Rapid Response Team activation after major hip surgery: patient characteristics and outcomes

Abstract

Background: Rapid response teams (RRTs) are a critical care resource that review deteriorating patients within the hospital. We aimed to describe demographic, preoperative, surgical, anesthetic, and postoperative characteristics of patients who required RRT activation after major hip surgery. We also sought to assess whether these characteristics where associated with mortality during the index hospital admission.Methods: We reviewed an RRT database of adult patients undergoing orthopedic surgery at a university teaching hospital. We then retrospectively reviewed the medical records to extract a priori–defined patient, preoperative, surgical, anesthetic, and postoperative data of major hip surgery admissions between September 2014 and December 2017. Patients who survived the index hospital stay were compared to those who died.Results: Overall, 187 patients had postoperative RRT activations. Median (interquartile range) age was 84.0 (78-90) years; 125 (67%) were female, and most patients had at least one significant comorbidity, median Charlson Comorbidity Index (CCI) 5.0 (4.0-7.0). The majority of patients were frail (68%), American Society of Anesthesiologists physical status Class 3 or greater (91%), and underwent nonelective surgery (88%). Median (interquartile range) time from surgery to RRT activation was 29.4 (11.3–75.0) hours, and 25 (13%) patients had unplanned admissions to intensive care or high dependency units. Compared to patients who survived RRT activation, those who died displayed higher mean CCI (6.5 [1.8] vs. 5.5 [2.1], p = 0.02), were more frail (80.1% vs. 56.5%, OR = 3.2, 95% CI: 1.2,8.1; p = 0.03), and received less intraoperative opioids (intravenous morphine equi-analgesia: median = 5.8 (0.1–8.20 vs. 11.7 (3.7–19.0) mg, p = 0.03). They were also more likely to have received an urgent medical review prior to RRT activation (62% vs. 40%, OR = 2.4, 95% CI: 1.1, 5.6); p = 0.05.Conclusions: Death after RRT activation occurred in 1 in 7 patients undergoing major hip surgery. Common patient characteristics included advanced age (> 82 years), frailty, high CCI, and emergency surgery. Further studies investigating perioperative surveillance teams in the identification of the high-risk patients before surgery and deteriorating patients after major hip surgery are warranted.

Epidemiology and Prognostic Significance of Rapid Response System Activation in Patients Undergoing Liver Transplantation

“…Importantly, this clinical deterioration could not be explained by an increased baseline comorbidity burden or older age, with a lower ACCI recorded in patients receiving MET activation. The MET activation rate of 698 per 1000 LT admissions in this study is significantly higher than other cohorts of medical or non-transplant surgical patients [ 12 , 13 , 14 ], and higher than the rate of 149 per 1000 LT admissions reported by Parmar et al [ 10 ], although that study only included post-LT MET activations. Institutional and cultural factors leading to increased RRS utilization at the study site may partially account for this high MET activation rate [ 15 ], but it is important to note that MET utilization in LT patients is far higher than other surgical patients at our institution.…”

“…Institutional and cultural factors leading to increased RRS utilization at the study site may partially account for this high MET activation rate [ 15 ], but it is important to note that MET utilization in LT patients is far higher than other surgical patients at our institution. For example, a recent analysis of patients undergoing major hip surgery demonstrated a 9% postoperative MET activation rate [ 14 ], even though these patients were, on average, 26 years older and had higher mean ACCI scores than LT recipients. This high rate of MET activation undoubtedly reflects the complexity of LT patients and a propensity for perioperative acute clinical deterioration.…”