|Year : 2020 | Volume
| Issue : 4 | Page : 123-129
Exploring factors affecting critical care response team service at a tertiary hospital in Riyadh: A retrospective cohort study
Abdulmajeed Alhaidari1, Maram Busuhail2, Sara Alsultan3, Sultan Alshammari4, Abdullah Alshimemeri5
1 College of medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
2 College of medicine, King Faisal University, Alahsa, Saudi Arabia
3 College of medicine, King Saud University, Riyadh, Saudi Arabia
4 College of medicine, Almaarefa University, Riyadh, Saudi Arabia
5 Department of Intensive Care Medicine, College of medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
|Date of Submission||10-Oct-2020|
|Date of Decision||11-Nov-2020|
|Date of Acceptance||12-Nov-2020|
|Date of Web Publication||31-Dec-2020|
Alhaidari College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh 11159
Source of Support: None, Conflict of Interest: None
Background: Critical care response team (CCRT) is a proactive department of intensive care unit (ICU) that consists of an intensivist, a staff physician, a critical care nurse, and a respiratory therapist. The purpose of this team is to manage patients in their wards to avoid unnecessary ICU bed occupancies. The aim of the study is to explore factors affecting CCRT service in terms of patient disposition and mortality rate and to analyze interventions provided to the patients by the team. Materials and Methods: This is a retrospective cohort study conducted at a tertiary hospital in Riyadh. All CCRT event data collection forms from the period between February 2018 and April 2019 were reviewed. Patients meeting our criteria were included. Outcome measures were as follows: (1) patient disposition. (2) mortality rate. Factors that were tested for effect on CCRT service were patient age, activation time, and reasons for activation. All statistical analyses were done using SAS software 9.4. Results: A total of 1088 CCRT events were considered during the period of the study. Out of all deaths, the mean age was 70.90 ± 16.67 compared to the mean age of survivors 61.21 ± 20.65 (P < 0.0001). Furthermore, older patients had higher chances for ICU transfer (P = 0.0399). CCRT service was not affected by activation time as patient disposition and mortality rates were almost the same in activations during and out of work hours. The most common reason for CCRT activation was tachypnea (28.49%). Majority of patients within each reason for activation were not transferred to the ICU, except for low oxygen saturation (50.54% transferred to the ICU) (P = 0.0001), decreased level of consciousness (DLOC) (49.40% transferred to ICU) (P = 0.0001). Patients not transferred to the ICU had lower mortality rate (15.18%) than those transferred to the ICU (55.41%) (P < 0.0001). Conclusion: Given these results, increased vigilance and quick responses to CCRT calls for older patients, and those with low oxygen saturation and DLOC, must be considered. Increased vigilance is also needed for those spending more time in ICUs.
Keywords: Critical care response team, intensive care unit admission, intensive care unit mortality, rapid response teams
|How to cite this article:|
Alhaidari A, Busuhail M, Alsultan S, Alshammari S, Alshimemeri A. Exploring factors affecting critical care response team service at a tertiary hospital in Riyadh: A retrospective cohort study. Saudi Crit Care J 2020;4:123-9
|How to cite this URL:|
Alhaidari A, Busuhail M, Alsultan S, Alshammari S, Alshimemeri A. Exploring factors affecting critical care response team service at a tertiary hospital in Riyadh: A retrospective cohort study. Saudi Crit Care J [serial online] 2020 [cited 2021 May 15];4:123-9. Available from: https://www.sccj-sa.org/text.asp?2020/4/4/123/305823
| Introduction|| |
During the early 1990s, the analysis of the reasons of hospital deaths was done, and it was found that majority of deaths were preventable if patients had received intensive care earlier. More than 50% of deaths in hospitals occurred outside the intensive care units (ICU). Several studies found that patients showed signs of deterioration 6–8 h before the onset of cardiopulmonary arrest. Clinicians in charge of the patients failed to report or intervene during this period. The most common reasons of failure to rescue the deterioration in the patients at this stage included limited monitoring technology, lack of periodic assessment of patients, lack of technical training, and failure of the frontline staff to start interventions independently.,, Common symptoms or patterns that patients experience before critical deterioration are a respiratory rate either >30 breaths/min or <10 breaths a minute; a heart rate >120 or <45 beats/min; arterial blood pressure >130 mmHg or <70 mmHg. Other patterns that require immediate attention for patients admitted in wards include diminished consciousness, seizures, delirium, arrhythmia, gastrointestinal bleeding, and kidney failure. Majority of patients experience several of these symptoms before cardiac arrest, and hospital mortality can be prevented if at this stage they are stabilized and further deterioration is prevented.,,,,,
