Differences in outcomes between ICU attending and senior resident physician led medical emergency team responses

Introduction

Although rapid response systems (RRS) have been shown to decrease the incidence of cardiac arrest (CA), there are no studies evaluating optimal staffing. We hypothesize that there are no outcome differences between ICU physician and senior resident led events.

Methods

A retrospective study of the RRS database at a single, academic hospital was performed from July 1, 2006 to May 31, 2010. Surgical patients and those in the ICU were excluded. Daytime (D) was defined as 7 am–5 pm Monday through Friday, and weekends were defined as 5 pm on Friday to 6:59 am on Monday. The nurse to patient ratio is constant during all shifts. An ICU physician leads daytime events on weekdays whereas night/weekend (NW) events are led by residents. NW events were compared against D events using chi square or Fischer's exact test. Significance was defined as p < 0.05.

Results

A total of 1404 events were reviewed with 534 (38%) D and 870 (62%) NW events. Respiratory and staff concerns were more likely during NW compared to D (50% vs. 39% and 46% vs. 34%, p < 0.001, respectively). Following RRS activation, no difference was noted between D and NW periods in the incidence of progression to CA, transfer to ICU, or hospital mortality. Invasive procedures were more common in the NW period.

Conclusion

Resident-led RRS may have similar outcomes to attending intensivist led events. Prospective studies are needed to determine the ideal team composition.     

Rapid response systems: identification and management of the "prearrest state"

Rapid response systems (RRS) are both intuitive and supported by data, but the institution of an RRS is not a panacea for in-hospital cardiac arrest or unexpected deaths. RRS implementation should be one component of an institution-wide effort to improve patient safety that includes adequate nursing education and staffing, availability and involvement of a patient's primary caregivers, and hospital provision of sufficient resources and efficiency.     

Early impact of medical emergency team implementation in a country with limited medical resources: a before-and-after study

Purpose

The purpose of the study was to determine whether earlier clinical intervention by a medical emergency team (MET) can improve patient outcomes in an Asian country.

Methods

A nonrandomized study was performed during two 6-month periods before and after the introduction of a MET.

Results

The rates of cardiac arrests and “potentially preventable” cardiac arrests were lower after MET introduction, but the differences did not reach statistical significance. There was a statistically significant decrease in the incidence of cardiac arrests in the first 3 months of the academic year (2.3 vs 1.2 per 1000 admissions, P = .012). Introduction of MET reduced the time interval from physiologic derangement meeting MET activation criteria to intensive care unit (ICU) admission (“derangement-to-ICU interval”) (10.8 vs 6.3 hours, P < .001). Multivariate analysis revealed that the mortality of unplanned ICU admissions was independently associated with simplified acute physiology score 3 and “derangement-to-ICU interval.”

Conclusions

Introduction of a MET reduced the number of cardiac arrests in the general ward during the first 3 months of the academic year. Introduction of MET also decreased the “derangement-to-ICU interval,” which was an independent predictor of survival in patients with unplanned ICU admissions. Therefore, MET introduction may lead to improved outcomes for hospitalized patients in a country with limited medical resources.     

The impact of implementing a rapid response system: A comparison of cardiopulmonary arrests and mortality among four teaching hospitals in Australia

Aims

To compare clinical outcomes between a teaching hospital with a mature rapid response system (RRS), with three similar teaching hospitals without a RRS in Sydney, Australia.

Methods

For the period 2002–2009, we compared a teaching hospital with a mature RRS, with three similar teaching hospitals without a RRS. Two non-RRS hospitals began implementing the system in 2009 and a third in January 2010. We compared the rates of in-hospital cardiopulmonary arrest (IHCA), IHCA-related mortality, overall hospital mortality and 1-year post discharge mortality after IHCA between the RRS hospital and the non-RRS hospitals based on three separate analyses: (1) pooled analysis during 2002–2008; (2) before–after difference between 2008 and 2009; (3) after implementation in 2009.

