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Ranji SR, Shojania KG. Implementing patient safety interventions in your hospital: what to try and what to avoid. Med Clin North Am 2008; 92:275-93, vii-viii. [PMID: 18298979 DOI: 10.1016/j.mcna.2007.10.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Hospitalists play an important role in improving patient safety through clinical expertise and leadership in hospital quality improvement activities. The evidence base in patient safety remains incomplete, despite an increasing body of published research in recent years. Thus, physicians must consider other factors in addition to the strength of evidence supporting a practice when deciding which patient safety interventions to implement. These factors include the prevalence of the safety problem targeted, the potential for unintended consequences of the intervention, the costs and complexity of implementing the intervention, and the potential of the intervention to generate momentum for further safety initiatives. In this article, the authors define a framework for evaluating patient safety interventions and discuss specific interventions hospitalists should consider.
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Affiliation(s)
- Sumant R Ranji
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco 94143, USA.
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202
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203
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Dagnone JD, McGraw RC, Pulling CA, Patteson AK. Interprofessional resuscitation rounds: a teamwork approach to ACLS education. MEDICAL TEACHER 2008; 30:e49-e54. [PMID: 18464132 DOI: 10.1080/01421590701769548] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
PURPOSE We developed and implemented a series of interprofessional resuscitation rounds targeting fourth year nursing and medical students, and junior residents from a variety of specialty programs. METHODS Each two hour session was conducted in our patient simulation lab, and was held weekly during the academic year. Students were given specific instruction on the roles and responsibilities of resuscitation team members, and then teams of five worked through pre-defined Advanced Cardiac Life Support (ACLS) scenarios on a high fidelity patient simulator. At the end of each session students completed an anonymous evaluation of the program via a standardized questionnaire using Likert rating scales. RESULTS A total of 222 evaluations (101 nursing students, 42 medical students, and 79 junior residents) were submitted from October 2005 to April 2006. Mean scores reflected a strong consensus that these rounds were valuable for their training, provided a vehicle for understanding team roles in resuscitation, and that these rounds should be mandatory for all medical and nursing trainees. Participants also expressed a desire for additional interprofessional training. CONCLUSION Despite challenges inherent in teaching a diverse group of learners, these interprofessional resuscitation rounds were rated highly by nursing and medical trainees as valuable learning experiences.
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204
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Ranji SR, Auerbach AD, Hurd CJ, O'Rourke K, Shojania KG. Effects of rapid response systems on clinical outcomes: systematic review and meta-analysis. J Hosp Med 2007; 2:422-32. [PMID: 18081187 DOI: 10.1002/jhm.238] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND A rapid response system (RRS) consists of providers who immediately assess and treat unstable hospitalized patients. Examples include medical emergency teams and rapid response teams. Early reports of major improvements in patient outcomes led to widespread utilization of RRSs, despite the negative results of a subsequent cluster-randomized trial. PURPOSE To evaluate the effects of RRSs on clinical outcomes through a systematic literature review. DATA SOURCES MEDLINE, BIOSIS, and CINAHL searches through August 2006, review of conference proceedings and article bibliographies. STUDY SELECTION Randomized and nonrandomized controlled trials, interrupted time series, and before-after studies reporting effects of an RRS on inpatient mortality, cardiopulmonary arrests, or unscheduled ICU admissions. DATA EXTRACTION Two authors independently determined study eligibility, abstracted data, and classified study quality. DATA SYNTHESIS Thirteen studies met inclusion criteria: 1 cluster-randomized controlled trial (RCT), 1 interrupted time series, and 11 before-after studies. The RCT showed no effects on any clinical outcome. Before-after studies showed reductions in inpatient mortality (RR = 0.82, 95% CI: 0.74-0.91) and cardiac arrest (RR = 0.73, 95% CI: 0.65-0.83). However, these studies were of poor methodological quality, and control hospitals in the RCT reported reductions in mortality and cardiac arrest rates comparable to those in the before-after studies. CONCLUSIONS Published studies of RRSs have not found consistent improvement in clinical outcomes and have been of poor methodological quality. The positive results of before-after trials likely reflects secular trends and biased outcome ascertainment, as the improved outcomes they reported were of similar magnitude to those of the control group in the RCT. The effectiveness of the RRS concept remains unproven.
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Affiliation(s)
- Sumant R Ranji
- Department of Medicine, University of California San Francisco, California 94143-0131, USA.
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205
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Kho A, Rotz D, Alrahi K, Cárdenas W, Ramsey K, Liebovitz D, Noskin G, Watts C. Utility of commonly captured data from an EHR to identify hospitalized patients at risk for clinical deterioration. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2007; 2007:404-408. [PMID: 18693867 PMCID: PMC2655808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/15/2007] [Revised: 07/19/2007] [Accepted: 10/11/2007] [Indexed: 05/26/2023]
Abstract
Rapid Response Teams (RRTs) respond to critically ill patients in the hospital. Activation of RRTs is highly subjective and misses a proportion of at-risk patients. We created an automated scoring system for non-ICU inpatients based on readily available electronic vital signs data, age, and body mass index. Over two weeks, we recorded scores on 1,878 patient with a range of scores from 0 to 10. Fifty patients reached the primary outcome of code call, cardiopulmonary arrest, or transfer to an ICU. Using a cutoff score of 4 or greater would result in identification of an additional 20 patients over the 7 patients identified by the current method of RRT activation. The area under the Receiver Operating Curve for the prediction model was 0.72 which compared favorably to other scoring systems. An electronic scoring system using readily captured EMR data may improve identification of patients at risk for clinical deterioration.
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Affiliation(s)
- Abel Kho
- Northwestern University, Chicago, IL, USA
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207
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Jacobs JL, Apatov N, Glei M. Increasing vigilance on the medical/surgical floor to improve patient safety. J Adv Nurs 2007; 57:472-81. [PMID: 17284271 DOI: 10.1111/j.1365-2648.2006.04161.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIM This paper reports a study designed to assess an automated non-invasive, patient vigilance system, the (L)G(1TM) system, for determining heart rate and respiration rate. The study uses collected data to optimize the (L)G(1TM)'s alert management scheme for medical/surgical wards. BACKGROUND Thousands of patients die unnecessarily each year because of compromised patient safety in hospitals. Economic pressures to reduce hospitalization costs, exacerbated by increasing nursing shortages, have created a need for new approaches to patient vigilance. Advanced technologies may help nurses to provide high-quality care while controlling costs and improving patient safety. METHODS Heart and respiration waveforms from 287 patients were captured by sensor arrays embedded in the mattress coverlets of their beds. No real-time monitoring was performed. Raw data were processed by proprietary algorithms and compared with data captured by a standard reference device. Alert performance was verified by hand-scoring the signal data and matching it against clinical events observed through a systematic review of each patient's medical record. The data were collected between June 2004 and February 2005. RESULTS Experimental algorithms for heart rate had an accuracy of -1.47 (sd 1.90) and a precision of 4.60 (sd 2.46). Respiration rate algorithms showed an accuracy of -0.94 (sd 1.26) and a precision of 4.02 (sd 1.17). Algorithms identified 178 true-positive physiological alerts on 15 patients. None of the events was deemed clinically significant at chart review. The combined false-positive alert rate for the algorithms was 0.007 events per hour. CONCLUSION This study demonstrates the accuracy and precision of the signal processing algorithms in the (L)G(1TM) system. Future work will focus on assessing the system's impact on patient outcomes and its integration into the nursing workflow.
