Intensive care patients receiving vasoactive medications: A retrospective cohort study

BackgroundVasoactive medications are high-risk drugs commonly used in intensive care units (ICUs), which have wide variations in clinical management.ObjectivesThe aim of this study was to describe the patient population, treatment, and clinical characteristics of patients who did and did not receive vasoactive medications while in the ICU and to develop a predictive tool to identify patients needing vasoactive medications.MethodsA retrospective cohort study of patients admitted to a level three tertiary referral ICU over a 12-month period from October 2018 to September 2019 was undertaken. Data from electronic medical records were analysed to describe patient characteristics in an adult ICU. Chi square and Mann–Whitney U tests were used to analyse data relating to patients who did and did not receive vasoactive medications. Univariate analysis and Pearson's r² were used to determine inclusion in multivariable logistic regression.ResultsOf 1276 patients in the cohort, 40% (512/1276) received a vasoactive medication for haemodynamic support, with 84% (428/512) receiving noradrenaline. Older patients (odds ratio [OR] = 1.02; 95% confidence interval [CI] = 1.01–1.02; p < 0.001) with higher Acute Physiology and Chronic Health Evaluation (APACHE) III scores (OR = 1.04; 95% CI = 1.03–1.04; p < 0.001) were more likely to receive vasoactive medications than those not treated with vasoactive medications during an intensive care admission. A model developed using multivariable analysis predicted that patients admitted with sepsis (OR = 2.43; 95% CI = 1.43–4.12; p = 0.001) or shock (OR = 4.05; 95% CI = 2.68–6.10; p < 0.001) and managed on mechanical ventilation (OR = 3.76; 95% CI = 2.81–5.02; p < 0.001) were more likely to receive vasoactive medications.ConclusionsMechanically ventilated patients admitted to intensive care for sepsis and shock with higher APACHE III scores were more likely to receive vasoactive medications. Predictors identified in the multivariable model can be used to direct resources to patients most at risk of receiving vasoactive medications.     

Physician Medical Direction andClinical Performance at an Established Emergency Medical Services System

Objective. Few developed emergency medical services (EMS) systems operate without dedicated medical direction. We describe the experience of Hamad Medical Corporation (HMC) EMS, which in 2007 first engaged an EMS medical director to develop andimplement medical direction andquality assurance programs. We report subsequent changes to system performance over time. Methods. Over one year, changes to the service's clinical infrastructure were made: Policies were revised, paramedic scopes of practice were adjusted, evidence-based clinical protocols were developed, andskills maintenance andeducation programs were implemented. Credentialing, physician chart auditing, clinical remediation, andonline medical command/hospital notification systems were introduced. Results. Following these interventions, we report associated improvements to key indicators: Chart reviews revealed significant improvements in clinical quality. A comparison of pre- andpost-intervention audited charts reveals a decrease in cases requiring remediation (11% to 5%, odds ratio [OR] 0.43 [95% confidence interval (CI) 0.20–0.85], p = 0.01). The proportion of charts rated as clinically acceptable rose from 48% to 84% (OR 6 [95% CI 3.9–9.1], p < 0.001). The proportion of misplaced endotracheal tubes fell (3.8% baseline to 0.6%, OR 0.16 [95% CI 0.004–1.06], (exact) p = 0.05), corresponding to improved adherence to an airway placement policy mandating use of airway confirmation devices andsecuring devices (0.7% compliance to 98%, OR 714 [95% CI 64–29,334], (exact) p < 0.001). Intravenous catheter insertion in unstable cases increased from 67% of cases to 92% (OR 1.31 [95% CI 1.09–1.71], p = 0.004). EMS administration of aspirin to patients with suspected ischemic chest pain improved from 2% to 77% (OR 178 [95% CI 35–1,604], p < 0.001). Conclusions. We suggest that implementation of a physician medical direction is associated with improved clinical indicators andoverall quality of care at an established EMS system     

Mental well-being of intensive care unit nurses after the second surge of the COVID-19 pandemic: A cross-sectional and longitudinal study

