The evolutionary process of Medical Emergency Team (MET) implementation: reduction in unanticipated ICU transfers

Examining the Occurrence of Adverse Events within 72 hours of Discharge from the Intensive Care Unit

Adverse events have negative consequences for patients, including increased risk of death or permanent disability. Reports describe suboptimal patient care on hospital wards and reasons for readmission to the intensive care unit (ICU) but limited data exists on the occurrence of adverse events, their characteristics and outcomes in patients recently discharged from the ICU to the ward. This prospective observational study describes the incidence and outcomes of adverse events within 72 hours of discharge from an Australian ICU over 12 weeks in 2006. Patients were excluded if they were admitted to ICU after booked surgery or uncomplicated drug overdose, were discharged from ICU to the high dependency unit or had a ‘do-not-resuscitate’ order. Clinical antecedents and preventability were determined for each event. Seventeen (10%) of the 167 discharges that met the inclusion criteria were associated with an adverse event, with nine (52%) judged as probably preventable. Seven adverse events occurred from discharges between 1700 and 0700 hours and seven were on weekends. The most common adverse events were related to fluid management (47%). Outcomes included three ICU readmissions, two high dependency unit admissions and two required one-to-one ward nursing. Two adverse events resulted in temporary disability, seven resulted in prolonged hospital stays and two were associated with death. Delay in taking action for abnormal physiological signs and infrequent charting were evident. Whilst the adverse event rate compared favourably with other reports, 64% of the events were considered preventable. A review of support systems and processes is recommended to better target transition from the ICU.

The epidemiology of in-hospital cardiac arrests in Australia and New Zealand

BACKGROUND

The epidemiology of in-hospital cardiac arrests (IHCA) in Australia and New Zealand (ANZ) has not been systematically assessed.

AIM

To conduct a systematic review of the frequency, characteristics and outcomes of adult IHCA in ANZ.

METHODS

Medline search for studies published in 1964-2014 using MeSH terms 'arrest AND hospital AND Australia', 'arrest AND hospital AND New Zealand', 'inpatient AND arrest AND Australia' and 'inpatient AND arrest AND New Zealand'.

RESULTS

We screened 934 studies, analysed 50 and included 30. Frequency of IHCA ranged from 1.31 to 6.11 per 1000 admissions in 4 population studies and 0.58 to 4.59 per 1000 in 16 cohort studies. The frequency was 4.11 versus 1.32 per 1000 admissions in hospitals with rapid response system (RRS) compared with those without (odds ratio: 0.32; 95% confidence interval 0.28-0.37; P < 0.001). On aggregate, the initial cardiac rhythm was ventricular tachycardia/fibrillation in 31.4% (range 19.0-48.8%) in 10 studies reporting such data. On aggregate, IHCA were witnessed in 80.2% cases (three studies) and monitored patients in 53.4% cases (four studies). Details of life support were poorly documented. On aggregate, return of spontaneous circulation occurred in 46.0% of patients. Overall, 74.6% (range 59.4-77.5%) died in-hospital but survival was higher among monitored or younger patients, in those with a shockable rhythm, or during working hours.

CONCLUSION

IHCA are uncommon in ANZ and three quarters die in-hospital. However, their frequency varies markedly across institutions and may be affected by the presence of RRS. Where reported, the long-term outcomes survivors appear to have acceptable neurological outcomes.

Original Research: The Benefits of Rapid Response Teams: Exploring Perceptions of Nurse Leaders, Team Members, and End Users

: The perceived benefits of rapid response teams (RRTs) influence whether RRTs are used and sustained. Perceived benefits are particularly important to sustaining RRTs when limited RRT data are shared with organizational members. Nurse leaders' perceptions of the benefits of RRTs likely influence their support, which is crucial for sustained RRT use. The perceptions of RRT members and end users similarly will affect use. But little is known regarding the perceptions of nurse leaders, RRT members, and RRT users in this regard.This study sought to explore and compare the perceptions of nurse leaders, RRT members, and RRT users regarding the benefits of RRTs.A qualitative, multiple-case study design was used. Semistructured interviews were conducted with nurse leaders, RRT members, and RRT users at four community hospitals, as part of a larger mixed-methods study examining RRT sustainability. Purposive and snowball sampling were used. Recruitment strategies included e-mail and listserv announcements, on-site presentations, direct personal contact, and a study flyer.All participants reported perceiving various ways that RRTs benefit the organization, staff members, and patients. Variations in the benefits perceived were observed between the three participant groups. Nurse leaders' perceptions tended to focus on macro-level benefits. RRT members emphasized the teaching and learning opportunities that RRTs offer. RRT users focused on the psychological support that RRTs can provide.Both similarities and differences were found between nurse leaders, RRT members, and RRT users regarding their perceptions of RRT benefits. Differences may be indicative of organizations' information-sharing processes; of variation in the priorities of nurse leaders, RRT members, and RRT users; and of the challenges nurses face daily in their work environments. Future research should investigate whether the perceived benefits of RRTs are borne out in actuality, as well as the relationships between the perceived benefits of RRTs and organizational and RRT characteristics.

