Change of target temperature from 36 °C to strict fever avoidance only in comatose cardiac arrest survivors - A before and after study.

AIM: The guidelines on temperature control for comatose cardiac arrest survivors were recently changed from recommending targeted temperature management (32-36 °C) to fever control (≤37.7 °C). We investigated the effect of implementing a strict fever control strategy on prevalence of fever, protocol adherence, and patient outcome in a Finnish tertiary academic hospital. METHODS: Comatose cardiac arrest survivors treated with either mild device-controlled therapeutic hypothermia (≤36 °C, years 2020-2021) or strict fever control (≤37 °C, year 2022) for the first 36 h were included in this before-after cohort study. Good neurological outcome was defined as a cerebral performance category score of 1-2. RESULTS: The cohort consisted of 120 patients (≤36 °C group n = 77, ≤37 °C group n = 43). Cardiac arrest characteristics, severity of illness scores, and intensive care management including oxygenation, ventilation, blood pressure management and lactate remained similar between the groups. The median highest temperatures for the 36 h sedation period were 36.3 °C (≤36 °C group) vs. 37.2 °C (≤37 °C group) (p < 0.001). Time of the 36 h sedation period spent >37.7 °C was 0.90% vs. 1.1% (p = 0.496). External cooling devices were used in 90% vs. 44% of the patients (p < 0.001). Good neurological outcome at 30 days was similar between the groups (47% vs. 44%, p = 0.787). In multivariable model the ≤37 °C strategy was not associated with any change in outcome (OR 0.88, 95% CI 0.33-2.3). CONCLUSIONS: The implementation strict fever control strategy was feasible and did not result in increased prevalence of fever, poorer protocol adherence, or worse patient outcomes. Most patients in the fever control group did not require external cooling.

Trends in the national early warning score are associated with subsequent mortality - A prospective three-centre observational study with 11,331 general ward patients.

Aim: To investigate whether trends in the NEWS values are associated with patient mortality in general ward patients. Methods: A one-year prospective observational study in three hospitals in Finland. All data on patients' NEWS values during the first three days of general ward admissions were collected. The linear regression model was used to investigate the association of the NEWS trajectories with subsequent mortality. We used three outcome measures: 4-7-day, 4-14-day and 4-21-day mortality rates after the 0-3 days of initial hospitalization, respectively. Results: The study cohort consisted of 11,331 general ward patients. The non-survivors had higher initial NEWS score values in all outcome categories (all p < 0.001). The non-survivors had a rising trajectory in their NEWS values in all the outcome categories, whereas the survivors had a downward trajectory in their NEWS values in all outcome categories (data presented as first- and third-day's median values): an increase from 5.0 to 6.0 vs. a decrease from 1.5 to 1.0 (4-7-day non-survivors vs. survivors), an increase from 4.0 to 5.0 vs. a decrease from 1.5 to 1.0 (4-14-day non-survivors vs. survivors) and an increase from 4.0 to 5.0 vs. a decrease from 1.5 to 1.0 (4-21-day non-survivors vs. survivors). In the linear regression model, these differences in trends were statistically significant in all the outcome categories (p < 0.05). Conclusion: The NEWS score trajectory during the first three days of general ward admission is associated with patient outcome. Further studies are warranted to determine specific thresholds for clinically relevant changes in the NEWS trajectories.

Ability of the National Early Warning Score and its respiratory and haemodynamic subcomponents to predict short-term mortality on general wards: a prospective three-centre observational study in Finland.

