Medical Emergency Response Team Research Articles

Casualty Rates Among Danish Soldiers in Iraq and Afghanistan

In 2002 – 2009 Danish forces suffered a mortality rate of 0.09% in Iraq and 0.38% in Afghanistan, and a morbidity rate of 0.30% in Iraq and 1.01% in Afghanistan,...

Maritime Pre-Hospital Emergency Care Primary Retrieval Team – Operational Considerations

This article examines the non clinical skills and training required for effective maritime pre-hospital emergency care provision within a Role Two Afloat facility, allowing for a Primary Retrieval Team to be deployed in support of boarding operations. The provision of pre-hospital emergency care and sending a retrieval team forward has been trialled in various forms. In 2010 and 2011 a R2A team was deployed aboard RFA FORT VICTORIA. This included a Primary Retrieval Team consisting of an Emergency Nurse Specialist, a Medical Assistant which can be enhanced when required by an Emergency Care or Anaesthetic Consultant. This differs from the land operations support provided by the airborne Medical Emergency Response Team (MERT) as the maritime environment requires a bespoke solution for casualty retrieval as the method of deployment and the type of casualties and their locations may be more varied, requiring greater flexibility of approach.

Simulation, Human Factors and Defence Anaesthesia

Simulation in healthcare has come a long way since it’s beginnings in the 1960s. Not only has the sophistication of simulator design increased, but the educational concepts of simulation have...

Vascular Access on the 21st Century Military Battlefield

Timely and appropriate access to the vascular circulation is critical in the management of 21st century battlefield trauma. It allows the administration of emergency drugs, analgesics and rapid replacement of...

Unplanned transfers to the intensive care unit: The role of the shock index

Unplanned (unexpected) transfers to the intensive care unit (ICU) are typically preceded by physiologic instability. However, trends toward instability may be subtle and not accurately reflected by changes in vital signs. The shock index (SI) (heart rate/systolic blood pressure as an indicator of left ventricular function, reference value of 0.54) may be a simple alternative means to predict clinical deterioration. To assess the association of the SI with unplanned ICU transfers. Retrospective case-control study. Academic medical center. Fifty consecutive general medical patients with unplanned ICU transfers between 2003 and 2004 and 50 matched controls admitted to the same general medical unit between 2002 and 2004. Demographic data and vital signs abstracted from chart review. The SI was associated with unplanned ICU transfer at values of 0.85 or greater (P < 0.02; odds ratio, 3.0) and there was a significant difference between the median of worst shock indices of cases and controls (0.87 vs. 0.72; P < 0.005). There was no significant difference in age, race, admission ward, or Charlson Comorbidity Index, but hospital stay for cases was significantly longer (mean [standard deviation, SD], 14.8 [9.7] days vs. 5.7 [6.3] days; P < 0.001). SI is associated with unplanned transfers to the ICU from general medical units at values of 0.85 or greater. Future studies will determine whether SI is more accurate than simple vital signs as an indicator of clinical decline. If so, it may be a useful trigger to activate medical emergency or rapid response teams (RRTs).

Doctor on board? What is the optimal skill-mix in military pre-hospital care?

BackgroundIn a military setting, pre-hospital times may be extended due to geographical or operational issues. Helicopter casevac enables patients to be transported expediently across all terrains. The skill-mix of the...

Advanced Airway Management – a Medical Emergency Response Team Perspective

ObjectivesTo determine the number of medical emergency response team (MERT) patients undergoing advanced airway management in the peri-evacuation phase and to determine the indications for airway interventions undertaken in flight.MethodsThis...

Optimal Clinical Timelines - A Consensus from the Academic Department of Military Surgery and Trauma

There are no published studies directly addressing the issue of what is an acceptable timeline from point of wounding to surgical intervention within the military context. The proximal threshold has...

