Elsevier

Resuscitation

Volume 81, Issue 4, April 2010, Pages 375-382
Resuscitation

Clinical paper
“Identifying the hospitalised patient in crisis”—A consensus conference on the afferent limb of Rapid Response Systems,☆☆

https://doi.org/10.1016/j.resuscitation.2009.12.008Get rights and content

Abstract

Background

Most reports of Rapid Response Systems (RRS) focus on the efferent, response component of the system, although evidence suggests that improved vital sign monitoring and recognition of a clinical crisis may have outcome benefits. There is no consensus regarding how best to detect patient deterioration or a clear description of what constitutes patient monitoring.

Methods

A consensus conference of international experts in safety, RRS, healthcare technology, education, and risk prediction was convened to review current knowledge and opinion on clinical monitoring. Using established consensus procedures, four topic areas were addressed: (1) To what extent do physiologic abnormalities predict risk for patient deterioration? (2) Do workload changes and their potential stresses on the healthcare environment increase patient risk in a predictable manner? (3) What are the characteristics of an “ideal” monitoring system, and to what extent does currently available technology meet this need? and (4) How can monitoring be categorized to facilitate comparing systems?

Results and conclusions

The major findings include: (1) vital sign aberrations predict risk, (2) monitoring patients more effectively may improve outcome, although some risk is random, (3) the workload implications of monitoring on the clinical workforce have not been explored, but are amenable to study and should be investigated, (4) the characteristics of an ideal monitoring system are identifiable, and it is possible to categorize monitoring modalities. It may also be possible to describe monitoring levels, and a system is proposed.

Introduction

Studies have repeatedly revealed widespread deficiencies in acquiring and acting upon abnormal vital signs to prevent critical events such as death, cardiopulmonary arrest, or unplanned intensive care unit (ICU) admission.1, 2, 3, 4, 5, 6, 7, 8, 9, 10 In attempts to rectify these matters, Rapid Response Teams (RRTs) have developed to provide processes for identifying patients at risk and delivering resources for the evaluation, stabilization, and transfer of deteriorating patients.11 However, it is now believed that successful elimination of these problems is best achieved by implementing a system of care, rather than from merely the existence of a specific clinical care team.12 The RRS comprises an afferent limb (the means of detecting patients at risk and obtaining help), an efferent limb (a care team that responds to calls for assistance) and administrative and data analysis limbs.12 Single-centre, before-and-after studies have suggested that hospitals implementing a RRS successfully lower their morbidity, mortality and cardiac arrests rates,13, 14, 15, 16, 17 although most reports have emphasized the team response rather than crisis detection and the call for help. This manuscript focuses on the afferent limb of the RRS – the part of the system that monitors the patient, detects deterioration, and triggers a response from an appropriate team12 – in particular, patient monitoring, risk assessment and event detection.

Given the cost of technology and the desire to improve patient safety, we considered it important to (a) review knowledge about the technology available for patient monitoring outside ICU, (b) evaluate its impact on morbidity and mortality, and (c) identify areas where research might clarify what type of monitoring patients need and what type of technologic improvements may yield benefit.

Investigators and clinicians involved in emergency care, adverse event prevention, RRS, nursing, epidemiology, monitoring, statistics, and hospital administration convened to discuss (1) how to identify sudden clinical deterioration in patients nursed in non-critical care areas of hospitals and (2) the monitoring of patients nursed in these areas.

Section snippets

Methods

A Consensus Conference on “Identifying the hospitalised patient in crisis” was arranged (by MD) immediately before the 4th International Symposium on Rapid Response Systems and Medical Emergency Teams in Toronto, Canada on May 5 and 6th 2008. Conference participants were selected because of expertise in clinical healthcare practice or patient safety, or because they represented a governmental healthcare agency or an organization with a stake in the conference findings.

Pre- and intra-conference

Results

Table 1 lists a summary of the conference recommendations.

Conclusion

Periodic patient assessments that focus on vital signs have been an important part of hospital care for over a century. Emphasis has recently been placed on responding quickly to derangements in vital signs in order to prevent adverse outcomes. The ability to respond hinges on the ability to detect and recognize abnormal vital signs. There is little data to help identify the type of assessment that is most likely to predict or detect a deteriorating patient. Recent emphasis on the ability of a

Role of the funding source

While some groups financially supported the conference, they neither officially reviewed, nor approved, the findings. Sponsors did not collect, analyze, interpret data, contribute to writing the manuscript or participate in the decision to submit the manuscript for publication. In addition to financial support, the AHA sponsored a delegate to the conference; The Agency for Healthcare Research and Quality provided financial support, but no representative. The following organizations sponsored

Conflict of interest statement

Gary Smith's wife is a shareholder in The Learning Clinic, the manufacturers of the VitalPAC system. Michael Buist is a Director and Shareholder of Patientrack. Rinaldo Bellomo is a paid consultant to Philips Medical Systems. No other author has declared a conflict of interest.

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    A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2009.12.008.

    ☆☆

    This work was support by grants from: Agency for Healthcare Research and Quality, Department of Veterans Affairs, UPMC Center for Quality and Innovation, American College of Chest Physicians, and the American Association of Critical Care Nurses.

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