Prevention of in-hospital cardiac arrest (IHCA) is critical to reducing morbidity and mortality as both the rates of return to pre-hospital functional status and overall survival after IHCAs are low. Early identification of patients at risk and prompt clinical intervention are vital patient safety strategies to reduce IHCA. One widespread strategy is the Rapid Response System (RRS), which incorporates early risk identification, expert consultation, and key clinical interventions to bedside nurses caring for patients in clinical deterioration. However, evidence of RRS effectiveness has been equivocal in the patient safety literature. This study utilized a holistic Realistic Evaluation (RE) framework to identify important clinical environment (context) and system triggers (mechanisms) to refine our understanding of an RRS to improve local patient emoutcomesem and develop a foundation for building the next level of evidence within RE research. The specific aims of the study are to describe a RRS through context, mechanism, and outcome variables; explore differences in RRS outcomes between medical and surgical settings, and identify relationships between RRS context and mechanism variables for patient outcomes. Study RRS data was collected retrospectively from a 397-bed community hospital in the Midwest; including all adult inpatient RRS events from May 2006 (2 weeks post-RRS implementation) through November 2013. RRS events were analyzed through descriptive, comparative, and proportional odds (ordinal) logistic regression analyses. The study found the majority of adult inpatient RRS events occurred in medical settings and most were activated by staff nurses. Significant differences were noted between RRS events in medical and surgical settings; including patient status changes in the preceding 12 hours, event trigger patterns, and immediate clinical outcomes. Finally, proportional odds logistic regression revealed significant relationships between context and mechanism factors with changes in the risk of increased clinical severity immediately following at RRS event. RE was utilized to structure a preliminary study to explore the complex variables and relationships surrounding RRSs and patient outcomes. Further exploration of settings, changes in clinical status, staffing and resource access, and the ways nurses use RRSs is necessary to promote the early identification of vulnerable patients and strengthen hospital patient safety strategies.

Objectives: The objective of this thesis is to explore the association between delayed rapid response team activation and patient mortality and morbidity in adult in-patients. Methods: Study 1 presents a protocol for a systematic review of literature regarding the association of delayed activation of rapid response teams and patient outcomes. Study 2 contains the results of the conducted systematic review, performing a search of the literature to critically appraise, aggregate, and present a narrative synthesis of included studies. The final study examines the association between delayed rapid response team activation and hospital mortality, ICU transfer, and cardiopulmonary arrest risk in a retrospective observational cohort study conducted as part of the “Hospital without Code Blues” initiative at Hamilton Health Sciences. Results: Studies included in the systematic review report an association between delayed activation and patient mortality and ICU transfer odds. Results of study three find that these delays may not be associated with patient mortality, but are significantly associated with ICU transfer events and a composite outcome of patient in-hospital mortality, ICU transfer, and cardiopulmonary arrest. Overall, patients experiencing a delayed rapid response team activation were at greater odds of experiencing a negative event during their course of stay in hospital. Conclusions: This thesis presents findings that suggest delayed activation of rapid response teams is associated with an increase in patient mortality and ICU transfers. Increased durations of delay are associated with increased odds of experiencing the above events. / Thesis / Master of Science (MSc)

