In Reply

Introduction: The process and outcomes of a novel Critical Care Outreach Team (CCOT) staffed with dedicated critical-care advanced practice providers (APPs) collaborating virtually with an intensivist responding to rapid response team (RRT) activations is described. Methods: Upon RRT activation, the CCOT APP responds to the bedside to assess the patient and acute clinical situation while the CCOT intensivist reviews the electronic medical record for situational awareness of the patient’s hospital course. The CCOT APP and Intensivist in conjunction with the primary team develop a clinical care plan to manage the acute event. The CCOT APP remains with the patient until stabilization or escalation to the intensive care unit (ICU). The CCOT intensivist helps facilitate communication with primary and ICU teams, ensuring timely ICU transfers. CCOT interventions include medications, diagnostics, facilitating consults, transport, escalation of care, transitioning to comfort care, timely follow-up, and multidisciplinary communication. Results: CCOT evaluated 1,862 patients from July 2021 to June 2022 in a large, academic adult hospital. The average time spent on activations was 52 minutes with an average of seven interventions/patient. The ICU transfer rate decreased (37.0% from 46.6%) with no change in mortality (9.0% to 9.8%). Stepdown transfer increased from 3.7% to 9.3%. RRT documentation increased to 100% from 74%. Conclusions: A CCOT with dedicated APPs collaborating with a virtual intensivist can stabilize acutely deteriorating patients by remaining at the bedside, providing advanced interventions, improving communication with bedside providers, and decreasing the need for ICU transfers without increasing mortality. Improved documentation provided improved communication and billing for the institution.

In the February 2010 issue, the article “Impact of pulse oximetry surveillance on rescue events and intensive care unit transfers: A before-and-after concurrence study” (Taenzer AH, Pyke JB, McGrath SP, Blike GT: Anesthesiology 2010; 112:282–7. doi: 10.1097/ALN.0b013e3181ca7a9b) contains an error in the denominator label for rates of rescue events presented. The correct denominator label is patient days, not discharges. This error does not alter the findings of the study. Clarification of the terminology, however, will allow other organizations implementing the same or similar technology to improve understanding of their comparative performance.The authors regret the error.

Nurse Practitioners in Emergency Care

In Brief Objective: To systematically risk assess and analyze the escalation of care process in surgery so as to identify problems and provide recommendations for intervention. Background: The ability to escalate care appropriately when managing deteriorating patients is a hallmark of surgical competence and safe postoperative care. Healthcare-Failure-Mode-Effects-Analysis (HFMEA) is a methodology adapted from safety-critical industries, which allows for hazardous process failures to be prospectively identified and solutions to be recommended. Methods: Forty-two hours of ethnographic observations on surgical wards in 3 London hospitals (phase 1) formed the basis of an escalation process diagram. A risk-assessment survey identified failures associated with process steps and attributed hazard scores (phase 2). Patient safety and clinical risk experts validated hazard scores through a group consensus meeting (phase 3). Hazardous failures were taken forward to multidisciplinary HFMEA where cause analysis was applied and interventions were recommended (phase 4). Results: Observations identified 33 steps in the escalation process. The risk-assessment survey (30 surgical staff members, 100% response) and expert consensus group identified 18 hazardous failures associated with these steps. The HFMEA team identified 3 adequately controlled failures; therefore, 15 were subjected to cause analysis. Outdated communication technology, understaffing, and hierarchical barriers were identified as root causes of failure. Participants recommended interventions based on these findings including defined escalation protocols, human factors education, enhanced communication technology, and improved clinical supervision. Conclusions: Failures in the escalation process amenable to intervention were systematically identified. This mapping of the escalation process will allow tailored interventions to enhance surgical training and patient safety. This quantitative, systematic study used Healthcare Failure Mode Effects Analysis to identify risks in the surgical escalation of care process. Participants identified communication, staffing, and hierarchical failures as root causes of a failure to escalate. Targeted interventions based on escalation protocols, educational sessions, and staff recruitment should improve patient safety.

ABSTRACTCatheter‐directed intervention (CDI) in patients presenting with pulmonary embolism (PE) is suggested to improve in‐hospital outcomes. We aimed to compare the effect of early versus late initiation of CDI on in‐hospital outcomes. A systematic review and meta‐analysis were conducted according to PRISMA guidelines. A comprehensive search of PubMed, Scopus, Web of Science, and Embase databases was performed from inception to May 2025. Data extraction was conducted independently by multiple reviewers. Statistical analysis was performed using R software version 4.3.2, and odds ratio (OR) and mean difference (MD) with 95% confidence intervals (CIs) were combined using a random‐effects model. Six studies, including 53,472 patients, were included. Early intervention before 24 h significantly reduced mortality (OR 0.61, 95% CI [0.44–0.84]; I² = 0%). Moreover, Early intervention before 24 h significantly reduced the all‐cause readmission in patients with acute PE (OR = 0.81 (95% CI: [0.73, 0.89]; I² = 0%). There was no significant difference in risk of major bleeding in early vs late intervention (OR = 0.82; 95% CI: [0.48, 1.39]; I² = 69.3%). Also, early intervention before 24 h significantly reduced the length of hospital stay (LOS) (MD = –3.11 days (95% CI: [–4.33, –1.89]; I² = 0%). This meta‐analysis showed that early CDI, particularly within 24 h of presentation, is associated with a significant reduction in both mortality and all‐cause readmission in patients with acute PE, without increasing the risk of bleeding. These findings support the concept of “time‐is‐myocardium” and reinforce the need for structured protocols that enable early therapeutic intervention. Further randomized controlled trials are needed to confirm these findings and to establish the optimal timing for this potentially life‐saving therapy.