Hence, critical care response teams (CCRT) were established in hospitals by early 2000s that brought critical care to the patients at their hospital beds in the wards, preventing loss of valuable time and consequently significantly reducing the mortality rates in hospitals. CCRT consists of trained staff and can be considered as the proactive department of the ICU of a hospital. It stabilizes the patient, preventing further deterioration and/or cardiopulmonary arrest. Several different terms are used for these teams worldwide such as rapid response teams or medical emergency teams. The use of CCRT avoids admission and re-admission in the ICUs and improves access to ICU beds. CCRT is also responsible for the education of health-care providers working in the general surgical and other hospital wards so as to optimize the patient care. It also encourages collaboration and increases the knowledge transfer within the hospital staff. Most CCRTs are activated by the hospital staff, although many hospitals also allow the patients and their families to activate CCRT if needed. CCRT was constituted in King Abdul Aziz Medical City in Riyadh (KAMC-R) in November 2007. Before its conception, a policy regarding the functioning of CCRT was setup. The CCRT is led by an intensivist and also has a staff physician, a critical care nurse, and a respiratory therapist. The team leader is certified by the North American medical board. Although resident doctors are not part of the core CCRT, they assist the team in their efforts. The patients are followed by the team for a minimum of 48 h or until the medical crisis is resolved, or the patient is admitted to the critical care unit, pronounced dead, or do not resuscitate orders are given. CCRT provides assistance to all the twenty-five hospital wards 24 h a day, 7 days a week.,
Since their inception, there have been various studies on the efficiency of CCRTs that supported their role in bringing down the mortality rates in hospital wards.,,,,,, Some conflicting reports have also suggested that no major benefit occurred after the constitution of CCRT; this anomaly may be due to the lack of a set benchmark for CCRT activation along with the complexity of medical interventions required.,,,, However, most hospitals now accept that the formation of a CCRT is essential for improving patient safety. The aim of this study is to evaluate the factors affecting CCRT service in terms of patient disposition and mortality rate and to analyze interventions provided to the patients by the team. The purpose of this study was to improve patient care by increasing vigilance to patients with factors affecting CCRT service.
| Materials and Methods|| |
This is a retrospective cohort study conducted at KAMC-R. All CCRT event data collection forms from the period between February 2018 and April 2019 were reviewed. There were 1181 CCRT event data collections from all departments. Patients younger than 18-year-old were excluded from the study. Since the data were handwritten, some of them were difficult to be appreciated and were excluded from the study. A total of (1088) CCRT event data collection forms were included in the study.
KAMC-R in the Kingdom of Saudi Arabia is a 1000-bed facility that includes twenty-five inpatient medical and surgical wards. It is a tertiary care hospital and also an academic center affiliated with King Saud bin Abdulaziz University for Health Sciences. The academic center has more than twenty different residency and fellowship programs. The center is a nonprofit organization, under the National Guard in the Kingdom of Saudi Arabia.
Each CCRT event data collection form was filled by one of the team members once the team was activated until the medical crisis was done. The form consists of date and time of the activation, location of the patient, time of the arrival, vital signs, reason for activation based on specific criteria, intervention done by the team, outcome in terms of mortality and disposition of the patient, and length of ICU stay. Data were collected, checked, and entered month by month.
Categorical data were expressed as number and percentages and compared using the Chi-square/Fisher's exact test. Continuous variables were summarized as mean and standard deviation (SD) and were compared using the t-test/Mann–Whitney-U test. All statistical tests were performed with two sided and at the 5% significance level. All statistical analyses were done using SAS software 9.4 SAS 9.4 (SAS Institute, Cary NC).
Approval of the study was obtained from the Institutional Review Board at King Abdullah International Medical Research Center. All information obtained in this study was stored in a secure place and kept strictly confidential and anonymous.
