Prediction and monitoring of in-hospital cardiac arrest

Background: In-hospital cardiac arrest (IHCA) is a global health concern of major importance, associated with a poor prognosis. IHCA is frequently heralded by a deterioration of vital signs, and many cases are considered preventable. Hence, prevention has become a key strategy. The overall aim of this thesis was to study the prevention of IHCA, by means of prediction and monitoring, with a view to improve patient safety. Methods: Study I and III are observational cohort studies, based on the Swedish Registry of Cardiopulmonary Resuscitation (SRCR). In study III, we also collected additional data from medical records in a small, hypothesis-generating group of patients. Study II and IV are prospective, observational cohort studies based on patients reviewed by Rapid Response Teams (RRTs) in 26 and 24 Swedish hospitals, respectively. In study IV, additional data on long-term survival was obtained from either medical records or the personal information directory, containing population registration data. Specific study aims and results: In study I, we investigated how 30-day survival after IHCA was influenced by ECG monitoring at the time of collapse, as well as clinical factors that determined whether patients were ECG monitored adjacent to cardiac arrest (CA). In all, 24,790 patients were enrolled in the SRCR between 2008 and 2017. After applying the exclusion criteria, 19,225 patients remained, of which 52% were monitored at the time of collapse. In all, 30-day survival was 30%. ECG monitoring at the time of CA was associated with a Hazard Ratio of 0.62 (95% Confidence Interval 0.60-0.64) for 30-day mortality. The strongest predictor of ECG monitoring adjacent to IHCA was location in hospital. There were tangible variations in the frequency of patients who were ECG monitored at the time of collapse between Swedish regions and across hospitals. In study II, we investigated the predictive power of NEWS 2, as compared to NEWS, in identifying patients at risk of Serious Adverse Events (SAEs) within 24 hours of an RRT-review. In all, 1,065 patients, reviewed by RRTs in general wards during the study period between October 2019 and January 2020, were included. After applying the exclusion criteria, 898 patients were eligible for complete case analyses. In all, 37% of the patients were admitted to the Intensive care unit (ICU) within 24 hours of RRT-review. In-hospital mortality and IHCA were uncommon (6% and 1% respectively). The Area Under the Receiver Operating Characteristic (AUROC) for both NEWS and NEWS 2 was 0.62 for the composite outcome, and 0.69/0.67 for mortality. Regarding the outcome unanticipated ICU admission, the AUROC was 0.59 and 0.60, respectively, while the AUROC for IHCA was 0.51 (NEWS) and 0.47 (NEWS 2), respectively. In study III, we investigated 30-day survival and ROSC in patients suffering from IHCA, who were reviewed by an RRT within 24 hours prior to the CA, as compared to those without such review. Furthermore, we studied patient centred factors prior to RRT activation, the timeliness of the RRT-review as well as the reason for the RRT-review. We also investigated the association between RRT interventions and outcome. During the study period between 2014 and 2021, 19,973 patents were enrolled in the SRCR. After applying the exclusion criteria, 12,915 patients remained. Among these IHCA patients, there was an RRT/ICU contact within 24 hours prior to the CA in 2,058 cases (19%). The adjusted 30-day survival was lower among patients reviewed by an RRT prior to IHCA (25% vs. 33%, p <0.001). Regarding ROSC, we did not observe any difference between the groups. The propensity score based Odds Ratio for 30- day survival was 0.92 for patients who were reviewed by an RRT (95% CI 0.90 to 0.94, p <0.001), as compared to those who were not RRT- reviewed within 24 hours prior to IHCA. A respiratory cause of CA was more common among IHCA patients who were reviewed by an RRT. In the small, explorative subgroup (n=82), 24% of the RRT activations were delayed, and respiratory distress was the most common RRT trigger. We observed a significantly lower 30-day survival among patients triaged to remain at ward compared to those triaged to a higher level of care (2% vs. 20%, p 0.016). In study IV, we explored the impact of age on the ability of NEWS 2 to predict IHCA, unanticipated ICU-admission, or death, and the composite of these three SAEs, within 24 hours of review by an RRT. Furthermore, we aimed to investigate 30-, 90- and 180-day mortality, and the discriminative ability of NEWS 2 in the prediction of long-term mortality among RRT-reviewed patients. In this multi-centre study based on data prospectively collected by RRTs, the NEWS 2 scores of all patients were retrospectively, digitally calculated by the study team. Age was analysed as a continuous variable, in a spline regression model, and categorized into five different models, subsequently explored as additive variables to NEWS 2. The discriminative ability of NEWS 2 in predicting 30-day mortality improved by adding age as a covariate (from AUROC 0.66, 0.62-0.70 to 0.70, 0.65-0.73, p=0.01). There were differences across age groups, with the best predictive performance identified among patients aged 45-54 years. The 30-, 90-and 180-day mortality was 31%, 33%, and 36%, respectively. Conclusion: ECG monitoring at the time of IHCA was associated with a 38% reduction of adjusted mortality. Despite this finding, only one in two IHCA patients were ECG monitored. The most important factor influencing ECG monitoring was which type of hospital ward the patient was admitted to. The tangible variations in the frequency of ECG monitoring adjacent to IHCA observed between Swedish regions and across hospitals need to be investigated in future studies. Guidelines for the monitoring of patients at risk of CA could contribute to an improved outcome. The prognostic accuracy of NEWS 2 in predicting mortality within 24 hours of an RRT-review was acceptable, whereas the discriminative ability in prediction of unanticipated ICU-admission and the composite outcome was rather weak. Regarding the prediction of IHCA, NEWS 2 performed poorly. There was no difference in the prognostic accuracy between NEWS and NEWS 2; however, the discriminative ability was not considered sufficient to serve as a triage tool in RRT-reviewed patients. In-hospital cardiac arrest among patients who were reviewed by an RRT prior to CA was associated with a poorer prognosis, and a more frequent respiratory aetiology of the CA. In the explorative sub-group of patients, RRT activation was frequently delayed, the most common trigger for RRT-review was respiratory distress, and escalation of the level of care was associated with an improved prognosis. Early identification of patients with abnormal respiratory vital signs, followed by a timely response, may have a potential to improve the prognosis for patients reviewed by an RRT and prevent IHCA. Adding age as a covariate improved the discriminative ability of NEWS 2 in the prediction of 30-day mortality among RRT-reviewed patients. The ability differed across age categories. Overall, the long-term prognosis of RRT-reviewed patients was poor. Our results indicate that age merits further validation as a covariate to improve the performance of NEWS 2