Akutsjuksköterskans roll är att tillhandahålla omedelbar vård till människor eller att utföra en omvårdnadsåtgärd som kan förhindra att en nödsituation uppstår. Akutsjuksköterskan ska leda, initiera och samordna patientvården. Faktorer som påverkar patientsäkerheten är ledarskapet, att arbeta i team, att arbeta evidensbaserat, kommunikation, utbildning och att arbeta patientcentrerat. Rapid response system (RRS) utvecklades för att förbättra patientsäkerheten inom akutsjukvården. Det finns fyra enheter som är grundläggande för systemet. Den afferenta komponenten som omfattar av sjuksköterskan som ansvarar för identifiering av varningssignaler för kritiskt sjuka patienter och aktivering av RRS. Till sin hjälp har sjuksköterskan ett track- and triggersystem som baseras på patientens vitalparametrar för att identifiera kritiskt sjuka patienter på avdelning. De vanligaste förekommande vitalparametrarna inom akutsjukvården är: respiration, temperatur, blodtryck, hjärtfrekvens, medvetandegrad samt urinproduktion. Den efferenta komponenten är den hjälpinsats som den afferenta komponenten tillkallar vid aktivering av RRS när avvikande vitalparametrar är observerade och genererar hög poängsumma i ett track- and triggersystem alternativt på inrådan av sjuksköterskans instinktiva känsla av att patientens tillstånd försämrats. Syftet var att belysa sjuksköterskans upplevelser av att arbeta utefter ett rapid response system och belysa dess påverkan på patientsäkerheten. Metoden som användes var litteraturöversikt. Databassökningar gjordes i PubMed, CINAHL och Web Of Science, vilket resulterade i att 16 artiklar inkluderades i studien. Inklusionskriterier som användes var att artikeln skulle vara publicerad på engelska, ’peer- reviewed’ och publicerade i vetenskapliga tidskrifter mellan år 2006–2016. En integrerad analysmetod användes för att finna likheter och skillnader i resultatet. I resultatet framkom det att RRS ökade identifieringen av kritiskt sjuka patienter och flertalet artiklar konstaterade att RRS minskade antalet hjärtstopp och oväntade dödsfall. I resultatet framkom svårigheter och begränsningar med att arbeta utefter RRS så som otillräcklig kompetens, hög arbetsbelastning och hierarki. Avvikande vitalparametrar togs mer på allvar jämfört med ”tysta” förändringar. Sjuksköterskorna aktiverade systemet på grund av oro relaterat till klinisk erfarenhet, trots att vitalparametrarna var normala RRS var till hjälp att hantera kritiskt sjuka patienter och fungerade som sjukhusets 112. Avdelningssjuksköterskorna upplevde att de mestadels fick stöttning av det medicinska akutvårdsteamet men tillfällen då sjuksköterskan upplevde otrevligt bemötande påverkade det beslutsfattandet av aktivering av RRS negativt framöver. Slutsatsen av denna litteraturöversikt tyder på att RRS främjar patientsäkerheten och hjälper sjuksköterskan i sitt dagliga arbete genom att främja säker vård. Sjuksköterskans upplevelser belyser gynnsamma omständigheter och upplevda svårigheter med RRS som kan användas till vidare forskning för att utveckla systemet. / The role of the emergency nurse is to provide immediate care to patients or to perform a nursing intervention that can prevent an emergency. They should lead, initiate and coordinate patient care. Factors that affect patient safety could be leadership, working in teams, evidence-based work, communication, training, or patient-centered work. Rapid response system (RRS) was developed to improve patient safety in emergency care. There are four units that are essential for the system to function. The afferent component includes the nurse who is responsible to identify warning signs if the patient is deteriorating and activate RRS. A track-and trigger system based on the patient’s vital signs is used to assist the nurse to identify deteriorating patients on wards. The most common vital signs in emergency care are: respiration, temperature, blood pressure, heart rate, consciousness and urine production. The efferent component is the relief effort that the afferent component calls for by activating RRS when abnormal vital signs are observed and generate a high score in the track-and trigger system. Alternatively, on the advice of the nurse's instinctive feeling that the patient's condition has deteriorated. The aim of this study was to highlight nurses' experiences of applying rapid response system in their work and illustrate its impact on patient safety. The method used was a literature review. Database searches were made in PubMed, CINAHL and Web of Science, which resulted in 16 articles being included in the study. Inclusion criteria used were English language, ’peer-reviewed’ and published in scientific journals between the years 2006-2016. An integrated analysis was used to find similarities and differences in the results. The result showed that RRS increased identification of critically ill patients, resulting in reduced number of cardiac arrests and unexpected deaths and led to more patients being moved to a higher level of care. Difficulties or limitations that emerged were inadequate skills, high workload and hierarchy. Abnormal vital signs were taken more seriously compared to "silent" changes. The nurses sometimes activated the system due to concerns based on their clinical experience, despite vital signs being normal. RRS was a help to manage critically ill patients and served as the hospital's Department 112. The emergency medical team mostly supported the nurses, but sometimes they experienced negative attitudes, which affected the future activations negatively. The conclusion of this literature review indicates that RRS for patient safety could help nurses in their daily work by promoting safe care. The nurse's experiences highlight the favorable circumstances and perceived difficulties with the RRS, which could be used for further research to develop the system.