ObjectivesTo determine the impact of the second surge of the COVID-19 pandemic (October 2020 to June 2021) on mental well-being of intensive care unit nurses and factors associated with mental health outcomes.MethodsAn online survey was available for Dutch intensive care unit nurses in October 2021, measuring mental health symptoms; anxiety, depression (Hospital Anxiety and Depression Scale), and post-traumatic stress disorder (Impact of Event Scale-6). Additionally, work-related fatigue was measured using the Need For Recovery-11 questionnaire. Previous data from the first surge (March until June 2020) were used to study mental well-being longitudinally in a subgroup of intensive care unit nurses. Logistic regression analyses were performed to determine factors associated with mental health symptoms.ResultsIn total, 589 nurses (mean age 44.8 [SD, 11.9], 430 [73.8 %] females) participated, of whom 164 also completed the questionnaire in 2020. After the second surge, 225/589 (38.2 %) nurses experienced one or more mental health symptoms and 294/589 (49.9 %) experienced work-related fatigue. Compared to the first measurement, the occurrence of mental health symptoms remained high (55/164 [33.5 %] vs 63/164 [38.4 %], p = 0.36) and work-related fatigue was significantly higher (66/164 [40.2 %] vs 83/164 [50.6 %], p = 0.02). Granted holidays as requested (aOR, 0.54; 95 % CI, 0.37–0.79), being more confident about the future (aOR, 0.59; 95 % CI, 0.37–0.93) and a better perceived work-life balance (aOR, 0.42; 95 % CI, 0.27–0.65) were significantly associated with less symptoms.ConclusionThe second surge of the COVID-19 pandemic further drained the mental reserves of intensive care unit nurses, resulting in more work-related fatigue.     

Intervention effect of neuromuscular electrical stimulation on ICU acquired weakness: A meta-analysis

ObjectiveThe early use of neuromuscular electrical stimulation (NMES) to prevent intensive care unit-acquired weakness (ICU-AW) in critical patients is still a controversial topic. We conducted a systematic review to clarify the effectiveness of NMES in preventing ICU-AW.MethodsThe Cochrane Library, PubMed, EMBASE, MEDLINE, Web of Science, Ovid, CNKI, Wanfang, VIP, China Biology Medicine disc (CBMdisc) and other databases were searched for randomized controlled trials on the influence of NMES on ICU-AW. The studies were selected according to the inclusion and exclusion criteria. After data and quality were evaluated, a meta-analysis was performed by RevMan 5.3 software.ResultsA total of 11 randomized controlled trials with 576 patients were included. The meta-analysis results showed that NMES can improve muscle strength [MD = 1.78, 95% CI (0.44, 3.12, P = 0.009); shorten the mechanical ventilation (MV) time [SMD = −0.65, 95% CI (−1.03, −0.27, P = 0.001], ICU length of stay [MD = −3.41, 95% CI (−4.58, −4.24), P < 0.001], and total length of stay [MD = −3.97, 95% CI (−6.89, −1.06, P = 0.008]; improve the ability of patients to perform activities of daily living [SMD = 0.9, 95% CI (0.45, 1.35), P = 0.001]; and increase walking distance [MD = 239.03, 95% CI (179.22298.85), P < 0.001]. However, there is no evidence indicating that NMES can improve the functional status of ICU patients during hospitalization, promote the early awakening of patients or reduce mortality (P > 0.05).ConclusionEarly implementation of the NMES intervention in ICU patients can prevent ICU-AW and improve their quality of life by enhancing their muscle strength and shortening the MV duration, length of stay in the ICU and total length of stay in the hospital.     

