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Effectiveness of Multicomponent Nonpharmacological Delirium Interventions
Clinical question: How effective are multicomponent, nonpharmacological interventions at reducing delirium and preventing poor outcomes?
Background: Delirium is an acute disorder with significant morbidity and mortality. Systemic reviews and clinical guidelines recommend targeted, multicomponent, nonpharmacologic strategies for prevention. The Hospital Elder Life Program (HELP) uses an interdisciplinary team to implement nonpharmacologic interventions, such as reorientation, early mobilization, therapeutic activities, hydration, nutrition, sleep strategies, and hearing and vision adaptation. Trials of nonpharmacological strategies to prevent this disorder have been limited to small-scale studies.
Study design: Systemic literature review and meta-analysis.
Synopsis: Fourteen studies involving 12 unique interventions were identified and results were pooled for meta-analysis, with primary outcomes being incidence and falls. Secondary outcomes were length of stay, institutionalization, and change in functional or cognitive status. Eleven studies were found to have demonstrated significant reductions in delirium incidence (odds ratio [OR], 0.47; 95% CI, 0.38-0.58), with four trials reducing delirium incidence by 44% (OR, 0.56; 95%CI, 0.42-0.76). Four studies demonstrated a significant decrease in the rate of falls (OR, 0.38; 95% CI, 0.25-0.60), with two studies reducing falls by 64% (OR, 0.36; 95% CI, 0.22-0.61). Institutionalization and length of stay did not demonstrate statistical significance between the two groups.
Bottom line: Multicomponent, nonpharmacological delirium prevention interventions were found to be effective in decreasing the occurrence of both delirium and falls during hospitalization in older persons.
Citation: Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions. JAMA. 2015;175(4):512-520.
Clinical question: How effective are multicomponent, nonpharmacological interventions at reducing delirium and preventing poor outcomes?
Background: Delirium is an acute disorder with significant morbidity and mortality. Systemic reviews and clinical guidelines recommend targeted, multicomponent, nonpharmacologic strategies for prevention. The Hospital Elder Life Program (HELP) uses an interdisciplinary team to implement nonpharmacologic interventions, such as reorientation, early mobilization, therapeutic activities, hydration, nutrition, sleep strategies, and hearing and vision adaptation. Trials of nonpharmacological strategies to prevent this disorder have been limited to small-scale studies.
Study design: Systemic literature review and meta-analysis.
Synopsis: Fourteen studies involving 12 unique interventions were identified and results were pooled for meta-analysis, with primary outcomes being incidence and falls. Secondary outcomes were length of stay, institutionalization, and change in functional or cognitive status. Eleven studies were found to have demonstrated significant reductions in delirium incidence (odds ratio [OR], 0.47; 95% CI, 0.38-0.58), with four trials reducing delirium incidence by 44% (OR, 0.56; 95%CI, 0.42-0.76). Four studies demonstrated a significant decrease in the rate of falls (OR, 0.38; 95% CI, 0.25-0.60), with two studies reducing falls by 64% (OR, 0.36; 95% CI, 0.22-0.61). Institutionalization and length of stay did not demonstrate statistical significance between the two groups.
Bottom line: Multicomponent, nonpharmacological delirium prevention interventions were found to be effective in decreasing the occurrence of both delirium and falls during hospitalization in older persons.
Citation: Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions. JAMA. 2015;175(4):512-520.
Clinical question: How effective are multicomponent, nonpharmacological interventions at reducing delirium and preventing poor outcomes?
Background: Delirium is an acute disorder with significant morbidity and mortality. Systemic reviews and clinical guidelines recommend targeted, multicomponent, nonpharmacologic strategies for prevention. The Hospital Elder Life Program (HELP) uses an interdisciplinary team to implement nonpharmacologic interventions, such as reorientation, early mobilization, therapeutic activities, hydration, nutrition, sleep strategies, and hearing and vision adaptation. Trials of nonpharmacological strategies to prevent this disorder have been limited to small-scale studies.
Study design: Systemic literature review and meta-analysis.
Synopsis: Fourteen studies involving 12 unique interventions were identified and results were pooled for meta-analysis, with primary outcomes being incidence and falls. Secondary outcomes were length of stay, institutionalization, and change in functional or cognitive status. Eleven studies were found to have demonstrated significant reductions in delirium incidence (odds ratio [OR], 0.47; 95% CI, 0.38-0.58), with four trials reducing delirium incidence by 44% (OR, 0.56; 95%CI, 0.42-0.76). Four studies demonstrated a significant decrease in the rate of falls (OR, 0.38; 95% CI, 0.25-0.60), with two studies reducing falls by 64% (OR, 0.36; 95% CI, 0.22-0.61). Institutionalization and length of stay did not demonstrate statistical significance between the two groups.
Bottom line: Multicomponent, nonpharmacological delirium prevention interventions were found to be effective in decreasing the occurrence of both delirium and falls during hospitalization in older persons.
Citation: Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions. JAMA. 2015;175(4):512-520.
ProMISe Trial Adds Skepticism to Early Goal-Directed Therapy for Sepsis
Clinical question: Does EGDT for sepsis reduce mortality at 90 days compared with standard therapy?
Background: EGDT is recommended in international guidelines for the resuscitation of patients presenting with early septic shock; however, adoption has been limited, and uncertainty about its effectiveness remains.
Study design: Pragmatic, multicenter, randomized controlled trial (RCT) with intention to treat analysis.
Setting: Fifty-six National Health Service EDs in the United Kingdom.
Synopsis: ProMISe trial enrolled 1,251 patients with severe sepsis or septic shock and patients were randomized to usual-care group (as determined by the treating clinicians) or algorithm-driven EGDT, which included continuous central venous oxygen saturation (ScvO2) using the original EGDT protocol. The primary outcome of all-cause mortality at 90 days was not significantly different between the two groups: 29.5% in EGDT and 29.2% in the usual-care group (P=0.9). This translated into a relative risk of 1.01% (95% CI 0.85-1.20) in the EGDT group. There were no meaningful differences in secondary outcomes.
Both groups in this study were actually well matched for most interventions. The main difference was in the use of continuous ScvO2 measurement and central venous pressure to guide management. Perhaps we should not completely dismiss the term EGDT. Most of our “usual care” consists of early intervention and goal-directed therapy.
Bottom line: In patients identified early with septic shock, the use of EGDT vs. “usual” care did not result in a statistical difference in 90-day mortality.
Citation: Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372:1301-1311.
Clinical question: Does EGDT for sepsis reduce mortality at 90 days compared with standard therapy?
Background: EGDT is recommended in international guidelines for the resuscitation of patients presenting with early septic shock; however, adoption has been limited, and uncertainty about its effectiveness remains.
Study design: Pragmatic, multicenter, randomized controlled trial (RCT) with intention to treat analysis.
Setting: Fifty-six National Health Service EDs in the United Kingdom.
Synopsis: ProMISe trial enrolled 1,251 patients with severe sepsis or septic shock and patients were randomized to usual-care group (as determined by the treating clinicians) or algorithm-driven EGDT, which included continuous central venous oxygen saturation (ScvO2) using the original EGDT protocol. The primary outcome of all-cause mortality at 90 days was not significantly different between the two groups: 29.5% in EGDT and 29.2% in the usual-care group (P=0.9). This translated into a relative risk of 1.01% (95% CI 0.85-1.20) in the EGDT group. There were no meaningful differences in secondary outcomes.
Both groups in this study were actually well matched for most interventions. The main difference was in the use of continuous ScvO2 measurement and central venous pressure to guide management. Perhaps we should not completely dismiss the term EGDT. Most of our “usual care” consists of early intervention and goal-directed therapy.
Bottom line: In patients identified early with septic shock, the use of EGDT vs. “usual” care did not result in a statistical difference in 90-day mortality.
Citation: Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372:1301-1311.
Clinical question: Does EGDT for sepsis reduce mortality at 90 days compared with standard therapy?
Background: EGDT is recommended in international guidelines for the resuscitation of patients presenting with early septic shock; however, adoption has been limited, and uncertainty about its effectiveness remains.
Study design: Pragmatic, multicenter, randomized controlled trial (RCT) with intention to treat analysis.
Setting: Fifty-six National Health Service EDs in the United Kingdom.
Synopsis: ProMISe trial enrolled 1,251 patients with severe sepsis or septic shock and patients were randomized to usual-care group (as determined by the treating clinicians) or algorithm-driven EGDT, which included continuous central venous oxygen saturation (ScvO2) using the original EGDT protocol. The primary outcome of all-cause mortality at 90 days was not significantly different between the two groups: 29.5% in EGDT and 29.2% in the usual-care group (P=0.9). This translated into a relative risk of 1.01% (95% CI 0.85-1.20) in the EGDT group. There were no meaningful differences in secondary outcomes.
Both groups in this study were actually well matched for most interventions. The main difference was in the use of continuous ScvO2 measurement and central venous pressure to guide management. Perhaps we should not completely dismiss the term EGDT. Most of our “usual care” consists of early intervention and goal-directed therapy.
Bottom line: In patients identified early with septic shock, the use of EGDT vs. “usual” care did not result in a statistical difference in 90-day mortality.
Citation: Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372:1301-1311.
Predictors of Sepsis, Septic Shock in Emergency Department Patients
Clinical question: Among patients presenting to the ED with sepsis, who will progress to septic shock within 48 hours of arrival?
Background: This study describes patient characteristics present within four hours of ED arrival associated with developing septic shock between four and 48 hours after arrival.
Study design: Retrospective chart review.
Setting: ED patients hospitalized at two large academic institutions.