In 1999, the Institute of Medicine estimated as many as 98,000 patients died each year in US hospitals as the result of medical errors. Five years later, another report estimated 195,000 people died unnecessarily. A recent study of patient safety in American hospitals concluded that 87% of Medicare deaths identified over a three-year period were "potentially preventable." The rapid response team (RRT) has been recommended as an effective strategy for reducing avoidable patient deaths as measured by patient safety indicator #4 (PSI#4), Death among surgical inpatients with treatable serious complications [formerly failure to rescue]. There is no research evidence to support the recommendation. The purpose of this exploratory research study was to describe RRT characteristics, determine RRT penetration, and measure PSI#4 (Death among surgical inpatients) rates among hospitals in a large metropolitan area hospital council. A retrospective, descriptive design was used during analysis of survey data collected from members of the hospital council and secondary analysis of administrative data submitted by the same hospitals to a regional data warehouse. All of the hospitals represented by survey submissions had implemented RRTs. The majority of teams was nurse-led and could be activated by a wide range of hospital staff and family members. The hospitals used evidence-based criteria for RRT activation. There was a downward trend in the regional PSI#4 rate from 2003 to 2008, which was not statistically significant, but may be considered clinically significant. Nurse administrators viewed RRTs as effectively supporting nursing care. This study provided a first look at RRTs in relation to an untested patient safety indicator that measured avoidable patient deaths. More research with a larger sample size with adequate power to support statistical analysis of differences in PSI #4 rates over time will provide evidence regarding relationships among hospital characteristics, RRT characteristics, and avoidable deaths among surgical inpatients. / text

The Clemson GRB Follow-Up program utilizes the SARA 0.9-m telescope to observe optical afterglows of Gamma Ray Bursts. SARA is not yet robotic; it operates under direct and Target-of-Opportunity (ToO) interrupt modes. To facilitate rapid response and timely reporting of data analysis results, we developed a software suite that operates in two phases: first, to notify observers of a burst and assist in data collection, and second, to quickly analyze the images.

The nursing culture of an inpatient pediatric unit was resistant to activating pediatric rapid response team (PRRT) alerts despite guidelines for activation. Nurses routinely assessed patients and assigned a pediatric early warning score (PEWS); however, the level of illness severity was not interpreted consistently among nurses and a PEWS action algorithm did not exist to guide nurses' minimal actions based on the PEWS score. Guided by 3 adult learning theories (Knowles, Kolb, and Bandura) and 1 evaluation model (Kirkpatrick), this staff education project sought to educate pediatric nurses on a PEWS action algorithm and determine whether this project improved nurses' knowledge, situational awareness, and attitude toward activating PRRT alerts. A convenience sample of 30 pediatric nurses completed a preeducation knowledge survey (EKS), attended an interactive PEWS education class, and completed a postEKS. After participating in the class, correct responses on the EKS increased from 43% to 82% and, using the Wilcoxon-signed rank test, a significant increase was noted in nurses' responses to questions related to self-efficacy, factual knowledge, and application. The overall increase in the nurses' self-efficacy and knowledge about the PEWS might enhance critical-thinking skills, foster identification of patients at risk for clinical deterioration, and empower nurses to follow the PEWS action algorithm including activation of PRRT alerts when indicated. This project has the potential to effect positive social change by supporting nurses' actions designed to improve pediatric patient outcomes.

