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Tsang JNJ, Bacchi S, Ovenden CD, Goh R, Kovoor JG, Gupta AK, Min Le Y, Lam A, Stretton B, To MS, Woodman R, Mangoni AA, Malycha J. Meeting medical emergency response criteria for hypertension is not associated with an increased likelihood of in-hospital mortality in a tertiary referral center. Resusc Plus 2024; 19:100679. [PMID: 38912533 PMCID: PMC11190537 DOI: 10.1016/j.resplu.2024.100679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 05/22/2024] [Accepted: 05/24/2024] [Indexed: 06/25/2024] Open
Abstract
Backgrounds Rapid response team or medical emergency team (MET) calls are typically activated by significant alterations of vital signs in inpatients. However, the clinical significance of a specific criterion, blood pressure elevations, is uncertain. Objectives The aim of this study was to evaluate the likelihood ratios associated with MET-activating vital signs, particularly in-patient hypertension, for predicting in-hospital mortality among general medicine inpatients who met MET criteria at any point during admission in a South Australian metropolitan teaching hospital. Results Among the 15,734 admissions over a two-year period, 4282 (27.2%) met any MET criteria, with a positive likelihood ratio of 3.05 (95% CI 2.93 to 3.18) for in-hospital mortality. Individual MET criteria were significantly associated with in-hospital mortality, with the highest positive likelihood ratio for respiratory rate ≤ 7 breaths per minute (9.83, 95% CI 6.90 to 13.62), barring systolic pressure ≥ 200 mmHg (LR + 1.26, 95% CI 0.86 to 1.69). Conclusions Our results show that meeting the MET criteria for hypertension, unlike other criteria, was not significant associated with in-hospital mortality. This observation warrants further research in other patient cohorts to determine whether blood pressure elevations should be routinely included in MET criteria.
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Affiliation(s)
- Jin Nuo Joan Tsang
- College of Medicine and Public Health, Flinders University, Bedford Park SA 5042, Australia
| | - Stephen Bacchi
- University of Adelaide, Adelaide SA 5005, Australia
- Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide SA 5000, Australia
| | - Christopher D Ovenden
- University of Adelaide, Adelaide SA 5005, Australia
- Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide SA 5000, Australia
| | - Rudy Goh
- University of Adelaide, Adelaide SA 5005, Australia
- Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide SA 5000, Australia
| | - Joshua G Kovoor
- Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide SA 5000, Australia
- Queen Elizabeth Hospital, Central Adelaide Local Health Network, Woodville SA 5011, Australia
| | - Aashray K Gupta
- University of Adelaide, Adelaide SA 5005, Australia
- Gold Coast University Hospital, Southport QLD 4215, Australia
| | - Yong Min Le
- University of Adelaide, Adelaide SA 5005, Australia
- Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide SA 5000, Australia
| | - Antoinette Lam
- College of Medicine and Public Health, Flinders University, Bedford Park SA 5042, Australia
- University of Adelaide, Adelaide SA 5005, Australia
| | - Brandon Stretton
- College of Medicine and Public Health, Flinders University, Bedford Park SA 5042, Australia
- University of Adelaide, Adelaide SA 5005, Australia
| | - Minh-Son To
- College of Medicine and Public Health, Flinders University, Bedford Park SA 5042, Australia
| | - Richard Woodman
- College of Medicine and Public Health, Flinders University, Bedford Park SA 5042, Australia
| | - Arduino A Mangoni
- College of Medicine and Public Health, Flinders University, Bedford Park SA 5042, Australia
- Flinders Medical Centre, Southern Adelaide Local Health Network, Bedford Park SA 5042, Australia
| | - James Malycha
- University of Adelaide, Adelaide SA 5005, Australia
- Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide SA 5000, Australia
- Queen Elizabeth Hospital, Central Adelaide Local Health Network, Woodville SA 5011, Australia
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Messmer AS, Elmer A, Ludwig R, Pfortmueller CA, Cioccari L, Schefold JC. Characteristics and outcomes of medical emergency team calls in a Swiss tertiary centre - a retrospective observational study. Swiss Med Wkly 2022; 152:40006. [PMID: 36455160 DOI: 10.57187/smw.2022.40006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
