Medical Emergency Team Criteria Research Articles

Long term survival following a medical emergency team call at an Australian regional hospital

Objective: To investigate the long term survival of medical emergency team (MET) patients at an Australian regional hospital and describe associated patient and MET call characteristics. Design: Retrospective cohort study. Data linkage to the statewide death registry was performed to allow for long term survival analysis, including multivariable Cox proportional hazards regression and production of Kaplan-Meier survival curves. Setting: A large Australian regional hospital. Participants: Adult patients who received a MET call from 1 July 2012 to 3 March 2020. Main outcome measures: Survival to 30, 90 and 180 days; one year; and 5-years after index MET call. Results: The study included 6499 eligible patients. The cohort median age was 71 years, and 52.4% of the patients were female. Surgical (39.6%) and medical (36.9%) patients comprised most of the cohort. Thirty-day survival was 86.5% one-year survival was 66.1%. Among patients aged < 75 years, factors independently associated with significantly higher long term mortality included age (hazard ratio [HR], 3.26 [95% CI, 2.63-4.06]; for patients aged 65-74 v 18-54 years), male sex (HR, 0.71 [95% CI, 0.61-0.83]; for females) and pre-existing limitation of medical therapy (HR, 2.76; 95% CI, 2.28-3.35). Among patients aged ≥ 75 years, factors independently associated with significantly higher long term mortality included age (HR, 1.46 [95% CI, 1.29-1.65]; for patients aged ≥ 85 years), male sex (HR, 0.74 [95% CI, 0.66-0.83]; for females), and altered MET criteria (HR, 1.33; 95% CI, 1.03-1.71). Conclusions: Long term survival probabilities of MET call patients are affected by factors including age, sex, and limitation of medical therapy status. These data may be useful for clinicians conducting end-of-life discussions with patients.

Activities of a Medical Emergency Team: a prospective observational study of 795 calls.

Relatively few papers have examined specific causes for Medical Emergency Team (MET) review and the assessment and management undertaken by the MET. The aim of our study was to describe the type of patients who require MET review, the reasons such reviews are requested and the subsequent immediate management of these patients. Our prospective single-centre observational study was conducted in a university-affiliated tertiary hospital in New Zealand between October 2012 and September 2013. Each trigger for MET review was assessed separately to allow analysis of the main associated underlying conditions and interventions. Seven hundred and ninety-five MET calls were generated for 630 patients. Mean patient age was 64 years. Sixty percent of all calls involved medical patients. There was a marked diurnal variation in the incidence of MET calls, with MET calls more likely during the daytime and evening compared to the night. The most common triggers for MET calls were an unresponsive or fitting patient (25.2%), tachycardia (24.2%), and an Early Warning Score of 8 or more (22.8%). Neurological causes (30.7%), cardiovascular failure (hypotension, pulmonary oedema) (26.7%), respiratory failure (22.6%), and sepsis (19.2%) were the most common underlying conditions. One of these top four conditions was present in nearly all patients (99.2%). The majority of MET calls were made for a relatively small number of underlying conditions and triggers, supporting the concept of 'MET syndromes'. The pattern of interventions is predictable from the triggering condition. This may guide education and training of ward staff to improve detection of deteriorating patients and prevent or pre-emptively manage causes of such deterioration prior to MET criteria being reached. The association between time of day and crisis recognition suggests the hospital system does not reliably detect deteriorating patients. This questions the adequacy of monitoring of deteriorating patients on hospital wards.

Medical emergency team involvement in patients hospitalized with acute myeloid leukemia

Patients with acute myeloid leukemia (AML) are at risk for sudden clinical deterioration. We aimed to describe the incidence of medical emergency team (MET) activation, intensive care unit (ICU) admissions and outcomes for patients with AML. We performed a 5-year retrospective cohort study of patients hospitalized with AML. One hundred and seventy patients were divided into three groups: (1) MET activated (n = 34); (2) MET criteria present but MET not activated (n = 17); and (3) all other patients with AML (n = 119). MET activation incidence was 200 calls/1000 admissions (95% confidence interval [CI], 138–279), compared with a hospital-wide rate of 29.3 calls/1000 admissions (95% CI, 28.2–30.4) (relative risk 6.90; 95% CI, 4.77–9.67, p < 0.0001). Some 77% (n = 26) were triaged to the ICU. Hospital mortality was higher in MET activated and MET fulfilled without activation groups compared with all others (27% vs. 12% vs. 7%, p = 0.007). Changes to goals of care were more common with MET activation. Patients with AML commonly receive MET activation. Approximately one in 10 fulfill MET criteria, however do not receive MET activation.