Evaluating processes of care and outcomes of children in hospital (EPOCH): study protocol for a randomized controlled trial

Background

The prevention of near and actual cardiopulmonary arrest in hospitalized children is a patient safety imperative. Prevention is contingent upon the timely identification, referral and treatment of children who are deteriorating clinically. We designed and validated a documentation-based system of care to permit identification and referral as well as facilitate provision of timely treatment. We called it the Bedside Paediatric Early Warning System (BedsidePEWS). Here we describe the rationale for the design, intervention and outcomes of the study entitled Evaluating Processes and Outcomes of Children in Hospital (EPOCH).

Methods/Design

EPOCH is a cluster-randomized trial of the BedsidePEWS. The unit of randomization is the participating hospital. Eligible hospitals have a Pediatric Intensive Care Unit (PICU), are anticipated to have organizational stability throughout the study, are not using a severity of illness score in hospital wards and are willing to be randomized. Patients are >37 weeks gestational age and <18 years and are hospitalized in inpatient ward areas during all or part of their hospital admission.

Randomization is to either BedsidePEWS or control (no severity of illness score) in a 1:1 ratio within two strata (<200, ≥200 hospital beds). All-cause hospital mortality is the selected primary outcome. It is objective, independent of do-not-resuscitate status and can be reliably measured. The secondary outcomes include (1) clinical outcomes: clinical deterioration, severity of illness at and during ICU admission, and potentially preventable cardiac arrest; (2) processes of care outcomes: immediate calls for assistance, hospital and ICU readmission, and perceptions of healthcare professionals; and (3) resource utilization: ICU days and use of ICU therapies.

Discussion

Following funding by the Canadian Institutes of Health Research and local ethical approvals, site enrollment started in 2010 and was closed in February 2014. Patient enrollment is anticipated to be complete in July 2015. The results of EPOCH will strengthen the scientific basis for local, regional, provincial and national decision-making and for the recommendations of national and international bodies. If negative, the costs of hospital-wide implementation can be avoided. If positive, EPOCH will have provided a scientific justification for the major system-level changes required for implementation.

Trial registration: NCT01260831 ClinicalTrials.gov date: 14 December 2010.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-0712-3) contains supplementary material, which is available to authorized users.

The performance of a rapid response team in the management of code yellow events at a university hospital

Objective

To describe the epidemiological data of the clinical instability events in patients attended to by the rapid response team and to identify prognostic factors.

Methods

This was a longitudinal study, performed from January to July 2010, with an adult inpatient population in a hospital environment. The data collected regarding the code yellow service included the criteria of the clinical instability, the drug and non-drug therapies administered and the activities and procedures performed. The outcomes evaluated were the need for intensive care unit admission and the hospital mortality rates. A level of p=0.05 was considered to be significant.

Results

A total of 150 code yellow events that occurred in 104 patients were evaluated. The most common causes were related to acute respiratory insufficiency with hypoxia or a change in the respiratory rate and a concern of the team about the patient's clinical condition. It was necessary to request a transfer to the intensive care unit in 80 of the 150 cases (53.3%). It was necessary to perform 42 procedures. The most frequent procedures were orotracheal intubation and the insertion of a central venous catheter. The patients who were in critical condition and had to wait for an intensive care unit bed had a higher risk of death compared to the other patients (hazard ratio: 3.12; 95% CI: 1.80-5.40; p<0.001).

Conclusions

There are patients in critical condition that require expert intensive care in the regular ward unit hospital beds. The events that most frequently led to the code yellow activation were related to hemodynamic and respiratory support. The interventions performed indicate the need for a physician on the team. The situation of pent-up demand is associated with a higher mortality rate.

Deployment of rapid response teams by 31 hospitals in a statewide collaborative

The Institute of Medicine (IOM) report, To Err is Human: Building a Safer Health system (1999), highlighted the need for improvements in the quality of health care, advocating for improvements in patient safety, preventing avoidable harm, and providing the necessary care to patients who could benefit from it. Rapid Response Teams (RRTs) are one crucial aspect of a hospital's RRS, providing hospitals with a mechanism to respond and care for patients experiencing an avoidable medical crisis. RRTs became imbedded in US hospitals following the launch of the 100 000 Lives Campaign in 2004 by the Institute for Healthcare Improvement and the introduction of RRTs as one of six initiatives to improve the quality of patient care. RRT adoption also provides hospitals the opportunity to meet a Joint Commission requirement for hospitals to implement a mechanism that enabled staff members to obtain help from experts when their patient's condition is worsening. Despite the proliferation of RRTs in hospitals, descriptive reports of these teams across groups of hospitals have been relatively few and provided limited descriptive information on RRTs. Therefore, using data we collected as part of a larger mixed-methods study of RRTs to examine their sustainability, we describe RRTs in a group of hospitals that were part of a collaborative to facilitate RRT adoption and implementation.

Activation of a medical emergency team using an electronic medical recording-based screening system*

OBJECTIVES

To evaluate the efficacy of a medical emergency team activated using 24-hour monitoring by electronic medical record-based screening criteria followed by immediate intervention by a skilled team.

DESIGN

Retrospective cohort study.

SETTING

Academic tertiary care hospital with approximately 2,700 beds.

