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Ischemic stroke, caused by the interruption of the blood supply to the brain, requires prompt medical intervention to prevent irreversible damage. Anesthetic management is pivotal during surgical treatments like mechanical thrombectomy, where precise strategies ensure patient safety and procedural success. This narrative review highlights key aspects of anesthetic management in ischemic stroke, focusing on preoperative evaluation, anesthetic choices, and intraoperative care. A rapid yet thorough preoperative assessment is crucial, prioritizing essential diagnostic tests and cardiovascular evaluations to determine patient frailty and potential complications. The decision between general anesthesia (GA) and conscious sedation (CS) remains debated, with GA offering better procedural conditions and CS enabling continuous neurological assessment. The selection of anesthetic agents—such as propofol, sevoflurane, midazolam, fentanyl, remifentanil, and dexmedetomidine—depends on local protocols and expertise balancing neuroprotection, hemodynamic stability, and rapid postoperative recovery. Effective blood pressure management, tailored airway strategies, and vigilant postoperative monitoring are essential to optimize outcomes. This review underscores the importance of coordinated care, incorporating multimodal monitoring and maintaining neuroprotection throughout the perioperative period. [ABSTRACT FROM AUTHOR]

There is mounting evidence that the pre-medical emergency team (pre-MET) of rapid response systems is underutilised in clinical practice due to suboptimal structures and processes and resource constraints. In this perspective article, we argue for examining the pre-MET through a 'Behaviour Change Wheel' lens to improve the pre-MET and maximise the associated patient safety benefits. Using pre-MET communication practices as an example, we illustrate the value of the COM-B model, where clinicians' 'capability', 'opportunity', and 'motivation' drive 'behaviour'. Optimising clinicians' behaviours and establishing failsafe rapid response systems is a complex undertaking; however, examining clinicians' behaviours through the COM-B model enables reframing barriers and facilitators to develop multifaceted and coordinated solutions that are behaviourally and theoretically based. The COM-B model is recommended to clinical governance leaders and health services researchers to explore the underlying causes of behaviour and successfully enact change in the design, implementation, and use of the pre-MET to improve patient safety. What is known about the topic? The pre-medical emergency team (pre-MET) was implemented to enhance hospital patient safety; however, there is evidence that it is underused by health professionals. What does this paper add? We argue that health professionals' behaviours within the pre-MET be understood differently by using the 'Behaviour Change Wheel', where behaviour is driven by capability, opportunity, and motivation. What are the implications for practitioners? To improve patient safety and assist in formulating theory-based solutions, hospital leaders and health services researchers are called upon to examine the pre-MET using behaviour change theory. [ABSTRACT FROM AUTHOR]

OBJECTIVES: The limitations of current early warning scores have prompted the development of deep learning-based systems, such as deep learning-based cardiac arrest risk management systems (DeepCARS). Unfortunately, in South Korea, only two institutions operate 24-hour Rapid Response System (RRS), whereas most hospitals have part-time or no RRS coverage at all. This study validated the predictive performance of DeepCARS during RRS operation and nonoperation periods and explored its potential beyond RRS operating hours. DESIGN: Retrospective cohort study. SETTING: In this 1-year retrospective study conducted at Yonsei University Health System Severance Hospital in South Korea, DeepCARS was compared with conventional early warning systems for predicting in-hospital cardiac arrest (IHCA). The study focused on adult patients admitted to the general ward, with the primary outcome being IHCA-prediction performance within 24 hours of the alarm. PATIENTS: We analyzed the data records of adult patients admitted to a general ward from September 1, 2019, to August 31, 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Performance evaluation was conducted separately for the operational and nonoperational periods of the RRS, using the area under the receiver operating characteristic curve (AUROC) as the metric. DeepCARS demonstrated a superior AUROC as compared with the Modified Early Warning Score (MEWS) and the National Early Warning Score (NEWS), both during RRS operating and nonoperating hours. Although the MEWS and NEWS exhibited varying performance across the two periods, DeepCARS showed consistent performance. CONCLUSIONS: The accuracy and efficiency for predicting IHCA of DeepCARS were superior to that of conventional methods, regardless of whether the RRS was in operation. These findings emphasize that DeepCARS is an effective screening tool suitable for hospitals with full-time RRS, part-time RRS, and even those without any RRS. [ABSTRACT FROM AUTHOR]

Objective: We investigated the role of rapid response systems (RRSs) in limitations of medical treatment (LOMT) planning among children, their families, and health care providers. Methods: This multicenter retrospective cohort study examined children with clinical deterioration using the Japanese RRS registry between 2012 and 2021. Results: Children (n = 348) at 28 hospitals in Japan who required RRS calls were analyzed. Eleven (3%) of the 348 patients had LOMT before RRS calls and 11 (3%) had newly implemented LOMT after RRS calls. Patients with LOMT were significantly less likely to be admitted to an intensive care unit compared with those without (36% vs. 61%, p < 0.001) and were more likely to die within 30 days (45% vs. 11%, p < 0.001). Conclusions: LOMT issues existed in 6% of children who received RRS calls. RRS calls for clinically deteriorating children with LOMT were associated with less intensive care and higher mortality. [ABSTRACT FROM AUTHOR]

Background Various rapid response systems have been developed to detect clinical deterioration in patients. Few studies have evaluated single-parameter systems in children compared to scoring systems. Therefore, in this study we evaluated a single-parameter system called the acute response system (ARS). Methods This retrospective study was performed at a tertiary children’s hospital. Patients under 18 years old admitted from January 2012 to August 2023 were enrolled. ARS parameters such as systolic blood pressure, heart rate, respiratory rate, oxygen saturation, and whether the ARS was activated were collected. We divided patients into two groups according to activation status and then compared the occurrence of critical events (cardiopulmonary resuscitation or unexpected intensive care unit admission). We evaluated the ability of ARS to predict critical events and calculated compliance. We also analyzed the correlation between each parameter that activates ARS and critical events. Results The critical events prediction performance of ARS has a specificity of 98.5%, a sensitivity of 24.0%, a negative predictive value of 99.6%, and a positive predictive value of 8.1%. The compliance rate was 15.6%. Statistically significant increases in the risk of critical events were observed for all abnormal criteria except low heart rate. There was no significant difference in the incidence of critical events. Conclusions ARS, a single parameter system, had good specificity and negative predictive value for predicting critical events; however, sensitivity and positive predictive value were not good, and medical staff compliance was poor.

Ischemic stroke, caused by the interruption of the blood supply to the brain, requires prompt medical intervention to prevent irreversible damage. Anesthetic management is pivotal during surgical treatments like mechanical thrombectomy, where precise strategies ensure patient safety and procedural success. This narrative review highlights key aspects of anesthetic management in ischemic stroke, focusing on preoperative evaluation, anesthetic choices, and intraoperative care. A rapid yet thorough preoperative assessment is crucial, prioritizing essential diagnostic tests and cardiovascular evaluations to determine patient frailty and potential complications. The decision between general anesthesia (GA) and conscious sedation (CS) remains debated, with GA offering better procedural conditions and CS enabling continuous neurological assessment. The selection of anesthetic agents—such as propofol, sevoflurane, midazolam, fentanyl, remifentanil, and dexmedetomidine—depends on local protocols and expertise balancing neuroprotection, hemodynamic stability, and rapid postoperative recovery. Effective blood pressure management, tailored airway strategies, and vigilant postoperative monitoring are essential to optimize outcomes. This review underscores the importance of coordinated care, incorporating multimodal monitoring and maintaining neuroprotection throughout the perioperative period.