IntroductionThe combination of a reduction in the Danish hospital bed count, the shortage of hospital staff and demographic changes challenges the Danish hospital capacity. This was further highlighted during the COVID-19 pandemic when hospitals worldwide were overwhelmed by infected patients requiring acute hospital care. To address these challenges, a hospital-at-home (HaH) programme offers an alternative to conventional in-hospital admission. Furthermore, HaH has the potential to improve patient outcomes, reduce costs and increase patient satisfaction. However, few studies have evaluated HaH in a Scandinavian setting, and this article describes the protocol for a randomised controlled trial (RCT) comparing an HaH model with continued conventional in-hospital admission. The main aim of the trial is to evaluate physical activity level and mental wellbeing in patients admitted at home compared with conventionally admitted patients.Methods and analysis110 clinically stable patients from two internal medical wards at Nordsjaellands Hospital in Denmark will be included and randomised in a ratio of 1:1 to either continued conventional in-hospital admission (control group) or virtual HaH model (intervention group). The control group will receive standard hospital treatment, and the intervention group will be transferred home for continued treatment (eg, intravenous antibiotics or oxygen treatment). The primary outcome measures are physical activity assessed using daily step count (during the first 24 hours after inclusion, as an intermediary indicator of the risk of adverse events) and treatment satisfaction (assessed using a patient satisfaction survey). Secondary outcome measures are adverse events of special interest, escalation of care, readmission rate postdischarge (30 days and 90 days), mortality (associated and 7 days, 30 days and 90 days postdischarge), process data (eg, the number of teleconsultations) and a health economic evaluation.Ethics and disseminationThe study was approved by the Danish Research Ethics Committees (no. 2303051) and the Danish Medicines Agency (CIV-23-03-042542) and will be monitored by the Copenhagen University Hospital Good Clinical Practice unit. Results will be published in peer-reviewed journals and presented at relevant national and international conferences. We also plan to communicate the results to relevant stakeholders in the Danish healthcare system.Trial registration numberNCT05920304.

Using Qualitative and Quantitative Patient Satisfaction Data to Improve the Quality of Cardiac Care

The Relationship between Inpatient Discharge Timing and Emergency Department Boarding

Early identification and treatment of clinical deterioration is crucial for improving outcomes among hospital patients. A high-acuity response team (HART) program can integrate early warning systems and proactive rounding by critical care nurses to prevent unplanned escalations in care. During the COVID-19 pandemic, a HART program was inconsistently implemented because of intensive care unit staffing shortages. Barriers to optimizing the HART nurse role included inconsistent practices, lack of clear role expectations, and frequent reassignment of HART nurses to compensate for staffing shortages. Postpilot implementation of the HART program began in October 2019. Critical care nurses were designated as HART nurses, responsible for monitoring the Rothman Index, and assisted bedside nurses with high-acuity patients. Data were collected from 2019 to 2023 and were analyzed using IBM SPSS Statistics, version 29, with statistical significance defined as P ≤ .05. The HART program significantly reduced 24-hour intensive care unit readmissions by 33.9% and 72-hour readmissions by 32.7%. HART nurse consultations increased by 35.7%. There were clinically significant decreases in code blue emergencies outside the intensive care unit (22.2%) and overall (16.7%), although no statistically significant differences were found for rapid response team activations or unplanned intensive care unit transfers. The HART nurse program effectively integrates early warning systems and rapid response teams, significantly reducing intensive care unit readmissions and improving patient care. Clear role expectations and dedicated staffing are needed, and continuous stakeholder engagement and resource allocation are essential for sustaining the program's success.

Background/Objectives: Despite the popularity of vascularized lymph node transfers (VLNTs) for treatment of breast cancer-related lymphedema (BCRL), the comparative effectiveness of VLNT placement locations is unknown. In this meta-analysis, we examined the impact of VLNT recipient site (proximal vs. distal vs. dual) and adjunct surgical techniques, including scar release, supercharging, and intervention timing on patient outcomes. Methods: PRISMA-guided search of PubMed, MEDLINE, and Embase (January 2015–March 2025). Patient outcomes including limb circumference/volume reduction, cellulitis frequency, compression garment discontinuation, and patient satisfaction were analyzed. Subgroup analyses assessed node placement, scar release, supercharging, and timing. Results: A total of 1440 patients were analyzed (proximal 63.8%; distal 29.2%; dual 7.0%). No significant differences in mean volume/circumference reductions, patient satisfaction rates, and compression garment discontinuation were observed amongst placement strategies (p > 0.30). Adjunct scar release (65%) was associated with significantly greater patient satisfaction (p = 0.04) and showed trends toward improved volume reduction and compression discontinuation. Earlier intervention (<5 years from diagnosis) showed improved volume reduction, patient satisfaction, and compression discontinuation. Longitudinal analysis revealed dual placement maintained superiority throughout a 12-month follow-up. Conclusions: VLNT is an effective treatment for BCRL regardless of placement location, with all strategies demonstrating substantial clinical improvements. While dual placement showed numerically superior outcomes across all measures, differences did not reach statistical significance due to limited number of studies. Adjunct scar release significantly improves patient satisfaction, and earlier intervention may optimize outcomes. These findings suggest that recipient site selection may be guided by technical factors, vessel availability, and patient preference rather than efficacy differences.

