G Gaba, D.M., 382 Galhotra, D., 150 Gao, H., 150 Gibson, R., 245, 247 Gleeson, M., 115 Goals and benefits, RRS implementation, 3 Goldman, L.

Transcription

1 A Acute care education, Ward staff. See also Ward staff costs effectiveness, 402 evidence for benefit in, 407 improvement, evidence, response team role, resuscitation training, 406 roles and responsibilities, 402 short courses, 406 simulation-based courses, 405 Acute Care Undergraduate Teaching (ACUTE), 400 Acute hospitalist medicine. See Hospitalist Acute Life-threatening Events: Recognition and Treatment (ALERT) course, 406 Administrative limb, 14 aims and objectives, clinical governance unit, 333 components, costs and savings, defibrillators, 16 deteriorating ward patient, chain of events, 328 MET administrative group component interaction, 330 future aspects, 332 management training, 332 members of, 330 nurse unit manager (NUM), 331 outcomes, monitoring, 332 senior hospital administration group, 329, 330 vital sign monitoring, Adult crash cart, 316 Afferent limb, 14, components, 15 costs and savings, deteriorate patient identification clinical observations, continuous monitoring advantages, track-and-trigger systems, regular monitoring and assessment improvement, selection/diagnostic/triggering criteria, 15 steps involved, 15 summoning protocol, 188 technologic monitoring, 15 technology role, triggering response mechanism, 15 vital signs measurements, 183 Aggregate weighted track-and-trigger systems (AWTTS), Aiken, L.H., 152 Aiken s conceptual model, 152 Allgower, M., 118 Area-under-the-receiver-operating curves (AUROC), 125, 149 AWTTS. See Aggregate weighted track-andtrigger systems B Bader, M.K., 227 Baker, R.B., 248 Baldisseri, M., 277 Barriers, RRS implementation demanding analysis, 174 impediments cost cutting, 171 individual errors, medical and nursing education, 173 patients intervention, 172 professional differences, patients safety improvement, 176 residency education program, 175 M.A. DeVita et al. (eds.), Textbook of Rapid Response Systems: Concepts and Implementation, DOI / , Springer Science+Business Media, LLC

2 430 Barriers, RRS implementation (cont.) social changes, sources cohort comparison study, 167 entrenched professional silos, 169 general reluctance, 169 healthcare education, 170 MET implementation, 168 staff education, 176 team-triggering criteria, 177 unconsulted doctors, 175 Bayesian approach, 393 Bell, M.B., 69, 149, 347 Bellomo, R., 105, 157, 195, 231, 327, 431 Berg, R.A., 227 Bessant, J., 95 Blood administration team (BAT), 270 Blum, R.H., 382 Bradycardia, 116 Braithwaite, J., 83 Braithwaite, R.S., 42 Brewer, T.L., 248 Brilli, R.J., 243, 245, 247 Buist, M., 99 Buist, M.D., 195, 198 Buri, C., 118 C Cardiac arrests evidence based studies deteriorating patient, incidence, aggregate analysis, 73 RRS effectiveness, iatrogenic patient death prediction electronic observation data capture, 106 Harvard Medical Practice Study (HMPS), 103 hazards, individual and organizational accidents, latent conditions, nested case control study, 104 patient crisis, risk factors for, 107 prospective cohort studies, 105 QAHCS, 103 retrospective case study, 103 risk of mortality, independent predictors, 106 scoring systems, 106 soft defenses, organizational crises theory, Carroll, J.S., 42 Casamento, A.J., 198 Castle, N., 236 Chan, P.S., 227 Chen, J., 72, 83, 387, 421 Chest pain team, Clinical governance unit, 333 Coba, V., 257 Complex system interventions characteristics, components, cost and cost-effectiveness, critical linkages and process, RRS outcomes, 389 health services research, 388 research methodology ANZ Feeding Guideline Trial, 391 incomplete implementation, 391 intra-class correlation coefficients (ICCs), 391 large sample size, 391 MERIT study intervention phase, 391 randomized controlled trial (RCT), 390 time frames, 392 result interpretation, sub-system interactions after, 392 Comprehensive Unit Safety Program (CUSP), 30 Condition M, Condition O usage goal, 285 medical crisis team activation, indications, parameters of, patient safety initiatives, 286 reasons for, Cooper, S., 380 Cost and saving implications adverse events, rapid response system administrative arm costs, afferent arm costs, efferent arm costs, hidden costs, quality improvement arm costs, societal costs, 438 hospital savings, societal savings, template for calculating, 441 Cox, K., 335 Crash cart process. See Equipments, crisis response; Medication and supplies Cretikos, M., 104