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Affiliation(s)
- Joshua L Jacobs
- Division of Medical Informatics, Department of Medicine, John A Burns School of Medicine, University of Hawaii, Honolulu, HI, USA.
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208
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Whittington J, White R, Haig KM, Slock M. Using an Automated Risk Assessment Report to Identify Patients at Risk for Clinical Deterioration. Jt Comm J Qual Patient Saf 2007; 33:569-74. [PMID: 17915531 DOI: 10.1016/s1553-7250(07)33061-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- John Whittington
- Institute for Healthcare Improvement, Cambridge, Massachusetts, USA
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209
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Auerbach AD, Landefeld CS, Shojania KG. The tension between needing to improve care and knowing how to do it. N Engl J Med 2007; 357:608-13. [PMID: 17687138 DOI: 10.1056/nejmsb070738] [Citation(s) in RCA: 228] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Andrew D Auerbach
- University of California, San Francisco, Department of Medicine, San Francisco, USA
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210
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Jones D, Opdam H, Egi M, Goldsmith D, Bates S, Gutteridge G, Kattula A, Bellomo R. Long-term effect of a Medical Emergency Team on mortality in a teaching hospital. Resuscitation 2007; 74:235-41. [PMID: 17367913 DOI: 10.1016/j.resuscitation.2006.12.007] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2006] [Revised: 12/10/2006] [Accepted: 12/15/2006] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Daryl Jones
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
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211
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Morse KJ, Warshawsky D, Moore JM, Pecora DC. Rapid response teams: reducers of death. Find out how response teams save lives by rendering care to a patient before a cardiac or respiratory arrest occurs. Nursing 2007; 37 Suppl Critical:2, 4, 6 passim. [PMID: 17440330 DOI: 10.1097/01.nurse.0000267879.50852.32] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Kate J Morse
- Chester County Hospital in West Chester, Pa., USA
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212
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McGaughey J, Alderdice F, Fowler R, Kapila A, Mayhew A, Moutray M. Outreach and Early Warning Systems (EWS) for the prevention of intensive care admission and death of critically ill adult patients on general hospital wards. Cochrane Database Syst Rev 2007:CD005529. [PMID: 17636805 DOI: 10.1002/14651858.cd005529.pub2] [Citation(s) in RCA: 115] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Despite the fact that outreach and early warning systems (EWS) are an integral part of a hospital wide systems approach to improve the early identification and management of deteriorating patients on general hospital wards, the widespread implementation of these interventions in practice is not based on robust research evidence. OBJECTIVES The primary objective was to determine the impact of critical care outreach services on hospital mortality rates. Secondary objectives included determining the effect of outreach services on intensive care unit (ICU) admission patterns, length of hospital stay and adverse events. SEARCH STRATEGY The review authors searched the following electronic databases: EPOC Specialised Register, The Cochrane Central Register of Controlled Trials (CENTRAL) and other Cochrane databases (all on The Cochrane Library 2006, Issue 3), MEDLINE (1996-June week 3 2006), EMBASE (1974-week 26 2006), CINAHL (1982-July week 5 2006), First Search (1992-2005) and CAB Health (1990-July 2006); also reference lists of relevant articles, conference abstracts, and made contact with experts and critical care organisations for further information. SELECTION CRITERIA Randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series designs (ITS) which measured hospital mortality, unanticipated ICU admissions, ICU readmissions, length of hospital stay and adverse events following implementation of outreach and EWS in a general hospital ward to identify deteriorating adult patients versus general hospital ward setting without outreach and EWS were included in the review. DATA COLLECTION AND ANALYSIS Three review authors independently extracted data and two review authors assessed the methodological quality of the included studies. Meta-analysis was not possible due to heterogeneity. Summary statistics and descriptive summaries of primary and secondary outcomes are presented for each study. MAIN RESULTS Two cluster-randomised control trials were included: one randomised at hospital level (23 hospitals in Australia) and one at ward level (16 wards in the UK). The primary outcome in the Australian trial (a composite score comprising incidence of unexpected cardiac arrests, unexpected deaths and unplanned ICU admissions) showed no statistical significant difference between control and medical emergency team (MET) hospitals (adjusted P value 0.640; adjusted odds ratio (OR) 0.98; 95% confidence interval (CI) 0.83 to 1.16). The UK-based trial found that outreach reduced in-hospital mortality (adjusted OR 0.52; 95% CI 0.32 to 0.85) compared with the control group. AUTHORS' CONCLUSIONS The evidence from this review highlights the diversity and poor methodological quality of most studies investigating outreach. The results of the two included studies showed either no evidence of the effectiveness of outreach or a reduction in overall mortality in patients receiving outreach. The lack of evidence on outreach requires further multi-site RCT's to determine potential effectiveness.
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Affiliation(s)
- J McGaughey
- Queen's University Belfast, School of Nursing and Midwifery, Belfast, UK.
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213
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Abstract
The use of rapid response teams is a relatively new approach for decreasing or eliminating codes in acute care hospitals. Based on the principles of a code team for cardiac and/or respiratory arrest in non-critical care units, the rapid response teams have specially trained nursing, respiratory, and medical personnel to respond to calls from general care units to assess and manage decompensating or rapidly changing patients before their conditions escalate to a full code situation. This article describes the processes used to develop a rapid response team, clinical indicators for triggering a rapid response team call, topics addressed in an educational program for the rapid response team members, and methods for evaluating effectiveness of the rapid response team.
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Affiliation(s)
- Lisa Halvorsen
- Critical and Progressive Care, Dialysis and Magnet at Providence Portland Medical Center, 4805 NE Glisan, Nursing Administration, Portland, OR 97213, USA.
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214
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Winters BD, Pham JC, Hunt EA, Guallar E, Berenholtz S, Pronovost PJ. Rapid response systems: a systematic review. Crit Care Med 2007; 35:1238-43. [PMID: 17414079 DOI: 10.1097/01.ccm.0000262388.85669.68] [Citation(s) in RCA: 160] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
CONTEXT Rapid response systems have been advocated as a potential model to identify and intervene in patients who are experiencing deterioration on general hospital wards. OBJECTIVE To conduct a meta-analysis to evaluate the impact of rapid response systems on hospital mortality and cardiac arrest rates. DATA SOURCE We searched MEDLINE, EMBASE, and the Cochrane Library from January 1, 1990, to June 30, 2005, for all studies relevant to rapid response systems. We restricted the search to the English language and by age category (all adults: >or=19 years). STUDY SELECTION We selected observational and randomized trials of rapid response systems that provided empirical data on hospital mortality and cardiac arrest in control and intervention groups. We reviewed 10,228 abstracts and identified eight relevant studies meeting these criteria. DATA SYNTHESIS Of the included studies, five used historical controls, one used concurrent controls, and two used a cluster-randomized design. The pooled relative risk for hospital mortality comparing rapid response teams to control was 0.76 (95% confidence interval, 0.39-1.48) between the two randomized studies and 0.87 (95% confidence interval, 0.73-1.04) among the five observational studies. The pooled relative risk for cardiac arrest comparing rapid response systems to control was 0.94 (95% confidence interval, 0.79-1.13) in the single randomized study and 0.70 (95% confidence interval, 0.56-0.92) in four observational studies. CONCLUSIONS We found weak evidence that rapid response systems are associated with a reduction in hospital mortality and cardiac arrest rates, but limitations in the quality of the original studies, the wide confidence intervals, and the presence of heterogeneity limited our ability to conclude that rapid response systems are effective interventions. Large randomized controlled trials are needed to clarify the efficacy of rapid response systems before they should become standard of care.