OBJECTIVES: To validate the ability of the National Early Warning Score (NEWS) to predict short-term mortality on hospital wards, with a special reference to the NEWS's respiratory and haemodynamic subcomponents. DESIGN: A large, 1-year, prospective, observational three-centre study. First measured vital sign datasets on general wards were prospectively collected using a mobile solution system during routine patient care. Area under receiver operator characteristic curves were constructed, and comparisons between ROC curves were conducted with Delong's test for two correlated ROC curves. SETTING: One university hospital and two regional hospitals in Finland. PARTICIPANTS: All 19 001 adult patients admitted to 45 general wards in the three hospitals over the 1-year study period. After excluding 102/19 001 patients (0.53%) with data on some vital signs missing, the final cohort consisted of 18 889 patients with full datasets. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measure was 1-day mortality and secondary outcomes were 2-day and 30-day mortality rates. RESULTS: Patients' median age was 70 years, 51% were male and 31% had a surgical reason for admission. The 1-day mortality was 0.36% and the 30-day mortality was 3.9%. The NEWS discriminated 1-day non-survivors with excellent accuracy (AUROC 0.91, 95% CI 0.87 to 0.95) and 30-day mortality with acceptable accuracy (0.75, 95% CI 0.73 to 0.77). The NEWS's respiratory rate component discriminated 1-day non-survivors better (0.78, 95% CI 0.72 to 0.84) as compared with the oxygen saturation (0.66, 95% CI 0.59 to 0.73), systolic blood pressure (0.65, 95% CI 0.59 to 0.72) and heart rate (0.67, 95% CI 0.61 to 0.74) subcomponents (p<0.01 in all ROC comparisons). As with the total NEWS, the discriminative performance of the individual score components decreased substantially for the 30-day mortality. CONCLUSIONS: NEWS discriminated general ward patients at risk for acute death with excellent statistical accuracy. The respiratory rate component is especially strongly associated with short-term mortality. TRIAL REGISTRATION NUMBER: NCT04055350.

Advising and limiting medical treatment during phone consultation: a prospective multicentre study in HEMS settings.

BACKGROUND: We investigated paramedic-initiated consultation calls and advice given via telephone by Helicopter Emergency Medical Service (HEMS) physicians focusing on limitations of medical treatment (LOMT). METHODS: A prospective multicentre study was conducted on four physician-staffed HEMS bases in Finland during a 6-month period. RESULTS: Of all 6115 (mean 8.4/base/day) paramedic-initiated consultation calls, 478 (7.8%) consultation calls involving LOMTs were included: 268 (4.4%) cases with a pre-existing LOMT, 165 (2.7%) cases where the HEMS physician issued a new LOMT and 45 (0.7%) cases where the patient already had an LOMT and the physician further issued another LOMT. The most common new limitation was a do-not-attempt cardiopulmonary resuscitation (DNACPR) order (n = 122/210, 58%) and/or 'not eligible for intensive care' (n = 96/210, 46%). In 49 (23%) calls involving a new LOMT, termination of an initiated resuscitation attempt was the only newly issued LOMT. The most frequent reasons for issuing an LOMT during consultations were futility of the overall situation (71%), poor baseline functional status (56%), multiple/severe comorbidities (56%) and old age (49%). In the majority of cases (65%) in which the HEMS physician issued a new LOMT for a patient without any pre-existing LOMT, the physician felt that the patient should have already had an LOMT. The patient was in a health care facility or a nursing home in half (49%) of the calls that involved issuing a new LOMT. Access to medical records was reported in 29% of the calls in which a new LOMT was issued by an HEMS physician. CONCLUSION: Consultation calls with HEMS physicians involving patients with LOMT decisions were common. HEMS physicians considered end-of-life questions on the phone and issued a new LOMT in 3.4% of consultations calls. These decisions mainly concerned termination of resuscitation, DNACPR, intubation and initiation of intensive care.

Rapid response team nurses' attitudes and barriers to the rapid response system: A multicentre survey.

