Use of medical emergency team responses to reduce hospital cardiopulmonary arrests

Rapid response systems: a mandatory system of care or an optional extra for bedside clinical staff

Two articles in this issue describe different approaches to implementing a rapid response system--one approach involving a wide-ranging marketing plan, the other entailing a policy change to make activation mandatory.

Evolution of a rapid response system from voluntary to mandatory activation

A policy requiring rapid response activation for all patients who met physiologic instability criteria, which was initiated four years after the rapid response system's inception, significantly increased the number of rapid response calls and was associated with a reduction in cardiorespiratory arrests outside of critical care areas.

An implementation strategy for a multicenter pediatric rapid response system in Ontario

A rapid response system using a medical emergency team was implemented across four pediatric hospitals in Ontario, Canada, in a social marketing approach.

Caring for our own: deploying a systemwide second victim rapid response team

A unique rapid response system was designed to provide social, psychological, emotional, and professional support for health care providers who are "second victims"--traumatized as a result of their involvement in an unanticipated adverse event, medical error, or patient-related injury.

Changing cardiac arrest and hospital mortality rates through a medical emergency team takes time and constant review

OBJECTIVE

To determine the long-term impact of a medical emergency team on survival and to assess the utility of administrative data to monitor outcomes.

DESIGN

Prospective study of cardiac arrests and survival. Retrospective study of administrative data.

SETTING

University affiliated tertiary referral hospital in Melbourne, Australia.

PATIENTS

All patients admitted to hospital in three 6-month periods between 2002-2007 (prospective) and 1993-2007 (retrospective).

INTERVENTION

Implementation of a medical emergency team in November 2002.

MEASUREMENTS AND MAIN RESULTS

In the prospective analysis, rates of unexpected cardiac arrest and hospital mortality (referenced to 1000 patient-care days) were measured before (July-August 2002) and after (December 2002-May 2003, December 2004-May 2005, December 2006-May 2007) the introduction of the medical emergency team. Cardiac arrest rates decreased progressively from 0.78 per 1000 (95% confidence interval, 0.50-1.16) to 0.25 per 1000 (95% confidence interval, 0.15-0.39, p < .001), and hospital mortality from 0.58 per 1000 (95% confidence interval, 0.35-0.92) to 0.30 per 1000 (95% confidence interval, 0.20-0.46, p < .05); cardiac arrest rates achieved statistical significance at 2 yrs and hospital mortality at 4 yrs. Using administrative data adjusted for age, sex, case-mix, and comorbidity, hazard ratios for mortality for the three post implementation periods were statistically lower than for the 10 yrs pre implementation (0.85, 0.74, 0.65). The intensity of calling (calls/1000 patient-days) inversely correlated with cardiac arrest rate, unexpected mortality rate, and total hospital mortality rate.

CONCLUSIONS

The introduction of a medical emergency team was associated with a progressive decline of unexpected cardiac arrests within 2 yrs, and of unexpected mortality within 4 yrs. This suggests that changes to organizational practice take time and benefits may not be immediately obvious. Such changes are reflected in total hospital mortality measured from administrative data and make monitoring simpler in the longer term. Finally, efforts to increase calling of emergency teams should reduce cardiac arrests and mortality.

Clinical nurse specialists as leaders in rapid response

The purposes of this article were to provide background information about rapid response teams (RRTs), to describe the actual and potential outcomes of RRTs, to define the potential role of the clinical nurse specialist in leading RRTs, and to provide recommendations for implementation of RRTs. Rapid response teams provide the opportunity for early intervention for patients demonstrating clinical decline before they reach a point of no return. The long-standing practice of waiting for intensive intervention (code blue) until the patient experiences cardiopulmonary arrest has shown poor outcomes, bringing this practice into question. Although research results are mixed, there is evidence to suggest that the successful use of RRTs results in clinically significant patient outcomes as evidenced by decreased cardiopulmonary arrests and decreased rates in mortality. Other positive patient, nursing, and organizational outcomes can result from RRTs and are discussed. Clinical nurse specialists are uniquely qualified to provide leadership in the development and implementation of RRTs and the monitoring of outcomes. As RRTs become a more common standard practice, further research is needed to examine their benefits and to further refine effective early intervention for high-risk patients.

