Wednesday, June 17, 2009

Can in-hospital code blues be anticipated and prevented?

We know that rapid response teams (RRTs) and telemetry monitoring have been disappointing in this regard. Telemetry monitoring is known to be overutilized. Although telemetry guidelines, published in 1991, are no longer available on line, here is a modified version of those guidelines adopted by Jackson Memorial Hospital, Miami Florida.

Why have these tools been ineffective? While telemetry monitoring can alert staff to a code in progress (thus theoretically improving the resuscitation outcome) it is of limited usefulness for anticipating cardiac arrest, which is usually heralded by deterioration of multiple clinical parameters besides cardiac rhythm.

The disappointing results of RRTs have been subject to much speculation. Physiologic deterioration often precedes cardiac arrest by 24 hours or more. Given that RRTs focus on an “emergency” response triggered at the last minute they may represent inappropriate substitutes for clinical vigilance. This fact has led to heightened interest in clinical tools such as the early warning score (EWS) and the modified early warning score (MEWS). Although research results on the EWS and MEWS have been mixed, a recent paper in the International Journal of Clinical Practice (via Medscape) was encouraging:

In comparison with the lowest score, the risk of death was incremental among all the MEWS categories, as well as the risk of the combined outcome of death and transfer, and highly significant…

We have confirmed that the MEWS, even when calculated once on admission, is a simple but highly useful tool to predict a worse in-hospital outcome.

Patients with MEWS scores of 2, 3, 4 and 5 or greater had a risk of in hospital death or transfer to higher acuity of care of 17.5%, 26.8%, 36.4% and 43.6% respectively.

Here’s a quick link for the MEWS calculation.

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