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Affiliation(s)
- Bradford D Winters
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, MD, USA
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215
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Abstract
Rapid response teams have been advocated as an intervention to reduce failure to rescue events. Such teams can improve nurse autonomy and control to rescue patients deteriorating in a medical surgical setting. The purpose of this review is to enhance nurse executives' understanding of failure to rescue as a nurse sensitive outcome, tested interventions, and implications for future research. The emergence of failure to rescue as an outcome measure will be initially discussed. Research regarding the relationship between failure to rescue and registered nurse staffing as well as research examining the potential to reduce failure-to-rescue events will be explored.
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Affiliation(s)
- Andrea Schmid
- Patient Care Services, University of Pittsburgh Medical Center, PA 15213, USA.
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216
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Price RJ, Cuthbertson BH, Cairns CJ. The findings of the International Conference on Medical Emergency Teams are biased and misleading. Crit Care Med 2007; 35:992-3. [PMID: 17421116 DOI: 10.1097/01.ccm.0000257474.01932.2f] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Offner PJ, Heit J, Roberts R. Implementation of a Rapid Response Team Decreases Cardiac Arrest Outside of the Intensive Care Unit. ACTA ACUST UNITED AC 2007; 62:1223-7; discussion 1227-8. [PMID: 17495728 DOI: 10.1097/ta.0b013e31804d4968] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patient safety and preventable inhospital mortality remain crucial aspects of optimum medical care and continue to receive public scrutiny. Signs of physiologic instability often precede overt clinical deterioration in many patients. The purpose of this study was to evaluate our early experience with implementation of a rapid response team (RRT) which would evaluate and treat nonintensive care unit (nonICU) patients with early signs of physiologic instability. We hypothesized that early evaluation and intervention before deterioration would avoid progression to cardiac arrest in patients. METHODS In March 2005, our urban Level I trauma center implemented an RRT to react to patient clinical deterioration; in effect, bringing critical care to the bedside. This team is available 24 hours/day, 7 seven days/week and consists of an intensivist, an ICU nurse, and a respiratory therapist. Activation criteria include pulse<40 or>130 beats per minute, systolic blood pressure<90 mm Hg, respiratory rate<8 or>24 breaths per minute, seizure, an acute change in mental status, or nursing staff concern for any other reason. Data were prospectively collected, including the number of RRT activations and the occurrence of inhospital cardiac arrest. RESULTS Between March and December 2005, the RRT was activated 76 times. All RRT activations were reviewed and thought to be appropriate. During the same time period the year before initiation of the RRT, there were 27 nonICU cardiac arrests. After RRT implementation, there were 13 cardiac arrests that occurred on the floor, representing just over a 50% reduction in cardiac arrest. Medical staff feedback regarding the RRT was uniformly positive. CONCLUSIONS Implementation of the RRT was well received by the hospital staff. Despite initial concerns to the contrary, the RRT was not over utilized. RRT activation resulted in early patient transfer to a higher level of care and avoided progression to cardiac arrest.
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Affiliation(s)
- Patrick J Offner
- Saint Anthony Central Hospital, Trauma Service, Denver, CO 80204, USA.
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218
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Brilli RJ, Gibson R, Luria JW, Wheeler TA, Shaw J, Linam M, Kheir J, McLain P, Lingsch T, Hall-Haering A, McBride M. Implementation of a medical emergency team in a large pediatric teaching hospital prevents respiratory and cardiopulmonary arrests outside the intensive care unit. Pediatr Crit Care Med 2007; 8:236-46; quiz 247. [PMID: 17417113 DOI: 10.1097/01.pcc.0000262947.72442.ea] [Citation(s) in RCA: 184] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We implemented a medical emergency team (MET) in our free-standing children's hospital. The specific aim was to reduce the rate of codes (respiratory and cardiopulmonary arrests) outside the intensive care units by 50% for >6 months following MET implementation. DESIGN Retrospective chart review and program implementation. SETTING A children's hospital. PATIENTS None. INTERVENTIONS The records of patients who required cardiorespiratory resuscitation outside the critical care areas were reviewed before MET implementation to determine activation criteria for the MET. Codes were prospectively defined as respiratory arrests or cardiopulmonary arrests. MET-preventable codes were prospectively defined. The incidence of codes before and after MET implementation was recorded. MEASUREMENTS AND MAIN RESULTS Twenty-five codes occurred during the pre-MET baseline compared with six following MET implementation. The code rate (respiratory arrests + cardiopulmonary arrests) post-MET was 0.11 per 1,000 patient days compared with baseline of 0.27 (risk ratio, 0.42; 95% confidence interval, 0-0.89; p = .03). The code rate per 1,000 admissions decreased from 1.54 (baseline) to 0.62 (post-MET) (risk ratio, 0.41; 95% confidence interval, 0-0.86; p = .02). For MET-preventable codes, the code rate post-MET was 0.04 per 1,000 patient days compared with a baseline of 0.14 (risk ratio, 0.27; 95% confidence interval, 0-0.94; p = .04). There was no difference in the incidence of cardiopulmonary arrests before and after MET. For codes outside the intensive care unit, the pre-MET mortality rate was 0.12 per 1,000 days compared with 0.06 post-MET (risk ratio, 0.48; 95% confidence interval, 0-1.4, p = .13). The overall mortality rate for outside the intensive care unit codes was 42% (15 of 36 patients). CONCLUSIONS Implementation of a MET is associated with a reduction in the risk of respiratory and cardiopulmonary arrest outside of critical care areas in a large tertiary children's hospital.
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Affiliation(s)
- Richard J Brilli
- Pediatric Intensive Care Unit, Cincinnati College of Medicine, Cincinnati, OH, USA.
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Brindley PG, Simmonds M, Gibney RTN. Medical emergency teams: Is there M.E.R.I.T? Can J Anaesth 2007; 54:389-91. [PMID: 17470891 DOI: 10.1007/bf03022662] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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221
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Cooper BE. Pharmacist involvement in a rapid-response team at a community hospital. Am J Health Syst Pharm 2007; 64:694, 697-8. [PMID: 17384353 DOI: 10.2146/ajhp060189] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Schmid A. Frequency and pattern of medical emergency team activation among medical cardiology patient care units. Crit Care Nurs Q 2007; 30:81-4. [PMID: 17198040 DOI: 10.1097/00002727-200701000-00010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Medical emergency teams are developing across the United States. The organization and implementation for a rapid response team to failing medical-surgical patients has been shown to reduce in-house cardiac arrest rates. Further investigation into the frequency and pattern for rapid response team calls has been shown to have a diurnal pattern and clustered around times associated with routine care activities. The medical emergency calls in the descriptive analysis reveal that calls to the medical cardiology units constitute--% of the total calls. The calls are found to be called with--frequency during the hours of 7 AM and 7 PM. The frequency of calls is shown to be clustered around the times of. The small descriptive analysis here suggests that further investigation in the patterns and monitoring of patient for early recognition to call for help is still needed.
