Arthas Flabouris

Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial.

BACKGROUNDnPatients with cardiac arrests or who die in general wards have often received delayed or inadequate care. We investigated whether the medical emergency team (MET) system could reduce the incidence of cardiac arrests, unplanned admissions to intensive care units (ICU), and deaths.nnnMETHODSnWe randomised 23 hospitals in Australia to continue functioning as usual (n=11) or to introduce a MET system (n=12). The primary outcome was the composite of cardiac arrest, unexpected death, or unplanned ICU admission during the 6-month study period after MET activation. Analysis was by intention to treat.nnnFINDINGSnIntroduction of the MET increased the overall calling incidence for an emergency team (3.1 vs 8.7 per 1000 admissions, p=0.0001). The MET was called to 30% of patients who fulfilled the calling criteria and who were subsequently admitted to the ICU. During the study, we recorded similar incidence of the composite primary outcome in the control and MET hospitals (5.86 vs 5.31 per 1000 admissions, p=0.640), as well as of the individual secondary outcomes (cardiac arrests, 1.64 vs 1.31, p=0.736; unplanned ICU admissions, 4.68 vs 4.19, p=0.599; and unexpected deaths, 1.18 vs 1.06, p=0.752). A reduction in the rate of cardiac arrests (p=0.003) and unexpected deaths (p=0.01) was seen from baseline to the study period for both groups combined.nnnINTERPRETATIONnThe MET system greatly increases emergency team calling, but does not substantially affect the incidence of cardiac arrest, unplanned ICU admissions, or unexpected death.

The relationship between early emergency team calls and serious adverse events

Objective:To examine the relationship between early emergency team calls and the incidence of serious adverse events—cardiac arrests, deaths, and unplanned admissions to an intensive care unit—in a cluster randomized controlled trial of medical emergency team implementation (the MERIT study). Design:Post hoc analysis of data from cluster randomized controlled trial. Setting and Participants:Twenty-three public hospitals in Australia and 741,744 patients admitted during the conduct of the study. Interventions:Attendance by a rapid response system team or cardiac arrest team. Main Outcome Measures:The relationship between the proportion of rapid response system team calls that were early emergency team calls (defined as calls not associated with cardiac arrest or death) and the rate (events/1000 admissions) of the adverse events. Results:We analyzed 11,242 serious adverse events and 3700 emergency team calls. For every 10% of increase in the proportion of early emergency team calls there was a 2.0 reduction per 10,000 admissions in unexpected cardiac arrests (95% confidence interval [CI] −2.6 to −1.4), a 2.2 reduction in overall cardiac arrests (95% CI −2.9 to −1.6), and a 0.94 reduction in unexpected deaths (95% CI −1.4 to −0.5). We found no such relationship for unplanned intensive care unit admissions or for the aggregate of unexpected cardiac arrests, unplanned intensive care unit admissions, and unexpected deaths. Conclusions:As the proportion of early emergency team calls increases, the rate of cardiac arrests and unexpected deaths decreases. This inverse relationship provides support for the notion that early review of acutely ill ward patients by an emergency team is desirable.

Clinical examination is an inaccurate predictor of intraabdominal pressure.

