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1.
Calzavacca P Licari E Tee A Egi M Haase M Haase-Fielitz A Bellomo R 《Intensive care medicine》2008,34(11):2112-2116
Objective To identify factors that predict outcome in patients receiving a Medical Emergency Team review.
Design Prospective observational study.
Setting Tertiary hospital.
Patients Cohort of 228 patients receiving one or more Medical Emergency Team reviews during daytime hours over a 1-year-period. Control
cohort of all patients (n = 900) receiving a Medical Emergency Team review in the same period.
Measurements and results We prospectively collected information from patients receiving a Medical Emergency Team review during daytime hours from Monday
to Friday (audit group) including the clinical cause of deterioration and timing of call in relation to the first documented
Medical Emergency Team call criterion (activation delay). We also collected information from the hospital Medical Emergency
Team database regarding all patients visited by the Medical Emergency Team during the same period (complete cohort). Audit
group patients had several similar characteristics to complete cohort patients but were less likely to be not-for-resuscitation
before Medical Emergency Team review and more likely to receive a Medical Emergency Team review because of hypotension, change
in neurological status and oliguria. Delayed Medical Emergency Team activation and not-for resuscitation orders were the only
factors to show an independent statistical association with mortality (OR 2.53, 95% CI: 1.2–5.31, P = 0.01 and OR 5.63, 95% CI: 2.81–11.28, P < 0.01, respectively).
Conclusion Delayed Medical Emergency Team activation and NFR orders are the strongest independent predictors of mortality in patients
receiving a Medical Emergency Team review. Avoidance of delayed Medical Emergency Team activation should be a priority for
hospitals operating rapid response systems. 相似文献
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Paolo Calzavacca Elisa Licari Augustine Tee Moritoki Egi Andrew Downey Jon Quach Anja Haase-Fielitz Michael Haase Rinaldo Bellomo 《Resuscitation》2010,81(1):31-35
Objective
To evaluate the impact of Rapid Response System (RRS) maturation on delayed Medical Emergency Team (MET) activation and patient characteristics and outcomes.Design
Observational study.Setting
Tertiary hospital.Patients
Recent cohort of 200 patients receiving a MET review and early control cohort of 400 patients receiving a MET review five years earlier at the start of RRS implementation.Measurements and results
We obtained information including demographics, clinical triggers for and timing of MET activation in relation to the first documented MET review criterion (activation delay) and patient outcomes. We found that patients in the recent cohort were older, more likely to be surgical and to have Not For Resuscitation (NFR) orders before MET review. Furthermore, fewer patients (22.0% vs. 40.3%, p < 0.001) had delayed MET activation. When delayed activation occurred, there was a non-significant difference in its duration (early cohort: 12.0 [IQR 23.0] h vs. recent cohort: 9.0 [IQR 20.5] h, p = 0.554). Similarly, unplanned ICU admissions decreased from 31.3% to 17.3% (p < 0.001). Delayed MET activation was independently associated with greater risk of unplanned ICU admission and hospital mortality (O.R. 1.79, 95% C.I. 1.33.-2.93, p = 0.003 and O.R. 2.18, 95% C.I. 1.42-3.33, p < 0.001, respectively). Being part of the recent cohort was independently associated with a decreased risk of delayed activation (O.R. 0.45, 95% C.I. 0.30-0.67, p < 0.001) and unplanned ICU admission (O.R. 0.5, 95% C.I. 0.32-0.78, p = 0.003).Conclusions
Maturation of a RRS is associated with a decrease in the incidence of unplanned ICU admissions and MET activation delay. Assessment of a RRS early in the course of its implementation may underestimate its efficacy. 相似文献4.
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Aim
To determine the attitudes and barriers to an established paediatric Medical Emergency Team (MET) system among nurses and doctors.Methods
Invitation to all clinical staff in a paediatric hospital to complete an electronic 41-item branched survey. Responses were graded on a Likert scale.Results
407 staff completed the survey (280 nurses, 127 doctors). The MET system was highly valued for obtaining urgent assistance for the seriously ill patients by 85% of nurses and 83% of doctors. However, barriers to MET activation included; preference to contact the covering (attending) doctors by 80% of nurses and 45% of doctors, active discouragement to activating a MET by 41% of nurses and 12% of doctors, and fear of criticism by 17% of nurses and 9% of doctors if the patient was not deemed seriously ill by the MET attendees. Less experienced staff were significantly more likely to report barriers to calling a MET. Negative attitudes from MET attendees were reported by nurses (24%) and doctors (6.5%). Failure to recognize serious illness was revealed by unwillingness of 47% of doctors and 32% of nurses to activate MET when activation criteria were attained and by retrospective realization by 30% of doctors and 15% of nurses that they had failed to activate MET when needed.Conclusions
Cultural and behavioral barriers to MET activation and inability to recognize serious illness may explain in part the failure of a MET system to completely eliminate unexpected cardiac arrest and death. Unless these issues are addressed, the full benefits of a MET system may not be realised. 相似文献6.