Successful use of a rapid response team in the pediatric oncology outpatient setting

In a clinic setting, the RRT, in conjunction with the ICU intensivist, succesfully treated a septic patient with fluid resuscitation and a vasoactive medication, and subsequently facilitated a quick transport to a higher level of care. St. Jude Children's Research Hospital's successful use of the RRT in the clinic setting suggests that RRTs can be used to improve patient outcomes across the spectrum of inpatient as well as outpatient hospital settings. Our experience suggests that RRTs can be beneficial in filling a gap in patient safety in outpatient clinics.

Resident and RN perceptions of the impact of a medical emergency team on education and patient safety in an academic medical center

OBJECTIVE

To assess the perceptions of residents and RNs about the effects of a medical emergency team on patient safety and their own educational experiences.

DESIGN

Survey-based study.

SETTING

A single academic medical center.

PARTICIPANTS

In 2007, 1 yr after the introduction of a medical emergency team, a Web-based survey was administered to 141 internal medicine and general surgery residents and 497 RNs in a single academic medical center. Residents' and RNs' beliefs about the effects of the medical emergency team on patient safety and education were measured using 12 Likert scale items. Group differences were assessed using Mann-Whitney U test and Kruskal-Wallis test.

RESULTS

The overall response rate was 79% (67% for residents and 83% for RNs). Residents and RNs agreed that the medical emergency team improved patient safety, but RNs held this belief more strongly than did residents. Residents neither agreed nor disagreed with the notion that the creation of the medical emergency team decreased their opportunities to obtain critical care skills or education, whereas RNs disagreed with this statement. Relative to surgical residents, medical residents were more involved in activation of the medical emergency team and believed more strongly that the team improved patient safety. Residents and RNs who perceived that they were involved in the call activation had more positive attitudes toward the team.

CONCLUSION

Residents and RNs believe that a medical emergency team improves patient safety in the hospital without compromising educational experiences or skills. Frequency of involvement in the events and the decision to activate the team correlated with more positive attitudes.

Baseline hospital performance and the impact of medical emergency teams: modelling vs. conventional subgroup analysis

BACKGROUND

To compare two approaches to the statistical analysis of the relationship between the baseline incidence of adverse events and the effect of medical emergency teams (METs).

METHODS

Using data from a cluster randomized controlled trial (the MERIT study), we analysed the relationship between the baseline incidence of adverse events and its change from baseline to the MET activation phase using quadratic modelling techniques. We compared the findings with those obtained with conventional subgroup analysis.

RESULTS

Using linear and quadratic modelling techniques, we found that each unit increase in the baseline incidence of adverse events in MET hospitals was associated with a 0.59 unit subsequent reduction in adverse events (95%CI: 0.33 to 0.86) after MET implementation and activation. This applied to cardiac arrests (0.74; 95%CI: 0.52 to 0.95), unplanned ICU admissions (0.56; 95%CI: 0.26 to 0.85) and unexpected deaths (0.68; 95%CI: 0.45 to 0.90). Control hospitals showed a similar reduction only for cardiac arrests (0.95; 95%CI: 0.56 to 1.32). Comparison using conventional subgroup analysis, on the other hand, detected no significant difference between MET and control hospitals.

CONCLUSIONS

Our study showed that, in the MERIT study, when there was dependence of treatment effect on baseline performance, an approach based on regression modelling helped illustrate the nature and magnitude of such dependence while sub-group analysis did not. The ability to assess the nature and magnitude of such dependence may have policy implications. Regression technique may thus prove useful in analysing data when there is a conditional treatment effect.

Reducing in-hospital cardiac arrests and hospital mortality by introducing a medical emergency team

PURPOSE

To prospectively evaluate the implementation of a rapid response team in the form of a medical emergency team (MET) with regard to cardiac arrests and hospital mortality.

METHODS

Prospective before-and-after trial of implementation of a MET at the Karolinska University Hospital, Stockholm, Sweden. All adult patients, apart from cardiothoracic, admitted to the hospital were regarded as participants in the study. A control period of 5 years and 203,892 patients preceded the 2-year intervention period of 73,825 patients.

MAIN RESULTS

Number of MET calls was 9.3 per 1,000 hospital admissions. Cardiac arrests per 1,000 admissions decreased from 1.12 to 0.83, OR 0.74 (95% CI 0.55-0.98, p = 0.035). Adjusted for age, sex, hospital length of stay, acute/elective admission as well as co-morbidities, MET implementation was associated with a reduction in total hospital mortality by 10%, OR 0.90 (95% CI 0.84-0.97), p = 0.003. Hospital mortality was also reduced for medical patients by 12%, OR 0.88 (95% CI 0.81-0.96, p = 0.002) and for surgical patients not operated upon by 28%, OR 0.72 (95% CI 0.56-0.92, p = 0.008). FOR PATIENTS FULFILLING THE MET CRITERIA: Thirty-day mortality pre-MET was 25% versus 7.9% following MET compared with historical controls. Similarly, 180-day mortality was 37.5% versus 15.8%, respectively.