This study was designed to establish if clinical examination can accurately predict intraabdominal pressure (IAP). Between August 1998 and March 2000 a prospective blinded observational study of postoperative intensive care unit patients was undertaken at a major trauma center. IAP was measured using an intravesicular technique and compared with clinical evaluation. An IAP of at least 18 mmHg was considered elevated. The sensitivity, specificity, positive predicative value (npv), negative predictive value (npv), kappa score, and reliability analysis were calculated. A total of 110 patients provided 150 estimates of IAP, which was elevated in 21%. The kappa score was 0.37; sensitivity, 60.9%; specificity, 80.5%; ppv, 45.2%; npv, 88.6%. The mean difference in IAP values between intravesicular readings and clinical estimates was −1.0±4.1. Prediction of IAP using clinical examination is not accurate enough to replace intravesicular IAP measurements.RésuméLe but de cette étude a été d’établir si l’examen clinique peut prédire avec précision la pression intra-abdominale (PIA). Entre août 1998 et mars 2000 on a entrepris une étude observationnelle prospective à l’insu des patients post-opératoires en soins intensifs (SI) hospitalisés dans un centre de traumatologie majeure. La PIA a été mesurée par la technique intravésicale et comparée à l’évaluation clinique. On a considéré qu’une PIA ≥ 18 mmHg était «élevée». On a calculé la sensibilité (Se), la spécificité (Sp), la valeur prédictive positive (VPP), la valeur prédictive négative (VPN), le score kappa, et la fiabilité. On a estimé cliniquement la PIA 150 fois chez 110 patients. La PIA était élevée dans 21% des cas. Le score Kappa a été de 0.37, la Se de 60.9%, la Sp, de 80.5%, la VPP de 45.2%, la VPN, de 88.6%. La différence moyenne en PIA entre la valeur intra-vésicale et l’estimation clinique a été de −1.0±4.1. La prédiction de la PIA par examen clinique n’est pas suffisamment précise pour remplacer la mesure par pression intravésicale.ResumenEl objetivo del estudio fue averiguar si la exploración clínica permite evaluar con exactitud la presión intraabdominal (IAP). Entre agosto de 1998 y marzo de 2000, se efectuó un estudio prospective ciego, durante el postoperatorio de pacientes ingresados en la UCI de un Centro Traumatológico de referencia. La IAP se midió mediante la técnica intravesical comparandose con los hallazgos clínicos obtenidos. Se consideró que la presión estaba elevada cuando la IAP era ≥18 mm Hg. Comprobamos: la sensibilidad, especificidad, valor predictivo positivo (ppv) y negativo (npv), la puntuación de Kappa y la fiabilidad de los análisis. La puntuación de Kappa fue de 0.37, la sensibilidad del 60.9%, especificidad 80.5%, ppv 45.2% y npv 88.6%. La diferencia media entre los valores de la IAP registrados mediante sonda intravesical y los estimados por la exploración clínica fueron de −1.0±4.1. La valoración clínica de la IAP no es lo suficientemente precisa como para reemplazar la medición intravesical.

Redefining in-hospital resuscitation: the concept of the medical emergency team

Cardiopulmonary resuscitation (CPR) has evolved over centuries with the greatest progress being made in the last 4 decades [1]. In 1958 and 1960 key advances were described by Safar [2] and Kouwenhoven [3] which have now become the basis for modern day basic life support (BLS) CPR. Extending BLS, advanced life support (ALS) guidelines have been developed to deal with the complex scenarios that result in and accompany cardiac arrest situations [4–6]. Cardiopulmonary resuscitation (CPR) is accepted practice for sudden in-hospital and out of hospital death. Cardiopulmonary resuscitation has become something of an industry. There are international organisations and conferences on resuscitation, numerous textbooks are written on the subject and journals, such as Resuscitation, are dedicated to improving resuscitation outcomes. Resuscitation features increasingly in the lay media. Television medical dramas commonly feature CPR. Interestingly, the results of television CPR are usually shown as successful and unrealistic in the US while in the UK the TV outcome is more likely to be bad and realistic [7,8]. The general public perception of outcome following CPR is overoptimistic while unfortunately CPR is usually a perimortem event. A recent review stated that CPR will be futile in some victims of cardiac arrest [9]. In fact, the majority of patients requiring in-hospital CPR die before hospital discharge. Survival to discharge rates after in-hospital CPR vary from 1 to 2% [10] to around 14% [11,12]. Other studies indicate survival figures between these figures [13–19]. It is interesting to note that there has not been a demonstrated improvement in general mortality rates after in-hospital CPR over the last 30 years. This is in spite of the enormous resources devoted to CPR in terms of education, research and the clinician’s time as well as refinements and developments related to CPR. Cardiopulmonary resuscitation has become something of a medical icon. Most are enthusiastic about its use in spite of the poor outcomes, few have urged restraint [20–22]. Increasingly there * Corresponding author. Present address: Division of Critical Care, The Liverpool Hospital, Locked Bag 7103, Liverpool BC, NSW, 1871, Australia.

