Outreach and Early Warning Systems (EWS) for the prevention of Intensive Care admission and death of critically ill adult patients on general hospital wards

 

Abstract

Background

Despite the fact that outreach and early warning systems (EWS) are an integral part of a hospital wide systems approach to improve the early identification and management of deteriorating patients on general hospital wards, the widespread implementation of these interventions in practice is not based on robust research evidence.

Objectives

The primary objective was to determine the impact of critical care outreach services on hospital mortality rates. Secondary objectives included determining the effect of outreach services on intensive care unit (ICU) admission patterns, length of hospital stay and adverse events.

Search methods

The review authors searched the following electronic databases: EPOC Specialised Register, The Cochrane Central Register of Controlled Trials (CENTRAL) and other Cochrane databases (all on The Cochrane Library 2006, Issue 3), MEDLINE (1996-June week 3 2006), EMBASE (1974-week 26 2006), CINAHL (1982-July week 5 2006), First Search (1992-2005) and CAB Health (1990-July 2006); also reference lists of relevant articles, conference abstracts, and made contact with experts and critical care organisations for further information.

Selection criteria

Randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series designs (ITS) which measured hospital mortality, unanticipated ICU admissions, ICU readmissions, length of hospital stay and adverse events following implementation of outreach and EWS in a general hospital ward to identify deteriorating adult patients versus general hospital ward setting without outreach and EWS were included in the review.

Data collection and analysis

Three review authors independently extracted data and two review authors assessed the methodological quality of the included studies. Meta-analysis was not possible due to heterogeneity. Summary statistics and descriptive summaries of primary and secondary outcomes are presented for each study.

Main results

Two cluster-randomised control trials were included: one randomised at hospital level (23 hospitals in Australia) and one at ward level (16 wards in the UK). The primary outcome in the Australian trial (a composite score comprising incidence of unexpected cardiac arrests, unexpected deaths and unplanned ICU admissions) showed no statistical significant difference between control and medical emergency team (MET) hospitals (adjusted P value 0.640; adjusted odds ratio (OR) 0.98; 95% confidence interval (CI) 0.83 to 1.16). The UK-based trial found that outreach reduced in-hospital mortality (adjusted OR 0.52; 95% CI 0.32 to 0.85) compared with the control group.

Authors' conclusions

The evidence from this review highlights the diversity and poor methodological quality of most studies investigating outreach. The results of the two included studies showed either no evidence of the effectiveness of outreach or a reduction in overall mortality in patients receiving outreach. The lack of evidence on outreach requires further multi-site RCT's to determine potential effectiveness.

 

Plain language summary

Ward and organisational practices to recognise and manage patient deterioration in hospital

Research has shown that patients in general hospital wards often show early signs and symptoms, such as changes in breathing and pulse, when their condition is getting worse. If treatment for these patients is delayed they could die or require admission to intensive care (ICU). It is thought that if hospital staff could identify and manage these patients earlier then there would be less deaths and ICU admissions. One way to identify and treat patients who are deteriorating is to introduce outreach services. This usually includes the introduction of an Early Warning System to record physiological observations, training of hospital staff to recognise signs or creating special teams to respond to calls when a patient is deteriorating.

This summary of a Cochrane review presents what we know from research about the effect of outreach services for patients on general hospital wards. The review found two studies which were of good quality. One study compared 12 hospitals with outreach services to 11 that did not. Another study compared 16 wards with outreach to general wards without outreach.

One of the studies showed that outreach reduced the number of hospital deaths, while the other study found no differences between hospitals with outreach and those with no outreach. It is not clear whether outreach reduces hospital deaths or ICU admissions. High quality research is needed to determine the effect of outreach services.

