High value healthcare analysis of “triggers” in deteriorating patients

Abstract

Objective: To review “triggers” for deteriorating patients who required intervention by a medical emergency response team (MET). In addition, to assess whether these “triggers” differed by medical or surgical governance of these patients. A secondary objective was to report laboratory investigations performed via the MET, with particular interest in tests duplicating haemoglobin (Hb) values and their degree of concordance within the context of low-cost, high value inpatient care.
Methods: This quality improvement initiative involved a prospective observational cohort of inpatients, who were attended to by the MET at Royal Perth Hospital in Perth, Western Australia over a 2-year period between 2020 and 2022.
Results: The mean number of MET calls for inpatients under surgical governance was slightly higher than for those patients under medical governance (1.34 vs. 1.25 calls respectively p =.03). Hypotension triggered a MET call in 184 (40.9%) surgical patients compared to 154 (28%) under medical governance (p <.001). Comparing haemoglobin values obtained from FBP and VBG, Lin’s concordance correlation coefficient (CCC) was found to be 0.986, 95%CI: 0.983, 0.989. The Bland-Altman limits of agreement suggest that the haemoglobin value on a VBG ranges from 9.55 g/L higher than the FBP to 4.7 g/L lower than the FBP.
Conclusions: Significant differences in the frequency of triggers for patients under medical vs surgical governance highlight the need for proactive planning around hypotension management of patients under surgical governance. In addition, understanding the nuances between haemoglobin values obtained from FBP and VBG can help with value-based health care and efficiencies in patient care, since measuring haemoglobin values is one of the key components in hypotension management.

Keywords

High value healthcare / Haemoglobin / Medical emergency review / Tertiary hospital / Venous blood gas

ACKNOWLEDGEMENTS

Not applicable.

AUTHORS CONTRIBUTIONS

FUNDING

Not applicable.

CONFLICTS OF INTEREST DISCLOSURE

The authors declare they have no conflict of interest. This quality improvement initiative was approved by the Hospital Operations and Logistics Access Divisional Committee at Royal Perth Hospital, under registration QI: 39013, and approved for publishing with approval reference number 289.

INFORMED CONSENT

This was done as part of the quality improvement initiative.

ETHICS APPROVAL

The Publication Ethics Committee of the Sciedu Press. The journal’s policies adhere to the Core Practices established by the Committee on Publication Ethics (COPE).

PROVENANCE AND PEER REVIEW

Not commissioned; externally double-blind peer reviewed.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

DATA SHARING STATEMENT

No additional data are available.

OPEN ACCESS

This is an open-access article distributed under the terms and conditions of the Creative Commons Attribution license (http://creativecommons.org/licenses/by/4.0/).

COPYRIGHTS

Copyright for this article is retained by the author(s), with first publication rights granted to the journal.

References

[1] Badgery-Parker T, Pearson SA, Chalmers K, et al. Low-value care in Australian public hospitals: prevalence and trends over time. BMJ Qual Saf. 2019; 28: 205-214. PMid: 30082331. https://doi.org/10.1136/bmjqs-2018-008338

[2] Berwick D, Hackbarth A. Eliminating waste in US healthcare. JAMA. 2012; 307: 1513-6. PMid: 22419800. https://doi.org/10.1001/jama.2012.362

[3] O’Callaghan G, Meyer H, Elshaug AG. Choosing Wisely: the message, messanger and method. MJA (Perspectives). 2015; 202(4): 175-178. PMid: 25716590. https://doi.org/10.5694/mja14.00673

[4] Scott I, Duckett S. In search of professional consensus in defining and reducing low-value care. Med J Aust. 2015; 203: 179-81. PMid: 26268286. https://doi.org/10.5694/mja14.01664

[5] Krishnasivam D, Bennett L, Birkett K, et al. The ’SAFE’ initiative - An innovative approach to safer patient care in a tertiary hospital setting. Journal of Hospital Administration. 2019; 8(1): 65-72. https://doi.org/10.5430/jha.v8n1p65

[6] Ruiz M, Bottle A, Aylin PP. The Global Comparators project: international comparison of 30-day in-hospital mortality by day of the week. British Medical Journal Quality Safety. 2015: 1-13. https://doi.101136/bmjqs-2014-003467