CONCLUSIONS

Implementing the MET team was associated with significant improvement in both cardiac arrest rate and overall adjusted hospital mortality. Significant reductions in hospital mortality for un-operated surgical patients as well as for medical patients were also seen. Thus, introduction of the MET seemed to improve outcome for hospitalized patients.

Enhanced end-of-life care associated with deploying a rapid response team: a pilot study

HYPOTHESIS

Institution of a rapid response team (RRT) improves patients' quality of death (QOD).

SETTING

A 425-bed community teaching hospital.

PATIENTS

: All medical-surgical patients whose end-of-life care was initiated on the hospital wards during the 8 months before (pre-RRT) and after (post-RRT) actuation.

STUDY DESIGN

Retrospective cohort study.

METHODS

Medical records of all patients were reviewed using a uniform data abstraction tool. Demographic information, diagnoses, physiologic and laboratory data, and outcomes were recorded.

RESULTS

A total of 197 patients died in both the pre-RRT and post-RRT periods. There were no differences in age, sex, advance directives, ethnicity, or religion between groups. Restorative outcomes, including in-hospital mortality (27 vs. 30/1000 admissions), unexpected transfers to intensive care (17 vs. 19/1000 admissions) and cardiac arrests (3 vs. 2.5/1000 admissions) were similar during the 2 periods. Outcomes, including formal comfort care only orders (68 vs. 46%), administration of opioids (68 vs. 43%), pain scores (3.0 +/- 3.5 vs. 3.7 +/- 3.2), patient distress (26 vs. 62%), and chaplain visits (72 vs. 60%), were significantly better in the post-RRT period compared to the pre-RRT period (all P < 0.05). During the post-RRT period, 61 patients died with RRT care and 136 died without RRT care. End-of-life care outcomes were similar for these groups except more RRT patients had chaplain visits proximate to their deaths (80% vs. 68%; P = 0.0001).

CONCLUSIONS

Institution of an RRT in our hospital had negligible impact on outcomes of patients whose goal was restorative care. Deployment of the RRT was associated with generally improved end-of-life pain management and psychosocial care.

Developing and evaluating a trigger response system

Based on its experience in implementing a rapid response system, a Level III trauma medical center recommends that other organizations (1) involve key stakeholders in the development process, (2) develop an awareness campaign, (3) hardwire the trigger response process, (4) develop quality success measures and metrics, and (5) implement a pilot and make data-driven changes accordingly.

Rapid response system

There is growing evidence that early detection and response to physiological deterioration can improve outcomes for hospitalized infants, children, and adults. A rapid response system (RRS) is a multidisciplinary system to decrease the incidence of in-hospital cardiopulmonary arrests by detecting a crisis event and triggering a response and by dispatching a responding team. For quality improvement of the system, a review mechanism is vital to identify opportunities for preventing future events or improving response after crises occur. The whole system requires an administrative component that oversees the RRS and provides support. The system is designed to locate and respond rapidly to a suddenly critically ill patient who lacks necessary critical care resources. Over the past decade, RRSs have been widely implemented in adult practice in the United States, Canada, Australia, the United Kingdom, and Scandinavian countries.

Reduction of hospital mortality and of preventable cardiac arrest and death on introduction of a pediatric medical emergency team

OBJECTIVE

To determine the effect of a medical emergency team (MET) on the incidence of unexpected cardiac arrest and death.

DESIGN

Comparison of retrospective data (pre-MET) before introduction of MET with prospective data after introduction of MET system (post-MET).

SETTING

Tertiary care pediatric hospital.

PATIENTS

A total of 104,780 admissions during a 41-month period pre-MET; 138,424 admissions during 48 months post-MET.

INTERVENTIONS

Introduction of a MET.