3 Crisis response team. See also Equipments, crisis response; Obstetric-specific crisis team A-B-C (airway-breathing-circulation) ad hoc nature of, 371 ad hoc team being all-capable concept, 297 communication, 297 MET responders, roles and goals, 298 operating room crisis teams, resource management, 301 structure, 25 designated roles assignment role, human-simulator crisis team-training program, pediatric crisis response, 377, 379 performance improvement, role related task, 376 pre-set task-completion goals, 375 responsibilities, resuscitation training sessions, 379 educational objectives for, goals of, 374 herd immunity, 290 hierarchical system, 289 human resources, inexperienced anesthesiology residents, 291 medical education model, 289 non-educational healthcare setting, 290 organization fixation error, 292 hospital-crisis team training, 293 institutional or system advantage, 292 latent error correction, 292 role-oriented goals and objectives, 292 team member s tasks, 293 respiratory distress, 290 roles and goals of, 378 RRS activation, 295 RRT implementation, 290 simulation of, structure, 294 teamwork training, 291 time-honored method, 290 time-inefficient process, 290 unique aspects of, 371 untrained, 291 Critical care physicians, 1 2 Critical Care Response Team Project (CCRT), 92 Critical incident stress management (CISM), D Dalby, P., 277 Deane, B., 115 Decision making, Not-for-Resuscitation status critical-care physicians, delegation, variability and change, 422 hospital in-patient population, chronic disease and co-morbidities, 423 junior medical staff and nursing staff, 422 senior clinician, 442 Defibrillators, 16, Delayed RRS activation avoidance of, 199 causes of, classification, consequences of, 197, 198 objective calling criteria, 198 principles of, retrospective studies, 196 Delgado, E., 305 Demeritt, B., 248 Denham, C., 342 Deteriorate patient identification clinical observations, continuous monitoring advantages, track-and-trigger systems aggregate weighted, efficiency of, 186 single parameter, Deteriorations, 1 DeVita, M.A., 1, 13, 149, 267, 289, 305, 371 Difficult airway team (DAT), 272 Diffusion of innovation, 94 Dodgson, M., 95 Donabedian s approach, 22 Dongilli, T., 372 Downey, A.W., 197 Duke, T., 245, 247, 248 Duncan, K.D., 215 E Early goal-directed therapy (EGDT) definition, 258 entry criteria, 258 implementation barriers, 261 components, 260 ED-based model, 260 ICU-based model, 261 mobile ICU, 261 protocol, 259

4 432 Early warning score (EWS) pediatric RRS Bristol tool, 250 Cardiff and Vale Paediatric Early Warning System, development, 248 scoring system, 249 vital signs, 125, 149 Edelson, D., 431 Edwards, E.D., 248 Efferent limb, 14 16, basic condition response, 268 blood administration, 270 chest pain, condition M, cost and savings, difficult airway, 272 lost patient condition, pediatric response, stroke, trauma, Equipments, crisis response airway equipment, annual competency evaluations, 306 crash carts adult crash cart, 316 crash code and supply contents, fully-stocked, 306 house-wide, 318 pediatric crash cart, replacement process, 311 selection of, standardization, 315 syringe drawer contents list, expiration dates, and billing, 310 syringe drawer layout, 311 vial drawer layout, vial tray contents, medication list, expiration dates, and billing, crisis event management, training, emergency airway bag contents, 307 implementation, barriers, intubating equipment, mock code scenarios, 306 nursing responder equipment, 314 types of, 306 in University of Pittsburgh Medical Center Presbyterian Hospital, Evidence based studies guiding principles, 68 levels of evidence, 68 patient deterioration barriers, 70 cardiorespiratory arrest, 69 physiological limits, 69 simulation, 70 staffing model, 70 vital sign criteria, 70 quality and quantity, 68 RRS effectiveness cardiorespiratory arrest, cost, 75 Hawthorne effect, 71 historical control methodology, 71 hospital mortality, 72 long-term mortality, 73 MERIT study data, nursing and hospital satisfaction, 72 septic and hypovolemic shock, 72 unanticipated ICU admission, 72 F Failure mode and effect analysis (FMEA), Failure-to-rescue (FTR) cardiorespiratory instability, 151 complications, dynamic patient-level factors early warning scores (EWS), 149 integrated monitoring systems (IMS), 150 medical emergency teams (METs), 148 personal digital assistant (PDA), 150 sign parameters and thresholds, 150 track-and-trigger mechanisms, 150 hospital-level factors, static patient-level factors, 149 system-level factors, Family-activated rapid response systems. See Patient-and family-activated rapid response systems Family Activated Safety Team (FAST) program, 205 Flabouris, A., 57, 421 Foraida, M.I., 198 G Gaba, D.M., 382 Galhotra, D., 150 Gao, H., 150 Gibson, R., 245, 247 Gleeson, M., 115 Goals and benefits, RRS implementation, 3 Goldman, L., 50