ANZICS-CORE MET dose Investigators Jones D Drennan K Hart GK Bellomo R Web SA 《Resuscitation》2012,83(5):563-567
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. 相似文献7.
Bucknall TK Jones D Barrett J Bellomo R Botti M Considine J Currey J Dunning TL Green D Levinson M Livingston PM O'Connell B Ruseckaite R Staples M 《Resuscitation》2011,82(5):529-534
Objective
The RESCUE study examined the prevalence of patients at risk of a medical emergency in acute care settings by assessing the prevalence of cases where patients fulfil the hospital-specific criteria for MET activation. This article will detail the study methodology including the ethics applications and approvals process, organisational preparation, research staff training, tools for data collection, as well as barriers encountered during the conduct of the study.Design and Setting
A point prevalence design conducted at 10 hospitals, comprising of private and public, secondary and tertiary referral, ICU equipped, metropolitan and regional settings.Patients
All inpatients were eligible except intensive care and psychiatric patients.Measurement and main results
On a single day consenting inpatients in each hospital had a single set of vital signs obtained, their observation chart reviewed and followed up for MET activations, unplanned ICU admissions, cardiac arrests and 30 and 60 day mortality. Of 2199 eligible patients, 1688 (76.76%) were assessed, 175 (7.95%) refused consent and 336 (15.28%) were unavailable. Access to patients was refused in some wards despite ethics approval. Data collection required 2 student nurses approximately 14 min per patient assessment.Conclusion
In conducting a large multi-site point prevalence study, critical organisational processes were shown to influence the access to patients. This study demonstrated the impact of variation in Human Research Ethics Committee interpretations of protocols on consenting processes and the importance of communication and leadership at ward level to promote access to patients. 相似文献8.
AIM: To compare activity and outcomes of a mature Medical Emergency Team (MET) in two hospitals. SETTING AND POPULATIONS: A Tertiary Referral Hospital (TRH) and a Metropolitan General Hospital (MGH) who combined have approximately 82,000 admissions annually with 38,000 patients meeting the eligibility criteria. The population included all admissions to the two hospitals aged 15 years and over with a stay>1 day (12 months period). Admissions that had a MET call originating in general wards were defined as Admissions Associated with a MET call (AAMET). METHODS: A retrospective analysis of MET call audit forms, a Death Review database, and routinely collected hospital data for the period 1st October 2004 to 30th September 2005, inclusive. Chronic morbidity was calculated as a Charlson Index (CI) score over previous visits and admissions using ICD10 & ICD9 diagnosis and procedure codes. RESULTS: There were 633 and 349 AAMETs. The incidence rates (MET calls/1000 admissions) were 37.6 and 34.1. They were associated with being elderly; males; higher CI scores; surgical admissions, Emergency Department (ED) admissions, and longer length of stay (LOS). A systolic BP<90mm Hg, and "worried" were the most frequent MET call criteria. There were 27 (4.3%) and 9 (2.6%) deaths following a MET call, of these 17 and 5 had Cardiac Arrest (CA) as the reason for the call. Death occurred for 192 and 54 AAMETs, only 38 (20%) and 14 (26%) were Do Not Attempt Resuscitation (DNAR) deaths. One hundred and forty-seven (23.2%) and eighty-seven (24.9%) AAMETs had a MET call within 24h of transfer from a critical care area; the proportions of transfers differed significantly between the two hospitals. CONCLUSION: A well established MET system identified similar AAMET populations from two different hospital populations. Sick, elderly, and surgical rather than medical patients were associated with MET activity in both hospitals. Further research is needed to estimate the impact of increased monitoring and interventions on patient outcomes, and the role of MET teams in end of life decision-making. 相似文献
9.