This letter, published in the Journal of Anesthesia, discusses the trends in do-not-attempt-resuscitation (DNAR) orders for deteriorating patients in Japan. The study analyzed data from a previous study and found that the prevalence of patients with pre-existing DNAR orders increased from 8.0% to 12.4% between 2014 and 2020, with a temporary decrease around 2017. The prevalence of newly implemented DNAR orders remained unchanged at approximately 5% over the past 7 years. The study suggests that end-of-life care discussions and DNAR orders are becoming more frequent in Japan's aging society. However, the reasons for the difference in trends between pre-existing and newly implemented DNAR orders are unclear. The study acknowledges limitations and calls for further research to better understand the factors influencing DNAR order-related decisions. [Extracted from the article]

Background: While rapid response systems have been widely implemented, their impact on patient outcomes remains unclear. Further understanding of their components—including medical emergency team triggers, medical emergency team member composition, additional roles in patient care beyond responding to medical emergency team events, and their involvement in “Do-Not-Resuscitate” order placement—may elucidate the relationship between rapid response systems and outcomes. Objective: To explore how recent studies have examined rapid response system components in the context of relevant adverse patient outcomes, such as in-hospital cardiac arrests and hospital mortality. Design: Scoping review. Methods: PubMed, CINAHL, and Embase were searched for articles published between November 2014 and June 2022. Studies mainly focused on rapid response systems and associations with in-hospital cardiac arrests were considered. The following were extracted for analysis: study design, location, sample size, participant characteristics, system characteristics (including medical emergency team member composition, additional system roles outside of medical emergency team events), medical emergency team triggers, in-hospital cardiac arrests, and hospital mortality. Results: Thirty-four studies met inclusion criteria. While most studies described triggers used, few analyzed medical emergency team trigger associations with outcomes. Of those, medical emergency team triggers relating to respiratory abnormalities and use of multiple triggers to activate the medical emergency team were associated with adverse patient outcomes. Many studies described medical emergency team member composition, but the way composition was reported varied across studies. Of the seven studies with dedicated medical emergency team members, six found their systems were associated with decreased incidence of in-hospital cardiac arrests. Six of seven studies that described additional medical emergency team roles in educating staff in rapid response system use found their systems were associated with significant decreases in adverse patient outcomes. Four of five studies that described proactive rounding responsibilities reported found their systems were associated with significant decreases in adverse patient outcomes. Reporting of rapid response system involvement in “Do-Not-Resuscitate” order placement was variable across studies. Conclusions: Inconsistencies in describing rapid response system components and related data and outcomes highlights how these systems are complex to a degree not fully captured in existing literature. Further large-scale examination of these components across institutions is warranted. Development and use of robust and standardized metrics to track data related to rapid response system components and related outcomes are needed to optimize these systems and improve patient outcomes.

Objective: To explore clinicians' use and perceptions of interdisciplinary communication pathways for escalating care within the pre-medical emergency team (pre-MET) tier of rapid response systems. Method: A sequential mixed-methods study was conducted using observations and interviews. Participants were clinicians (nurses, allied health, doctors) caring for orthopaedic and general medicine patients at one hospital. Descriptive and thematic analyses were conducted. Results: Escalation practices were observed for 13 of 27 pre-MET events. Leading communication methods for escalating pre-MET events were alphanumeric pagers (61.5%) and in-person discussions (30.8%). Seven escalated pre-MET events led to bedside pre-MET reviews by doctors. Clinician interviews (n = 29) culminated in two themes: challenges in escalation of care, and navigating information gaps. Clinicians reported deficiencies in communication methods for escalating care that hindered interdisciplinary communication and clinical decision-making pertaining to pre-MET deterioration. Conclusion: Policy-defined escalation pathways were inconsistently utilised for pre-MET deterioration. Available communication methods for escalating pre-MET events inadequately fulfilled clinicians' needs. Variable perceptions of escalation pathways illuminated a lack of of a shared mental model about clinicians' roles and responsibilities. To optimise timely and appropriate management of patient deterioration, communication infrastructure and interdisciplinary collaboration must be enhanced. What is known about the topic? To promote earlier recognition of, and response to, deteriorating ward patients, Australian rapid response systems include a pre-medical emergency team (pre-MET) tier. Escalation pathways within the pre-MET tier are poorly understood. What does this paper add? Policy-defined escalation pathways were inconsistently utilised. Clinicians identified deficiencies in communication methods (e.g. alphanumeric pagers) for escalating pre-MET deterioration. Perceptions of escalation pathways illuminated a lack of of a shared mental model about clinicians' roles and responsibilities. What are the implications for practitioners? To optimise the management of pre-MET deterioration, ward-based communication infrastructure and interdisciplinary collaboration must be enhanced. [ABSTRACT FROM AUTHOR]

The surge in clinical demand, shortage in personal protective equipment and high-exposure risk for healthcare workers during the COVID-19 pandemic has challenged hospital common practices and forced a reassessment of care delivery models. Code blue teams are highly specialised units that partake in life-saving situations that can jeopardise the safety of team members. There is a paucity of guidance in regards to proper infection control measures to protect the responders.This study describes a methodical approach to assessing vulnerabilities to transmission of SARS-CoV-2 within existing code blue practices, modalities to limit the number of code blue team responders and modifications to the protocol at a large community teaching hospital. The effort undertaken faced challenges due to the nature of the pandemic and the increased demand on healthcare workers. Quality improvement methods facilitated our protocol design and implementation. To this date, there has been no identified COVID-19 disease in any protected code blue (PCB) team members. We recommend that similar practices be considered and adopted widely and practised periodically.

Background: Studies have shown that standardized code teams may improve outcomes following cardiac arrests. Pediatric intra‐operative cardiac arrests are rare events and are associated with a mortality rate of 18%. There is limited data available regarding use Medical Emergency Team (MET) response to pediatric intra‐operative cardiac arrest. The purpose of this study was to identify the use of MET in response to pediatric intraoperative cardiac arrest as an exploratory step in establishing evidence‐based standardized practice across the hospital for training and management of this rare event. Methods: An anonymous electronic survey was created and sent to two populations: The Pediatric Anesthesia Leadership Council, a section of the Society for Pediatric Anesthesia, and the Pediatric Resuscitation Quality Collaborative, a multinational collaborative group, which works to improve resuscitation care in children. Standard summary and descriptive statistics were used for survey responses. Results: The overall response rate was 41%. The majority of respondents worked in a university affiliated, free‐standing children's hospital. Ninety‐five percent of respondents had a dedicated pediatric MET at their hospital. In 60% of responses from Pediatric Resuscitation Quality Collaborative and 18% of Pediatric Anesthesia Leadership Council hospitals, the MET responds to pediatric intra‐operative cardiac arrest; however, the majority of times MET involvement is requested rather than automatic. The MET was found to be activated intraoperatively for situations other than cardiac arrest such as, massive transfusion events, need for extra staff, and for specialty expertise. In 65% of institutions, simulation‐based training for cardiac arrest is supported but lacking pediatric intra‐operative focus. Conclusions: This survey revealed heterogeneity in the composition and response of the medical response teams responding to pediatric intra‐operative cardiac arrests. Improved collaboration and cross training among MET, anesthesia, and operating room nursing may improve outcomes of pediatric intra‐operative code events. [ABSTRACT FROM AUTHOR]

Abstract Background Hospital-onset sepsis is associated with a higher in-hospital mortality rate than community-onset sepsis. Many hospitals have implemented rapid response teams (RRTs) for early detection and timely management of at-risk hospitalized patients. However, the effectiveness of an all-day RRT over a non-all-day RRT in reducing the risk of in-hospital mortality in patient with hospital-onset sepsis is unclear. We aimed to determine the effect of the RRT’s operating hours on in-hospital mortality in inpatient patients with sepsis. Methods We conducted a nationwide cohort study of adult patients with hospital-onset sepsis prospectively collected from the Korean Sepsis Alliance (KSA) Database from 16 tertiary referral or university-affiliated hospitals in South Korea between September of 2019 and February of 2020. RRT was implemented in 11 hospitals, of which 5 (45.5%) operated 24-h RRT (all-day RRT) and the remaining 6 (54.5%) had part-day RRT (non-all-day RRT). The primary outcome was in-hospital mortality between the two groups. Results Of the 405 patients with hospital-onset sepsis, 206 (50.9%) were admitted to hospitals operating all-day RRT, whereas 199 (49.1%) were hospitalized in hospitals with non-all-day RRT. A total of 73 of the 206 patients in the all-day group (35.4%) and 85 of the 199 patients in the non-all-day group (42.7%) died in the hospital (P = 0.133). After adjustments for co-variables, the implementation of all-day RRT was associated with a significant reduction in in-hospital mortality (adjusted odds ratio 0.57; 95% confidence interval 0.35–0.93; P = 0.024). Conclusions In comparison with non-all-day RRTs, the availability of all-day RRTs was associated with reduced in-hospital mortality among patients with hospital-onset sepsis.

