National early warning score (NEWS) and the new alternative SpO2 scale during rapid response team reviews: a prospective observational study

Peer reviewe

Outcome of adult patients attended by rapid response teams : A systematic review of the literature

Background: An abundance of studies have investigated the impact of rapid response teams (RRTs) on in-hospital cardiac arrest rates. However, existing RRT data appear highly variable in terms of both study quality and reported uses of limitations of care, patient survival and patient long-term outcome. Methods: A systematic electronic literature search (January, 1990-March, 2016) of the PubMed and Cochrane databases was performed. Bibliographies of articles included in the full-text review were searched for additional studies. A predefined RRT cohort quality score (range 0-17) was used to evaluate studies independently by two reviewers. Results: Twenty-nine studies with a total of 157,383 RRT activations were included in this review. The quality of data reporting related to RRT patients was assessed as modest, with a median quality score of 8 (range 2-11). Data from the included studies indicate that a median 8.1% of RRT reviews result in limitations of medical treatment (range 2.1-25%) and 23% (8.2-56%) result in a transfer to intensive care. A median of 29% (6.9-35%) of patients transferred to intensive care died during that admission. The median hospital mortality of patients reviewed by RRT is 26% (12-60%), and the median 30-day mortality rate is 29% (8-39%). Data on long-term survival is minimal. No data on functional outcomes was identified. Conclusions: Patients reviewed by rapid response teams have a high and variable mortality rate, and limitations of care are commonly used. Data on the long-term outcomes of RRT are lacking and needed. (C) 2017 Elsevier B.V. All rights reserved.Peer reviewe

Aetiology of in-hospital cardiac arrest on general wards

Aim: Aetiology of in-hospital cardiac arrests (IHCAs) on general wards has not been studied. We aimed to determine the underlying causes for IHCAs by the means of autopsy records and clinical judgement of the treating consultants. Furthermore, we investigated whether aetiology and preceding vital dysfunctions are associated with long-term survival. Design and setting: Prospective observational study between 2009-2011 including 279 adult IHCA patients attended by medical emergency team in a Finnish university hospital's general wards. Results: The median age of the patients was 72 (64, 80) years, 185 (66%) were male, 178 (64%) of events were monitored/witnessed, first rhythm was shockable in 42 (15%) cases and 53 (19%) patients survived six months. Aetiology was determined as cardiac in 141 events, 73 of which were due to acute myocardial infarction. There were 138 non-cardiac IHCAs; most common causes were pneumonia (39) and exsanguination (16). No statistical difference was observed in the incidence of objective vital dysfunctions preceding the event between the cardiac and non-cardiac groups (40% vs. 44%, p = 0.448). Subjective antecedents were more common in the cardiac cohort (47% vs. 32%, p = 0.022), chest pain being an example (11% vs. 0.7%, p <0.001). Reviewing all 279 IHCAs, only shockable primary rhythm, monitored/witnessed event and low comorbidity score were independently associated with 180-day survival. Conclusions: Cardiac aetiology underlies half of the IHCAs on general wards. Both objective and subjective antecedents are common. However, neither the cardiac aetiology nor the absence of preceding deterioration of vital signs were factors independently associated with a favourable outcome. (C) 2016 Elsevier Ireland Ltd. All rights reserved.Peer reviewe

In-hospital cardiac arrest in hospitals with mature rapid response systems - a multicentre, retrospective cohort study

Aim: To investigate in-hospital cardiac arrests (IHCAs) according to the Ustein template in hospitals with mature systems utilizing rapid response teams (RRTs), with a special reference to preceding RRT factors and factors associated with a favourable neurological outcome (cerebral performance category (CPC) 1-2) at hospital discharge. Methods: Multicentre, retrospective cohort study between 2017-2018 including two Finnish and one Australian university affiliated tertiary hospitals. Results: A total 309 IHCAs occurred with an incidence of 0.78 arrests per 1000 hospital admissions. The median age of the patients was 72 years, 63% were male and 73% had previously lived a fully independent life with a median Charlson comorbidity index of two. Before the IHCA, 16% of the patients had been reviewed by RRTs and 26% of the patients fulfilled RRT activation criteria in the preceding 8 h of the IHCA. Return of spontaneous circulation was achieved in 53% of the patients and 28% were discharged from hospital with CPC 1-2. In a multivariable model, younger age, no pre-arrest RRT criteria, arrest in normal work hours, witnessed arrest and shockable initial rhythm were independently associated with CPC 1-2 at hospital discharge. Conclusions: In hospitals with mature rapid response systems most IHCA patients live a fully independent life with low burden of comorbid diseases before their hospital admission, the IHCA incidence is low and outcome better than traditionally believed. Deterioration before IHCA is present in a significant number of patients and improved monitoring and earlier interventions may further improve outcomes.Peer reviewe

Ability of the National Early Warning Score and its respiratory and haemodynamic subcomponents to predict short-term mortality on general wards : a prospective three-centre observational study in Finland