5 Goldsmith, D., 355 Gosbee, J., 39 Gosman, G.G., 277 Grbach, W.J., 305 H Haase, M., 195 Hahn-Cover, K., 335 Hall, L.W., 335 Hamilton, M.F., 371 Haskell, H., 203 Havstad, S., 258 Healthcare environment, 58 Healthcare systems and integration complex surgery, 84 education programs, essential components, 86 evaluation data, 88 hospital system, 84 medical training, doctor/patient relationship, 84 multiple co-morbidities, 84 public hospitals, 83 seriously ill patient response to, 87 at risk, 87 teaching and research, 84 silo-based care, 86 support system, Hillman, K., 83 Hirschinger, L.E., 335 Hodgetts, T., 236 Hooker, E.A., 121 Hospitalist as acute providers, benefits dedicated physician caring, 51 hospital medicine, 51 literature and journals, 52 history, models hospitalist models, 51 hospital physician, 50 PCP model, 50 private practice group, 50 Society of Hospital Medicine (SHM), 50 Hospital quality improvement (QI) process, 3 4 Hospital size and localization adverse events and unexpected deaths, 157 district general hospitals, 162 intensive care unit (ICU), 163 Medical Emergency Team (MET) reviews, 158, operative death risk, 158 secondary referral centers, small city hospitals, ICU, 163 teaching hospitals, Hospital-wide systematic approach failure, 423 Hravnak, M., 147 Hunt, E.A., 21, 371 Hutchinson, J., 115 Hypotension, 117 I Ikeda, M., 118 Institute for Healthcare Improvement (IHI), 2, 88, 216 Integrated monitoring systems (IMS), 150 Intra-class correlation coefficients (ICCs), 391 J Jäderling, G., 413 Jenkins, W., 91 Johnson, L., 227 Johnston, L., 245, 247, 248 Jones, D., 157, 195, 231, 327, 349 K Kaplan Meier graph, patient survival, 351 Kause, J., 131 Kellett, J., 115 Kenward, G., 236 Kerridge, R.K., 204 Khalid, A., 227 King, S., 204 Kinney, S., 245, 247, 248 Konrad, D., 347, 413 Kosiborod, M., 227 Kowiatek, J., 305 L Lam, S.W., 57 Lawless, B., 91 Leeson-Payne, C.G., 132 Leong, K., 247, 248 Levels of care acute illness, response to, 135 care and resuscitation limitation, 139 definitions, 133 early therapy, emergency department, 137 incorrect placement of patients,

6 434 Levels of care (cont.) new generalist physician on-call admission, 138 physician-of-the-week concept, 138 responsibilities, new patient admission processes, 137 patient illness identification clinical signs, 134 smart alarms, 135 track-and-trigger systems, rapid response and medical emergency teams, 138 staffing levels and patient flow, clinical outcomes, 136 ward staff, Levine, C., 215 Lighthall, G.K., 361 Longmire, L.S., 227 Lost patient condition, Luria, J.W., 245, 247 M Mackowiak, P.A., 120 Magee-Womens Hospital, 278 Marsch, S.C.U., 380 Mason, B.W., 248 McAdams, D.J., 49 McCoig, M., 335 McFadden, J.P., 121 McQuillan, P., 362 Medical emergency team (MET), 221 activation criteria, 233 administrative group component interaction, 330 future aspects, 332 management training, 332 members of, 330 nurse unit manager (NUM), 331 outcomes, monitoring, 332 barriers, cost and saving implications administrative arm costs, afferent arm costs, efferent arm costs, hidden costs, quality improvement arm costs, societal costs, 438 efferent limb teams, MET call A G approach, causes, 236 standards, 235 nurse-led rapid response team, physician-led MET, structure and roles, 234 Medical trainees patient safety acute medical emergencies, provision of care, postgraduate clinical training healthcare facilities, 57 hospitalist, 61 integral components, 61 requirements for, 61 specialization, undergraduate training, Medication and supplies, 318 airway management bags, controlled substances, 320 emergency cart defibrillators, 324 exchange process, 321 restocking medications, 321 supply standardization, implementation, barriers, pediatric crash cart layout of, 320 syringe medication list, 319 vial medication list, 319 warning labels, 320 Miller, M., 21 Mininni, N.C., 355 Mobile sepsis team, 261 Monaghan, A., 248 Morgan, R.J., 125 Murray, A.W., 289 N National Institute of Health and Clinical Excellence (NICE), 400 Neal, B., 227 Needleman, J., 152 Nguyen, B., 258 Non-physician-led rapid response teams (RRTs). See Physician-led MET Not-for-Resuscitation status decision making critical-care physicians, delegation, variability and change, 422 hospital in-patient population, chronic disease and co-morbidities, 423 junior medical staff and nursing staff, 422 senior clinician, 442 rapid response teams critical care-based staff, 422 evidence for,