Results

During the 2002–2008 period, the mature RRS hospital had a greater than 50% lower IHCA rate, a 40% lower IHCA-related mortality, and 6% lower overall hospital mortality. Compared to 2008, in their first year of RRS (2009) two hospitals achieved a 22% reduction in IHCA rate, a 22% reduction in IHCA-related mortality and an 11% reduction in overall hospital mortality. During the same time, the mature RRS hospital showed no significant change in those outcomes but, in 2009, it still achieved a crude 20% lower IHCA rate, and a 14% lower overall hospital mortality rate. There was no significant difference in 1-year post-discharge mortality for survivors of IHCA over the study period.

Conclusions

Implementation of a RRS was associated with a significant reduction in IHCA, IHCA-related mortality and overall hospital mortality.     

Epidemiology and patient outcome after medical emergency team calls triggered by atrial fibrillation

Introduction

Atrial fibrillation (AF) in hospitalized patients may lead to activation of the medical emergency team (MET). We sought to assess the baseline characteristics and outcomes of the patients presenting AF as a cause of MET call activation.

Methods

Using a prospectively constructed MET database, we retrospectively reviewed all patients with AF as a trigger for MET activation between August 2005 and April 2010. Demographics, principal diagnostic and outcome of these patients were compared with those of a control group of patients matched for age, sex and ward of origin, randomly selected from the database.

Results

We studied 5431 MET calls of which 557 (10.3%), in 458 patients were triggered by AF. Mean age for AF patients was 74.8 years, 230 (50.2%) were female and 271 (59.1%) were in a surgical ward. 92 (20.1%) AF patients died in hospital compared with 131 (28.6%) in the control group. Among the 336 patients without limitations of medical therapy (LOMT), 46 (13.7%) died in hospital. In total, 46 (13.7%) patients were transferred to a higher level care ward while 290 (86.3%) remained on the ward. Only 2 (4.3%) of these patients died compared with 44 (15.2%) among those who remained in the general ward (p = 0.03).

Conclusions

In our hospital, AF triggers one tenth of MET activations and mortality associated with it is high even when issues of LOMT are excluded. The decreased mortality among patients admitted to a higher level ward suggests that some of these deaths may be avoidable.     

Factors affecting attitudes and barriers to a medical emergency team among nurses and medical doctors: A multi-centre survey

AimTo identify factors underlying attitudes towards the medical emergency team (MET) and barriers to its utilisation among ward nurses and physicians.MethodsMulticentre survey using an anonymous questionnaire in hospitals with a fully operational MET system in the Piedmont Region, Italy. Response to questions was scored on a 5-point Likert-type agreement scale. Dichotomised results were included in a logistic regression model.ResultsAmong 2279 staff members who were contacted, 1812 (79.6%) completed the survey. The vast majority of respondents valued the MET. Working in a surgical vs. medical ward and having participated in either the MET educational programme (METal course) or MET interventions were associated with better acceptance of the MET system. Reluctance by nurses to call the covering doctor first instead of the MET for deteriorating patients (62%) was significantly less likely in those working in surgical vs. medical wards or having a higher seniority or a METal certification (OR 0.51 [0.4–0.65], 0.69 [0.47–0.99], and 0.6 [0.46–0.79], respectively). Reluctance to call the MET in a patient fulfilling calling criteria (21%), was less likely to occur in medical doctors vs. nurses and in surgical vs. medical ward staff, and it was unaffected by the METal certification.ConclusionsThe MET was well accepted in participating hospitals. Nurse referral to the covering physician was the major barrier to MET activation. Medical status, working in surgical vs. medical wards, seniority and participation in the METal educational programme were associated with lower likelihood of showing barriers to MET activation.     

Prognostic value of the calling criteria in patients receiving a medical emergency team review

Aim

To describe the reasons for medical emergency team (MET) activation, and to verify the association of the MET score with 30-day mortality.

Methods

This retrospective observational study took place in a 794-bed university-affiliated hospital. The population included all adult admissions reviewed by the MET during the period between January 2007 and June 2008. MET score was defined as the sum of each of the physiological triggers, and score zero was considered the calls made due to concern about the patient, without any physiological alteration.

