Elderly patients are at high risk of night-time admission to the intensive care unit following a rapid response team call.

Previous studies have shown that elderly patients (age ≥65 years) are less likely to be admitted to the intensive care unit following a rapid response team call and have high hospital mortality rates. This study has shown that elderly patients have a significantly higher probability of being admitted to an intensive care unit following a rapid response team call at night than during the day. However, at no time are they at greater risk than younger patients of incomplete vital sign recording, a failure to escalate care for acute deterioration or mortality.

A newly designed observation and response chart's effect upon adverse inpatient outcomes and rapid response team activity.

BACKGROUND: Adverse inpatient events may diminish with earlier response to clinical deterioration. Observation and response charts with a tiered escalation response are recommended for use. AIMS: To examine the impact of an observation and response chart and altered calling criteria on rapid response team (RRT) calls, cardiac arrests and intensive care unit (ICU) admissions from the ward and hospital deaths. METHODS: Linked administrative and clinical data from an Australian, adult tertiary hospital for August 2007 to June 2013 (pre-chart) and July 2013 to December 2014 (post-chart) and analysed using interrupted time series analysis. RESULTS: Pre-chart RRT calls were increasing by 1.7 calls per 10 000 hospital admissions per month, whilst ICU admissions from the ward, deaths and cardiac arrests were decreasing by 0.3, 0.25 and 0.079 per 10 000 admissions per month respectively. Immediately upon chart introduction, the RRT call rate increased by 82% (66-98% CI; P < 0.01), the ward admissions to ICU rate increased by 41% (14-67% CI; P < 0.01) and the rates of deaths and cardiac arrests did not change. In the post chart period, both the pre-chart increasing trend in the rate of RRT and decreasing trend in the rate of ICU admissions changed significantly to become constant. The pre chart trends in the cardiac arrest rate and hospital mortality did not change. CONCLUSION: Observation and response charts increased RRT and ICU workload without improving cardiac arrest rate or mortality. Future chart evaluation should identify features beneficial to patient outcomes and refine those that consume critical care resources that are not associated with improved patient outcomes.

Documentation of limitation of medical therapy at the time of a rapid response team call.

OBJECTIVES: The aims of the present study were to: (1) describe the documentation process of limitation of medical therapy (LMT) orders at the time of a rapid response team (RRT) call; and (2) compare documented LMT orders not associated with an RRT call (control, Group 1) with LMT orders documented at the time of an RRT call (Group 2). METHODS: A descriptive study, over a 6-month period (February-August 2011), involving the review of the medical records of patients prospectively identified as either Group 1 or Group 2. RESULTS: There were 994 RRT calls; of these, 50 patients (5%) had an LMT order documented by the RRT. A cardiac arrest was the trigger for the RRT for six patients (12%). Patients in Group 1 (n=50) and Group 2 were of similar median age (80.5 vs 78.5 years; P=0.30), LMTs were recorded at a similar time of day (15:30 vs 15:55 hours; P=0.52) and day of the week (weekend: 32% vs 35%; P=0.72). Comparing group 2 with Group 1, the RRT was less likely to document a not-for-resuscitation (NFR; 31 (62%) vs 49 (98%); P<0.01) or a not-for-ICU (NFICU; 18 (36%) vs 41 (82%); P<0.01) order, but more likely to document a not-for-RRT call (NFRRT; 31 (62%) vs 22 (44%); P=0.04) and modified RRT calling criteria (MRRT; 4 (8%) vs 0 (0%); P=0.04) orders. For Group 2 compared with Group 1 orders, involvement of the patient in the decision making process (9 (18%) vs 25 (50%); P<0.01) or the next of kin (29 (58%) vs 45 (90%); P<0.01) was documented less often. CONCLUSIONS: Documentation of LMT orders at the time of an RRT call is less likely to include documented involvement of patients or their next of kin, and is more likely to be an NFRRT or MRRT order. These findings have implications for overall clinical governance. What is known about the topic? RRT are not infrequently involved in documenting LMT orders. What does this paper add? This is the first study in Australasia to look into the timing and circumstances surrounding the issuing of a NFR order during an RRT call. The study findings clarify the type of LMT orders documented by RRT and to what extent patients, their carers and senior medical staff are involved. What are the implications for practitioners? Our findings indicate that, in the setting of a rapid response system, there is a need to consider beyond the narrow interpretation of the NFR order, when a NFRRT may also be appropriate. This will require standardisation of such nomenclature, and training and education of those involved in documenting and interpreting such orders. Equally, it will require a different approach to the discussion with patients and their carers as to what the implications of an NFRRT order are. The findings also have significant implications as to the senior medical oversight of LMT, in particular for RRT, for whom it is their first encounter with such patients. Finally, the findings suggest that consideration be given to better delineating the documentation of the role of nursing staff when setting LMT orders.