Synopsis: A total of 18,100 patients were admitted from the ED, of which 3,960 patients had two or more systemic inflammatory response syndrome criteria, and 1,316 patients had sepsis within four hours of arrival. One hundred eleven patients with sepsis (8.4%) progressed to septic shock between four to 48 hours of ED arrival.
Characteristics associated with the progression included female gender (odds ratio, 1.59; 95% CI, 1.02-2.47), nonpersistent hypotension (odds ratio, 6.24; 95% CI, 3.58-10.86), bandemia at least 10% (odds ratio, 2.60; 95% CI, 1.50-4.51), lactate of at least 4.0 mmol/L (odds ratio, 5.30; 95% CI, 2.59-10.84), and past medical history of coronary artery disease (odds ratio, 2.01; 95% 1.26-3.44).
Bottom line: Although everyone presenting with sepsis should be treated aggressively, special consideration should be given to patients who are “high risk” to develop septic shock, using the predictors delineated above.
Citation: Capp R, Horton CL, Takhar SS, et al. Predictors of patients who present to the emergency department with sepsis and progress to septic shock between 4 and 48 hours of emergency department arrival. Crit Care Med. 2015;43(5):983-988.
Clinical question: Among patients presenting to the ED with sepsis, who will progress to septic shock within 48 hours of arrival?
Background: This study describes patient characteristics present within four hours of ED arrival associated with developing septic shock between four and 48 hours after arrival.
Study design: Retrospective chart review.
Setting: ED patients hospitalized at two large academic institutions.
Synopsis: A total of 18,100 patients were admitted from the ED, of which 3,960 patients had two or more systemic inflammatory response syndrome criteria, and 1,316 patients had sepsis within four hours of arrival. One hundred eleven patients with sepsis (8.4%) progressed to septic shock between four to 48 hours of ED arrival.
Characteristics associated with the progression included female gender (odds ratio, 1.59; 95% CI, 1.02-2.47), nonpersistent hypotension (odds ratio, 6.24; 95% CI, 3.58-10.86), bandemia at least 10% (odds ratio, 2.60; 95% CI, 1.50-4.51), lactate of at least 4.0 mmol/L (odds ratio, 5.30; 95% CI, 2.59-10.84), and past medical history of coronary artery disease (odds ratio, 2.01; 95% 1.26-3.44).
Bottom line: Although everyone presenting with sepsis should be treated aggressively, special consideration should be given to patients who are “high risk” to develop septic shock, using the predictors delineated above.
Citation: Capp R, Horton CL, Takhar SS, et al. Predictors of patients who present to the emergency department with sepsis and progress to septic shock between 4 and 48 hours of emergency department arrival. Crit Care Med. 2015;43(5):983-988.
Clinical question: Among patients presenting to the ED with sepsis, who will progress to septic shock within 48 hours of arrival?
Background: This study describes patient characteristics present within four hours of ED arrival associated with developing septic shock between four and 48 hours after arrival.
Study design: Retrospective chart review.
Setting: ED patients hospitalized at two large academic institutions.
Synopsis: A total of 18,100 patients were admitted from the ED, of which 3,960 patients had two or more systemic inflammatory response syndrome criteria, and 1,316 patients had sepsis within four hours of arrival. One hundred eleven patients with sepsis (8.4%) progressed to septic shock between four to 48 hours of ED arrival.
Characteristics associated with the progression included female gender (odds ratio, 1.59; 95% CI, 1.02-2.47), nonpersistent hypotension (odds ratio, 6.24; 95% CI, 3.58-10.86), bandemia at least 10% (odds ratio, 2.60; 95% CI, 1.50-4.51), lactate of at least 4.0 mmol/L (odds ratio, 5.30; 95% CI, 2.59-10.84), and past medical history of coronary artery disease (odds ratio, 2.01; 95% 1.26-3.44).
Bottom line: Although everyone presenting with sepsis should be treated aggressively, special consideration should be given to patients who are “high risk” to develop septic shock, using the predictors delineated above.
Citation: Capp R, Horton CL, Takhar SS, et al. Predictors of patients who present to the emergency department with sepsis and progress to septic shock between 4 and 48 hours of emergency department arrival. Crit Care Med. 2015;43(5):983-988.
Individualized Patient Care Plans Impact Utilization, Costs
Clinical question: Does developing individualized care plans in the inpatient setting reduce unnecessary ED visits, hospital readmissions, and hospital costs for frequent users of hospital services?
Background: High utilizers of healthcare services are recognized as medically and psychosocially complex and are at risk for adverse outcomes. Although they make up a small fraction of the patient population (1%), they have high rates of ED visits and hospital admissions and account for 21% of national healthcare spending and hospital costs.
Study design: QI intervention with retrospective pre-/post-intervention analysis.
Setting: Inpatient, tertiary academic medical center.
Synopsis: A multidisciplinary team integrated individualized care plans for 24 high utilizer patients into the EHR from August 1, 2012, to August 31, 2013. These plans summarized medical, psychiatric, and social histories, hospital utilization patterns, and management strategies, including connecting individuals to appropriate services. Outcomes were measured six and 12 months after implementation.
Hospital admissions decreased by 56% (P<0.001) and 50.5% (P>0.003); 30-day readmission decreased by 66% (P<0.001) and 51.5% (P<0.002); ED costs, ED visits, and inpatient length of stay did not change significantly. Inpatient variable direct costs were reduced by 47.7% and 35.8% (P=0.052) at six- and 12-month analysis, respectively.
Bottom line: Individualized care plans developed by a multidisciplinary team and integrated into the EHR at the time of hospitalization can reduce hospital admissions, 30-day readmissions, and hospital costs for high-utilizing patients.
Citation: Mercer T, Bae J, Kipnes J, Velazquez M, Thomas S, Setji N. The highest utilizers of care: individualized care plans to coordinate care, improve healthcare service utilization, and reduce costs at an academic tertiary care center [published online ahead of print April 9, 2015]. J Hosp Med. doi 10.1002/jhm.2351
Clinical question: Does developing individualized care plans in the inpatient setting reduce unnecessary ED visits, hospital readmissions, and hospital costs for frequent users of hospital services?
Background: High utilizers of healthcare services are recognized as medically and psychosocially complex and are at risk for adverse outcomes. Although they make up a small fraction of the patient population (1%), they have high rates of ED visits and hospital admissions and account for 21% of national healthcare spending and hospital costs.
Study design: QI intervention with retrospective pre-/post-intervention analysis.
Setting: Inpatient, tertiary academic medical center.
Synopsis: A multidisciplinary team integrated individualized care plans for 24 high utilizer patients into the EHR from August 1, 2012, to August 31, 2013. These plans summarized medical, psychiatric, and social histories, hospital utilization patterns, and management strategies, including connecting individuals to appropriate services. Outcomes were measured six and 12 months after implementation.
Hospital admissions decreased by 56% (P<0.001) and 50.5% (P>0.003); 30-day readmission decreased by 66% (P<0.001) and 51.5% (P<0.002); ED costs, ED visits, and inpatient length of stay did not change significantly. Inpatient variable direct costs were reduced by 47.7% and 35.8% (P=0.052) at six- and 12-month analysis, respectively.
Bottom line: Individualized care plans developed by a multidisciplinary team and integrated into the EHR at the time of hospitalization can reduce hospital admissions, 30-day readmissions, and hospital costs for high-utilizing patients.
Citation: Mercer T, Bae J, Kipnes J, Velazquez M, Thomas S, Setji N. The highest utilizers of care: individualized care plans to coordinate care, improve healthcare service utilization, and reduce costs at an academic tertiary care center [published online ahead of print April 9, 2015]. J Hosp Med. doi 10.1002/jhm.2351
Clinical question: Does developing individualized care plans in the inpatient setting reduce unnecessary ED visits, hospital readmissions, and hospital costs for frequent users of hospital services?
Background: High utilizers of healthcare services are recognized as medically and psychosocially complex and are at risk for adverse outcomes. Although they make up a small fraction of the patient population (1%), they have high rates of ED visits and hospital admissions and account for 21% of national healthcare spending and hospital costs.
Study design: QI intervention with retrospective pre-/post-intervention analysis.
Setting: Inpatient, tertiary academic medical center.
Synopsis: A multidisciplinary team integrated individualized care plans for 24 high utilizer patients into the EHR from August 1, 2012, to August 31, 2013. These plans summarized medical, psychiatric, and social histories, hospital utilization patterns, and management strategies, including connecting individuals to appropriate services. Outcomes were measured six and 12 months after implementation.
Hospital admissions decreased by 56% (P<0.001) and 50.5% (P>0.003); 30-day readmission decreased by 66% (P<0.001) and 51.5% (P<0.002); ED costs, ED visits, and inpatient length of stay did not change significantly. Inpatient variable direct costs were reduced by 47.7% and 35.8% (P=0.052) at six- and 12-month analysis, respectively.
Bottom line: Individualized care plans developed by a multidisciplinary team and integrated into the EHR at the time of hospitalization can reduce hospital admissions, 30-day readmissions, and hospital costs for high-utilizing patients.
Citation: Mercer T, Bae J, Kipnes J, Velazquez M, Thomas S, Setji N. The highest utilizers of care: individualized care plans to coordinate care, improve healthcare service utilization, and reduce costs at an academic tertiary care center [published online ahead of print April 9, 2015]. J Hosp Med. doi 10.1002/jhm.2351
Revised Guideline for Adult Bacterial Meningitis Improves Treatment, Outcome
Clinical question: Did revision of guidelines recommending computerized tomography (CT) scan before lumbar puncture (LP) reduce delayed treatment of acute bacterial meningitis (ABM)?