Results

During the period of the study, 1051 calls were generated for 901 patients. Respiratory distress and hypotension accounted for most of MET calls. The triggers that showed an independent association with mortality were threatened airway, systolic blood pressure <90 mmHg, decrease in Glasgow Coma Scale score ≥2 points and respiratory frequency >36 breaths/min. Logistic regression analysis revealed MET score, age, medical patient, documented do not resuscitate orders and MET decision to transfer to the intensive care unit to be significant predictors of 30-day mortality.

Conclusions

MET score presents a strong association with 30-day mortality in patients seen on the ward.     

The use of altered rapid response calling criteria in a tertiary referral facility

PurposeThe purpose of this study was to examine the current utilisation of altered rapid response calling criteria (ARRCCs) at a tertiary hospital.MethodsA retrospective review of all acute care admissions across 17 months was undertaken using the hospital administration system and electronic medical record to identify patients with ARRCCs. In patients with altered criteria, the type of alteration, frequency of rapid response calls, cardiac arrest, intensive care admission, and death in the hospital were identified. Comparisons were made using standard statistical methods.ResultsThe total hospital admissions numbered 45 912, with ARRCCs used in 768 (1.7%). Patients with an ARRCC during hospital admission were older (68.5 [55.5, 79.0] vs 59.0 [43.0, 72.0] years, p < 0.001) and had a significantly longer length of hospital stay (6.9 [3.0, 16.3] vs 2 [1, 5] days, p < 0.001).Compared with the total group of patient admissions, patients with ARRCCs more frequently triggered a rapid response team (9.0% vs 14.2%, χ²(1, n = 46 680) = 23.87, p < 0.001), more frequently suffered a cardiac arrest (0.2 vs 0.9%, χ²(1, n = 46 678) = 20.34, p < 0.001), more frequently died in the hospital (p < 0.001), and were less frequently discharged home (χ²(1, n = 46 680) = 43.91, p < 0.001).ConclusionPatients with an ARRCC stayed longer in the hospital and were at increased risk of cardiac arrest and death during hospitalisation. Further exploration of the role of ARRCCs in facilitating individualised care to meet the needs and treatment goals of each patient in the acute hospital setting is required.     

Rapid Response Team composition, resourcing and calling criteria in Australia

Introduction

Rapid Response Teams (RRTs) have been introduced into at least 60% of Intensive Care Unit (ICU) – equipped Australian hospitals to review deteriorating ward patients. Most studies have assessed their impact on patient outcome and less information exists on team composition or aspects of their calling criteria.

Methods

We obtained information on team composition, resourcing and details of activation criteria from 39 of 108 (36.1%) RRT-equipped Australian hospitals.

Results

We found that all 39 teams operated 24/7 (h/days), but only 10 (25.6%) had received additional funding for the service. Although 38/39 teams, were physician-led medical emergency teams, in 7 (17.9%) sites the most senior member would be unlikely to have advanced airway skills. Three quarters of calling criteria were structured into “ABCD”, and approximately 40% included cardiac and/or respiratory arrest as a calling criterion. Thresholds for calling criteria varied widely (particularly for respiratory rate and heart rate), as did the wording of the worried/concerned criterion. There was also wide variation in the number and nature of additional activation criteria.

Conclusions

Our findings imply the likelihood of significant practice variation in relation to RRT composition, staff skill set and activation criteria between hospitals. We recommend improved resourcing of RRTs, training of the team members, and consideration for improved standardisation of calling criteria across institutions.     