Background: Cardiac arrests are often preceded by several hours of physiological deterioration that may go undetected. Local Problem: Cardiac arrests frequently occurred on medical-surgical units without prior rapid response team intervention. Methods: A pre/postintervention design was used to evaluate a protocol to guide the use of the Modified Early Warning Score (MEWS) by medical-surgical nurses to escalate the care of deteriorating adult patients. Interventions: Following staff education, the MEWS protocol was implemented across 8 medical-surgical units. Results: There was a significant increase in patients experiencing a rapid response prior to a cardiac arrest after implementing the MEWS protocol (P <.0001). Conclusion: Implementing a consistent review of MEWS values allows medical-surgical nurses to initiate assistance from a rapid response team that may prevent an inpatient cardiac arrest. [ABSTRACT FROM AUTHOR]

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This prospective cohort study aimed to assess the predictive value of the Nurse Intuition Patient Deterioration Scale (NIPDS) combined with the National Early Warning Score (NEWS) for identifying serious adverse events in patients admitted to diverse hospital wards. Data was collected between December 2020 and February 2021 in a 350-bed acute hospital near Brussels, Belgium. The study followed a prospective cohort design, employing NIPDS alongside NEWS for risk assessment. Patients were monitored for 24 h post-registration, with outcomes recorded. The study was conducted in a hospital with a Rapid Response System (RRS) and electronic patient record wherein NEWS was routinely collected. Patients admitted to two medical, two surgical, and two geriatric wards were included. The primary outcome included death, urgent code calls, or unplanned ICU transfers within 24 h after NIPDS registration. The secondary outcome comprised rapid response team activations or changes in Do-Not-Resuscitate codes. In a cohort of 313 patients, 10/313 and 31/313 patients reached the primary and secondary outcome respectively. For the primary outcome, NIPDS had a sensitivity of 0.900 and specificity of 0.927, while NEWS had a sensitivity of 0.300 and specificity of 0.974. Decision Curve Analysis demonstrated that NIPDS provided more Net Benefit across various Threshold Probabilities. Combining NIPDS and NEWS showed potential for optimizing rapid response systems. Especially in resource-constrained settings, NIPDS could be used as a calling criterion. The NIPDS displayed strong predictive capabilities for adverse events. Integrating NIPDS into existing rapid response systems can objectify nurse intuition, enhancing patient safety. The Nurse Intuition Patient Deterioration Scale (NIPDS) is a valuable tool for detecting patient deterioration. Implementing NIPDS alongside traditional scores such as NEWS can improve patient care and safety. The optimal NIPDS threshold to activate rapid response is ≥5. [ABSTRACT FROM AUTHOR]

Abstract Aim The rapid response system (RRS) was initially aimed to improve patient outcomes. Recently, some studies have implicated that RRS might facilitate do‐not‐attempt‐resuscitation (DNAR) orders among patients, their families, and healthcare providers. This study aimed to examine the incidence and factors independently associated with DNAR orders newly implemented after RRS activation among deteriorating patients. Methods This observational study assessed patients who required RRS activation between 2012 and 2021 in Japan. We investigated patients’ characteristics and the incidence of new DNAR orders after RRS activation. Furthermore, we used multivariable hierarchical logistic regression models to explore independent predictors of new DNAR orders. Results We identified 7904 patients (median age, 72 years; 59% male) who required RRS activation at 29 facilities. Of the 7066 patients without pre‐existing DNAR orders before RRS activation, 394 (5.6%) had new DNAR orders. Multivariable hierarchical logistic regression analyses revealed that new DNAR orders were associated with age category (adjusted odds ratio [aOR], 1.56; 95% confidence interval, 1.12–2.17 [65–74 years old reference to 20–64 years old], aOR, 2.56; 1.92–3.42 [75–89 years old], and aOR, 6.58; 4.17–10.4 [90 years old]), malignancy (aOR, 1.82; 1.42–2.32), postoperative status (aOR, 0.45; 0.30–0.71), and National Early Warning Score 2 (aOR, 1.07; 1.02–1.12 [per 1 score]). Conclusion The incidence of new DNAR orders was one in 18 patients after RRS activation. The factors associated with new DNAR orders were age, malignancy, postoperative status, and National Early Warning Score 2.

Background: Hospital-onset sepsis is associated with a higher in-hospital mortality rate than community-onset sepsis. Many hospitals have implemented rapid response teams (RRTs) for early detection and timely management of at-risk hospitalized patients. However, the effectiveness of an all-day RRT over a non-all-day RRT in reducing the risk of in-hospital mortality in patient with hospital-onset sepsis is unclear. We aimed to determine the effect of the RRT's operating hours on in-hospital mortality in inpatient patients with sepsis.Methods: We conducted a nationwide cohort study of adult patients with hospital-onset sepsis prospectively collected from the Korean Sepsis Alliance (KSA) Database from 16 tertiary referral or university-affiliated hospitals in South Korea between September of 2019 and February of 2020. RRT was implemented in 11 hospitals, of which 5 (45.5%) operated 24-h RRT (all-day RRT) and the remaining 6 (54.5%) had part-day RRT (non-all-day RRT). The primary outcome was in-hospital mortality between the two groups.Results: Of the 405 patients with hospital-onset sepsis, 206 (50.9%) were admitted to hospitals operating all-day RRT, whereas 199 (49.1%) were hospitalized in hospitals with non-all-day RRT. A total of 73 of the 206 patients in the all-day group (35.4%) and 85 of the 199 patients in the non-all-day group (42.7%) died in the hospital (P = 0.133). After adjustments for co-variables, the implementation of all-day RRT was associated with a significant reduction in in-hospital mortality (adjusted odds ratio 0.57; 95% confidence interval 0.35-0.93; P = 0.024).Conclusions: In comparison with non-all-day RRTs, the availability of all-day RRTs was associated with reduced in-hospital mortality among patients with hospital-onset sepsis. [ABSTRACT FROM AUTHOR]

Objective: To test the validity of the paediatric early warning score (PEWS) and to identify the patients with deteriorating clinical conditions who were reviewed by a rapid response team (RRT) and were advised higher level of care., Study Design: Observational study. Place and Duration of the Study: Paediatric ward and high dependency unit (HDU) of The Aga Khan University Hospital (AKUH), Karachi, Pakistan, from January 2021 to March 2022., Methodology: All children aged 1 month to 18 years, admitted with non-surgical diagnoses at AKUH and referred for an RRT consultation were identified by non-probability consecutive sampling. The bedside nurse assessed the PEWS and alerted the clinical team. The patient's further course of action was decided based on the PEWS, detailed systemic examination, and laboratory workup. This aided in deciding the level of care (General ward, HDU, Paediatric Intensive Care Unit) required by the patients. Patients with length of stay >24 hours were included and those with did not resuscitate orders were excluded., Results: Overall 10,032 patients were admitted to the ward and high dependency unit (HDU). Out of which, 323 (3.2%) patients had an RRT call and were included in the study. The median age of the study population was 3.15 years during the study period, and 30.3% were <1 year. System-wise admission diagnoses included respiratory (33.2%) and neurological diseases (16.1%). Median [interquartile range (IQR)] PEWS at RRT call was 2 (IQR, 1-2) on median admission day 2 (IQR, 1-3). The cumulative data at PEWS ≥3 demonstrated an area under the curve of 63% with a sensitivity of 90% and a specificity of 30%., Conclusion: PEWS >3 can probably identify the patients at risk of deterioration with excellent sensitivity., Key Words: Paediatrics, Rapid response team, Early warning score.

