Medical Emergency Team Calls Research Articles

A comparison of ambulance responses to incidents of Medical Emergency Teams led by nurses and paramedics––A retrospective single-center study

BackgroundIn Poland there are currently two main types of Medical Emergency Team: basic, run by nurses or paramedics, and specialist, led by physicians. They differ not only in professional qualifications but also in their terms of reference. ObjectivesWe compared the responses to incidents of Medical Emergency Teams led by nurses and paramedics, in terms of the frequency of pharmacotherapy use and medical rescue activities. Study designAmbulance call reports. SettingsMedical Emergency Teams in Eastern Poland. ParticipantsMedical Emergency Teams led by nurses or paramedics. Exclusion criteria were cancelation of calls by the dispatcher, calls with no patient on the scene, and neonatal and interhospital transportation. MethodsA retrospective analysis of ambulance call reports. A comparison of actions of nurses and paramedics taken in the field, and decisions concerning transportation of the patient to a hospital or leaving the home were collected. ResultsOf 1115 Medical Emergency Teams calls, those led by paramedics (60.5%) were more common. Paramedics, more often than nurses, provided aid solely in the field—27.5% and 16.0%, respectively—and less frequently transported patients to the hospital—38.5% and 50.7%, respectively. Significant differences in administration of oxygen therapy and analgesics were identified; paramedics used them more often than nurses. Paramedics used cervical collars, 3.6% and 1.1% (p=0.01), respectively, and performed 12-lead electrocardiograms, 4.7% and 1.4% (p=0.002), respectively, significantly more frequently than did nurses. ConclusionsDespite the comparable competency of paramedics and emergency nurses in Poland, Medical Emergency Teams’ activities varied depending on whether a nurse or a paramedic was the team leader. It is recommended that further in-depth research is conducted in this area.

Nostradamus in a tube of blood?

Nostradamus in a tube of blood?

Development of Heart and Respiratory Rate Percentile Curves for Hospitalized Children

To develop and validate heart and respiratory rate percentile curves for hospitalized children and compare their vital sign distributions to textbook reference ranges and pediatric early warning score (EWS) parameters. For this cross-sectional study, we used 6 months of nurse-documented heart and respiratory rates from the electronic records of 14,014 children on general medical and surgical wards at 2 tertiary-care children's hospitals. We developed percentile curves using generalized additive models for location, scale, and shape with 67% of the patients and validated the curves with the remaining 33%. We then determined the proportion of observations that deviated from textbook reference ranges and EWS parameters. We used 116,383 heart rate and 116,383 respiratory rate values to develop and validate the percentile curves. Up to 54% of heart rate observations and up to 40% of respiratory rate observations in our sample were outside textbook reference ranges. Up to 38% of heart rate observations and up to 30% of respiratory rate observations in our sample would have resulted in increased EWSs. A high proportion of vital signs among hospitalized children would be considered out of range according to existing reference ranges and pediatric EWSs. The percentiles we derived may serve as useful references for clinicians and could be used to inform the development of evidence-based vital sign parameters for physiologic monitor alarms, inpatient electronic health record vital sign alerts, medical emergency team calling criteria, and EWSs.