RESULTS

Total hospital deaths decreased from 4.38 to 2.87/ 1000 admissions (risk ratio 0.65, 95% confidence interval [CI] 0.57-0.75, p < 0.0001). Ward unexpected death decreased from 13 (0.12/1000) to 6 (0.04/1000) (risk ratio 0.35, 95% CI 0.13- 0.92, p = 0.03) but unexpected cardiac arrests did not change from 0.19/1000 to 0.17/1000 (risk ratio 0.91, 95% CI 0.50 -1.64, p = 0.75). Thirty-four hospital deaths, including three unexpected deaths (1 out of 72 MET calls), were prevented each year of MET operation. Preventable cardiac arrest (children whose symptoms or signs fulfilled MET calling criteria) decreased from 17 (0.16/ 1000) to 10 (0.07/1000) (risk ratio 0.45, 95% CI 0.20-0.97, p = 0.04) and in whom death decreased from 12 to 2 (0.11/1000 to 0.01/1000) (risk ratio 0.13, 95% CI 0.03-0.56, p = 0.001). Nonpreventable cardiac arrest (children whose symptoms or signs did not fulfill MET calling criteria) increased from 3 to 14 (0.03/1000 to 0.10/1000, p = 0.03) but death did not increase. Survival from cardiac arrest increased from 7 of 20 patients to 17 of 23 (risk ratio 2.11, 95% CI 1.11- 4.02, p = 0.01). Annual calls for urgent assistance were 202 in the post-MET era and 46 during the pre-MET era (ratio 4.4:1).

CONCLUSIONS

Introduction of a MET was associated with reduction of total hospital death and reduction of preventable cardiac arrest and death with increased survival in wards of a pediatric hospital. MET calling criteria identified some but not all children at risk of unexpected cardiac arrest and death.

Leading successful rapid response teams: A multisite implementation evaluation

The purpose of this article is to report findings from the preliminary evaluation of a major initiative to support the implementation of rapid response teams. From 2004 to 2006, the Robert Wood Johnson Foundation funded diverse learning collaboratives fostering the implementation of rapid response teams. The authors report preliminary evaluation findings exploring the impact of rapid response teams "through the eyes of the nurse." Results may be especially useful to clinical and administrative leaders who are either preparing to implement rapid response teams or considering how to strengthen rapid response team initiatives in their settings.

Rapid response: a quality improvement conundrum

Many in-hospital cardiac arrests and other adverse events are heralded by warning signs that are evident in the preceding 6 to 8 hours. By promptly intervening before further deterioration occurs, rapid response teams (RRTs) are designed to decrease unexpected intensive care unit (ICU) transfers, cardiac arrests, and inpatient mortality. While implementing RRTs is 1 of the 6 initiatives recommended by the Institute for Healthcare Improvement, data supporting their effectiveness is equivocal. Before implementing an RRT in our institution, we reviewed cases of failure to rescue and found that (1) poor outcomes were often associated with attempts to manage early decompensations without a bedside evaluation, and (2) the common causes of decompensation for floor patients (early sepsis, aspiration, pulmonary embolism) were within the scope of our primary teams' practice. Therefore, we felt that prompt, mandatory bedside evaluations by the primary team would decrease untoward outcomes.

The front line of patient safety: staff nurses and rapid response team calls

BACKGROUND

In response to growing concerns about patient safety, many hospitals are implementing rapid response teams (RRTs). Although the staff nurse plays a critical role in recognizing the need for the RRT and initiating the call, little is known about actions of staff nurses in relation to the RRT.

OBJECTIVE

The purpose of this study was to examine relationships between nurse educational preparation, years of experience, degree of engagement, and the RRT call status (independent vs dependent). Nurse engagement was measured by the Manifestations of Early Recognition Scale.

METHODS

A descriptive correlational design was used. The sample comprised 75 staff nurses at an academic medical center who cared for patients for whom the RRT was called. Educational level and nursing experience were independent predictors of call status, after controlling for effects of other independent variables.

RESULTS

Independent callers were almost 5 times more likely to have a BSN degree, and almost 4 times more likely to have more than 3 years of experience, than did RNs who called because someone asked them to call. High levels of engagement were also significantly associated with call status, but after controlling for educational level and nursing experience, the relationship was not significant.

CONCLUSIONS

This study has implications for clinicians and managers in health care facilities that rely on RRTs.

Outcomes of a hospital-wide plan to improve care of comatose survivors of cardiac arrest

BACKGROUND

Therapeutic hypothermia (TH) improves outcomes in comatose survivors of cardiac arrest. Few hospitals have protocol-driven plans that include TH. We implemented a series of process interventions designed to increase TH use and improve outcomes in patients successfully resuscitated from out-of-hospital cardiac arrest (OHCA) or in-hospital cardiac arrest (IHCA).