PATIENTS

A total of 3,030 events activated by a medical emergency team from March 1, 2008, to February 28, 2010.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

We collected data for all medical emergency team activations: patient characteristics, trigger type for medical emergency team (electronic medical record-based screening vs calling criteria), interventions during each event, outcomes of the medical emergency team intervention, and 28-day mortality after medical emergency team activation. We analyzed data for 2009, when the medical emergency team functioned 24 hours a day, 7 days a week (period 2), compared with that for 2008, when the medical emergency team functioned 12 hours a day, 7 days a week (period 1). The commonest cause of medical emergency team activation was respiratory distress (43.6%), and the medical emergency team performed early goal-directed therapy (21.3%), respiratory care (19.9%), and difficult airway management (12.3%). For patients on general wards, 51.3% (period 1) and 38.4% (period 2) of medical emergency team activations were triggered by the electronic medical record-based screening system (electronic medical record-triggered group). In 23.4%, activation occurred because of an abnormality in laboratory screening criteria. The commonest activation criterion from electronic medical record-based screening was respiratory rate (39.4%). Over half the patients were treated in the general ward, and one third of the patients were transferred to the ICU. The electronic medical record-triggered group had lower ICU admission with an odds ratio of 0.35 (95% CI, 0.22-0.55). In surgical patients, the electronic medical record-triggered group showed the lower 28-day mortality (10.5%) compared with the call-triggered group (26.7%) or the double-triggered group (33.3%) (odds ratio 0.365 with 95% CI, 0.154-0.867, p = 0.022).

CONCLUSIONS

We successful managed the medical emergency team with electronic medical record-based screening criteria and a skilled intervention team. The electronic medical record-triggered group had lower ICU admission than the call-triggered group or the double-triggered group. In surgical patients, the electronic medical record-triggered group showed better outcome than other groups.

The epidemiology of adult Rapid Response Team patients in Australia

Rapid Response Teams (RRT) are specialised teams that review deteriorating ward patients in an attempt to prevent morbidity and mortality. Most studies have assessed the effect of implementing an RRT into a hospital. There is much less literature on the characteristics and outcomes of RRT patients themselves. This article reviews the epidemiology of adult RRT patients in Australia and proposes three models of RRT syndromes. The number of RRT calls varies considerably in Australian hospitals from 1.35 to 71.3/1000 hospital admissions. Common causes of RRT calls include sepsis, atrial fibrillation, seizures and pulmonary oedema. Approximately 20% of patients to whom an RRT has responded have more than one RRT call, and up to one-third have issues around end-of-life care. Calls are least common overnight. Between 10 to 25% of patients are admitted to a critical care area after the call. The in-hospital mortality for RRT patients is approximately 25% overall but only 15% in patients without a limitation of medical therapy. RRT syndromes can be conceptually described by the trigger for the call (e.g. hypotension) or the clinical condition causing the call (e.g. sepsis). Alternatively, the RRT call can be described by the major theme of the call: "end-of-life care", "requiring critical care" and "stable enough to initially remain on the ward". Based on these themes, education strategies and quality improvement initiatives may be developed to reduce the incidence of RRT calls, further improving patient outcome.

The role of the non-ICU staff nurse on a medical emergency team: perceptions and understanding

OBJECTIVE

Medical emergency teams (METs) have been shown to contribute to a decrease in in-hospital cardiac arrests, unplanned ICU admissions, and overall hospital mortality rates. But their use is relatively new and our understanding of them is incomplete; in particular, the role of the non-ICU staff nurse during a MET call has received scant attention. To better understand the role of such nurses, and possibly to increase the effectiveness of these teams, we sought to determine the nursing staff's familiarity with and perceptions of the MET at one hospital.

METHODS

After examining survey formats used in previous studies of nurses' perceptions of and attitudes toward METs, a 30-item survey was developed, consisting of 13 demographic and background items and 17 items based on a 5-point Likert agreement scale. In August 2008, the survey was distributed to the 388 nurses at Allegheny General Hospital in Pittsburgh, Pennsylvania, for whom the MET is a possible resource-that is, non-ICU staff nurses working outside critical care units or the ED. Responses were anonymous and voluntary. Data were entered and analyzed using Microsoft Excel software.

RESULTS

One hundred and thirty-one surveys (34%) were returned. Nearly all of the respondents (97%) were familiar with the MET, and a majority (72%) had participated in a MET call. Initiating the call (77%) and relaying the patient's history (84%) were the most common actions. A majority of respondents agreed or strongly agreed that use of the MET improved patient care (92%) and nurses' working conditions (83%). But only 41% agreed or strongly agreed that they were comfortable with their role as a member of the MET, and 39% reported neutral feelings about this. Just 41% agreed or strongly agreed that they felt prepared to administer nursing care during a MET call. A majority (52%) agreed or strongly agreed that an increase in experience corresponded to an increase in preparedness, but only 28% agreed or strongly agreed that their MET education had prepared them for their role. Nearly a third (31%) reported that they'd been hesitant to call a MET, citing physician discouragement as the most common reason.