Evaluation of incoming calls to intensive care unit for emergency assistance

Abstract Aim. The aim of this retrospective study was to determine mean admission time after calls, resuscitation success rate, and determine the rate of medical emergency team (MET) calls of clinics in hospital by assessing the incoming calls to MET at intensive care unit. Methods. This study was conducted by collecting emergency call forms of 147 patients. The data including age, gender, medical diagnosis, the name of the caller department, cause of call, occurrence time, call time, attending time, medical care termination time and the outcomes were extracted from the forms or patient files. Event declaration time was accepted as minute time difference between occurrence time and call time. Duration of admission was accepted as minute time difference between call times and attending time. Duration of resuscitation was accepted as minute time difference between attending time and medical care termination time. Results. Mean event declaration time was 3.3 ± 3.0 minutes. Mean duration of admission was 3.7 ± 1.6 minutes. Mean duration of resuscitation was 20.5 ± 12.7 minutes. The resuscitation of 84 patients (63.6%) was successful while 48 patients (36.4%) died at the end of resuscitation. It was found that the patients with a result of successful resuscitation were significantly younger and their duration of resuscitation was significantly shorter. Conclusion. We indicate that MET system is an essential part of in-hospital emergency medical care system. We suggest that a blue code call system should be established by intensive care unit members and announced to all hospital staff. Keywords: Emergency medical care, medical emergency team, cardiac arrest, blue code, call Ozet Amac. Bu retrospektif calismanin amaci hastane icinde yogun bakim unitemizdeki acil yardim ekibine yapilan cagrilari degerlendirerek, ortalama varis suresi, resusitasyon basari oranlari ve arayan kliniklerin belirlenmesidir. Yontem. Bu calisma 147 hastanin formlari incelenerek yapildi. Yas, cinsiyet, tani, klinik adi, cagri nedeni, olay zamani, arama zamani, varis zamani, tibbi bakim sonlandirma zamani ve sonuc bilgileri kaydedildi. Olay bildirim suresi, varis suresi, resusitasyon suresi bilgileri hesaplanarak kaydedildi. Olay bildirim suresi olay zamani ile arama zamani arasi, varis suresi arama zamani ila varis zamani arasi, resusitasyon suresi varis zamani ile tedaviyi sonlandirma zamani arasi sureler olarak alindi. Bulgular. Ortalama olay bildirim suresi 3,3 ± 3,0 dakika idi. Ortalama varis suresi 3,7 ± 1,6 dakika idi. Ortalama resusitasyon suresi 20,5 ± 12,7 dakika idi. 84 (%63,6) hastanin resusitasyonu basarili iken 48 (%36,4) i resusitasyon sonunda mortaliteyle sonuclandi. Sonuclari basarili olan hastalarin yaslari belirgin olarak daha genc olarak bulundu ve resusitasyon sureleri de belirgin olarak dusuktu. Sonuc. Acil yardim ekibinin hastane ici acil durumlar icin onemli oldugunu belirtmekteyiz. Bir mavi kod cagri sisteminin yogun bakim uyeleri tarafindan olusturularak tum hastaneye bildirilmesi gerektigi kanaatindeyiz. Anahtar sozcukler: Acil tibbi bakim, acil yardim ekibi, kardiak arrest, mavi kod, cagri

Common laboratory tests predict imminent medical emergency team calls, intensive care unit admission or death in emergency department patients

To estimate the ability of commonly measured laboratory variables to predict imminent (within the same or next calendar day) medical emergency team (MET) calls, ICU admission or death. We performed a retrospective observational study of ED patients. We estimated the ability of each laboratory variable or combination of variables together with patient age to predict imminent MET calls, ICU admission or death. We externally validated our findings in patients from a different hospital. We studied 160 341 batches in 71 453 ED patients (average age: 59.9 ± 22.1 years) for a total of 1 million individual measurements. There were 341 MET calls, 160 ICU admissions from the wards and 858 deaths. Multivariable modelling achieved a receiver operating characteristic area under the curve (ROC-AUC) of 0.69 (95% CI 0.63-0.74) for imminent MET call with prediction occurring a mean of 11.9 h before the call. Additionally, it achieved a ROC-AUC of 0.82 (95% CI 0.73-0.87) for imminent ICU admission. Finally, it achieved a ROC-AUC of 0.90 (95% CI 0.87-0.91) for imminent death. When tested using an additional 37 367 batches from a cohort of 21 430 ED patients from a second teaching hospital, the multivariate model achieved a ROC-AUC of 0.70 (95% CI 0.66-0.73) for imminent MET call, a ROC-AUC of 0.84 (95% CI 0.78-0.90) for imminent ICU admission. Finally, it achieved a ROC-AUC of 0.89 (95% CI 0.86-0.91) for imminent death. Commonly performed laboratory tests can help predict imminent MET calls, ICU admission or death in ED patients. Prospective investigations of the clinical utility of such predictions appear desirable.