Background: While timely activation and collaborative teamwork of Rapid Response Teams (RRTs) are crucial to promote a culture of safety and reduce preventable adverse events, these do not always occur. Understanding nurses' perceptions of and experiences with RRTs is important to inform education and policy that improve nurse performance, RRT effectiveness, and patient outcomes., Aim: The aim of this study was to explore nurse perceptions of detecting patient deterioration, deciding to initiate RRTs, and experience during and at conclusion of RRTs., Methods: A qualitative descriptive study using semi-structured focus group interviews was conducted with 24 nurses in a Chicago area hospital. Interviews were audio-recorded, transcribed verbatim, and coded independently by investigators. Thematic analysis identified and organized patterns of meaning across participants. Several strategies supported trustworthiness., Results: Data revealed five main themes: identification of deterioration, deciding to escalate care, responsiveness of peers/team, communication during rapid responses, and perception of effectiveness., Conclusions: Findings provide insight into developing a work environment supportive of nurse performance and interprofessional collaboration to improve RRT effectiveness. Nurses described challenges in identification of subtle changes in patient deterioration. Delayed RRT activation was primarily related to negative attitudes of responders and stigma. RRT interventions were often considered a temporary fix leading to subsequent RRTs, especially when patients needing a higher level of care were not transferred. Implications include the need for ongoing RRT monitoring and education on several areas such as patient hand-off, RRT activation, nurse empowerment, interprofessional communication, role delineation, and code status discussions., Competing Interests: Declaration of competing interest None., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Code Blue activations in patients who are not for resuscitation (NFR) may be regarded as non-beneficial and may cause harm to patients, relatives and hospital staff., Aims: To estimate the prevalence of non-beneficial Code Blue calls in a metropolitan teaching hospital and identify modifiable factors that could be utilised to reduce these events., Methods: The study consisted of two parts: (i) a retrospective analysis of all Code Blue activations over a 12-month period using prospectively collected data. Non-beneficial activations were defined as calls made in patients with a NFR order in either the current or any previous hospital admissions and (ii) an anonymous voluntary survey of staff who were present at a Code Blue activation., Results: There were 186 Code Blue activations over the study period, with 48 (25.8%) defined as non-beneficial. Such patients had more comorbidities, previous hospitalisations and greater levels of frailty. Most non-beneficial calls occurred on general wards and more than three-quarters of patients had been reviewed by a consultant prior to the call. The survey determined that despite ward staff having a considerable degree of resuscitation experience, there were deficiencies in understanding of Code Blue criteria, the resuscitation status of patients under their care and the interpretation of goals of care., Conclusions: Over a quarter of Code Blue calls were deemed non-beneficial. Improving the visibility of NFR status and staff understanding of patient goals of care are needed, along with timely, proactive documentation of NFR status by experienced clinicians., (© 2024 Royal Australasian College of Physicians.)

Aim: To analyse the qualitative evidence on the role of critical care nurses in rapid response teams., Design: Qualitative systematic review., Methods: This qualitative systematic review employed Bettany-Saltikov and McSherry's guidelines and is reported according to the Enhancing Transparency in Reporting the Synthesis of Qualitative Research checklist. Two pairs of blinded researchers screened the articles. The data were synthesised using a thematic analysis approach., Data Sources: A systematic literature search was conducted using the CINAHL, Embase and MEDLINE databases., Results: Seven studies were included, and three main roles were identified: (1) balancing between confidence and fear in clinical encounters, (2) facilitating collaboration and (3) managing challenging power dynamics in decision-making., Conclusion: Critical care nurses possess extensive knowledge and skills in providing critical care to patients experiencing deterioration on general wards. They play a vital role in facilitating collaboration between team members and ward staff. Furthermore, within the rapid response team, critical care nurses assume leadership responsibilities by overseeing the comprehensive coordination of patient care and actively engaging in the decision-making process concerning patient care., Implications for the Profession: Highlighting the central role of critical care nurses in rapid response teams as well such a team's benefits in healthcare organisations can promote applications for funding to support further quality assurance of rapid response teams and thus enhance patient safety., Impact: Health care organisations can assure the quality of rapid response team by providing economical resources and training. The education providers should facilitate and standardise curriculum for critical care nursing students to achieve necessary knowledge and skills as members in rapid response teams., Patient or Public Contribution: No patient or public contribution., (© 2024 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd.)

Aim: To explore patient and family narratives about their recognition and response to clinical deterioration and their interactions with clinicians prior to and during Medical Emergency Team (MET) activations in hospital., Background: Research on clinical deterioration has mostly focused on clinicians' roles. Although patients and families can identify subtle cues of early deterioration, little research has focused on their experience of recognising, speaking up and communicating with clinicians during this period of instability., Design: A narrative inquiry., Methods: Using narrative interviewing techniques, 33 adult patients and 14 family members of patients, who had received a MET call, in one private and one public academic teaching hospital in Melbourne, Australia were interviewed. Narrative analysis was conducted on the data., Results: The core story of help seeking for recognition and response by clinicians to patient deterioration yielded four subplots: (1) identifying deterioration, recognition that something was not right and different from earlier; (2) voicing concerns to their nurse or by family members on their behalf; (3) being heard, desiring a response acknowledging the legitimacy of their concerns; and (4) once concerns were expressed, there was an expectation of and trust in clinicians to act on the concerns and manage the situation., Conclusion: Clinical deterioration results in an additional burden for hospitalised patients and families to speak up, seek help and resolve their concerns. Educating patients and families on what to be concerned about and when to notify staff requires a close partnership with clinicians., Implications for the Profession And/or Patient Care: Clinicians must create an environment that enables patients and families to speak up. They must be alert to both subjective and objective information, to acknowledge and to act on the information accordingly., Reporting Method: The consolidated criteria for reporting qualitative research (COREQ) guidelines were used for reporting., Patient or Public Contribution: The consumer researcher was involved in design, data analysis and publication preparation., (© 2024 The Author(s). Journal of Clinical Nursing published by John Wiley & Sons Ltd.)