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Affiliation(s)
- Andrea Schmid
- University of Pittsburgh Medical Center, Presbyterian-Shadyside, Pittsburgh, PA 15213, USA.
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223
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Jones DA, Mitra B, Barbetti J, Choate K, Leong T, Bellomo R. Increasing the use of an existing medical emergency team in a teaching hospital. Anaesth Intensive Care 2007; 34:731-5. [PMID: 17183890 DOI: 10.1177/0310057x0603400606] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Cultural barriers in hospital ward staff may limit the use of a Medical Emergency Team (MET) service. In December 2000 the role of the existing Code Blue team in our hospital was expanded to incorporate review of patients fulfilling commonly employed MET criteria. Between January 2001 and June 2003, the average call rate was only 9.8 calls/ 1000 admissions. Anecdotal feedback and a group-administered questionnaire conducted in July 2003 demonstrated a number of obstacles to initiating calls and the system was modified in October 2004. Specifically, emergency response calls were separated into Code Blue calls (for cardiorespiratory arrests) and MET calls (with physiological and worried criteria). Further loud overhead chimes as well as anaesthetist and cardiologist attendance were used only in the case of Code Blue calls (suspected arrests). Finally, the heart rate and respiratory rate criteria for MET service activation were modified. In the 12 months before the intervention (October 2003 to September 2004) there were 817 emergency response calls and 51,963 admissions (15.7 calls/1000 admissions). In the 12 months after the intervention there were 1349 emergency response calls (Code Blue plus MET calls) and 54,593 admissions (24.7 calls/1000 admissions [OR 1.59; 95% CI=1.45-1.73; P<0.0001]). Our findings suggest that increasing the use of an existing service to review patients fulfilling MET criteria requires repeated education and a periodic assessment of site-specific obstacles to utilization.
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Affiliation(s)
- D A Jones
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University
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Requirements of the afferent arm of rapid response systems. Crit Care Med 2007. [DOI: 10.1097/01.ccm.0000257250.35337.66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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225
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Affiliation(s)
- Corinne Grimes
- The University of Texas at Austin, Austin, TX 78701, USA
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226
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Abstract
OBJECTIVE Develop a scoring system that can assess the management of septic shock by individuals and teams. DESIGN Retrospective review of videotapes of critical care house staff managing a standardized simulation of septic shock. SETTING Academic medical center; videotapes were made in a recreated intensive care unit environment using a high-fidelity patient simulator. SUBJECTS Residents in medicine, surgery, and anesthesiology who had participated in the intensive care unit rotation. INTERVENTIONS The septic patient was managed by the intensive care unit team in a graded manner with interns present for the first 10 mins and more senior-level help arriving after 10 mins. The intern was graded separately for the first 10 mins, and the team was graded for the entire 35-min performance. MEASUREMENTS AND MAIN RESULTS Both technical and nontechnical scoring systems were developed to rate the management of septic shock. Technical scores are based on guidelines and principles of managing septic shock. Team leadership, communication, contingency planning, and resource utilization were addressed by the nontechnical rating. Technical scores were calculated for both interns and teams; nontechnical scores applied only to the team. Of 16 technical checklist items, interns completed a mean of 7 with a range of 1.5-11. Team technical ratings had a mean of 9.3 with a range of 3.3-13. Nontechnical scores showed similar intergroup variability with a mean of 26 and a range of 10-35. Technical and nontechnical scores showed a modest correlation (r = .40, p = .05). Interrater reliabilities for intern and team technical scores were both r = .96 and for nontechnical scores r = .88. CONCLUSIONS Objective measures of both knowledge-based and behavioral skills pertinent to the management of septic shock were made. Scores identified both adequate and poor levels of performance. Such assessments can be used to benchmark clinical skills of individuals and groups over time and may allow the identification of interventions that improve clinical effectiveness in sepsis management.
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Affiliation(s)
- Einar Ottestad
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA
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227
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Gao H, McDonnell A, Harrison DA, Moore T, Adam S, Daly K, Esmonde L, Goldhill DR, Parry GJ, Rashidian A, Subbe CP, Harvey S. Systematic review and evaluation of physiological track and trigger warning systems for identifying at-risk patients on the ward. Intensive Care Med 2007; 33:667-79. [PMID: 17318499 DOI: 10.1007/s00134-007-0532-3] [Citation(s) in RCA: 290] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2006] [Accepted: 01/04/2007] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Physiological track and trigger warning systems (TTs) are used to identify patients outside critical care areas at risk of deterioration and to alert a senior clinician, Critical Care Outreach Service, or equivalent. The aims of this work were: to describe published TTs and the extent to which each has been developed according to established procedures; to review the published evidence and available data on the reliability, validity and utility of existing systems; and to identify the best TT for timely recognition of critically ill patients. DESIGN AND SETTING Systematic review of studies identified from electronic, citation and hand searching, and expert informants. Cohort study of data from 31 acute hospitals in England and Wales. MEASUREMENTS AND RESULTS Thirty-six papers were identified describing 25 distinct TTs. Thirty-one papers described the use of a TT, and five were studies examining the development or testing of TTs. None of the studies met all methodological quality standards. For the cohort study, outcome was measured by a composite of death, admission to critical care, 'do not attempt resuscitation' or cardiopulmonary resuscitation. Fifteen datasets met pre-defined quality criteria. Sensitivities and positive predictive values were low, with median (quartiles) of 43.3 (25.4-69.2) and 36.7 (29.3-43.8), respectively. CONCLUSION A wide variety of TTs were in use, with little evidence of reliability, validity and utility. Sensitivity was poor, which might be due in part to the nature of the physiology monitored or to the choice of trigger threshold. Available data were insufficient to identify the best TT.
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Affiliation(s)
- Haiyan Gao
- Intensive Care National Audit & Research Centre, Tavistock House, Tavistock Square, London, WC1H 9HR, UK
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228
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Cuthbertson BH, Boroujerdi M, McKie L, Aucott L, Prescott G. Can physiological variables and early warning scoring systems allow early recognition of the deteriorating surgical patient?*. Crit Care Med 2007; 35:402-9. [PMID: 17205002 DOI: 10.1097/01.ccm.0000254826.10520.87] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Early warning scoring systems are widely used in clinical practice to allow early recognition of the deteriorating patient, but they lack validation. We aimed to test the ability of physiologic variables, either alone or in existing early scoring systems, to predict major deterioration in a patient's condition and attempt to derive functions with superior accuracy. DESIGN A comparative cohort study. SETTING A teaching hospital in Scotland. PATIENTS Two cohorts of general surgical high-dependency patients. The cohorts are a group of surgical high-dependency care patients who did not require intensive care admission and another group of patients who did require admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Prospective physiologic data on consecutive surgical high-dependency unit patients were collected and compared with physiologic data on patients admitted to the intensive care unit from the same surgical high-dependency units. Data were quality checked and summarized, and discriminant analysis and receiver operator curves were used to discriminate between the groups. There were significant physiologic differences between groups with regard to heart rate (p<.001, area under the receiver operating characteristic curve [AUC] 0.7), respiratory rate (p<.001, AUC 0.71), and oxygen saturation (p<.001, AUC 0.78) across time points. This was not present for systolic blood pressure or temperature. Existing early warning scoring systems had good discriminatory power (AUC 0.83-0.86). We derived discriminant functions, which have a high predictive ability to determine differences between groups (p<.0001, AUC 0.86-0.90). We found that heart rate and respiratory rate could detect differences between groups at 6 and 8 hrs before ICU admission, but oxygen saturation and the discriminant function 2 could detect differences 48 hrs before ICU admission. CONCLUSIONS Some commonly used physiologic variables have reasonable power in determining the difference between patients requiring intensive care unit admission, but others are poor. Existing early warning scores have comparatively good discriminatory power. We have derived functions with excellent predictive power in this derivation cohort.