Reduced emergency calls and improved weekend discharge after introduction of a new electronic handover system

To measure the frequency and content of electronic handover before and after implementation of the Blue BARRWUE handover system, and to measure its effect on patient safety and hospital efficiency over weekends. Point-prevalence study comparing outcomes for general medical inpatients present over weekends before implementation (1 May 2008 to 30 April 2009) and after implementation (1 May 2009 to 30 April 2010) of the Blue BARRWUE handover system at Geelong Hospital. Implementation of the Blue BARRWUE handover system and its components (updated working diagnosis, background, alerts, resuscitation status, requests, who to do what and when, updates and executable discharge plan). Presence of any written handover notes or updated working diagnoses in the BOSSnet clinical information system, content of handover notes, frequency of weekend discharges and medical emergency team (MET) calls before and after implementation. In the 12 months before implementation of the Blue BARRWUE handover system, 976 patients (47.98%) had a handover note in BOSSnet, versus 1646 patients (95.09%) in the 12 months after implementation (P< 0.001; rate ratio [RR], 20.75; 95% CI, 16.33-26.44). Before implementation, 289 patients (14.21%) were discharged over weekends, versus 353 patients (20.39%) after implementation, (P < 0.001; RR, 1.44; 95% CI, 1.25-1.65). MET calls were made for 152 general medical patients before implementation (7.47%), versus 95 general medical patients (5.49%) after implementation (P = 0.01; RR, 0.73; 95% CI, 0.57-0.94). The Blue BARRWUE system has sustainably improved written handover in our organisation and was associated with improvement in both patient safety and hospital efficiency.

Medical emergency team calls in the radiology department: patient characteristics and outcomes

ObjectiveWe sought to identify the characteristics of patients who experience medical emergency team calls in the radiology department (MET-RD) and the relationship between these characteristics and patient outcomes.Design/participantsRetrospective review of...

The role of the medical emergency team in end-of-life care

To investigate the role of medical emergency teams in end-of-life care planning. One month prospective audit of medical emergency team calls. Seven university-affiliated hospitals in Australia, Canada, and Sweden. Five hundred eighteen patients who received a medical emergency team call over 1 month. None. There were 652 medical emergency team calls in 518 patients, with multiple calls in 99 (19.1%) patients. There were 161 (31.1%) patients with limitations of medical therapy during the study period. The limitation of medical therapy was instituted in 105 (20.3%) and 56 (10.8%) patients before and after the medical emergency team call, respectively. In 78 patients who died with a limitation of medical therapy in place, the last medical emergency team review was on the day of death in 29.5% of patients, and within 2 days in another 28.2%.Compared with patients who did not have a limitation of medical therapy, those with a limitation of medical therapy were older (80 vs. 66 yrs; p < .001), less likely to be male (44.1% vs. 55.7%; p = .014), more likely to be medical admissions (70.8% vs. 51.3%; p < .001), and less likely to be admitted from home (74.5% vs. 92.2%, p < .001). In addition, those with a limitation of medical therapy were less likely to be discharged home (22.4% vs. 63.6%; p < .001) and more likely to die in hospital (48.4% vs. 12.3%; p < .001). There was a trend for increased likelihood of calls associated with limitations of medical therapy to occur out of hours (51.0% vs. 43.8%, p = .089). Issues around end-of-life care and limitations of medical therapy arose in approximately one-third of calls, suggesting a mismatch between patient needs for end-of-life care and resources at participating hospitals. These calls frequently occur in elderly medical patients and out of hours. Many such patients do not return home, and half die in hospital. There is a need for improved advanced care planning in our hospitals, and to confirm our findings in other organizations.

Medical Emergency Teams and Death at the Hospital – Do They Call Us? Results from an Integrated Educational Program with Medical Emergency Teams

Objective: The present study was conducted with the main objective of evaluating the occurrence of Medical Emergency Team (MET) calls in patients who died during their hospital stay and their association with the presence of MET calling criteria in the 24 hour and 8 hour period before death and the existence of a do not resuscitate (DNR) order. Patients and methods: Retrospective analysis of the medical records of patients that died at the hospital between 1st October 2007 and 30th June 2008. Patients from the emergency room and intensive care department were excluded, as METs are not activated for these areas. Studied variables included demographics, MET calls, the presence of MET calling criteria within the 24 hour and 8 hour period before death and the existence of a DNR order. The occurrence of MET calls in patients who died during their hospital stay and their association with the presence of MET calling criteria in the 24 hours and 8 hours before death and the existence of a do not resuscitate (DNR) order were analyzed. Results: 348 patients died – in-hospital mortality rate - 2, 5%. 56% were male, mean age was 75 years old. Seventy-five percent exhibited an explicit DNR order written in their clinical records. Twenty-five percent (88 patients) had no explicit DNR order in their clinical records. For 39% of these MET was activated. Twenty–four percent of these presented at least one alarm sign 24h before the MET activation, being the most common threatened airway and persistent hypotension, 82% had an alarm sign during the last 8 h before MET activation, with airway threatened (59%) and downgrade of Glasgow Coma Scale > 2 points (32%) the most frequent. In 5 of the 88 patients there was no DNR order and no MET activation. In these patients no alarm signs were found 24h before death, and only in 2 patients, alarm signs 8 h before death were identified: downgrade of Glasgow Coma Scale > 2 points in one patient and hypotension in another patient. Four of these 5 patients died during the night shift. Conclusion: In the present study the detection of alarm signs in patients and the subsequent MET activation is a good quality of care indicator. When there is no MET system these data are not available and patients with alarm signs, if not corrected might proceed, with clinical deterioration until cardiac arrest and eventually death occur.

