Rapid response team calls to obstetric patients in a busy quaternary maternity hospital.

AIMS: There is limited published information regarding intensive care unit (ICU) led rapid response team (RRT) calls to obstetric patients. We examined the characteristics of RRT calls to obstetric patients at a tertiary teaching hospital. METHODS: Details of calls to pregnant and postpartum patients between October 2010 and June 2014 were obtained from the hospital RRT database. Each was retrospectively examined for data on patient demographics, call trigger, interventions and outcomes. Local obstetric-specific escalation practices (Code Pink/Green) for obstetrical concerns (not mandating maternal instability/involvement of the ICU team), were excluded. RESULTS: There were 106 RRT calls logged during 43 months, and 97 had data available for analysis. Women currently pregnant accounted for 33% of calls and postpartum women 67%, with nearly half of these occurring more than 24 h post-delivery. The most common reason (29% of calls) for calling the RRT was hypotension, followed by 'concern about patient' (21%) and decreased Glasgow Coma Score (GCS) (17%). An escalation in the environment of care occurred after 32% of calls, with approximately 11% of calls necessitating direct ICU admission. Twenty-three percent of all calls were to women who had an ICU admission during their hospital stay. Among the cohort who received an RRT call, there was one maternal and three neonatal deaths. CONCLUSION: At our institution generic RRT calls are called to both pregnant and postpartum women, and frequently result in an escalation in the care environment. Further study is required to understand better the specific needs of this important population.

Why don't hospital staff activate the rapid response system (RRS)? How frequently is it needed and can the process be improved?

BACKGROUND: The rapid response system (RRS) is a process of accessing help for health professionals when a patient under their care becomes severely ill. Recent studies and meta-analyses show a reduction in cardiac arrests by a one-third in hospitals that have introduced a rapid response team, although the effect on overall hospital mortality is less clear. It has been suggested that the difficulty in establishing the benefit of the RRS has been due to implementation difficulties and a reluctance of clinical staff to call for additional help. This assertion is supported by the observation that patients continue to have poor outcomes in our institution despite an established RRS being available. In many of these cases, the patient is often unstable for many hours or days without help being sought. These poor outcomes are often discovered in an ad hoc fashion, and the real numbers of patients who may benefit from the RRS is currently unknown. This study has been designed to answer three key questions to improve the RRS: estimate the scope of the problem in terms of numbers of patients requiring activation of the RRS; determine cognitive and socio-cultural barriers to calling the Rapid Response Team; and design and implement solutions to address the effectiveness of the RRS. METHODS: The extent of the problem will be addressed by establishing the incidence of patients who meet abnormal physiological criteria, as determined from a point prevalence investigation conducted across four hospitals. Follow-up review will determine if these patients subsequently require intensive care unit or critical care intervention. This study will be grounded in both cognitive and socio-cultural theoretical frameworks. The cognitive model of situation awareness will be used to determine psychological barriers to RRS activation, and socio-cultural models of interprofessional practice will be triangulated to inform further investigation. A multi-modal approach will be taken using reviews of clinical notes, structured interviews, and focus groups. Interventions will be designed using a human factors analysis approach. Ongoing surveillance of adverse outcomes and surveys of the safety climate in the clinical areas piloting the interventions will occur before and after implementation.

Acute stress ulceration prophylaxis: point prevalence surveys in intensive care units in Victoria, 1997 and 2005.

OBJECTIVE: To assess current practice in acute stress ulceration (ASU) prophylaxis in adult intensive care units in Victoria, Australia, in 1997 and 2005. METHODS: Point prevalence surveys using a structured telephone questionnaire of ASU prophylaxis practices were performed in adult ICUs in Victoria on 11 November 1997 and 13 April 2005. RESULTS: All Victorian ICUs identified on each study day participated, comprising 30 ICUs in 1997 and 35 ICUs in 2005. Presence of a clinical protocol or guideline for ASU prophylaxis increased significantly from 23% in 1997 to 54% in 2005 (P = 0.01). Overall provision of ASU prophylaxis to ICU patients also increased significantly from 67% in 1997 to 86% in 2005 (P < 0.001). H2-receptor antagonists were the preferred first-line agent in at least 50% of ICUs, and were also the most commonly used agents in both point prevalence surveys, with no change over 8 years. Use of proton-pump inhibitors increased significantly, both as first-line ASU prophylaxis agents and in clinical use, from 13% in 1997 to 45% in 2005 (P < 0.001). Use of sucralfate and antacids for ASU prophylaxis ceased between 1997 and 2005. CONCLUSIONS: Use of ASU prophylaxis for patients admitted to Victorian ICUs increased significantly from 1997 to 2005, with an associated increase in the presence of protocols or guidelines for ASU prophylaxis. Although agents currently used for ASU prophylaxis in Victorian ICUs are consistent with available evidence, we are concerned that ASU prophylaxis is given to all patients admitted to the ICU rather than targeted to patients in high-risk categories.