Implementation Of Medical Emergency Team Research Articles

Update Resuscitation - In-hospital Cardiac Arrest

The structure of emergency care is a key element for patients' safety in hospital. Early warning scores and the implementation of medical emergency teams (MET) can help to detect deteriorating patients early and prevent unexpected deaths. This article summarizes essential elements of a modern emergency management in hospitals.

Observational study of the implementation of medical emergency team in hospital

To analyze the implementation of medical emergency team (MET) in Fuxing Hospital of Capital Medical University, and to investigate the characteristics such as the time, department, disease, cause of the MET calls, in order to provide a basis for the improvement of MET's implementation. A retrospective study was conducted. MET calls that received between January 1st, 2015 and December 31st, 2018 at Fuxing Hospital were collected. The calls' information included the quarter, time, and the patients' gender, age, admission time, department, admission diagnosis, the reason for the calls, the operation and outcome of the MET upon arrival. A total of 846 MET calls were occurred during 4 years from 2015 to 2018. The frequencies of the first and third quarter were relatively high with 28.0% (237/846) and 26.5% (224/846), respectively. The events mainly occurred during the day (08:00-19:59) with 611 calls (72.2%). There were more men [64.3% (544/846)] than women [35.7% (302/846)]. The calls were mainly from the elderly over 60 years old, and gradually increased with age, which distributed the most in patients aging 80-89 years old, accounting for 51.5% of all calls (436/846). Among all the MET events, 80.5% (681/846) were from department of internal medicine, 18.8% (159/846) were from department of surgery, and 0.7% (6/846) were from department of gynecology and obstetrics. The top 3 diseases reported in the calls were respiratory diseases [31.6% (267/846)], nervous system diseases [20.8% (176/846)] and circulatory diseases [9.9% (84/846)]. The reason of MET calls showed that abnormal pulse oxygen saturation [SpO2, 27.8% (235/846)] were the most among 4 vital signs. After MET rescue, 7.3% (62/846) of the patients died, 48.7% (412/846) were transferred to intensive care unit (ICU) for further treatment, and 41.9% (354/846) remained under observation. The frequency of MET calls in Fuxing Hospital of Capital Medical University was relatively stable over the years, mostly received in the daytime (08:00-19:59) of the first and third quarter. Most of the patients were male aged 80-89 years old. The most MET calls were from department of internal medicine and due to respiratory disease. SpO2 was the most common abnormal indicator. According to the above characteristics, MET can focus on them in the future.

A call for better doctor–nurse collaboration: A qualitative study of the experiences of junior doctors and nurses in escalating care for deteriorating ward patients

BackgroundDespite the widespread implementation of medical emergency teams (METs) in hospitals to provide immediate interventions to deteriorating ward patients, little is known about how junior doctors and nurses escalate care for deteriorating ward patients in hospitals with established MET services. ObjectivesThe objective of this research study was to explore the experiences of junior doctors and nurses in escalating care for clinically deteriorating patients in general wards. MethodsTwenty-four individual interviews were conducted with 10 junior doctors and 14 registered nurses of a 1000-bed acute general hospital with the most established MET service in Singapore. Interviews were transcribed verbatim and analysed using an interpretive thematic analysis approach. FindingsThree salient themes emerged from thematic analysis: (1) MET activations versus the primary team doctors' reviews, (2) challenges in obtaining medical reviews, and (3) unspoken rules of the escalation of care. Participants' decisions to call the MET or to escalate to the primary team doctors not only depended on the severity of a patient's deterioration and their perceptions of the primary team doctors' capacity to manage the patient but also were largely influenced by sociocultural factors that were shaped by the hierarchy of medical professions. Key challenges faced by nurses in obtaining medical reviews from junior doctors for patients with early deterioration included presenting “convincing” evidence of patient deterioration and “packaging” information about patient deterioration. ConclusionsThe decision to call a MET or the primary team doctors is a complex judgement that is greatly influenced by the dynamics of perceived hierarchy between the medicine and nursing professions and within the medicine profession. Educational and organisational changes that enhance doctor–nurse interprofessional and intraprofessional collaboration among all levels of doctors may improve the process of the escalation of care for deteriorating patients and thus improve patient safety for hospitalised patients.