Abstract 18406: Are Medical Emergency Team Call Event Rates to the Radiology Department Greater Than to the General Hospital Wards?

Objective : To establish if hospital in-patients are at greater risk for requiring Medical Emergency Team (MET) assistance while in the Radiology Department, we determined the event rates of MET calls to the Radiology department (MET-RD) and the general hospital wards (MET-W). Design/Participants : Retrospective review of in-patients experiencing a MET call in 2009. Setting : Tertiary care hospital with a well-established MET system admitting 32,000 patients and performing 160,000 in-patient Radiology (RD) procedures per year. Measurements : The number of MET-RD was adjusted for length of stay (LOS) to determine the number of MET-RD/hour/1000 RD admissions. The number of MET-W was adjusted for LOS to determine the number of MET-W/hour/1000 hospital admissions. Main Results : The MET-RD event rate was slightly higher than MET-W (0.42 v. 0.31 events/hour/1000 hospital admissions) but not statistically different (p=0.73). The overall average LOS in the RD (LOS-RD) was 58 min. General x-ray (XR) comprised 63% of RD admissions but only 11% of MET-RD (LOS 40 min, XR event rate 0.09). Event rates and LOS in the radiology specialty modality areas revealed that 38% of MET-RDs occurred in computed tomography (CT) (average CT LOS 47 min) and an event rate (0.94) over twice the RD average. Magnetic resonance imaging (MRI) represented only 5% of the RD admissions but had 27% of MET-RD (average MRI LOS-RD 90 minutes) and an event rate (1.43) that was 3.5 times higher than the RD average. The longest LOS-RD was in Nuclear medicine (NM; 111 minutes) and represented only 1% of RD admissions but 5% of MET-RD, with an NM event rate (1.34) that was 3.2 times higher than the RD average. Analysis of event rates for the combined RD specialty modalities (minus XR) revealed an average RD specialty modality event rate that was significantly higher when compared to MET-W (0.76 v. 0.31, p=.007). Conclusions : Although overall MET-RD event rates were similar to MET-W, they were unevenly distributed across patients receiving CT, MRI and NM studies. The combined event rate in the RD specialty modalities suggest increased MET risk for patients in these areas, which may have implications for RD surveillance practices.

Is postoperative intensive care unit admission a prerequisite for elective craniotomy?

Routine postoperative admission to the intensive care unit (ICU) is often considered a necessity in the treatment of patients following elective craniotomy but may strain already limited resources and is of unproven benefit. In this study the authors investigated whether routine postoperative admission to a regular stepdown ward is a safe alternative. Three hundred ninety-four consecutive patients who had undergone elective craniotomy over 54 months at a single institution were retrospectively analyzed. Indications for craniotomy included tumor (257 patients) and transsphenoidal (63 patients), vascular (31 patients), ventriculostomy (22 patients), developmental (13 patients), and base of skull conditions (8 patients). Recorded data included age, operation, reason for ICU admission, medical emergency team (MET) calls, in-hospital mortality, and postoperative duration of stay. Three hundred forty-three patients were admitted to the regular ward after elective craniotomy, whereas there were 43 planned and 8 unplanned ICU admissions. The most common reasons for planned ICU admissions were anticipated lengthy operations (42%) and anesthetic risks (40%); causes for unplanned ICU admissions were mainly unexpected slow neurological recovery and extensive intraoperative blood loss. Of the 343 regular ward admissions, 10 (3%) required a MET call; only 3 of these MET calls occurred within the first 48 postoperative hours and did not lead to an ICU admission. The overall mortality rate in the investigated cohort was 1%, with no fatalities in patients admitted to the normal ward postoperatively. Routine ward admission for patients undergoing elective craniotomies with selective ICU admission appears safe; however, approximately 2% of patients may require a direct postoperative unplanned ICU admission. Patients with anticipated long operation times, extensive blood loss, and high anesthetic risks should be selected for postoperative ICU admission, but further study is needed to determine the preoperative factors that can aid in identifying and caring for these groups of patients.

