A literature review: factors that impact on nurses’ effective use of the Medical Emergency Team (MET)

Aims and objectives. The aim of this literature review is to identify factors, both positive and negative, that impact on nurses’ effective use of the Medical Emergency Team (MET) in acute care settings. Background. Outcomes for patients are often dependent on nurses’ ability to identify and respond to signs of increasing illness and initiate medical intervention. In an attempt to improve patient outcomes, many acute hospitals have implemented a rapid response system known as the Medical Emergency Team (MET) which has improved management of critically ill ward patients. Subsequent research has indicated that the MET system continues to be underused by nurses. Design. A comprehensive thematic literature review. Methods. The review was undertaken using key words and the electronic databases of Cumulative Index to Nursing and Allied Health Literature (CINAHL), OVID/MEDLINE, Blackwell Synergy, Science Direct and Informit. Fifteen primary research reports were relevant and included in the review. Results. Five major themes emerged from the analysis of the literature as the major factors effecting nurses’ use of the MET system. They were: education on the MET, expertise, support by medical and nursing staff, nurses’ familiarity with and advocacy for the patient and nurses’ workload. Conclusions. Ongoing education on all aspects of the MET system is recommended for nursing, medical and MET staff. Bringing MET education into undergraduate programs to prepare new graduates entering the workforce to care for acutely ill patients is also strongly recommended. Further research is also needed to determine other influences on MET activation. Relevance to clinical practice. Strategies that will assist nurses to use the MET system more effectively include recruitment and retention of adequate numbers of permanent skilled staff thereby increasing familiarity with and advocacy for the patient. Junior doctors and nurses should be encouraged to attend ward MET calls to gain skills in management of acutely ill patients.     

国家级应急医疗救援队内科ICU护理人员配置方法的探讨

目的 通过对北京军区总医院国家级应急医疗救援队内科ICU的训练和演练效果的评价,探寻更加合理的ICU护理人员配置方法.方法 将40例患者随机分为观察组和对照组各20例.对照组按平均分床法对患者进行护理,观察组运用重症监护护理评分系统进行人员配备,比较2组护理效果.结果 2组重症护理评分比较差异无统计学意义,但观察组通过ICU单元的时间明显短于对照组.结论 ICU单元护理人员需要有更高的综合素质;重症监护护理评分系统有利于人员合理配置.内科ICU单元护理人员的合理配置及高素质可以提高ICU的救治效率.     

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.     

The development and implementation of a Hospital Emergency Response Team (HERT) for out-of-hospital surgical care

Over the past two decades, Los Angeles County has implemented a Hospital Emergency Response Team (HERT) to provide on-scene, advanced surgical care of injured patients as an element of the local Emergency Medical Services (EMS) system. Since 2008, the primary responsibility of the team has been to perform surgical procedures in the austere field setting when prolonged extrication is anticipated. Following the maxim of "life over limb," the team is equipped to provide rapid amputation of an entrapped extremity as well as other procedures and medical care, such as anxiolytics and advanced pain control. This report describes the development and implementation of a local EMS system HERT.     

Effectiveness of the Medical Emergency Team: the importance of dose

Up to 17% of hospital admissions are complicated by serious adverse events unrelated to the patients presenting medical condition. Rapid Response Teams (RRTs) review patients during early phase of deterioration to reduce patient morbidity and mortality. However, reports of the efficacy of these teams are varied. The aims of this article were to explore the concept of RRT dose, to assess whether RRT dose improves patient outcomes, and to assess whether there is evidence that inclusion of a physician in the team impacts on the effectiveness of the team. A review of available literature suggested that the method of reporting RRT utilization rate, (RRT dose) is calls per 1,000 admissions. Hospitals with mature RRTs that report improved patient outcome following RRT introduction have a RRT dose between 25.8 and 56.4 calls per 1,000 admissions. Four studies report an association between increasing RRT dose and reduced in-hospital cardiac arrest rates. Another reported that increasing RRT dose reduced in-hospital mortality for surgical but not medical patients. The MERIT study investigators reported a negative relationship between MET-like activity and the incidence of serious adverse events. Fourteen studies reported improved patient outcome in association with the introduction of a RRT, and 13/14 involved a Physician-led MET. These findings suggest that if the RRT is the major method for reviewing serious adverse events, the dose of RRT activation must be sufficient for the frequency and severity of the problem it is intended to treat. If the RRT dose is too low then it is unlikely to improve patient outcomes. Increasing RRT dose appears to be associated with reduction in cardiac arrests. The majority of studies reporting improved patient outcome in association with the introduction of an RRT involve a MET, suggesting that inclusion of a physician in the team is an important determinant of its effectiveness.     