CONCLUSIONS

Nurses felt that the MET improved both patient care and their working conditions, something that other studies have found may contribute to nurse retention and recruitment. But the role of the non-ICU staff nurse during a MET call remains unclear; nurses were neutral about their level of understanding of and comfort with their roles as members of the MET. More specific guidelines and further education may help the non-ICU staff nurse feel more valued as a team member and better prepared to administer nursing care during a MET call. Intimidation by other team members proved not to be a significant factor in nurse participation on the team, but the data may not have accurately described the unique relationship between the non-ICU staff nurse and the responding ICU nurses. Some non-ICU staff nurses were hesitant to call the team, for reasons that included physician discouragement; this could seriously undermine the effectiveness of the MET and indicates that better interprofessional education is needed.

KEYWORDS

bedside nurse, medical emergency team, non-ICU staff nurse, nurse attitudes, patient crisis, patient safety, rapid response system, survey.

Rapid response teams: qualitative analysis of their effectiveness

BACKGROUND

Multidisciplinary rapid response teams focus on patients' emergent needs and manage critical situations to prevent avoidable deaths. Although research has focused primarily on outcomes, studies of the actual team effectiveness within the teams from multiple perspectives have been limited.

OBJECTIVE

To describe effectiveness of rapid response teams in a large teaching hospital in California that had been using such teams for 5 years.

METHODS

The grounded-theory method was used to discover if substantive theory might emerge from interview and/or observational data. Purposeful sampling was used to conduct in-person semistructured interviews with 17 key informants. Convenience sampling was used for the 9 observed events that involved a rapid response team. Analysis involved use of a concept or indicator model to generate empirical results from the data. Data were coded, compared, and contrasted, and, when appropriate, relationships between concepts were formed. Results Dimensions of effective team performance included the concepts of organizational culture, team structure, expertise, communication, and teamwork.

CONCLUSIONS

Professionals involved reported that rapid response teams functioned well in managing patients at risk or in crisis; however, unique challenges were identified. Teams were loosely coupled because of the inconsistency of team members from day to day. Team members had little opportunity to develop relationships or team skills. The need for team training may be greater than that among teams that work together regularly under less time pressure to perform. Communication between team members and managing a crisis were critical aspects of an effective response team.

The Cardiac Children's Hospital Early Warning Score (C-CHEWS)

Inpatient pediatric cardiovascular patients have higher rates of cardiopulmonary arrests than other hospitalized children. Pediatric early warning scoring tools have helped to provide early identification and treatment to hospitalized children experiencing deterioration thus preventing arrests from occurring. However, the tools have rarely been used and have not been validated in the pediatric cardiac population. This paper describes the modification of a pediatric early warning scoring system for cardiovascular patients, the implementation of the tool, and its companion escalation of care algorithm on an inpatient pediatric cardiovascular unit.

Suboptimal care of the acutely unwell ward patient: a concept analysis

AIM

This paper presents a concept analysis of suboptimal care of the acutely unwell ward patient.

BACKGROUND

Acutely unwell patients exhibit abnormal vital signs which are either not recognized or are treated inappropriately. This is frequently termed 'suboptimal care'. However, use of the term 'suboptimal care' is ambiguous and not clearly defined. Critical review of this concept is required to ensure nurses have a better understanding of why and how suboptimal care occurs.

DATA SOURCES

Electronic databases (CINAHL, Medline, Cochrane) were searched for literature related to suboptimal care of acutely unwell ward patients. Reference lists from relevant publications were reviewed. No date or language restrictions were imposed. Only articles relevant to suboptimal care of the acutely unwell adult ward patient were included. All literature reviewed was in English and was published between 1990 and 2009.

METHOD

The Walker and Avant approach was used.

RESULTS

The attributes of suboptimal care are delays in diagnosis, treatment or referral, poor assessment and inadequate or inappropriate patient management. These attributes are preceded by contextual antecedents which can be categorized into patient complexity, healthcare workforce, organization and education factors. Suboptimal care may have catastrophic consequences for patients such as death, Intensive Care Unit admission or cardiac arrests which are preventable or avoidable.

CONCLUSION

For future research, investigators need to develop more objective measures which capture delays in the treatment and inappropriate or inadequate management of acutely unwell patients. This should occur through critical focus on the antecedents to suboptimal care.

The effect of medical emergency teams on patient outcome: a review of the literature

This paper presents a review of literature on the impact of the medical emergency team (MET) on inpatient mortality, cardiopulmonary arrests or unscheduled intensive care unit (ICU) admissions. A total of 14,172 abstracts and 98 full text papers were reviewed. In total, 24 met the inclusion criteria, 2 used a cluster-randomized controlled trial, 11 before and after, 6 retrospective analyses, 4 prospective cohorts and 1 not reported. There is moderate to strong evidence that METs are associated with decreased mortality and cardiac arrest rates, and weak evidence on its impact on ICU admission rate reductions. This evidence suffers from the flaws with only two randomized controlled trials examining differing outcome measures with differing results. Poor methodology and failure to report both quality improvement co-interventions and time response rates of METs, limit the strength of the evidence that METs are effective interventions for preventing mortality, code rates or unscheduled ICU admissions. Studies with improved implementation practices and evaluation of the efficacy of MET is warranted.

The impact of medical emergency teams on ICU admission rates, cardiopulmonary arrests and mortality in a regional hospital

CONTEXT

In-hospital cardiac arrests are commonly associated with poor outcomes and preceded by observable signs of clinical deterioration. Medical emergency teams (METs) have emerged to provide early specialist care intervention to critically ill patients.