METHODS AND RESULTS

Linked interventions including a TH order sheet, verbal and written feedback to individual providers, an educational program, TH "kit" and on-call consultants to assist with patient care and hypothermia induction were implemented between January 1, 2005 and December 31, 2007 in a large, university-affiliated, tertiary care center. We then completed a retrospective review of all patients treated for cardiac arrest during the study period. Descriptive statistics, chi-squared analyses, or Fisher's exact test were used as appropriate. A p value <0.05 was considered significant. 135 OHCA patients and 106 IHCA patients were eligible for post-arrest care. TH use increased each year in the OHCA group (from 6% to 65% to 76%; p<0.001) and IHCA group (from 0% to 36% to 53%; p=.02). A good outcome was achieved in 21% and 8% of comatose patients with OHCA and IHCA, respectively. Patients with OHCA and ventricular dysrhythmia were more likely to have a good outcome with TH treatment than without it (good outcome in 57% vs. 8%; p=.005).

CONCLUSION

Implementing a series of aggressive interventions increased appropriate TH use and was associated with improved outcomes in our facility.

Practice Guideline Dissemination and Implementation Strategies for Healthcare Teams and Team-Based Practice: a systematic review

OBJECTIVES

The objective of this systematic review is to describe and identify the effectiveness of different practice guideline implementation strategies on team-based practice and/or patient outcomes.

METHODS

A systematic review was conducted, using a comprehensive, reproducible search strategy that revealed 88 studies that met the inclusion criteria.

RESULTS

A descriptive analysis revealed multiple approaches using teams of health care providers with 72.7% of the studies reporting statistically significant results in knowledge, practice and/or outcomes. Of 10 dissemination strategies the most effective were reminders, and audit and feedback. The most popular strategy was education meetings. A secondary analysis revealed different populations with chronic or complex disorders where a team approach was effective in practice guideline dissemination and implementation.

CONCLUSIONS

Many of the studies provided caveats to explain how or why the strategies did or did not demonstrate improvements. Overall, authors described complex health care requiring increasingly complex approaches to ensure evidence based guidelines were utilised in practice, including using multiple dissemination and implementation strategies. The review has provided evidence that a multi-pronged approach to dissemination and implementation of practice guidelines will assist in gaining significant improvements in change in knowledge, practice and patient outcomes.

A controlled trial of a rapid response system in an academic medical center

A medical emergency team composed of house staff and existing float-pool nurses was successfully implemented on the general medical floor of an academic medical center without increasing personnel. The intervention had little noticeable impact, although the number of cardiac arrests and deaths were low both before and after the intervention.

[Medical emergency teams: current situation and perspectives of preventive in-hospital intensive care medicine]

Severe clinical incidents occur in up to 10% of all non-intensive care unit (ICU) patients, which have an estimated mortality of 5-8%. As in the prehospital setting, early clinical warning signs can be identified in the majority of cases. Studies suggest that introduction of an in-hospital medical emergency team (MET) which responds to objective criteria of physiological deterioration, may effectively reduce the incidence of in-hospital cardiac arrests as well as unanticipated or readmissions to the ICU. According to this concept, METs would evaluate and treat non-ICU patients at risk at an early stage before a potentially fatal deterioration of cardiorespiratory parameters occurs. This article reviews available data on preventive in-hospital intensive care medicine and reflects on the circumstances for an implementation of METs in Germany, Austria and Switzerland.

Outreach in obstetric critical care

The present chapter considers the evolving role of critical care outreach in the general hospital setting and applied to obstetric patients, the mechanics of transferring critically ill obstetric patients to critical care and radiology areas, the scoring systems in use in critical care, and the difficulties in applying these scoring systems to obstetric patients.

Paediatric Rapid Response Systems: a literature review

BACKGROUND

Paediatric cardiorespiratory arrest carries a poor prognosis. The most common cause is respiratory insufficiency or hypotension/shock, which can be reversible. The use of RRSs in adult hospitals that proactively intervene when signs of physiological instability occur is widespread and increasing although the level of evidence for their efficiency is a matter of debate.

METHODS

A systematic literature review was undertaken to evaluate and summarise the current knowledge about paediatric RRSs.