Defining Components of Team Leadership and Membership in Prehospital Emergency Medical Services

Background: Teamwork is critical for patient and provider safety in high-stakes environments, including the setting of prehospital emergency medical services (EMS). Objective: We sought to describe the components of team leadership and team membership on a single patient call where multiple EMS providers are present. Methods: We conducted a two-day focus group with nine subject matter experts in crew resource management (CRM) and EMS using a structured nominal group technique (NGT). The specific question posed to the group was, “What are the specific components of team leadership and team membership on a single patient call where multiple EMS providers are present?” After round-robin submission of ideas and in-depth discussion of the meaning of each component, participants voted on the most important components of team leadership and team membership. Results: Through the NGT process, we identified eight components of team leadership: a) creates an action plan; b) communicates; c) receives, processes, verifies, and prioritizes information; d) reconciles incongruent information; e) demonstrates confidence, compassion, maturity, command presence, and trustworthiness; f) takes charge; g) is accountable for team actions and outcomes; and h) assesses the situation and resources and modifies the plan. The eight essential components of team membership identified included: a) demonstrates followership, b) maintains situational awareness, c) demonstrates appreciative inquiry, d) does not freelance, e) is an active listener, f) accurately performs tasks in a timely manner, g) is safety conscious and advocates for safety at all times, and h) leaves ego and rank at the door. Conclusions: This study used a highly structured qualitative technique and subject matter experts to identify components of teamwork essential for prehospital EMS providers. These findings and may be used to help inform the development of future EMS training and assessment initiatives.     

Long-term effect of a Medical Emergency Team on mortality in a teaching hospital

AIM: To assess the effect of a Medical Emergency Team (MET) service on patient mortality in the 4 years since its introduction into a teaching hospital. METHODS: Using the hospital electronic database we obtained the number of admissions and in-hospital deaths "before-" (September 1998-August 1999), "during education-" (September 1999-August 2000), the "run-in period-" (September 2000-October 2000), and "after-" (November 2000-December 2004) the introduction of a MET service, intended to review and treat acutely unwell ward patients. RESULTS: There were 42,230 surgical and 112,321 medical admissions over the study period. During the education period for the MET the odds ratio (OR) of death for surgical patients was 0.82 compared to the "before" MET period (95% CI 0.67-1.00; p=0.055). During the 2 month "run-in" period it remained statistically unchanged at 1.01 (95% CI 0.67-1.51; p=0.33). In the 4 years "after" introduction of the MET, the OR of death for surgical patients remained lower than the "before" MET period (multiple chi(2)-test p=0.0174). There were 1252 surgical MET calls, and in December 2004 the ratio of surgical MET calls to surgical deaths was 1.76:1. In contrast, in-hospital deaths for medical patients increased during the "education period", the "run-in" period and into the first year "after" the introduction of the MET (multiple chi(2)-test p<0.0001). There were 1278 medical MET calls, and in December 2004 the ratio of medical MET calls to medical deaths was 1:2.47 (0.41:1). For each 12-month period, the relative risk of death for medical patients as opposed to surgical patients ranged between 1.32 and 2.40. CONCLUSIONS: Introduction of an Intensive Care-based MET in a university teaching hospital was associated with a fluctuating reduction in post-operative surgical mortality which was already apparent during the education phase, but a sustained increase in the mortality of medical patients which was similarly already apparent during the education phase. The differential effects on mortality may relate to differences in the degree of disease complexity and reversibility between medical and surgical patients.     

The Emergency Medical Treatment and Active Labor Act (EMTALA): guidelines for compliance

Every patient presenting to a hospital emergency department must have a medical screening examination to determine whether an emergency medical condition exists. If there is no emergency medical condition, the Act does not apply. Any patient who is found to have an emergency medical condition must be stabilized. If necessary. the appropriate on-call physician must be consulted to administer necessary stabilizing treatment. Once the patient has been stabilized, the Act no longer applies. If a hospital is unable to provide the necessary stabilizing treatment, arrangements must be made for an appropriate transfer to a facility with the capacity to provide treatment. A hospital with specialized capabilities or facilities may not refuse to accept an appropriate transfer of an individual who requires such specialized capabilities or facilities if the hospital has the capacity to treat the individual. If a woman is in active labor and there is insufficient time to effect an appropriate transfer safely. maternal and newborn care must be provided to the woman and her infant.     

The Medical Emergency Team: 12 month analysis of reasons for activation, immediate outcome and not-for-resuscitation orders.