BACKGROUND: Despite wide implementation of rapid response teams (RRTs), no published data exist on RRT nurses' attitudes and barriers to the rapid response system (RRS). METHODS: We piloted a 5-point Likert-type scale questionnaire among all Finnish university hospitals' RRT nurses with optional open-ended comments. The impact of more frequent RRT participation was further investigated. RESULTS: The response rate was 46% (n = 176/379, 34%-93% between hospitals). The respondents median experience on a RRT was three years (0.8-5) and median participation was two (1-5) RRT activations per month. Over 90% of the RRT nurses felt that RRS prevented cardiac arrests and improved patient safety. Nurses with five or more RRT activations/month believed their critical care skills had improved through these duties (94% vs 71%, P = .001), considered their RRT work meaningful (94% vs 76%, P = .005) and wanted to continue as RRT nurses (91% vs 74%, P = .015) more often than nurses with less than five RRT activations/month. In addition to the infrequent RRT participation, further negative experiences with RRS among the RRT nurses included feeling overworked (68%) or undercompensated (94%) for the RRT duties and conflicts between RRT and ward doctors (25%). CONCLUSION: RRT nurses consider their work important and believe it fosters improved critical care skills; these beliefs are emphasized among those with more frequent RRT participation. Infrequent RRT participation, feeling overworked and/or undercompensated and conflicts between RRT and ward doctors may present barriers for successful RRS among RRT nurses.

Afferent limb failure revisited - A retrospective, international, multicentre, cohort study of delayed rapid response team calls.

AIM: The efficiency of rapid response teams (RRTs) is decreased by delays in activation of RRT (afferent limb failure, ALF). We categorized ALF by organ systems and investigated correlations with the vital signs subsequently observed by the RRT and associations with mortality. METHODS: International, multicentre, retrospective cohort study including adult RRT patients without treatment limitations in 2017-2018 in one Australian and two Finnish tertiary hospitals. RESULTS: A total of 5,568 RRT patients' first RRT activations were included. In 927 patients (17%) ALF was present within 4 h before the RRT call, most commonly for respiratory criteria (419 patients, 7.5%). In 3516 patients (63%) overall, and in 756 (82%) of ALF patients, the RRT observed abnormal vital signs upon arrival. The organ-specific ALF corresponded to the RRT observations in 52% of cases for respiratory criteria, in 60% for haemodynamic criteria, in 55% for neurological criteria and in 52% of cases for multiple organ criteria. Only ALF for respiratory criteria was associated with increased hospital mortality (OR 1.71, 95% CI 1.29-2.27), whereas all, except haemodynamic, criteria at the time of RRT review were associated with increased hospital mortality. CONCLUSIONS: Vital signs were rarely normal upon RRT arrival in patients with ALF, while organ-specific ALF corresponded to subsequent RRT observations in just over half of cases. Our results suggest that systems mandating timely responses to abnormal respiratory criteria in particular may have potential to improve deteriorating patient outcomes.

Limiting treatment in pre-hospital care: A prospective, observational multicentre study.

BACKGROUND: Data are scarce on the withdrawal of life-sustaining therapies and limitation of care orders (LCOs) during physician-staffed Helicopter Emergency Medical Service (HEMS) missions. We investigated LCOs and the quality of information available when physicians made treatment decisions in pre-hospital care. METHODS: A prospective, nationwide, multicentre study including all Finnish physician-staffed HEMS bases during a 6-month study period. All HEMS missions where a patient had pre-existing LCOs and/or a new LCO were included. RESULTS: There were 335 missions with LCOs, which represented 5.7% of all HEMS missions (n = 5895). There were 181 missions with pre-existing LCOs, and a total of 170 new LCOs were issued. Usually, the pre-existing LCO was a do not attempt cardiopulmonary resuscitation order only (n = 133, 74%). The most frequent new LCO was 'termination of cardiopulmonary resuscitation' only (n = 61, 36%), while 'no intensive care' combined with some other LCO was almost as common (n = 54, 32%). When issuing a new LCO for patients who did not have any preceding LCOs (n = 153), in every other (49%) case the physicians thought that the patient should have already had an LCO. When the physician made treatment decisions, patients' background information from on-scene paramedics was available in 260 (78%) of the LCO missions, while patients' medical records were available in 67 (20%) of the missions. CONCLUSION: Making LCOs or treating patients with pre-existing LCOs is an integral part of HEMS physicians' work, with every twentieth mission involving LCO patients. The new LCOs mostly concerned withholding or withdrawal of cardiopulmonary resuscitation and intensive care.