Background: Guidelines were introduced in Sweden in 2004 identifying patients at risk for LP-induced brain herniation. They were revised in 2009 to exclude moderate to severe mental status impairment and new seizures as contraindications to LP. This study evaluates the effects of the revision.
Study design: Retrospective.
Setting: Inpatient; two to six months post-discharge.
Synopsis: Data from the Swedish Quality Registry for Community-Acquired Acute Bacterial Meningitis from 2005 to 2009 (394 patients) was compared to data from 2010 to 2012 (318 patients). Mortality and neurological deficits were analyzed, as were effects of LP-CT sequence on time to treatment and outcome.
Treatment was started 1.18 hours earlier (95%CI, .46-1.90 hours, P<0.01) in 2010-2012. After adjusting for confounding factors, there was a nonsignificant reduction in mortality. Treatment delay was significantly associated with increased mortality of 12.6% per hour (95% CI, 3.4%-14.4%; P<0.01). There was significant reduction of neurological sequelae during 2010-2012.
CT performed before LP was associated with a treatment delay of 1.6 hours. In patients with impaired mental status in whom LP was done before CT, mortality was similar and the risk of neurological sequelae was lower.
The study is limited by its retrospective design, nonspecific criteria for diagnosing ABM, and frequent use of meropenem between 2010-2012.
Bottom line: The 2009 revision of Swedish guidelines resulted in earlier treatment of ABM, lower mortality, and fewer unfavorable results, suggesting further revision of international guidelines.
Citation: Glimåker M, Johansson B, Grindborg Ö, Bottai M, Lindquist L, Sjölin J. Adult bacterial meningitis: earlier treatment and improved outcome following guideline revision promoting prompt lumbar puncture. Clin Infect Dis. 2015;60(8):1162-1169.
Clinical question: Did revision of guidelines recommending computerized tomography (CT) scan before lumbar puncture (LP) reduce delayed treatment of acute bacterial meningitis (ABM)?
Background: Guidelines were introduced in Sweden in 2004 identifying patients at risk for LP-induced brain herniation. They were revised in 2009 to exclude moderate to severe mental status impairment and new seizures as contraindications to LP. This study evaluates the effects of the revision.
Study design: Retrospective.
Setting: Inpatient; two to six months post-discharge.
Synopsis: Data from the Swedish Quality Registry for Community-Acquired Acute Bacterial Meningitis from 2005 to 2009 (394 patients) was compared to data from 2010 to 2012 (318 patients). Mortality and neurological deficits were analyzed, as were effects of LP-CT sequence on time to treatment and outcome.
Treatment was started 1.18 hours earlier (95%CI, .46-1.90 hours, P<0.01) in 2010-2012. After adjusting for confounding factors, there was a nonsignificant reduction in mortality. Treatment delay was significantly associated with increased mortality of 12.6% per hour (95% CI, 3.4%-14.4%; P<0.01). There was significant reduction of neurological sequelae during 2010-2012.
CT performed before LP was associated with a treatment delay of 1.6 hours. In patients with impaired mental status in whom LP was done before CT, mortality was similar and the risk of neurological sequelae was lower.
The study is limited by its retrospective design, nonspecific criteria for diagnosing ABM, and frequent use of meropenem between 2010-2012.
Bottom line: The 2009 revision of Swedish guidelines resulted in earlier treatment of ABM, lower mortality, and fewer unfavorable results, suggesting further revision of international guidelines.
Citation: Glimåker M, Johansson B, Grindborg Ö, Bottai M, Lindquist L, Sjölin J. Adult bacterial meningitis: earlier treatment and improved outcome following guideline revision promoting prompt lumbar puncture. Clin Infect Dis. 2015;60(8):1162-1169.
Clinical question: Did revision of guidelines recommending computerized tomography (CT) scan before lumbar puncture (LP) reduce delayed treatment of acute bacterial meningitis (ABM)?
Background: Guidelines were introduced in Sweden in 2004 identifying patients at risk for LP-induced brain herniation. They were revised in 2009 to exclude moderate to severe mental status impairment and new seizures as contraindications to LP. This study evaluates the effects of the revision.
Study design: Retrospective.
Setting: Inpatient; two to six months post-discharge.
Synopsis: Data from the Swedish Quality Registry for Community-Acquired Acute Bacterial Meningitis from 2005 to 2009 (394 patients) was compared to data from 2010 to 2012 (318 patients). Mortality and neurological deficits were analyzed, as were effects of LP-CT sequence on time to treatment and outcome.
Treatment was started 1.18 hours earlier (95%CI, .46-1.90 hours, P<0.01) in 2010-2012. After adjusting for confounding factors, there was a nonsignificant reduction in mortality. Treatment delay was significantly associated with increased mortality of 12.6% per hour (95% CI, 3.4%-14.4%; P<0.01). There was significant reduction of neurological sequelae during 2010-2012.
CT performed before LP was associated with a treatment delay of 1.6 hours. In patients with impaired mental status in whom LP was done before CT, mortality was similar and the risk of neurological sequelae was lower.
The study is limited by its retrospective design, nonspecific criteria for diagnosing ABM, and frequent use of meropenem between 2010-2012.
Bottom line: The 2009 revision of Swedish guidelines resulted in earlier treatment of ABM, lower mortality, and fewer unfavorable results, suggesting further revision of international guidelines.
Citation: Glimåker M, Johansson B, Grindborg Ö, Bottai M, Lindquist L, Sjölin J. Adult bacterial meningitis: earlier treatment and improved outcome following guideline revision promoting prompt lumbar puncture. Clin Infect Dis. 2015;60(8):1162-1169.
Multifaceted Intervention to Decrease Frequency of Common Labs
Clinical question: Can a multifaceted intervention decrease the frequency of unnecessary labs?
Background: Implementation of a multifaceted QI intervention within a large, community-based hospitalist group to decrease ordering of common labs.
Study design: QI project.
Setting: Large, community-based hospitalist group.
Synopsis: QI intervention was composed of academic detailing, audit and feedback, and transparent reporting of the frequency with which common labs were ordered daily. Researchers performed a pre-post analysis, comparing a cohort of patients during the 10-month baseline period before the QI intervention and the seven-month intervention period. The baseline (n=7,824) and intervention (n=5,759) cohorts were similar in their demographics.
Adjusting for age, sex, and principle discharge diagnosis, the number of common labs ordered per patient-day decreased by 0.22 (10.7%) during the intervention period compared with baseline (95% confidence interval [CI], 0.34 to 0.11; P<0.01). No effect was seen on length of stay or readmission rate. The intervention decreased hospital direct costs by an estimated $16.19 per admission or $151,682 annualized (95% CI, $119,746 to $187,618).
Bottom line: A community-based, hospitalist-led, QI intervention focused on daily labs can be effective in safely reducing healthcare waste without compromising quality of care.
Citation: Corson AH, Fan VS, White T, et al. A multifaceted hospitalist quality improvement intervention: decreased frequency of common labs. J Hosp Med. 2015;10(6):390-395.
Clinical question: Can a multifaceted intervention decrease the frequency of unnecessary labs?
Background: Implementation of a multifaceted QI intervention within a large, community-based hospitalist group to decrease ordering of common labs.
Study design: QI project.
Setting: Large, community-based hospitalist group.
Synopsis: QI intervention was composed of academic detailing, audit and feedback, and transparent reporting of the frequency with which common labs were ordered daily. Researchers performed a pre-post analysis, comparing a cohort of patients during the 10-month baseline period before the QI intervention and the seven-month intervention period. The baseline (n=7,824) and intervention (n=5,759) cohorts were similar in their demographics.
Adjusting for age, sex, and principle discharge diagnosis, the number of common labs ordered per patient-day decreased by 0.22 (10.7%) during the intervention period compared with baseline (95% confidence interval [CI], 0.34 to 0.11; P<0.01). No effect was seen on length of stay or readmission rate. The intervention decreased hospital direct costs by an estimated $16.19 per admission or $151,682 annualized (95% CI, $119,746 to $187,618).
Bottom line: A community-based, hospitalist-led, QI intervention focused on daily labs can be effective in safely reducing healthcare waste without compromising quality of care.
Citation: Corson AH, Fan VS, White T, et al. A multifaceted hospitalist quality improvement intervention: decreased frequency of common labs. J Hosp Med. 2015;10(6):390-395.
Clinical question: Can a multifaceted intervention decrease the frequency of unnecessary labs?
Background: Implementation of a multifaceted QI intervention within a large, community-based hospitalist group to decrease ordering of common labs.
Study design: QI project.
Setting: Large, community-based hospitalist group.
Synopsis: QI intervention was composed of academic detailing, audit and feedback, and transparent reporting of the frequency with which common labs were ordered daily. Researchers performed a pre-post analysis, comparing a cohort of patients during the 10-month baseline period before the QI intervention and the seven-month intervention period. The baseline (n=7,824) and intervention (n=5,759) cohorts were similar in their demographics.
Adjusting for age, sex, and principle discharge diagnosis, the number of common labs ordered per patient-day decreased by 0.22 (10.7%) during the intervention period compared with baseline (95% confidence interval [CI], 0.34 to 0.11; P<0.01). No effect was seen on length of stay or readmission rate. The intervention decreased hospital direct costs by an estimated $16.19 per admission or $151,682 annualized (95% CI, $119,746 to $187,618).
Bottom line: A community-based, hospitalist-led, QI intervention focused on daily labs can be effective in safely reducing healthcare waste without compromising quality of care.