The Implementation of an Early Warning System to a Sub-Acute Unit

Changes in legislation and regulation inIrelandhave resulted in significant care of the elderly beds being incompatible with Health Information and Quality Authority (HIQA) standards regarding aging infrastructure. To ensure organisational viability, alternative deployment of these beds to sub-acute care, in line with Government policy is necessary. Additionally, hospitalised patients are in danger of experiencing deterioration at many points during their stay, a fact further compounded by this change in designation with lack of policy, procedure or protocol further exasperating patient risk. This change project outlines the introduction and implementation of an Early Warning System (EWS) to a twelve bedded sub-acute unit, utilising the Health service Executive (HSE) change model, based on the organisational development approach. A transformational leadership system is employed to establish this concept, progressing the team through training, development and reflection whilst engaging externally utilising an appropriate improvement framework. The change is then evaluated via a multi-method approach, outlining action necessary for future, further dissemination. The implementation of the EWS facilitated recognition of abnormal physiological considerations and prioritisation of care, enveloping the concept of continuous quality improvement by means of improved clinical reasoning skills and interdisciplinary communication. However, the success of the initiative was heavily dependent on considerable training, development and support over a two month period. To facilitate subsequent successful implementation elsewhere, will necessitate the allocation of specific resources, ensuring context driven interventions, training and evaluation. Such evidence will determine the effectiveness of the EWS in improving patient safety and preventing unsavoury patient outcomes, demonstrating the hospital’s ability to adequately care for this category of patient, standardising patient care and ensuring organisational sustainability in line with present Government strategy

Interventions to reduce mortality from in-hospital cardiac arrest: a mixed-methods study