In-hospital cardiac arrest in hospitals with mature rapid response systems - a multicentre, retrospective cohort study.

AIM: To investigate in-hospital cardiac arrests (IHCAs) according to the Ustein template in hospitals with mature systems utilizing rapid response teams (RRTs), with a special reference to preceding RRT factors and factors associated with a favourable neurological outcome (cerebral performance category (CPC) 1-2) at hospital discharge. METHODS: Multicentre, retrospective cohort study between 2017-2018 including two Finnish and one Australian university affiliated tertiary hospitals. RESULTS: A total 309 IHCAs occurred with an incidence of 0.78 arrests per 1000 hospital admissions. The median age of the patients was 72 years, 63% were male and 73% had previously lived a fully independent life with a median Charlson comorbidity index of two. Before the IHCA, 16% of the patients had been reviewed by RRTs and 26% of the patients fulfilled RRT activation criteria in the preceding 8 h of the IHCA. Return of spontaneous circulation was achieved in 53% of the patients and 28% were discharged from hospital with CPC 1-2. In a multivariable model, younger age, no pre-arrest RRT criteria, arrest in normal work hours, witnessed arrest and shockable initial rhythm were independently associated with CPC 1-2 at hospital discharge. CONCLUSIONS: In hospitals with mature rapid response systems most IHCA patients live a fully independent life with low burden of comorbid diseases before their hospital admission, the IHCA incidence is low and outcome better than traditionally believed. Deterioration before IHCA is present in a significant number of patients and improved monitoring and earlier interventions may further improve outcomes.

National early warning score (NEWS) and the new alternative SpO2 scale during rapid response team reviews: a prospective observational study.

BACKGROUND: The national early warning score (NEWS) enables early detection of in-hospital patient deterioration and timely activation of hospital's rapid response team (RRT). NEWS was updated in 2017 to include a separate SpO2 scale for those patients with type II respiratory failure (T2RF). In this study we investigated whether NEWS with and without the new SpO2 scale for the T2RF patients is associated with immediate and in-hospital patient outcomes among the patients actually attended by the RRT. METHODS: We conducted a two-year prospective observational study including all adult RRT patients without limitations of medical treatment (LOMT) in a large Finnish university associated tertiary level hospital. According to the first vital signs measured by the RRT, we calculated NEWSs for the RRT patients and further utilized the new SpO2 scale for the patients with confirmed T2RF. We used multivariate logistic regression and area under the receiver operating characteristic analyses to test NEWS's accuracy to predict two distinct outcomes: RRT patient's I) immediate need for intensive care and/or new LOMT and 2) in-hospital death or discharge with cerebral performance category >2 and/or LOMT. RESULTS: The final cohort consisted of 886 RRT patients attended for the first time during their hospitalization. Most common reasons for RRT activation were respiratory (343, 39%) and circulatory (226, 26%) problems. Cohort's median (Q1, Q3) NEWS at RRT arrival was 8 (5, 10) and remained unchanged if the new SpO2 scale was applied for the 104 patients with confirmed T2RF. Higher NEWS was independently associated with both immediate (OR 1.28; 95% CI 1.22-1.35) and in-hospital (1.15; 1.10-1.21) adverse outcomes. Further, NEWS had fair discrimination for both the immediate (AUROC 0.73; 0.69-0.77) and in-hospital (0.68; 0.64-0.72) outcomes. Utilizing the new SpO2 scale for the patients with confirmed T2RF did not improve the discrimination capability (0.73; 0.69-0.76 and 0.68; 0.64-0.71) for these outcomes, respectively. CONCLUSIONS: We found that in patients attended by a RRT, the NEWS predicts patient's hospital outcome with moderate accuracy. We did not find any improvement using the new SpO2 scale in T2RF patients.