Trauma: we care. More for discussion

I read with interest the recent letter by Zafar et al. [1] and felt that some of the issues raised required clarification. Firstly, there seems to be some confusion in the letter between transfer/retrieval medicine and pre-hospital medicine. Transfer and retrieval in civilian practice in the United Kingdom is concerned with delivery of patients between hospitals, i.e. patients who have already been admitted to a medical care facility. Pre-hospital medicine may include this role, but more commonly refers to ‘the provision of skilled healthcare at the site of a trauma incident or medical emergency’ [2]. Secondly, the authors also make reference to pre-hospital tracheal intubation, implying that paramedics intubate trauma patients. Paramedics in the United Kingdom currently do intubate patients, but only those who do not require pharmacological agents to assist intubation. This group of patients, in the context of trauma, have a near 100% mortality rate [3]. Rapid sequence induction of anaesthesia is only performed currently by pre-hospital doctors. This seems unlikely to change in light of a Joint Royal Colleges Ambulance Liaison Committee report of June 2008, which states ‘paramedic tracheal intubation cannot be recommended as a mandatory component of paramedic practice and should not be continued to be practiced in its current format’ [4]. The authors seem to suggest a retrieval system based on the military model, presumably referring to Medical Emergency Response Teams, currently operating in Afghanistan. A typical Medical Emergency Response Team setup will include a consultant or senior trainee anaesthetist. As the authors rightly state, medical treatment is started en route to base, in the back of the helicopter. Cramped as it may be, a CH-47 helicopter is still a great deal larger than the majority of civilian air ambulances. There are also restrictions on when civilian air ambulances may fly without an instrument rating; some may not carry passengers after dusk. Most are not based at the site of tertiary referral or trauma centres, necessitating a crew waiting at the airfield and removed from other clinical work. In particular, I find the suggestion regarding a Physician’s Assistant being utilised in retrieval particularly worrying. The Royal College of Anaesthetists explicitly states that Physician’s Assistants must not undertake initial airway assessment and management of acutely ill or injured patients and cannot work without a named consultant being both within the theatre suite and being immediately available [5]. The authors summarise by calling for raised standards for transfer training, which appears to be a perfectly reasonable aim. There are already many in the pre-hospital community who are working tirelessly towards raising standards in the field of pre-hospital care. It is important however that we don’t lose sight of the issues surrounding each speciality by confusing transfer/retrieval medicine with pre-hospital care.

414: Emergency Medicine as a Staffing Model for Medical Emergency Response Teams

The 2008 National Patient Safety Goals require hospitals to develop rapid response systems (RRS). Most RRS teams in large academic teaching hospitals have been staffed by intensivists. We describe a staffing model using emergency medicine (EM) that we believe is unique to medical emergency teams (METs) in academic teaching hospitals.

GS14P ROUTINE USE OF MEDICAL EMERGENCY TEAMS IN MANAGING SURGICAL EMERGENCIES

Introduction Trauma teams and cardiac arrest teams provide an urgent and expert multi‐disciplinary response to time critical emergencies. The present study documents the contribution of a medical emergency team (MET) to managing non‐trauma surgical emergencies.Materials and Methods Data was prospectively collected over a two year period concerning the contribution of medical emergency teams to the resuscitation of all patients with non‐trauma surgical emergencies and altered vital signs in hospital wards.Results Over the study period, the details of 19 patients with surgical emergencies were recorded. 63% of emergencies occurred outside of normal working hours. In 53% of cases, the surgical registrar was off‐site or physically unavailable to attend the emergency immediately. In 11% of cases, the medical emergency team was activated prior to the arrival of the surgical registrar. In 26% of cases, the patient was left unattended whilst awaiting arrival of the surgical registrar. The medical emergency team provided resuscitation procedures and arranged urgent investigations in all patients, physically transported the patient to the operating theatre in 16% of patients and prepared for general anaesthetic in the operating theatre in 11% of cases. The surgical registrar complemented the medical emergency team response by liaising with consultant surgeons, anaesthetists and operating theatre staff in all cases. All patients received definitive treatment within 30 minutes of MET response.Conclusion Routine use of medical emergency teams in the initial resuscitation of patients with surgical emergencies expedites definitive management.

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.