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Affiliation(s)
- Brian H Cuthbertson
- Health Services Research Unit and Department of Public Health, University of Aberdeen, Foresterhill, Aberdeen, Aberdeen, Scotland, UK
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229
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DiNardo M, Noschese M, Korytkowski M, Freeman S. The medical emergency team and rapid response system: finding, treating, and preventing hypoglycemia. Jt Comm J Qual Patient Saf 2007; 32:591-5. [PMID: 17066997 DOI: 10.1016/s1553-7250(06)32077-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Administrative and quality improvement processes that occurred in response to one patient's series of critical hypoglycemic events ultimately contributed to systematic improvements in patient safety.
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Affiliation(s)
- Monica DiNardo
- Inpatient Diabetes Intiatives, Department of Endocrinology and Metabolism, University of Pittsburgh Medical Center, USA.
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230
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Galhotra S, Scholle CC, Dew MA, Mininni NC, Clermont G, DeVita MA. Medical emergency teams: a strategy for improving patient care and nursing work environments. J Adv Nurs 2006; 55:180-7. [PMID: 16866810 DOI: 10.1111/j.1365-2648.2006.03901.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIM This paper reports a study of nurses' perceptions about medical emergency teams and their impact on patient care and the nursing work environment. BACKGROUND In many acute care hospitals, nurses can summon emergency help by calling a medical emergency team, which is a team of expert critical care professionals adept at handling patient crisis scenarios. Critical care nurses form the core of such teams. In addition, of all the healthcare professionals, nurses are the ones who most often need and call for medical emergency team assistance. METHODS A simple anonymous questionnaire distributed amongst 300 staff nurses at two sites of an acute care teaching hospital in the United States of America in mid-January of 2005. RESULTS A total of 248 nurses responded to the survey (response rate = 82.7%). Ninety-three per cent of the nurses reported that medical emergency teams improved patient care and 84% felt that they improved the nursing work environment. Veteran nurses (with at least 10 years of experience) and new nurses (<1 year's experience) were more likely to perceive an improvement in patient care than other nurses (P = 0.025). Nurses who had called a medical emergency team on more than one occasion were more likely to value their ability to call a team (P = 0.002). Nearly sixty-five per cent of respondents said they would consider institutional medical emergency team response as a factor when seeking a new job in the future. Only 7% suggested a change in the team response process, and 4% suggested a change in activation criteria. CONCLUSIONS Most nurses surveyed had a favourable opinion of the medical emergency team. Our findings suggest that other institutions should consider implementing a medical emergency team programme as a strategy to improve patient care and nurse working environment.
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Affiliation(s)
- Sanjay Galhotra
- Department of Critical Care Medicine, University of Pittsburgh, Pennsylvania 15213, USA
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231
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Abstract
BACKGROUND A high incidence of preventable adverse events and deaths in hospitals has triggered initiatives to improve the quality of care of acutely ill in-hospital patients. System changes involving the introduction of medical emergency teams, outreach services or rapid response teams are an integral part of these initiatives. The rationale for implementing a designated team is that early recognition and rapid institution of adequate therapy for the deteriorating patient can improve outcome. The concept of bringing intensive care expertise to any acutely ill patient irrespective of location within the hospital is envisioned as "critical care without walls". METHODS Studies were identified by a PubMed search and cited references in key publications provided additional material including www-resources. More than 80 studies were identified and selected for review, however, no formal search strategy for a systematic review or meta-analysis was attempted. Only studies published in English were considered. RESULTS Several non-randomized, before-and-after cohort studies demonstrate that implementation of medical emergency teams and equivalents can reduce the incidence of cardiac arrests, unexpected deaths, and unplanned intensive care admissions. However, one recent randomized, controlled trial of medical emergency teams failed to demonstrate any differences in outcomes. CONCLUSION Several key operational issues need to be addressed before introducing medical emergency response teams based on current evidence. These issues include differences in healthcare systems and performance, patient case-mix, resources available, composition of the teams and calling criteria, and strategies for education, audit and governance.
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Affiliation(s)
- A Aneman
- Intensive Care Unit, Liverpool Hospital, Sydney South-West Area Health Service, Sydney, Australia.
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232
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Smith GB, Prytherch DR, Schmidt P, Featherstone PI, Knight D, Clements G, Mohammed MA. Hospital-wide physiological surveillance–A new approach to the early identification and management of the sick patient. Resuscitation 2006; 71:19-28. [PMID: 16945465 DOI: 10.1016/j.resuscitation.2006.03.008] [Citation(s) in RCA: 129] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2006] [Accepted: 03/10/2006] [Indexed: 10/24/2022]
Abstract
Hospitalised patients, who suffer cardiac arrest and require unanticipated intensive care unit (ICU) admission or die, often exhibit premonitory abnormalities in vital signs. Sometimes, the deterioration is well documented, though there is little discernable evidence of intervention. In other cases, monitoring and recording of vital signs is infrequent or incomplete. Healthcare providers have introduced "track and trigger" systems to allow early identification of patients with physiological abnormalities, and rapid response teams to facilitate rapid and appropriate management. However, even when "track and trigger" systems are used, the recording of vital signs, patient chart completion and team activation remain sub-optimal. We have developed a system for collecting routine vital signs data at the bedside using standard personal digital assistants (PDA). The PDAs act as "thin clients" linked by a wireless local area network (W-LAN) to the hospital's intranet system, where raw and derived data are integrated with other patient information, e.g., name, hospital number, laboratory results. It is possible for raw physiology data, early warning scores (EWS), vital signs charts and oxygen therapy records to be made instantaneously available to any member of the hospital healthcare team via the W-LAN or hospital intranet. Early and direct contact with members of the patient's primary clinical team or rapid response team can be made through an automated alerting system, triggered by the EWS data. The ability to capture physiological data at the bedside, and to make these available to anyone with appropriate access rights at any time and in any place, should provide previously unattainable, clinical and administrative benefits. Analysis of the raw physiological data and patient outcomes will also make it possible to validate existing and future "track and trigger" systems.
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Affiliation(s)
- Gary B Smith
- Portsmouth Hospitals NHS Trust & University of Bournemouth, United Kingdom.