Limitation of treatment in prehospital care - the experiences of helicopter emergency medical service physicians in a nationwide multicentre survey.

BACKGROUND: Making ethically sound treatment limitations in prehospital care is a complex topic. Helicopter Emergency Medical Service (HEMS) physicians were surveyed on their experiences with limitations of care orders in the prehospital setting, including situations where they are dispatched to healthcare facilities or nursing homes. METHODS: A nationwide multicentre study was conducted among all HEMS physicians in Finland in 2017 using a questionnaire with closed five-point Likert-scale questions and open questions. The Ethics Committee of the Tampere University Hospital approved the study protocol (R15048). RESULTS: Fifty-nine (88%) physicians responded. Their median age was 43 (IQR 38-47) and median medical working experience was 15 (IQR 10-20) years. All respondents made limitation of care orders and 39% made them often. Three fourths (75%) of the physicians were often dispatched to healthcare facilities and nursing homes and the majority (93%) regularly met patients who should have already had a valid limitation of care order. Every other physician (49%) had sometimes decided not to implement a medically justifiable limitation of care order because they wanted to avoid conflicts with the patient and/or the next of kin and/or other healthcare staff. Limitation of care order practices varied between the respondents, but neither age nor working experience explained these differences in answers. Most physicians (85%) stated that limitations of care orders are part of their work and 81% did not find them especially burdensome. The most challenging patient groups for treatment limitations were the under-aged patients, the severely disabled patients and the patients in healthcare facilities or residing in nursing homes. CONCLUSION: Making limitation of care orders is an important but often invisible part of a HEMS physician's work. HEMS physicians expressed that patients in long-term care were often without limitations of care orders in situations where an order would have been ethically in accordance with the patient's best interests.

Early termination of resuscitation in in-hospital cardiac arrest and impact to the outcome calculations.

BACKGROUND: Some in-hospital resuscitation attempts are assessed futile and terminated early on. We hypothesized that if these cases are reported separately, the true outcome of in-hospital cardiac arrest is better reflected. METHODS: We conducted a 3-year prospective observational Utstein-style study in Tampere, Finland. All adult in-hospital cardiac arrests outside critical care areas attended by hospital's rapid response team were included. Resuscitation attempts that were terminated within 10 minutes were considered early terminations. RESULTS: The cohort consisted of 199 in-hospital cardiac arrest patients. Twenty-seven (14%) resuscitation attempts were terminated early due to the presumed futility of the attempt with median resuscitation duration of 5 (4, 7) minutes. These cases and the 172 patients with full resuscitation attempt were of comparable age, sex and comorbidity. Early terminated resuscitation attempts were more often unwitnessed (63% vs. 10%, P < .001) with initial non-shockable rhythm (100% vs. 80%, P = .006) when compared with full attempts. The most frequently reported reasons for termination decisions were non-witnessed arrest presenting asystole as initial rhythm and severe acute illness. The hospital survival with good neurological outcome and 1-year survival were 30% and 25% for the whole cohort, and 34% and 29% when early terminated resuscitation attempts were excluded. CONCLUSION: One-seventh of resuscitation attempts were terminated early on due to presumed futility of the attempt. Short- and long-term outcomes were 5% and 4% better when early terminated attempts were excluded from the outcome analyses. We believe that in-hospital cardiac arrest outcome is not as poor as repeatedly presented in the literature.

National early warning score (NEWS) in a Finnish multidisciplinary emergency department and direct vs. late admission to intensive care.