Citation: Corson AH, Fan VS, White T, et al. A multifaceted hospitalist quality improvement intervention: decreased frequency of common labs. J Hosp Med. 2015;10(6):390-395.
When Do Patient-Reported Outcome Measures Inform Readmission Risk?
Clinical question: Among patients discharged from the hospital, how do patient-reported outcome (PRO) measures change after discharge, and can they predict readmission or ED visit?
Background: Variables to predict 30-day rehospitalizations of discharged general medical patients have been looked into, but not many strategies have incorporated PRO measures in predictive models.
Study design: Longitudinal cohort study.
Setting: Patients discharged from an urban safety-net hospital that serves 128 municipalities in northeastern Illinois, including the city of Chicago.
Synopsis: One hundred ninety-six patients completed the initial survey; completion rates were 98%, 90%, and 88% for the 30-, 90-, and 180-day follow-up surveys, respectively. The Memorial Symptom Assessment Scale (MSAS) and the Patient Reported Outcomes Measurement Information System (PROMIS) Global Health short form assessing general self-rated health (GSRH), global physical health (GPH), and global mental health (GMH) were administered. In-hospital assessments of GMH and GSRH predicted 14-day reutilization, whereas post-hospitalization assessments of MSAS and GPH predicted subsequent utilizations. Notable limitations of the study include small sample size with high proportion of uninsured and racial/ethnic minorities and inability to count utilization at hospital(s) other than the hospital studied.
Bottom line: PRO measures are likely to be useful predictors in clinical medicine. More research is needed to improve the generalizability of PRO measures. Perhaps determination of specific measures of high predictive value may be more useful.
Citation: Hinami K, Smith J, Deamant CD, DuBeshter K, Trick WE. When do patient-reported outcome measures inform readmission risk? J Hosp Med. 2015;10(5):294-300.
Clinical question: Among patients discharged from the hospital, how do patient-reported outcome (PRO) measures change after discharge, and can they predict readmission or ED visit?
Background: Variables to predict 30-day rehospitalizations of discharged general medical patients have been looked into, but not many strategies have incorporated PRO measures in predictive models.
Study design: Longitudinal cohort study.
Setting: Patients discharged from an urban safety-net hospital that serves 128 municipalities in northeastern Illinois, including the city of Chicago.
Synopsis: One hundred ninety-six patients completed the initial survey; completion rates were 98%, 90%, and 88% for the 30-, 90-, and 180-day follow-up surveys, respectively. The Memorial Symptom Assessment Scale (MSAS) and the Patient Reported Outcomes Measurement Information System (PROMIS) Global Health short form assessing general self-rated health (GSRH), global physical health (GPH), and global mental health (GMH) were administered. In-hospital assessments of GMH and GSRH predicted 14-day reutilization, whereas post-hospitalization assessments of MSAS and GPH predicted subsequent utilizations. Notable limitations of the study include small sample size with high proportion of uninsured and racial/ethnic minorities and inability to count utilization at hospital(s) other than the hospital studied.
Bottom line: PRO measures are likely to be useful predictors in clinical medicine. More research is needed to improve the generalizability of PRO measures. Perhaps determination of specific measures of high predictive value may be more useful.
Citation: Hinami K, Smith J, Deamant CD, DuBeshter K, Trick WE. When do patient-reported outcome measures inform readmission risk? J Hosp Med. 2015;10(5):294-300.
Clinical question: Among patients discharged from the hospital, how do patient-reported outcome (PRO) measures change after discharge, and can they predict readmission or ED visit?
Background: Variables to predict 30-day rehospitalizations of discharged general medical patients have been looked into, but not many strategies have incorporated PRO measures in predictive models.
Study design: Longitudinal cohort study.
Setting: Patients discharged from an urban safety-net hospital that serves 128 municipalities in northeastern Illinois, including the city of Chicago.
Synopsis: One hundred ninety-six patients completed the initial survey; completion rates were 98%, 90%, and 88% for the 30-, 90-, and 180-day follow-up surveys, respectively. The Memorial Symptom Assessment Scale (MSAS) and the Patient Reported Outcomes Measurement Information System (PROMIS) Global Health short form assessing general self-rated health (GSRH), global physical health (GPH), and global mental health (GMH) were administered. In-hospital assessments of GMH and GSRH predicted 14-day reutilization, whereas post-hospitalization assessments of MSAS and GPH predicted subsequent utilizations. Notable limitations of the study include small sample size with high proportion of uninsured and racial/ethnic minorities and inability to count utilization at hospital(s) other than the hospital studied.
Bottom line: PRO measures are likely to be useful predictors in clinical medicine. More research is needed to improve the generalizability of PRO measures. Perhaps determination of specific measures of high predictive value may be more useful.
Citation: Hinami K, Smith J, Deamant CD, DuBeshter K, Trick WE. When do patient-reported outcome measures inform readmission risk? J Hosp Med. 2015;10(5):294-300.
Improving Patient Satisfaction
Patient satisfaction has received increased attention in recent years, which we believe is well deserved and long overdue. Anyone who has been hospitalized, or has had a loved one hospitalized, can appreciate that there is room to improve the patient experience. Dedicating time and effort to improving the patient experience is consistent with our professional commitment to comfort, empathize, and partner with our patients. Though patient satisfaction itself is an outcome worthy of our attention, it is also positively associated with measures related to patient safety and clinical effectiveness.[1, 2] Moreover, patient satisfaction is the only publicly reported measure that represents the patient's voice,[3] and accounts for a substantial portion of the Centers for Medicare and Medicaid Services payment adjustments under the Hospital Value Based Purchasing Program.[4]
However, all healthcare professionals should understand some key fundamental issues related to the measurement of patient satisfaction. The survey from which data are publicly reported and used for hospital payment adjustment is the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, developed by the Agency for Healthcare Research and Quality.[5, 6] HCAHPS is sent to a random sample of 40% of hospitalized patients between 48 hours and 6 weeks after discharge. The HCAHPS survey uses ordinal response scales (eg, never, sometimes, usually, always) that generate highly skewed results toward favorable responses. Therefore, results are reported as the percent top box (ie, the percentage of responses in the most favorable category) rather than as a median score. The skewed distribution of results indicates that most patients are generally satisfied with care (ie, most respondents do not have an axe to grind), but also makes meaningful improvement difficult to achieve. Prior to public reporting and determination of effect on hospital payment, results are adjusted for mode of survey administration and patient mix. The same is not true when patient satisfaction data are used for internal purposes. Hospital leaders typically do not perform statistical adjustment and therefore need to be careful not to make apples‐to‐orangestype comparisons. For example, obstetric patient satisfaction scores should not be compared to general medical patient satisfaction scores, as these populations tend to rate satisfaction differently.
The HCAHPS survey questions are organized into domains of care, including satisfaction with nurses and satisfaction with doctors. Importantly, other healthcare team members may influence patients' perception in these domains. For example, a patient responding to nurse communication questions may also reflect on experiences with patient care technicians, social workers, and therapists. A patient responding to physician communication questions might also reflect on experiences with advanced practice providers. A common mistake is the practice of attributing satisfaction with doctors to the individual who served as the discharge physician. Many readers have likely seen patient satisfaction reports broken out by discharge physician with the expectation that giving this information to individual physicians will serve as useful formative feedback. The reality is that patients see many doctors during a hospitalization. To illustrate this point, we analyzed data from 420 patients admitted to our nonteaching hospitalist service who had completed an HCAHPS survey in 2014. We found that the discharge hospitalist accounted for only 34% of all physician encounters. Furthermore, research has shown that patients' experiences with specialist physicians also have a strong influence on their overall satisfaction with physicians.[7]
Having reliable patient satisfaction data on specific individuals would be a truly powerful formative assessment tool. In this issue of the Journal of Hospital Medicine, Banka and colleagues report on an impressive approach incorporating such a tool to give constructive feedback to physicians.[8] Since 2006, the study site had administered surveys to hospitalized patients that assess their satisfaction with specific resident physicians.[9] However, residency programs only reviewed the survey results with resident physicians about twice a year. The multifaceted intervention developed by Banka and colleagues included directly emailing the survey results to internal medicine resident physicians in real time while they were in service, a 1‐hour conference on best communication practices, and a reward program in which 3 residents were identified monthly to receive department‐wide recognition via email and a generous movie package. Using difference‐in‐differences regression analysis, the investigators compared changes in patient satisfaction results for internal medicine residents to results for residents from other specialties (who were not part of the intervention). The percentage of patients who gave top box responses to all 3 physician‐related questions and to the overall hospital rating was significantly higher for the internal medicine residents.
The findings from this study are important, because no prior study of an intervention, to our knowledge, has shown a significant improvement in patient satisfaction scores. In this study, feedback was believed to be the most powerful factor. The importance of meaningful, timely feedback in medical education is well recognized.[10] Without feedback there is poor insight into how intended results from specific actions compare with actual results. When feedback is lacking from external sources (in this case the voice of the patient), an uncontested sense of mastery develops, allowing mistakes to go uncorrected. This false sense of mastery contributes to an emotional and defensive response when performance is finally revealed to be less than optimal. The simple act of giving more timely feedback in this study encouraged self‐motivated reflection and practice change aimed at improving patient satisfaction, with remarkable results.
The study should inspire physician leaders from various hospital settings, and researchers, to develop and evaluate similar programs to improve patient satisfaction. We agree with the investigators that the approach should be multifaceted. Feedback to specific physicians is a powerful motivator, but needs to be combined with strategies to enhance communication skills. Brief conferences are less likely to have a lasting impact on behaviors than strategies like coaching and simulation based training.[11] Interventions should include recognition and reward to acknowledge exceptional performance and build friendly competition.