AIMS OF THE STUDY To describe reasons for medical emergency team (MET) activation over time, to analyse outcomes, and to describe the circadian distribution of MET calls and Intensive Care Unit (ICU) admissions following MET activation. METHODS Monocentric retrospective observational study of prospectively collected data on all MET calls between 1st of January 2012 until 31st of May 2019. We analysed data on baselines, referring wards, and disposition of all MET patients. In addition, we allocated all MET calls to the hourly intervals over the 24-hour cycle of the day in order to identify peak times of team activation. RESULTS A total of 4068 calls in 3277 patients (37% female, n = 1210) were analysed. The mean age was 65.9 years (± 15.7). The MET dose (defined as MET calls/1000 hospital admissions) remained relatively stable over the years with a median of 8.0 calls/1000 hospitalisations (interquartile range [IQR] 7.0-10.0). A total of 2526 calls (62%) occurred out of hours (17:00 to 8:00). The hourly rate of MET activations was greatest during the evening shift (33.8% of calls in seven hours), followed by the day shift (35.8% calls in nine hours) and night shift (30.4% in eight hours). Over the years, staff concern was the main reason for a MET call (n = 1192, 34%), followed by low peripheral oxygen saturation (SpO2) not responding to oxygen therapy (n = 776, 22%). Abnormal respiratory rate was a trigger to call the MET in 44 cases (1.3%), and was not documented prior to 2017. Overall, in-hospital mortality was 22%. CONCLUSION While most common reasons for MET calls over the years were staff concern and low SpO2, abnormal respiratory rate was the least frequent, but increased after the introduction of the quick sequential organ failure assessment (qSOFA) in 2016. Most MET calls occurred out of hours with peak hours during the evening shift, highlighting the importance of resource allocation during this shift when planning to introduce a MET system in a hospital. In-hospital mortality after a MET call was 22%.
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Affiliation(s)
- Anna S Messmer
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Annina Elmer
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Roger Ludwig
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Carmen A Pfortmueller
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luca Cioccari
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of Intensive Care Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Considine J, Fry M, Curtis K, Shaban RZ. Systems for recognition and response to deteriorating emergency department patients: a scoping review. Scand J Trauma Resusc Emerg Med 2021; 29:69. [PMID: 34022933 PMCID: PMC8140439 DOI: 10.1186/s13049-021-00882-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 04/28/2021] [Indexed: 11/24/2022] Open
Abstract
Background Assessing and managing the risk of clinical deterioration is a cornerstone of emergency care, commencing at triage and continuing throughout the emergency department (ED) care. The aim of this scoping review was to assess the extent, range and nature of published research related to formal systems for recognising and responding to clinical deterioration in emergency department (ED) patients. Materials and methods We conducted a scoping review according to PRISMA-ScR guidelines. MEDLINE complete, CINAHL and Embase were searched on 07 April 2021 from their dates of inception. Human studies evaluating formal systems for recognising and responding to clinical deterioration occurring after triage that were published in English were included. Formal systems for recognising and responding to clinical deterioration were defined as: i) predefined patient assessment criteria for clinical deterioration (single trigger or aggregate score), and, or ii) a predefined, expected response should a patient fulfil the criteria for clinical deterioration. Studies of short stay units and observation wards; deterioration during the triage process; system or score development or validation; and systems requiring pathology test results were excluded. The following characteristics of each study were extracted: author(s), year, design, country, aims, population, system tested, outcomes examined, and major findings. Results After removal of duplicates, there were 2696 publications. Of these 33 studies representing 109,066 patients were included: all were observational studies. Twenty-two aggregate scoring systems were evaluated in 29 studies and three single trigger systems were evaluated in four studies. There were three major findings: i) few studies reported the use of systems for recognising and responding to clinical deterioration to improve care of patients whilst in the ED; ii) the systems for recognising clinical deterioration in ED patients were highly variable and iii) few studies reported on the ED response to patients identified as deteriorating. Conclusion There is a need to re-focus the research related to use of systems for recognition and response to deteriorating patients from predicting various post-ED events to their real-time use to improve patient safety during ED care. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-021-00882-6.