Implementation of Medical Emergency Teams to Improve Perioperative Patient Safety. Who? When? How?

In contrast to prehospital emergency medicine, there are no comparable established structures or statutory requirements for structural and procedural organisation, or qualification of personnel and equipment for in-hospital emergency care in Germany. However, in perioperative patients, unexpected complications are fairly common on regular wards. Often, even hours before a possible critical event, warning signs of deterioration are present, which too often go unnoticed. Subsequently, potentially avoidable serious complications or cardiac arrest may occur. The establishment of so-called medical emergency teams (MET) serves to improve the emergency care organisation of the hospital and helps to avoid in-hospital cardiac arrest. The MET is alerted at an early stage of deterioration and uses a preventive therapy approach for pathophysiological deviations of the vital signs. This preventative approach can help to avoid in-hospital cardiac arrest and unplanned admission to an intensive care unit and thus contribute to increase perioperative patient safety.

Association of Pediatric Medical Emergency Teams With Hospital Mortality.

Implementation of medical emergency teams has been identified as a potential strategy to reduce hospital deaths, because these teams respond to patients with acute physiological decline in an effort to prevent in-hospital cardiac arrest. However, prior studies of the association between medical emergency teams and hospital mortality have been limited and typically have not accounted for preimplementation mortality trends. Within the Pediatric Health Information System for freestanding pediatric hospitals, annual risk-adjusted mortality rates were calculated for sites between 2000 and 2015. A random slopes interrupted time series analysis then examined whether implementation of a medical emergency team was associated with lower-than-expected mortality rates based on preimplementation trends. Across 38 pediatric hospitals, mean annual hospital admission volume was 15 854 (range, 6684-33 024), and there were a total of 1 659 059 hospitalizations preimplementation and 4 392 392 hospitalizations postimplementation. Before medical emergency team implementation, hospital mortality decreased by 6.0% annually (odds ratio [OR], 0.94; 95% confidence interval [CI], 0.92-0.96) across all hospitals. After medical emergency team implementation, hospital mortality continued to decrease by 6% annually (OR, 0.94; 95% CI, 0.93-0.95), with no deepening of the mortality slope (ie, not lower OR) in comparison with the preimplementation trend, for the overall cohort (P=0.98) or when analyzed separately within each of the 38 study hospitals. Five years after medical emergency team implementation across study sites, there was no difference between predicted (hospital mean of 6.18 deaths per 1000 admissions based on preimplementation trends) and actual mortality rates (hospital mean of 6.48 deaths per 1000 admissions; P=0.57). Implementation of medical emergency teams in a large sample of pediatric hospitals in the United States was not associated with a reduction in hospital mortality beyond existing preimplementation trends.

The Medical Emergency Team Call

Several studies have questioned the effectiveness of rapid-response systems when measured by outcomes such as decreased overall hospital mortality or cardiac arrest rates. We studied an alternative outcome of rapid-response system implementation, namely, its effect on goals of care and designation of do not resuscitate. Retrospective chart review. Veterans Administration Hospital in New York City. All patients requiring a medical emergency team call. None : Monthly hospital census and discharge data, death occurrences, and do-not-resuscitate order placements were collected over an 8-year pre-medical emergency team and 5-year post-medical emergency team period. All medical emergency team calls and subsequent transfers to a critical care unit were reviewed and correlated to the placement and timing of do-not-resuscitate orders. Interrupted time-series analysis was used to evaluate the impact of the medical emergency team implementation on the change in trend of do-not-resuscitate orders and the hospital mortality. A total of 390 medical emergency team calls were associated with 109 do-not-resuscitate orders (28%). Of the 209 medical emergency team calls (54%) resulting in transfer to a critical care unit, 66 were associated with do-not-resuscitate orders, 73% of which were obtained after transfer. The odds of becoming do not resuscitate for a patient going to the ICU after the medical emergency team call were 2.9 (95% CI, 1.6-5.5; p = 0.001) times greater than for patients staying on the floors after the medical emergency team call. The medical emergency team implementation significantly changed the trend of do-not-resuscitate orders (p < 0.001) but had no impact on hospital mortality rate (p = 0.638). Implementation of a rapid-response system was associated with an increase in do-not-resuscitate order placement. As a sentinel event, medical emergency team activation and transfer to a critical care unit foster consideration of goals of care and frequently results in a transition to a palliative care strategy.