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233
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Esmonde L, McDonnell A, Ball C, Waskett C, Morgan R, Rashidian A, Bray K, Adam S, Harvey S. Investigating the effectiveness of critical care outreach services: a systematic review. Intensive Care Med 2006; 32:1713-21. [PMID: 17019547 DOI: 10.1007/s00134-006-0380-6] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2006] [Accepted: 08/10/2006] [Indexed: 01/13/2023]
Abstract
OBJECTIVE We explored the impact of critical care outreach activity on patient and service outcomes and aimed to contribute to developing a typology of critical care outreach services. DESIGN Following a sample search of Medline 15 relevant electronic databases were systematically searched from 1996 to 2004. Searches for publications from nine key authors and citations of eight key articles were performed. Hand searches of journals, bibliographies of reports and review articles, and conference abstracts were conducted. Relevant experts were contacted. A further two studies published after the review date were also included. Two reviewers assessed studies for inclusion, conducted quality assessment and extracted data. Data were synthesised using narrative techniques. MEASUREMENTS AND RESULTS Seventeen papers and six brief reports were selected for inclusion from a list of 1,760 titles. As anticipated with a relatively new service such as critical care outreach, there were few controlled trials. There were two randomised controlled trials, 16 uncontrolled before and after studies, three quasi-experimental studies, one controlled before and after study and one post-only controlled study. The most frequent outcomes measured were mortality, cardiac arrest, unplanned critical care admissions from wards, length of stay, and critical care readmission rates. CONCLUSIONS Although improvements in patient outcomes were found, the evidence in this review is insufficient to demonstrate this conclusively. The many differences in service delivery do not permit identification of service typology. Our findings point to a need for more comprehensive research of this expanding service in the United Kingdom.
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Affiliation(s)
- Lisa Esmonde
- School of Healthcare, University of Leeds, Leeds, UK.
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234
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King E, Horvath R, Shulkin DJ. Establishing a rapid response team (RRT) in an academic hospital: one year's experience. J Hosp Med 2006; 1:296-305. [PMID: 17219515 DOI: 10.1002/jhm.114] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Rapid response teams and medical emergency teams have been utilized to rapidly manage seriously ill patients at risk of cardiopulmonary arrest and other high-risk conditions but have not been extensively described in the American medical literature. OBJECTIVES To describe a full year's experience of implementing a rapid response team (RRT) in an academic medical center. DESIGN Retrospective analysis of our hospital's RRT database and description of the implementation process from July 2004 to July 2005. SETTING Urban, academic medical center. RESULTS The RRT system was activated for 307 potentially unstable patients. The most common reasons for an RRT activation were cardiac, respiratory, and neurological conditions. At least 37% of RRT calls were for off-unit inpatients and to outpatient/common areas frequented by outpatients and visitors, whereas at least 42% occurred in inpatient units. Most RRT calls, 82.9%, occurred during daytime hours. In the opinion of RRT leaders 98% of the evaluated calls were appropriate and 85% of the RRT responses resulted in the prevention of further clinical deterioration. CONCLUSIONS An RRT was introduced into an academic medical center, and the results suggested it is capable of preventing clinical deterioration in unstable patients and may have the potential to decrease the frequency of cardiac arrests. The RRT also may fill a gap in patient safety by enabling rapid triage and expedited treatment of off-unit inpatients, outpatients, and visitors. The keys to the early success of our implementation of an RRT were multidisciplinary input and improvements made in real time.
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Affiliation(s)
- Emmanuel King
- Department of Internal Medicine, Section of Hospital Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania, USA.
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235
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Peet H, Smith GB, Prytherch D, Featherstone PI, Schmidt P. Proposed guidelines for uniform reporting of Medical Emergency Team data are inadequate. Resuscitation 2006; 70:291-2; author reply 292. [PMID: 16828953 DOI: 10.1016/j.resuscitation.2006.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2006] [Revised: 03/02/2006] [Accepted: 03/02/2006] [Indexed: 11/20/2022]
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236
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Jones D, Bates S, Warrillow S, Goldsmith D, Kattula A, Way M, Gutteridge G, Buckmaster J, Bellomo R. Effect of an education programme on the utilization of a medical emergency team in a teaching hospital. Intern Med J 2006; 36:231-6. [PMID: 16640740 DOI: 10.1111/j.1445-5994.2006.01045.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Medical Emergency Teams (MET) have been developed to identify, review and manage acutely unwell ward patients. Previous studies have suggested that there may be obstacles to the utilization and activation of the MET. AIMS To determine the effect of a detailed education programme on the rate of utilization of the MET system 3.5 years after its introduction in a University teaching hospital. METHODS Prospective interventional study involving a detailed programme of education, feedback and decision support for nursing and medical staff given before, during and after implementation of a MET system. We measured the number of MET calls per month for both medical and surgical patients for 109 250 consecutive admissions to the acute care campus of Austin Health from August 2000 to June 2004. RESULTS Overall activation of the MET increased from 25 calls per month to a peak of 79 calls per month over the study period (average increase of one MET call/month). After standardization for monthly admissions, the increase in MET utilization for surgical patients (increase by 1.13 MET/1000 admissions/month) was 4.9-fold greater than for medical patients (increase by 0.23 MET/1000 admissions/month; P < 0.0001). At the peak level of activity (April 2004), the MET was called to review 8.4% of surgical and 2.7% of medical admissions (P < 0.0001). CONCLUSIONS There was a progressive increase in the utilization of the MET service in the 3.5 years after implementation, with the rate of uptake 4.9 times greater for surgical than for medical patients. Sustained uptake of the MET system is possible, but increased utilization may take several years to develop. Short-term studies testing the efficacy of the MET system are likely to significantly underestimate its effect on reducing adverse events. Intensive care unit resource adjustments will become necessary to meet increased demand.
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Affiliation(s)
- D Jones
- Clinical Governance Unit, Melbourne University, Austin Hospital, Victoria, Australia
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237
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Jones D, Bellomo R, Bates S, Warrillow S, Goldsmith D, Hart G, Opdam H. Patient monitoring and the timing of cardiac arrests and medical emergency team calls in a teaching hospital. Intensive Care Med 2006; 32:1352-6. [PMID: 16826391 DOI: 10.1007/s00134-006-0263-x] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2006] [Accepted: 06/06/2006] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe the timing of cardiac arrest detection in relation to episodes of Medical Emergency Team (MET) review and routine nursing observations. DESIGN AND SETTING Retrospective observational study in a university-affiliated hospital. PATIENTS 279 cardiac arrests involving ward patients MEASUREMENTS AND RESULTS Cardiac arrests were allocated to one of 24 1-h intervals (24:00-00:59, 01:00-01:59, etc.). The actual hourly rate of cardiac arrests was related to the expected average hourly rate. Peak levels of cardiac arrest detection occurred during times of routine overnight nursing clinical observations between 02:00 and 03:00 (OR 3.06) and 06:00-07:00 (OR 1.95). The lowest level of cardiac arrest detection occurred between 20:00 and 21:00 (OR 0.42). After introduction of the MET there were 162 cardiac arrests, 28% of which occurred shortly after an initial MET call. The odds ratio for risk of cardiac arrest during periods of lowest MET activation (24:00-08:00) when compared with periods of highest MET activation (16:00-24:00) was 2.26. CONCLUSIONS Cardiac arrest detection in our hospital is episodic with peak levels corresponding to periods of overnight routine nursing observations following a period when patient review is likely to be low. After the introduction of the MET there was an inverse link between detection of cardiac arrests and levels of MET activation over the 24-h period. Increased overnight utilization and earlier MET activation may further reduce the incidence of cardiac arrests at our hospital.