Findings of the First Consensus Conference on Medical Emergency Teams*

Studies have established that physiologic instability and services mismatching precede adverse events in hospitalized patients. In response to these considerations, the concept of a Rapid Response System (RRS) has emerged. The responding team is commonly known as a medical emergency team (MET), rapid response team (RRT), or critical care outreach (CCO). Studies show that an RRS may improve outcome, but questions remain regarding the benefit, design elements, and advisability of implementing a MET system. In June 2005 an International Conference on Medical Emergency Teams (ICMET) included experts in patient safety, hospital medicine, critical care medicine, and METs. Seven of 25 had no experience with an RRS, and the remainder had experience with one of the three major forms of RRS. After preconference telephone and e-mail conversations by the panelists in which questions to be discussed were characterized, literature reviewed, and preliminary answers created, the panelists convened for 2 days to create a consensus document. Four major content areas were addressed: What is a MET response? Is there a MET syndrome? What are barriers to METS? How should outcome be measured? Panelists considered whether all hospitals should implement an RRS. Patients needing an RRS intervention are suddenly critically ill and have a mismatch of resources to needs. Hospitals should implement an RRS, which consists of four elements: an afferent, "crisis detection" and "response triggering" mechanism; an efferent, predetermined rapid response team; a governance/administrative structure to supply and organize resources; and a mechanism to evaluate crisis antecedents and promote hospital process improvement to prevent future events.

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

This paper reports a study of nurses' perceptions about medical emergency teams and their impact on patient care and the nursing work environment. 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. 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. 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. 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.

Twenty four hour medical emergency response teams in a mental health in-patient facility – New approaches for safer restriant

The National Institute for Clinical Excellence (2005) published guidance on the management of disturbed behaviour in mental health settings and emergency departments. The guidance included some of the recommendations made in the Independent Inquiry into the death of David Bennett (2003). One important recommendation requires that staff implementing physical interventions (restraint) and/or parenteral rapid tranquilisation are able to effectively manage the physical health of the patient including any immediate complications that may arise.This article provides background and a syllabus for training for staff to be able to meet the physical assessment skills and interventions required by recent UK national guidance. Also reported is the creation, role and deployment of a 24-hour Medical Emergency Response Team in an in-patient mental health setting to ensure responses to both medical and psychiatric emergencies offer improved safety and adhere to the new guidance. The article describes the provision of a person with the sole responsibility monitoring a patients physical safety during restriant, 24 hour a day, 7 days a week.The article will be of interest to those working in in-patient mental health and learning disability services, especially those where they are not served by a resuscitation team as part of a District General Hospital and where there is no resident Duty Medical Officer.

Experienced Critical Care Nurse-led Rapid Response Teams Rescue Patients on In-patient Units

The rapid response team, called the medical emergency team (MET) at Tallahassee Memorial Hospital (TMH), is one of the latest strategies being used by hospitals across the nation to provide early intervention and prevent patient deaths. The MET helps nurses intervene early in a patient's course to avert complications, failure to rescue, and unexpected deaths. Different from the “code team” but sometimes involving many of the same intensive care unit (ICU) nurses, a MET response is initiated most often by nurse-to-nurse consultation. To initiate the MET, an inpatient unit nurse or other hospital colleague concerned about a patient calls the ICU. Whichever critical care nurse is on call for the MET responds with equipment, such as a portable monitor-defibrillator. Experienced clinicians care expertise to the bedside at the first sign that the patient maybe in trouble. Depending on the case, the MET nurse may then call other resources that she or he feels is indicated, such as a respiratory therapist. The MET may be called by a staff nurse, nursing supervisor, a physician, respiratory therapist, or another provider, essentially anyone within the hospital system. Most often, MET responses are nurses consulting nurses.

Smallpox looms large—in life, and on the web

Several new websites devoted to smallpox preparedness launched recently, and many established sites were updated to reflect growing concerns about a smallpox bioterrorist attack. The trigger was US President Bush's announcement that military personnel would be vaccinated against smallpox, and that the vaccine would offered on a voluntary basis to medical professionals and emergency personnel and response teams that would be the first on the scene in a smallpox emergency (see p 60 and http://www.whitehouse.gov/news/releases/2002/12/20021213-7.html). Details of the vaccination programme and assurances that the USA has plenty of vaccine to hand were quickly posted on the CDC website (http://www.bt.cdc.gov/agent/smallpox/vaccination/vaccination-program-statement.asp). About the same time, the non-profit RAND institute released a study that warns that undertaking widespread smallpox vaccination is “too dangerous” in the absence of a “substantial” risk of a major biological attack (http://www.rand.org/pox.html); the study was published in the January 30, 2003, issue of the New England Journal of Medicine and may be downloaded free of charge on the journal's website (http://content.nejm.org/cgi/reprint/NEJMsa025075v1.pdf). Nonetheless, Bush himself was vaccinated (http://www.nytimes.com/2002/12/22/national/22VACC.html), and shortly thereafter, the US government launched Smallpox.gov (http://www.smallpox.gov) and the Infectious Diseases Society launched Bioterrorism Information and Resources (http://www.idsociety.org/BT/ToC.htm). Highlights of the new sites are included here, along with details on other smallpox information sites of interest.