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Affiliation(s)
- Julie Considine
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia. .,Centre for Quality and Patient Safety Research, Deakin University, Geelong, Victoria, Australia. .,Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia. .,Centre for Quality and Patient Safety Research, Eastern Health Partnership, Box Hill, Victoria, Australia.
| | - Margaret Fry
- Faculty of Health, University of Technology Sydney, St Leonards, New South Wales, Australia.,Northern Sydney Local Health District, St Leonards, New South Wales, Australia
| | - Kate Curtis
- Susan Wakil School of Nursing and Midwifery, The University of Sydney, Camperdown, New South Wales, Australia.,Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
| | - Ramon Z Shaban
- Susan Wakil School of Nursing and Midwifery, The University of Sydney, Camperdown, New South Wales, Australia.,Marie Bashir Institute for Infectious Diseases and Biosecurity, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia.,Western Sydney Local Health District, Westmead, New South Wales, Australia
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McGaughey J, O'Halloran P, Porter S, Blackwood B. Early warning systems and rapid response to the deteriorating patient in hospital: A systematic realist review. J Adv Nurs 2017; 73:2877-2891. [DOI: 10.1111/jan.13398] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Jennifer McGaughey
- School of Nursing & Midwifery; Medical Biology Centre; Queen's University Belfast; Belfast UK
| | - Peter O'Halloran
- School of Nursing & Midwifery; Queen's University of Belfast; Belfast UK
| | - Sam Porter
- Department of Social Sciences and Social Work; Bournemouth University; Poole UK
| | - Bronagh Blackwood
- School of Medicine, Dentistry & Biomedical Sciences; Centre for Experimental Medicine; Queen's University Belfast; Belfast UK
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Considine J, Currey J. Ensuring a proactive, evidence-based, patient safety approach to patient assessment. J Clin Nurs 2014; 24:300-7. [PMID: 24942476 DOI: 10.1111/jocn.12641] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2014] [Indexed: 12/01/2022]
Abstract
AIMS AND OBJECTIVES To argue that if all nurses were to adopt the primary survey approach (assessment of airway, breathing, circulation and disability) as the first element of patient assessment, they would be more focused on active detection of clinical deterioration rather than passive collection of patient data. BACKGROUND Nurses are the professional group that carry the highest level of responsibility for patient assessment, accurate data collection and interpretation. The timely recognition of, and response to deteriorating patients, is dependent on the measurement and interpretation of pertinent physiological data by nurses. DESIGN Discursive paper. METHODS Traditionally taught and commonly used approaches to patient assessment such as 'vital signs' and 'body systems' are not evidence-based nor framed in patient safety. The primary survey approach as the first element in patient assessment has three major advantages: (1) data are collected according to clinical importance; (2) data are collected using the same framework as most organisation's rapid response system activation criteria; and (3) the primary survey acts as a patient safety checklist, thereby decreasing the risk of failure to recognise, and therefore respond to, deteriorating patients. CONCLUSION The vital signs and body systems approaches to patient assessment have significant limitations in identifying clinical deterioration. The primary survey approach provides nurses with a consistent, evidence-based and sequenced approach to patient assessment in every clinical setting. RELEVANCE TO CLINICAL PRACTICE All nurses should use a primary survey approach as the first element of patient assessment in every patient encounter as a patient safety strategy.
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Affiliation(s)
- Julie Considine
- Eastern Health - Deakin University Nursing & Midwifery Research Centre, School of Nursing and Midwifery, Deakin University, Burwood, Australia
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Activation of a medical emergency team using an electronic medical recording-based screening system*. Crit Care Med 2014; 42:801-8. [PMID: 24335439 DOI: 10.1097/ccm.0000000000000031] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Setälä P, Jokela K, Yli-Hankala A, Hoppu S. Prognostic value of MET-criteria in patients treated by the physician in the emergency medical service. Resuscitation 2014. [DOI: 10.1016/j.resuscitation.2014.03.194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Merz TM, Etter R, Mende L, Barthelmes D, Wiegand J, Martinolli L, Takala J. Risk assessment in the first fifteen minutes: a prospective cohort study of a simple physiological scoring system in the emergency department. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R25. [PMID: 21244659 PMCID: PMC3222061 DOI: 10.1186/cc9972] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2010] [Revised: 12/20/2010] [Accepted: 01/18/2011] [Indexed: 01/20/2023]
Abstract