OBJECTIVES: To validate the ability of the National Early Warning Score (NEWS) to predict short-term mortality on hospital wards, with a special reference to the NEWS's respiratory and haemodynamic subcomponents. DESIGN: A large, 1-year, prospective, observational three-centre study. First measured vital sign datasets on general wards were prospectively collected using a mobile solution system during routine patient care. Area under receiver operator characteristic curves were constructed, and comparisons between ROC curves were conducted with Delong's test for two correlated ROC curves. SETTING: One university hospital and two regional hospitals in Finland. PARTICIPANTS: All 19 001 adult patients admitted to 45 general wards in the three hospitals over the 1-year study period. After excluding 102/19 001 patients (0.53%) with data on some vital signs missing, the final cohort consisted of 18 889 patients with full datasets. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measure was 1-day mortality and secondary outcomes were 2-day and 30-day mortality rates. RESULTS: Patients' median age was 70 years, 51% were male and 31% had a surgical reason for admission. The 1-day mortality was 0.36% and the 30-day mortality was 3.9%. The NEWS discriminated 1-day non-survivors with excellent accuracy (AUROC 0.91, 95% CI 0.87 to 0.95) and 30-day mortality with acceptable accuracy (0.75, 95% CI 0.73 to 0.77). The NEWS's respiratory rate component discriminated 1-day non-survivors better (0.78, 95% CI 0.72 to 0.84) as compared with the oxygen saturation (0.66, 95% CI 0.59 to 0.73), systolic blood pressure (0.65, 95% CI 0.59 to 0.72) and heart rate (0.67, 95% CI 0.61 to 0.74) subcomponents (p<0.01 in all ROC comparisons). As with the total NEWS, the discriminative performance of the individual score components decreased substantially for the 30-day mortality. CONCLUSIONS: NEWS discriminated general ward patients at risk for acute death with excellent statistical accuracy. The respiratory rate component is especially strongly associated with short-term mortality. TRIAL REGISTRATION NUMBER: NCT04055350.publishedVersionPeer reviewe

Afferent limb failure revisited - A retrospective, international, multicentre, cohort study of delayed rapid response team calls

Aim: The efficiency of rapid response teams (RRTs) is decreased by delays in activation of RRT (afferent limb failure, ALF). We categorized ALF by organ systems and investigated correlations with the vital signs subsequently observed by the RRT and associations with mortality. Methods: International, multicentre, retrospective cohort study including adult RRT patients without treatment limitations in 2017-2018 in one Australian and two Finnish tertiary hospitals. Results: A total of 5,568 RRT patients' first RRT activations were included. In 927 patients (17%) ALF was present within 4 h before the RRT call, most commonly for respiratory criteria (419 patients, 7.5%). In 3516 patients (63%) overall, and in 756 (82%) of ALF patients, the RRT observed abnormal vital signs upon arrival. The organ-specific ALF corresponded to the RRT observations in 52% of cases for respiratory criteria, in 60% for haemodynamic criteria, in 55% for neurological criteria and in 52% of cases for multiple organ criteria. Only ALF for respiratory criteria was associated with increased hospital mortality (OR 1.71, 95% CI 1.29-2.27), whereas all, except haemodynamic, criteria at the time of RRT review were associated with increased hospital mortality. Conclusions: Vital signs were rarely normal upon RRT arrival in patients with ALF, while organ-specific ALF corresponded to subsequent RRT observations in just over half of cases. Our results suggest that systems mandating timely responses to abnormal respiratory criteria in particular may have potential to improve deteriorating patient outcomes.Peer reviewe

Suositus peruselintoimintojen arvioinnista ja seurannasta

NEWS-pisteytys yhtenäistää ja systematisoi peruselintoimintojen arviointia. Se kannattaa ottaa kattavasti käyttöön ensihoidon alkuarviosta aina kotiutuspäätökseen saakka

Advising and limiting medical treatment during phone consultation : a prospective multicentre study in HEMS settings

Background We investigated paramedic-initiated consultation calls and advice given via telephone by Helicopter Emergency Medical Service (HEMS) physicians focusing on limitations of medical treatment (LOMT). Methods A prospective multicentre study was conducted on four physician-staffed HEMS bases in Finland during a 6-month period. Results Of all 6115 (mean 8.4/base/day) paramedic-initiated consultation calls, 478 (7.8%) consultation calls involving LOMTs were included: 268 (4.4%) cases with a pre-existing LOMT, 165 (2.7%) cases where the HEMS physician issued a new LOMT and 45 (0.7%) cases where the patient already had an LOMT and the physician further issued another LOMT. The most common new limitation was a do-not-attempt cardiopulmonary resuscitation (DNACPR) order (n = 122/210, 58%) and/or 'not eligible for intensive care' (n = 96/210, 46%). In 49 (23%) calls involving a new LOMT, termination of an initiated resuscitation attempt was the only newly issued LOMT. The most frequent reasons for issuing an LOMT during consultations were futility of the overall situation (71%), poor baseline functional status (56%), multiple/severe comorbidities (56%) and old age (49%). In the majority of cases (65%) in which the HEMS physician issued a new LOMT for a patient without any pre-existing LOMT, the physician felt that the patient should have already had an LOMT. The patient was in a health care facility or a nursing home in half (49%) of the calls that involved issuing a new LOMT. Access to medical records was reported in 29% of the calls in which a new LOMT was issued by an HEMS physician. Conclusion Consultation calls with HEMS physicians involving patients with LOMT decisions were common. HEMS physicians considered end-of-life questions on the phone and issued a new LOMT in 3.4% of consultations calls. These decisions mainly concerned termination of resuscitation, DNACPR, intubation and initiation of intensive care.Peer reviewe