Clinical and Cancer-Related Predictors for Venous Thromboembolism in Cancer Patients Presenting to the Emergency Department

BackgroundThe accurate detection of cancer-associated venous thromboembolism (VTE) can avoid unnecessary diagnostic imaging or laboratory tests.ObjectiveWe sought to determine clinical and cancer-related risk factors of VTE that can be used as predictors for oncology patients presenting to the emergency department (ED) with suspected VTE.MethodsWe retrospectively analyzed all consecutive patients who presented with suspicion of VTE to The University of Texas MD Anderson Cancer Center ED between January 1, 2009, and January 1, 2013. Logistic regression models were used to identify risk factors that were associated with VTE. The ability of these factors to predict VTE was externally validated using a second cohort of patients who presented to King Hussein Cancer Center ED between January 1, 2009, and January 1, 2016.ResultsCancer-related covariates associated with the occurrence of VTE were high-risk cancer type (odds ratio [OR] 3.64 [95% confidence interval {CI} 2.37–5.60], p < 0.001), presentation within 6 months of the cancer diagnosis (OR 1.92 [95% CI 1.62–2.28], p < 0.001), active cancer (OR 1.35 [95% CI 1.10–1.65], p = 0.003), advanced stage (OR 1.40 [95% CI 1.01–1.94], p = 0.044), and the presence of brain metastasis (OR 1.73 [95% CI 1.32–2.27], p < 0.001). When combined, these factors along with other clinical factors showed high prediction performance for VTE in the external validation cohort.ConclusionsCancer risk group, presentation within 6 months of cancer diagnosis, active and advanced cancer, and the presence of brain metastases along with other related clinical factors can be used to predict VTE in patients with cancer presenting to the ED.     

Care and treatments related to intensive care unit–acquired muscle weakness: A cohort study

BackgroundIntensive care unit–acquired muscle weakness (ICUAW) has an incidence of 40–46%. Early mobilisation is known to be a protective factor.ObjectiveThe aim of the study was to identify the incidence of ICUAW in Spain and to evaluate variables likely to contribute to the development of ICUAW.MethodsA 4-month, prospective observational multicentre cohort study was conducted on patients receiving invasive mechanical ventilation for at least 48 h. Data were collected from ICU day 3 until ICU discharge. The primary outcome was presence of ICUAW (diagnosed using the Medical Research Council [MRC] scale). The secondary outcome was nurse–patient ratio, physiotherapist availability, analgesia, sedation and delirium management, glycaemic control, and daily level of mobility during the ICU stay as per the ICU Mobility Scale. A logistic regression model was constructed based exclusively on days 3–5 of the ICU stay.ResultsThe data of 642 patients were analysed from 80 ICUs, accounting for 35% of all ICUs in Spain. The incidence of ICUAW was 58% (275 of 474 patients; 95% confidence interval [CI] [53–62]). The predictors for ICUAW were older age (odds ratio [OR] = 1.01; 95% CI [1.00–1.03]) and more days with renal replacement therapy (OR = 1.01; 95% CI [1.00–1.02]). The protective factors for ICUAW were male gender (OR = 0.58; 95% CI [0.38–0.89]), higher Barthel Index (showing prehospital functional independence) (OR = 0.97; 95% CI [0.95–0.99]), more days of being awake and cooperative (defined by a feasible MRC assessment) (OR = 0.98; 95% CI [0.97–0.99]), presence of delirium (OR = 0.98; 95% CI [0.97–0.99]), and more days with active mobilisation (ICU Mobility Scale ≥ 4) (OR = 0.98; 95% CI [0.97–0.99]).ConclusionsThe risk factors for ICUAW were functional dependence before admission, female gender, older age, and more days on renal replacement therapy. The protective factors for ICUAW were feasibility of MRC assessment, the presence of delirium, and being actively mobilised during the first 5 days in the ICU.     

