standard introduction. Conventional inferential statistics, interrupted time series analysis, and adjusted hierarchical multiple logistic regression analysis. Setting: More than 110 ICU-equipped Australian hospitals. Patients or Subjects: Adult patients (≥ 18 yr old) admitted to participating ICUs. Interventions: Introducing a national framework to improve care of deteriorating patients including color-coded observation charts, mandatory rapid response system, enhanced governance, and staff education for managing deteriorating patients. Measurements and Main Results: Cardiac arrest–related ICU admissions from the ward decreased from 5.6% (baseline) to 4.9% (rollout) and 4.1% (intervention period). Interrupted time series analysis revealed a decline in the rate of cardiac arrest– related ICU admissions in the rollout period, compared with the baseline period (p = 0.0009) with a subsequent decrease in the rate in the intervention period (p = 0.01). Cardiac arrest–related ICU admissions were less likely in the intervention period compared with the baseline period (odds ratio, 0.85; 95% CI, 0.78– 0.93; p = 0.001), as was in-hospital mortality from cardiac arrests (odds ratio, 0.79; 95% CI, 0.65–0.96; p = 0.02). Conclusions: Introducing a national standard to improve the care of deteriorating patients was associated with reduced cardiac arrest–related ICU admissions and subsequent in-hospital mortality of such patients. [ABSTRACT FROM AUTHOR]

Purpose: Controversy exists as to whether the physician turnover affects patient outcome in academic hospitals. In-hospital cardiopulmonary resuscitation (CPR) is an important indicator of in-hospital mortality. This study aimed to investigate whether the physician turnover is associated with the in-hospital CPR rate.Methods: This retrospective cohort study was conducted at a single center; all in-hospital CPR cases among in-patients from 1 January 2007 to 31 December 2016 were analyzed. The turnover period was defined as the changeover of the trainee workforce in March, May, and November. The primary outcome was any variation in the monthly in-hospital CPR events (per 1000 admissions). The secondary outcomes were return of spontaneous circulation (ROSC), CPR in intensive care unit (ICU), monthly in-hospital deaths per 1000 admissions, and average length of hospital stay.Results: A total of 2182 in-hospital CPR cases were included in the analysis. Monthly in-hospital CPR rates were greater during the turnover period when compared to the non-turnover period (4.66 ± 1.02 vs. 4.18 ± 1.56, P = 0.027). There was no significant difference in ROSC rate, CPR in ICU rate, monthly in-hospital deaths per 1000 admissions, or average length of hospital stay between the two periods.Conclusion: Our findings indicate that physician turnover may be associated with in-hospital CPR rate. However, physician turnover was not associated with ROSC rate, rate of CPR in the ICU, in-hospital death, or length of hospital stay. [ABSTRACT FROM AUTHOR]

Rapid response teams (RRTs) were implemented to provide critical care services for deteriorating patients outside of intensive care units. To date, research on RRT has been conflicting, with some studies showing significant mortality benefit and reduction in cardiac arrest events and others showing no benefit. However, studies have consistently showed improved outcomes when RRTs work closely with primary services. Baseline data analysis at our institution found that primary services were present only on 50% of RRT activations. This quality improvement project aimed to improve the presence of primary services during RRT activations by 25%. With a survey, the main barrier that prevented primary services to be present was identified as the primary services' failure to recognize them as a crucial part of the RRT. Education tools and in-person sessions were implemented reinforcing the importance of primary services presence during RRT activations. The intervention leads to increasing presence of primary services at RRT activations, transfers to higher level of care, and changes in code status. However, there was no difference in hospital or intensive care unit length of stay or in survival. [ABSTRACT FROM AUTHOR]