Bakgrund: Västvärlden har hög medellivslängd vilket inte bara innebär att människor är friska utan att de också finns många som lever med svåra sjukdomar och stort lidande. I Australien startades den Mobila Intensivvårds Gruppen, MIG-team för att minska dödlighet av akut sviktande patienter, som sedan infördes runt om i världen.   Syfte: Syftet med denna litteraturstudie var att beskriva sjuksköterskornas upplevelser av den mobila intensivvårdgruppen (MIG-team) samt National Early Warning Score (NEWS), samt beskriva de inkluderade artiklarnas datainsamlingsmetod.   Metod: Beskrivande litteraturstudie. De inkluderade vetenskapliga artiklarna söktes fram i databasen PubMed. Elva artiklar inkluderades som svarade på syftet. Artiklarna inkluderade både kvalitativ och kvantitativ ansats.   Huvudresultat: Många sjuksköterskor ansåg att kommunikationen var viktig. NEWS – National Early Warning Score sågs som ett viktigt verktyg för att effektivisera patientvården då kommunikationen blev snabb och exakt mellan sjuksköterskan och MIG-team. Detta ökade även patientsäkerheten genom att både hjärtstoppslarm och dödsfall har minskat. Sjuksköterskorna önskar överlag mer utbildning för att stärka den egna kompetensen. Det har påvisats att en del av sjuksköterskorna känner sig osäkra att hantera NEWS samt att de känner sig osäkra vid vilken tidpunkt de bör kontakta MIG-team. Osäkerheten skulle med största sannolikhet minska om de fick tillgång till mer utbildning samtidigt som det skulle stärka teamarbetet kring patienten. Datainsamlingsmetoderna i de inkluderade studierna var ett flertal intervjuer, en observationsstudie och datainsamlingar från olika dataprogram.   Slutsats: Kommunikation har visat sig ha stor betydelse både för att säkerhetsställa patientarbete och främja teamarbete i personalgruppen. Införande av NEWS och MIG-team runt om i världen har visats minska hjärtstopplarm och dödligheten på sjukhus, vilket skulle kunna motivera till ytterligare utbildning för sjuksköterskor i NEWS och MIG-team. / Background: In the west world it is a high life expectancy, which not only means thatpeople are healthy but that they also are many who are living with serious illnesses andgreat suffering. The Mobile Intensive Care Group (MIG team) started in Australia toreduce mortality from acute fragile patients, who then introduced around the world. Aim: To describe the nurse´s experiences of Rapid Response Team (MIG-team), andthe National Early Warning Score (NEWS), and to describe the data collection of theincluded articles. Methods: A literature study with descriptive design. The included scientific articleswere sought out in the PubMed database. Eleven articles were included who answeredthe aim. The articles included both qualitative and quantitative approach. Results: Many of the nurse´s concider that the communication was important. NEWSseen as an important tool to streamline patient care when communication was fast andaccurately between the nurse and the MIG- team. This also increased patient safety,which showed that both cardiac arrest alarm and deaths have declined. Nurses wishgenerally more education to enhance their skills. It has been demonstrated that some ofthe nurses feel insecure dealing with NEWS and that they feel uncertain when theyshould contact MIG -Team. The uncertainty would most likely decrease if they hadaccess to more education while it also would strengthen the teamwork around thepatient. Data collection methods in the included studies were several interviews, oneobservational study and data collection from various data programs. Conclusion: Communication has proved to be very important both to the collateralpatient work and promote teamwork in the personnel group. Introduction of NEWS andMIG teams around the world have been shown to reduce cardiac alarms and mortality inhospitals, which could warrant additional training in the MEWS and MIG team for thenurse´s.

Introdução: O Escore de Alerta Precoce Modificado (MEWS) foi desenvolvido para identificação de pacientes em deterioração clínica. O objetivo foi avaliar o desempenho deste escore em enfermaria de hospital público brasileiro. Método: Parâmetros do MEWS (pressão arterial sistólica, frequência cardíaca, frequência respiratória, temperatura e nível de consciência) foram avaliados de 6/6 horas. Os seguintes eventos foram registrados: óbito, parada cardiorrespiratória e transferência para terapia intensiva. Resultados: Foram incluídos 300 pacientes (57±18 anos, sexo masculino: 65%). Observou-se número crescente de eventos combinados de acordo com o maior valor do escore (00%;00%;01%; 09%;19%;28%;89%, respectivamente para os MEWS 0;1;2;3;4;5 e 6; p<0,0001). MEWS>=4 foi o ponto de corte mais adequado para predição destes eventos (sensibilidade:87%, especificidade:85% e acurácia:0,86). Conclusões: MEWS mensura adequadamente a ocorrência de eventos graves em pacientes hospitalizados em enfermaria de um hospital público brasileiro. MEWS>=4 parece ser o ponto de corte mais adequado para predição destes eventos. / Introduction: The Modified Early Warning Score (MEWS) was developed for identification of patients in clinical deterioration. The objective was to evaluate the performance of this score in a Brazilian public hospital ward. Method: MEWS parameters (systolic blood pressure, heart rate, respiratory rate, temperature and level of consciousness) were evaluated 6/6 hours. The following events were recorded: death, cardiorespiratory arrest and transfer to intensive care. Results: 300 patients (57 ± 18 years old, male: 65%) were included. We observed a growing number of events combined according to the highest score (00%, 00%, 01%, 09%, 19%, 28%, 89%, respectively for the MEWS 0; 1; 2; 3; 4, 5 and 6, p <0.0001). MEWS>=4 was the most appropriate cutoff point for prediction of these events (sensitivity: 87%, specificity: 85% and accuracy: 0.86). Conclusions: MEWS adequately measures the occurrence of serious events in patients hospitalized in a ward of a Brazilian public hospital. MEWS>=4 seems to be the most appropriate cutoff point for predicting these events.

