Observational Study. Shannon M. Fernando, MD, MSc1,2, Peter M. Reardon, MD1,2,. Damon C. Scales, MD, PhD3,4, Kyle Murphy, MD1, Peter Tanuseputro, MD ...
Prevalence, Risk Factors, and Clinical Consequences of Recurrent Activation of a Rapid Response Team: A Multicenter Observational Study
Journal of Intensive Care Medicine 1-8 ª The Author(s) 2018 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0885066618773735 journals.sagepub.com/home/jic
Shannon M. Fernando, MD, MSc1,2, Peter M. Reardon, MD1,2, Damon C. Scales, MD, PhD3,4, Kyle Murphy, MD1, Peter Tanuseputro, MD, MHSc5,6,7, Daren K. Heyland, MD, MSc8, and Kwadwo Kyeremanteng, MD, MHA1,5,7
Abstract Introduction: Rapid response teams (RRTs) are groups of health-care providers, implemented by hospitals to respond to distressed hospitalized patients on the hospital wards. Patients assessed by the RRT for deterioration may be admitted to the intensive care unit (ICU) or may be triaged to remain on the wards, putting them at risk of recurrent deterioration and repeat RRT activation. Previous studies evaluating outcomes of patients with recurrent deterioration and multiple RRT activations have produced conflicting results. Methods: We used a prospectively collected multicenter registry from 2 hospitals within a single tertiary-level hospital system between 2012 and 2016. Comparisons were made between patients with a single RRT activation and those with multiple RRT activations over the course of their admission. Primary outcome was in-hospital mortality, which was analyzed using multivariable logistic regression. Results: A total of 5995 patients who had any RRT activation were analyzed. Of that, 1183 (19.7%) patients had recurrent deterioration and multiple RRT activations during their admission. Risk factors for recurrent deterioration included admission from a home setting (as opposed to a long-term care facility), RRT activation during nighttime hours, and delay (>1 hour) to RRT activation. Recurrent deterioration was associated with increased odds of mortality (adjusted odds ratio [OR]: 1.44 [1.28-1.64], P ¼ 130 or 1 RRT activation, using the Student t test for continuous variables and w2 test for categorical variables. In order to identify characteristics associated with recurrent deterioration, we utilized multivariable logistic regression. Similarly, in evaluating the outcomes of in-hospital mortality and ICU admission following RRT activation, we used multivariable logistic regression modeling to adjust for potential confounders, including patient characteristics (age, sex, comorbidities, comorbidity index, previous ED visits in the past year, previous hospital admissions in the past year, and previous ICU admissions in the past year), admitting service, time of initial RRT activation (daytime [08:00-16:59] vs nighttime [17:00-07:59]), most recent laboratory investigations at the time of RRT activation, and vital signs at the time of RRT activation. Patients were further categorized by increasing number of RRT activations (1, 2, 3, or 4). Logistic regression was performed, using the group with 1 activation as the reference. Adjusted odds ratio (OR) with 95% confidence intervals (CI), and adjusted P values are provided. A P value .05 was taken to represent statistical significance.
3 Table 1. Characteristics of Patients With and Without Recurrent RRT Activation. Repeat RRT Activation Variable Age, years, mean (SD) Male, n (%) Admission source, n (%) Home Acute care facility transfer Long-term care facility transfer Unknown Comorbidities, n (%) Congestive heart failure Arrhythmia Valvular disease Peripheral vascular disease Hypertension Chronic obstructive pulmonary disease Diabetes mellitus Renal failure Liver disease Metastatic cancer Elixhauser comorbidity score, mean (SD) Emergency department visits in past year, median (IQR) Hospital admissions in past year, median (IQR) ICU admissions in past year, median (IQR) Admitting service, n (%) Surgical service Nonsurgical service Limits of care, n (%) Full care No ICU-level care Do not resuscitate Other/unknown
No, n ¼ 4812
Yes, n ¼ 1183
68.0 (16.5) 67.3 (16.5) 2554 (51.9) 633 (52.3)
P Value .21 .79