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

OBJECTIVEnTo describe the reasons for, and immediate outcome following Medical Emergency Team (MET) activation.nnnMETHODSnRetrospective analysis of MET calls in 1998.nnnRESULTSnThere 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.nnnCONCLUSIONSnThe 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.

Documenting Rapid Response System afferent limb failure and associated patient outcomes

OBJECTIVEnDescribe afferent limb failure (ALF), defined as documented Rapid Response System (RRS) calling criteria, but no associated call, in the 24h prior to an event.nnnMETHODSnRetrospective medical record and database review. Adult in-patients whose hospital length of stay (LOS) was greater than 24h, an event being a cardiac arrest, Medical Emergency Team (MET) call or unanticipated Intensive Care Unit (ICU) admission.nnnRESULTSnOver 6 months, there were 443 patients with 575 events, of which 35 (6.1%) were cardiac arrests, 395 (68.7%) MET calls, and 145 (25.2%) ICU admissions. 131 (22.8%) events had documented ALF, of which 47/131 (35.9%) had documented criteria across more than one time period. Patients with ALF, compared to those without ALF, were significantly more likely to have an unanticipated ICU admission (45/131 (34.4%) vs 100/443 (22.5%), p=0.01), but be of similar age (71 years vs 72 years, p=0.44), male gender (51.1% vs 53.2%, p=0.38), APACHE 2 score (22.8 vs 21.4, p=0.67), predicted risk of death (0.394 vs 0.367, p=0.55), ICU LOS (2 days vs 2 days, p=0.56), likelihood of not-for-resuscitation order during an event (4/131 (3.4%) vs 22/444 (5.0%), p=0.34), and hospital mortality (42/107 (39.3%) vs 125/236 (37.2%), p=0.70). Hospital mortality for patients with ALF across multiple, compared to single time periods was higher, 21/40 (52.5%) vs 22/69 (31.9%), p=0.03.nnnCONCLUSIONSnRRS ALF is a useful performance measure for a mature RRS, and is associated with unanticipated ICU admissions. The duration of, and not timing of, ALF criterion occurrence may affect hospital mortality.

The impact of introducing medical emergency team system on the documentations of vital signs

OBJECTIVEnTo study the rate of documentation of vital signs in the period before the occurrence of an adverse event or emergency team call and to measure the effect of introducing the medical emergency team (MET) system on the rate of such documentation.nnnMETHODSnDuring a cluster, randomised trial of the MET in 23 Australian hospitals, we collected the data on lowest systolic blood pressure, highest and lowest respiratory rate and heart rate from 15min to 24h before an adverse event (cardiac arrest, death or unexpected intensive care unit admission) or emergency team call. We derived the document of these vital signs (yes/no) from the numerical values recorded. We used analytically weighted and random-effect regression models to examine the association between non-documented (missing) vital signs, hospital characteristics and MET allocation, and to examine their trend over time.nnnRESULTSnWe found marked variability in documentation, with a high proportion of missing vital signs in some hospitals. Close to 77% of patients suffering adverse events had at least one vital sign missing immediately before the event. Allocation to a MET system was associated with significantly increased documentation of respiratory rate and blood pressure before emergency team review (P<0.01) as well as an improvement in documentation over time (P<0.01). At all stages and for both MET and control hospitals, the respiratory rate was the least commonly documented vital sign (P<0.01).nnnCONCLUSIONSnThe documentation of vital signs in the period before adverse events was commonly incomplete with a particular deficiency in the documentation of the respiratory rate. Introduction of a MET system was associated with improvement in the rate of documentation of vital signs.