Frequency and nature of medical emergency team afferent limb failure in patients with documented vital sign abnormalities: A retrospective point prevalence study

BackgroundMedical emergency team (MET) afferent limb failure is the presence of MET triggers and the absence of a documented MET call.ObjectivesThe aim of this study was to measure and understand the frequency and nature of MET afferent limb failure in patients with documented vital sign abnormalities in an Australian major teaching hospital.MethodsA retrospective point prevalence study was conducted at a 600-bed teaching hospital in Melbourne, Australia. Data were collected for all adult inpatients (aged ≥18 years) on 13 wards (three general medicine, three surgical, and seven specialist wards) during a randomly selected 24-h period. Data were extracted from the electronic medical record.ResultsThere were 357 patients included in the study, with a median age of 72 y. Of the 9716 vital sign measures extracted, 0.9% fulfilled patient-specific MET activation criteria. There were 93 MET triggers documented in 36 patients: 25 patients experienced MET afferent limb failure. The major issues related to MET afferent limb failure were MET trigger modification processes, resolution of vital sign abnormalities, alternative escalation of care, and limitations of medical treatment orders without specific modifications to MET triggers.ConclusionsMandating MET activation for one aberrant vital sign at a single point in time warrants further assessment: lack of timely vital sign resolution may be a more appropriate trigger for MET calls and should be formally tested in future research. The frequency and effectiveness of alternative escalation pathways and local management of patients with MET triggers also warrant further investigation.     

Medical emergency team response for the non-hospitalized patient

Objectives

Rapid response systems (RRS) evolved to care for deteriorating hospitalized patients outside of the ICU. However, emergent critical care needs occur suddenly and unexpectedly throughout the hospital campus, including areas with non-hospitalized persons. The efficacy of RRS in this population has not yet been described or tested. We hypothesize that non-hospitalized patients accrue minimal benefit from ICU physician participation in the RRS.

Design

A retrospective review of all RRS events in non-hospitalized patients for a 28 month period was performed in a large, urban university medical center. Location, patient type and age, activation trigger, interventions performed, duration of event and disposition were recorded. Admission diagnosis and length of stay were also recorded for patients admitted to the hospital.

Setting

Academic medical center.

Patients

Non-hospitalized persons requiring evaluation by the medical emergency team.

Interventions

None.

Measurements and main results

There were a total of 1778 RRS activations during the study period. 232 (13%) of activations were for non-hospitalized patients. The patient cohort consisted of outpatients, visitors, and staff. Triggers for RRS activation were neurologic change (42%), cardiac (27%), respiratory (16%), and staff concerns (16%). The mean duration of the response was 38 min. The most common interventions performed included administration of oxygen (46%), intravenous fluids (13%) and dextrose (6%). 82% of patients were taken to the emergency department and 32% of the ED cohort were admitted to the hospital.

Conclusions

Perceived emergencies in non-hospitalized patients occur commonly but require minimal emergent intervention. Restriction of critical care physician involvement to inpatient deteriorations should be considered when designing a RRS. Future studies are needed to evaluate the utility of non-physician provider led rapid response teams with protocol-driven interventions for similar populations.     

Medical emergency team: a review of the literature

Background: A medical emergency team (MET) comprises of a team of doctors and nurses with advanced life support skills, which are hospital based, who respond to emergency calls following a deterioration in a patient’s clinical condition. The role and contribution of such approaches promoting the early recognition and intervention of these vulnerable patients demands critical appraisal. Aim: To investigate the contribution of medical emergency teams and whether there are clinical antecedents evident prior to the triggering the MET system. The paper will also discuss factors influencing effective utilization and implementation strategies to encourage a culture change required to adopt the MET system. Methods: A critical review the relevant literature of studies focussed on the MET system. Results: The majority of published work relating to MET systems was conducted in single‐centres. The introduction of MET systems appears to be linked to a reported reduction in adverse outcomes and early recognition and intervention in clinically deteriorating patients. Additionally, a consistent observation in the studies reviewed was the reported presence of clinically abnormal physiological observations prior to the clinical events such as the cardiac arrest. The evidence in support of MET or equivalent systems, is not straightforward. Issues such as education, resources (human and financial) and communication are vital to success with implementation. Responding promptly to patients who unexpectedly become acutely ill demands skill and competence; however, more research evaluating the role of early ’response’ systems is warranted.     

Serious adverse events in a hospital using early warning score – What went wrong?

Aim

To evaluate the performance of a new early warning score (EWS) system by reviewing all serious adverse events in our hospital over a 6-month time period.

