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Background: Recent data suggest that acidosis alone is not a good predictor of mortality in trauma patients. Little data are currently available regarding factors associated with survival in trauma patients presenting with acidosis. Aims: The aims were to characterize the outcomes of trauma patients presenting with acidosis and to identify modifiable risk factors associated with mortality in these patients. Settings and Design: This is a retrospective observational study of University of Arkansas for Medical Sciences (UAMS) trauma patients between November 23, 2013, and May 21, 2017. Methods: Data were collected from the UAMS trauma registry. The primary outcome was hospital mortality. Analyses were performed using t-test and Pearson's Chi-squared test. Simple and multiple logistic regressions were performed to determine crude and adjusted odds ratios. Results: There were 532 patients identified and 64.7% were acidotic (pH < 7.35) on presentation: 75.9% pH 7.2–7.35; 18.5% pH 7.0–7.2; and 5.6% pH ≤ 7.0. The total hospital mortality was 23.7%. Nonsurvivors were older and more acidotic, with a base deficit >−8, Glasgow Coma Scale (GCS) ≤ 8, systolic blood pressure ≤ 90, International Normalized Ratio (INR) >1.6, and Injury Severity Score (ISS) >15. Mortality was significantly higher with a pH ≤ 7.2 but mortality with a pH 7.2–7.35 was comparable to pH > 7.35. In the adjusted model, pH ≤ 7.0, pH 7.0–7.2, INR > 1.6, GCS ≤ 8, and ISS > 15 were associated with increased mortality. For patients with a pH ≤ 7.2, only INR was associated with increase in mortality. Conclusions: A pH ≤ 7.2 is associated with increased mortality. For patients in this range, only the presence of coagulopathy is associated with increased mortality. A pH > 7.2 may be an appropriate treatment goal for acidosis. Further work is needed to identify and target potentially modifiable factors in patients with acidosis such as coagulopathy.

Background ICUs' provision of complex care for critically ill patients results in an environment with a high potential for adverse events. A study was conducted to characterize adverse events in Veterans Health Administration (VHA) ICUs that underwent root cause analysis (RCA) and to identify the root causes and their recommended actions. Methods This retrospective observational study of RCA reports concerned events that occurred in VHA ICUs or as a result of ICU processes from January 1, 2013, through December 31, 2014. The type of event, root causes, and recommended actions were measured. Results Some 70 eligible RCAs were identified in 47 of the 120 facilities with an ICU in the VHA system. Delays in care (30.0%) and medication errors (28.6%) were the most common types of events. There were 152 root causes and 277 recommended actions. Root causes often involved rules, policies, and procedure processes (28.3%), equipment/supply issues (15.8%), and knowledge deficits/education (15.1%). Common actions recommended were policy, procedure, and process actions (34.4%) and training/education actions (31.4%). Of the actions implemented, 84.4% had a reported effectiveness of "much better" or "better." Conclusion ICU adverse events often had several root causes, with protocols and process-of-care issues as root causes regardless of event type. Actions often included standardization of processes and training/education. Several recommendations can be made that may improve patient safety in the ICU, such as standardization of care process, implementation of team training programs, and simulation-based training.

BACKGROUND In 2004, the Institute for Healthcare Improvement's 100,000 Lives Campaign recommended that hospitals implement rapid response teams (RRTs) charged with identifying non–intensive care unit (ICU) patients at risk for rapid deterioration. Although RRTs are now in widespread use, there have been conflicting results regarding the impact of RRTs on hospital mortality and cardiopulmonary arrest. PURPOSE To assess the effectiveness of RRTs on reducing hospital mortality and non-ICU cardiopulmonary arrest rates. DATA SOURCES We conducted a systematic review using MEDLINE (1966–2014), Cochrane Central Register of Controlled Trials (1898–2014), Cumulative Index to Nursing and Allied Health Literature (1994–2014), and ClinicalTrials.gov (1997–2014) during October 2014. There were no constraints on language or publication status. DATA EXTRACTION We included before-after studies, cohort studies, and cluster randomized trials that reported hospital mortality and/or non-ICU cardiopulmonary arrest for adults hospitalized in a non-ICU setting after the implementation of RRTs and/or medical emergency teams (METs). Data were extracted by 2 sets of 2 independent reviewers using a standardized data-collection form. Disagreements were resolved by a third reviewer. Authors were contacted to obtain any missing data. DATA SYNTHESIS Our search identified 691 studies, of which 30 met criteria for inclusion in the analysis. Implementation of an RRT/MET was associated with a significant decrease in hospital mortality (relative risk [RR] = 0.88, 95% confidence interval [CI]: 0.83-0.93, I2 = 86%, 3,478,952 admissions) and a significant decrease in the number of non-ICU cardiac arrests (RR = 0.62, 95% CI: 0.55-0.69, I2 = 71%, 3,045,273 admissions). CONCLUSIONS Implementation of an RRT/MET is associated with a reduction in both hospital mortality and non-ICU cardiopulmonary arrests. Journal of Hospital Medicine 2016;11:438–445. © 2016 Society of Hospital Medicine