A novel predictive tool for prognosis in elderly patients with urinary tract infection: Modified PRACTICE

PurposeWe evaluated whether combining the serum albumin level and the Prediction Rule for Admission policy in Complicated urinary Tract InfeCtion LEiden (PRACTICE) class could be a prognostic predictor in elderly patients with urinary tract infection (UTI).MethodsWe retrospectively included adult patients (age ≥ 65 years) with UTI who were hospitalized in the emergency department (ED) between January 1, 2014 and December 31, 2018. We graded the serum albumin level and classified the PRACTICE score; the modified PRACTICE was defined as the sum of the albumin level grade and the PRACTICE class. We comparatively assessed the predictive value for in-hospital mortality and admission to the intensive care unit (ICU) in survivor and non-survivor groups.ResultsIn total, the study analysis included 1159 patients, and in-hospital mortality was 3.4% (n = 39). The modified PRACTICE score (4.0 [1.4] vs 6.1 [1.2], p < 0.001) was significantly increased in the non-survivor group. The area under the curve value of factors associated with in-hospital mortality were the Modified Early Warning Score (MEWS) 0.57 (95% CI 0.54–0.60), albumin 0.83 (95% CI 0.81–0.85), PRACTICE 0.71 (95% CI 0.69–0.74), and the modified PRACTICE 0.86 (95% CI 0.84–0.88). Factors associated with ICU admission were MEWS 0.65 (95% CI 0.62–0.68), albumin 0.66 (95% CI 0.64–0.69), PRACTICE 0.66 (95% CI 0.63–0.68), and the modified PRACTICE 0.72 (95% CI 0.69–0.74).ConclusionThe modified PRACTICE score can be a useful prognostic predictor in elderly patients with UTI.     

A baseline assessment of patient safety culture and its associated factors from the perspective of critical care nurses: Results from 10 hospitals

IntroductionCritical care nurses are considered the key to patient safety improvement and play a vital role in enhancing quality of care in intensive care units (ICUs) where adverse events are frequent and have severe consequences. Moreover, there is recognition of the importance of the assessment and the development of patient safety culture (PSC) as a strategic focus for the improvement of patient safety and healthcare quality, notably in critical care settings.ObjectivesThis study aimed to assess critical care nurses' perception of PSC and to determine its associated factors.MethodsThis cross-sectional study was conducted among nurses working in the ICUs of the Tunisian centre (six Tunisian governorates). The study instrument was the French validated version of the Hospital Survey on Patient Safety Culture questionnaire, comprising 10 dimensions and a total of 50 items.ResultsA total of 249 nurses from 18 ICUs participated in the study, with a participation rate of 87.36%. The dimensions scores ranged between 17.2% for the dimension “frequency of events reported” and 50.1% for the dimension “teamwork within units”. Multivariable logistic regression indicated that respondents who worked in private hospitals were five times more likely to have a developed PSC (adjusted odds ratio [AOR]: 5.34; 95% confidence interval [CI], [2.28, 12.51]; p < 10^–3). Similarly, participants who worked in a certified hospital were two times more likely to have a more developed PSC than respondents who work in noncertified hospitals (AOR: 2.51; 95% CI, [.92–6.82]; p = 0.041). In addition, an increased nurse-per-patient ratio (i.e., reduced workload) increased PSC (AOR: 1.10; 95% CI, [1.02–1.12]; p = 0.018).ConclusionThis study has shown that the state of critical care nurses' PSC is critically low and these baseline results can help to form a plan of actions for improvements.     

Effectiveness of interventions to prevent pressure injury in adults admitted to intensive care settings: A systematic review and meta-analysis of randomised controlled trials