Strategy for Developing a Hospital Affiliated Ambulatory Care Medical Emergency Response Team

Health care facilities should reassess their resuscitation team response strategies in light of the shift in care from inpatient to outpatient facilities. This article discusses a strategy for assessing a health care facility's resuscitation needs globally, including a detailed analysis of the physical layout, population requiring coverage, personnel, and equipment. Resuscitation system design is reviewed, with particular emphasis on training, equipment, process variables, administration, cost, and quality improvement. Widespread training of nurse-first responders in the use of automated external defibrillators along with an in-hospital or community emergency medical services advanced life-support response is a cost-effective way of providing tiered coverage to remote outpatient facilities or satellite units.

The Medical Emergency Team: 12 month analysis of reasons for activation, immediate outcome and not-for-resuscitation orders

Objective: To describe the reasons for, and immediate outcome following Medical Emergency Team (MET) activation. Methods: Retrospective analysis of MET calls in 1998. Results: There were 713 MET calls to 559 in-patients. Of the 559 patients 252 (45%) were admitted to ICU and 49 (6.9%) died during the MET response. The three commonest criteria for calling the MET were a fall in GCS>2 ( n=155); a systolic blood pressure<90 mmHg ( n=142) and a respiratory rate>35 ( n=109). Cardiac arrests accounted for 61 calls and had an immediate mortality of 59%. The most common MET criterion associated with admission to ICU was a respiratory rate >35. Of patients who received MET calls based only on the ‘worried’ criterion 16% were admitted to ICU. The MET felt that a not-for-resuscitation order would have been appropriate in 130 cases (23%). NFR orders were documented during 27 of the MET calls. Conclusions: The MET system provides objective and subjective criteria by which medical and nursing staff can identify patients who become acutely unwell. A high proportion of these patients will require admission to Intensive Care. The MET system also provides the opportunity to identify patients for whom an NFR order should be considered.

Evidence for peripheral neurotoxic effect of trichloroethylene.

<h3>Background</h3> Hypocalcaemia is a common metabolic derangement in critically ill patients. Blood transfusion can also contribute to depleted calcium levels. The aims of this study were to identify the incidence of hypocalcaemia in military trauma patients receiving blood products en route to a deployed hospital facility and to determine if intravenous calcium, given during the prehospital phase, has an effect on admission calcium levels. <h3>Methods</h3> This was a retrospective review of patients transported by the UK Medical Emergency Response Team in Afghanistan between January 2010 and December 2014 who were treated with blood products in the prehospital setting. Total units of blood products administered, basic demographics, Injury Severity Score and trauma type were collected. Ionised serum calcium levels on admission to hospital were compared between those who received blood products without prehospital intravenous calcium supplemental therapy (non-treatment) and patients who were treated with 10 mL of intravenous calcium chloride (10%) concurrently with blood products (treatment). <h3>Results</h3> The study included 297 patients; 237 did not receive calcium and 60 did. The incidence of hypocalcaemia in the non-treatment group was 70.0% (n=166) compared with 28.3% (n=17) in the treatment group. Serum calcium levels were significantly different between the groups (1.03 mmol/L vs 1.25 mmol/L, difference 0.22 mmol/L, 95% CI 0.15 to 0.27). In the non-treatment group, 26.6% (n=63) had calcium levels within the normal range compared with 41.7% (n=25) in those who received calcium. There was a dose response of calcium level to blood products with a significant decrease in calcium levels as the volume of blood products increased. <h3>Conclusion</h3> Trauma patients who received blood products were at high risk of hypocalcaemia. Aggressive management of these patients with intravenous calcium during transfusion may be required.