[7] Bell CM, Redelmeier DA. Mortality among patients admitted to hospitals on weekends as compared with weekdays. New England Journal of Medicine. 2002; 345(9): 663-668. PMid: 11547721. https://doi.org/10.1056/NEJMsa003376

[8] Barba R, Losa JE, Velasco C, et al. Mortality among adult patients admitted to the hospital on weekends. European Journal of Internal Medicine. 2006; 17(5): 322-324. PMid: 16864005. https://doi.org/10.1016/j.ejim.2006.01.003

[9] Aylin PP, Yunus A, Bottle A, et al. Weekend mortality for emergency admissions. A large, multicentre study. Quality and Safety in Health Care. 2010; 19(213): e217. PMid: 20110288. https://doi.org/10.1136/qshc.2008.028639

[10] De Vita MA, Braithwaite RS, Mahidara R, et al. Use of medical emergency team responses to reduce hospital cardiopulmonary arrests. BMJ Quality & Safety. 2004; 13: 251-254. https://doi.org/10.1136/qshc.2003.006585

[11] Braithwaite R, De Vita M, Mahidhara R, et al. Use of medical emergency team (MET) responses to detect medical errors. BMJ Quality & Safety. 2004; 13: 255-259. https://doi.org/10.1136/qshc.2003.009324

[12] Maharaj R, Raffaele I, Wendon J. Rapid response systems: a systematic review and meta-analysis. Crit Care. 2015; 19: 254. PMid: 26070457. https://doi.org/10.1186/s13054-015-0973-y

[13] Bindraban RS ten Berg MJ, Naaktgeboren CA, et al. Reducing Test Utilization in Hospital Settings: A Narrative Review. Ann Lab Med. 2018; 38: 402-412. PMid: 29797809. https://doi.org/10.3343/alm.2018.38.5.402

[14] Hauser RG, Shirts BH. Do we now know what inappropriate laboratory utilization is? Am J Clin Pathol. 2014; 141: 774-83. PMid: 24838320. https://doi.org/10.1309/AJCPX1HIEM4KLGNU

[15] Bland JM, Altman DG. Statistical methods for assessing agreement between two pairs of clinical measurement. Lancet. 1986; I(307-310). https://doi.org/10.1016/S0140-6736(86)90837-8

[16] Lin LIK. A concordance correlation coefficent to evaluate reproducibility. Biometrics. 1989; 45: 255-268. PMid: 2720055. https://doi.org/10.2307/2532051

[17] Jones D, Bellomo R, A DeVita M. Effectiveness of the Medical Emergency Team: the importance of dose. Critical Care. 2009; 13: 313. PMid: 19825203. https://doi.org/10.1186/cc7996

[18] Jones D, Opdam H, Egi M, et al. Long-term effect of a Medical Emergency Team on mortality in a teaching hospital. Resuscitation. 2007; 74: 235-241. PMid: 17367913. https://doi.org/10.1016/j.resuscitation.2006.12.007

[19] Hillman K, Chen J, Cretikos M, et al. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet. 2005; 365: 2091-2097. PMid: 15964445. https://doi.org/10.1016/S0140-6736(05)66733-5

[20] Quach JL, Downey A, Haase M, et al. Characteristics and outcomes of patients receiving a medical emergency team review for respiratory distress or hypotension. Journal of Critical Care. 2008; 23(3): 325-331. PMid: 18725036. https://doi.org/10.1016/j.jcrc.2007.11.002

[21] Griffiths P, Saucedo AR, Schmidt P, et al. Vital signs monitoring in hospitals at night. Nursing Times. 2015; 111(36/37): 16-17.

[22] Fossum M, Hewitt N, Weir-Phyland J, et al. Providing timely quality care after-hours: Perceptions of a hospital model of care. Australian College of Nursing Ltd. 2018; 2-7.

[23] Barbour CM, Little DM. Post operative Hypotension. JAMA. 1957; 165(12): 1529-1532. PMid: 13475055. https://doi.org/10.1001/jama.1957.02980300009003