Association Between Survival and Time of Day for Rapid Response Team Calls in a National Registry. (Patel)

Churpek MM, et al. Association Between Survival and Time of Day for Rapid Response Team Calls in a National Registry. Crit Care Med. 2017 Oct;45(10):1677-1682.

OBJECTIVES: Decreased staffing at nighttime is associated with worse outcomes in hospitalized patients. Rapid response teams were developed to decrease preventable harm by providing additional critical care resources to patients with clinical deterioration. We sought to determine whether rapid response team call frequency suffers from decreased utilization at night and how this is associated with patient outcomes.

DESIGN: Retrospective analysis of a prospectively collected registry database.

SETTING: National registry database of inpatient rapid response team calls.

PATIENTS: Index rapid response team calls occurring on the general wards in the American Heart Association Get With The Guidelines-Medical Emergency Team database between 2005 and 2015 were analyzed.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: The primary outcome was inhospital mortality. Patient and event characteristics between the hours with the highest and lowest mortality were compared, and multivariable models adjusting for patient characteristics were fit. A total of 282,710 rapid response team calls from 274 hospitals were included. The lowest frequency of calls occurred in the consecutive 1 AM to 6:59 AM period, with 266 of 274 (97%) hospitals having lower than expected call volumes during those hours. Mortality was highest during the 7 AM hour and lowest during the noon hour (18.8% vs 13.8%; adjusted odds ratio, 1.41 [1.31-1.52]; p < 0.001). Compared with calls at the noon hour, those during the 7 AM hour had more deranged vital signs, were more likely to have a respiratory trigger, and were more likely to have greater than two simultaneous triggers.

CONCLUSIONS: Rapid response team activation is less frequent during the early morning and is followed by a spike in mortality in the 7 AM hour. These findings suggest that failure to rescue deteriorating patients is more common overnight. Strategies aimed at improving rapid response team utilization during these vulnerable hours may improve patient outcomes.

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The Epidemiology of Hospital Death Following Pediatric Severe Sepsis: When, Why, and How Children With Sepsis Die. (Dodd)

Weiss SL, et al. The Epidemiology of Hospital Death Following Pediatric Severe Sepsis: When, Why, and How Children With Sepsis Die. Pediatr Crit Care Med. 2017 Sep;18(9):823-830.

OBJECTIVE: The epidemiology of in-hospital death after pediatric sepsis has not been well characterized. We investigated the timing, cause, mode, and attribution of death in children with severe sepsis, hypothesizing that refractory shock leading to early death is rare in the current era.

DESIGN: Retrospective observational study.

SETTING: Emergency departments and ICUs at two academic children’s hospitals.

PATIENTS: Seventy-nine patients less than 18 years old treated for severe sepsis/septic shock in 2012-2013 who died prior to hospital discharge.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: Time to death from sepsis recognition, cause and mode of death, and attribution of death to sepsis were determined from medical records. Organ dysfunction was assessed via daily Pediatric Logistic Organ Dysfunction-2 scores for 7 days preceding death with an increase greater than or equal to 5 defined as worsening organ dysfunction. The median time to death was 8 days (interquartile range, 1-12 d) with 25%, 35%, and 49% of cumulative deaths within 1, 3, and 7 days of sepsis recognition, respectively. The most common cause of death was refractory shock (34%), then multiple organ dysfunction syndrome after shock recovery (27%), neurologic injury (19%), single-organ respiratory failure (9%), and nonseptic comorbidity (6%). Early deaths (≤ 3 d) were mostly due to refractory shock in young, previously healthy patients while multiple organ dysfunction syndrome predominated after 3 days. Mode of death was withdrawal in 72%, unsuccessful cardiopulmonary resuscitation in 22%, and irreversible loss of neurologic function in 6%. Ninety percent of deaths were attributable to acute or chronic manifestations of sepsis. Only 23% had a rise in Pediatric Logistic Organ Dysfunction-2 that indicated worsening organ dysfunction.

CONCLUSIONS: Refractory shock remains a common cause of death in pediatric sepsis, especially for early deaths. Later deaths were mostly attributable to multiple organ dysfunction syndrome, neurologic, and respiratory failure after life-sustaining therapies were limited. A pattern of persistent, rather than worsening, organ dysfunction preceded most deaths.