Aim of the study
The introduction of a paediatric Medical Emergency Team (pMET) was accompanied by integration of weekly in situ simulation team training into routine clinical practice. On a rotational basis, all key ward staff participated in team training, which focused on recognition of the deteriorating child, teamwork and early consultant review of patients with evolving critical illness. This study aimed to evaluate the impact of regular team training on the hospital response to deteriorating in-patients and subsequent patient outcome.Methods
Prospective cohort study of all deteriorating in-patients of a tertiary paediatric hospital requiring admission to paediatric intensive care (PICU) the year before, and after, the introduction of pMET and concurrent team training.Results
Deteriorating patients were: recognised more promptly (before/after pMET: median time 4/1.5 h, p < 0.001), more often reviewed by consultants (45%/76%, p = 0.004), more often transferred to high dependency care (18%/37%, p = 0.021) and more rapidly escalated to intensive care (median time 10.5/5 h, p = 0.024). These improved responses by ward staff extended beyond direct involvement of pMET.There was a trend towards fewer PICU admissions, reduced level of sickness at the time of PICU admission, reduced length of PICU stay and reduced PICU mortality. Introduction of pMET coincided with significantly reduced hospital mortality (p < 0.001).Conclusions
These results indicate that lessons learnt by ward staff during regular in situ team training led to significantly improved recognition and management of deteriorating in-patients with evolving critical illness. Integration of in situ simulation team training in clinical care has potential applications beyond paediatrics. 相似文献10.
11.
《Australian critical care》2023,36(4):536-541
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. 相似文献
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Imran Khalid Mohammad R. Qabajah Wasfy J. Hamad Tabindeh Jabeen Khalid Bruno DiGiovine 《Journal of critical care》2014
Purpose
We evaluated the outcome of hypotensive ward patients who re-deteriorated after initial stabilization by the Medical Emergency Team (MET) in our hospital, due to limited data in this regard.Methods
One thousand one hundred seventy-nine MET calls in 32184 ward patients from January 2009 to August 2011 were evaluated. Four hundred ten hypotensive patients met study criteria and were divided into: (1)“Immediate Transfers (IT), n = 136”:admitted by MET to intensive care unit (ICU) immediately; (2)“Re-deteriorated Transfers (RDT) n = 72”:initially stabilized and signed off by MET, but later re-deteriorated within 48-hours and admitted to ICU; (3)“Ward Patients (WP) n = 202”: remained stable on ward after treatment.Results
The RDT and IT had similar APACHE II scores (20.2 ± 5.1 vs. 19.8 ± 4.8; P= .57], but RDT showed hemodynamic stabilization with initial MET resuscitation. Patients who re-deteriorated were younger, took longer for eventual ICU transfer, had higher initial lactic acid and delayed normalization as compared to IT (P < .04). The re-deterioration predominantly occurred within 8-hours of MET evaluation. RDT had higher 28-day mortality than IT and WP; 42% vs. 27% vs. 7% respectively (P < .03). RDT also had a higher rate of endotracheal intubation and worse ICU mortality (P < .01).Conclusion
Hypotensive ward patients who re-deteriorate after initial stabilization have higher mortality. METs should consider implementing at least an 8-hour follow-up in patients who are deemed stable to remain on the wards after hypotensive episodes. 相似文献14.
Aim
The aim of this study was to evaluate the effect of multi-professional full-scale simulation-based education of staff on the mortality and staff awareness of patients at risk on general wards.Design, settings and patients
A prospective before-and-after study conducted on four general wards at Herlev Hospital, Denmark. In the pre-intervention period (June–July 2006) and post-intervention period (November–December 2007), all patients on the wards had vital signs measured in the evening by study personnel, who also asked nursing staff questions about patients with abnormal vital signs. The mortality of patients with abnormal vital signs was registered from the hospital database. Simplified medical emergency team calling criteria were used to define abnormal vital signs.Intervention
In the intervention period (February–June 2007), 50% of medical and 70% of nursing staff on the wards (app. 220 members of staff) were trained in a 1-day multi-professional full-scale simulation-based course.Results
In the pre- and post-intervention periods, 690 and 873 patients were included and of these 129 and 155, respectively, had abnormal vital signs. No significant differences were observed between the pre- and post-intervention periods concerning the incidence of patients with abnormal vital signs (p = 0.64), staff awareness of patients at risk (p = 0.80), 30-day mortality (p = 1.00), 180-day mortality (p = 1.00) or length of hospital stay (p = 0.11) among patients at risk.Conclusions
This multi-professional education of staff did not affect the rate of mortality or staff awareness of patients at risk on the wards. 相似文献15.
Background
Rapid Response Teams aim to accelerate recognition and treatment of acutely unwell patients. Delays in delivery might undermine efficiency of the intervention. Our understanding of the causes of these delays is, as yet, incomplete.Aim
To identify modifiable causes of delays in the treatment of critically ill patients outside intensive care with a focus on factors amenable to system design.Methods
Review of care records and direct observation with process mapping of care delivered to 17 acutely unwell patients attended by a Rapid Response Team in a District General Hospital in the United Kingdom. Delays were defined as processes with no added value for patient care.Results
Essential diagnostic and therapeutic procedures accounted for only 31% of time of care processes. Causes for delays could be classified into themes as (1) delays in call-out of the Rapid Response Team, (2) problems with team cohesion including poor communication and team efficiency and (3) lack of resources including lack of first line antibiotics, essential equipment, experienced staff and critical care beds.Conclusion
We identified a number of potentially modifiable causes for delays in care of acutely ill patients. Improved process design could include automated call-outs, a dedicated kit for emergency treatment in relevant clinical areas, increased usage of standard operating procedures and staff training using crew resource management techniques. 相似文献16.