Limitation of treatment in prehospital care – the experiences of helicopter emergency medical service physicians in a nationwide multicentre survey

Making ethically sound treatment limitations in prehospital care is a complex topic. Helicopter Emergency Medical Service (HEMS) physicians were surveyed on their experiences with limitations of care orders in the prehospital setting, including situations where they are dispatched to healthcare facilities or nursing homes.Peer reviewe

Osakeyhtiön verotus ja verosuunnittelu

Tutkimuksen tarkoituksena on luoda katsaus osakeyhtiön verotukseen sekä verosuunnitteluun case-yrityksen pohjalta. Case-yrityksen toimialana on kirjanpito- ja tilinpäätöspalvelut. Tutkimus on tehty vastaamaan toimeksiantajan odotuksia ja vaatimuksia verosuunnittelusta Yhtiö X Oy:ssä. Odotuksia ja vaatimuksia selvitettiin yritykseen tehdyn SWOT- haastattelun avulla. Työn tavoitteena on ensisijaisesti tutkia verosuunnittelun mahdollisuuksia Yhtiö X Oy:n tilanteessa, mutta samalla myös perehdyttää aihetta tuntematon lukija osakeyhtiön verotuksen perusteisiin sekä verosuunnitteluun. Vuoden 2012 alussa voimaantulleet verouudistukset vaikuttavat omalta osaltaan verosuunnitteluun ja sen keinoihin. Työ voidaan jakaa teoria- ja tutkimusosaan. Teoriaosan tehtävä on valmistella lukijaa työn loppuolelta löytyvään tutkimusosaan, jonka tutkimus on toteutettu käyttäen kvalitatiivista eli laadullista tutkimusta. Laadullisen tutkimuksen luonne sopii aiheen tutkimustavaksi hyvin eikä muiden tutkimustapojoen käyttö ole perusteltua. Lähteinä on käytetty muun muassa aihetta käsittelevää kirjallisuutta, lainsäädäntöä, verkkolähteitä sekä SWOT- haastattelusta saatua informaatiota. Tuloksien perusteella voidaan sanoa yhtiö X Oy:n yritysostojen vaikuttaneen yhtiön kirjanpidon tulokseen. Tästä johtuen oma pääoma on tällä hetkellä negatiivinen, mutta korjaavia toimenpiteitä on ryhdytty tekemään. Yhtiön tulee keskittyä lähitulevaisuudessa negatiivisen oman pääoman saattamiseen lain vaatimalle tasolle. Tällä hetkellä Yhtiö X Oy ei voi jakaa varoja, osakeyhtiölain kieltäessä varojen jakamisen oman pääoman ollessa negatiivinen. Varojen jako tulee ajankohtaiseksi vasta kun yhtiö on saanut kerrytettyä vapaata jakokelpoista omaa pääomaa. Tulevaisuudessa voidaan tutkia yrityksen mahdollisuuksia laajentaa toimintaansa ja sitä, mitä käytännön tarpeita tämä yritykseltä vaatisi. Myös jatkuva verosuunnittelun kehittäminen verokäytäntöjen muuttuessa voisi olla yksi jatkotutkimuksen aiheista.The study aims to provide an overview of company taxation and tax planning in view of the case company. The case company's line of business is accounting and financial services. The thesis project was implemented to meet the client's expectations and requirements concerning tax planning in company X Ltd. To meet this goal, the commissioning company’s needs were examined through SWOT- interview. The aim of this study is primarily to search tax planning opportunities for company X Ltd's situation, but also to familiarize the reader with the essentials of the taxation of limited liability companies and tax planning. Tax reforms, which came into force in early 2012, are contributing to the design of tax planning and its means. The research can be divided into theory and empirical sections. The theoretical part aims to prepare the reader for the empirical part, which was conducted using qualitative research methods. The nature of qualitative research is well suited with the subject of the research and no other methodology can be as justified. As sources we have used relevant literature, legislation, online resources as well as information gathered from the SWOT- interview. Based on the results it may be concluded that company X Ltd's acquisitions have contributed to the company's result yielded. Consequently, shareholder’s equity is currently negative, but actions have been taken to correct the situation. In the near future the company will have to focus on the measures striving to turn the equity to the level that is required by the law. At present, the company X Ltd cannot distribute assets as the limited liability companies act forbids it until reserves of unrestricted equity allow it. A limited liability company is only entitled to the distribution of dividend or of assets from reserves of unrestricted equity with sufficient reserves as defined in legislation. In the future further research could be carried out into the company's opportunities to expand their operations and what practical needs the company would require. Also, the focus of such future studies could lie on the continuous development of tax planning along with the foreseeable tax policy reforms