Cardiogenic shock (CS) is a highly morbid condition with mortality remaining greater than 30% despite improved pathophysiologic understanding and access to mechanical circulatory support (MCS). In response, shock teams modeled on successful multidisciplinary care structures for other diseases are being implemented nationwide. Primary data supporting a benefit of shock team implementation on patient outcomes are relatively limited and entirely observational. Four single-center before-and-after studies and one multicenter registry study have demonstrated improved outcomes in patients with CS, potentially driven by increased pulmonary artery catheter (PAC) utilization and earlier (and more appropriate) initiation of MCS. Shock teams are also supported by a growing body of literature recognizing the independent benefit of the interventions they seek to implement, including patient phenotyping with PAC use and an algorithmic approach to CS care. Though debated, MCS is also highly likely to improve CS outcomes when applied appropriately, which further supports a multidisciplinary shock team approach to patient and device selection. Shock teams likely improve patient outcomes by facilitating early patient phenotyping and appropriate intervention. Institutions should strongly consider adopting a multidisciplinary shock team approach to CS care, though additional data supporting these interventions are needed.

Background Pediatric intermediate care units (IC) function to provide a higher level of inpatient pediatric care such as frequent monitoring or nursing intervention compared to routine inpatient general pediatric care. A small subset of these patients in IC deteriorate further and require transfer to the pediatric intensive care unit (PICU). By identifying patient characteristics at the time of admission that predict secondary transfer, specific monitoring, resource allocation and early intervention may be …

Periorbital laceration can result in complex, permanent scars, and even lead to serious complications such as cicatricial ectropion. Early intervention with laser devices has been suggested as a novel modality to reduce scar formation. However, no consensus exists regarding the optimal treatment parameters for scar management. This study evaluated the efficacy and safety of ultrapulse fractional CO 2 laser (UFCL) with different fluences and densities in preventing periorbital surgical scars. To assess the efficacy and safety of UFCL with different fluences and densities in the prevention of periorbital laceration scars. A prospective, randomized, blinded study was conducted on 90 patients with periorbital laceration scars of 2 weeks old. Four treatment sessions of UFCL were administered to each half of the scar at 4-week intervals, with halves treated with high fluences with low density versus low fluences with low-density treatment. Vancouver Scar Scale was used to assess the 2 portions of each individual scar at baseline, final treatment, and 6 months. The patient's 4-point satisfaction scale was used to evaluate the patient's satisfaction at baseline and 6 months. Safety was evaluated by registration of adverse events. Eighty-two of 90 patients completed the clinical trial and follow-up. There was no significant difference in Vancouver Scar Scale and satisfaction score between different laser settings between the two groups ( P > 0.05). Adverse events were minor and no long-term side effects were noted. Early application of UFCL is a safe, strategy to significantly improve the final traumatic periorbital scar appearance. Objective evaluation of scars did not identify differences in scar appearance between high fluences with low density versus low fluences with low density of UFCL treatment. Level III.

Risk stratification with the Modified Early Warning System (MEWS) or electronic cardiac arrest trigger (eCART) has been utilized with ward patients to preemptively identify high-risk patients who might benefit from enhanced monitoring, including early intensive care unit (ICU) transfer. In-hospital mortality from cardiac arrest is ∼80%, making preventative interventions an important focus area. ICUs have lower patient to nurse ratios than wards, resulting in less emphasis on the development of ICU early warning systems. Our institution developed an early warning dashboard (EWD) identifying patients who may benefit from earlier interventions. Using the adverse outcomes of cardiac arrest, ICU mortality, and ICU readmissions, a retrospective case-control study was performed using three demographic items (age, diabetes, and morbid obesity) and 24 EWD measured items, including vital signs, laboratory values, ventilator information, and other clinical information, to validate the EWD. Ten statistically significant areas were identified for cardiac arrest and 13 for ICU death. Identified items included heart rate, dialysis, leukocytosis, and lactate. The ICU readmission outcome was compared to controls from both ICU patients and ward patients, and statistical significance was identified for respiratory rate >30. With several statistically significant data elements, the EWD parameters have been incorporated into advanced clinical decision algorithms to identify at-risk ICU patients. Earlier identification and treatment of organ failure in the ICU improve outcomes and the EWD can serve as a safety measure for both at-risk in-house patients and also extend critical care expertise through telemedicine to smaller hospitals.

108 An automated home blood pressure monitoring program: a pilot study to improve postpartum hypertension care