Background: Research continues to be conducted on rapid response systems as patient outcomes associated with rapid response team activations are still not consistently showing benefit. One particular area of focus that is a growing area is the literature regarding training and education for individual team members of the rapid response team., Objective: The purpose of this narrative review was to describe the current literature regarding educational interventions for rapid response team members., Methods: This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. To be included in the narrative review, studies needed to be reporting on educational interventional research for rapid response team members of the efferent limb. No studies were excluded based upon study design or publication years., Results: This narrative review included 6 studies. Four studies assessed outcomes associated with rapid response team members, and 2 of the studies assessed patient outcomes associated with implementing education routinely for rapid response teams. All studies found a positive impact of implementing educational interventions., Discussion: Our narrative review found that limited research has been conducted in the area of educational interventions for rapid response team members, and of the articles identified, most did not assess patient-associated outcomes. The findings demonstrate that this area of research is in its early stages, and further work is needed to identify what content should be provided in the education and what educational methodologies should be employed, and to continue to assess patient health outcomes associated with educational interventions for rapid response team members., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: This study aimed to determine whether implementing a rapid response system (RRS) is associated with improved short-term outcomes in critically ill patients with haematological malignancies., Methods: Our monocentric pre- versus post-intervention study was conducted between January 2012 and April 2020. RRS was activated at early signs of haemodynamic or respiratory failure. The primary outcome was the reduction in Sequential Organ Failure Assessment (SOFA) score on Day 3 after intensive care unit (ICU) admission. Secondary outcomes included time to ICU admission and mortality., Results: A total of 209 patients with a median age of 59 years were enrolled (108 in the pre-intervention period and 101 in the post-intervention period). 22% of them had received an allogeneic transplant. The post-intervention period was associated with a shorter time to ICU admission (195 vs. 390 min, p < .001), a more frequent favourable trend in SOFA score (57% vs. 42%, adjusted odds ratio, 2.02, 95% confidence interval, 1.09 to 3.76), no significant changes in ICU (22% vs. 26%, p = .48) and 1-year (62% vs. 58%, p = .62) mortality rates., Conclusion: Detection of early organ failure and activation of an RRS was associated with faster ICU admission and lower SOFA scores on Day 3 of admission in critically ill patients with haematological malignancies., (© 2024 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Rapid response systems (RRSs) have been introduced to intervene with patients experiencing non-code medical emergencies and operate widely around the world. An RRS has four components: an afferent limb, an efferent limb, quality improvement, and administration. A proper triggering system, a hospital culture that embraces the RRS from the afferent limb, experienced primary responders, and dedicated physicians from the efferent limb are key for successful implementation. After initial implementation, quality improvement through objective outcome measures and self-evaluation are crucial, which lead to a better outcome when this process is well performed. Furthermore, better outcomes lead to more investment, which is essential for effective development of the system. The RRS is successfully maintained when these four components are closely interconnected.

Abstract Objective Patient crowding and boarding in the emergency department (ED) is associated with adverse outcomes and has become increasingly problematic in recent years. We investigated the impact of an ED patient flow countermeasure using an early warning score. Methods We conducted a cross‐sectional analysis of observational data from patients who presented to the ED of a Level 1 Trauma Center in Pennsylvania. We implemented a modified version of the Modified Early Warning Score (MEWS), called mMEWS, to address patient flow. Patients aged ≥18 years old admitted to the adult hospital medicine service were included in the study. We compared the pre‐mMEWS (February 19, 2017–February 18, 2019) to the post‐mMEWS implementation period (February 19, 2019–June 30, 2020). During the intervention, low MEWS (0–1) scoring admissions went directly to the inpatient floor with expedited orders, the remainder waited in the ED until the hospital medicine admitting team evaluated the patient and then placed orders. We investigated the association between mMEWS, ED length of stay (LOS), and 24‐hour rapid response team (24 hour‐RRT) activation. RRT activation rates were used as a measure of adverse outcome for the new process and are a network team response for admitted patients who are rapidly decompensating. The association between mMEWS and the outcomes of ED length of stay in minutes and 24 hour‐RRT activation was assessed using linear and logistic regression adjusting for a priori selected confounders, respectively. Results Of the total 43,892 patients admitted, 19,962 (45.5%) were in the pre‐mMEWS and 23,930 (54.5%) in the post‐mMEWS implementation period. The median post‐mMEWS ED LOS was shorter than the pre‐mMEWS (376 vs 415 minutes; P

Background: Hospital medical emergency team (MET) activation events involving end‐of‐life care (EOLC) are common. The issues faced by medical staff attending these events are incompletely described. Aims: The purpose of this study was to measure the perceptions of Victorian hospital medical staff, training in the speciality of intensive care, about multiple aspects of EOLC MET calls. We sought to determine the overall extent of formal training in MET and EOLC and assess the domains of self‐perceived confidence, barriers to communication, frequency of clinician agreement and trainee distress. Methods: We conducted an anonymous, voluntary, Internet‐based survey of registered trainees of the College of Intensive Care Medicine of Australia and New Zealand in May 2019. The participants eligible were those trainees working in an adult intensive care unit in Victoria, Australia, during the study period. The main outcome measures were self‐reported levels of confidence, barriers to communication, frequency of conflict and distress, senior support, supervision and access to training. Results: Of 124 trainees surveyed, 75 (60%) responded. Overall, 78% of respondents felt confident to manage EOLC MET calls, but the frequently reported barriers to effective patient/next of kin communication included: (i) lack of private meeting rooms; (ii) resource and time constraints; and (iii) lack of patient and family availability during a MET call to discuss medical treatment limitations. Two‐thirds of respondents reported emotional distress at least occasionally, this being frequent in one in five. Most (68%) trainees experienced conflict with other medical teams at least occasionally. Factors associated with experiencing distress at least occasionally include greater trainee age, patients' being unable to participate in discussion due to illness, resource and time constraints and negative encounters with other medical teams. Conclusions: Victorian intensive care trainees were confident managing EOLC MET activation events. However, distress was reported commonly and strategies are required to address the areas of concern. [ABSTRACT FROM AUTHOR]

Abstract Background Rapid response systems aim to achieve a timely response to the deteriorating patient; however, the existing literature varies on whether timing of escalation directly affects patient outcomes. Prior studies have been limited to using ‘decision to admit’ to critical care, or arrival in the emergency department as ‘time zero’, rather than the onset of physiological deterioration. The aim of this study is to establish if duration of abnormal physiology prior to critical care admission [‘Score to Door’ (STD) time] impacts on patient outcomes. Methods A retrospective cross-sectional analysis of data from pooled electronic medical records from a multi-site academic hospital was performed. All unplanned adult admissions to critical care from the ward with persistent physiological derangement [defined as sustained high National Early Warning Score (NEWS) > / = 7 that did not decrease below 5] were eligible for inclusion. The primary outcome was critical care mortality. Secondary outcomes were length of critical care admission and hospital mortality. The impact of STD time was adjusted for patient factors (demographics, sickness severity, frailty, and co-morbidity) and logistic factors (timing of high NEWS, and out of hours status) utilising logistic and linear regression models. Results Six hundred and thirty-two patients were included over the 4-year study period, 16.3% died in critical care. STD time demonstrated a small but significant association with critical care mortality [adjusted odds ratio of 1.02 (95% CI 1.0–1.04, p = 0.01)]. It was also associated with hospital mortality (adjusted OR 1.02, 95% CI 1.0–1.04, p = 0.026), and critical care length of stay. Each hour from onset of physiological derangement increased critical care length of stay by 1.2%. STD time was influenced by the initial NEWS, but not by logistic factors such as out-of-hours status, or pre-existing patient factors such as co-morbidity or frailty. Conclusion In a strictly defined population of high NEWS patients, the time from onset of sustained physiological derangement to critical care admission was associated with increased critical care and hospital mortality. If corroborated in further studies, this cohort definition could be utilised alongside the ‘Score to Door’ concept as a clinical indicator within rapid response systems.

Background: Although a rapid response system (RRS) can reduce the incidence of cardiopulmonary resuscitation (CPR) in general wards, avoidable CPR cases still occur. This study aimed to investigate the incidence and causes of avoidable CPR. Methods: We retrospectively reviewed the medical records of all adult patients who received CPR between April 2013 and March 2016 (35 months) at a tertiary teaching hospital where a part-time RRS was introduced in October 2012. Four experts reviewed all of the CPR cases and determined whether each event was avoidable. Results: A total of 192 CPR cases were identified, and the incidence of CPR was 0.190 per 1,000 patient admissions. Of these, 56 (29.2%) were considered potentially avoidable, with the most common cause being doctor error (n=32, 57.1%), followed by delayed do-not-resuscitate (DNR) placement (n=12, 21.4%) and procedural complications (n=5, 8.9%). The percentage of avoidable CPR was significantly lower in the RRS operating time group than in the RRS non-operating time group (20.7% vs. 35.5%; P=0.026). Among 44 avoidable CPR events (excluding cases related to DNR issues), the rapid response team intervened in only three cases (6.8%), and most of the avoidable CPR cases (65.9%) occurred during the non-operating time. Conclusions: A significant number of avoidable CPR events occurred with a well-functioning, part-time RRS in place. However, RRS operation does appear to lower the occurrence of avoidable CPR. Thus, it is necessary to extend RRS operation time and modify RRS activation criteria. Moreover, policy and cultural changes are needed prior to implementing a full-time RRS.

