Krish.S.Rajan

Senior Specialist in Intensive Care Medicine

A/Prof Arthas Flabouris

Prof Campbell Thompson

ANZICS CTG point prevalence programme

George Institute

RAH MET database

SA health

The early detection and response to patients who become acutely unwell is a key Safety & Quality initiative across Australia

Prognosis of in-hospital cardiac arrest (IHCA) is poor.

Survival rates at hospital discharge do not exceed 20%1.

Prompt recognition of signs of deterioration may prevent subsequent

cardiac arrests2.

84% of IHCA show signs of deterioration prior to their cardiac arrest

Ward level recognition and response is often inadequate3

Rapid response systems (RRSs) have been proposed as a measure to

detect and respond to the deteriorating patient so as to prevent subsequent

adverse events4

Sandroni C, Nolan J, Cavallaro F, Antonelli M. In-hospital cardiac arrest: incidence, prognosis and possible measures to improve survival. Intensive Care Med

2007;33:237–45.

. Schein RM, Hazday N, Pena M, Ruben BH, Sprung CL. Clinical antecedents to in-hospital cardiopulmonary arrest. Chest 1990;98:1388–92.

. Hodgetts TJ, Kenward G, Vlackonikolis I, et al. Incidence, location and reasons for avoidable in-hospital cardiac arrest in a district general hospital. Resuscitation

2002;54:115–23.

. DeVita MA, Bellomo R, Hillman K, et al. Findings of the first consensus conference on medical emergency teams. Crit Care Med 2006;34:2463–78.

Palliative care

Efferent limb

Afferent Limb

Afferent Limb Failure is common and associated with patient harm 22.8% of events preceded by ALF

60% of ALF occurrences at night Trinkle, et al. Resuscitation 2011;82:810-14

The type of medical review prior to an adverse event influences patient outcome

Trinkle et al. Critical Care and Resuscitation 2011; 13; 175-180

Absence of increased mortality associated with ALF group

Shorter duration of the delay in the MET call observed in this study as compared with the previous ones*

Afferent limb failure is still a major issue even in mature RRSs.

Reducing the incidence of ALF could potentially reduce the risk of adverse events.

*Calzavacca P, Licari E, Tee A, et al. The impact of Rapid Response System on delayed emergency team activation patient characteristics and outcomes—a follow-up study. Resuscitation 2010;81:31–5.

*Downey AW, Quach JL, Haase M, Haase-Fielitz A, Jones D, Bellomo R. Characteristics and outcomes of patients receiving a medical emergency team review for acute change in conscious state or arrhythmias. Crit Care Med 2008;36: 477–81.

Diurnal variations in MET dose and patient outcomes

◦ DeVita, et al Medical emergency teams: deciphering clues

to crises in hospitals. Critical Care 2005;9:325-326

◦ Mitchell, et al A prospective controlled trial of the effect of a multi-faceted intervention on early recognition and intervention in deteriorating hospital patients. Resuscitation 2010;81:658-666

◦ Bhonagiri, et al. Increased mortality associated with after-hours and weekend admission to the intensive care unit: a retrospective analysis. MJA 2011;194:287-292

Diurnal variations in patient outcomes

Hospital mortality rate and length of stay in patients admitted

at night to the intensive care unit.

Crit Care Med 2003; 31: 858-863.

Weekend and weeknight admissions have the same outcome of weekday admissions to an intensive care unit with onsite intensivist coverage.

Crit Care Med 2006; 34: 605-611.

Mortality among patients admitted to intensive care units during weekday day shifts compared with “off” hours.

Crit Care Med 2007; 35: 3-11.