 

摘要

背景

範圍擴展和預警系統(Early Warning Systems, EWS)對於預防在一般住院病房內危急疾病的成年病人住入加護護理單位和死亡的效果

雖然範圍擴展和預警系統(Early Warning Systems, EWS)事實上是一個醫院達到改善在一般住院病房病人狀態惡化時的早期識別及處理的寬廣系統的一個完整的部份，但是普遍的執行這樣的措施並沒有堅實的研究證據。

目標

主要的目標是要確認緊急護理擴大服務對醫院死亡率的影響。次要目標包括確認擴大服務對加護單位(ICU)住院型態、醫院停留天數及負向事件的影響。

搜尋策略

評論作者搜尋以下電子資料庫：EPOC、登錄在Cochrane中心的控制的試驗及其他Cochrane資料庫(所有在Cochrane圖書館2006年第3期的)、MEDLINE(1996年到2006年6月3週)、EMBASE(1974年到2006年26週)、CINAHL(1982到2006年7月5週)，第一次搜尋(1992 – 2005年)及CAB Health(1990年到2006年7月)；也參考有關文章的文獻目錄、會議摘要、及為了更進一步的訊息和專家及加護護理機構接觸。

選擇標準

隨機控制試驗(Randomised controlled trials, RCTs)、臨床控制試驗(controlled clinical trials, CCTs)、前及後控制的研究(controlled before and after studies, CBAs)、及打斷時間序列(interrupted time series designs, ITS)；此評論納入上述研究中追蹤執行範圍擴展和預警系統(EWS)在一般醫院病房有關成年病人的狀態惡化，比對一般醫院病房沒有範圍擴展和預警系統(EWS)設備者，測量醫院死亡率、非預期的入住加護單位、加護單位再住院、醫院住院天數及負向事件。

資料收集與分析

三位評論作者獨立摘取資料及兩位評論作者評估納入研究之方法學的品質。由於其異質性，執行統合分析(Metaanalysis)是不可能的。統合每一篇研究的主要及次要結果的統計和描述性的摘要。

主要結論

納入兩篇群集的隨機控制性試驗：一篇隨機試驗在醫院的層級(23家在澳洲的醫院)及一篇在病房層級(16個在歐洲的病房)。在澳洲的試驗其主要的結果是(一個綜合的得分包括非預期心跳停止、非預期死亡及非計畫的入住加護單位的發生率)，顯示控制組和醫學緊急團隊(medical emergency team、MET)醫院之間在上述事件中沒有統計上的顯著差異(adjusted P value 0.640; adjusted odds ratio (OR) 0.98; 95% confidence interval (CI) 0.83 to 1.16)。歐洲為基礎的試驗發現，擴展服務範圍比較和控制組，可降低在醫院中的死亡率(adjusted OR 0.52; 95% CI 0.32 to 0.85)。

作者結論

從這篇評論的證據強調大多數研究調查擴展服務範圍的差異和不良方法學的品質。兩篇納入的研究的結果，顯示擴展服務範圍沒有證據證實有效，或是證明接受擴展服務範圍的病人整體死亡率降低。在擴展服務範圍的效果仍缺乏證據，需要更進一步多場所的RCT研究，來確認其潛在的效果。

翻譯人

本摘要由高雄榮民總醫院林麗英翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

研究顯示病人在一般醫院病房，當他們的情況變得不好時，常常表現早期症狀及徵象，像是呼吸及脈搏的改變。假如對這些病人的治療延遲，他們可能會死亡或需要住到加護單位(ICU)。一般認為，如果醫院工作人員能夠較早的發現及處理病人，則將有較少病人死亡及入住加護單位。引進擴展服務範圍被認為是一個辨識及治療惡化中病人的方法。通常包括引進一個早期警示系統，去記錄生理學上的觀察，訓練醫院工作人員，當病人情況惡化時能認識症狀或建立特別的小組對呼叫作回應。 摘要Cochrane的評論，我們知道在一般醫院病房關於對病人的擴展服務範圍的效果。此篇評論發現有兩篇品質好的研究。一篇研究比較12家有擴展服務範圍的醫院和11家沒有擴展服務範圍的醫院。另一篇研究比較有擴展服務範圍的16個病房和沒有擴展服務範圍的一般病房。 其中一篇研究顯示擴展服務範圍者有降低醫院死亡數，另一篇研究發現有和沒有擴展服務範圍的醫院之間沒有差異。目前仍然不清楚擴展服務範圍是否可降低醫院的死亡或入住加護單位，擴展服務範圍的效果需要高品質的研究才可確認。