Utility and assessment of non-technical skills for rapid response systems and medical emergency teams.

Efforts are ongoing to improve outcomes from cardiac arrest and medical emergencies. A promising quality improvement modality is use of non-technical skills (NTS) that aim to address human factors through improvements in performance of leadership, communication, situational awareness and decision-making. Originating in the airline industry, NTS training has been successfully introduced into anaesthesia, surgery, emergency medicine and other acute medical specialities. Some aspects of NTS have already achieved acceptance for cardiac arrest teams. Leadership skills are emphasised in advanced life support training and have shown favourable results when employed in simulated and clinical resuscitation scenarios. The application of NTS in medical emergency teams as part of a rapid response system attending medical emergencies is less certain; however, observations of simulations have also shown promise. This review highlights the potential benefits of NTS competency for cardiac arrest teams and, more importantly, medical emergency teams because of the diversity of clinical scenarios encountered. Discussion covers methods to assess and refine NTS and NTS training to optimise performance in the clinical environment. Increasing attention should be applied to yielding meaningful patient and organisational outcomes from use of NTS. Similarly, implementation of any training course should receive appropriate scrutiny to refine team and institutional performance.

Cardiac pacing in patients with a cervical spinal cord injury.

STUDY DESIGN: Retrospective medical record review. OBJECTIVES: To compare patients, admitted to an intensive care unit (ICU) with an acute cervical spinal cord injury (SCI) and documented motor deficit, who did, with those who did not, require a cardiac pacemaker. SETTING: South Australian Tertiary Referral Intensive Care and Spinal Injury Unit. METHODS: Retrospective medical record review and data set linkage. RESULTS: From 1995 to 2007, 465 patients sustained a cervical SCI. Of these, 30 (6.5%) were admitted to ICU with a clinically assessable motor deficit and 3 (0.6% of all patients, or 10% of those admitted to ICU) required a cardiac pacemaker. All three patients had a cervical SCI, C5 (American Spinal Injury Association A) tetraplegia, and required invasive mechanical respiratory and inotropic support and a tracheostomy for weaning. Two patients (66%) were discharged alive to rehabilitation. Patients requiring a pacemaker had bradycardic episodes over a longer period (11 vs 4 days, P=0.01), a trend towards a later onset of bradycardia (8 vs 1.5 days, P=0.05) and a longer ICU length of stay (37 vs 10 days, P=0.02). CONCLUSION: Patients with a cervical SCI requiring a cardiac pacemaker are characterized by a higher level of SCI injury and motor loss, require mechanical respiratory and inotropic support, a tracheostomy to wean, and bradycardic episodes of a later onset and over a longer period of time. These findings suggest that such patients should be managed at hospitals with specialized acute spinal injury, intensive care and cardiac pacemaker services.

Awareness in retrieval medicine.