7 hospital in-patients indentification program, 423 hospital-wide systematic approach failure, 423 Nurse-led rapid response team benefits goal, 223 rapid response evaluation, 225 role, 223 staff member feedback, 226 components command process, communication tools, specific protocols, data collection mnemonic tools, 227 quality improvement initiatives, tool, efficacy, 227 hospital resources identification, 217 leadership role, mentoring, 224 Nurse unit manager (NUM), 331 Nurse view, RRS critical thinking, 355 MERIT study intervention survey, 357 nurse-led RRT, 357 physician-led MET, Robert Wood Johnson Foundation, RRT evaluation project, 356 RRT activation criterion, 356 successful RRS communication, education, 358 empowerment, 358 experience, 358 not-an-option-to-not-call practice, 358 O Observed structured clinical examination (OSCE), 59 Obstetric-specific crisis team background, 278 condition O usage goal, 285 medical crisis team activation, indications, parameters of, patient safety initiatives, 286 reasons for, data collection, 282 design core skills, medical crisis vs. obstetric crisis, neonatal resuscitation team, nursing, 279 response team training, 282 staff education, 281 Oliver, A., 248 One-tiered system, Ontario s critical care strategy, 92 Otis, A.B., 121 Ott, L., 147 Oximetry, 115, 121 P Parast, L.M., 247, 248 Patient-and family-activated rapid response systems accreditation and safety organizations, 206 features of administration and design, data collection, 208 follow-up, 208 patient education, 207 screening, team composition, 208 triggering criteria, 207 gauging success, legislation, 205 origins of, Patient education, 207 Patient safety complexity normalization, 45 creating and sustaining, 40 defect investigation caregiver factors, 32 institutional environment factors, 33 local environment factors, 33 patient factors, 32 process of, 31 task factors, 32 team factors, 32 training and education factors, deviance normalization, 45 medical trainees (see also Medical trainees) acute medical emergencies, provision of care, MET, driving force broad-sweeping, 41 difficulties and limitations, 41 failure mode and effect analysis, functions, 41 root cause analysis, 41 43

8 436 Patient safety (cont.) safety culture and high-reliability organizations, organizational evaluation of adverse drug events, 23 components, 24 Donabedian s approach, 22 institutional scorecard, framework for, 24 intervention, impact of, 24 measuring defects, medication safety, 23 organization s learning and culture, 23 process and outcome measures, 22 safety improvement, reliability checklists, evidence-based therapies, 34 physician autonomy, 34 standardization aspects, transfusion medicine, 34 Pediatric crash cart layout of, 320 syringe medication list, 319 vial medication list, 319 Pediatric response team, critical illness recognition, 245 development, 244 early warning scores Bristol tool, 250 Cardiff and Vale Paediatric Early Warning System, development, 248 scoring system, 249 institutional barriers, one-tiered system, outcomes cardiac and respiratory arrest, prevention, rapid response system, origin, 251 two-tiered system, 251 triggers/calling criteria MET activation criteria, 246 surrogate marker, types, 245 two-tiered systems, Personal digital assistant (PDA), 150 Personnel response, crisis event, 307 Pham, J.C., 67 Physician-led MET advantages, 237 definition, disadvantages, key members, 234 management plan deteriorating patient, 235 MET call, prompt patient review, 231 need for, principles, Pinsky, M.R., 147 Policy creation, RRS communication strategy, 95 Critical Care Response Team Project (CCRT), 92 diffusion of innovation, 94 healthcare innovation, 94 late majority adopters, 95 Ontario s critical care strategy, 92 opinion leaders, 94 social science paradigm, 94 Powell, C.V., 248 Primary Care Physician (PCP), 49 Pronovost, P.J., 21 Q Quach, J.L., 197 Quality improvement arm costs, Quality improvement limb, 16 R Rao, A.D., 13 Reason, J., 99 Resident training, 361, cardiac arrest, opportunities for cross-discipline training, 364 residents perceptions, trainees, 364 patient safety error analysis, 367 patient outcome monitoring, practice-based learning, 366 socio-medical interactions, 367 suboptimal care, 362 US Accreditation Council of Graduate Medical Education, Reynolds, S.F., 91 Rivers, E.P., 257 Rodgers, E., 44 Rogers, E.M., 94 Root cause analysis (RCAs), 40 S Safar, P., 89 Santiano, N., 15

