krish rajan - adelaide hospital - hospital overnight and evaluation of systems and timelines
DESCRIPTION
Krish Rajan presented this at the 2014 Managing the Deteriorating Patient Conference. The conference discussed the latest strategies to recognise and respond to the acute patient in clinical deterioration. You can find out more about next year's conference at http://bit.ly/1sjQubiTRANSCRIPT
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Krish.S.Rajan
Senior Specialist in Intensive Care Medicine
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A/Prof Arthas Flabouris
Prof Campbell Thompson
ANZICS CTG point prevalence programme
George Institute
RAH MET database
SA health
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The early detection and response to patients who become acutely unwell is a key Safety & Quality initiative across Australia
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Prognosis of in-hospital cardiac arrest (IHCA) is poor.
Survival rates at hospital discharge do not exceed 20%1.
Prompt recognition of signs of deterioration may prevent subsequent
cardiac arrests2.
84% of IHCA show signs of deterioration prior to their cardiac arrest
Ward level recognition and response is often inadequate3
Rapid response systems (RRSs) have been proposed as a measure to
detect and respond to the deteriorating patient so as to prevent subsequent
adverse events4
Sandroni C, Nolan J, Cavallaro F, Antonelli M. In-hospital cardiac arrest: incidence, prognosis and possible measures to improve survival. Intensive Care Med
2007;33:237–45.
. Schein RM, Hazday N, Pena M, Ruben BH, Sprung CL. Clinical antecedents to in-hospital cardiopulmonary arrest. Chest 1990;98:1388–92.
. Hodgetts TJ, Kenward G, Vlackonikolis I, et al. Incidence, location and reasons for avoidable in-hospital cardiac arrest in a district general hospital. Resuscitation
2002;54:115–23.
. DeVita MA, Bellomo R, Hillman K, et al. Findings of the first consensus conference on medical emergency teams. Crit Care Med 2006;34:2463–78.
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Palliative care
Efferent limb
Afferent Limb
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Afferent Limb Failure is common and associated with patient harm 22.8% of events preceded by ALF
60% of ALF occurrences at night Trinkle, et al. Resuscitation 2011;82:810-14
The type of medical review prior to an adverse event influences patient outcome
Trinkle et al. Critical Care and Resuscitation 2011; 13; 175-180
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Absence of increased mortality associated with ALF group
Shorter duration of the delay in the MET call observed in this study as compared with the previous ones*
Afferent limb failure is still a major issue even in mature RRSs.
Reducing the incidence of ALF could potentially reduce the risk of adverse events.
*Calzavacca P, Licari E, Tee A, et al. The impact of Rapid Response System on delayed emergency team activation patient characteristics and outcomes—a follow-up study. Resuscitation 2010;81:31–5.
*Downey AW, Quach JL, Haase M, Haase-Fielitz A, Jones D, Bellomo R. Characteristics and outcomes of patients receiving a medical emergency team review for acute change in conscious state or arrhythmias. Crit Care Med 2008;36: 477–81.
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Diurnal variations in MET dose and patient outcomes
◦ DeVita, et al Medical emergency teams: deciphering clues
to crises in hospitals. Critical Care 2005;9:325-326
◦ Mitchell, et al A prospective controlled trial of the effect of a multi-faceted intervention on early recognition and intervention in deteriorating hospital patients. Resuscitation 2010;81:658-666
◦ Bhonagiri, et al. Increased mortality associated with after-hours and weekend admission to the intensive care unit: a retrospective analysis. MJA 2011;194:287-292
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Diurnal variations in patient outcomes
Hospital mortality rate and length of stay in patients admitted
at night to the intensive care unit.
Crit Care Med 2003; 31: 858-863.
Weekend and weeknight admissions have the same outcome of weekday admissions to an intensive care unit with onsite intensivist coverage.
Crit Care Med 2006; 34: 605-611.
Mortality among patients admitted to intensive care units during weekday day shifts compared with “off” hours.
Crit Care Med 2007; 35: 3-11.