The purpose of the present study were to (a) explore the relationship between the frequency of use of Rapid Response Teams (RRTs) by hospital staff nurses and the support received from RRTs; (b) to investigate staff nurses’ perceptions of their individual level, group level and organizational level learning as a result of single or multiple exposures to the RRT; (c) to identify predictors of learning outcomes and (d) to identify overall impressions and advantages and disadvantages of the RRT. A mail survey was used to collect data. The response responses rate was 33%, 131 registered nurses responded to the survey (pre-test = 12, study = 119). The results of Pearson r correlation suggest that a high frequency of access of RRTs was positively related to process support (r = .25, p < .01). Also, perceived content and process support from RRTs was positively related to maintenance and building of staff nurses’ mental models regarding patient deterioration pertaining to self, group and organization. Multiple regression analyses show that sociodemographic and independent variables predict organizational learning outcomes (mental model maintenance and building). Overall impressions of the RRTs were high. A content analysis of nurses’ comments indicated that there were more advantages to having the RRTs than disadvantages. This study suggests that RRTs are influential in changing nurses’ perceptions about managing patient deterioration. Training programs for RRTs should include both content and process support, which may enhance building and maintaining mental models. / Thesis (Master, Nursing) -- Queen's University, 2008-09-25 21:27:44.682

1a,25-Dihydroxyvitamin D3 (1a,25(OH)2D3) is a major functional metabolic form of vitamin D. 1a,25(OH)2D3 has drawn increasing attention due to its functions in addition to maintaining calcium phosphate homeostasis. It directly regulates mineralization by osteoblasts, matrix production and remodeling by chondrocytes, and contraction of cardiomyocytes. 1a,25(OH)2D3 and its analogues have shown beneficial effects in treating multiple sclerosis, diabetes and various types of cancer. In order to maximize the pharmaceutical potential of 1a,25(OH)2D3, a better understanding its cell signaling pathway is necessary. 1a,25(OH)2D3 regulates osteoblasts through both classical nuclear vitamin D receptor (nVDR) mediated genomic effects and plasma membrane receptor-mediated rapid responses. The identity of the plasma membrane receptor for 1a,25(OH)2D3 is controversial. Protein disulfide isomerase associated 3 (Pdia3) has been hypothesized as one of the putative plasma membrane receptors for 1a,25(OH)2D3. The overall goal of this thesis was to understand the general role and the molecular mechanism of Pdia3 in 1a,25(OH)2D3-initiated rapid responses, and to determine the role of Pdia3 and its dependent signaling in osteoblast biology. The results show that Pdia3 is required for membrane-mediated responses of 1a,25(OH)2D3. Moreover, both Pdia3 and nVDR are critical components of the plasma membrane receptor complex for 1a,25(OH)2D3. Finally, Pdia3 and signaling via Pdia3 regulate osteoblast differentiation and mineralization. Taken together, this study demonstrates the role of Pdia3 in rapid responses to 1a,25(OH)2D3 and osteoblast biology, reveals the unexpected complexity of the 1a,25(OH)2D3 plasma receptor complex and opens the new target, Pdia3, for pharmaceutical application and tissue engineering.