Method

All incidents of unexpected death (UD), cardiac arrest (CA) and unanticipated intensive care unit admission(UICU) of adult patients on general wards were reviewed to see if the escalation protocol that is part of the EWS system was followed in the 24 h preceding the event, and if not where in the chain of events failure occurred.

Results

We found 77 UICU and 67 cases of the combined outcome (CO) of CA and UD. At least two full sets of EWS were recorded in 87, 94 and 75% of UICU, CA and UD. Patients were monitored according to the escalation protocol in 13, 31 and 13% of UICU, CA and UD. Nurses escalated care and contacted physicians in 64% and 60% of events of UICU and the corresponding proportions for CO were 58% and 55%. On call physicians provided adequate care in 49% of cases of UICU and 29% of cases of the CO. Senior staff was involved according to protocol in 53% and 36% of cases of UICU and CO, respectively.

Conclusion

Poor compliance with the escalation protocol was commonly found when serious adverse events occurred but level of care provided by physicians was also a problem in a hospital with implemented early warning system. This information may prove useful in improving performance of EWS systems.     

Timing and interventions of emergency teams during the MERIT study

Aims

To examine interventions and timing of emergency team calls in hospitals with or without a medical emergency team (MET).

Methods

Interventions were recorded, categorized and classified as critical care interventions (e.g. airway intervention, ventilation and use of inotropic drugs); ward level interventions (e.g. fluids, oxygen by mask); assessment, physical examination and investigations.

Results

Only 5 of the 2376 calls were free of critical care interventions. For non-cardiac arrest-related calls, MET hospitals had a lower proportion of airway, circulation and drug-related interventions and a higher proportion of ward level interventions. The majority of calls were between 0601 and 1200 h and cardiac arrest survival was greatest in the 1200-2400 h period. Overall median time at the scene was 25 min.

Conclusions

Nearly all emergency team calls required critical care type interventions. Emergency team calls show a unique temporal pattern for both MET and control hospitals. These findings have important organizational and resource-related implications for hospitals evaluating and establishing rapid response systems.     

Medical emergencies in the imaging department of a university hospital: Event and imaging characteristics

We aimed to describe the characteristics of medical emergencies that occurred in the medical imaging department (MID) of a university hospital in Melbourne, Australia.     

The impact of rapid response systems on mortality and cardiac arrests – A literature review

BackgroundRapid response systems were created to improve recognition of and response to deterioration of general ward patients.AimThis literature review aimed to evaluate the evidence on whether rapid response systems decrease in-hospital mortality and non-intensive care unit cardiac arrests.MethodSix databases (MEDLINE, Cochrane Central Register of Controlled Trials, Cumulative Index of Nursing and Allied Health Literature, SCOPUS, Web of Science and PubMed) were systematically searched for primary studies published between 1st January 2014 and 31st October 2017, recruiting general ward patients, where the intervention involved introducing/maintaining a rapid response system, the comparison referred to a hospital setting without a rapid response system and the outcomes included mortality and cardiac arrests.ResultsFifteen studies met eligibility criteria: one stepped wedge cluster randomised controlled trial, one concurrent cohort controlled study and thirteen historically controlled studies. Thirteen studies investigated mortality of which seven reported statistically significant findings in favour of rapid response systems. Thirteen studies investigated cardiac arrests, of which eight reported statistically significant findings in favour of rapid response systems.ConclusionEvidence suggests that when the process of introducing/maintaining a rapid response system is successful and under certain favourable conditions, rapid response systems significantly decrease mortality and cardiac arrests.     

Clinician and manager perceptions of factors leading to ward patient clinical deterioration

Background

Improving the timely recognition and response to clinical deterioration is a critical challenge for clinicians, educators, administrators and researchers. Clinical deterioration leading to Rapid Response Team review is associated with poor patient outcomes. A range of factors associated with clinical deterioration and its outcomes have been identified, and may help with early identification of deteriorating patients. However, the relative importance of each factor on the development of clinical deterioration is unknown.