The biggest challenge to adopting an intervention such as the one used in the Banka study relates to the feasibility of implementing physician‐specific patient satisfaction reporting. Several survey instruments are available for use as tools to assess satisfaction with specific physicians.[9, 12, 13] However, who will administer these instruments? Most hospitals do not have undergraduate students available. Hospitals could use their volunteers, but this is not likely to be a sustainable solution. Hospitals could consider administering the survey via email, but many hospitals are just starting to collect patient email addresses and many patients do not use email. Once data are collected, who will conduct analyses and create comparative reports? Press Ganey recently developed a survey assessing satisfaction with specific hospitalists, using photographs, and offers the ability to create comparative reports.[14] Their service addresses the analytic challenge, but the quandary of survey administration remains.
In conclusion, we encourage hospital medicine leaders to develop and evaluate multifaceted interventions to improve patient satisfaction such as the one reported by Banka et al. Timely, specific feedback to physicians is an essential feature. The collection of physician‐specific data is a major challenge, but not an insurmountable one. Novel use of personnel and/or technology is likely to play a role in these efforts.
Disclosure: Nothing to report.
- A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open. 2013;3(1). , , .
- Patients' perception of hospital care in the United States. N Engl J Med. 2008;359(18):1921–1931. , , , .
- Medicare.gov. Hospital Compare. Available at: http://www.medicare.gov/hospitalcompare/search.html. Accessed April 27, 2015.
- Centers for Medicare 67(1):27–37.
- Who's behind an HCAHPS score? Jt Comm J Qual Patient Saf. 2011;37(10):461–468. , , , et al.
- Improving patient satisfaction through physician education, feedback, and incentives. J Hosp Med. 2015;10(8):497–502. , , , et al.
- Promoting patient‐centred care through trainee feedback: assessing residents' C‐I‐CARE (ARC) program. BMJ Qual Saf. 2012;21(3):225–233. , , , .
- Feedback in clinical medical education. JAMA. 1983;250(6):777–781. .
- Impact of hospitalist communication‐skills training on patient‐satisfaction scores. J Hosp Med. 2013;8(6):315–320. , , , .
- Assessing patient perceptions of hospitalist communication skills using the Communication Assessment Tool (CAT). J Hosp Med. 2010;5(9):522–527. , , , , , .
- Development and validation of the tool to assess inpatient satisfaction with care from hospitalists. J Hosp Med. 2014;9(9):553–558. , , , , , .
- Press Ganey. A true performance solution for hospitalists. Available at: http://www.pressganey.com/ourSolutions/patient‐voice/census‐based‐surveying/hospitalist.aspx. Accessed April 27, 2015.
Patient satisfaction has received increased attention in recent years, which we believe is well deserved and long overdue. Anyone who has been hospitalized, or has had a loved one hospitalized, can appreciate that there is room to improve the patient experience. Dedicating time and effort to improving the patient experience is consistent with our professional commitment to comfort, empathize, and partner with our patients. Though patient satisfaction itself is an outcome worthy of our attention, it is also positively associated with measures related to patient safety and clinical effectiveness.[1, 2] Moreover, patient satisfaction is the only publicly reported measure that represents the patient's voice,[3] and accounts for a substantial portion of the Centers for Medicare and Medicaid Services payment adjustments under the Hospital Value Based Purchasing Program.[4]
However, all healthcare professionals should understand some key fundamental issues related to the measurement of patient satisfaction. The survey from which data are publicly reported and used for hospital payment adjustment is the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, developed by the Agency for Healthcare Research and Quality.[5, 6] HCAHPS is sent to a random sample of 40% of hospitalized patients between 48 hours and 6 weeks after discharge. The HCAHPS survey uses ordinal response scales (eg, never, sometimes, usually, always) that generate highly skewed results toward favorable responses. Therefore, results are reported as the percent top box (ie, the percentage of responses in the most favorable category) rather than as a median score. The skewed distribution of results indicates that most patients are generally satisfied with care (ie, most respondents do not have an axe to grind), but also makes meaningful improvement difficult to achieve. Prior to public reporting and determination of effect on hospital payment, results are adjusted for mode of survey administration and patient mix. The same is not true when patient satisfaction data are used for internal purposes. Hospital leaders typically do not perform statistical adjustment and therefore need to be careful not to make apples‐to‐orangestype comparisons. For example, obstetric patient satisfaction scores should not be compared to general medical patient satisfaction scores, as these populations tend to rate satisfaction differently.
The HCAHPS survey questions are organized into domains of care, including satisfaction with nurses and satisfaction with doctors. Importantly, other healthcare team members may influence patients' perception in these domains. For example, a patient responding to nurse communication questions may also reflect on experiences with patient care technicians, social workers, and therapists. A patient responding to physician communication questions might also reflect on experiences with advanced practice providers. A common mistake is the practice of attributing satisfaction with doctors to the individual who served as the discharge physician. Many readers have likely seen patient satisfaction reports broken out by discharge physician with the expectation that giving this information to individual physicians will serve as useful formative feedback. The reality is that patients see many doctors during a hospitalization. To illustrate this point, we analyzed data from 420 patients admitted to our nonteaching hospitalist service who had completed an HCAHPS survey in 2014. We found that the discharge hospitalist accounted for only 34% of all physician encounters. Furthermore, research has shown that patients' experiences with specialist physicians also have a strong influence on their overall satisfaction with physicians.[7]
Having reliable patient satisfaction data on specific individuals would be a truly powerful formative assessment tool. In this issue of the Journal of Hospital Medicine, Banka and colleagues report on an impressive approach incorporating such a tool to give constructive feedback to physicians.[8] Since 2006, the study site had administered surveys to hospitalized patients that assess their satisfaction with specific resident physicians.[9] However, residency programs only reviewed the survey results with resident physicians about twice a year. The multifaceted intervention developed by Banka and colleagues included directly emailing the survey results to internal medicine resident physicians in real time while they were in service, a 1‐hour conference on best communication practices, and a reward program in which 3 residents were identified monthly to receive department‐wide recognition via email and a generous movie package. Using difference‐in‐differences regression analysis, the investigators compared changes in patient satisfaction results for internal medicine residents to results for residents from other specialties (who were not part of the intervention). The percentage of patients who gave top box responses to all 3 physician‐related questions and to the overall hospital rating was significantly higher for the internal medicine residents.
The findings from this study are important, because no prior study of an intervention, to our knowledge, has shown a significant improvement in patient satisfaction scores. In this study, feedback was believed to be the most powerful factor. The importance of meaningful, timely feedback in medical education is well recognized.[10] Without feedback there is poor insight into how intended results from specific actions compare with actual results. When feedback is lacking from external sources (in this case the voice of the patient), an uncontested sense of mastery develops, allowing mistakes to go uncorrected. This false sense of mastery contributes to an emotional and defensive response when performance is finally revealed to be less than optimal. The simple act of giving more timely feedback in this study encouraged self‐motivated reflection and practice change aimed at improving patient satisfaction, with remarkable results.
The study should inspire physician leaders from various hospital settings, and researchers, to develop and evaluate similar programs to improve patient satisfaction. We agree with the investigators that the approach should be multifaceted. Feedback to specific physicians is a powerful motivator, but needs to be combined with strategies to enhance communication skills. Brief conferences are less likely to have a lasting impact on behaviors than strategies like coaching and simulation based training.[11] Interventions should include recognition and reward to acknowledge exceptional performance and build friendly competition.
The biggest challenge to adopting an intervention such as the one used in the Banka study relates to the feasibility of implementing physician‐specific patient satisfaction reporting. Several survey instruments are available for use as tools to assess satisfaction with specific physicians.[9, 12, 13] However, who will administer these instruments? Most hospitals do not have undergraduate students available. Hospitals could use their volunteers, but this is not likely to be a sustainable solution. Hospitals could consider administering the survey via email, but many hospitals are just starting to collect patient email addresses and many patients do not use email. Once data are collected, who will conduct analyses and create comparative reports? Press Ganey recently developed a survey assessing satisfaction with specific hospitalists, using photographs, and offers the ability to create comparative reports.[14] Their service addresses the analytic challenge, but the quandary of survey administration remains.
In conclusion, we encourage hospital medicine leaders to develop and evaluate multifaceted interventions to improve patient satisfaction such as the one reported by Banka et al. Timely, specific feedback to physicians is an essential feature. The collection of physician‐specific data is a major challenge, but not an insurmountable one. Novel use of personnel and/or technology is likely to play a role in these efforts.
Disclosure: Nothing to report.
Patient satisfaction has received increased attention in recent years, which we believe is well deserved and long overdue. Anyone who has been hospitalized, or has had a loved one hospitalized, can appreciate that there is room to improve the patient experience. Dedicating time and effort to improving the patient experience is consistent with our professional commitment to comfort, empathize, and partner with our patients. Though patient satisfaction itself is an outcome worthy of our attention, it is also positively associated with measures related to patient safety and clinical effectiveness.[1, 2] Moreover, patient satisfaction is the only publicly reported measure that represents the patient's voice,[3] and accounts for a substantial portion of the Centers for Medicare and Medicaid Services payment adjustments under the Hospital Value Based Purchasing Program.[4]
However, all healthcare professionals should understand some key fundamental issues related to the measurement of patient satisfaction. The survey from which data are publicly reported and used for hospital payment adjustment is the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, developed by the Agency for Healthcare Research and Quality.[5, 6] HCAHPS is sent to a random sample of 40% of hospitalized patients between 48 hours and 6 weeks after discharge. The HCAHPS survey uses ordinal response scales (eg, never, sometimes, usually, always) that generate highly skewed results toward favorable responses. Therefore, results are reported as the percent top box (ie, the percentage of responses in the most favorable category) rather than as a median score. The skewed distribution of results indicates that most patients are generally satisfied with care (ie, most respondents do not have an axe to grind), but also makes meaningful improvement difficult to achieve. Prior to public reporting and determination of effect on hospital payment, results are adjusted for mode of survey administration and patient mix. The same is not true when patient satisfaction data are used for internal purposes. Hospital leaders typically do not perform statistical adjustment and therefore need to be careful not to make apples‐to‐orangestype comparisons. For example, obstetric patient satisfaction scores should not be compared to general medical patient satisfaction scores, as these populations tend to rate satisfaction differently.