Early impact of medical emergency team implementation in a country with limited medical resources: A before-and-after study

PurposeThe purpose of the study was to determine whether earlier clinical intervention by a medical emergency team (MET) can improve patient outcomes in an Asian country. MethodsA nonrandomized study was performed during two 6-month periods before and after the introduction of a MET. ResultsThe rates of cardiac arrests and “potentially preventable” cardiac arrests were lower after MET introduction, but the differences did not reach statistical significance. There was a statistically significant decrease in the incidence of cardiac arrests in the first 3 months of the academic year (2.3 vs 1.2 per 1000 admissions, P = .012). Introduction of MET reduced the time interval from physiologic derangement meeting MET activation criteria to intensive care unit (ICU) admission (“derangement-to-ICU interval”) (10.8 vs 6.3 hours, P < .001). Multivariate analysis revealed that the mortality of unplanned ICU admissions was independently associated with simplified acute physiology score 3 and “derangement-to-ICU interval.” ConclusionsIntroduction of a MET reduced the number of cardiac arrests in the general ward during the first 3 months of the academic year. Introduction of MET also decreased the “derangement-to-ICU interval,” which was an independent predictor of survival in patients with unplanned ICU admissions. Therefore, MET introduction may lead to improved outcomes for hospitalized patients in a country with limited medical resources.

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

To prospectively evaluate the implementation of a rapid response team in the form of a medical emergency team (MET) with regard to cardiac arrests and hospital mortality. Prospective before-and-after trial of implementation of a MET at the Karolinska University Hospital, Stockholm, Sweden. All adult patients, apart from cardiothoracic, admitted to the hospital were regarded as participants in the study. A control period of 5 years and 203,892 patients preceded the 2-year intervention period of 73,825 patients. Number of MET calls was 9.3 per 1,000 hospital admissions. Cardiac arrests per 1,000 admissions decreased from 1.12 to 0.83, OR 0.74 (95% CI 0.55-0.98, p = 0.035). Adjusted for age, sex, hospital length of stay, acute/elective admission as well as co-morbidities, MET implementation was associated with a reduction in total hospital mortality by 10%, OR 0.90 (95% CI 0.84-0.97), p = 0.003. Hospital mortality was also reduced for medical patients by 12%, OR 0.88 (95% CI 0.81-0.96, p = 0.002) and for surgical patients not operated upon by 28%, OR 0.72 (95% CI 0.56-0.92, p = 0.008). FOR PATIENTS FULFILLING THE MET CRITERIA: Thirty-day mortality pre-MET was 25% versus 7.9% following MET compared with historical controls. Similarly, 180-day mortality was 37.5% versus 15.8%, respectively. Implementing the MET team was associated with significant improvement in both cardiac arrest rate and overall adjusted hospital mortality. Significant reductions in hospital mortality for un-operated surgical patients as well as for medical patients were also seen. Thus, introduction of the MET seemed to improve outcome for hospitalized patients.

Medical emergency teams and rapid response triggers - the ongoing quest for the 'perfect' patient safety system

We read with interest the article by Iyengar and colleagues [1] on the impact of standardized implementation of medical emergency teams (METs) for the early identification and management of acutely deteriorating patients on the ward. The vast majority (88%) of all preventable adverse events were classified as ‘therapeutic errors’. The authors have to be commended for their proactive patient safety approach by implementation of a standardized method for root cause analysis and classification of preventable adverse events. We and others have recently proposed an alternative model to the MET, namely one based on defined clinical triggers to initiate a rapid response escalation [2-4]. A clinical triggers system overcomes the ‘classic’ limitations of the MET system, as related to an overuse of resources and the fragmentation of patient care. The clinical triggers program established at Denver Health Medical Center involves a standardized ‘afferent’ limb of patient identification based on objective, physiological response triggers for a rapid response escalation. The ‘efferent’ limb is provided by the designated primary house staff team caring for the individual patient [2,3]. While the present study [1] was not designed to address issues related to response system modalities, the root cause analysis by Iyengar and colleagues supports the rationale of a clinical triggers-based response system. As such, the therapeutic errors identified as the major determinant of preventable adverse events [1] are likely recognized and corrected in a more accurate and timely fashion by a team of providers associated with the continuum of care, as opposed to a MET, which involves people who are unfamiliar with patients’ pertinent medical conditions. These aspects should be taken into consideration in the ongoing debate and controversy about safety and efficiency of the ‘perfect’ rapid response system [5].

