Ken Hillman

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

BACKGROUND Patients 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. METHODS We 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. FINDINGS Introduction 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. INTERPRETATION The MET system greatly increases emergency team calling, but does not substantially affect the incidence of cardiac arrest, unplanned ICU admissions, or unexpected death.

Findings of the First Consensus Conference on Medical Emergency Teams

Background:Studies have established that physiologic instability and services mismatching precede adverse events in hospitalized patients. In response to these considerations, the concept of a Rapid Response System (RRS) has emerged. The responding team is commonly known as a medical emergency team (MET), rapid response team (RRT), or critical care outreach (CCO). Studies show that an RRS may improve outcome, but questions remain regarding the benefit, design elements, and advisability of implementing a MET system. Methods:In June 2005 an International Conference on Medical Emergency Teams (ICMET) included experts in patient safety, hospital medicine, critical care medicine, and METs. Seven of 25 had no experience with an RRS, and the remainder had experience with one of the three major forms of RRS. After preconference telephone and e-mail conversations by the panelists in which questions to be discussed were characterized, literature reviewed, and preliminary answers created, the panelists convened for 2 days to create a consensus document. Four major content areas were addressed: What is a MET response? Is there a MET syndrome? What are barriers to METS? How should outcome be measured? Panelists considered whether all hospitals should implement an RRS. Results:Patients needing an RRS intervention are suddenly critically ill and have a mismatch of resources to needs. Hospitals should implement an RRS, which consists of four elements: an afferent, “crisis detection” and “response triggering” mechanism; an efferent, predetermined rapid response team; a governance/administrative structure to supply and organize resources; and a mechanism to evaluate crisis antecedents and promote hospital process improvement to prevent future events.

Antecedents to hospital deaths

Background: Recent studies have suggested there are a large number of potentially preventable deaths in Australian hospitals.

Limitation of myocardial infarction by early infusion of recombinant tissue-type plasminogen activator.

In a double-blind randomized trial involving five Sydney hospitals and the city ambulance paramedical service, 145 patients with a first evolving myocardial infarction and with onset of pain less than 2.5 (mean 1.9 +/- 0.5 [SD]) hr previously were allocated to intravenous infusion of 100 mg recombinant tissue-type plasminogen activator (rt-PA) or placebo over 3 hr. The groups at entry were similar. At assessment 21 days later, left ventricular ejection fraction measured both by contrast and radionuclide ventriculography was higher in the rt-PA compared with the placebo group (61 +/- 13%, n = 64, vs 54 +/- 14%, n = 62, contrast, 2p = .006; 52 +/- 13%, n = 66, vs 48 +/- 13%, n = 62 isotope, 2p = .08). This indicates limitation of myocardial infarction by rt-PA.

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.

Study of diarrhea in critically ill patients.

There has been an impression that diarrhea occurs commonly in seriously ill patients treated in ICUs. In view of the sparsity of published work on the problem, we embarked on a prospective study of all patients admitted to the ICU for more than 48 h over a 12-month period.Three factors were examined in detail: nasogastric feeding, cimetidine administration, and antibiotic treatment. Other factors also were considered, notably the nature of the underlying illness and the spread of a possible infective agent by cross-infection.There was a 41% incidence of diarrhea. A significant increase in the incidence of diarrhea occurred in patients on nasogastric feeding (p < 0.01) and in those receiving cimetidine (p < 0.05); there was no increased incidence in those receiving antibiotic therapy.The cytotoxin of Clostridium difficile was specifically looked for in all patients with diarrhea, but was not detected.

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.

Colonization of the gastric contents in critically ill patients.

In a study of 28 ventilated patients in the ICU, cimetidine was ineffective in maintaining gastric pH above 4. Quantitative and qualitative bacteriological examination of daily gastric aspirates showed that when the pH was above 4, there was rapid colonization with high counts of organisms, predominantly coliforms. Progressive colonization by yeasts, independent of pH, was noted in nearly one-half of the patients. Gastric colonization has possible implications in terms of crossinfection of development of aspiration pneumonia. As these are seriously ill patients with compromised gastrointestinal (GI) barriers and decreased immunity, the large numbers of bacteria or their endotoxins may contribute to the high incidence of septicemia.

Access Block and Emergency Department Overcrowding

Access block affecting the emergency department (ED), also known as boarding in the United States and Canada, can be described as a phenomenon comprising almost all the challenges in the world of modern EDs. We use the analogy of parallel universes to illustrate both the complexity and the severity of the problem. In the world of physics, many attempts have been made to create a mathematical solution that can answer the more basic questions about physical phenomena in the universe. This has been known as ‘Theory of Everything’. Albert Einstein spent 30 years of his life trying to solve this ‘Theory of Everything’, but failed [1].