OBJECTIVE

To determine the effect of MET implementation on hospital-wide mortality rates, cardiopulmonary arrests and admissions to the intensive care unit (ICU) in a regional Queensland hospital.

METHOD

A prospective cohort before and after interventional trial was conducted on adult and paediatric inpatients admitted in 2004-2008 at a 150 bed regional teaching hospital in Australia. MET was introduced in 2006 and attended clinically unstable patients. Response was activated by the bedside nurse or doctor according to predefined criteria.

RESULTS

There were a total of 296 MET activations. After MET implementation, mean hospital-wide mortality rates decreased from 9.9 to 7.5 per 1000 admissions (relative risk reduction, RRR: 24.2%; p = 0.003). Similarly, ICU admissions decreased from 22.4 to 17.6 per 1000 admissions (RRR: 21.4%; p < 0.0001). There was also a significant decline in hospital-wide cardiopulmonary arrests post intervention (77 versus 42, RRR: 45.5%; p = 0.0025) however this may be explained by the increase in the number of patients deemed not for resuscitation by the MET. Secondary analysis revealed evidence of MET underuse that may have affected the mortality findings.

CONCLUSION

Implementation of the MET in a regional hospital was associated with statistically significant reductions in hospital-wide mortality rates, ICU admissions and cardiopulmonary arrests.

Unplanned admission to intensive care after emergency hospitalisation: risk factors and development of a nomogram for individualising risk

BACKGROUND AND AIMS

Unplanned admission to an intensive care unit (ICU) is associated with high mortality, having the highest incidence among patients who are emergency admissions to the hospital. This study was designed to identify factors associated with unplanned ICU admission in emergency admissions to hospital and develop an absolute risk tool to individualise the risk of an event during a hospital stay.

METHODS

Emergency department (ED) and in-patient hospital data from a large teaching hospital of consecutive admissions from 1 January 1997 to 31 December 2007 aged over 14 years was included in this study. Patient data extracted from 126826 emergency presentations admitted as in-patients consisted of demographic and clinical variables.

RESULTS

During an 11-year period 1582 incident unplanned ICU admissions occurred. Predictors of unplanned ICU admission included older age, being male, having a higher acuity triage category and a history of co-morbid conditions. Emergency department diagnostic groups associated with higher incidence of unplanned ICU admission included: sepsis, acute renal failure, lymphatic-hematopoietic tissue neoplasms, pneumonia, chronic-airways disease and bowel obstruction. The final model used to develop the nomogram had an ROC curve AUC of 0.7.

CONCLUSION

This study identified factors associated with unplanned ICU admission and developed a nomogram to individualise risk prior to a patient being transferred from the ED. This nomogram provides clinicians the opportunity prior to transfer from the ED, to either (1) review the appropriateness of the ward level of planned transfer or (2) flag patients for follow-up on the general ward to assess for deterioration.

[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.

Rapid Response Teams: Policy Implications and Recommendations for Future Research

Health care organizations are continually challenged with improving the safety of and the quality of care delivered to patients. Research studies often bring to the forefront interventions that health care organizations may choose to institute in an effort to provide evidence-based, quality care. Rapid response teams are one such intervention. Rapid response teams were introduced by the Institute for Healthcare Improvement as part of their "100,000 Lives" Campaign. Rapid response teams are one initiative health care organizations can implement in an effort to improve the quality of care delivered to patients. This article uses Donabedian's model of structure, process, and outcomes to discuss the United States health care systems, rapid response teams, and the outcomes of rapid response teams. National and organizational policy implications associated with rapid response teams are discussed and recommendations made for future research.

Using administrative data to develop a nomogram for individualising risk of unplanned admission to intensive care

AIM

Although unplanned admissions to the intensive care unit (ICU) are associated with poorer prognoses, there is no published prognostic tool available for predicting this risk in an individual patient. We developed a nomogram for calculating the individualised absolute risk of unplanned ICU admission during a hospital stay.

METHOD

Hospital administrative data from a large district hospital of consecutive admissions from 1 January 2000 to 31 December 2006 of aged over 14 years was used. Patient data was extracted from 94,482 hospital admissions consisted of demographic and clinical variables, including diagnostic categories, types of admission and time and day of admission. Multivariate logistic regression coefficients were used to develop a predictive nomogram of individual risk to patients admitted to the study hospital of unplanned ICU admission.

RESULTS

A total of 672 incident unplanned ICU admissions were identified over this period. Independent predictors of unplanned ICU admissions included being male, older age, emergency department (ED) admissions, after-hour admissions, weekend admissions and six principal diagnosis groups: fractured femur, acute pancreatitis, liver disease, chronic airway disease, pneumonia and heart failure. The area under the receiver operating characteristic curve was 0.81.

CONCLUSION

The use of a nomogram to accurately identify at-risk patients using information that is readily available to clinicians has the potential to be a useful tool in reducing unplanned ICU admissions, which in turn may contribute to the reduction of adverse events of patients in the general wards.

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.

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.

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.

