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Background New resident work-hour restrictions are expected to result in further increases in the number of handoffs between inpatient care providers, a known risk factor for poor outcomes. Strategies for improving the accuracy and efficiency of provider sign-outs are needed. Objective To develop and test a judgment-based scale for conveying the risk of clinical deterioration. Design Prospective observational study. Setting University teaching hospital. Subjects Internal medicine clinicians and patients. Measurement The Patient Acuity Rating (PAR), a 7-point Likert score representing the likelihood of a patient experiencing a cardiac arrest or ICU transfer within the next 24 hours, was obtained from physicians and midlevel practitioners at the time of sign-out. Cross-covering physicians were blinded to the results, which were subsequently correlated with outcomes. Results Forty eligible clinicians consented to participate, providing 6034 individual scores on 3419 patient-days. Seventy four patient-days resulted in cardiac arrest or ICU transfer within 24 hours. The average PAR was 3±1 and yielded an area under the receiver operator characteristics curve (AUROC) of 0.82. Provider-specific AUROC values ranged from 0.69 for residents to 0.85 for attendings (p=0.01). Interns and midlevels did not differ significantly from the other groups. A PAR of 4 or higher corresponded to a sensitivity of 82% and a specificity of 68% for predicting cardiac arrest or ICU transfer in the next 24 hours. Conclusions Clinical judgment regarding patient stability can be reliably quantified in a simple score with the potential for efficiently conveying complex assessments of at-risk patients during handoffs between healthcare members.

Objective-Hyperventilation is both common and detrimental during cardiopulmonary resuscitation (CPR). Chest wall impedance algorithms have been developed to detect ventilations during CPR. However, impedance signals are challenged by noise artifact from multiple sources, including chest compressions. Capnography has been proposed as an alternate method to measure ventilations. We sought to assess and compare the adequacy of these two approaches.Methods-Continuous chest wall impedance and capnography were recorded during consecutive in-hospital cardiac arrests. Algorithms utilizing each of these data sources were compared to a manually determined "gold standard" reference ventilation rate. In addition, a combination algorithm, which utilized the highest of the impedance or capnography values in any given minute, was similarly evaluated.Results-Data were collected from 37 cardiac arrests, yielding 438 min of data with continuous chest compressions and concurrent recording of impedance and capnography. The manually calculated mean ventilation rate was 13.3±4.3/min. In comparison, the defibrillator's impedancebased algorithm yielded an average rate of 11.3±4.4/min (p=0.0001) while the capnography rate was 11.7±3.7/min (p=0.0009). There was no significant difference in sensitivity and positive predictive value between the two methods. The combination algorithm rate was 12.4±3.5/min (p=0.02), which yielded the highest fraction of minutes with respiratory rates within 2/min of the reference. The Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Conclusions-Both the impedance and capnography-based algorithms underestimated the ventilation rate. Reliable ventilation rate determination may require a novel combination of multiple algorithms during resuscitation. Conflict of Interest

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