OBJECTIVES: We investigated the national early warning scores (NEWSs) and related outcomes of patients in a tertiary referral center's multidisciplinary emergency department (ED). Patients were further categorized into three groups: triaged directly to intensive care unit (EDICU), triaged to general ward with later ICU admission (EDwardICU) and triaged to general ward (EDward). NEWSs and subsequent outcomes among these sub groups were compared. METHODS: We conducted a prospective one-month cohort study in Tampere University Hospital's ED, Finland. ED-NEWSs were obtained for all adult patients without treatment limitations, and control (ward) NEWSs were further obtained for the EDwardICU and EDward patients. RESULTS: Cohort consisted of 1,354 patients with a median ED-NEWS of 2, and higher ED-NEWS was associated with in-hospital mortality (OR 1.26, 95% CI 1.11-1.42; AUROC 0.75, 0.64‒0.86, p < 0.001) and 30-day mortality (OR 1.27, 1.17-1.39; AUROC 0.78, 0.71‒0.84, p < 0.001) irrespective of age and comorbidity. There were 64 patients in EDICU group, 12 patients in EDwardICU group and 1,278 patients in EDward group with median ED-NEWSs of 7, 3 and 2 (p < 0.001), respectively. After the first 24 h in wards, median NEWSs of the EDwardICU patients had substantially increased as compared with EDward patients (6 vs. 2, p < 0.001). There were no statistical differences in last NEWS before ICU admission between the EDICU and EDwardICU patients (7 vs. 8, p = 0.534), or in ICU severity-of-illness scores or patient outcomes. CONCLUSIONS: ED-NEWS is independently associated with in-hospital and 30-day mortality with acceptable discrimination capability. Direct and late ICU admissions occurred with comparable NEWSs at admission.

In-hospital cardiac arrest after a rapid response team review: A matched case-control study.

AIM: Study the incidence and reasons behind in-hospital cardiac arrests (IHCAs) after rapid response team (RRT) reviews. METHODS: We conducted a matched case-control study at Tampere University Hospital, Finland. Data on adult patients who were triaged to remain on general ward after first (index) RRT review without treatment limitations but who suffered an IHCA within the following 48 h were prospectively collected for 5.3 years. These cases were matched (age ±3 years, sex, surgical/medical ward, admission year) at a 1:4 ratio to controls (no ICHA after RRT review). RESULTS: Of 2653 index RRT reviews, 17 patients suffered an IHCA on general ward within the 48 h after review. Their 30-day mortality rate was 88%. The incidence was 6.3/1000 index RRT reviews or 4.6/100,000 hospital admissions. Patients who suffered an IHCA within 48 h after RRT review were more likely to have a preceding ICU admission, and their median national early warning scores (NEWSs) at the end of the index RRT reviews (=last NEWSs) were higher than those of the controls. Higher last NEWS was the only factor associated with ICHA after RRT review (OR 1.22, 95% CI 1.00-1.49, p = 0.048) in a conditional multivariable regression model. CONCLUSIONS: IHCA within 48 h after an index RRT review on general ward is a rare event with poor prognosis. It is independently associated with higher NEWS at the end of the index RRT review. Careful consideration is stressed, when patients with high NEWS are left on ward after RRT reviews.

Characteristics and outcome of rapid response team patients ≥75 years old: a prospective observational cohort study.