BackgroundUnchecked patient deterioration can lead to in-hospital cardiac arrest (IHCA) and avoidable death. The National Cardiac Arrest Audit (NCAA) has found fourfold variation in IHCA rates and survival between English hospitals. Key to reducing IHCA is both the identification of patients at risk of deterioration and prompt response. A range of targeted interventions have been introduced but implementation varies between hospitals. These differences are likely to contribute to the observed variation between and within hospitals over time.ObjectiveTo determine how interventions aimed at identification and management of deteriorating patients are associated with IHCA rates and outcomes.DesignA mixed-methods study involving a systematic literature review, semistructured interviews with 60 NHS staff, an organisational survey in 171 hospitals and interrupted time series and difference-in-difference analyses (106 hospitals).SettingEnglish hospitals participating in the NCAA audit.ParticipantsNHS staff (approximately 300) and patients (13 million).InterventionsEducation, track-and-trigger systems (TTSs), standardised handover tools and outreach teams.Main outcome measuresIHCA rates, survival and hospital-wide mortality.Data sourcesNCAA, Hospital Episode Statistics, Office for National Statistics Mortality Statistics.MethodsA literature review and qualitative interviews were used to design an organisational survey that determined how interventions have been implemented in practice and across time. Associations between variations in services and IHCA rates and survival were determined using cross-sectional, interrupted time series and difference-in-difference analyses over the index study period (2009/10 to 2014/15).ResultsAcross NCAA hospitals, IHCAs fell by 6.4% per year and survival increased by 5% per year, with hospital mortality decreasing by a similar amount. A national, standard TTS [the National Early Warning Score (NEWS)], introduced in 2012, was adopted by 70% of hospitals by 2015. By 2015, one-third of hospitals had converted from paper-based TTSs to electronic TTSs, and there had been an increase in the number of hospitals with an outreach team and an increase in the number with a team available at all times. The extent of variation in the uses of educational courses and structured handover tools was limited, with 90% of hospitals reporting use of standardised communication tools, such as situation, background, assessment and recommendation, in 2015. Introduction of the NEWS was associated with an additional 8.4% decrease in IHCA rates and, separately, a conversion from paper to electronic TTS use was associated with an additional 7.6% decrease. However, there was no associated change in IHCA survival or hospital mortality. Outreach teams were not associated with a change in IHCA rates, survival or hospital mortality. A sensitivity analysis restricted to ward-based IHCAs did not alter the findings but did identify an association between increased outreach team intensity in 2015 and IHCA survival.LimitationsThe organisational survey was not able to explore all aspects of the interventions and the contextual factors that influenced them. Changes over time were dependent on respondents’ recall.ConclusionsStandardisation of TTSs and introduction of electronic TTSs are associated with a reduction in IHCAs. The apparent lack of impact of outreach teams may reflect their mode of introduction, that their effect is through providing support for implementation of TTS or that the organisation of the response to deterioration is not critical, as long as it is timely. Their role in end-of-life decision-making may account for the observed association with IHCA survival.Future workTo assess the potential impact of outreach teams at hospital level and patient level, and to establish which component of the TTS has the greatest effect on outcomes.FundingThe National Institute for Health Research Health Services and Delivery Research programme.</jats:sec

Facilitators and Barriers to Nursing Surveillance of Instability in Hospitalized Pediatric Patients: A Grounded Theory Study

Identification of patients at risk for deterioration initially started with studies that focused predictors of cardiopulmonary and neurovascular demise. This spawned research to evaluate the utility of predictor models followed by the performance studies of early warning track and trigger systems in adults. Mandates to provide emergency services early in the course of instability in the 1990s fueled research to analyze the outcomes of rapid response systems and early warning systems in both adults and pediatrics. Recently studies have looked at system and human factors that impact failure to rescue. Given the dearth of systems research in early prevention of deterioration in pediatrics this study was designed to explore what nurses do during deterioration and the factors that impact their actions. Interview and observations of 13 pediatric nurses and 16 parents of pediatric patients admitted to a non ICU environment were conducted at one academic children’s hospital in the Northwest USA. Grounded theory methods were used to guide data collection and analysis. Findings describe nursing actions associated with nursing surveillance of instability as well as factors that facilitate or impede surveillance efficacy. We present a theoretical model for how nurses and parents integrate their roles in surveillance of pediatric patients. We also further developed a sociotechnical model of nursing surveillance

Examination of the constructs of the Transtheoretical model in patients with heart failure: a focus on physical activity readiness