Awareness is the spontaneous recall of an event(s) that occurred during general anaesthesia and surgery. The incidence of awareness is approximately 0.2% of cases where neuromuscular blockers are used and half that where they are omitted. The majority of data relating to awareness is from anaesthetic practice. We report a case of awareness associated with an out-of-hospital transportation of a critically ill patient requiring a medical escort (retrieval). We discuss the risk factors associated with awareness during retrieval, in particular the trend toward excessive administration of neuromuscular blockers, and the unique challenges for the prevention of awareness within the retrieval environment.

Incidents during out-of-hospital patient transportation.

Out-of-hospital patient transportation (retrieval) of critically ill patients occurs within highly complex environments. Adverse events are not uncommon. Incident monitoring provides a means to better understand such events. The aim of this study was to characterize incidents occurring during retrieval to provide a basis for developing corrective strategies. Four organizations contributed 125 reports, documenting 272 incidents; 91% of forms documented incidents as preventable. Incidents related to equipment (37%), patient care (26%), transport operations (11%), interpersonal communication (9%), planning or preparation (9%), retrieval staff (7%) and tasking (2%). Incidents occurred during patient transport to the receiving facility (26%), at patient origin (26%), during patient loading (20%), at the retrieval service base (18%) and receiving facility (9%). Contributing factors were system-based for 54% and human-based for 42%. Haste (7.5%), equipment malfunctioning (7.2%) or missing (5.5%), failure to check (5.8%) and pressure to proceed (5.2%) were the most frequent contributing factors. Harm was documented in 59% of incidents with one death. Minimizing factors were good crew skills/teamwork (42%), checking equipment (17%) and patient (8%), patient monitors (15%), good luck (14%) and good interpersonal communication (4%). Incident monitoring provides sufficient insight into retrieval incidents to be a useful quality improvement tool for retrieval services. Information gathered suggested improvements in retrieval equipment design and use of alternative power sources, the use of pro formae for equipment checking, patient assessment, preparation for transportation and information transfer Lessons from incidents in other areas applicable to retrieval should be linked for analysis with retrieval incidents.

ARDS with severe hypoxia--aeromedical transportation during prone ventilation.

Severe hypoxia, despite maximal conventional respiratory support, is one of the few remaining limitations to aeromedical transportation. A case of a 35-year-old female, who was referred 36 hours following major trauma for transfer by air to a tertiary center, is presented. At the time of referral the PaO2/FiO2 ratio was 48. Usual manoeuvres to improve oxygenation had only minimal impact. The patient was turned and subsequently transported prone with resultant improvement in PaO2/FiO2 ratio to 260. There were no patient- or transport-related adverse events. The implication of prone positioning during aeromedical transportation is discussed.

The Medical Emergency Team: 12 month analysis of reasons for activation, immediate outcome and not-for-resuscitation orders.

OBJECTIVE: To describe the reasons for, and immediate outcome following Medical Emergency Team (MET) activation. METHODS: Retrospective analysis of MET calls in 1998. RESULTS: There were 713 MET calls to 559 in-patients. Of the 559 patients 252 (45%) were admitted to ICU and 49 (6.9%) died during the MET response. The three commonest criteria for calling the MET were a fall in GCS>2 (n=155); a systolic blood pressure<90 mmHg (n=142) and a respiratory rate>35 (n=109). Cardiac arrests accounted for 61 calls and had an immediate mortality of 59%. The most common MET criterion associated with admission to ICU was a respiratory rate >35. Of patients who received MET calls based only on the 'worried' criterion 16% were admitted to ICU. The MET felt that a not-for-resuscitation order would have been appropriate in 130 cases (23%). NFR orders were documented during 27 of the MET calls. CONCLUSIONS: The MET system provides objective and subjective criteria by which medical and nursing staff can identify patients who become acutely unwell. A high proportion of these patients will require admission to Intensive Care. The MET system also provides the opportunity to identify patients for whom an NFR order should be considered.

Clinical features, patterns of referral and out of hospital transport events for patients with suspected isolated spinal injury.