Introduction The survival of patients admitted to an emergency department is determined by the severity of acute illness and the quality of care provided. The high number and the wide spectrum of severity of illness of admitted patients make an immediate assessment of all patients unrealistic. The aim of this study is to evaluate a scoring system based on readily available physiological parameters immediately after admission to an emergency department (ED) for the purpose of identification of at-risk patients. Methods This prospective observational cohort study includes 4,388 consecutive adult patients admitted via the ED of a 960-bed tertiary referral hospital over a period of six months. Occurrence of each of seven potential vital sign abnormalities (threat to airway, abnormal respiratory rate, oxygen saturation, systolic blood pressure, heart rate, low Glasgow Coma Scale and seizures) was collected and added up to generate the vital sign score (VSS). VSSinitial was defined as the VSS in the first 15 minutes after admission, VSSmax as the maximum VSS throughout the stay in ED. Occurrence of single vital sign abnormalities in the first 15 minutes and VSSinitial and VSSmax were evaluated as potential predictors of hospital mortality. Results Logistic regression analysis identified all evaluated single vital sign abnormalities except seizures and abnormal respiratory rate to be independent predictors of hospital mortality. Increasing VSSinitial and VSSmax were significantly correlated to hospital mortality (odds ratio (OR) 2.80, 95% confidence interval (CI) 2.50 to 3.14, P < 0.0001 for VSSinitial; OR 2.36, 95% CI 2.15 to 2.60, P < 0.0001 for VSSmax). The predictive power of VSS was highest if collected in the first 15 minutes after ED admission (log rank Chi-square 468.1, P < 0.0001 for VSSinitial;,log rank Chi square 361.5, P < 0.0001 for VSSmax). Conclusions Vital sign abnormalities and VSS collected in the first minutes after ED admission can identify patients at risk of an unfavourable outcome.
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Affiliation(s)
- Tobias M Merz
- Department of Intensive Care Medicine, Bern University Hospital and University of Bern, Freiburgstrasse, 3010 Bern, Switzerland.
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Boniatti MM, Azzolini N, da Fonseca DLO, Ribeiro BSP, de Oliveira VM, Castilho RK, Raymundi MG, Coelho RS, Filho EMR. Prognostic value of the calling criteria in patients receiving a medical emergency team review. Resuscitation 2010; 81:667-70. [DOI: 10.1016/j.resuscitation.2010.01.025] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2009] [Revised: 01/14/2010] [Accepted: 01/28/2010] [Indexed: 10/19/2022]
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Triggers for emergency team activation: a multicenter assessment. J Crit Care 2010; 25:359.e1-7. [PMID: 20189754 DOI: 10.1016/j.jcrc.2009.12.011] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2009] [Revised: 11/28/2009] [Accepted: 12/29/2009] [Indexed: 11/23/2022]
Abstract
PURPOSE The purpose of the study was to examine triggers for emergency team activation in hospitals with or without a medical emergency team (MET) system. MATERIALS AND METHODS Within a cluster randomized controlled trial examining the effect of introducing a MET system, we recorded the triggers for emergency team activation. We compared the proportion and rate of such triggers in hospitals with or without a MET system and in relation to type of hospital, type of patient ward, and time of day. RESULTS In control hospitals, the most common trigger for emergency team activation was a decrease in Glasgow Coma Score by 2 or more points (45.6%), whereas in MET hospitals, it was the fact that staff members were "worried" or the call occurred despite the lack of a "specified reason" (39.3%). In particular, MET hospitals were 35 times more likely to make a call because of staff being "worried" about the patient (14.1% vs 0.4%, P < .001). Control hospitals were also significantly more likely to call an emergency team because of a deteriorating respiratory (P = .003) or pulse (P < .001) rate, more calls had at least 3 triggers for activation (20.8% vs 10.2%, P = .036), and the average number of triggers per call was significantly higher (P = .013). Nonmetropolitan hospitals were more likely to call an emergency team because of respiratory rate abnormalities (33.6% vs 23.2%, P = .015). Coronary care unit calls were more likely to be triggered by abnormalities in pulse rate and systolic blood pressure, and more calls occurred during the period from 6:00 am to noon. CONCLUSIONS In MET hospitals, more emergency team calls are triggered because staff members are worried about the patient; and fewer calls have multiple triggers. Type of hospital, type of ward, and time of day also affect the nature and frequency of triggers for emergency team activation.
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The Effect of Telephone Nurse Triage on the Appropriate Use of the Emergency Department. Nurs Clin North Am 2010; 45:65-9. [DOI: 10.1016/j.cnur.2009.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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