The Medical Emergency Team system: a two hospital comparison

AIM

To compare activity and outcomes of a mature Medical Emergency Team (MET) in two hospitals. SETTING AND POPULATIONS: A Tertiary Referral Hospital (TRH) and a Metropolitan General Hospital (MGH) who combined have approximately 82,000 admissions annually with 38,000 patients meeting the eligibility criteria. The population included all admissions to the two hospitals aged 15 years and over with a stay>1 day (12 months period). Admissions that had a MET call originating in general wards were defined as Admissions Associated with a MET call (AAMET).

METHODS

A retrospective analysis of MET call audit forms, a Death Review database, and routinely collected hospital data for the period 1st October 2004 to 30th September 2005, inclusive. Chronic morbidity was calculated as a Charlson Index (CI) score over previous visits and admissions using ICD10 & ICD9 diagnosis and procedure codes.

RESULTS

There were 633 and 349 AAMETs. The incidence rates (MET calls/1000 admissions) were 37.6 and 34.1. They were associated with being elderly; males; higher CI scores; surgical admissions, Emergency Department (ED) admissions, and longer length of stay (LOS). A systolic BP<90mm Hg, and "worried" were the most frequent MET call criteria. There were 27 (4.3%) and 9 (2.6%) deaths following a MET call, of these 17 and 5 had Cardiac Arrest (CA) as the reason for the call. Death occurred for 192 and 54 AAMETs, only 38 (20%) and 14 (26%) were Do Not Attempt Resuscitation (DNAR) deaths. One hundred and forty-seven (23.2%) and eighty-seven (24.9%) AAMETs had a MET call within 24h of transfer from a critical care area; the proportions of transfers differed significantly between the two hospitals.

CONCLUSION

A well established MET system identified similar AAMET populations from two different hospital populations. Sick, elderly, and surgical rather than medical patients were associated with MET activity in both hospitals. Further research is needed to estimate the impact of increased monitoring and interventions on patient outcomes, and the role of MET teams in end of life decision-making.

Implementation and Impact of a Rapid Response Team in a Children’s Hospital

Like the previous two studies of RRS implementation in a children's hospital, this study--the first to use an RRT model--showed a decrease in the incidence of arrests (although not at a significant level). Low mortality rates and infrequent arrests in children's hospitals make changes in these measures insensitive indicators of the positive impact of RRT implementation. RRTs provide an immediate response for children whose clinical condition is worrisome and whose attending physicians are not immediately present. Children receive significant care through the RRT, and nurse response is very favorable to having access to fast, dependable, and knowledgeable backup 24 hours a day. The RRT program is a vital component of the safety net for children's hospitals, and RRT data provides an avenue for quality improvement efforts and further research.

Implementation of a Rapid Response Team Decreases Cardiac Arrest Outside of the Intensive Care Unit

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.

Systematic review and evaluation of physiological track and trigger warning systems for identifying at-risk patients on the ward

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.

Medical emergency teams: a strategy for improving patient care and nursing work environments

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.

Medical emergency teams: a role for expanding intensive care?

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.

An evaluation of an early warning clinical marker referral tool

OBJECTIVES

The purpose of this study was to evaluate the introduction of a clinical marker tool using a pre- and post-test design in a tertiary university-affiliated hospital. The clinical marker tool was designed to assist in the early identification of unstable patients in the general surgical and medical ward environment based on abnormal vital signs.

METHODS

A pre- and post-test design of the clinical marker tool was undertaken over a 3-year period. All unstable ward patients who were admitted to the Intensive Care Unit (ICU) from 1 February 2002 to 31 January 2003 (pre- implementation period) and from 1 February 2003 to 31 January 2005 (post-implementation period) were included in the study. A secondary analysis was performed on annual medical emergency calls made to the resuscitation team and mortality from such events from 1 January 2002 to 31 December 2004.

RESULTS

Prior to implementing the clinical marker tool, 63 (41.2%) unplanned ICU admissions from the ward had clinical markers present for > or =6h. Following implementation of the clinical marker tool, 101 (24.5%) patients had clinical markers present for > or =6h (p=0.0002). There was no difference in ICU or hospital length of stay or hospital mortality for unplanned admissions to the ICU following implementation of the clinical marker tool. The number of patients found to be still breathing with a pulse on arrival of the resuscitation team was significantly increased from 56 (47.9%) patients to 181 (64.6%) patients post-implementation of the clinical marker tool (p=0.0024). Additionally, we found an associated increase in survival of this group of patients discharged home from 33 (59%) patients to 136 (75.1%) patients post-implementation of the clinical marker tool (p=0.0003).

CONCLUSIONS

The clinical marker tool implemented by an ICU Liaison Team improved the management of patients in the ward environment, including proactive admission of patients to the ICU. Additionally, implementation of the clinical marker tool was associated with a reduction in the number of cardiac arrests and improvement in hospital mortality for patients experiencing a medical emergency call. The timeframe of instability on the ward prior to the ICU admission may be used as a quality indicator to measure ICU Liaison Team performance. Further research is required to substantiate these findings.

Investigating the effectiveness of critical care outreach services: a systematic review

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.

Prevalence and sensitivity of MET-criteria in a Scandinavian University Hospital

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.

