Kaplan Lewis J, Maerz Linda L, Schuster Kevin, Lui Felix, Johnson Dirk, Roesler Daniel, Luckianow Gina, Davis Kimberly A
Department of Surgery, Section of Trauma, Surgical Critical Care and Surgical Emergencies, Yale University School of Medicine, New Haven, Connecticut 06520, USA.
J Trauma. 2009 Jul;67(1):173-8; discussion 178-9. doi: 10.1097/TA.0b013e31819ea514.
Because of the 80-hour work week, extensive service cross-coverage creates great potential for patient care errors. These patient care emergencies are increasingly managed using a rapid response team (RRT) to reduce patient morbidity. We examine the proximate causes of a surgical RRT activation. We hypothesize that most RRTs would occur during cross-coverage hours and be preventable or potentially preventable.
All surgical RRTs more than a 15-month period were captured using a nursing database and the note from the staffing intensivist/fellow. RRTs were reviewed for appropriateness (pre-existing criteria) and proximate cause. Proximate causes were further classified as patient disease, team error, nursing error, or system error as well as preventable, potentially preventable, or nonpreventable.
Of 98 RRT activations, complete data were available for 82 (84%); 100% met activation criteria; and 76 (93%) occurred between 2100 and 0600. Seventy-six patients were 48 hours to 72 hours postoperative; six had nonoperatively managed injuries. The most common reason for activation was impending respiratory failure and acute volume overload (n = 72; 88%). RRT therapies included diuretics (n = 72), antiarrhythmics (n = 48), oxygen (n = 82), and bronchodilators (n = 36); only 2 received blood component therapy. Seventy-eight patients (95%) were transferred to higher level of care (61, surgical intensive care unit; 17, SSDU). Only 46% of patients required intubation. Performance improvement review identified 90% of physician related RRTs as preventable/potentially preventable because of errors in judgment or omission. Four RRTs because of patient disease were unpreventable. Two potentially preventable errors were each ascribed to RN or system concerns.
RRT activations principally result from team-based errors of omission, more often occur between 2100 and 0600, and are more often preventable or potentially preventable. Careful attention to fluid balance and medications for comorbid diseases would reduce RRT needs.
由于实行每周80小时工作制，广泛的服务交叉覆盖给患者护理差错带来了巨大隐患。这些患者护理紧急情况越来越多地通过快速反应小组（RRT）来处理，以降低患者的发病率。我们研究了外科RRT启动的直接原因。我们假设大多数RRT启动会发生在交叉覆盖时段，并且是可预防的或潜在可预防的。
使用护理数据库和值班重症监护医生/住院医生的记录，收集了15个多月期间所有的外科RRT启动情况。对RRT启动情况进行适当性（预先制定的标准）和直接原因审查。直接原因进一步分为患者疾病、团队失误、护理失误或系统失误，以及可预防、潜在可预防或不可预防。
在98次RRT启动中，82次（84%）有完整数据；100%符合启动标准；76次（93%）发生在21:00至06:00之间。76例患者处于术后48小时至72小时；6例为非手术治疗的损伤。启动的最常见原因是即将发生的呼吸衰竭和急性容量超负荷（n = 72；88%）。RRT治疗包括利尿剂（n = 72）、抗心律失常药（n = 48）、氧气（n = 82）和支气管扩张剂（n = 36）；只有2例接受了血液成分治疗。78例患者（95%）被转至更高水平的护理病房（61例转至外科重症监护病房；17例转至SSDUs）。只有46%的患者需要插管。绩效改进审查发现，90%与医生相关的RRT启动是由于判断失误或疏忽而可预防/潜在可预防的。4次因患者疾病导致的RRT启动是不可预防的。2次潜在可预防的失误分别归因于注册护士或系统问题。
RRT启动主要是由于基于团队的疏忽失误导致的，更多发生在21:00至06:00之间，并且更多是可预防或潜在可预防的。密切关注液体平衡和合并疾病的用药情况将减少对RRT的需求。