Clinical deterioration in the condition of patients with acute medical illness in Australian hospitals: improving detection and response

Medical Assessment Units (MAUs) provide an opportunity for multidisciplinary staff to manage recently admitted acutely unwell patients with complex medical illnesses. We propose concerted development of robust mechanisms for identifying and managing patients whose condition is unstable as they move through hospital departments. Track, trigger and response (TTR) systems (eg, medical emergency team calls and early warning scores) have been introduced to hospital practice, but evidence for their effectiveness is, so far, incomplete. The current variation in TTR systems within and between hospitals impairs intersite comparisons. A range of outcome measures, including risk of physiological deterioration, mortality and projected hospital length of stay, could be usefully investigated by future intersite collaborative research. More deliberate, systematic, evidence-based design of "response" in TTR systems may help in identifying patients who need early attention from skilled medical staff. We need more uniform TTR systems, more research on TTR systems and more multisite research; MAUs are ideally situated to address this important area.

The epidemiology and outcome of medical emergency team call patients treated with non-invasive ventilation

IntroductionUse of non-invasive ventilation (NIV) is normally limited to the Emergency Department, Intensive Care Unit (ICU), Coronary Care Unit (CCU) or High Dependency Unit (HDU). However, NIV is sometimes used by the Medical Emergency Team (MET) as respiratory support for ward patients. ObjectivesWe reviewed the characteristics and outcome of ward patients treated with NIV in the setting of a MET Call and determined the clinical and prognostic significance of such treatment. MethodsWe used our MET database to assess the characteristics and outcome of patients treated with NIV and compared them to a control group of patients with similar MET diagnoses but not treated with NIV. ResultsWe studied 5389 calls in 3880 patients. NIV was delivered during 483 (9.0%) calls to 426 patients (11% of the total). The four most common MET diagnoses associated with NIV were acute pulmonary edema (156 calls, 32.3%), pneumonia (84 calls, 17.4%), acute respiratory failure of unclear origin (59 calls, 12.2%) and exacerbation of chronic obstructive pulmonary disease (32 calls, 6.6%). Limitations of medical therapy (LOMT) were documented in 151 (35.4%) patients. Among NIV patients without LOMT, 115 (41.8%) were transferred to ICU and 50 (18.2%) to the coronary care or high dependency unit (CCU/HDU) compared with only 50 (18.0%) and 16 (5.8%) respectively in the control group (p<0.001). Overall, 76 NIV patients (27.6%) received endotracheal intubation (ETT) compared with 61 (21.9%) in controls. Mortality was 23.6% in the NIV group versus 18.8% in the control group. ConclusionOne in ten MET call patients received NIV. In those without LOMT, two thirds were transferred to ICU/HDU/CCU, one in four received ETT, and one in four died. NIV use at the time of a MET call identified high risk patients for whom admission to ICU/HDU/CCU should be strongly considered.

Documenting Rapid Response System afferent limb failure and associated patient outcomes