Staff experiences of an early warning indicator for unstable patients in Australia

The objective of this study is to explore nursing and medical staff's perceptions of a clinical marker referral tool implemented to assist in the early identification of unstable patients in the general surgical and medical ward environment. A descriptive, exploratory survey design was undertaken 6 months after the implementation of a clinical marker referral tool. The target population for the survey was all ward nursing, junior medical staff and intensive care unit (ICU) registrars in a metropolitan tertiary referral hospital in Australia. The survey consisted of open-ended and closed-ended questions, as well as statements asking participants to explore their perceptions, attitudes and perceived understanding of the clinical marker referral tool. The surveys were sent to all targeted staff in a personally addressed envelope via the internal mail system. Overall, nursing and medical staff (n = 178) responses were positive to the clinical marker project/tool, offering clear guidelines for staff to respond to the patient's clinical condition and contact the medical staff and the ICU liaison team as appropriate. Furthermore, comments were made in relation to the ICU liaison team acting as a 'support' and 'prompt back-up' for nursing staff when needed. However, ward medical staff had reservations with the clinical markers chosen and with ward nurses being able to contact the ICU registrar after hours. Additionally, the ICU registrars commented on an increase to their workload in having to review unstable patients after hours. These results suggest that the ward nurses required additional support and guidance in caring for the unstable patient in the ward which may improve patient outcomes. Further research investigating the less-favourable responses of the ward medical staff and ICU medical staff is warranted.

Voices from the floor: Nurses’ perceptions of the medical emergency team

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.

Impact of patient monitoring on the diurnal pattern of medical emergency team activation*

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.

Reduction of paediatric in-patient cardiac arrest and death with a medical emergency team: preliminary results

AIMS

To determine the impact of a paediatric medical emergency team (MET) on cardiac arrest, mortality, and unplanned admission to intensive care in a paediatric tertiary care hospital.

METHODS

Comparison of the retrospective incidence of cardiac arrest and death during 41 months before introduction of a MET service with the prospective incidence of these events during 12 months after its introduction. Comparison of transgression of MET call criteria in patients who arrested and died before and after introduction of MET.

RESULTS

Cardiac arrest decreased from 20 among 104 780 admissions (0.19/1000) to 4 among 35 892 admissions (0.11/1000) (risk ratio 1.71, 95% CI 0.59 to 5.01), while death decreased from 13 (0.12/1000) to 2 (0.06/1000) during these periods (risk ratio 2.22, 95% CI 0.50 to 9.87). Unplanned admissions to intensive care increased from 20 (SD 6) to 24 (SD 9) per month. The incidence of transgression of MET call criteria in patients who arrested decreased from 17 to 0 (risk difference 0.16/1000, 95% CI 0.09 to 0.24), and in those who died, decreased from 12 to 0 (risk difference 0.11/1000, 95% CI 0.05 to 0.18) after introduction of MET.

CONCLUSIONS

Introduction of a medical emergency team service was coincident with a reduction of cardiac arrest and mortality and a slight increase in admissions to intensive care.

Early and innovative interventions for severe sepsis and septic shock: taking advantage of a window of opportunity

The pathogenic, diagnostic and therapeutic landscape of sepsis is no longer confined to the intensive care unit: many patients from other portals of entry to care, both outside and within the hospital, progress to severe disease. Approaches that have led to improved outcomes with other diseases (e.g., acute myocardial infarction, stroke and trauma) can now be similarly applied to sepsis. Improved understanding of the pathogenesis of severe sepsis and septic shock has led to the development of new therapies that place importance on early identification and aggressive management. This review emphasizes approaches to the early recognition, diagnosis and therapeutic management of sepsis, giving the clinician the most contemporary and practical approaches with which to treat these patients.

Beyond the intensive care unit: A review of interventions aimed at anticipating and preventing in-hospital cardiopulmonary arrest

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.

Impact of a critical care outreach team on critical care readmissions and mortality

AIMS

The aim of a critical care outreach team is to facilitate discharges from critical care beds, educate ward staff in the management of deteriorating patients, facilitate transfer to critical care and reduce readmission rates to critical care. Although intuitively a good idea, there are few data to support outreach in terms of reducing the readmission rate to critical care and subsequent patient mortality. This retrospective observational study attempted to determine the change in the critical care readmission rate, an indicator of the quality of critical care, critical care mortality and in-hospital mortality following the introduction of a critical care outreach team in a major teaching hospital.

METHODS

A retrospective review of 1380 discharges from critical care was undertaken and the readmissions identified (n = 176). Readmission rate, mortality and other demographic data were compared between the pre and post-outreach periods.

RESULTS

Critical care mortality, in-hospital mortality and 30-day mortality were all reduced in the post-outreach period amongst readmissions to critical care. There was also a decease in the overall mortality of all patients admitted to critical care. There were no apparent causative factors for this reduction in mortality before and following outreach.

CONCLUSIONS

There are many confounding factors in assessing the impact of outreach teams in hospitals. This study tentatively concludes that outreach teams may have a favourable impact on mortality rate amongst readmissions to critical care, but more data is needed from multicentre trials.

Evaluation of a Medical Emergency Team one year after implementation

AIM

To evaluate the activity and impact of a Medical Emergency Team (MET) one year after implementation.