OBJECTIVE: To describe the reasons for, and immediate outcome following Medical Emergency Team (MET) activation. METHODS: Retrospective analysis of MET calls in 1998. RESULTS: There were 713 MET calls to 559 in-patients. Of the 559 patients 252 (45%) were admitted to ICU and 49 (6.9%) died during the MET response. The three commonest criteria for calling the MET were a fall in GCS>2 (n=155); a systolic blood pressure<90 mmHg (n=142) and a respiratory rate>35 (n=109). Cardiac arrests accounted for 61 calls and had an immediate mortality of 59%. The most common MET criterion associated with admission to ICU was a respiratory rate >35. Of patients who received MET calls based only on the 'worried' criterion 16% were admitted to ICU. The MET felt that a not-for-resuscitation order would have been appropriate in 130 cases (23%). NFR orders were documented during 27 of the MET calls. CONCLUSIONS: The MET system provides objective and subjective criteria by which medical and nursing staff can identify patients who become acutely unwell. A high proportion of these patients will require admission to Intensive Care. The MET system also provides the opportunity to identify patients for whom an NFR order should be considered.     

Rating medical emergency teamwork performance: Development of the Team Emergency Assessment Measure (TEAM)

Aim

To develop a valid, reliable and feasible teamwork assessment measure for emergency resuscitation team performance.

Background

Generic and profession specific team performance assessment measures are available (e.g. anaesthetics) but there are no specific measures for the assessment of emergency resuscitation team performance.

Methods

(1) An extensive review of the literature for teamwork instruments, and (2) development of a draft instrument with an expert clinical team. (3) Review by an international team of seven independent experts for face and content validity. (4) Instrument testing on 56 video-recorded hospital and simulated resuscitation events for construct, consistency, concurrent validity and reliability and (5) a final set of ratings for feasibility on fifteen simulated ‘real time’ events.

Results

Following expert review, selected items were found to have a high total content validity index of 0.96. A single ‘teamwork’ construct was identified with an internal consistency of 0.89. Correlation between the total item score and global rating (rho 0.95; p < 0.01) indicated concurrent validity. Inter-rater (k 0.55) and retest reliability (k 0.53) were ‘fair’, with positive feasibility ratings following ‘real time’ testing. The final 12 item (11 specific and 1 global rating) are rated using a five-point scale and cover three categories leadership, teamwork and task management.

Conclusion

In this primary study TEAM was found to be a valid and reliable instrument and should be a useful addition to clinicians’ tool set for the measurement of teamwork during medical emergencies. Further evaluation of the instrument is warranted to fully determine its psychometric properties.     

Design and implementation of a medical student hazardous materials response team: the Medical Student HazMat Team

Background

To design and implement a replicable disaster training curriculum for the first on-call medical student hazardous materials response team.

Methods

Twenty-eight first-year medical students participated in a simulated citywide bioterrorism disaster drill. Students were notified of the Code Orange via email, a pager system, and group SMS text message. Twenty-five students participated in the drill, while the three remaining student leaders worked with the ED staff and HazMat Branch Director to ensure that all protocols were followed properly. Five groups of five students took turns donning HazMat gear, decontaminating three mannequins (an infant, a child, and an unconscious adult), and then safely removing the gear.

Results

All modes of communication were received within 5 min, and all the students arrived at the ED within 20 min. The decontamination was determined to be sufficient by the team leader, Emergency Department staff, and HazMat Branch Director and was completed approximately 10 min after the entrance to the decontamination chamber.

Conclusions

Current US medical school curricula lack emergency preparedness training in response to potential terrorist attacks and hazardous material exposures. Our program, while still in its early workings, not only allows students to develop critical knowledge and practical skills but also provides a unique opportunity to leverage much-needed manpower and resources during emergency situations.

     

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.     

Air Medical Services: Future Development as an Integrated Component of the Emergency Medical Services (EMS) System

Objective. To determine whether televised public service announcements (PSAs) demonstrating the fundamentals of CPR were effective in increasing the rate of layperson bystander-initiated CPR. Methods. Two 30-second PSAs were shown 597 times from September 8, 1996, through April 12, 1997. In each, CPR was given to one member of an older couple by the other in the home. The authors measured rates of bystander CPR in communities that were exposed to the PSA and in communities that were not exposed in two time periods, a before-airing period, January 1, 1993, through September 7, 1996, and a during-airing period, September 8, 1996, through April 12, 1997. A case was defined as a patient with a nontraumatic cardiac arrest that occurred before arrival of EMS personnel, and for whom CPR was initiated by EMS personnel or lay bystanders. Results. There were 1,786 cardiac arrests in the “before” period and 289 in the “during” period. The rate of bystander CPR increased from 43% to 55% (p < 0.05) in the intervention community and remained the same in the comparison community (33%). Conclusion. Airing of the PSA was accompanied by an increase in the rate of bystander CPR, though the increase may be attributable to a secular trend.