The relationship between early emergency team calls and serious adverse events*

To examine the relationship between early emergency team calls and the incidence of serious adverse events--cardiac arrests, deaths, and unplanned admissions to an intensive care unit--in a cluster randomized controlled trial of medical emergency team implementation (the MERIT study). Post hoc analysis of data from cluster randomized controlled trial. Twenty-three public hospitals in Australia and 741,744 patients admitted during the conduct of the study. Attendance by a rapid response system team or cardiac arrest team. The relationship between the proportion of rapid response system team calls that were early emergency team calls (defined as calls not associated with cardiac arrest or death) and the rate (events/1000 admissions) of the adverse events. We analyzed 11,242 serious adverse events and 3700 emergency team calls. For every 10% of increase in the proportion of early emergency team calls there was a 2.0 reduction per 10,000 admissions in unexpected cardiac arrests (95% confidence interval [CI] -2.6 to -1.4), a 2.2 reduction in overall cardiac arrests (95% CI -2.9 to -1.6), and a 0.94 reduction in unexpected deaths (95% CI -1.4 to -0.5). We found no such relationship for unplanned intensive care unit admissions or for the aggregate of unexpected cardiac arrests, unplanned intensive care unit admissions, and unexpected deaths. As the proportion of early emergency team calls increases, the rate of cardiac arrests and unexpected deaths decreases. This inverse relationship provides support for the notion that early review of acutely ill ward patients by an emergency team is desirable.

Medizinische Notfallteams

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.

Implementation of a medical emergency team in a large pediatric teaching hospital prevents respiratory and cardiopulmonary arrests outside the intensive care unit*

We implemented a medical emergency team (MET) in our free-standing children's hospital. The specific aim was to reduce the rate of codes (respiratory and cardiopulmonary arrests) outside the intensive care units by 50% for >6 months following MET implementation. Retrospective chart review and program implementation. A children's hospital. None. The records of patients who required cardiorespiratory resuscitation outside the critical care areas were reviewed before MET implementation to determine activation criteria for the MET. Codes were prospectively defined as respiratory arrests or cardiopulmonary arrests. MET-preventable codes were prospectively defined. The incidence of codes before and after MET implementation was recorded. Twenty-five codes occurred during the pre-MET baseline compared with six following MET implementation. The code rate (respiratory arrests + cardiopulmonary arrests) post-MET was 0.11 per 1,000 patient days compared with baseline of 0.27 (risk ratio, 0.42; 95% confidence interval, 0-0.89; p = .03). The code rate per 1,000 admissions decreased from 1.54 (baseline) to 0.62 (post-MET) (risk ratio, 0.41; 95% confidence interval, 0-0.86; p = .02). For MET-preventable codes, the code rate post-MET was 0.04 per 1,000 patient days compared with a baseline of 0.14 (risk ratio, 0.27; 95% confidence interval, 0-0.94; p = .04). There was no difference in the incidence of cardiopulmonary arrests before and after MET. For codes outside the intensive care unit, the pre-MET mortality rate was 0.12 per 1,000 days compared with 0.06 post-MET (risk ratio, 0.48; 95% confidence interval, 0-1.4, p = .13). The overall mortality rate for outside the intensive care unit codes was 42% (15 of 36 patients). Implementation of a MET is associated with a reduction in the risk of respiratory and cardiopulmonary arrest outside of critical care areas in a large tertiary children's hospital.

Medical emergency teams: a role for expanding intensive care?

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". 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. 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. 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.