The HCAHPS survey questions are organized into domains of care, including satisfaction with nurses and satisfaction with doctors. Importantly, other healthcare team members may influence patients' perception in these domains. For example, a patient responding to nurse communication questions may also reflect on experiences with patient care technicians, social workers, and therapists. A patient responding to physician communication questions might also reflect on experiences with advanced practice providers. A common mistake is the practice of attributing satisfaction with doctors to the individual who served as the discharge physician. Many readers have likely seen patient satisfaction reports broken out by discharge physician with the expectation that giving this information to individual physicians will serve as useful formative feedback. The reality is that patients see many doctors during a hospitalization. To illustrate this point, we analyzed data from 420 patients admitted to our nonteaching hospitalist service who had completed an HCAHPS survey in 2014. We found that the discharge hospitalist accounted for only 34% of all physician encounters. Furthermore, research has shown that patients' experiences with specialist physicians also have a strong influence on their overall satisfaction with physicians.[7]
Having reliable patient satisfaction data on specific individuals would be a truly powerful formative assessment tool. In this issue of the Journal of Hospital Medicine, Banka and colleagues report on an impressive approach incorporating such a tool to give constructive feedback to physicians.[8] Since 2006, the study site had administered surveys to hospitalized patients that assess their satisfaction with specific resident physicians.[9] However, residency programs only reviewed the survey results with resident physicians about twice a year. The multifaceted intervention developed by Banka and colleagues included directly emailing the survey results to internal medicine resident physicians in real time while they were in service, a 1‐hour conference on best communication practices, and a reward program in which 3 residents were identified monthly to receive department‐wide recognition via email and a generous movie package. Using difference‐in‐differences regression analysis, the investigators compared changes in patient satisfaction results for internal medicine residents to results for residents from other specialties (who were not part of the intervention). The percentage of patients who gave top box responses to all 3 physician‐related questions and to the overall hospital rating was significantly higher for the internal medicine residents.
The findings from this study are important, because no prior study of an intervention, to our knowledge, has shown a significant improvement in patient satisfaction scores. In this study, feedback was believed to be the most powerful factor. The importance of meaningful, timely feedback in medical education is well recognized.[10] Without feedback there is poor insight into how intended results from specific actions compare with actual results. When feedback is lacking from external sources (in this case the voice of the patient), an uncontested sense of mastery develops, allowing mistakes to go uncorrected. This false sense of mastery contributes to an emotional and defensive response when performance is finally revealed to be less than optimal. The simple act of giving more timely feedback in this study encouraged self‐motivated reflection and practice change aimed at improving patient satisfaction, with remarkable results.
The study should inspire physician leaders from various hospital settings, and researchers, to develop and evaluate similar programs to improve patient satisfaction. We agree with the investigators that the approach should be multifaceted. Feedback to specific physicians is a powerful motivator, but needs to be combined with strategies to enhance communication skills. Brief conferences are less likely to have a lasting impact on behaviors than strategies like coaching and simulation based training.[11] Interventions should include recognition and reward to acknowledge exceptional performance and build friendly competition.
The biggest challenge to adopting an intervention such as the one used in the Banka study relates to the feasibility of implementing physician‐specific patient satisfaction reporting. Several survey instruments are available for use as tools to assess satisfaction with specific physicians.[9, 12, 13] However, who will administer these instruments? Most hospitals do not have undergraduate students available. Hospitals could use their volunteers, but this is not likely to be a sustainable solution. Hospitals could consider administering the survey via email, but many hospitals are just starting to collect patient email addresses and many patients do not use email. Once data are collected, who will conduct analyses and create comparative reports? Press Ganey recently developed a survey assessing satisfaction with specific hospitalists, using photographs, and offers the ability to create comparative reports.[14] Their service addresses the analytic challenge, but the quandary of survey administration remains.
In conclusion, we encourage hospital medicine leaders to develop and evaluate multifaceted interventions to improve patient satisfaction such as the one reported by Banka et al. Timely, specific feedback to physicians is an essential feature. The collection of physician‐specific data is a major challenge, but not an insurmountable one. Novel use of personnel and/or technology is likely to play a role in these efforts.
Disclosure: Nothing to report.
- A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open. 2013;3(1). , , .
- Patients' perception of hospital care in the United States. N Engl J Med. 2008;359(18):1921–1931. , , , .
- Medicare.gov. Hospital Compare. Available at: http://www.medicare.gov/hospitalcompare/search.html. Accessed April 27, 2015.
- Centers for Medicare 67(1):27–37.
- Who's behind an HCAHPS score? Jt Comm J Qual Patient Saf. 2011;37(10):461–468. , , , et al.
- Improving patient satisfaction through physician education, feedback, and incentives. J Hosp Med. 2015;10(8):497–502. , , , et al.
- Promoting patient‐centred care through trainee feedback: assessing residents' C‐I‐CARE (ARC) program. BMJ Qual Saf. 2012;21(3):225–233. , , , .
- Feedback in clinical medical education. JAMA. 1983;250(6):777–781. .
- Impact of hospitalist communication‐skills training on patient‐satisfaction scores. J Hosp Med. 2013;8(6):315–320. , , , .
- Assessing patient perceptions of hospitalist communication skills using the Communication Assessment Tool (CAT). J Hosp Med. 2010;5(9):522–527. , , , , , .
- Development and validation of the tool to assess inpatient satisfaction with care from hospitalists. J Hosp Med. 2014;9(9):553–558. , , , , , .
- Press Ganey. A true performance solution for hospitalists. Available at: http://www.pressganey.com/ourSolutions/patient‐voice/census‐based‐surveying/hospitalist.aspx. Accessed April 27, 2015.
- A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open. 2013;3(1). , , .
- Patients' perception of hospital care in the United States. N Engl J Med. 2008;359(18):1921–1931. , , , .
- Medicare.gov. Hospital Compare. Available at: http://www.medicare.gov/hospitalcompare/search.html. Accessed April 27, 2015.
- Centers for Medicare 67(1):27–37.
- Who's behind an HCAHPS score? Jt Comm J Qual Patient Saf. 2011;37(10):461–468. , , , et al.
- Improving patient satisfaction through physician education, feedback, and incentives. J Hosp Med. 2015;10(8):497–502. , , , et al.
- Promoting patient‐centred care through trainee feedback: assessing residents' C‐I‐CARE (ARC) program. BMJ Qual Saf. 2012;21(3):225–233. , , , .
- Feedback in clinical medical education. JAMA. 1983;250(6):777–781. .
- Impact of hospitalist communication‐skills training on patient‐satisfaction scores. J Hosp Med. 2013;8(6):315–320. , , , .
- Assessing patient perceptions of hospitalist communication skills using the Communication Assessment Tool (CAT). J Hosp Med. 2010;5(9):522–527. , , , , , .
- Development and validation of the tool to assess inpatient satisfaction with care from hospitalists. J Hosp Med. 2014;9(9):553–558. , , , , , .
- Press Ganey. A true performance solution for hospitalists. Available at: http://www.pressganey.com/ourSolutions/patient‐voice/census‐based‐surveying/hospitalist.aspx. Accessed April 27, 2015.
Letter to the Editor
The impact of rapid response teams (RRTs) on preventing nonintensive care unit (ICU) cardiopulmonary arrests (CPA) and decreasing in‐hospital mortality is a complex issue that goes beyond the structure of RRTs. The success of RRTs depends upon institutional culture, resources, RRT structure, hospital size, and expertise. These are some of the major reasons RRTs have failed to show benefit consistently across the board, because not all institutions are able muster enough resources, reasonable nurse‐to‐patient ratio, advanced ongoing training, and easily accessible onsite intensivists or physicians. An institutional culture where nurses and ancillary staff do not feel intimidated or retaliated on for calling unnecessary RRT codes is extremely important for the success of any RRT program. We have observed at our institution and others where just improvement in culture reduced non‐ICU CPAs, although it also led to a higher number of RRT codes. As a hospitalist leader of RRTs for many years, it sometimes felt as if unwarranted RRT codes were overwhelming already busy hospitalists. However, the real improvement in patient mortality and morbidity reminded us of the importance of creating an open and stress‐free environment for the nurse responsible for initiating RRTs. Davis et al.'s novel RRT program showed improvement in non‐ICU CPAs and in‐hospital mortality.[1] The researchers and their institutions did a great job in improving outcomes, perhaps by devoting enough resources and creating a positive work environment for the nursing staff.