- Outcome measures: (1) Patient disposition: Transfer patient to the ICU. (2) Final outcome: Survival and death
- Factors tested for effect on CCRT service: Patient age, activation time, reasons for activation. Furthermore, patient disposition was tested for effect on the mortality rate
- Work hours: 07:00–16:00.
| Results|| |
A total of 1088 CCRT events were considered during the period of the study which is from February 2018 to April 2019. Of these, 543 patients were male, whereas 545 patients were female. The average age of the patients approached by CCRT was 64.01 ± 20.07 with a minimum age of 18 and maximum of 107 [Table 1] for more baseline characteristics.
- There were 1088 CCRT events triggered by different, and sometimes multiple, reasons [Figure 1]. The most common reasons for CCRT activation are tachypnea, followed by tachycardia and hypotension, whereas the least common are allergic reactions and chest pain
- There are two outcome measures of CCRT service: Disposition of the patient after the event and the final outcome in terms of mortality rate. In general, 65.99% of the events did not require transfer to the ICU and the overall survival rate was 71.14%
- Our study found that patient age affected the final outcome. Out of those who activated CCRT and died, the mean age was 70.90 and the SD was 16.67 compared to those who survived with a mean of 61.21 and a SD of 20.65 (P < 0.0001). Moreover, there was an association between patient age and the decision of patient disposition. Those who needed ICU transfer had a mean age of 65.68 with a SD of 18.46 compared to those who were not transferred to the ICU with a mean of 63.14 and a SD of 20.80 (P = 0.0399)
- One of the factors tested for effect on the outcome measures is the activation time [Figure 2]. About 35.01% of events during work hours required ICU transfer, almost the same percentage for ICU transfer out of work hours (33.47%). There was no significant difference between events during work hours and event out of work hours in terms of disposition.
|Figure 1: Most common reasons for critical care response team activation|
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In terms of the final outcome, out of those who activated the team during work hours, 28.65% died. Out of work hours, the mortality rate was 28.97%. There was no significant difference [Figure 3].
- The most important factor affecting CCRT outcomes is the reason for activation. [Table 2] shows the most common reasons affecting outcome measures. Out of the most common reasons, the leading reason to ICU transfer was tachypnea (comprises 32.70% of all CCRT events transferred to ICU). On the other hand, out of all events transferred to ICU, decreased urine output comprises 4.86%. Majority of patients within each reason for activation were not transferred to the ICU, except for low oxygen saturation (50.54% transferred to ICU) (P = 0.0001), decreased level of consciousness (DLOC) (49.40% transferred to ICU) (P = 0.0001). In terms of the final outcome, out of overall deaths, the leading reason for the highest mortality rate was tachypnea with 30.89%. On the other hand, out of overall deaths, decreased urine output comprises 8.28%. Within each reason for activation, majority of patients survived
- There had been an association between the disposition of the patient and the final outcome [Figure 4]. Patients not transferred to ICU had lower mortality rate than those transferred to ICU (P < 0.0001)
- Another finding was the length of ICU stay in relation with the final outcome. Those who were transferred to ICU and died had a mean length of ICU stay of 13.6 days and a SD of 14.05 days compared to those transferred to ICU and survived, their mean length of ICU stay was 9.55 days and their SD was 10.63 days (P = 0.0068)
- CCRT do intervene in most events with different, and sometimes multiple, interventions. Drug and nondrug interventions are shown in [Table 3] and [Table 4].
| Discussion|| |
The present study evaluates the factors affecting CCRT service in terms of patient disposition and mortality rate and analyses reasons for CCRT activation and interventions provided to the patient by the team. Based on our knowledge, this is the first study that addresses factors affecting CCRT service after 12 years of implementation.
In our study, the most common CCRT triggers remain in line with previous studies which reported respiratory-related issues as leading triggers of CCRT activation,,,, followed by tachycardia and hypotension. Other studies reported hemodynamic instability, staff concern as the leading triggers of the team, followed by respiratory-related issues., Furthermore, the least common trigger is allergic reaction, which is consistent with Sharek et al. We found significant relations between reasons for CCRT activation and the outcome measures (disposition and mortality rate). Those with decrease in oxygen saturation, DLOC, hypotension, and tachypnea had higher chances for transfer to the ICU than other reasons. This might be due to the fact that those reasons had higher mortality rates than other reasons.