BACKGROUND: Prehospital diagnostic accuracy and risks of transportation associated neurological deterioration for patients with spinal injury remain imprecise. METHODS: Retrospective review of medical records for patients with suspected spinal injury assessed and escorted by medically staffed team. RESULTS: One hundred and ninety six patients had follow up for spinal injury, 61% with actual injury. Of the 196 patients, 93% involved helicopter transport, 3.5% road vehicle and 3.5% fixed wing transports. Fifty one percent were interhospital transfers. Medical team's scene diagnostic accuracy of spinal injury was 31%. Scene medical interventions were those consistent with current paramedical skills. Of interhospital transferred patients, 19% had no injury. Cervical injuries as part of mixed injuries were the most often missed injuries. Abnormal neurological findings occurred equally amongst patients with and without spinal injury. Transport related incidents were documented for 15%. Interhospital transport patient related incidents occurred for 12% helicopter and 36% road vehicle transports (P=0.094). No transport related neurological injury or other morbidity was documented. CONCLUSION: Prehospital diagnosis of spinal injury, even by medical teams remains imprecise. Choice of helicopter transport, based purely upon the suspected presence of spinal injury could not be supported.

Routine blood test ordering for patients in intensive care.

Current practice is for a number of blood tests to be routinely performed on intensive care unit (ICU) patients. A survey of routine blood testing amongst ICUs in Australia and New Zealand was conducted. Ninety-six ICUs completed the survey form. Blood electrolytes, liver function, arterial blood gases and full blood count were the most frequently ordered tests. Routine blood testing was not practised in 12.6% of ICUs. The presence or absence of written guidelines did not influence the frequency of the most commonly performed routine blood tests. Clinical and operational factors specific to each ICU appear to impact on such blood tests and guidelines for their use.

Patient referral and transportation to a regional tertiary ICU: patient demographics, severity of illness and outcome comparison with non-transported patients.

A descriptive analysis and comparison of critically ill transported patients with non-transported patients will assist in selecting the appropriate referral and transportation process and subsequent incorporation into the critical care services of receiving hospitals. A retrospective review of transported and non-transported patients admitted to the same Intensive Care Unit was conducted. Patient demographics, disease categories, source of admission to ICU, APACHE II scores, predicted and actual hospital mortality, hospital and ICU length of stay were examined. Of all ICU admissions, 16% were transported. Transported patients had a different case mix, significantly higher severity of illness measures, mortality and length of ICU stay. Observed mortality of transported patients with sepsis, gastrointestinal disease or bleeding, intracranial haemorrhage and post respiratory arrest was less than predicted whilst those with neurological disease, post cardiac arrest and overdose had a higher than predicted mortality.

The utility of open lung biopsy in patients requiring mechanical ventilation.

STUDY OBJECTIVE: To determine the diagnostic yield, morbidity, mortality, and therapeutic impact of the open lung biopsy in patients requiring mechanical ventilation. DESIGN: Retrospective review of patient records. SETTING: Tertiary ICU. PATIENTS: Patients with respiratory failure and diffuse pulmonary infiltrates requiring mechanical ventilation, leading up to or following an open lung biopsy. MEASUREMENTS: Information included patient demographics, organ failure, microbiological results before open-lung biopsy, Pao,/fraction of inspired oxygen values before and after biopsy, immunosuppression, timing of open lung biopsy, biopsy-related morbidity and mortality, duration of after-biopsy ventilation, open lung biopsy results, biopsy-initiated treatment alterations, and hospital outcome. RESULTS: Twenty-four patients were identified. The mean age was 48.9 years (confidence interval, 42.1 to 55.7). Twenty-one percent had respiratory infections diagnosed before open lung biopsy but not confirmed by open lung biopsy. Intraoperative complications occurred in 21% of patients, and postoperative complications occurred in 17% of patients. Operative mortality was 8.4%. The specific and the nonspecific diagnostic rates were both 46%. Lung histology was normal in two patients; one of those patients had a false-negative finding. No patient with respiratory failure plus 2 2 other organ failures survived. Alteration of therapy did not differentiate between survivors. Open lung biopsy-guided alteration of therapy directly benefited 39%, and withdrawal was possible in 8.4% of the patients. CONCLUSIONS: The multiple organ dysfunction score should be considered when deciding the relative risk of performing an open lung biopsy, which in this group of patients provided a specific diagnosis in 46% and carried a mortality rate of 8.4%.

