Medical emergency response in a sub-acute hospital: improving the model of care for deteriorating patients.

OBJECTIVE: To assess the frequency, characteristics and outcomes of medical emergency response (MER) calls in a sub-acute hospital setting. METHODS: The present study was a retrospective observational study in a sub-acute hospital providing aged care, palliative care, rehabilitation, veteran's mental health and elective surgical services. We assessed annual MER call numbers between 2005 and 2011 in the context of contemporaneous changes to hospital services. We also assessed MER calls over a 12-month period in detail using standardised case report forms and the scanned medical record. RESULTS: There were 2285 multiday admissions in the study period where 141 MER calls were triggered in 132 patients (61.7 calls per 1000 admissions). The median patient age was 83.0 years, and 55.3% of patients were men. Most calls occurred on weekdays and during the daytime, and were triggered by altered conscious state, low oxygen saturations and hypotension. Documentation of escalation of care before the MER call was not present in 99 of 141 (70.2%) calls. Following the call, in 70 of 141 (49.6%) cases, the patient was transferred to the acute campus, where 52 (74.2%) and 14 (20%) patients required ward and intensive care level treatment, respectively. Thirty-seven of 132 (28%) patients died. A palliative care physician adjudicated that most of these patients who died (24/37; 64.9%) were appropriate for a call, but that 19 (51.4%) should have received palliation at the time of the call. Compared with survivors, patients who died after the MER call were more likely originally admitted from supported accommodation. CONCLUSIONS: MER calls in our sub-acute hospital occurred in elderly patients and are associated with an in-hospital mortality of 28%. A small proportion of patients required intensive care level treatment. There is a need to improve processes involving escalation of care before MER call activation and to revise advance care directives. What is known about this topic? Rapid response team (RRT) activation has been well described in the acute hospital setting. Although the impact on survival benefit to patients remains controversial, it has been widely adopted as a model of care to respond to deteriorating ward patients. This is particularly relevant in Australia at present with the implementation of the new National Safety and Quality Health Service Standards. What does this paper add? There have not been any previous papers published on rapid response systems in a sub-acute hospital. This paper describes some of the changes and challenges associated with increasing RRT activations in a sub-acute health care facility. What are the implications for practitioners? For clinicians in a sub-acute setting, the study reinforces the importance of pre-emptively documenting and communicating advance care directives. In addition, it is important to identify patients with reversible pathology likely to benefit from transfer and acute care, and to avoid the transfer of those who will not and, instead, provide appropriate palliation. For practitioners involved in models of care for deteriorating patients, the study provides information on where problems occurred in our system and the strategies used to address these issues.

Factors involved in intensive care unit mortality following medical retrieval: identifying differences between intensive care unit survivors and non-survivors.

OBJECTIVE: The study aimed to determine factors related to ICU mortality in critically ill patients transferred by Adult Retrieval Victoria (ARV) medical staff. Patients who died in ICU after interhospital transfer were compared against those who survived. METHODS: This was a retrospective cohort study of ARV cases between 1 January 2009 and 30 June 2010. Retrieval data were linked with data from the ANZICS CORE APD (Australia and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation Adult Patient Database). Victoria Data Linkage (VDL) performed linkage of data. Data included demographic and clinical data obtained during transfer and clinical data recorded in ICU. RESULTS: Of the 601 cases transferred by ARV during the study period, 549 cases were eligible for linkage to 25 543 ANZICS APD case records for the same period. VDL matched 460 of these cases (83.8%). Mortality rate in the matched sample was 13.9%. Variables associated with mortality were: advanced age (odds ratios [OR] 1.02, 95% confidence interval [CI] 1.00-1.04, P = 0.02), principal referral problem cardiac (OR 1.84, 95%CI 1.02-3.32, P = 0.04), lower mean arterial blood pressure (OR 0.97, 95% CI 0.95-0.99, P = 0.005) and tachycardia (OR 1.02, 95% CI 1.00-1.03, P = 0.008) on arrival at destination hospital. CONCLUSIONS: Advanced age, lower mean arterial blood pressure and tachycardia towards the completion of transfer were associated with increased ICU mortality in this population. Clinicians should be aware of the additional risk for cardiac patients.