BACKGROUND: Rapid response teams (RRTs) attend severely ill general ward patients whose average 30-day mortality is near 30%. A major part of RRT patients are over 75 years old, but there are no studies on the characteristics and outcome of this geriatric RRT population. We compared the characteristics and outcome of geriatric RRT sub-population with the RRT patients <75 years old. We further investigated, whether the accumulation of risk factors (RFs) for mortality among the general RRT population predicts a tenuous outcome among the geriatric sub-population. METHODS: Prospective three-year observational cohort study of adult RRT patients in Tampere University Hospital, Finland. After identifying independent RFs for 30-day mortality among RRT patients with multivariate logistic regression, we further studied the impact of the accumulation of these RFs among geriatric RRT patients who had no limitations of medical treatment. RESULTS: A total of 1372 patients were reviewed 1722 times. Geriatric patients (n = 449, 33%), when compared to non-geriatric patients, had higher 30-day (33% vs. 21%, respectively; p < 0.001) and one-year (54% vs. 35%, respectively; p < 0.001) mortality rates. Among the general RRT population, positive RRT criteria as measured by RRT during the review, high comorbidity index, age ≥ 75 years, non-elective hospital admission, medical reason for admission and afferent limb failure were identified as independent RFs for 30-day mortality and classified as feasible to obtain during a routine RRT review. The observed rates of these RFs among the geriatric RRT patients substantially affected their 30-day mortality (e.g. no RFs: 5.3%; one RF: 14%; two RFs: 27%; three RFs: 38%; four RFs: 52%; five RFs: 38%). CONCLUSIONS: One-third of patients reviewed by RRT were ≥75 years old, and age statistics were comparable to previous RRT studies suggesting that this is the case globally. Outcome of geriatric RRT patients is poorer as compared with RRT patients <75 years. However, the outcome is substantially affected by the accruement (or lack) of RFs generally increasing the mortality of RRT patients. Considering these factors during a geriatric RRT review may aid with the decision to either escalate or de-escalate care.

Outcome of adult patients attended by rapid response teams: A systematic review of the literature.

BACKGROUND: An abundance of studies have investigated the impact of rapid response teams (RRTs) on in-hospital cardiac arrest rates. However, existing RRT data appear highly variable in terms of both study quality and reported uses of limitations of care, patient survival and patient long-term outcome. METHODS: A systematic electronic literature search (January, 1990-March, 2016) of the PubMed and Cochrane databases was performed. Bibliographies of articles included in the full-text review were searched for additional studies. A predefined RRT cohort quality score (range 0-17) was used to evaluate studies independently by two reviewers. RESULTS: Twenty-nine studies with a total of 157,383 RRT activations were included in this review. The quality of data reporting related to RRT patients was assessed as modest, with a median quality score of 8 (range 2-11). Data from the included studies indicate that a median 8.1% of RRT reviews result in limitations of medical treatment (range 2.1-25%) and 23% (8.2-56%) result in a transfer to intensive care. A median of 29% (6.9-35%) of patients transferred to intensive care died during that admission. The median hospital mortality of patients reviewed by RRT is 26% (12-60%), and the median 30-day mortality rate is 29% (8-39%). Data on long-term survival is minimal. No data on functional outcomes was identified. CONCLUSIONS: Patients reviewed by rapid response teams have a high and variable mortality rate, and limitations of care are commonly used. Data on the long-term outcomes of RRT are lacking and needed.

Aetiology of in-hospital cardiac arrest on general wards.

AIM: Aetiology of in-hospital cardiac arrests (IHCAs) on general wards has not been studied. We aimed to determine the underlying causes for IHCAs by the means of autopsy records and clinical judgement of the treating consultants. Furthermore, we investigated whether aetiology and preceding vital dysfunctions are associated with long-term survival. DESIGN AND SETTING: Prospective observational study between 2009-2011 including 279 adult IHCA patients attended by medical emergency team in a Finnish university hospital's general wards. RESULTS: The median age of the patients was 72 (64, 80) years, 185 (66%) were male, 178 (64%) of events were monitored/witnessed, first rhythm was shockable in 42 (15%) cases and 53 (19%) patients survived six months. Aetiology was determined as cardiac in 141 events, 73 of which were due to acute myocardial infarction. There were 138 non-cardiac IHCAs; most common causes were pneumonia (39) and exsanguination (16). No statistical difference was observed in the incidence of objective vital dysfunctions preceding the event between the cardiac and non-cardiac groups (40% vs. 44%, p=0.448). Subjective antecedents were more common in the cardiac cohort (47% vs. 32%, p=0.022), chest pain being an example (11% vs. 0.7%, p<0.001). Reviewing all 279 IHCAs, only shockable primary rhythm, monitored/witnessed event and low comorbidity score were independently associated with 180-day survival. CONCLUSIONS: Cardiac aetiology underlies half of the IHCAs on general wards. Both objective and subjective antecedents are common. However, neither the cardiac aetiology nor the absence of preceding deterioration of vital signs were factors independently associated with a favourable outcome.