RESULTS

Paediatric RRSs are in use in several places around the world. One study shows a statistically significant decrease in mortality rate after implementation. Two studies show a non-significant association with decreased mortality rate. Cardiac and/or respiratory arrest rates decreased in all four before-after studies with statistical significance in two.

CONCLUSIONS

Cardiac arrest and death are rare in paediatric hospitals, which can in part explain the difficulties to demonstrate statistically significant benefits. There are also specific problems regarding calling criteria due to age related physiological diversity as well as chronic disease.

Medical emergency and rapid response teams

Hospitals that care for children are establishing medical emergency or rapid response teams as system solutions for preventing unexpected but foreseeable respiratory and cardiac arrest on inpatient units. Typically, an experienced team of doctors and nurses responds quickly to a direct request by any level of staff or even a parent for assistance with a child whose physiologic parameters meet predetermined criteria or whose condition causes concern to them. Several pediatric studies comparing outcomes before and after introduction of these rapid response systems reported reductions in rates of respiratory or cardiac arrest and death but no prospective study has compared pediatric hospitals that have implemented rapid response teams to hospitals that have not.

Medical emergency teams at The Ottawa Hospital: the first two years

PURPOSE

Medical emergency teams (MET) merge earlier-than-conventional treatment of worrisome vital signs with a skilled resuscitation response team, and may possibly reduce cardiac arrests, postoperative complications, and hospital mortality.

METHODS

At the two sites of The Ottawa Hospital, MET was introduced in January 2005. We reviewed call diagnoses, interventions, and outcomes from MET activity, and examined outcomes [cardiac arrests, intensive care unit (ICU) admissions, and readmissions] from Health Records and the ICU database. We compared the first fully operational year, 2006, with pre-MET years, 2003-4.

RESULTS

In 5,741 patient encounters, the teams (nurse, respiratory therapist, and intensivist) responded to 1,931 calls over two years, predominantly for high-risk in-patients. As well, there were 3,810 follow-up visits to these patients and to recently discharged ICU patients. In 2006, there were 40.3 calls/team/1,000 hospital admissions, with 71.2% of in-patient ICU admissions preceded by MET calls. Patient illness severity scores decreased from 4.9 +/- 2.6 (mean +/- SD) before implementing MET to 2.9 +/- 2.3 (P < 0.0001) after MET interventions. Intervention on the respiratory system was performed on 72% of patients. Admission to the ICU occurred in 27% of MET patients. Compared with the pre-MET period, we observed decreases in: cardiac arrests (from 2.53 +/- 0.8 to 1.3 +/- 0.4/1,000 admissions, P < 0.001); ICU admissions from in-patient nursing units/month (42.3 +/- 7.3 to 37.6 +/- 5.1, P = 0.05); readmissions after ICU discharge/month (13.5 +/- 5.1 to 8.8 +/- 4.5, P = 0.01); and readmissions within 48 hr of ICU discharge/month (4.4 +/- 2.4 to 2.8 +/- 1.0 ICU readmissions/month, P = 0.01).

CONCLUSIONS

Successful implementation of MET reduces patient morbidity and ICU resource utilization.

Clinical profile of hospitalized children provided with urgent assistance from a medical emergency team

OBJECTIVE

The purpose of this work was to describe the frequency, characteristics, and outcomes of critical events and hospitalized children requiring medical emergency team review.

PATIENTS AND METHODS

We conducted an audit of prospectively collected medical emergency team forms and a retrospective review of medical charts during an 18-month period at a tertiary pediatric hospital in Australia. Critical events were defined as cardiac arrest, endotracheal intubation on the ward, reversal of analgesia or sedation, fluid resuscitation at >/=40 mL/kg, hyponatremia (serum sodium level of </=125 mmol/L), hypernatremia (serum sodium level of >/=155 mmol/L), hypoglycemia (glucose level of </=2 mmol/L), or severe metabolic acidosis (pH </= 7.1).

RESULTS

A total of 172 children had 225 medical emergency team calls (10.6 calls per 1000 hospital admissions and 2.0 calls per 1000 patient-days). Forty-two percent of calls were for infants <1 year old. Preexisting chronic disease was common, with 20% having a chronic underlying neurologic disorder. Forty-four percent of the children were postoperative. The mortality rate of the 172 children was 7.6% in the hospital and 13.4% within 1 year. Thirty-three children had a critical event, with reversal of analgesia being the most common event (n = 11). Postoperative children were more frequently seen in the critical-event group (64% vs 40%). Hospital and 1-year mortality rates were higher for children who had a critical event (16.1% vs 22.6%, respectively) than those who did not (5.7% vs 11.3%).

