Clinical emergencies and outcomes in patients admitted to a surgical versus medical service

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  • Resuscitation 82 (2011) 415418

    Contents lists available at ScienceDirect

    Resuscitation

    journa l homepage: www.e lsev ier .com/ lo

    Clinical paper

    Clinical emergencies and outcomes in patients admedica

    Babak Sa ithWilliama Department o nia, Unb Department o , Unit

    a r t i c l

    Article history:Received 15 July 2010Received in revised form23 November 2010Accepted 8 December 2010

    Keywords:Rapid responsMedical emergMortalityCardiac arrest

    nse sspecic groups may increase the efcacy of these teams. The purpose of this study was to comparedifferences in triggers for RRS activation, interventions, and outcomes in patients onmedical and surgicalservices.Methods: A retrospective review RRS events was performed. The incidence of out of ICU cardiac arrestsand hospital mortality were compared 2 years prior to and following RRS implementation. Call trigger,

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    interventions, and disposition between medical and surgical patients were compared over a 15 monthperiod.Results: Out of ICU cardiac arrest was signicantly more prevalent in the medical group both beforeand after implementation of RRS. The out of ICU cardiac arrest rate decreased 32% in the surgical group(p=0.05) but hospital mortality did not change. Out of ICU cardiac arrest decreased 40% in the medicalgroup (p

  • 416 B. Sarani et al. / Resuscitation 82 (2011) 415418

    Table 1Criteria for rapid response activation.

    Respiratory Rate 32 breaths/min Oxygen Acute in Dyspne

    Cardiac Rate 110mmHgset chest painsara

    hange in mental statusousrolled bleedingy to contact house-ofcer after 2 pagesoncern/discretionn concern/discretion

    ly ill patients due to activities in the operating room. Astwo groups may manifest different signs of impendingss, experience varyingperiods of vulnerability, andmaynt urgent intervention(s) to re-establish homeostasis.ose of this study was to evaluate the impact of a RRSCU cardiac arrest and hospital mortality in hospital-s on themedical and surgical services. Additionally, weentify differences in triggers for RRS activation, inter-rformed and outcomes in hospitalized patients in thesetions. We hypothesized that outcomes, emergent clini-d interventions rendered by amedical emergency teamr based on the population served.

    s

    pital of the University of Pennsylvania implemented a2006. In July 2007, the team was split into a medicall arm. Members of the MET that are common to bothe: an intensive care unit (ICU) nurse, pharmacist, res-rapist, and a member of the patients primary residentg the day, an ICU attending physician or fellow from

    l or surgical intensive care unit respond to all calls fromtive services. Night and weekend MET activations arecovering residents from the respective services withnsivists who are available for consultation by phoneThe surgical MET (sMET) responds to all events thattients admitted to the departments of surgery, otorhi-gy, orthopaedics, neurological surgery, and obstetricslogy. The cardiac surgical service is excluded from thedicalMET (mMET) responds to all other patient groups.may activate the team, including non-clinical hospitalnd families/visitors. Formal activation criteria that are

    CardiaDischaCardiaCMI**

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  • B. Sarani et al. / Resuscitation 82 (2011) 415418 417

    Table 3Service-based incidence of cardiac arrest outside of the ICU before and after RRSimplementation.

    20042006(before MET)

    20062008(after MET)

    Medical serviceCardiac arrest on medicine service 156 102Discharges on medicine service 31,101 33,721Cardiac arrest/1000 discharges* 5.01 3.02Mortality* 4.29% 3.23%

    Surgical serviceCardiac arrest on surgical service 64 44Discharges on surgical service 37,769 37,992Cardiac arrest/1000 discharges** 1.69 1.16Mortality 1.21% 1.11%Cardiac arrest on other services 70 31

    * p

  • 418 B. Sarani et al. / Resuscitation 82 (2011) 415418

    arrest incidence and mortality in the medical cohort may be dueto greater or (hypothetically) earlier utilization of this resource bymedical than surgical services. In the period surrounding imple-mentation of the RRS, the Department of Medicine instituted aseries of didactic lectures focusing on patient safety and the roleof RRSs, potentially increasing utilization of the system. A previousstudy in our institution found thatmedical residentsmore stronglybelieved that RRS improve patient safety,17 and therefore may bemore likely to activate the system early. If this were the case, aprior observational studyhasdemonstrated that both cardiac arrestand mortality rates decrease as the time from instability to RRSactivation d

    Mortalitthat concomcontributedthe reductioThis conclu83% of surgiing that theto the ICURather, thepeutic interfor cardiac

    Anotherferences beevaluated.Asmall sampate adminisof surgical pdeterioratiouation by tis less likelferences innot nd a sopiate overing occurremeans of inand was ducian in themother thanmedical recevaluation oattention tocation betwvulnerable

    Althouggencies stranature, singitations thaadvocate astratied byences in tristudied in ogency team