The Medical Emergency Team System and Not-for-Resuscitation Orders: Results from the MERIT Study

OBJECTIVEnTo examine NFR orders in relation to adverse events and emergency team calls in hospitals with or without a Medical Emergency Team (MET) system during the MERIT study.nnnMETHODnWithin a cluster randomized controlled trial (the MERIT study), examining the effect of introducing a MET system, we recorded NFR orders in relation to adverse events and emergency team calls. We compared the proportion and rate of NFR orders issued in relation to adverse events and adverse event-free emergency team calls in hospitals with or without a MET system.nnnRESULTSnInformation on NFR orders was available for 3650 patients who died, 1466 patients who had an unplanned ICU admission, 574 patients who suffered a cardiac arrest and 1529 patients who had a adverse event-free emergency team call. Close to 90% of deaths occurred in patients with a previously documented NFR order. Only approximately 4% of cardiac arrests had a previously documented NFR order. In patients with unplanned ICU admission, NFR orders were present in approximately 3% of cases. An NFR order was issued at the time of an event in 3.85% of cases in MET hospitals compared with 1.72% in control hospitals (OR=2.29; 95% CI: 1.31-4.01; p=0.005). This difference was mostly due to a greater proportion of patients being made NFR in MET hospitals at the time of a adverse event-free emergency team call (7.96% vs. 3.05%; OR=2.75; 95% CI: 0.97-7.80; p=0.048). The number of NFR orders issued at the time of a serious adverse event-free emergency team call was 10 times higher in MET hospitals (0.398 vs. 0.041 per 1000 admissions; weighted absolute risk difference: 0.49 (95% CI: 0.20-0.78; p=0.002). Multivariate models could only account for less than 50% of the variance in the issuing of NFR orders.nnnCONCLUSIONSnIn a cohort of Australian hospitals, most deaths occurred in patients with a previously documented NFR order but NFR orders were uncommon before cardiac arrest calls or unplanned ICU admissions. During the conduct of a cluster randomised controlled trial, more NFR orders were issued by emergency teams in those hospitals that implemented a MET system than in control hospitals. MET allocation, teaching hospital status, number of hospital beds and metropolitan location could only explain less than 50% of variance in NFR orders.

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

AIMSnTo 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.nnnMETHODSnFor 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.nnnRESULTSnDuring 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.nnnCONCLUSIONSnImplementation of a RRS was associated with a significant reduction in IHCA, IHCA-related mortality and overall hospital mortality.

Triggers for emergency team activation: A multicenter assessment ☆,☆☆

PURPOSEnThe purpose of the study was to examine triggers for emergency team activation in hospitals with or without a medical emergency team (MET) system.nnnMATERIALS AND METHODSnWithin a cluster randomized controlled trial examining the effect of introducing a MET system, we recorded the triggers for emergency team activation. We compared the proportion and rate of such triggers in hospitals with or without a MET system and in relation to type of hospital, type of patient ward, and time of day.nnnRESULTSnIn control hospitals, the most common trigger for emergency team activation was a decrease in Glasgow Coma Score by 2 or more points (45.6%), whereas in MET hospitals, it was the fact that staff members were worried or the call occurred despite the lack of a specified reason (39.3%). In particular, MET hospitals were 35 times more likely to make a call because of staff being worried about the patient (14.1% vs 0.4%, P < .001). Control hospitals were also significantly more likely to call an emergency team because of a deteriorating respiratory (P = .003) or pulse (P < .001) rate, more calls had at least 3 triggers for activation (20.8% vs 10.2%, P = .036), and the average number of triggers per call was significantly higher (P = .013). Nonmetropolitan hospitals were more likely to call an emergency team because of respiratory rate abnormalities (33.6% vs 23.2%, P = .015). Coronary care unit calls were more likely to be triggered by abnormalities in pulse rate and systolic blood pressure, and more calls occurred during the period from 6:00 am to noon.nnnCONCLUSIONSnIn MET hospitals, more emergency team calls are triggered because staff members are worried about the patient; and fewer calls have multiple triggers. Type of hospital, type of ward, and time of day also affect the nature and frequency of triggers for emergency team activation.