November 29th, 2016

Is too sick to go home also too sick for the floor?

By Daniel Cabrera, M.D.

What patients admitted from the Emergency Department to a general floor/ward will deteriorate?

Author Shawna Bellew, MD (@SBellzMD)

shutterstock_145689659

 

“That patient is going to trigger a rapid response team activation the minute they hit the floor.” Whether said by a nurse, a resident, or the accepting physician, most emergency medicine physicians have heard some version of this statement.

Rapid response teams (RRTs), multidisciplinary groups of providers tasked with evaluating and managing patients with signs of impending deterioration, have become ubiquitous throughout the US healthcare system, partially owing to their inclusion in the 2005 Institute for Healthcare Improvement’s “100,000 Lives Campaign.” Recommendations for instituting these teams rest on the theory that early intervention can prevent further deterioration. Likewise, patients who trigger RRT activation early in their hospital course or similarly those who are expectantly transferred to the intensive care unit after admission have worse outcomes than those admitted directly to the ICU.1-3 Early RRT activation (eRRT) may therefore represent an opportunity for improvement.4

The PeRRT Score
Feature Score Adjustment
Diagnosis Infectious +5

+3

+2

−3

Mental disorder
Respiratory
Musculoskeletal
Respiratory rate First ≥24 +2
Last ≥23 +2
Oxygen saturation First ≤92% +3
Last ≤92% +1
Heart rate Last ≥106 +3
Systolic blood pressure Last ≤102 +2
Last ≥159 +2
Score Predicted Probability of eRRT
≤ −1 0.05
0 0.07
1 0.09
2 0.12
3 0.16
4 0.21
5 0.27
6 0.34
7 0.42
8 0.50
9 0.58
10 0.65
≥ 11 0.72

 

Emergency physicians must excel at a variety of skills. In addition to the obvious-evaluating the undifferentiated patient as well as resuscitating the critically ill-we must also be the masters of negotiating with other providers in the best interest of our patient and pertinently determining disposition. Disposition decision-making must account for a dizzying array of factors. In addition to admitting diagnosis, hemodynamics, and respiratory status at the time of admission, more nuanced considerations also come into play such as gut feeling (gestalt), practice setting, co-morbidities, social supports, hospital census, and even the time of day. This type of complex decision-making is characteristic of Emergency Medicine. While not as glamorous as running the perfect code or performing a live-saving ED thoracotomy, great dispositions can save resources and lives.

For this reason, we set out to determine the characteristics of patients who triggered RRT activation in 12 hours. Ultimately, we wanted to be able to help inform emergency physicians when faced with uncertain dispositions, answering the question, “How likely is this patient to trigger a rapid response team activation?” Initially, we conducted a matched case-control study comparing patients who triggered eRRT to patients with matched (to age, gender, and diagnosis) control patients.5 We found that the eRRT patients had a four-fold increase in mortality and vital sign abnormalities in the ED were suggestive of eRRT. This was unsurprising given that RRT activation criteria are largely based on vital sign abnormalities. The results of this study led us to compare the original eRRT group to a randomly selected control population in order to create a clinical decision instrument that would quantify the risk of eRRT.6 While this tool lacks external validation and the risk of eRRT is likely very variable according to specific hospital characteristics, we believe we have taken an interesting first step in creating such an instrument.

“That patient is going to trigger a rapid response team activation the minute they hit the floor.” Will they? Enter the PeRRT (predicting early rapid response team activation) Score.  See the full paper here.

 

"Too sick to go home, too sick for the floor" - Andy Boggust, MD

 

References

  1. Litvak E, Pronovost PJ. Rethinking rapid response teams. JAMA. 2010;304:1375-1376.
  2. Bapoje SR, Gaudiani JL, Narayanan V, Albert RK. Unplanned transfers to a medical intensive care unit: causes and relationship to preventable errors in care. J Hosp Med. 2011;6:68-72.
  3. Frost SA, Alexandrou E, Bogdanovski T, Salamonson Y, Parr MJ, Hillman KM. Unplanned admission to intensive care after emergency hospitalisation: risk factors and development of a nomogram for individualising risk. Resuscitation. 2009;80:224-230.
  4. Lovett PB, Massone RJ, Holmes MN, Hall RV, Lopez BL. Rapid response team activations within 24 hours of admission from the emergency department: an innovative approach for performance improvement. Acad Emerg Med. 2014;21:667-672.
  5. Walston JM, Cabrera D, Bellew SD, Olive MN, Lohse CM, Bellolio MF. Vital Signs Predict Rapid-Response Team Activation Within Twelve Hours of Emergency Department Admission. West J Emerg Med. 2016;17:324-330.
  6. Bellew SD, Cabrera D, Lohse CM, Bellolio MF. Predicting early rapid response team activation in patients admitted from the emergency department: The PeRRT Score. Acad Emerg Med. 2016.

 

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