Education, Teaching, and Quality Improvement |

Rapid Responses Within 48 Hours of Hospital Admission FREE TO VIEW

Stella Hahn, MD; Janice Wang, MD; Rubin Cohen, MD
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Hofstra North Shore LIJ School of Medicine, New Hyde Park, NY

Chest. 2015;148(4_MeetingAbstracts):490A. doi:10.1378/chest.2260043
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SESSION TITLE: Process Improvement in Obstructive Lung Disease Education, Pneumonia Readmissions and Rapid Response Systems II

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM

PURPOSE: Rapid responses (RRs) often occur early in the hospital course, shortly following admission. We determined the frequency and primary reason for RRs occurring within 48 hours of hospital admission.

METHODS: A retrospective chart review of RRs within 48 hours of admission was conducted in an academic medical center over eight months by two independent critical-care-trained reviewers. Reasons for RRs may be triage error, medical error (inadequate care or delay in care, incorrect medical management, abnormal vital signs not addressed, or miscommunication), iatrogenic, or disease trajectory despite appropriate care. We also assessed ICU consultations, APACHE-II and MEWS scores, Elixhauser comorbidity score, and housestaff versus non-housestaff coverage.

RESULTS: Out of 655 RRs within the study period, 161 (24.6%) were within 48 hours of admission. Of these, 20.5% occurred < 12 hours, 29.8% between 12 to 24 hours, and 49.7% between 24:01 to 48 hours. 55% of RRs occurred during the day (7 am to 7 pm). Neurologic instability (45.9%), cardiac/hemodynamic instability (23.3%), and respiratory instability (18.9%) accounted for the majority of RRs. Disease trajectory was the primary perceived reason for RRs (56.9% and 60.8%, by reviewer 1 and 2, respectively) followed by medical error (21.3% and 19%). Triage error was thought to account for only 5% and 6.3%. Substantial agreement was demonstrated between case reviewers (inter-rater reliability coefficient 0.62). 36% of RRs had ICU consultation and 87% of these were accepted. APACHE-II and MEWS scores were significantly higher at time of RR compared to admission (p=0.0001), however, APACHE-II at RR was not significantly associated with increased likelihood of ICU acceptance. There were no associations between Elixhauser score and MICU acceptance, or between housestaff coverage and medical or triage error.

CONCLUSIONS: A quarter of all RRs occurred within 48 hours of admission. More than half of perceived reasons for early RR occurrence was disease trajectory, followed by medical error. Triage error played a minor role.

CLINICAL IMPLICATIONS: Disease trajectory accounted for most early RRs, however, a relatively high rate of medical error leaves opportunity for improvement in care.

DISCLOSURE: The following authors have nothing to disclose: Stella Hahn, Janice Wang, Rubin Cohen

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