WEEKDAY

Courtesy : Adam Deane

Diurnal variation of MET and Cardiac Arrest occurrence

MET hour of day

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Diurnal variation of MET and Cardiac Arrest occurrence

Diurnal variation in MET outcomes Based upon patients who had a MET call during their hospital stay

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Is there a diurnal variation in RRT performance as measured by ◦ Afferent limb failure (ALF)

◦ Efferent limb failure (ELF)

Is there a diurnal variation in the consequences of ALF and ELF

Do newly implemented track and trigger systems influence diurnal variation and associated patient outcomes

Preliminary data from the RAH ◦ Explore diurnal variation

Point prevalence study across ANZ units ◦ Baseline information across a number of sites on

diurnal variation

◦ Afferent and Efferent limb failure

Before and after implementation of new patient observation charts ◦ Retrospective case note review

◦ Data linkage

Diurnal variation in MET outcomes Based upon patients who had a MET call during their hospital stay

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Prospective Observational Chart review across Australian and New Zealand ICUs

ICU admissions from a general ward

Data from the 24 hours immediately preceding admission to ICU

Objectives ◦ Ascertain diurnal variation in patient monitoring,

and responding to clinical deterioration

◦ Across a diverse group of hospitals

◦ Ascertain any association with patient outcomes

Emergency admission directly from ward

↓

Emergency admissions

from other

ICU

OT

Recovery

ED

CCU

Yes No Excluded

ICU

Excluded

Included

Adult >16 years

Descriptive Statistics

N=48

Distribution of ICU LOS

Distribution of Hospital LOS

Distribution of Age

Inferential Statistics

Incidence of afferent limb failure (ALF)

Relationship between ALF

o ICU mortality

o Hospital mortality

o Length of stay

Diurnal variation in ALF

Frequency of Observations

Frequency of complete vital signs

o Is there a diurnal variation in Observations

o Is there a diurnal variation in admission to the ICU

Variable N Median Lower Quartile

Upper Quartile

Age 48 62.50 51.50 74.00

APACHE 2 47 21.00 17.00 26.00

Sex Frequency Percent

Female 16 33.33

Male 32 66.67

ALF (overall) frequency percent

NO 30 62.50

YES 18 37.50

Those patients who had overall ALF had odds of dying in hospital

approximately 50% the odds of those who did not have overall ALF

Odds ratio= 0.47 95% CI: 0.07, 2.93 P=0.42

Patients with Afferent Limb Failure and ICU mortality

Day/night frequency percent

Day & Night 8 44.44

Day 5 27.78

Night 5 27.78

Afferent Limb Failure and Observations made during the day compared to night

time

Odds ratio 0.93 CI 0.23;3.79 P=0.92

Afferent limb failure and association with a complete set of observations

odds ratio 2.5 CI 0.5; 13.1 P=0.25

24 patients (50%) were admitted following a cardiac arrest to ICU

None of these patients had afferent limb failure

The remaining patients were admitted to ICU following a RRT call and Consults

Small sample size

Accuracy of survey data and completeness of data on the CRF

◦ ICU Length of stay

◦ D28 outcomes

The prevalence of afferent limb failure amongst patients admitted to the ICU from the ward is high

This point prevalence study was unable to identify a diurnal variation in the incidence of afferent limb failure, completeness of observations and admission times to ICU and efferent limb failure

Afferent limb failure is potentially avoidable

Reducing afferent limb failure may reduce unanticipated ICU admissions from the ward

a larger study is needed to definitively answer this topical and pertinent question f diurnal variation in the consequences of ALF and ELF

Period prevalence study across SA units ?

Parameters PPP Chart review

Study type Prospective observational chart review on a day

Before and after RDR chart Data linkage (ICU, MET, Hospital administrative datasets

Settings Multicentre, ANZ ICU’s RAH

Patients Admissions to ICU from general ward

RRT call Unanticipated ICU adm Cardiac arrest

Measures In the 24 hrs prior to admission, occurrence of ALF, Discharge from a critical care area (ED/ICU/OT)

Frequency of, type and recorded patient observations

Time of day

Outcome ICU and Hospital mortality and LOS

ALF ELF Diurnal variation Unanticipated ICU admissions Hospital mortality

◦ Add further knowledge towards diurnal variation and its consequences

◦ Evaluate the impact upon diurnal variation and RRT performance of newly implemented strategies for the detection and response to the deteriorating patient

◦ Make recommendations as to how such strategies may be improved in the future

‘ No power on earth can

STOP an idea whose

time has come ‘

Victor Hugo