9 Schmid, A., 147 Scott, S.D., 335 Second victim recovery trajectory case study, critical incident stress management (CISM), 341 emotional vulnerability, healthcare institutions, 343 high-risk clinical events, 339, 340 impact realization emotional response, patient stabilization, 338 stages of, 338 traumatic clinical event, 339 professional colleagues and peers, support network, 342 team debriefings, Senior hospital administration group, 329, 330 Sepsis response team. See Early goal-directed therapy (EGDT) Seriously ill patient, healthcare systems response to, 87 at risk, 87 Shaefer III, J.J., 289 Shaikh, L., 236 Sharek, P.J., 245, 247, 248 Shearn, D., 267 Shock, Silber, J.H., 147, 148, 152 Simhan, H.N., 277 Single parameter track-and-trigger systems (SPTTS), Smith, G.B., 131, 149, 218, 397 Societal costs, 438 Society of Hospital Medicine (SHM), 50 Spertus, T.A., 227 Spodick, D.H., 116 SPTTS. See Single parameter track-and-trigger systems (SPTTS) Staff education, 281 Staff member feedback, 226 Standardization tool and assessment, RRS process cluster-randomized controlled trial, 413 conventional grading system, 413 data collection, evaluation, fundamental system change, 414 initiation criteria validation, 414 protocol implementation, 415 trial design, 415 outcomes, 417 single-center studies, Stein, K., 277 Stroke team, Sund-Levander, M., 120 Surrogate marker, T Teaching hospitals, 347 adverse events, 348 afferent limb arm, 349 benefits of, 348 calls distribution, 160 composition of, 159 culture and management, 350 efferent limb arm, 350 eminence-based medicine, 349 Kaplan Meier graph, patient survival, 351 medical management, 348 medical staff., 352 role of, 161 RRS implementation, 349 Terminology, RRS afferent limb, 5 6 critical care outreach teams, 5 efferent limb, 5 6 history, 4 5 Track-and-trigger systems, deteriorate patient identification aggregate weighted, efficiency of, 186 single parameter, failure-to-rescue (FTR), 150 Trauma team, Tucker, K.M., 248 U University of Pittsburgh Medical Center (UPMC). See also Equipments, crisis response Presbyterian hospital differences, 204 team members responsibilities, 268 teams, 267 Shadyside hospital assessment process, 208 condition C (MET) program, 204 condition H, 205 patient advise, 207 V Vital signs age, mortality, blood pressure, 115,

10 438 Vital signs (cont.) EWS systems, 125 patients proportion, 116, 117 pulse oximetry, 115, 121 pulse rate, respiratory rate, 115, 121 Shock, temperature, 115, Vital signs measurements, 183 Vossmeyer, M.T., 248 W Wachter, R.M., 50 Wakelam, A., 380 Ward staff acute care education costs effectiveness, 402 evidence for benefit in, 407 improvement, evidence, response team role, resuscitation training, 406 roles and responsibilities, 402 short courses, 406 simulation-based courses, 405 Acute Care Undergraduate Teaching (ACUTE), 400 DoH competencies grades, 401 organization, 402 recognizers, 401 responders, 401 level 1 care, 398 National Institute of Health and Clinical Excellence (NICE), 400 patient deterioration, 397 Ward, W.J., 75 Welch, J.R., 397 Winters, B.D., 1, 21, 67, 72