Another factor that was tested for effect on CCRT service and found to be significant was patient age. Those who activated CCRT and died were found to be older than those who survived. Moreover, those who needed ICU transfer were also found to be older than those managed on wards. These relations could be due to chronic comorbidities that older people suffer from.
Moving to activation time effect on CCRT, 65.35% of events were out of working hours, almost the same percentage in Bellomo et al., but not Segon et al. whose study reported that 69% of calls occurred during work hours. About 35.01% of those who activated the team during work hours were transferred to the ICU and 33.47% of out of work hour activations required ICU admissions. The percentages were almost the same even in terms of mortality rate during and out of working hours (28.65% and 28.97%, respectively), although majority of events were out of hospital work hours. This may indicate good quality of CCRT as the team is maintaining the same percentages of disposition and mortality rate during and out of work hours. The activation time was not statistically significant in terms of mortality rate and disposition of the patient in our study as well as literature.
Majority of calls were for patients in the medical floors (67.92%), followed by surgical and obstetrics and gynecology wards (27.21% and 4.23%, respectively) that is consistent with Segon et al., Baxter et al., and Dacey et al.,,,
Furthermore, we tested the effect of patient disposition on mortality rate and we found that those who were transferred to ICU had significant higher mortality rates than those who were managed in their wards. In our study, having the CCRT program implemented, the number of events approached by the CCRT in 15 months and required ICU admission was 370 out of 1088 events (34.01%). Out of those ICU admissions, the mortality rate was 55.41%. This high percentage of mortality for those admitted to ICU in our study does not necessarily indicate poor service from the CCRT. In fact, considering that 65.99% of critical events were managed in their wards with a survival rate of 84.82%, and the overall mortality rate of all critical events (transferred to ICU and not) was 28.86% compared to the overall mortality rate for those centers without CCRT programs such as Buist et al. (62%), it means that only very seriously critical events were transferred to the ICU and that fulfills one of the main purposes of the CCRT program which is avoiding unnecessary ICU bed occupancies. A previous study on the critical events that happened in 1 year at a tertiary hospital which does not have CCRT service stated that 79 out of 122 critical events (64.75%) required unplanned ICU admissions. Of those unplanned ICU admissions, the mortality rate was 40.5%. Another study done at a high-volume academic arthroplasty center stated that 45% of activations required ICU admission. Other studies reported that ICU admission rates for those activated the team were 29% and 27% with mortality rate of 31.4%. Another study reported that the mortality rate of those activated the team was 9.79%; this low percentage might be due to the fact that their study was done on the pediatric population whose management may have different considerations.
The mean length of ICU stay for those activated the team and transferred to the ICU was 11.83 days ± 12.79 and that is more than Baxter et al. whose mean was 7.65 days. However, as indicated earlier, this might reflect the good quality of CCRT as only critical cases are transferred to the ICU which explains the long ICU stay. Furthermore, our study found a significant increase in mortality rate in relation to the length of ICU stay; this might be attributed to patients' comorbidities and the ICU environmental factors.
The most common drug interventions provided by the team are fluid bolus (intravenous), diuretics, and inhaled bronchodilators. They are consistent with the literature. [16,18-21] In general, 33% of CCRT events did not require drug interventions, and 0.7% (8 out of 1088 events) did not require nondrug interventions. Only 0.4% (5 out of 1088 events) received neither drug nor nondrug interventions after activation which further indicates that there is an excellent adherence to CCRT calling criteria.
There are several limitations for this study. First, comorbidities were not considered and there are no previous studies that considered this factor as a possible reason for affecting the mortality rate. Second, it was conducted at a single institution, so we cannot generalize our results. Finally, in some cases, there were several criteria listed for CCRT activation, and it was thus challenging to identify the single trigger.
| Conclusion|| |
Patient age significantly affected CCRT service as older patients had higher mortality rates and higher chances of ICU transfer than younger patients. Furthermore, reasons for activation significantly affected CCRT service as majority of patients with low oxygen saturation and DLOC were transferred to the ICU, unlike other reasons. Moreover, patients transferred to the ICU had higher mortality rates than those managed in their wards. Activation time had no significant effects. A significant increase in mortality rates in relation to the length of ICU stay was noted. Given these results, increased vigilance and quick responses to CCRT calls for older patients, and those with low oxygen saturation and DLOC, must be considered. Increased vigilance is also needed for those spending more time in ICUs.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]