Surgical emphysema following percutaneous tracheostomy.

We report two patients in whom a Portex GWDFT was complicated by surgical emphysema. Subsequent examination revealed posterior tracheal wall tears in these patients. The exact aetiology of these tears is unknown, although the tracheostomy tube introducer may have been implicated. We suggest a management plan for this complication.

Ethnicity and proficiency in English as factors affecting community cardiopulmonary resuscitation (CPR) class attendance.

Communities with a high prevalence of cardiopulmonary resuscitation (CPR) knowledge have a greater out of hospital cardiac arrest survival rate. Within metropolitan Adelaide, 12.4% of the community is from a non-English speaking country and 20.3% of these have a poor proficiency in English. The purpose of this study was to examine the effect of ethnicity (specifically, Southern European born (SEB) and South East Asian born (SEAB)) and a poor proficiency in English (PENG) on CPR skill acquisition. Population Census postcode data were compared to postcode student CPR classes attendance. Results showed a negative correlation between SEB (-0.44), SEAB (-0.36), PENG (-0.42) with CPR class attendance. Postcodes with a less than community average of SEB, SEAB and PENG had an average proportion of CPR class attendees of 2.64% (C.I. 2.43, 2.85), 2.54% (C.I. 2.35, 2.73) and 2.65% (C.I. 2.35, 2.73), respectively, whilst those postcodes with a greater than community average had 2.03% (C.I. 1.90, 2.16), 2.07% (C.I. 1.90, 2.24) and 2.04% (C.I. 1.90, 2.18) proportion of CPR class attendees. The difference for each category was significant to a P < 0.001. This study points to SEB, SEAB, and PENG as factors associated with fewer CPR class attendances. Future CPR classes should specifically target and cater for ethnic groups from non-English speaking countries with poor English skills if CPR skills are to be widely disseminated throughout the entire community.

An analysis of demand for first-aid care at a major public event.

INTRODUCTION: First aid is the initial care of the ill or injured. It aims to preserve and protect life, prevent further injury or deterioration of illness, and help promote recovery. At major public events, there is a large gathering of people, physical spectacles, and equipment within a concentrated area, where organized first-aid care is provided. OBJECTIVE: To analyze the demand for primary medical care at a public event by identifying the patients and initial symptoms that may predict that demand, and to use such information to improve the efficiency and delivery of medical care. METHODS: A questionnaire was completed by St. John Operations Branch personnel after each patient consultation and a retrospective analysis of the data was conducted. RESULTS: A total of 1,276 questionnaires were returned. Mean patient presentation rate (PPR) was 1.9 +/- 0.47 per 1,000 show attendees. This correlated best with the maximum daily temperature (r = 0.715, p <0.02) and show day (r = 0.615, p <0.05). There was poor correlation with daily attendance (r = -0.235, p >0.54). Mean presentation time was 15:13 h. Of those whose gender was recorded, 58.4% were females, and 41.6% were males. The most frequent age group was 13 to 20 years. The nature and number of initial symptoms are listed. Basic first-aid skills were used for 96.7% of symptoms; 2.4% of patients were referred to the hospital. CONCLUSIONS: Temperature and show day significantly contributed to variability of PPR. These factors, together with an estimated PPR and predicted attendance, can be used to forecast demand. Most cases required only basic first-aid skills. Guidelines are suggested for management by nonmedical personnel. A medical officer's role is not reliably defined, but involvement in consultation is suggested.