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WEEKDAY
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Courtesy : Adam Deane
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Diurnal variation of MET and Cardiac Arrest occurrence
MET hour of day
0%
1%
2%
3%
4%
5%
6%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
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0%
1%
2%
3%
4%
5%
6%
7%
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Cardiac Arrest
Diurnal variation of MET and Cardiac Arrest occurrence
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Diurnal variation in MET outcomes Based upon patients who had a MET call during their hospital stay
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Hour of Day
% M
ort
alit
y at
tim
e o
f M
ET
0
5
10
15
20
25
30
35
40
45
% H
osp
ital
Mo
rtal
ity
DiedatMET Hospital mortality
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Is there a diurnal variation in RRT performance as measured by ◦ Afferent limb failure (ALF)
◦ Efferent limb failure (ELF)
Is there a diurnal variation in the consequences of ALF and ELF
Do newly implemented track and trigger systems influence diurnal variation and associated patient outcomes
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Preliminary data from the RAH ◦ Explore diurnal variation
Point prevalence study across ANZ units ◦ Baseline information across a number of sites on
diurnal variation
◦ Afferent and Efferent limb failure
Before and after implementation of new patient observation charts ◦ Retrospective case note review
◦ Data linkage
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Diurnal variation in MET outcomes Based upon patients who had a MET call during their hospital stay
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Hour of Day
% M
ort
alit
y at
tim
e o
f M
ET
0
5
10
15
20
25
30
35
40
45
% H
osp
ital
Mo
rtal
ity
DiedatMET Hospital mortality
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Prospective Observational Chart review across Australian and New Zealand ICUs
ICU admissions from a general ward
Data from the 24 hours immediately preceding admission to ICU
Objectives ◦ Ascertain diurnal variation in patient monitoring,
and responding to clinical deterioration
◦ Across a diverse group of hospitals
◦ Ascertain any association with patient outcomes
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Emergency admission directly from ward
↓
Emergency admissions
from other
ICU
OT
Recovery
ED
CCU
Yes No Excluded
ICU
Excluded
Included
Adult >16 years
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Descriptive Statistics
N=48
Distribution of ICU LOS
Distribution of Hospital LOS
Distribution of Age
Inferential Statistics
Incidence of afferent limb failure (ALF)
Relationship between ALF
o ICU mortality
o Hospital mortality
o Length of stay
Diurnal variation in ALF
Frequency of Observations
Frequency of complete vital signs
o Is there a diurnal variation in Observations
o Is there a diurnal variation in admission to the ICU
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Variable N Median Lower Quartile
Upper Quartile
Age 48 62.50 51.50 74.00
APACHE 2 47 21.00 17.00 26.00
Sex Frequency Percent
Female 16 33.33
Male 32 66.67
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ALF (overall) frequency percent
NO 30 62.50
YES 18 37.50
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Those patients who had overall ALF had odds of dying in hospital
approximately 50% the odds of those who did not have overall ALF
Odds ratio= 0.47 95% CI: 0.07, 2.93 P=0.42
Patients with Afferent Limb Failure and ICU mortality
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Day/night frequency percent
Day & Night 8 44.44
Day 5 27.78
Night 5 27.78
Afferent Limb Failure and Observations made during the day compared to night
time
Odds ratio 0.93 CI 0.23;3.79 P=0.92
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Afferent limb failure and association with a complete set of observations
odds ratio 2.5 CI 0.5; 13.1 P=0.25
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24 patients (50%) were admitted following a cardiac arrest to ICU
None of these patients had afferent limb failure
The remaining patients were admitted to ICU following a RRT call and Consults
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Small sample size
Accuracy of survey data and completeness of data on the CRF
◦ ICU Length of stay
◦ D28 outcomes
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The prevalence of afferent limb failure amongst patients admitted to the ICU from the ward is high
This point prevalence study was unable to identify a diurnal variation in the incidence of afferent limb failure, completeness of observations and admission times to ICU and efferent limb failure
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Afferent limb failure is potentially avoidable
Reducing afferent limb failure may reduce unanticipated ICU admissions from the ward
a larger study is needed to definitively answer this topical and pertinent question f diurnal variation in the consequences of ALF and ELF
Period prevalence study across SA units ?
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Parameters PPP Chart review
Study type Prospective observational chart review on a day
Before and after RDR chart Data linkage (ICU, MET, Hospital administrative datasets
Settings Multicentre, ANZ ICU’s RAH
Patients Admissions to ICU from general ward
RRT call Unanticipated ICU adm Cardiac arrest
Measures In the 24 hrs prior to admission, occurrence of ALF, Discharge from a critical care area (ED/ICU/OT)
Frequency of, type and recorded patient observations
Time of day
Outcome ICU and Hospital mortality and LOS
ALF ELF Diurnal variation Unanticipated ICU admissions Hospital mortality
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◦ Add further knowledge towards diurnal variation and its consequences
◦ Evaluate the impact upon diurnal variation and RRT performance of newly implemented strategies for the detection and response to the deteriorating patient
◦ Make recommendations as to how such strategies may be improved in the future
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‘ No power on earth can
STOP an idea whose
time has come ‘
Victor Hugo