CONCLUSIONS

Chronic and complex illnesses were prevalent among children provided with urgent medical assistance from the medical emergency team in a tertiary hospital. Children in the postoperative phase were overrepresented among those with a critical event. A critical event significantly increased the risk of hospital mortality. Greater knowledge of high-risk groups is required to further improve outcomes for hospitalized children.

Early prognostic value of the medical emergency team calling criteria in patients admitted to intensive care from the emergency department

OBJECTIVES

To evaluate the early prognostic value of the medical emergency team (MET) calling criteria in patients admitted to intensive care from the emergency department.

DESIGN

Retrospective cohort study.

SETTING

Emergency department and department of intensive care medicine of a 960-bed tertiary referral hospital.

PATIENTS

A total of 452 consecutive adult patients admitted to intensive care from the emergency department from January 1, 2004, to December 31, 2004.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

MET calling criteria were retrospectively extracted from patient records, and the sum of positive criteria was calculated for the first hour in the emergency department (METinitial) and subsequently until admission to the intensive care unit in a series of time periods. The maximum number of positive MET calling criteria during any time period was defined (METmax). Logistic regression analysis revealed METinitial (odds ratio [OR] 3.392, 95% confidence interval [CI] 2.534-4.540) and METmax (OR 3.867, 95% CI 2.816-5.312) to be significant predictors of hospital mortality, the need for mechanical ventilation (METinitial: OR 4.151, 95% CI 3.53-4.652; METmax: OR 4.292, 95% CI 3.151-5.846), and occurrence of hemodynamic instability (METinitial: OR 1.548, 95% CI 1.258-1.905; METmax: OR 1.685, 95% CI 1.355-2.094) (all p < .0001).

CONCLUSIONS

MET scores collected early after admission or throughout the stay in the emergency department allow for simple identification of patients at risk of unfavorable outcome during the subsequent intensive care unit stay.

Introduction of an obstetric-specific medical emergency team for obstetric crises: implementation and experience

OBJECTIVE

We describe the implementation and experience with adding an obstetric-specific medical emergency team (called Condition O for obstetric crisis) to an existing rapid response system at Magee-Womens Hospital.

STUDY DESIGN

In response to deficits identified during patient safety review of adverse obstetric events in 2004 and 2005, the hospital administration decided to add a crisis team with expertise specifically designed for maternal and/or fetal crises.

RESULTS

During the first 6 months, staff rarely called Condition O (14 per 10,000 obstetric admissions). After reeducation efforts, use of Condition O increased to 62 per 10,000 obstetric admissions during 2006.

CONCLUSION

We outline our hospital's experience with implementation, efforts to address low utilization, and 1.5 years of Condition O event data. Condition O is a work in progress. In light of this, we discuss the challenges of measuring its patient safety outcome, considerations for team size and composition, and our efforts to determine an optimal Condition O rate.

Medical emergency team: a review of the literature

BACKGROUND

A medical emergency team (MET) comprises of a team of doctors and nurses with advanced life support skills, which are hospital based, who respond to emergency calls following a deterioration in a patient's clinical condition. The role and contribution of such approaches promoting the early recognition and intervention of these vulnerable patients demands critical appraisal.

AIM

To investigate the contribution of medical emergency teams and whether there are clinical antecedents evident prior to the triggering the MET system. The paper will also discuss factors influencing effective utilization and implementation strategies to encourage a culture change required to adopt the MET system.

METHODS

A critical review the relevant literature of studies focussed on the MET system.

RESULTS

The majority of published work relating to MET systems was conducted in single-centres. The introduction of MET systems appears to be linked to a reported reduction in adverse outcomes and early recognition and intervention in clinically deteriorating patients. Additionally, a consistent observation in the studies reviewed was the reported presence of clinically abnormal physiological observations prior to the clinical events such as the cardiac arrest. The evidence in support of MET or equivalent systems, is not straightforward. Issues such as education, resources (human and financial) and communication are vital to success with implementation. Responding promptly to patients who unexpectedly become acutely ill demands skill and competence; however, more research evaluating the role of early 'response' systems is warranted.

Implementing an MET-based RRS at Toronto General Hospital

A rapid response system was introduced through a three-phase program, which entailed introductory presentations, training, and finally, full implementation.