ObjectiveDescribe afferent limb failure (ALF), defined as documented Rapid Response System (RRS) calling criteria, but no associated call, in the 24h prior to an event. MethodsRetrospective medical record and database review. Adult in-patients whose hospital length of stay (LOS) was greater than 24h, an event being a cardiac arrest, Medical Emergency Team (MET) call or unanticipated Intensive Care Unit (ICU) admission. ResultsOver 6 months, there were 443 patients with 575 events, of which 35 (6.1%) were cardiac arrests, 395 (68.7%) MET calls, and 145 (25.2%) ICU admissions. 131 (22.8%) events had documented ALF, of which 47/131 (35.9%) had documented criteria across more than one time period. Patients with ALF, compared to those without ALF, were significantly more likely to have an unanticipated ICU admission (45/131 (34.4%) vs 100/443 (22.5%), p=0.01), but be of similar age (71 years vs 72 years, p=0.44), male gender (51.1% vs 53.2%, p=0.38), APACHE 2 score (22.8 vs 21.4, p=0.67), predicted risk of death (0.394 vs 0.367, p=0.55), ICU LOS (2 days vs 2 days, p=0.56), likelihood of not-for-resuscitation order during an event (4/131 (3.4%) vs 22/444 (5.0%), p=0.34), and hospital mortality (42/107 (39.3%) vs 125/236 (37.2%), p=0.70). Hospital mortality for patients with ALF across multiple, compared to single time periods was higher, 21/40 (52.5%) vs 22/69 (31.9%), p=0.03. ConclusionsRRS ALF is a useful performance measure for a mature RRS, and is associated with unanticipated ICU admissions. The duration of, and not timing of, ALF criterion occurrence may affect hospital mortality.

Level of agreement on resuscitation decisions among hospital specialists and barriers to documenting do not attempt resuscitation (DNAR) orders in ward patients

AimThis study assessed the level of agreement on CPR decisions among intensive care doctors and specialist physicians and surgeons, and the barriers to documenting do not attempt resuscitation (DNAR) orders for ward patients during Medical Emergency Team (MET) calls. MethodsWe prospectively assessed all patients having MET calls for 11 months. If the intensive care doctor on the MET considered a DNAR order appropriate for the patient, the primary care clinician was contacted to: (1) confirm agreement or disagreement with a DNAR order and (2) give reasons as to why a DNAR order was not considered or documented prior to the MET call. ResultsIn the study period, the MET attended 1458 patients. A DNAR order was considered appropriate in 129 cases. In 116 (90%), the primary care clinician agreed with a DNAR order at the time of the MET. Common reasons given by primary care clinicians for not documenting DNAR orders included acute or unexpected deterioration (22.5%), awaiting family discussion (22.5%), actively treating the patient for a reversible condition (17.1%), not knowing the patient well enough (10.9%) and resuscitation status not yet discussed by team (10.9%). ConclusionsThis study shows a high level of agreement on DNAR orders among intensive care doctors, physicians and surgeons for deteriorating ward patients. Barriers to timely documentation need to be addressed. Delay in documentation and communication of DNAR orders is common. The MET system provides an opportunity to identify patients for whom a DNAR order should be considered.

Epidemiology and patient outcome after medical emergency team calls triggered by atrial fibrillation

Introduction Atrial fibrillation (AF) in hospitalized patients may lead to activation of the medical emergency team (MET). We sought to assess the baseline characteristics and outcomes of the patients presenting AF as a cause of MET call activation. Methods Using a prospectively constructed MET database, we retrospectively reviewed all patients with AF as a trigger for MET activation between August 2005 and April 2010. Demographics, principal diagnostic and outcome of these patients were compared with those of a control group of patients matched for age, sex and ward of origin, randomly selected from the database. Results We studied 5431 MET calls of which 557 (10.3%), in 458 patients were triggered by AF. Mean age for AF patients was 74.8 years, 230 (50.2%) were female and 271 (59.1%) were in a surgical ward. 92 (20.1%) AF patients died in hospital compared with 131 (28.6%) in the control group. Among the 336 patients without limitations of medical therapy (LOMT), 46 (13.7%) died in hospital. In total, 46 (13.7%) patients were transferred to a higher level care ward while 290 (86.3%) remained on the ward. Only 2 (4.3%) of these patients died compared with 44 (15.2%) among those who remained in the general ward ( p = 0.03). Conclusions In our hospital, AF triggers one tenth of MET activations and mortality associated with it is high even when issues of LOMT are excluded. The decreased mortality among patients admitted to a higher level ward suggests that some of these deaths may be avoidable.