SETTING AND POPULATION

A 700-bed District General Hospital (DGH) in Southeast England with approximately 53,500 adult admissions per annum. The population studied included all adult admissions receiving intervention by the MET during a 12-month period between 1 October 2000 and 30 September 2001.

METHODS

Analysis of the activation of the MET using both prospective and retrospectively acquired data. Routinely collected hospital data for admissions, discharges and deaths was used to compare outcomes for the 12 months before and after the introduction of the MET.

RESULTS

There were 136 activations of MET over 1-year. Six cases were excluded. Mean age of patients was 73 years (range 20-97 years). 40% (52/130) survived to discharge following MET intervention. Of those who died 22% (28/130) were designated 'not for resuscitation'. Patients that died were more likely to have three or more physiological abnormalities present (odds ratio, OR 6.2, Chi-square (chi(2)) P = 0.004) and had higher MET scores (P = 0.004). Commonest interventions by the MET were initiation or increase of oxygen therapy or ventilatory support (80%), with or without the administration of intravenous fluids or medications. In 10% of cases, oxygen therapy was the sole intervention. One year after implementation of the MET a reduction in cardiac arrest rate and overall mortality was noted but this was not statistically significant.

CONCLUSION

Often only simple interventions are only required to reverse deterioration. Initiating 'do not attempt resuscitation' (DNAR) decisions is a key part of MET activity. Multiple physiological abnormalities are associated with increased mortality and therefore wider and earlier application of the MET to the hospital population may save lives or expedite DNAR decisions. New systems need time to develop ("bed in") and further research is needed to observe significant reductions in cardiac arrests and overall mortality.

Improving the utilization of medical crisis teams (Condition C) at an urban tertiary care hospital

PURPOSE

Serious clinical deterioration precedes most cardiopulmonary arrests, and there is evidence that organized responses to this deterioration may prevent a substantial proportion of in-hospital deaths. We aimed to increase the utilization of our medical crisis response team (Condition C) to impact this source of mortality.

METHODS

We have examined the change in numbers of Condition Cs and the main alternative response strategy (sequential stat pages) after the implementation of 4 strategies to increase Condition C utilization: (1) immediate reviews of all sequential STAT pages, (2) feedback to caregivers responsible for delays in Condition C activation, (3) creation of objective criteria for invoking a crisis response, and (4) dissemination of objective criteria through posting in units, e-mail, and in-service oral presentations.

RESULTS

Over a 3-year period, interventions were followed by increased use of organized responses to medical crises (Condition Cs) and decreased numbers of disorganized responses (sequential STAT pages). The interventions that involved objective definition and dissemination of criteria for initiating the Condition C response were followed by 19.2 more Condition Cs monthly (95% confidence interval [CI], 12.1-26.3; P<0001) and 5.7 fewer sequential STAT pages monthly (95% CI, 3.2-8.2). The interventions that involved giving feedback to medical personnel based on review of their care were not associated with changes in the measures.

CONCLUSION

Utilization of an important patient safety measure may be increased by focused interventions at an urban tertiary care hospital.

Impact of an outreach team on re-admissions to a critical care unit

Re-admissions have been cited as a measure of critical care quality and outreach teams have recently been introduced to improve critical care delivery. The aim of this study was to examine whether the number, causes and sequence of re-admissions to critical care altered as a result of the introduction of an outreach team. Re-admissions between April 2000 and November 2001 were examined. The reasons for re-admission were classified as (i) same pathology or disease process; (ii) new, but related, pathology; (iii) new and unrelated pathology; (iv) exacerbation of other comorbidities. During the two-year period, a total of 2546 patients were admitted to critical care of which 100 were re-admitted (49 before outreach and 51 after outreach). The reasons for re-admission did not vary before or after the introduction of the outreach team (same pathology 15 vs. 15; new, but related, pathology 17 vs. 23; new, but unrelated, 14 vs. 9; exacerbation of comorbidity 3 vs. 4, respectively, Chi-squared = 2.07, df = 3, p = 0.56). There was also no difference between the duration of stay on the general ward in between the critical care unit admissions before (median 2.93 [interquartile range 1.32-6.05] days) or after (median 2.25 [interquartile range 1.06-6.32] days) the introduction of an outreach team. As we could not detect any change in patterns of re-admissions as a result of the introduction of an outreach team, we would suggest that although outreach is an important development for critical care, its performance should be measured by other parameters.

Cardiorespiratory physical assessment for the acutely ill: 2

The second of this two-part article aims to develop advanced cardiovascular and respiratory knowledge to enhance practice for the nurse caring for an acutely ill patient on a general ward. The first part dealt with the core aspects of care in respiratory and cardiovascular physical assessment, including respiratory function and failure, pulse oximetry, oxygen therapy, fluid therapy, pulse measurement, blood pressure and electrocardiogram monitoring (Vol 11(11): 750-8). As the use of critical care beds within trusts becomes more difficult to manage, with ever-increasing patient dependency and occupancy figures remaining high, critically ill patients are likely to remain in wards longer or be discharged from a critical care environment earlier. These patients will require more frequent, direct, non-invasive and invasive monitoring to ensure that they do not deteriorate, and that any deteriorations are detected early and managed effectively. The skills and information discussed here will help nurses advance their practice and improve the quality of their care.