Racial and Ethnic Variation in Pediatric Cardiac Extracorporeal Life Support Survival. (Carroll)

Chan T, et al. Racial and Ethnic Variation in Pediatric Cardiac Extracorporeal Life Support Survival. Crit Care Med. 2017 Apr; 45(4):670-678.

OBJECTIVES: Previous studies have suggested an association between nonwhite race and poor outcomes in small subsets of cardiac surgery patients who require extracorporeal life support. This study aims to examine the association of race/ethnicity with mortality in pediatric patients who receive extracorporeal life support for cardiac support.

DESIGN: Retrospective analysis of registry data.

SETTING: Prospectively collected multi-institutional registry data.

SUBJECTS: Data from all North American pediatric patients in the Extracorporeal Life Support International Registry who received extracorporeal life support for cardiac support between 1998 and 2012 were analyzed. Multivariate regression models were constructed to examine the association between race/ethnicity and hospital mortality, adjusting for demographics, diagnosis, pre-extracorporeal life support care, extracorporeal life support variables, and extracorporeal life support-related complications.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: Of 7,106 patients undergoing cardiac extracorporeal life support, the majority of patients were of white race (56.9%) with black race (16.7%), Hispanic ethnicity (15.8%), and Asian race (2.8%) comprising the other major race/ethnic groups. The mortality rate was 53.9% (n = 3,831). After adjusting for covariates, multivariate analysis identified black race (relative risk = 1.10; 95% CI, 1.04-1.16) and Hispanic ethnicity (relative risk = 1.08; 95% CI, 1.02-1.14) as independent risk factors for mortality.

CONCLUSIONS: Black race and Hispanic ethnicity are independently associated with mortality in children who require cardiac extracorporeal life support.

Greater Protein and Energy Intake May Be Associated With Improved Mortality in Higher Risk Critically Ill Patients: A Multicenter, Multinational Observational Study. (Betters)

Compher C, Chittams J, Sammarco T, et al. Greater Protein and Energy Intake May Be Associated With Improved Mortality in Higher Risk Critically Ill Patients: A Multicenter, Multinational Observational Study. Crit Care Med. 2017 Feb; 45(2):156-163.

OBJECTIVES: Controversy exists about the value of greater nutritional intake in critically ill patients, possibly due to varied patient nutritional risk. The objective of this study was to investigate whether clinical outcomes vary by protein or energy intake in patients with risk evaluated by the NUTrition Risk in the Critically Ill score.

DESIGN: Prospective observational cohort.

SETTING: A total of 202 ICUs.

PATIENTS: A total of 2,853 mechanically ventilated patients in ICU greater than or equal to 4 days and a subset of 1,605 patients in ICU greater than or equal to 12 days.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: In low-risk (NUTrition Risk in the Critically Ill, < 5) and high-risk (NUTrition Risk in the Critically Ill, ≥ 5) patients, mortality and time to discharge alive up to day 60 were assessed relative to nutritional intake over the first 12 days using logistic regression and Cox proportional hazard regression, respectively. In high-risk but not low-risk patients, mortality was lower with greater protein (4-d sample: odds ratio, 0.93; 95% CI, 0.89-0.98; p = 0.003 and 12-d sample: odds ratio, 0.90; 95% CI, 0.84-0.96; p = 0.003) and energy (4-d sample: odds ratio, 0.93; 95% CI, 0.89-0.97; p < 0.001 and 12-d sample: odds ratio, 0.88; 95% CI, 0.83-0.94; p < 0.001) intake. In the 12-day sample, there was significant interaction among NUTrition Risk in the Critically Ill category, mortality, and protein and energy intake, whereas in the 4-day sample, the test for interaction was not significant. In high-risk but not low-risk patients, time to discharge alive was shorter with greater protein (4-d sample: hazard ratio, 1.05; 95% CI, 1.01-1.09; p = 0.01 and 12-d sample: hazard ratio, 1.09; 95% CI, 1.03-1.16; p = 0.002) and energy intake (4-d sample: hazard ratio, 1.05; 95% CI, 1.01-1.09; p = 0.02 and 12-d sample: hazard ratio, 1.09; 95% CI, 1.03-1.16; p = 0.002). In the 12-day sample, there was significant interaction among NUTrition Risk in the Critically Ill category, time to discharge alive, and protein and energy intake, whereas in the 4-day sample, the test for interaction was not significant.

CONCLUSIONS: Greater nutritional intake is associated with lower mortality and faster time to discharge alive in high-risk, longer stay patients but not significantly so in nutritionally low-risk patients.