    5. Conclus

    In concleffect of RR

    tality rateswhen stratied bymedical or surgical service.We foundthat the baseline incidence of out of ICU cardiac arrest and hospitalmortality were higher in patients on the medical service and thatimplementation of a RRS had a more pronounced impact on bothendpoints in the medical patient cohort (as opposed to the surgi-cal cohort). Despite this reduction, however, the medical servicecontinues to experience a higher incidence of cardiac arrest andmortality, and future studies are needed to determine the causefor these disproportionate effects and event rates. Furthermore, wefound that fewdifferences exist between the activation triggers andclinical interventions performed for the two cohorts. Future patient

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    scitat;48:1an K1;31:in RMospitat MDcts ofy from;324:itaMAical eml Saf Hotra Spoten2007s D, Bardiacer PJ,iac arrion 7ters B;296:ters Bonse sPS,

    ematiks SF,J Medlani Dcareulationni B, Smedicical cet F, Ments in2007ecreases.18

    y can be impacted upon in many ways and it is possibleitant changes in patient care and patient populationto the noted decrease; however, it is also likely thatn in cardiac arrest volume contributed to this nding.

    sion is supported by the nding that 72% ofmedical andcal patients survived to discharge, thereby demonstrat-RRS does not simply facilitate the transfer of patients

    where they ultimately cardiac arrest and possibly die.RRS ideally provides immediate diagnostic and thera-ventions that can rescue deteriorating patients at riskarrest and death.key nding of this study was that there were few dif-tween the medical and surgical clinical emergencieslthough the lackofdifferencemaybeabyproductofourle size, a few differences did exist as exemplied by opi-tration in the post-operative period. Fourteen percentatients evaluated by the sMET experienced physiologicn within 24h of sedation. Because the need for eval-he sMET was spread evenly over a 24h time period, ity that this is due to persistent anesthetic effect or dif-physician availability to direct care. Although we didingle consistent cause for deterioration in this group,dose accounted for over one-third of cases. This nd-d despite patient-controlled analgesia as our preferredtravenous narcotic administration outside of the ICU,e to high dosing of medication by the prescribing clini-ajorityof cases.Other causes, suchasdosingbypersonsthe patient him/herself, could not be assessed via theord. This further reinforces theneed for apost-operativef the patient by amember of the surgical team, nursingthe risk of over-sedation, and need for clear communi-een physician and nursing teamswhenmanaging thesepatients.h this is therst study to directly compare clinical emer-tiedbymedical andsurgical services, the retrospectivele institution, and small sample size create several lim-t should be explored in future studies. In particular, wemulti-institutional query of event rates and outcomeinpatient service. Given the lack of signicant differ-

    ggers and interventions performed in the two cohortsur institution, themerits of the two-armmedical emer-remain uncertain.

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    usion, this is the rst study to evaluate the differentialS implementation on cardiac arrest and hospital mor-

    safetythese dings shparticu

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    17. Saraof amed

    18. SebapatiMedesearch efforts should be aimed at evaluating whetherrdant benets are reproducible andwhether these nd-prompt novel RRS structuring to maximize benet invulnerable populations.

    interest statement

    ors do not have any nancial, personal, or other con-rest with any materials related to this work.

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    38790., Braithwaite RS,Mahidhara R, Stuart S, ForaidaM, SimmonsRL. Use ofergency team responses to reduce hospital cardiopulmonary arrests.

    ealth Care 2004;13:2514., DeVita MA, Simmons RL, Dew MA. Mature rapid response systemtially avoidable cardiopulmonary arrests in hospital. Qual Saf Health;16:2605.ellomo R, Bates S, et al. Long term effect of a medical emergency teamarrests in a teaching hospital. Crit Care 2005;9:R80815 [Epub 2005].Heit J, Roberts R. Implementation of a rapid response team decreasesest outside of the intensive care unit. J Trauma 2007;62:12237 [dis-8].D, Pham J, Pronovost PJ. Rapid response teams walk, dont run. JAMA16457.D, Pham JC, Hunt EA, Guallar E, Berenholtz S, Pronovost PJ. Rapidystems: a systematic review. Crit Care Med 2007;35:123843.Jain R, Nallmothu BK, Berg RA, Sasson C. Rapid response teams: ac review and meta-analysis. Arch Intern Med 2010;170:1826.Dobson A. Rening case-mix adjustment. The research evidence. N1987;317:67986.

    ,Moran JL, Sloggett A, Leeson RJ, Peake SL. Long-term survival of inten-and hospital patient cohorts compared with the general Australian: a relative survival approach. J Eval Clin Pract 2009;15:42535.onnad S, Bergey M, et al. Resident and RN perceptions of the impactal emergency team on education and patient safety in an academicnter. Crit Care Med 2009;37:30916.usthafa AA, Johnson D, et al. Effect of a rapid response system forshock on time to treatment and mortality during 5 years. Crit Care

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    Clinical emergencies and outcomes in patients admitted to a surgical versus medical serviceIntroductionMethodsResultsDiscussionConclusionConflict of interest statementReferences

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