Rapid Response Team Implementation and In-Hospital Mortality

756 clinicians should be aware of these risks and counsel patients accordingly. , INTERACTION BETWEEN FLUIDS AND VASOACTIVE AGENTS ON MORTALITY IN SEPTIC SHOCK: A MULTICENTER, OBSERVATIONAL STUDY. Waechter J, Kumar A, Lapinsky S, et al. Crit Care Med 2014;42:2158 68. Fluids and vasoactive agents are both used to correct for hypotension and hypoperfusion that arise as a consequence of septic shock. They, along with antibiotics and source control, are the mainstays of treatment for septic shock. Little is known about the interaction between fluids and vasoactive agents, however, and their effect on in-hospital mortality for septic shock patients. This retrospective observational study of 2849 intensive care unit patients from 28 hospitals in Canada, the United States, and Saudi Arabia aimed to prove a relevant interaction between these two treatments. Inclusion criteria included presence of septic shock, survival beyond 24 h after onset of hypotension, administration of antibiotics before or with 24 h of onset of hypotension, use of intravenous (i.v.) infusion of vasoactive agents within 24 h of onset of hypotension, and administration of # 20 L i.v. fluids. Total equivalent volume (TEV) and time to onset of vasoactive medication variables were assigned to terciles 0 1 h (early), 1 6 h (intermediate), and 6 24 h (late) after onset of hypotension. A total of 81 combinations of TEV of fluids and vasoactive medication administration were studied using multivariable logistic regression modeling. The lowest in-hospital mortality rates were associated with a combination of intermediate timing of vasoactive agents, high volume of fluids given in the early and intermediate intervals, and moderate volume in the late period (predicted hospital mortality 24.7 vs. 46%; p < 0.0001, compared with the same fluid volumes and timing but early interval administration of vasoactive agents). The authors comment that their data do not demonstrate causality for higher mortality associated with early initiation of vasoactive agents. They speculate that patients may receive less aggressive early fluid resuscitation with the early initiation of vasoactive agents due to visualizing higher blood pressure measurements and that the resulting vasoconstriction may contribute to higher mortality by precipitating end organ ischemia in a hypovolemic state. The notion, however, of improved mortality with early aggressive fluid resuscitation in the management of sepsis was again demonstrated in this study. A major limitation to this study was that type, dosing, or pharmacologic properties of vasoactive agents were not taken into consideration. [Christa Brink Kahn, MD Denver Health Medical Center, Denver, CO] Comments: Septic shock carries a tremendous mortality rate. A wide armamentarium of data, to which this study in part con-

Abstracts tributes, already exists to support the clinical practice of early fluid resuscitation in sepsis management today. While a prospective interventional study would be needed to investigate the hypotheses generated by this observational study, the idea of increased hospital mortality in sepsis management with early vasopressor administration is novel and has the potential to change future practice patterns and patient outcomes. , RAPID RESPONSE TEAM IMPLEMENTATION AND IN-HOSPITAL MORTALITY. Salvatierra G, Bindler R, Corbett C, et al. Crit Care Med 2014;42:2001 6. This observational cohort study from Washington State used a statewide dataset that enrolled 471,062 patients aged 18 years or older who were hospitalized in 1 of 10 tertiary care facilities in a 31-month pre- or post-intervention period to determine the relationship between the implementation of rapid response teams (RRTs) and in-hospital mortality. Implementation data collected from each of the 10 hospitals used in the final analysis for the pre- and post-RRT time periods included 235,718 and 235,344 patients, respectively. Variations in severity of illness and comorbidities were controlled for. Binary logistic regression was used to examine the risk for in-hospital mortality and an interrupted time series analysis was performed to examine the independent effect of RRT implementation on mortality rates. RRT implementation in 6 of the 10 hospitals was associated with a decrease in in-hospital mortality (RR = 0.76; 95% CI 0.72 0.80; p < 0.001). Four of the 10 hospitals showed no change in RR. The hospitals reporting reduced mortality rates also reported formal RRT education at time of implementation and ongoing training. A time series analysis for the full sample size, however, showed that medical complexity increased over time and in-hospital mortality declined during the course of the 62-month study period. There was no difference in in-hospital mortality between the pre- and post-RRT time periods (B = 0.12; 95% CI 0.05 to 0.28; p = 0.15) using an interrupted time series analysis controlled for changes over time. The authors conclude that the results of this study were similar to two meta-analyses that also demonstrated no in-hospital mortality reduction between pre- and post-RRT time periods. [Christa Brink Kahn, MD Denver Health Medical Center, Denver, CO] Comments: The study notes that up to 65% of U.S. hospitals currently have implemented an RRT, although many of these were implemented before evidence to support their effectiveness. Improvements in overall U.S. hospital patient outcomes as a result of enhanced technologies and education make it difficult to assess the contribution of specialized resuscitation groups, such as RRTs, to in-hospital mortality. More research is needed to comment on the efficacy of such strategies.