ObjectiveThe aim of the study was to investigate the effectiveness of interventions to prevent pressure injury in adults admitted to intensive care settings.Review method usedThis is a systematic review and meta-analysis of randomised controlled trials.Data sourcesFive databases (CINAHL, MEDLINE, Scopus, Web of Science, and Embase) were searched in mid-2019. Searches were updated (in April 2020) to year end 2019.Review methodsFrom an overarching systematic review and meta-analysis examining the effectiveness of pressure injury preventative interventions in adults admitted to acute hospital settings, trials conducted in intensive care were separated for an intensive care–specific synthesis. Two reviewers, with a third as an arbitrator, undertook study selection, data extraction, and risk-of-bias assessment. Included trials were grouped by intervention type for narrative synthesis and for random-effects meta-analysis using intention-to-treat data where appropriate.ResultsOverall, 26 trials were included. Ten intervention types were found (support surfaces, prophylactic dressings, positioning, topical preparations, continence management, endotracheal tube securement, heel protection devices, medication, noninvasive ventilation masks, and bundled interventions). All trials, except one, were at high or unclear risk of bias. Four intervention types (endotracheal tube securement, heel protection devices, medication, and noninvasive ventilation masks) comprised single trials. Support surface trials were limited to type (active, reactive, seating, other). Meta-analysis was undertaken for reactive surfaces, but the intervention effect was not significant (risk ratio = 0.24, p = 0.12, I² = 51%). Meta-analyses demonstrated the effectiveness of sacral (risk ratio = 0.22, p < 0.001, I² = 0%) and heel (risk ratio = 0.31, p = 0.02; I² = 0%) prophylactic dressings for pressure injury prevention.ConclusionsOnly prophylactic sacral and heel dressings demonstrated effectiveness in preventing pressure injury in adults admitted to intensive care settings. Further intensive care–specific trials are required across all intervention types. To minimise bias, we recommend that all future trials are conducted and reported as per relevant guidelines and recommendations.     

Linezolid induced thrombocytopenia in critically ill patients: Risk factors and development of a machine learning-based prediction model

IntroductionLinezolid is an antimicrobial with broad activity against Gram-positive bacteria. Thrombocytopenia is one of its most common side effects often leading to severe complications.The aim of this study is to identify factors related with development of this condition in critically ill patients and to develop and evaluate a predictive machine learning-based model considering easy-to-obtain clinical variables.MethodsData was obtained from the Medical Information Mart for Intensive Care III. Patients who received linezolid for over three days were considered, excluding those under 18 years and/or lacking laboratory data. Thrombocytopenia was considered as a platelet decrease of at least 50% from baseline.ResultsThree hundred and twenty patients met inclusion criteria of which 63 developed thrombocytopenia and presented significant greater duration of treatment, aspartate-aminotransferase, bilirubin and international normalized ratio; and lower renal clearance and platelet count at baseline. Thrombocytopenia development was associated with a worse outcome (30 days mortality [OR: 2.77; CI95%: 1.87–5.89; P < .001], 60 days mortality [OR: 3.56; CI95%: 2.18–7.26; P < .001]). Thrombocytopenia was also correlated with higher length of hospital stays (35.56 [20.40–52.99] vs 22.69 [10.05–38.61]; P < .001). Median time until this anomaly was of 23 days (CI95%:19.0-NE).Two multivariate models were performed. Accuracy, sensitivity, specificity and AUROC obtained in the best of them were of 0.75, 0.78, 0.62 and 0.80, respectively.ConclusionLinezolid associated thrombocytopenia entails greater mortality rates and hospital stays. Although the proposed predictive model has to be subsequently validated in a real clinical setting, its application could identify patients at risk and establish screening and surveillance strategies.     

Real-Time Cardiopulmonary Resuscitation Feedback and Targeted Training Improve Chest Compression Performance in a Cohort of International Healthcare Providers

BackgroundOptimal cardiopulmonary resuscitation (CPR) performance is the foundation of successful cardiac arrest resuscitation. However, health care providers perform inadequate compressions. Better training techniques and real-time CPR feedback may improve compression performance.ObjectiveWe sought to evaluate the impact of a targeted training program combined with real-time defibrillator CPR feedback on chest compression performance in an international cohort of health care providers.MethodsPhysicians, nurses, respiratory therapists, and technicians from 6 hospitals in 5 countries (Taiwan, Singapore, China, Bahrain, and Kuwait) participated in a standardized resuscitation workshop. Chest compression was measured before and after didactics and activation of CPR feedback. Compressions were performed for 1 min on standard CPR manikins placed on a hospital bed and backboard and measured using ZOLL R Series defibrillators. The percentage of compressions meeting target values for depth and rate were compared before and after the workshop and activation of real-time CPR feedback. No depth maximum was defined to allow for mattress compression.ResultsChest compressions were more likely to meet targets for depth (71–95%, odds ratio [OR] 8.61 [95% confidence interval {CI} 4.42–16.77], p < 0.001), rate (41–81%, OR 6.4 [95% CI 4.2–9.8], p < 0.001), and both depth and rate (5–42%, OR 2.4 [95% CI 6.7–22.9], p < 0.001) after the workshop and activation of real-time CPR feedback.ConclusionsA targeted training intervention combined with real-time CPR feedback improved chest compression performance among health care providers from various countries.     