Provision of humidification to at risk patients

Evidence today shows that providing a patient with optimal humidification of gases, not only maintains secretion clearance, it promotes gas exchange, decreases the risk of infection and prevents against desiccation of their airway. In 2008 it was discovered that the humidification system used at Monash Medical Centre demonstrated suboptimal performance and they had also been superseded by other systems. The suboptimal provision of humidification had also been identified as one of many contributing factors to Medical Emergency Team (MET) calls, and tracheostomy complications especially in patients who require long term oxygen therapy and/or have respiratory conditions. A business case was developed and presented to the hospital. Funding was granted to replace the existing bubble humidifier throughout Monash Medical Centre (excluding Intensive Care, Paediatrics and Emergency Department) with new Fisher and Paykel (MR810) humidifiers. A detailed roll out plan was made to ensure the introduction of these new humidifiers was effective and efficient. Included in this plan was on-going education and training provided by the ICU Outreach service, Fisher and Paykel and ward educators. 12 months post introduction of the humidifiers a staff survey revealed benefits such as increased staff awareness of the importance of humidification resulting in earlier implementation of the device, improved secretion management and enhanced patient comfort/compliance due to multiple delivery applications. Caregivers aim to provide, and patients want to receive, the best treatment possible in order to ensure the most favourable patient outcome. Provision of new humidification devices has ensured best practice and quality care.

A multi-faceted approach to the physiologically unstable patient

Patients on general hospital wards who deteriorate clinically are often not recognised as needing an escalation in care, and effective interventions are delayed. This study reviews a multifaceted approach to the identification and management of these patients in a large metropolitan hospital in Auckland, New Zealand. Four interventions were combined into the Physiologically Unstable Patient (PUP) programme. These were: (1) redesign of the vital sign observation chart; (2) introduction of an early warning scoring system; (3) deployment of a nurse-led rapid response team; and (4) a comprehensive ward-based education programme. Completeness and accuracy of routine observations; actions taken in accordance with the algorithm; impact on medical emergency team callouts, cardiac arrest calls and unplanned intensive care unit admissions. The PUP programme was implemented in 16 wards over 15 months. Vital sign recording improved, and the PUP score became a recognised metric for prioritising patients for review. Consistent with others' experience, there was a reluctance to call for help. Raised PUP scores prompted action around 30% of the time on average. Medical emergency team calls increased significantly from a median of 27.5 calls per month to 70.5. There was no significant change in unplanned transfers to intensive care unit or in cardiac arrest calls. A multifaceted programme to identify physiologically unstable patients on general wards can be introduced and can improve the recognition of such patients, but there are still barriers to ensuring that these patients receive the extra care that they require. These systemic failings need to be investigated and addressed for real change to occur.

Post-anaesthetic discharge scoring criteria: A comprehensive systematic review

Post-anaesthetic discharge scoring criteria: A comprehensive systematic review

Post-anaesthetic discharge scoring criteria: A comprehensive systematic review.

This review will systematically examine the evidence to answer the question: • What are the essential components of an effective scoring system to assess patients, following anaesthesia and surgery, thereby enhancing patient safety through timely and appropriate discharge? The key objectives to be addressed are: 1. To identify the most commonly used predetermined PACU discharge criteria, which can be used, predominantly but not exclusively, by nurses to assess patient readiness for discharge from PACU. 2. To investigate whether some variables have greater relevance than others in terms of determining readiness for discharge. 3. To develop, from the evidence synthesis, a draft of a discharge tool that can be later submitted for review by a panel of experts to establish content validity Inclusion criteria Types of participants The review will consider studies that include adult patients (over 18 years of age), male and female, who have received care in the PACU for any type of surgery, planned or unplanned. Types of Interventions The review will consider studies that evaluate variables suitable for assessment of patient readiness for discharge from the PACU. This will include studies evaluating both individual and grouped predetermined discharge criteria; for example, measure of vital signs (temperature, respiratory rate, heart rate, blood pressure) and /or return to pre-operative baseline, capillary oxygen saturation, assessing level of consciousness, blood loss, pain assessment, and existing tools for discharge. Type of Outcomes This review will consider studies that include variables for patient assessment, examples of which are the following outcome measures: • stable vital signs and/ or stable capillary oxygen saturation • presence or absence of nausea and/ vomiting • pain score • medication administration (such as anti-emetics and analgesics) • PACU time • PACU discharge delay • adverse events related to early discharge from PACU, e.g: o complications that may have been avoided (eg. medical emergency team (MET) calls) o unexpected admissions to intensive care, critical care or high dependency units o readmission rates (to theatre or hospital) o increased length of hospital stay