Aim: To examine whether introducing a national standard to improve the recognition of and response to clinical deterioration, was associated with a reduction in cardiovascular events in the hospital environment.Method: Interrupted time series was used to analyse the trajectories of monthly complication rates for 4.69 million admissions in 218 hospitals. Trajectory slopes determined for the "baseline period" (1 July 2007-30 June 2010) and the "Intervention period" (1 January 2013-30 June 2014) were compared (slope ratio).Results: Before the intervention, complication rates due to arrhythmias were increasing, acute coronary syndrome (ACS) and all-cause mortality decreasing, but were constant for cardiac arrest and heart failure and pulmonary oedema. Analysis of the overall data suggested reduction in the rate of cardiac and ACS complications after the intervention, but no significant change in overall hospital mortality. Analysis by age category showed significant reductions in monthly rate trajectories in the 80 plus years age group for cardiac arrest (slope ratio 0.983, 95% CI: 0.972-0.994) and ACS (0.989, 95% CI: 0.981-0.997) complications. Slope ratios indicating reduced monthly rates were seen in females for cardiac arrest (0.985, 95% CI: 0.977-0.994), ACS (0.991, 95% CI: 0.984-0.998) and heart failure (0.993, 95% CI: 0.986-1.000) complications. There were also significant reductions in cardiac arrest (0.983, 95% CI: 0.969-0.996), ACS (0.991, 95% CI: 0.982-1.000) and arrhythmia (0.996, 95% CI: 0.994-0.998) complications for surgical patients.Conclusions: Introduction of a national standard for deteriorating hospitalised patients was associated with a reduction in the rates of in-hospital cardiac arrests and acute coronary syndromes in acute hospitals. Greatest benefit was seen in the elderly, female and surgical patients. [ABSTRACT FROM AUTHOR]

To examine the frequency, clinical characteristics and nurse-led rapid response team experiences of calls that involve end-of-life issues. The study consisted of two parts: 1) a retrospective journal audit of registered rapid response team calls for 2011–2019 that involved end-of-life issues, and 2) interviews with intensive care rapid response team nurses. The quantitative data were analysed with descriptive statistics and the qualitative data with content analysis. The study was conducted at a Danish university hospital. Twelve percent (269/2,319) of the rapid response team calls involved end-of-life issues. "No indication for intensive care therapy" and "Do not resuscitate" were the main medical end-of-life orders. The patients had a mean age of 80 years, and the main reason for the calls was a respiratory problem. Ten rapid response team nurses were interviewed, and four themes evolved from the analysis: "Uncertain roles for the rapid response team nurses", "Solidarity with ward nurses", "Lack of information" and "Timing of decision-making". Twelve percent of the rapid response team calls involved end-of-life issues. The main reason for these calls was a respiratory problem, and the rapid response team nurses often found their role uncertain and experienced lack of information and sub-optimal timing of decision-making. Intensive care nurses working in a rapid response team often face end-of-life issues during calls. Therefore, end-of-life care should be included in training for rapid response team nurses. Furthermore, advanced care planning is recommended to secure high-quality end-of-life care and to decrease uncertainty in acute medical situations. [ABSTRACT FROM AUTHOR]

Background: A rapid response system (RRS) aims to prevent unexpected patient death due to clinical errors and is becoming an essential part of intensive care. We examined the activity and outcomes of RRS for patients admitted to our institution’s department of internal medicine. Methods: We retrospectively reviewed patients detected by the RRS and admitted to the medical intensive care unit (MICU) from October 2012 through August 2013. We studied the overall activity of the RRS and compared patient outcomes between those admitted via the RRS and those admitted conventionally. Results: A total of 4,849 alert lists were generated from 2,505 medical service patients. The RRS was activated in 58 patients: A (Admit to ICU), B (Borderline intervention), C (Consultation), and D (Do not resuscitate) in 26 (44.8%), 21 (36.2%), 4 (6.9%), and 7 (12.1%) patients, respectively. Low oxygen saturation was the most common criterion for RRS activation. MICU admission via the RRS resulted in a shorter ICU stay than that via conventional admission (6.2 vs. 9.9 days, p = 0.018). Conclusions: An RRS can be successfully implemented in medical services. ICU admission via the RRS resulted in a shorter ICU stay than that via conventional admission. Further study is required to determine long-term outcomes.