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. 相似文献17.
《Resuscitation》2015
IntroductionThe Royal College of Physicians (RCPL) National Early Warning Score (NEWS) escalates care to a doctor at NEWS values of ≥5 and when the score for any single vital sign is 3.MethodsWe calculated the 24-h risk of serious clinical outcomes for vital signs observation sets with NEWS values of 3, 4 and 5, separately determining risks when the score did/did not include a single score of 3. We compared workloads generated by the RCPL's escalation protocol and for aggregate NEWS value alone.ResultsAggregate NEWS values of 3 or 4 (n = 142,282) formed 15.1% of all vital signs sets measured; those containing a single vital sign scoring 3 (n = 36,207) constituted 3.8% of all sets. Aggregate NEWS values of either 3 or 4 with a component score of 3 have significantly lower risks (OR: 0.26 and 0.53) than an aggregate value of 5 (OR: 1.0). Escalating care to a doctor when any single component of NEWS scores 3 compared to when aggregate NEWS values ≥5, would have increased doctors’ workload by 40% with only a small increase in detected adverse outcomes from 2.99 to 3.08 per day (a 3% improvement in detection).ConclusionsThe recommended NEWS escalation protocol produces additional work for the bedside nurse and responding doctor, disproportionate to a modest benefit in increased detection of adverse outcomes. It may have significant ramifications for efficient staff resource allocation, distort patient safety focus and risk alarm fatigue. Our findings suggest that the RCPL escalation guidance warrants review. 相似文献
18.
The aim of this study was to estimate the incidence, staff awareness and subsequent mortality of patients with abnormal vital signs on general wards in a Danish university hospital. DESIGN AND SETTINGS: Prospective data collection in two surgical and three medical wards at Herlev University Hospital, Copenhagen. Study personnel measured vital signs of all patients present on the wards at random points during the evening and interviewed nursing staff about patients with abnormal vital signs. Simplified medical emergency team (MET) calling criteria were used to define abnormal vital signs. INTERVENTIONS: None. RESULTS: During the 2-month data collection period, 877 patients were included in the study and 155 (18%) had abnormal vital signs. The 30-day mortality in this group was 13% compared to 5% among patients with normal vital signs (p<0.0001). Of the 155 patients with abnormal signs, nursing staff were not aware of all of the patient's abnormalities in 67 (43%) cases. For 20 patients (13%), staff were aware of some of their abnormalities, while for 52 patients (34%), staff were aware of all their abnormalities. CONCLUSIONS: One out of five patients in the general wards developed abnormal vital signs during the 2-month study period and these patients had a 3-fold increased 30-day mortality. For almost half of the patients, nursing staff were unaware of their abnormal vital signs. Strategies to improve identification of patients at risk should be an initial step in preventing serious adverse events on the general wards. 相似文献
19.
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.Objective
To identify the relative importance of factors contributing to the development of clinical deterioration in ward patients, as perceived by health professionals who have experience in recognising or responding to clinical deterioration, or in the management, administration or governance of RRSs.Methods
A written questionnaire containing 12 pre-determined factors was provided to participants. Participants were asked to rank the items from most to least important contributors to ward patient deterioration. The study took place during a session of the Australia and New Zealand Intensive Care Society Rapid Response Team conference.Results
A final sample of 233 (83% response rate), returned the questionnaire. The sample comprised specialist ICU registered nurses with direct patient contact (64%), ICU consultant doctors (17%), ICU nurse managers (7%), hospital administrators (2%), ICU registrars (2%), quality coordinators (2%) and non-hospital staff (4%). The patient’s presenting illness/main diagnosis was the highest ranked factor, followed by pre-existing co-morbidities, seniority of nursing ward staff, medical documentation, senior medical staff, and interdisciplinary communication. Almost two-thirds of participants ranked patient characteristics as the most important contributor to clinical deterioration.Conclusion
Health professionals who have experience in recognising or responding to clinical deterioration, or in the management, administration or governance of RRSs perceive that patient characteristics such as the patient’s primary diagnosis and comorbidities to be the most important contributors to clinical deterioration. 相似文献20.
Márcio Manozzo Boniatti Neusa Azzolini Berenice Severino Pinto Ribeiro Rodrigo Kappel Castilho Renata Souza Coelho 《Resuscitation》2010,81(6):667-670