BackgroundAlthough hypothesized to be a hazard of hospitalization, it is unclear whether hospital-acquired anemia (HAA) is associated with increased adverse outcomes following discharge.ObjectiveTo examine the incidence, predictors, and postdischarge outcomes associated with HAA.DesignObservational cohort study using electronic health record data.SubjectsConsecutive medicine discharges between November 1, 2009 and October 30, 2010 from 6 Texas hospitals, including safety-net, teaching, and nonteaching sites. Patients with anemia on admission or missing hematocrit values at admission or discharge were excluded.MeasuresHAA was defined using the last hematocrit value prior to discharge and categorized by severity. The primary outcome was a composite of 30-day mortality and nonelective readmission.ResultsAmong 11,309 patients, one-third developed HAA (21.6% with mild HAA; 10.1% with moderate HAA; and 1.4% with severe HAA). The 2 strongest potentially modifiable predictors of developing moderate or severe HAA were length of stay (adjusted odds ratio [OR], 1.26 per day; 95% confidence interval [CI], 1.23-1.29) and receipt of a major procedure (adjusted OR, 5.09; 95% CI, 3.79-6.82). Patients without HAA had a 9.7% incidence for the composite outcome versus 16.4% for those with severe HAA. Severe HAA was independently associated with a 39% increase in the odds for 30-day readmission or death (95% CI, 1.09-1.78). Most patients with severe HAA (85%) underwent a major procedure, had a discharge diagnosis of hemorrhage, and/or a discharge diagnosis of hemorrhagic disorder.ConclusionsSevere HAA is associated with increased odds for 30-day mortality and readmission after discharge; however, it is uncertain whether severe HAA is preventable. Journal of Hospital Medicine 2017;12:317-322.

Abstract Background Rapid response system (RRS) is being increasingly adopted to improve patient safety in hospitals worldwide. However, predictors of survival outcome after RRS activation because of unexpected clinical deterioration are not well defined. We investigated whether hospital length of stay (LOS) before RRS activation can predict the clinical outcomes. Methods Using a nationwide multicenter RRS database, we identified patients for whom RRS was activated during hospitalization at 9 tertiary referral hospitals in South Korea between January 1, 2016, and December 31, 2017. All information on patient characteristics, RRS activation, and clinical outcomes were retrospectively collected by reviewing patient medical records at each center. Patients were categorized into two groups according to their hospital LOS before RRS activation: early deterioration (LOS

Recurrent clinical deterioration and repeat medical emergency team (MET) activation are common and associated with high in-hospital mortality. This study assessed the predictors for repeat MET activation in deteriorating patients admitted to a general ward. We retrospectively analyzed the data of 5512 consecutive deteriorating hospitalized adult patients who required MET activation in the general ward. The patients were divided into two groups according to repeat MET activation. Multivariate logistic regression analyses were used to identify the predictors for repeat MET activation. Hematological malignancies (odds ratio, 2.07; 95% confidence interval, 1.54–2.79) and chronic lung disease (1.49; 1.07–2.06) were associated with a high risk of repeat MET activation. Among the causes for MET activation, respiratory distress (1.76; 1.19–2.60) increased the risk of repeat MET activation. A low oxygen saturation-to-fraction of inspired oxygen ratio (0.97; 0.95–0.98), high-flow nasal cannula oxygenation (4.52; 3.56–5.74), airway suctioning (4.63; 3.59–5.98), noninvasive mechanical ventilation (1.52; 1.07–2.68), and vasopressor support (1.76; 1.22–2.54) at first MET activation increased the risk of repeat MET activation. The risk factors identified in this study may be useful to identify patients at risk of repeat MET activation at the first MET activation. This would allow the classification of high-risk patients and the application of aggressive interventions to improve outcomes. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Background: Rapid response teams (RRTs) have been used 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 preintervention chart review was conducted from January–March 2018 and revealed suboptimal 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 examination, intervention performed, response to intervention, plan of care, communication with care team, and communication with family. A postintervention 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 postintervention period, of which 60.8% were due to respiratory distress. The documentation of the six key elements improved (p <.05) after SmartPhrase creation and serial educational interventions. Conclusions: Standardized RRE documentation of six key elements significantly improved with the implementation of an Epic SmartPhrase. Improved quality of documentation enhances communication between team members and can contribute to safer patient care. [ABSTRACT FROM AUTHOR]

Purpose: This study investigated differences in the clinical outcomes of cardiopulmonary resuscitation (CPR) of patients hospitalized in general wards according to the operation of a rapid response team. Methods: This retrospective study included 122 patients over the age of 19 who were admitted to general ward of a hospital located in Suwon, between July 1, 2015 and December 31, 2019, and received CPR during the operating hours of the rapid response team. The collected data were analyzed by descriptive statistics, the χ² test, Fisher's exact test, and one-way analysis of variance using SPSS for Windows version 25.0. Results: The proportion of nurses who were the initial responders to cardiac arrest was 79.1% during the extended-operation period. 41.2% during the pre-operation period, and 42.2% during the limited-operation period (p<.001). The rate of good neurological recovery at discharge post-CPR was 25.0% in patients who received CPR during the pre-operation period, 36.4% during the limited-operation period, and 87.5% during the extended-operation period (p=.042). Conclusion: This study identified clinical outcomes in patients who received CPR according to the operation status of the rapid response team. These results are expected to help in the further implementation of rapid response teams. [ABSTRACT FROM AUTHOR]

Abstract Background In-hospital cardiac arrest is a major burden in health care. Although several track-and-trigger systems are used to predict cardiac arrest, they often have unsatisfactory performances. We hypothesized that a deep-learning-based artificial intelligence algorithm (DLA) could effectively predict cardiac arrest using electrocardiography (ECG). We developed and validated a DLA for predicting cardiac arrest using ECG. Methods We conducted a retrospective study that included 47,505 ECGs of 25,672 adult patients admitted to two hospitals, who underwent at least one ECG from October 2016 to September 2019. The endpoint was occurrence of cardiac arrest within 24 h from ECG. Using subgroup analyses in patients who were initially classified as non-event, we confirmed the delayed occurrence of cardiac arrest and unexpected intensive care unit transfer over 14 days. Results We used 32,294 ECGs of 10,461 patients and 4483 ECGs of 4483 patients from a hospital were used as development and internal validation data, respectively. Additionally, 10,728 ECGs of 10,728 patients from another hospital were used as external validation data, which confirmed the robustness of the developed DLA. During internal and external validation, the areas under the receiver operating characteristic curves of the DLA in predicting cardiac arrest within 24 h were 0.913 and 0.948, respectively. The high risk group of the DLA showed a significantly higher hazard for delayed cardiac arrest (5.74% vs. 0.33%, P

Abstract Background Rapid Response Team (RRT) calls are clinical crises. Clinical and time pressures can hinder effective liaison between staff who call the RRT (‘users’) and those responding as part of the RRT (‘members’). Non-technical skills (NTS) training has been shown to improve communication and cooperation but requires time and financial resources that may not be available in acute care hospitals. Rapid Response System (RRS) re-design, aiming to promote use of NTS, may provide an alternative approach to improving interactions within RRTs and between members and users. Methods Re-design of an existing mature RRS was undertaken in a tertiary, metropolitan hospital incorporating the addition of: 1) regular RRT meetings 2) RRT role badges and 3) a structured member-to-user patient care responsibility “hand-off” process. To compare experiences and perceptions of calls, users and members were surveyed pre and post re-design. Results Post re-design there were improvements in members’ understanding of RRT roles (P = 0.03) and responsibilities (P