Background: Biliary tract disease is a common condition often necessitating surgical intervention. It has been suggested that categorically admitting these patients to a surgical service rather than a medical service may improve patient outcomes. Our objective was to assess the impact of a protocol change that mandated preferentially admitting patients with biliary disease to a surgical service.Methods: This is a retrospective observational study of patients presenting with biliary disease to a single institution before and after a protocol change that mandated admitting these patients directly to a surgical service. A generalized linear regression model was conducted to analyze the effect of practice change on length of stay, which was primary studied outcome.Results: A total of 3,389 patients were included in the study (n = 1,866 for pre, and n=1,523 for post). There was no difference in hospital length of stay between pre and post groups for non-operative patients (1.9 days ± 4.3 versus 1.9 days ±5.2, p = .972). However, for operative patients, length of stay was shorter for the post group (4.1 days ± 6.1 vs 6.3 days ± 14.0, p = .066). The linear regression model found that operative patients had an increased probability of having a longer length of stay (coefficient, 0.21; 95% CI, 0.14, 0.29; p < .001).Conclusion: Admission of patients with biliary disease to a surgical service rather than a medical service is associated with shorter length of stay for patients who undergo an operative intervention. An approach of admitting all patients presenting with biliary disease to a surgical service has the potential to significantly reduce hospital costs. Our study supports primary responsibility for surgeons in the care of patients with potentially operative conditions.

Background There is limited information on where and how often Medicare beneficiaries seek care for non-urgent conditions when a physician office visit is not available. Emergency departments are often an alternative site of care, and urgent care centers have now also emerged to fill this need. The purpose of the study was to characterize the site of care for Medicare beneficiaries with non-urgent conditions; the relationship between physician office, urgent care center, and emergency department utilization; and specifically the role of urgent care centers. Methods The study is a retrospective, cross-sectional study of fee-for-service Medicare beneficiaries for fiscal year 2012. The main outcome was rate and geographic variation of urgent care center, emergency department, or physician office utilization. Results Care for non-urgent conditions most commonly occurred in physician offices (65.0 per 100 beneficiaries). In contrast, urgent care centers (6.0 per 100 beneficiaries) were a more common site of care than emergency departments (1.0 per 100 beneficiaries). Overall, 83% of non-urgent visits were physician offices, 14% urgent care centers, and 3% emergency departments. There was regional variation in urgent care center, emergency department, and physician office utilization for non-urgent conditions. Areas of higher emergency department utilization correspond to areas of lower urgent care center and physician office utilization, whereas areas of higher urgent care center utilization had lower emergency department utilization. Conclusions Urgent care centers are an important site of care for Medicare beneficiaries for non-urgent conditions. There is regional variation in the use of urgent care centers, emergency departments, and physician offices, with areas of low urgent care center utilization having higher emergency department utilization. The utilization of urgent care centers for treatment for non-urgent conditions may decrease emergency department utilization.

In 2004, the Institute for Healthcare Improvement's 100,000 Lives Campaign recommended that hospitals implement rapid response teams (RRTs) charged with identifying non-intensive care unit (ICU) patients at risk for rapid deterioration. Although RRTs are now in widespread use, there have been conflicting results regarding the impact of RRTs on hospital mortality and cardiopulmonary arrest.To assess the effectiveness of RRTs on reducing hospital mortality and non-ICU cardiopulmonary arrest rates.We conducted a systematic review using MEDLINE (1966-2014), Cochrane Central Register of Controlled Trials (1898-2014), Cumulative Index to Nursing and Allied Health Literature (1994-2014), and ClinicalTrials.gov (1997-2014) during October 2014. There were no constraints on language or publication status.We included before-after studies, cohort studies, and cluster randomized trials that reported hospital mortality and/or non-ICU cardiopulmonary arrest for adults hospitalized in a non-ICU setting after the implementation of RRTs and/or medical emergency teams (METs). Data were extracted by 2 sets of 2 independent reviewers using a standardized data-collection form. Disagreements were resolved by a third reviewer. Authors were contacted to obtain any missing data.Our search identified 691 studies, of which 30 met criteria for inclusion in the analysis. Implementation of an RRT/MET was associated with a significant decrease in hospital mortality (relative risk [RR] = 0.88, 95% confidence interval [CI]: 0.83-0.93, I(2) = 86%, 3,478,952 admissions) and a significant decrease in the number of non-ICU cardiac arrests (RR = 0.62, 95% CI: 0.55-0.69, I(2) = 71%, 3,045,273 admissions).Implementation of an RRT/MET is associated with a reduction in both hospital mortality and non-ICU cardiopulmonary arrests. Journal of Hospital Medicine 2016;11:438-445. © 2016 Society of Hospital Medicine.