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Affiliation(s)
- Daryl Jones
- Intensive Care, Alfred Hospital, Monash University, Melbourne, Australia
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238
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Bell MB, Konrad D, Granath F, Ekbom A, Martling CR. Prevalence and sensitivity of MET-criteria in a Scandinavian University Hospital. Resuscitation 2006; 70:66-73. [PMID: 16757089 DOI: 10.1016/j.resuscitation.2005.11.011] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2005] [Revised: 11/17/2005] [Accepted: 11/24/2005] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To make a preliminary estimation of the workload for a medical emergency team (MET) in a Scandinavian University Hospital by recording prevalent physiological data on all adult patients and to see if the patients with deviating physiology (i.e. fulfilling the study criteria, in essence a set of simplified MET-criteria) had an elevated mortality. We also tested sensitivity and specificity by altering the cut-off levels of the calling criteria. DESIGN Cross sectional prevalence study. SETTING University hospital in the capital of Sweden. PATIENTS Adult patients treated in the general wards of the hospital. Patients from psychiatric wards and intensive care units were excluded from the study. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS 4.5% of the scored patients fulfilled the study criteria. These patients had a 30-day mortality of 25% (confidence interval 12.7-41.2) as compared to 3.5% (2.4-5) for the patients not fulfilling the study criteria. Extended criteria revealed 18 deaths within 30 days, 8 more deaths than the original study criteria. However, 123 patients - equalling 13.8% of the cohort (CI 11.6-16.2) - fulfilled these criteria as compared to the 40 patients fulfilling the original study criteria. Thus, the 30-day mortality of the patients with positive extended criteria totalled 14.6% (CI 8.9-22.1). Restricted criteria showed a mere 20 patients (2.2%; CI 1.4-3.5) and only 4 deaths, making 30-day mortality 20% (CI 5.7-43.7); thus, sensitivity was actually lower using restricted criteria. CONCLUSIONS Even these modified - and simplified - MET-criteria proved to be able to single out patients with elevated mortality as compared to the rest of the hospital population. Extending the criteria significantly lowered sensitivity and would extend the MET-workload enormously. Restricting the criteria led to missed mortalities where intervention could be beneficial. The results suggest that a routine use of simple physiological tests can be of help in the identification of patients at risk.
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Affiliation(s)
- Max B Bell
- Department of Anesthesiology and Intensive Care, Karolinska University Hospital Solna, S-171 76 Stockholm, Sweden
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239
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Salamonson Y, van Heere B, Everett B, Davidson P. Voices from the floor: Nurses’ perceptions of the medical emergency team. Intensive Crit Care Nurs 2006; 22:138-43. [PMID: 16325408 DOI: 10.1016/j.iccn.2005.10.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2005] [Revised: 10/05/2005] [Accepted: 10/21/2005] [Indexed: 10/25/2022]
Abstract
Nurses are the main group of clinicians who activate the medical emergency team (MET), placing them in an excellent position to provide valuable insights regarding the effectiveness of this system. This descriptive study aimed to explore nurses' satisfaction with the MET, perceived benefits and suggestions for improvement. The study also sought to examine the characteristics of nurses who were more likely to activate the MET. Using a survey design, descriptive statistics as well as content analysis were used to analyse the data. Seventy-three nurses (79% response rate) returned their completed surveys. A positive and significant relationship was found between years of nursing experience and MET activation (p = 0.018). Overall, nurses were satisfied with the MET, with suggestions for improvement including more education on medical emergencies for both ward and MET staff. Whilst the MET system is meeting the expectations of the majority of ward nurses, there is room for improvement, which includes a more positive attitude of the MET when summoned for 'borderline' cases. Investment in ongoing education of clinicians and interdisciplinary communication is likely to encourage less experienced nurses to utilise this system, whilst decreasing the reticence of some nurses to call the MET.
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Affiliation(s)
- Yenna Salamonson
- School of Nursing, Family and Community Health, University of Western Sydney, Campbelltown Campus, Building 7, Locked Bag 1797, Penrith South DC, New South Wales 1797, Australia.
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240
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Galhotra S, DeVita MA, Simmons RL, Schmid A. Impact of patient monitoring on the diurnal pattern of medical emergency team activation*. Crit Care Med 2006; 34:1700-6. [PMID: 16625132 DOI: 10.1097/01.ccm.0000218418.16472.8b] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To study the impact of time of day, day of week and level of patient monitoring on medical emergency team (MET) activation. DESIGN Retrospective observational study of all MET and cardiac arrest events between October 2001 and March 2005. SETTING University of Pittsburgh Medical Center Presbyterian Hospital, a tertiary care teaching facility in the United States. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Cardiac arrest and MET event rate during the day (7 am to 6:59 pm) and night (7 pm to 6:59 am) overall; for weekdays and weekends; and from unmonitored, monitored, and intensive care units (ICUs). There were 605 cardiac arrest and 4,072 MET events. MET event rate was higher during the day than at night in unmonitored units (62% day vs. 38% night; p<.001) and monitored units (59% day vs. 41% night; p<.001) but not in ICUs (47% day vs. 53% night; p=.20). Unmonitored units had a greater daytime increase in MET event rate than monitored units (63% vs. 46%), whereas ICUs showed an 11% decline compared with night. The MET day vs. night difference was greater on weekdays (65% day vs. 35% night; p<.001) than on weekends (56% day vs. 44% night; p<.001). Cardiac arrest event rate showed no diurnal pattern in any unit setting but had a higher daytime event rate during weekdays (57% day vs. 43% night; p=.004). CONCLUSIONS More MET events take place during the day. MET events in unmonitored units have a greater diurnal variability than those from monitored units. ICUs show no diurnal variation in MET event rate. Our results suggest a significant variability in the hospital ability to consistently detect patients who meet MET activation criteria.
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Affiliation(s)
- Sanjay Galhotra
- Department of Critical Care Medicine, University of Pittsburgh, and the University of Pittsburgh Medical Center Presbyterian Hospital, Pittsburgh, PA 15213, USA
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241
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Tarassenko L, Hann A, Young D. Integrated monitoring and analysis for early warning of patient deterioration. Br J Anaesth 2006; 97:64-8. [PMID: 16707529 DOI: 10.1093/bja/ael113] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Recently there has been an upsurge of interest in strategies for detecting at-risk patients in order to trigger the timely intervention of a Medical Emergency Team (MET), also known as a Rapid Response Team (RRT). We review a real-time automated system, BioSign, which tracks patient status by combining information from vital signs monitored non-invasively on the general ward. BioSign fuses the vital signs in order to produce a single-parameter representation of patient status, the Patient Status Index. The data fusion method adopted in BioSign is a probabilistic model of normality in five dimensions, previously learnt from the vital sign data acquired from a representative sample of patients. BioSign alerts occur either when a single vital sign deviates by close to +/-3 standard deviations from its normal value or when two or more vital signs depart from normality, but by a smaller amount. In a trial with high-risk elective/emergency surgery or medical patients, BioSign alerts were generated, on average, every 8 hours; 95% of these were classified as 'True' by clinical experts. Retrospective analysis has also shown that the data fusion algorithm in BioSign is capable of detecting critical events in advance of single-channel alerts.