Background Clinical deteriorations during hospitalization are often preventable with a rapid response system (RRS). We aimed to investigate the effectiveness of a daytime RRS for surgical hospitalized patients. Methods A retrospective cohort study was conducted in 20 general surgical wards at a 1,779-bed University hospital from August 2013 to July 2017 (August 2013 to July 2015, pre-RRS-period; August 2015 to July 2017, post-RRS-period). The primary outcome was incidence of cardiopulmonary arrest (CPA) when the RRS was operating. The secondary outcomes were the incidence of total and preventable cardiopulmonary arrest, in-hospital mortality, the percentage of “do not resuscitate” orders, and the survival of discharged CPA patients. Results The relative risk (RR) of CPA per 1,000 admissions during RRS operational hours (weekdays from 7 AM to 7 PM) in the post-RRS-period compared to the pre-RRS-period was 0.53 (95% confidence interval [CI], 0.25 to 1.13; P=0.099) and the RR of total CPA regardless of RRS operating hours was 0.76 (95% CI, 0.46 to 1.28; P=0.301). The preventable CPA after RRS implementation was significantly lower than that before RRS implementation (RR, 0.31; 95% CI, 0.11 to 0.88; P=0.028). There were no statistical differences in in-hospital mortality and the survival rate of patients with in-hospital cardiac arrest. Do-not-resuscitate decisions significantly increased during after RRS implementation periods compared to pre-RRS periods (RR, 1.91; 95% CI, 1.40 to 2.59; P

Background: Recent advances in diagnosis and treatment have improved long-term outcomes in cancer patients. As a result, the requirement for a rapid response team (RRT) for cancer patients is also increasing. This study aimed to analyze utilization of an RRT and the associations between related factors and mortality in a population of cancer patients. Methods: This retrospective cohort study included hospitalized patients at a single academic medical center in Seoul, Korea, who required RRT activation during a 6-year period from June 2013 to December 2018. Results: Overall, 164 of the 457 patients who met the above criteria were cancer patients, and they had a significantly higher Charlson comorbidity score than the non-cancer patients (5.0 vs. 7.0, P

Background To determine the effects of implementing a rapid response system (RRS) on code rates and in-hospital mortality in medical wards. Methods This retrospective study included adult patients admitted to medical wards at Seoul National University Hospital between July 12, 2016 and March 12, 2018; the sample comprised 4,224 patients admitted 10 months before RRS implementation and 4,168 patients admitted 10 months following RRS implementation. Our RRS only worked during the daytime (7 AM to 7 PM) on weekdays. We compared code rates and in-hospital mortality rates between the preintervention and postintervention groups. Results There were 62.3 RRS activations per 1,000 admissions. The most common reasons for RRS activation were tachypnea or hypopnea (44%), hypoxia (31%), and tachycardia or bradycardia (21%). Code rates from medical wards during RRS operating times significantly decreased from 3.55 to 0.96 per 1,000 admissions (adjusted odds ratio [aOR], 0.29; 95% confidence interval [CI], 0.10 to 0.87; P=0.028) after RRS implementation. However, code rates from medical wards during RRS nonoperating times did not differ between the preintervention and postintervention groups (2.60 vs. 3.12 per 1,000 admissions; aOR, 1.23; 95% CI, 0.55 to 2.76; P=0.614). In-hospital mortality significantly decreased from 56.3 to 42.7 per 1,000 admissions after RRS implementation (aOR, 0.79; 95% CI, 0.64 to 0.97; P=0.024). Conclusions Implementation of an RRS was associated with significant reductions in code rates during RRS operating times and in-hospital mortality in medical wards.

Objective: To evaluate the effects of pulmonary embolism response team (PERT) on the quality of care and clinical outcomes in patients with acute pulmonary embolism. Methods: This was a single-center retrospective cohort study. Patients with acute pulmonary embolism treated in Beijing Anzhen Hospital Affiliated to Capital Medical University from July 5, 2016 to July 4, 2018 were enrolled. Patients with acute pulmonary embolism who had traditional care from July 5, 2016 to July 4, 2017 (before the implementation of PERT) were classified as PERT pre-intervention group. Patients with acute pulmonary embolism who started PERT care from July 5, 2017 to July 4, 2018 were divided into the PERT intervention group. The diagnosis and treatment information of patients was collected through the electronic medical record system, and the quality of care (time from visit to hospitalization, time from hospitalization to anticoagulation initiation, time from visit to definitive diagnosis, total hospital stay, time in intensive care unit (ICU), hospitalization cost) and clinical outcomes (in-hospital mortality and incidence of bleeding) were compared between the two groups. Results: A total of 210 patients with acute pulmonary embolism, aged (63.3±13.7) years old, with 102 (48.6%) female patients were included. There were 108 cases in PERT pre-intervention group and 102 cases in PERT intervention group. (1) Quality of diagnosis and treatment: there was a statistical significance between the two groups in the distribution of time from diagnosis to definitive diagnosis ( P= 0.002). Among them, the rate of completion of diagnosis within 24 hours after PERT intervention was higher than that before PERT intervention (80.4% (45/56) vs. 50.0% (34/68), P< 0.001). The time from treatment to hospitalization was shorter than that before PERT intervention (180.0 (60.0, 645.0) min vs. 900.0 (298.0, 1 806.5) min, P< 0.001). The total length of hospital stay was less than that before PERT intervention (12 (10, 14) d vs. 14 (11, 16) d, P= 0.001). There was no statistical significance in the time from hospitalization to anticoagulant therapy, the length of ICU stay and hospitalization cost between the two groups (all P> 0.05). (2) Clinical outcomes during hospitalization: There was no statistical significance in the incidence of hemorrhage and mortality between the two groups during hospitalization (both P> 0.05). Conclusion: PERT has improved the efficiency of diagnosis and treatment of patients with acute pulmonary embolism and significantly shortened the total hospital stay, but its impact on clinical outcomes still needs further study.

Background and Introduction: Rapid Response Teams (RRTs) are multidisciplinary, 'hospital at home' services which have developed over the last 10 years, aiming to improve recovery from illness more efficiently, prevent unnecessary hospital admission, and prevent early admission to residential care. However, little is known about the experience of professionals working in these roles., Purpose: The aim of this study was to explore how working in an RRT is experienced and perceived by physiotherapists., Methods: This study used phenomenographically inspired methodology. Six participants who were working in RRTs were recruited to this study and all were working in the South of England. Data were collected via semi-structured interviews, and phenomenographic analysis was undertaken., Results: Participants working in RRTs described a range of varied, concrete lived-through experiences in addition to a more rhetorical discussion of how they conceptualized their work. Six main categories of description were generated from the analysis; each was assigned a metaphor. These included 'the detective,' 'the guru,' 'the lone ranger,' 'the team player,' 'the bricoleur,' and 'an emotional rollercoaster'; all categories were present with varied meanings. 'An emotional rollercoaster' was present within and throughout participants' descriptions of all other categories., Conclusion: This study provides valuable insights into physiotherapists' experience and conceptualization of working within this discipline, which may have implications for physiotherapy practice, workforce development, new and current RR physiotherapy services, RRT health professionals, and physiotherapy education.

Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Background and Aims: Clinical deterioration within the first 24 h of patient admission triggering a Medical Emergency Team (MET) call is a common occurrence. A greater understanding of these events, with a focus on the recognition and management of sepsis, could lead to quality improvement interventions., Methods: A retrospective observational review of general and subspecialty medical admissions triggering a MET call within 24 h of admission at a quaternary Australian hospital., Results: 2648 MET calls occurred (47.9/1000 admissions), 527 (20% of total MET events, 9.5/1000 admissions) within 24 h of admission, with the trigger more likely to be hypotension (odds ratio: 1.5, P = 0.0013). There were 263 MET calls to 217 individual medical patients within 24 h of admission, of which 84 (38.7%) were admitted with suspected infection, 69% of which fulfilled sepsis criteria. Of these, 36.2% received antimicrobial therapy within the recommended timeframe and 39.6% received antibiotics in line with hospital guidelines. Sepsis was initially missed in 11% of patients. Afferent limb failure occurred in 29% of patients with 40.5% experiencing a failure of the ward-based response to deterioration prior to MET call. Median hospital length of stay was increased in patients admitted with suspected infection (7 vs 5 days, P = 0.015) and in those with sepsis not receiving antimicrobial therapy within guideline timeframes (9 vs 4 days, P = 0.017)., Conclusion: There is a significant opportunity to improve care for patients who trigger a MET within 24 h of admission. This study supports the implementation of a hospital sepsis management guideline., (© 2024 The Authors. Internal Medicine Journal published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Physicians.)

Importance: Inpatient clinical deterioration is associated with substantial morbidity and mortality but may be easily missed by clinicians. Early warning scores have been developed to alert clinicians to patients at high risk of clinical deterioration, but there is limited evidence for their effectiveness., Objective: To evaluate the effectiveness of an artificial intelligence deterioration model-enabled intervention to reduce the risk of escalations in care among hospitalized patients using a study design that facilitates stronger causal inference., Design, Setting, and Participants: This cohort study used a regression discontinuity design that controlled for confounding and was based on Epic Deterioration Index (EDI; Epic Systems Corporation) prediction model scores. Compared with other observational research, the regression discontinuity design facilitates causal analysis. Hospitalized adults were included from 4 general internal medicine units in 1 academic hospital from January 17, 2021, through November 16, 2022., Exposure: An artificial intelligence deterioration model-enabled intervention, consisting of alerts based on an EDI score threshold with an associated collaborative workflow among nurses and physicians., Main Outcomes and Measures: The primary outcome was escalations in care, including rapid response team activation, transfer to the intensive care unit, or cardiopulmonary arrest during hospitalization., Results: During the study, 9938 patients were admitted to 1 of the 4 units, with 963 patients (median [IQR] age, 76.1 [64.2-86.2] years; 498 males [52.3%]) included within the primary regression discontinuity analysis. The median (IQR) Elixhauser Comorbidity Index score in the primary analysis cohort was 10 (0-24). The intervention was associated with a -10.4-percentage point (95% CI, -20.1 to -0.8 percentage points; P = .03) absolute risk reduction in the primary outcome for patients at the EDI score threshold. There was no evidence of a discontinuity in measured confounders at the EDI score threshold., Conclusions and Relevance: Using a regression discontinuity design, this cohort study found that the implementation of an artificial intelligence deterioration model-enabled intervention was associated with a significantly decreased risk of escalations in care among inpatients. These results provide evidence for the effectiveness of this intervention and support its further expansion and testing in other care settings.

In this retrospective cohort study we sought to evaluate the association between the etiology and timing of rapid response team (RRT) activations in postoperative patients at a tertiary care hospital in the southeastern United States. From 2010 to 2016, there were 2,390 adult surgical inpatients with RRT activations within seven days of surgery. Using multivariable linear regression, we modeled the correlation between etiology of RRT and timing of the RRT call, as measured from the conclusion of the surgical procedure. We found that respiratory triggers were associated with an increase in time after surgical procedure to RRT of 10.6 h compared to activations due to general concern (95% CI 3.9 – 17.3) (p = 0.002). These findings may have an impact on monitoring of postoperative patients, as well as focusing interventions to better respond to clinically deteriorating patients. [ABSTRACT FROM AUTHOR]

Background: There are no published studies assessing learning needs and attitudes prior to attending a medical emergency team (MET) education programme. Aims: To conduct a learning needs assessment of MET education programme participants to assess what technical and non‐technical skills should be incorporated. Methods: All participants in a MET education programme over a 12‐month period were invited to complete a self‐administered electronic survey. Participants were ICU team members (intensive care registrars and nurses) and medical registrars. Responses were captured through a 5‐point Likert scale. Results: There were 62 responses out of 112 participants (55% response rate). Most participants either agreed or strongly agreed that MET training was valuable (59 respondents) and should be multidisciplinary (61 respondents). ICU team members were more likely to select 'Management of End‐of‐Life Care' (72% compared with only 16% of medical registrars, P < 0.05) as an important learning objective. Non‐technical skills such as 'Task Management' (67% compared with 37%, P < 0.05) and 'Team Communication' (79% compared with 32%, P < 0.05) were also more likely to be selected by ICU team members. Nursing team members were more likely to select 'Approach to Common MET Calls' (100% compared with 50% of medical team members, P < 0.05). Conclusions: MET education programme participants overwhelmingly feel that training should be multidisciplinary. However, there are disparities between the perceived learning needs of medical and nursing personnel, and between intensive care team members and medical registrars, which may impact on the design and implementation of a multidisciplinary education programme. [ABSTRACT FROM AUTHOR]

Rapid response teams (RRTs) can effectively foster discussions about appropriate goals of care and address other emergent palliative care needs of patients and families facing life-threatening illness on hospital wards. In this article, The Improving Palliative Care in the ICU (IPAL-ICU) Project brings together interdisciplinary expertise and existing data to address the following: special challenges for providing palliative care in the rapid response setting, knowledge and skills needed by RRTs for delivery of high-quality palliative care, and strategies for improving the integration of palliative care with rapid response critical care. We discuss key components of communication with patients, families, and primary clinicians to develop a goal-directed treatment approach during a rapid response event. We also highlight the need for RRT expertise to initiate symptom relief. Strategies including specific clinician training and system initiatives are then recommended for RRT care improvement. We conclude by suggesting that as evaluation of their impact on other outcomes continues, performance by RRTs in meeting palliative care needs of patients and families should also be measured and improved.

Background: Rapid response systems aim to achieve a timely response to the deteriorating patient; however, the existing literature varies on whether timing of escalation directly affects patient outcomes. Prior studies have been limited to using 'decision to admit' to critical care, or arrival in the emergency department as 'time zero', rather than the onset of physiological deterioration. The aim of this study is to establish if duration of abnormal physiology prior to critical care admission ['Score to Door' (STD) time] impacts on patient outcomes.Methods: A retrospective cross-sectional analysis of data from pooled electronic medical records from a multi-site academic hospital was performed. All unplanned adult admissions to critical care from the ward with persistent physiological derangement [defined as sustained high National Early Warning Score (NEWS) > / = 7 that did not decrease below 5] were eligible for inclusion. The primary outcome was critical care mortality. Secondary outcomes were length of critical care admission and hospital mortality. The impact of STD time was adjusted for patient factors (demographics, sickness severity, frailty, and co-morbidity) and logistic factors (timing of high NEWS, and out of hours status) utilising logistic and linear regression models.Results: Six hundred and thirty-two patients were included over the 4-year study period, 16.3% died in critical care. STD time demonstrated a small but significant association with critical care mortality [adjusted odds ratio of 1.02 (95% CI 1.0-1.04, p = 0.01)]. It was also associated with hospital mortality (adjusted OR 1.02, 95% CI 1.0-1.04, p = 0.026), and critical care length of stay. Each hour from onset of physiological derangement increased critical care length of stay by 1.2%. STD time was influenced by the initial NEWS, but not by logistic factors such as out-of-hours status, or pre-existing patient factors such as co-morbidity or frailty.Conclusion: In a strictly defined population of high NEWS patients, the time from onset of sustained physiological derangement to critical care admission was associated with increased critical care and hospital mortality. If corroborated in further studies, this cohort definition could be utilised alongside the 'Score to Door' concept as a clinical indicator within rapid response systems. [ABSTRACT FROM AUTHOR]