Causes, Diagnostic Testing, and Treatments Related to Clinical Deterioration Events among High-Risk Ward Patients
Authors: Churpek Matthew M. , Ingebritsen Ryan , Carey Kyle A. , Rao Saieesh A , Murnin Emily , Qyli Tonela , Oguss Madeline K. , Picart Jamila , Penumalee Leena , Follman Benjamin D. , Nezirova Lily K , Tully Sean T. , Benjamin Charis , Nye Christopher , Gilbert Emily R. , Shah Nirav S. , Winslow Christopher J. , Afshar Majid , Edelson Dana P. 
Published: February 2024

OBJECTIVE

Timely intervention for clinically deteriorating ward patients requires that care teams accurately diagnose and treat their underlying medical conditions. However, the most common diagnoses leading to deterioration and the relevant therapies provided are poorly characterized. Therefore, we aimed to determine the diagnoses responsible for clinical deterioration, the relevant diagnostic tests ordered, and the treatments administered among high-risk ward patients using manual chart review.

DESIGN

Multicenter retrospective observational study

SETTING

Inpatient medical-surgical wards at four health systems from 2006-2020PATIENTS:Randomly selected patients (1,000 from each health system) with clinical deterioration, defined by reaching the 95th percentile of a validated early warning score, electronic Cardiac Arrest Risk Triage (eCART), were included.

INTERVENTIONS

None

MEASUREMENTS AND MAIN RESULTS

Clinical deterioration was confirmed by a trained reviewer or marked as a false alarm if no deterioration occurred for each patient. For true deterioration events, the condition causing deterioration, relevant diagnostic tests ordered, and treatments provided were collected. Of the 4,000 included patients, 2,484 (62%) had clinical deterioration confirmed by chart review. Sepsis was the most common cause of deterioration (41%; n=1,021), followed by arrhythmia (19%; n=473), while liver failure had the highest in-hospital mortality (41%). The most common diagnostic tests ordered were complete blood counts (47% of events), followed by chest x-rays (42%), and cultures (40%), while the most common medication orders were antimicrobials (46%), followed by fluid boluses (34%), and antiarrhythmics (19%).

CONCLUSIONS

We found that sepsis was the most common cause of deterioration, while liver failure had the highest mortality. Complete blood counts and chest x-rays were the most common diagnostic tests ordered, and antimicrobials and fluid boluses were the most common medication interventions. These results provide important insights for clinical decision-making at the bedside, training of rapid response teams, and the development of institutional treatment pathways for clinical deterioration.

KEY POINTS

Question:What are the most common diagnoses, diagnostic test orders, and treatments for ward patients experiencing clinical deterioration?

Findings:In manual chart review of 2,484 encounters with deterioration across four health systems, we found that sepsis was the most common cause of clinical deterioration, followed by arrythmias, while liver failure had the highest mortality. Complete blood counts and chest x-rays were the most common diagnostic test orders, while antimicrobials and fluid boluses were the most common treatments.

Meaning:Our results provide new insights into clinical deterioration events, which can inform institutional treatment pathways, rapid response team training, and patient care.