The effectiveness of faecal collection devices in preventing incontinence-associated dermatitis in critically ill patients with faecal incontinence: A systematic review and meta-analysis

ObjectiveThe objective of this study was to investigate the effects of different types of faecal collection devices on incontinence-associated dermatitis (IAD) in critically ill patients with faecal incontinence.Review method usedThis was a systematic review and meta-analysis.Data sourcesA comprehensive electronic literature search was performed in PubMed, Embase, Cumulative Index of Nursing and Allied Health Literature (CINAHL), the Cochrane library, China Biology Medicine (CBM), China National Knowledge Infrastructure (CNKI), Wanfang, and WeiPu. All the databases were searched from their inception to July 31, 2019, and the data were updated on November 2, 2019.Review methodsRandomised controlled trials (RCTs) and quasi-experimental studies were included. Participants were critically ill patients with faecal incontinence, and the interventions involved care with faecal collection devices. Comparisons were usual care, and the outcome was the incidence of IAD. Odds ratios (ORs) were used to calculate the pooled effect sizes. Heterogeneity was tested using the inconsistency index (I²) method.ResultsNineteen studies were included in this systematic review including 16 RCTs and three quasi-experimental studies. Twelve RCTs were included in the meta-analysis, which showed that the use of faecal collection devices significantly reduced the incidence of IAD. Subgroup analyses based on device type showed significant effects for anal pouch collection devices (OR, 0.14; 95% confidence interval [CI], 0.07–0.26; P < 0.00001), anal pouch connected to negative-pressure suction devices (OR, 0.18; 95% CI, 0.08–0.42; P < 0.00001), anal catheter/tube collection devices (OR, 0.24; 95% CI, 0.13–0.44; P < 0.00001), and anal catheter/tube connected to negative-pressure suction devices (OR, 0.20; 95% CI, 0.07–0.59, P < 0.00001).ConclusionsFaecal collection devices can reduce the incidence of IAD in critically ill patients with faecal incontinence. It is suggested that when using a device to care for critically ill patients with faecal incontinence, an anal pouch connected to continuous low-negative-pressure suction device should be preferred. Further high-quality research is still needed regarding anal catheter/tube collection devices and anal catheter/tube connected to continuous low-negative-pressure suction devices.     

Contribution of alarm noise to average sound pressure levels in the ICU: An observational cross-sectional study

ObjectivesTo explore sound levels, alarm frequencies and the association between alarms and sound levels.DesignA single center observational cross-sectional study.SettingFour intensive care units.Main outcome measuresContribution of alarms: red (life threatening), yellow (indicate excess of limits) and blue (technical) to sound pressure levels dB(A) at nursing stations.ResultsMean sound pressure levels differed significantly between day (56.1 ± 5.5), evening (55.1 ± 5.7) and night periods 53.6 ± 5.6; p < 0.01. 175,996 alarms were recorded of which 149,764 (85%) were yellow, 18,080 (10%) were red and 8,152 (5%) were blue. The mean sound levels without alarms (background) is 56.8 dB(A), with only red: 56.0 dB(A), only yellow: 55.6 dB(A), only blue: 56.0 dB(A) and mixed alarms: 56.3 dB(A). Yellow alarms (b = −0.93; 95% CI: −1.26 to −0.6; p < 0.001) were weakly but significantly associated with mean sound levels and lead to a slight decrease in noise level (1 dB), Red alarms (b = −0.3; 95% CI: −1.237 to 0.63; p = 0.52). The R Square of the model with all alarms was 0.01 (standard error of estimate, 6.9; p < 0.001).ConclusionsSound levels were high during all day-periods. Alarms exceeding limits occurred most frequently. However, the contribution of alarms to sound levels measured at the nursing station is clinically limited.     