Ethically justified treatment limitations in emergency situations.

OBJECTIVE: Medical emergency teams (METs) implement do not attempt cardiopulmonary resuscitation (DNACPR) orders and other limitations of medical treatment (LOMTs) in hospitals regularly. However, METs operate in emergency situations with limited or no patient information at the scene. We aimed to study the medical ethics of LOMTs implemented in in-hospital emergency situations. METHODS: This was a prospective observational study with retrospect case-note analysis conducted in a single Finnish university hospital over 16 months. Data were collected according to the Utstein-style scientific statement. RESULTS: There were 774 reviews on 640 patients without preceding LOMT. During the reviews MET assigned LOMTs (including 55 DNACPR orders) for a group of 59 patients who were older (median 77 vs. 68 years; P<0.001) and had higher cumulative comorbidity (median Charlson comorbidity index 2 vs. 1; P=0.001) compared with patients without LOMTs (no-LOMT). Most reviews (71%) leading to new LOMTs occurred during on-call time. In the majority of LOMT cases at least two physicians (86%) and the patient/relatives (76%) were involved in the decision-making. All but one (98%) of the LOMT reviews were documented in the electronic patient records and included clearly described rationale for the LOMT. The median durations of the MET reviews (31 vs. 31 min, P=0.9) were comparable in the two groups. Age alone was never recorded as a reason for LOMT. CONCLUSION: LOMTs were implemented in a decent and ethically justified manner in emergency situations following the code of conduct recommended by guidelines, even though MET operated under highly suboptimal circumstances for end-of-life care planning.

Medical emergency team activation: performance of conventional dichotomised criteria versus national early warning score.

BACKGROUND: To activate the hospital's medical emergency team (MET), either conventional dichotomised activation criteria or an early warning scoring system may be used. The relative performance of these different activation patterns to discriminate high risk patients in a heterogenic general ward population after adjustment for multiple confounding factors has not been evaluated. We aimed to evaluate the dichotomised activation criteria used at our institution and the recently published national early warning score (NEWS, United Kingdom). MATERIALS AND METHODS: Prospective point prevalence study at a university hospital in Finland. On two separate days, the vital signs of all adult patients without treatment limitations were measured. Data on cumulative comorbidity (Charlson comorbidity index), age, gender, admission characteristics and subsequent mortality were collected. Univariate and multivariate logistic regression models were used for unadjusted and adjusted performance testing. RESULTS: The cohort consisted of 615 patients. The dichotomised activation criteria were not associated with in-hospital serious adverse events (odds ratio 1.87, 95% confidence interval 0.55-6.30) or 30-day mortality (2.13, 0.79-5.72) after adjustments. For a NEWS of seven or more (the suggested trigger level for immediate MET activation), the adjusted odds ratios for the above mentioned outcomes were 7.45 (2.39-23.3) and 11.4 (4.40-29.6), respectively. Unlike the dichotomised activation criteria, NEWS was also independently associated with a higher 60- and 180-day mortality after adjustments. CONCLUSIONS: NEWS discriminates high risk patients in a heterogenic general ward population independently of multiple confounding factors. The conventional dichotomised activation criteria were not able to detect high risk patients.

[Medical emergency treatment is here to stay]. / Sairaalansisäinen ensihoito on tullut jäädäkseen.

Lifelessness in a hospital ward is usually due to an hours-long disturbance of vital functions. The earlier the worsening of the patient's condition is observed, the simpler will the therapeutic measures often be that are sufficient to correct the condition. The medical emergency team will be called to a critically ill patient. The personnel of the hospital ward must be able to recognize in time a patient who will benefit from intensifying the treatment. The most important link of the medical emergency treatment chain is in fact the same as outside the hospital--calling for help early enough.