Efficacy of Ultrasound to Guide Management During a Rapid Response Event
Efficacy of Ultrasound to Guide Management During a Rapid Response Event
Rapid response team systems have been implemented in numerous hospitals throughout the world
 with the goal of improving the identification and safety of hospitalized patients who are
 clinically deteriorating. Despite their theoretical benefit, rapid response systems have not
 been proven in the medical literature to ultimately change outcomes.

 The traditional physical exam is helpful in evaluating and treating unstable medical patients
 during these types of events but has significant limitations of deceased sensitivity and
 specificity of findings. Ultrasound is a known tool for more accurately assessing patients in
 shock and respiratory failure in the ICU by highly trained operators but to the investigators
 knowledge has not been studied in the setting of rapid response events on hospital wards by
 critical care fellows after focused training. The investigators aim to assess the impact of
 ultrasound performed by critical care fellows during rapid response events.
This is an randomized controlled trial to determine if portable critical care ultrasound use
 is feasible, if its findings change clinical decision making by critical care fellows and
 whether ultrasound can improve patient outcomes during rapid response events at Beth Israel
 Medical Center.

 Patients for whom a rapid response has been called for cardiac or respiratory failure will be
 randomized to either have a bedside ultrasound performed by a critical care fellow at the
 time of rapid response or to undergo a bedside ultrasound only if clinically indicated and
 specifically requested by the RRT leader.

 For all patients on whom a rapid response is called with shock or respiratory failure who are
 randomized to the intervention group, a designated ultrasound critical care fellow will
 document their ranked top 2 preliminary cause for either shock or respiratory failure on a
 data collection instrument (DCI). These clinical (i.e. pre-ultrasound) diagnoses will be
 based on history, physical exam and all ancillary testing available prior to ultrasound
 performance. Available ancillary testing will be documented.

 An ultrasound exam will then be performed by the designated ultrasound fellow using a
 portable hand-carried unit (GE Vscan) and the findings documented on the same DCI. The GE
 Vscan will be used for all ultrasounds performed during this study. The ultrasound study will
 take approximately 5 -10 minutes and will not interfere with alternative evaluation or
 treatment modalities deemed to be necessary during the rapid response.

 The critical care ultrasound fellow will then provide the RRT leader team with their 2 most
 likely post ultrasound diagnosis for shock and respiratory failure and then document these on
 the DCI. Any changes to management made as a result of the ultrasound exam, including all new
 ancillary tests and therapeutic interventions will be recorded.

 At 72 hours following the initial event the ICU or general medical attending physician will
 be asked to document the "final" diagnosis as to the cause of the initial shock or
 respiratory failure. This "final" diagnosis will serve as the "gold standard" to allow the
 assessment of accuracy of the pre-ultrasound and post-ultrasound diagnoses.

 Patients randomized to the standard care group will not have an ultrasound performed at the
 time of rapid response unless it is deemed medically necessary by the responding RRT leader
 or critical care fellow. This is the current practice approach at the investigators hospital
 where ultrasound is performed only when clinically indicated.

 The study investigators will obtain all DCI's as well as the final diagnosis from the
 attending physician at 72 hours, and will enter this data into a database that will not
 contain any unique patient identifiers.

 The patient's time in respiratory failure and time in shock will be recorded as primary
 outcome measures. Secondary outcomes of in-hospital mortality, utilization of CT scan and
 chest x-ray in the 24 hours following rapid response and hospital length of stay will also be
 recorded. Also measured will be variability in pre and post-ultrasound diagnosis as well as
 changes in management following ultrasound performance.
Inclusion Criteria: Patients for whom a rapid response is called who have:

 1. Hemodynamic instability as defined by:

 -  Systolic blood pressure less than 90 mmHg or less than 40 mmHg from previously
 established baseline

 -  Heart rate greater than 130 beats per minute

 -  Known elevated lactate above normal value.

 2. Hypercapnic or hypoxemic respiratory failure as judged by the responding critical care
 fellow.

 Exclusion Criteria: Patients for whom a rapid response has been called who:

 1. Are not hemodynamically unstable and not in respiratory failure.

 2. Are hemodynamically unstable but who have an obvious source of bleeding to explain
 hemodynamic instability.