A large observational study conducted in 9 European countries showed that an increase in a nurses' workload by 1 patient increased the likelihood of a hospitalized patient dying within 30 days of admission by 7%. Furthermore, every 10% increase in nurses with a bachelor's degree was associated with a decrease in this likelihood by 7%.[2] Nursing staff can activate RRTs in a timely fashion if they are not overworked or undertrained. Additionally, having an intermediate‐care unit for the patients who do not quite meet the ICU criteria and yet require more intensive care has been shown to decrease in‐hospital mortality.[3] A study by Ghaferi et al. showed that survival after in‐hospital complications following pancreatectomy was high in hospitals with teaching status, those with a size greater than 200 beds and average daily census greater than 50% capacity, increased nurse‐to‐patient ratios, and high‐level hospital technology.[4] Therefore, there are many factors that could have had an impact on in‐hospital mortality in this study.[1] It will be interesting to know if there was a difference in the novel RRT's success rates in the primary medical center and smaller sister campus in the study by Davis et al.[1] Activation of RRTs based on the change in vital signs is challenging for the elderly.[5] Therefore, geriatrics‐unit staff need special training for RRTs to be successful.
In the study by Davis et al., the charge nurse on each inpatient unit conducted rounds on at‐risk patients throughout each shift.[1] Additionally, the charge nurse responded to each RRT code and received intensive training. This strategy may have contributed to the benefit shown by the novel RRT strategy. However, most community hospitals are struggling to maintain adequate nurse‐to‐patient ratios due cost constraints, and adding a significant burden to the already busy charge nurse's responsibilities is difficult to sustain for some institutions. Having a highly trained, dedicated, multidisciplinary team is likely to improve outcomes, but more sustainable solutions for smaller community hospitals are needed. As this study has demonstrated, devoting more resources to patients may pay off over time. The public and private payers should also recognize this as a quality‐of‐care indicator and reward hospitals making improvements in this arena.
- A novel configuration of a traditional rapid response team decreases non‐intensive care unit arrests and overall hospital mortality. J Hosp Med. 2015;10(6):352–357. , , , et al.
- Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet. 2014;384(9946):851–852. , , , ,
- Hospital mortality of adults admitted to intensive care units in hospitals with and without intermediate care units: a multicentre European cohort study. Crit Care. 2014;18(5):551. , , , et al.
- Hospital characteristics associated with failure to rescue from complications after pancreatectomy. J Am Coll Surg. 2010;211(3):325–330. , , ,
- Differences in vital signs between elderly and nonelderly patients prior to ward cardiac arrest. Crit Care Med. 2015;43(4):816–822. , , , ,
The impact of rapid response teams (RRTs) on preventing nonintensive care unit (ICU) cardiopulmonary arrests (CPA) and decreasing in‐hospital mortality is a complex issue that goes beyond the structure of RRTs. The success of RRTs depends upon institutional culture, resources, RRT structure, hospital size, and expertise. These are some of the major reasons RRTs have failed to show benefit consistently across the board, because not all institutions are able muster enough resources, reasonable nurse‐to‐patient ratio, advanced ongoing training, and easily accessible onsite intensivists or physicians. An institutional culture where nurses and ancillary staff do not feel intimidated or retaliated on for calling unnecessary RRT codes is extremely important for the success of any RRT program. We have observed at our institution and others where just improvement in culture reduced non‐ICU CPAs, although it also led to a higher number of RRT codes. As a hospitalist leader of RRTs for many years, it sometimes felt as if unwarranted RRT codes were overwhelming already busy hospitalists. However, the real improvement in patient mortality and morbidity reminded us of the importance of creating an open and stress‐free environment for the nurse responsible for initiating RRTs. Davis et al.'s novel RRT program showed improvement in non‐ICU CPAs and in‐hospital mortality.[1] The researchers and their institutions did a great job in improving outcomes, perhaps by devoting enough resources and creating a positive work environment for the nursing staff.
A large observational study conducted in 9 European countries showed that an increase in a nurses' workload by 1 patient increased the likelihood of a hospitalized patient dying within 30 days of admission by 7%. Furthermore, every 10% increase in nurses with a bachelor's degree was associated with a decrease in this likelihood by 7%.[2] Nursing staff can activate RRTs in a timely fashion if they are not overworked or undertrained. Additionally, having an intermediate‐care unit for the patients who do not quite meet the ICU criteria and yet require more intensive care has been shown to decrease in‐hospital mortality.[3] A study by Ghaferi et al. showed that survival after in‐hospital complications following pancreatectomy was high in hospitals with teaching status, those with a size greater than 200 beds and average daily census greater than 50% capacity, increased nurse‐to‐patient ratios, and high‐level hospital technology.[4] Therefore, there are many factors that could have had an impact on in‐hospital mortality in this study.[1] It will be interesting to know if there was a difference in the novel RRT's success rates in the primary medical center and smaller sister campus in the study by Davis et al.[1] Activation of RRTs based on the change in vital signs is challenging for the elderly.[5] Therefore, geriatrics‐unit staff need special training for RRTs to be successful.
In the study by Davis et al., the charge nurse on each inpatient unit conducted rounds on at‐risk patients throughout each shift.[1] Additionally, the charge nurse responded to each RRT code and received intensive training. This strategy may have contributed to the benefit shown by the novel RRT strategy. However, most community hospitals are struggling to maintain adequate nurse‐to‐patient ratios due cost constraints, and adding a significant burden to the already busy charge nurse's responsibilities is difficult to sustain for some institutions. Having a highly trained, dedicated, multidisciplinary team is likely to improve outcomes, but more sustainable solutions for smaller community hospitals are needed. As this study has demonstrated, devoting more resources to patients may pay off over time. The public and private payers should also recognize this as a quality‐of‐care indicator and reward hospitals making improvements in this arena.
The impact of rapid response teams (RRTs) on preventing nonintensive care unit (ICU) cardiopulmonary arrests (CPA) and decreasing in‐hospital mortality is a complex issue that goes beyond the structure of RRTs. The success of RRTs depends upon institutional culture, resources, RRT structure, hospital size, and expertise. These are some of the major reasons RRTs have failed to show benefit consistently across the board, because not all institutions are able muster enough resources, reasonable nurse‐to‐patient ratio, advanced ongoing training, and easily accessible onsite intensivists or physicians. An institutional culture where nurses and ancillary staff do not feel intimidated or retaliated on for calling unnecessary RRT codes is extremely important for the success of any RRT program. We have observed at our institution and others where just improvement in culture reduced non‐ICU CPAs, although it also led to a higher number of RRT codes. As a hospitalist leader of RRTs for many years, it sometimes felt as if unwarranted RRT codes were overwhelming already busy hospitalists. However, the real improvement in patient mortality and morbidity reminded us of the importance of creating an open and stress‐free environment for the nurse responsible for initiating RRTs. Davis et al.'s novel RRT program showed improvement in non‐ICU CPAs and in‐hospital mortality.[1] The researchers and their institutions did a great job in improving outcomes, perhaps by devoting enough resources and creating a positive work environment for the nursing staff.
A large observational study conducted in 9 European countries showed that an increase in a nurses' workload by 1 patient increased the likelihood of a hospitalized patient dying within 30 days of admission by 7%. Furthermore, every 10% increase in nurses with a bachelor's degree was associated with a decrease in this likelihood by 7%.[2] Nursing staff can activate RRTs in a timely fashion if they are not overworked or undertrained. Additionally, having an intermediate‐care unit for the patients who do not quite meet the ICU criteria and yet require more intensive care has been shown to decrease in‐hospital mortality.[3] A study by Ghaferi et al. showed that survival after in‐hospital complications following pancreatectomy was high in hospitals with teaching status, those with a size greater than 200 beds and average daily census greater than 50% capacity, increased nurse‐to‐patient ratios, and high‐level hospital technology.[4] Therefore, there are many factors that could have had an impact on in‐hospital mortality in this study.[1] It will be interesting to know if there was a difference in the novel RRT's success rates in the primary medical center and smaller sister campus in the study by Davis et al.[1] Activation of RRTs based on the change in vital signs is challenging for the elderly.[5] Therefore, geriatrics‐unit staff need special training for RRTs to be successful.
In the study by Davis et al., the charge nurse on each inpatient unit conducted rounds on at‐risk patients throughout each shift.[1] Additionally, the charge nurse responded to each RRT code and received intensive training. This strategy may have contributed to the benefit shown by the novel RRT strategy. However, most community hospitals are struggling to maintain adequate nurse‐to‐patient ratios due cost constraints, and adding a significant burden to the already busy charge nurse's responsibilities is difficult to sustain for some institutions. Having a highly trained, dedicated, multidisciplinary team is likely to improve outcomes, but more sustainable solutions for smaller community hospitals are needed. As this study has demonstrated, devoting more resources to patients may pay off over time. The public and private payers should also recognize this as a quality‐of‐care indicator and reward hospitals making improvements in this arena.
- A novel configuration of a traditional rapid response team decreases non‐intensive care unit arrests and overall hospital mortality. J Hosp Med. 2015;10(6):352–357. , , , et al.
- Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet. 2014;384(9946):851–852. , , , ,
- Hospital mortality of adults admitted to intensive care units in hospitals with and without intermediate care units: a multicentre European cohort study. Crit Care. 2014;18(5):551. , , , et al.
- Hospital characteristics associated with failure to rescue from complications after pancreatectomy. J Am Coll Surg. 2010;211(3):325–330. , , ,
- Differences in vital signs between elderly and nonelderly patients prior to ward cardiac arrest. Crit Care Med. 2015;43(4):816–822. , , , ,
- A novel configuration of a traditional rapid response team decreases non‐intensive care unit arrests and overall hospital mortality. J Hosp Med. 2015;10(6):352–357. , , , et al.
- Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet. 2014;384(9946):851–852. , , , ,
- Hospital mortality of adults admitted to intensive care units in hospitals with and without intermediate care units: a multicentre European cohort study. Crit Care. 2014;18(5):551. , , , et al.
- Hospital characteristics associated with failure to rescue from complications after pancreatectomy. J Am Coll Surg. 2010;211(3):325–330. , , ,
- Differences in vital signs between elderly and nonelderly patients prior to ward cardiac arrest. Crit Care Med. 2015;43(4):816–822. , , , ,
Letter to the Editor
We appreciate very much Dr. Singh's interest and insight regarding our article, A Novel Configuration of a Traditional Rapid Response Team Decreases NonIntensive Care Unit Arrests and Overall Hospital Mortality.[1] Dr. Singh makes several critical points that are worth emphasis and additional commentary.
The importance of cultural change in the success of a rapid response team (RRT) program cannot be emphasized enough. The willingness of frontline staff to access an RRT is based on a belief in the potential benefit to the patient as well as a lack of concern about the repercussions of such an activation, whether these are from the primary physician team or the RRT members themselves. Both of these require institutional commitmentideally from administrative and clinical leadershipas well as routine, direct feedback to providers as to the effectiveness of the program. Both of these have been addressed in our advanced resuscitation training (ART) program, which has replaced traditional life‐support training and consolidates many efforts related to patient safety and preventable death.[2] The ART program represents adaptive training, in which arrest prevention is emphasized for nonintensive care unit staff and the importance of institutional processes such as RRT is emphasized.
Our approach to RRT configuration reflects the resource constraints referenced by Dr. Singh. Although the ideal RRT would include critical‐care nurses located physically outside the intensive care unit to allow regular assessment of at‐risk patients, this would have required expenditures that were not available for the program. In our opinion, a reasonable alternative was to train charge nurses from nonintensive care units as RRT members. The role expectation for these charge nurses included twice‐daily rounds, and their proximity to at‐risk patients facilitated regular reassessments throughout each shift. In addition, the ART program allowed routine training for bedside nurses to emphasize code/RRT issues on an annual basis and underscores the importance of early recognition of patient safety and preventable death. The ART program actually reduced life‐support expenditures and allowed implementation of both our RRT and institutional cardiac arrest resuscitation programs in a cost‐effective manner.
The last point made by Dr. Singh that we wish to address involves the balance between over‐ and under‐utilization of RRT resources. Our RRT‐to‐code ratios are relatively favorable, allowing the program to exist with efficient allocation of resources. This may be due, in part, to the approach to training with regard to recognition of deterioration. Most RRT programs appear to emphasize vital sign thresholds or use of scoring systems for activation, both of which rely upon single sets of vital signs. Instead, we focus on pattern recognition, emphasizing dynamic changes in vital signs and other clinical assessments and de‐emphasizing absolute values. We believe that this helps develop clinical decision‐making skills and improves both sensitivity and specificity with regard to RRT activation. Again, the adaptive nature of the ART program allows annual training to enhance these skills without additional expense to the institution.
We very much appreciate Dr. Singh's comments and urge other institutions to listen to his message carefully. There is no substitute for efforts spent in establishing just culture and creating an institution that supports its staff in addressing patient safety issues, ultimately reducing preventable deaths.
- A novel configuration of a traditional rapid response team decreases non‐intensive care unit arrests and overall hospital mortality. J Hosp Med. 2015;10:352–357. , , , et al.
- A performance improvement‐based resuscitation programme reduces arrest incidence and increases survival from in‐hospital cardiac arrest. Resuscitation. 2015;92:63–69. , , , et al.
We appreciate very much Dr. Singh's interest and insight regarding our article, A Novel Configuration of a Traditional Rapid Response Team Decreases NonIntensive Care Unit Arrests and Overall Hospital Mortality.[1] Dr. Singh makes several critical points that are worth emphasis and additional commentary.
The importance of cultural change in the success of a rapid response team (RRT) program cannot be emphasized enough. The willingness of frontline staff to access an RRT is based on a belief in the potential benefit to the patient as well as a lack of concern about the repercussions of such an activation, whether these are from the primary physician team or the RRT members themselves. Both of these require institutional commitmentideally from administrative and clinical leadershipas well as routine, direct feedback to providers as to the effectiveness of the program. Both of these have been addressed in our advanced resuscitation training (ART) program, which has replaced traditional life‐support training and consolidates many efforts related to patient safety and preventable death.[2] The ART program represents adaptive training, in which arrest prevention is emphasized for nonintensive care unit staff and the importance of institutional processes such as RRT is emphasized.
Our approach to RRT configuration reflects the resource constraints referenced by Dr. Singh. Although the ideal RRT would include critical‐care nurses located physically outside the intensive care unit to allow regular assessment of at‐risk patients, this would have required expenditures that were not available for the program. In our opinion, a reasonable alternative was to train charge nurses from nonintensive care units as RRT members. The role expectation for these charge nurses included twice‐daily rounds, and their proximity to at‐risk patients facilitated regular reassessments throughout each shift. In addition, the ART program allowed routine training for bedside nurses to emphasize code/RRT issues on an annual basis and underscores the importance of early recognition of patient safety and preventable death. The ART program actually reduced life‐support expenditures and allowed implementation of both our RRT and institutional cardiac arrest resuscitation programs in a cost‐effective manner.
The last point made by Dr. Singh that we wish to address involves the balance between over‐ and under‐utilization of RRT resources. Our RRT‐to‐code ratios are relatively favorable, allowing the program to exist with efficient allocation of resources. This may be due, in part, to the approach to training with regard to recognition of deterioration. Most RRT programs appear to emphasize vital sign thresholds or use of scoring systems for activation, both of which rely upon single sets of vital signs. Instead, we focus on pattern recognition, emphasizing dynamic changes in vital signs and other clinical assessments and de‐emphasizing absolute values. We believe that this helps develop clinical decision‐making skills and improves both sensitivity and specificity with regard to RRT activation. Again, the adaptive nature of the ART program allows annual training to enhance these skills without additional expense to the institution.
We very much appreciate Dr. Singh's comments and urge other institutions to listen to his message carefully. There is no substitute for efforts spent in establishing just culture and creating an institution that supports its staff in addressing patient safety issues, ultimately reducing preventable deaths.
We appreciate very much Dr. Singh's interest and insight regarding our article, A Novel Configuration of a Traditional Rapid Response Team Decreases NonIntensive Care Unit Arrests and Overall Hospital Mortality.[1] Dr. Singh makes several critical points that are worth emphasis and additional commentary.
The importance of cultural change in the success of a rapid response team (RRT) program cannot be emphasized enough. The willingness of frontline staff to access an RRT is based on a belief in the potential benefit to the patient as well as a lack of concern about the repercussions of such an activation, whether these are from the primary physician team or the RRT members themselves. Both of these require institutional commitmentideally from administrative and clinical leadershipas well as routine, direct feedback to providers as to the effectiveness of the program. Both of these have been addressed in our advanced resuscitation training (ART) program, which has replaced traditional life‐support training and consolidates many efforts related to patient safety and preventable death.[2] The ART program represents adaptive training, in which arrest prevention is emphasized for nonintensive care unit staff and the importance of institutional processes such as RRT is emphasized.
Our approach to RRT configuration reflects the resource constraints referenced by Dr. Singh. Although the ideal RRT would include critical‐care nurses located physically outside the intensive care unit to allow regular assessment of at‐risk patients, this would have required expenditures that were not available for the program. In our opinion, a reasonable alternative was to train charge nurses from nonintensive care units as RRT members. The role expectation for these charge nurses included twice‐daily rounds, and their proximity to at‐risk patients facilitated regular reassessments throughout each shift. In addition, the ART program allowed routine training for bedside nurses to emphasize code/RRT issues on an annual basis and underscores the importance of early recognition of patient safety and preventable death. The ART program actually reduced life‐support expenditures and allowed implementation of both our RRT and institutional cardiac arrest resuscitation programs in a cost‐effective manner.
The last point made by Dr. Singh that we wish to address involves the balance between over‐ and under‐utilization of RRT resources. Our RRT‐to‐code ratios are relatively favorable, allowing the program to exist with efficient allocation of resources. This may be due, in part, to the approach to training with regard to recognition of deterioration. Most RRT programs appear to emphasize vital sign thresholds or use of scoring systems for activation, both of which rely upon single sets of vital signs. Instead, we focus on pattern recognition, emphasizing dynamic changes in vital signs and other clinical assessments and de‐emphasizing absolute values. We believe that this helps develop clinical decision‐making skills and improves both sensitivity and specificity with regard to RRT activation. Again, the adaptive nature of the ART program allows annual training to enhance these skills without additional expense to the institution.
We very much appreciate Dr. Singh's comments and urge other institutions to listen to his message carefully. There is no substitute for efforts spent in establishing just culture and creating an institution that supports its staff in addressing patient safety issues, ultimately reducing preventable deaths.
- A novel configuration of a traditional rapid response team decreases non‐intensive care unit arrests and overall hospital mortality. J Hosp Med. 2015;10:352–357. , , , et al.
- A performance improvement‐based resuscitation programme reduces arrest incidence and increases survival from in‐hospital cardiac arrest. Resuscitation. 2015;92:63–69. , , , et al.
- A novel configuration of a traditional rapid response team decreases non‐intensive care unit arrests and overall hospital mortality. J Hosp Med. 2015;10:352–357. , , , et al.
- A performance improvement‐based resuscitation programme reduces arrest incidence and increases survival from in‐hospital cardiac arrest. Resuscitation. 2015;92:63–69. , , , et al.