The goal of this research was to gain greater understanding about the management of heart failure patients. A particular focus was to evaluate exercise tolerance and behavior. The major findings of the first study included: (1) evidence that few heart failure patients receive adequate information regarding physical activity; (2) performance on a six-minute walk test were ~42% lower, and SF-36 scores were also lower in heart failure patients compared to controls; (3) stability in hemodynamic measures and distance walked on the 6-minute walk test were adequate, and (4) home exercise resulted in 19% improvement in maximum walking distance and 30% improvement in physical function score on the SF-36. The second study showed the feasibility to implement a care-managed program for heart failure patients in a family practice setting. However, a significant barrier was recruitment. Despite this failure, patients improved ~24% on the maximum walking distance and 29%, 46%, and 13% on the physical function, vitality, and mental health scores on the SF-36. The third study examined the motivation and readiness of heart failure patients to engage in planned physical activity. The findings revealed 22 patients in precontemplation, 33 in contemplation, 41 in preparation, 23 in action, and 29 in maintenance. In regards to the Transtheoretical model constructs (self-efficacy, pros and cons of decisional balance, and experiential processes) the data revealed that self-efficacy scores were lowest in the precontemplation and increased in linear fashion to maintenance. Decisional balance changed from greater perceived cons and lower perceived pros in precontemplation and contemplation to lower perceived cons and higher perceived pros in action and maintenance. Experiential processes were used predominantly in precontemplation and contemplation, whereas behavioral processes were more prominently used in action and maintenance. The most important predictors of physical activity stages of change were the behavioral processes (r2= .78)followed by perceived self-efficacy (r2= .66). Finally, this study indicated that patients in preaction stages of readiness to exercise have significant lower exercise tolerance then those in action and maintenance. These data suggest greater clinical emphasis should be placed on strategies to move patients toward the preparation and action stages of readiness

Support for older people with COPD in community settings: a systematic review of qualitative research.

There are an estimated three million people affected by Chronic Obstructive Pulmonary Disease (COPD) in the UK with only about 900,000 of these being diagnosed according to the Healthcare Commission, and prevalence is increasing. Significant progress has been made in respect of treatment and management of the disease. However, there is limited evidence related to the perspective of those with COPD despite an acknowledgement that lung function, as determined by spirometry, does not necessarily equate with pulmonary disease5 and subsequent functional level or disability. The impact of COPD on patients, their family, carers and healthcare services demands that better ill health prevention and disease maintenance strategies be employed. The objective of this review was to explore the common and shared experiences of those in caring partnership for patients with COPD receiving care and support in their community. For this review, the definition of support takes the view that support relates to ‘any activity or intervention aimed at improving or maintaining the health status of a patient with COPD’. The review focused on the experiences of patients, carers, family members, nurses and doctors involved in providing support to patients with COPD in their own home. Patients aged 65 years and over were included. The review considered studies that represented patient, carer, nursing and medical staff experiences and perceptions of support relating to COPD. The review considered evidence from qualitative research including phenomenology, grounded theory, and descriptive studies, where support for COPD in a community context was the focus. The search set out to find published studies in English from 1990-2010. The studies were appraised and findings extracted using the JBI critical appraisal tool for qualitative research. Three reviewers appraised the studies independently. 72 studies were critically appraised and 39 met the inclusion criteria. Findings from included papers were aggregated, categorised and synthesised. Three syntheses were extracted from the categorised findings: 1) Consistence in service provision. If those with COPD received more consistent support in relation to information, rehabilitation, end of life care and other service provision then their quality of life could be enhanced. 2) Home based care. Better planned and more integrated support for home based care around self-care/management and in managing exacerbations can reduce patient and carer anxiety and distress related to COPD. 3) Individualisation of care. Individualisation of care, which is not based on the patient's ‘disease state’ (i.e. physical parameters) but on assessed need, is a necessary part of care for those with COPD

Orthogeriatrics

This new open access edition supported by the Fragility Fracture Network aims at giving the widest possible dissemination on fragility fracture (especially hip fracture) management and notably in countries where this expertise is sorely needed. It has been extensively revised and updated by the experts of this network to provide a unique and reliable content in one single volume. Throughout the book, attention is given to the difficult question of how to provide best practice in countries where the discipline of geriatric medicine is not well established and resources for secondary prevention are scarce. The revised and updated chapters on the epidemiology of hip fractures, osteoporosis, sarcopenia, surgery, anaesthesia, medical management of frailty, peri-operative complications, rehabilitation and nursing are supplemented by six new chapters. These include an overview of the multidisciplinary approach to fragility fractures and new contributions on pre-hospital care, treatment in the emergency room, falls prevention, nutrition and systems for audit. The reader will have an exhaustive overview and will gain essential, practical knowledge on how best to manage fractures in elderly patients and how to develop clinical systems that do so reliably

New insights on the multidimensionality of fatigue and on its relationship with cognitive impairments in multiple sclerosis