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Affiliation(s)
- L Tarassenko
- Department of Engineering Science, Parks Road, University of Oxford, Oxford OX1 3PJ, UK.
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242
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Abstract
PURPOSE OF REVIEW Patient safety has become the primary focus of health-care improvement in the last few years as an increasing body of evidence emphasizes the magnitude of harm posed to patients by medical errors. The intensive-care unit, by virtue of the high technology aggressive level of care the unit provides, has been identified as a significant source of patient harm. Consequently, the intensive-care unit also represents a tremendous opportunity to study and implement patient-safety initiatives, as significant improvements can be realized in this environment. RECENT FINDINGS Several broad areas of successful patient-safety initiatives have been reported over the recent past including implementation of Comprehensive Unit-based Safety Programs, introduction of communication tools (for example daily goal sheets), application of care bundles (that is mechanical ventilation or sepsis), as well as team approaches that can eradicate catheter-related bloodstream infections. Specific interventions are gaining supportive evidence and widespread acceptance for their ability to reduce harm including tight glucose control and ultrasonography for reducing central-line placement complications. Recent data also demonstrate the value of an intensivist as the team leader for the critically ill within the intensive-care unit and potentially with rapid-response teams. SUMMARY Many patient safety and quality-of-care initiatives that have broad application to all areas of medical care have been successfully developed in the intensive-care unit. The intensive-care unit appears to be a fertile ground for the development of safety initiatives.
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Affiliation(s)
- Bradford Winters
- Department of Anesthesiology, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA.
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243
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Abstract
The implementation of a rapid response team or medical emergency team is 1 of the 6 initiatives of the Institute for Healthcare Improvement's 100,000 Lives Campaign with the goal to reduce the number of cardiopulmonary arrests outside the intensive care unit and inpatient mortality rates. The concept of RRT was pioneered in Australia and is now being implemented in many hospitals across the United States. This article reviews the current literature and describes the implementation of an RRT in a community hospital. The first-quarter data after implementation are described. The unique role of the acute care nurse practitioner in this hospital's model is described.
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Affiliation(s)
- Kate J Morse
- Chester County Hospital, West Chester, Penn, USA.
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244
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Affiliation(s)
- Carol C Scholle
- Critical Care and Transplant Services, University of Pittsburgh Medical Center-Presbyterian Hospital, Pittsburgh, PA, USA
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245
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Naeem N, Montenegro H. Beyond the intensive care unit: A review of interventions aimed at anticipating and preventing in-hospital cardiopulmonary arrest. Resuscitation 2005; 67:13-23. [PMID: 16150531 DOI: 10.1016/j.resuscitation.2005.04.016] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2005] [Revised: 04/12/2005] [Accepted: 04/12/2005] [Indexed: 01/01/2023]
Abstract
Despite more than four decades of experience with in-hospital cardiopulmonary arrest, outcomes have remained poor. Numerous studies have documented the physiological instability leading to clinical deterioration, which often precedes cardiopulmonary arrest. These physiological changes often go unrecognized or are acted upon inadequately. This has led to the development of interventions aimed at anticipating and/or preventing cardiopulmonary arrest. In this review, we summarize the current literature regarding outcomes from in-hospital cardiopulmonary arrest, the physiological instability leading to clinical deterioration which often precedes cardiopulmonary arrest, and the various interventions to anticipate and prevent in-hospital cardiopulmonary arrest. These interventions include the use of intermediate care units, Modified Early Warning Scores (MEWS) and Medical Emergency Teams (MET). These interventions may have the potential to decrease the cardiac arrest rate and in-hospital mortality rate associated with cardiac arrest; however, controversy remains regarding some of these interventions. The use of intermediate care units may require an organized approach to identify patients who are acutely ill and would benefit from this specialized care. There is not enough evidence currently to support the benefit of Modified Early Warning Scores to prevent in-hospital cardiopulmonary arrest. Recent studies of the Medical Emergency Team have shown a significant decrease in cardiac arrest and overall mortality rates with this intervention. The Medical Emergency Team is an intervention, which requires further studies to define its role in other aspects of hospital patient care.
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Affiliation(s)
- Nauman Naeem
- Division of Pulmonary and Critical care, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, OH, USA
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246
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Cretikos M, Parr M, Hillman K, Bishop G, Brown D, Daffurn K, Dinh H, Francis N, Heath T, Hill G, Murphy J, Sanchez D, Santiano N, Young L. Guidelines for the uniform reporting of data for Medical Emergency Teams. Resuscitation 2005; 68:11-25. [PMID: 16153768 DOI: 10.1016/j.resuscitation.2005.06.009] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2005] [Revised: 06/11/2005] [Accepted: 06/11/2005] [Indexed: 11/19/2022]
Abstract
It is more than 15 years since the first Medical Emergency Team (MET) system was introduced to identify patients at risk and prevent serious adverse events in Liverpool Hospital, Sydney, Australia. Since then the MET system has been introduced to many other hospitals in Australia and around the world. Standardised and complete reporting of data related to MET activity is increasingly important to identify the role and benefits of the system and to facilitate quality improvement in health care in general. A uniform method for reporting data related to MET activity will aid interpretation of results, comparisons, review and changes to the MET system. The guidelines for uniform reporting of data in relation to MET activities used in our group of hospitals are presented. Future refinement and consensus agreement on the reporting of MET data internationally should enable comparisons between MET systems in several countries.
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247
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Hillman K, Chen J, Cretikos M, Bellomo R, Brown D, Doig G, Finfer S, Flabouris A. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet 2005; 365:2091-7. [PMID: 15964445 DOI: 10.1016/s0140-6736(05)66733-5] [Citation(s) in RCA: 870] [Impact Index Per Article: 45.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Benezo C, Gaudy D, White TM. "Keeping each patient safe": quality safety teaching/learning packets. JOINT COMMISSION JOURNAL ON QUALITY AND SAFETY 2004; 30:676-80. [PMID: 15646100 DOI: 10.1016/s1549-3741(04)30080-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
BACKGROUND University of Pittsburgh Medical Center (UPMC) McKeesport developed a tool, the UPMC McKeesport Quality Safety Teaching/Learning Packet, to provide physicians, nurses, and therapists with a common language to address complex safety issues. Teaching/learning packets were developed to "keep each patient safe": by calling for help early; from falls and confusion; and from hospital-acquired infections (http://McKeesport.upmc.com/KeepingPatientsSafe.htm). TEACHING/LEARNING PACKETS In July 2002, the concept of calling for help early became a requirement at UPMC McKeesport. The code team was to be called for any significant change in status and for traditional code arrests. In 2004, a teaching/learning packet addressed the concepts of fall risk and acute (delirium) and chronic (dementia) confusion. Strategies were implemented to reduce the rate of falls through risk screening and interventions for falls and delirium. In April 2004, a teaching/learning packet was introduced to reduce hospital-acquired infections, and professionals were positioned to better address isolation, hand hygiene, central-line-associated bacteremia, Clostridium difficile, and appropriate antibiotic usage. SUMMARY AND CONCLUSIONS Three quality safety teaching/learning packets, which provided the professionals in the organization with the common language (culture) to advance patient safety, accomplished rapid change and were well accepted by staff and physicians.
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Affiliation(s)
- Chris Benezo
- Value and Education, University of Pittsburgh Medical Center McKeesport, PA, USA
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