Factors affecting the occurrence of pressure injuries among patients receiving targeted temperature management after cardiac arrest

BackgroundPressure injuries (PIs) are a well-known complication of critically ill patients admitted to the intensive care unit with targeted temperature management (TTM) after cardiac arrest (CA). However, little is known about the factors that impact the occurrence of PIs among these patients.ObjectivesThis study aimed to examine factors related to the occurrence of PIs among patients after CA treated with TTM.MethodsThis retrospective observational study collected data from 126 patients after CA aged 18 years or older from a single tertiary hospital admitted between January 2017 and December 2019. Demographic, clinical, and medical device–related characteristics were collected by patient chart review. Multivariable logistic regression analysis was performed to identify factors related to the occurrence of PIs.ResultsThe study showed that the incidence of PIs was 31.8%. Patients who were male (odds ratio [OR], 4.80; 95% confidence interval [CI], 1.21–19.08), developed diarrhoea (OR, 4.90, 95% CI, 1.31–18.41), or were subjected to physical restraint (OR, 6.03; 95% CI, 1.52–23.96) were at a higher risk of developing PIs. A lower risk of developing PIs was associated with the Glasgow Coma Scale score greater than 13 on the third day of admission (OR, 0.08; 95% CI, 0.01–0.52), higher haemoglobin level (OR, 0.65; 95% CI, 0.49–0.86), or low nutritional risk index (≤100) (OR, 0.10; 95% CI, 0.02–0.57).ConclusionsNurses should be aware that patients treated with TTM after CA are at a high risk of developing PIs from the moment of admission and should be closely monitored.     

The epidemiology of rapid response team activation amongst patients undergoing major gastrointestinal surgery

BackgroundClinical deterioration requiring rapid response team (RRT) review is associated with increased morbidity amongst hospitalised patients. The frequency of and association with RRT calls in patients undergoing major gastrointestinal surgery is unknown. Understanding the epidemiology of RRT calls might identify areas for quality improvement in this cohort.ObjectivesThe objective of this study is to identify perioperative risks and outcome associations with RRT review following major gastrointestinal surgery.MethodsWe conducted a retrospective cohort study using electronic databases at a large Australian university hospital. We included adult patients admitted for major gastrointestinal surgery between 1 January 2015 and 31 March 2018.ResultsOf 7158 patients, 514 (7.4%) required RRT activation postoperatively. After adjustment, variables associated with RRT activation included the following: hemiplegia/paraplegia (odds ratio [OR]: 8.0, 95% confidence interval [CI]: 2.3 to 27.8, p = 0.001), heart failure (OR: 6.9, 95% CI: 3.3 to 14.6, p < 0.001), peripheral vascular disease (OR: 5.3, 95% CI: 2.7 to 10.4, p < 0.001), peptic ulcer disease (OR: 4.2, 95% CI: 2.2 to 8.0, p < 0.001), chronic obstructive pulmonary disease (OR: 4.0, 95% CI: 2.2 to 7.2, p < 0.001), and emergency admission status (OR: 2.6, 95% CI: 2.1 to 3.3, p < 0.001). Following the index operation, 46% of first RRT activations occurred within 24 h of surgery and 61% had occurred within 48 h. The most common triggers for RRT activation were tachycardia, hypotension, and tachypnoea. Postoperative RRT activation was associated with in-hospital mortality (OR: 6.7, 95% CI: 3.8 to 11.8, p < 0.001), critical care admission (incidence rate ratio: 8.18, 95% CI: 5.23 to 12.77, p < 0.001), and longer median length of hospital stay (12 days vs. 2 days, p < 0.001) compared to no RRT activation.ConclusionAfter major gastrointestinal surgery, one in 14 patients had an RRT activation, almost half within 24 h of surgery. Such activation was independently associated with increased morbidity and mortality. Identified associations may guide more pre-emptive management for those at an increased risk of RRT activation.