Multiple Sclerosis (MS) is an inflammatory disease of the central nervous system (CNS), and it represents the most common cause of irreversible impairment in young adults, affecting about 2.5 million individuals worldwide. In MS, acute attacks of inflammation, leading to demyelination and axonal loss, determine the accumulation of disabilities, varying in number, nature, and severity. Indeed, motor, sensory, cognitive, and behavioral symptoms may manifest at different times during the disease's variable clinical course. Fatigue is a complex and multifaceted phenomenon and one of the most prevalent and disabling symptoms of MS, affecting 75%–90% of patients. Despite its prevalence, MS- related fatigue is still poorly understood. The absence of a well-validated definition and of clear insights into its pathophysiological causes makes fatigue a hybrid symptom, approached within the context of different disciplines, each with their own methods and tools. As a result, the scientific literature abounds with irreconcilable data, leaving fatigue in a dark shadow zone, at the expense of MS patients still lacking adequate therapies and strategies of management. The main topic of this thesis relates to the multidimensional nature of fatigue, to its variability, and its effects on attentional processes, most commonly affected in MS patients. Specifically, studies presented in the current thesis address four research issues: (i) are physical and mental fatigue two distinct constructs? (ii) how do physical and mental fatigue vary within a short (within a day) and long (within a year) period? (iii) how do induced physical and mental fatigue impact the attentional functions of alerting, orienting, and conflict resolution in MS? The main results of the studies are reported: a) A clear distinction between physical and mental fatigue has been psychometrically documented in MS patients. b) MS patients reported experiencing more overall fatigue than Controls. c) A gradual increase in overall fatigue from the morning to the evening was reported by MS participants. d) Across experiments physical fatigue was significantly more pronounced in MS patients as compared to Controls. e) Both MS patients and Controls reported having experienced more overall fatigue in the past (one year ago) than in the present (the last 24 hours). f) MS patients were slower as compared to Controls in performing attentional tasks; however, inconclusive results have emerged regarding the effects of physical and mental fatigue on attentional processes. g) Sleep quality and depression were both associated with fatigue across the experiments. The relationship between self-efficacy, general cognitive functioning, functional deterioration, and physical and mental fatigue is fragmented, thus preventing a clear conclusion

To convey, or not convey …? The effect and usefulness of the National Early Warning Score to support paramedics’ decisions to convey patients to hospital or treat closer to home.

Background: The ambulance service studied introduced the National Early Warning Score (NEWS) to help paramedics decide whether patients could be appropriately treated closer to home, via an alternative non-emergency care pathway, or needed conveying to hospital. I investigated the effectiveness and usefulness of the NEWS to support paramedics’ decisions to appropriately treat patients closer to home. Methods: I adopted a pragmatic approach and used mixed methods. I used an interrupted time-series design and autoregressive integrated moving average (ARIMA) methods to analyse ambulance data. My analysis focused on the change in outcome and trend in outcome, before and after NEWS was introduced. Primary outcomes measured were numbers and proportions of patients not conveyed to the emergency department (i.e. treated closer to home), which included those treated and left at scene and those conveyed to a minor injury unit or similar. Secondary outcomes measured were numbers and proportions treated and left at scene who recontacted the ambulance service within 24-hours. Numbers of 999-calls attended, patients treated and left at scene and life-threatening calls were also analysed to provide a baseline measure and enhance understanding about primary and secondary outcomes. A self-selected sample of paramedics participated in semi-structured interviews and a non-participant observation study. Semi-structured interviews were conducted to gain insight of perceived effectiveness and usefulness of the NEWS to support decision-making. Non-participant observations were conducted to observe how the NEWS was used in context. Results: Baseline measures showed no significant difference in the numbers of emergency calls attended to by ambulance, although numbers of life-threatening calls increased significantly. Despite the increase in life-threatening calls, the numbers and proportion of patients being treated closer to home remained constant. While a significant decline was found in the numbers of patients left at scene, the numbers and ii proportions of patients who recontacted within 24-hours did not differ significantly. Sixteen paramedics were interviewed. Those interviewed did not perceive the NEWS to have affected their decision-making or clinical practice. Other factors influenced their decision to convey or treat closer to home more than NEWS. They would use the NEWS to inform a decision only at times of uncertainty. NEWS was considered ineffective and not useful when assessing patients with complex conditions. NEWS was more readily adopted in localities where other healthcare providers were familiar and were using the NEWS. Eight paramedics were observed as they worked in the clinical setting. Those observed rarely calculated, documented or verbalised a NEWS. Half the NEWS documented, were calculated or documented incorrectly. There was no visible evidence of the NEWS tool being used; any scores documented were calculated from memory. Conclusions: The effectiveness and usefulness of the NEWS to support paramedics’ decision-making to appropriately treat patients closer to home was compromised by a lack of coherence between service providers and practitioners, and lack of accessibility to alternative care pathways. My findings will be of value to service providers seeking to achieve NHS England’s ambition to increase the uptake of the NEWS to 100%, and those responsible for redesigning and commissioning integrated care services