A prospective study of factors influencing the outcome of patients after a Medical Emergency Team review

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.     

The impact of Rapid Response System on delayed emergency team activation patient characteristics and outcomes—A follow-up study

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.     

Attitudes and barriers to a Medical Emergency Team system at a tertiary paediatric hospital

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.     

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.     

Point prevalence of patients fulfilling MET criteria in ten MET equipped hospitals. The methodology of the RESCUE study

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.     

The Medical Emergency Team system: a two hospital comparison

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.     

Regular in situ simulation training of paediatric Medical Emergency Team improves hospital response to deteriorating patients

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.     

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.     

Outcome of hypotensive ward patients who re-deteriorate after initial stabilization by the Medical Emergency Team

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.     

The effect of multi-professional education on the recognition and outcome of patients at risk on general wards

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.     

Timing and teamwork--an observational pilot study of patients referred to a Rapid Response Team with the aim of identifying factors amenable to re-design of a Rapid Response System

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.     

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.     

Aggregate National Early Warning Score (NEWS) values are more important than high scores for a single vital signs parameter for discriminating the risk of adverse outcomes

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.     

Incidence, staff awareness and mortality of patients at risk on general wards

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.     

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.

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.