Effect of a multifaceted intervention on documentation of vital signs and staff communication regarding deteriorating paediatric patients

To evaluate the impact of newly designed Paediatric Early Warning Scores and an accompanying education package, COMPASS, on the frequency of documentation of vital signs and communication between health professionals and associated medical review in deteriorating paediatric patients. One thousand fifty-nine patients in the pre-intervention phase and 899 in the post-intervention phase were studied. The daily frequency of documentation of vital sign measurement, incidence of health professional communication and related medical reviews following clinical deterioration of a random subgroup of 262 pre-intervention and 221 post-intervention patients were studied in detail. There were no significant differences in hospital mortality, medical emergency team reviews or unplanned admissions to critical care areas between the pre-intervention and post-intervention groups. There were significant increases in the post-intervention group for the median daily frequency of documentation of respiratory effort (0.0 (0-0) to 7.8 (5.8-12.6), P < 0.001), capillary refill (0 (0-0) to 1.1 (0-3.1), P < 0.001), blood pressure (0 (0-1.1) to 0 (0-1.6), P = 0.007) and level of consciousness (0 (0-0) to 7.8 (5.8-12.0), P < 0.001) and appropriate communication concerning patient deterioration 63 (8.5%) to 216 (40.9%), P < 0.001). There was a significant reduction in the number of children fulfilling the medical emergency team criteria (102 (38.9%) to 45 (20.4), P < 0.001). A multifaceted intervention for the early recognition and response to clinical deterioration in children significantly improved documentation of vital signs, communication and time to medical review.

Responding to medical emergencies: System characteristics under examination (RESCUE). A prospective multi-site point prevalence study

AimTo determine the point-prevalence of patients fulfilling hospital-specific Medical Emergency Team (MET) criteria and their subsequent outcomes. MethodInpatients from 10 hospitals with established METs were enrolled for a prospective, point-prevalence study. If MET criteria were present during a set of vital signs, the ward manager was notified. MET activations, unplanned Intensive Care Unit (ICU) admissions, cardiac arrests, Limitations of Medical Treatment (LOMT), hospital discharge and follow-up mortality data were collected. ResultsOf 1688 patients recruited, 3.26% (n=55) fulfilled MET criteria in a single set of vital signs. None of the 55 received MET review within 30min of notification, 2 (3.6%) had MET review within the next 24h, none experienced cardiac arrests or unplanned ICU admissions during the follow-up period, and 13 (23.6%) had a LOMT order prior to fulfilling MET criteria. In-hospital mortality was significantly higher for patients fulfilling MET activation criteria (9.1%) compared to those that did not (2.6%; p=0.005, RR=2.95; 95% confidence interval (CI) 1.22–7.15), as was mortality at 30 days (RR=2.64; 95% CI 1.37–5.11) and 60 days (RR=1.94; 95% CI 1.11–3.40). The 30 day mortality in patients without an LOMT order was similar to patients without MET criteria (RR=0.94; 95% CI 0.24–3.7). ConclusionsApproximately 1 in 30 hospitalised patients fulfilled MET criteria during data collection. The presence of MET criteria was associated with increased hospital, 30 and 60 day mortality, although much of this increased mortality seemed to be due to issues around end-of-life care. Despite ward manager notification, subsequent MET activation occurred infrequently in these hospitals with established METs. Further research is needed to assess factors that influence staff initiation of a MET call.

Peri-operative medical emergency team activation in liver transplantation

BackgroundThe medical emergency team (MET) system functions to promptly identify acutely ill patients at-risk for deterioration. Liver transplant (LT) patients are at-risk for serious post-operative complications.ObjectiveTo evaluate the characteristics of...

Unplanned Early Readmission to the Intensive Care Unit: A Case-Control Study of Patient, Intensive Care and Ward-Related Factors

The purpose of this study was to identify patient, intensive care and ward-based risk factors for early, unplanned readmission to the intensive care unit. A five-year retrospective case-control study at a tertiary referral teaching hospital of 205 cases readmitted within 72 hours of intensive care unit discharge and 205 controls matched for admission diagnosis and severity of illness was conducted. The rate of unplanned readmissions was 3.1% and cases had significantly higher overall mortality than control patients (odds ratio [OR] 4.7, 95% confidence interval [CI] 2.1 to 10.7). New onset respiratory compromise and sepsis were the most common cause of readmission. Independent risk factors for readmission were chronic respiratory disease (OR 3.7, 95% CI 1.2 to 12, P = 0.029), pre-existing anxiety/depression (OR 3.3, 95% CI 1.7 to 6.6, P < 0.001), international normalised ratio >1.3 (OR 2.3, 95% CI 1.1 to 4.9, P = 0.024), immobility (OR 2.3, 95% CI 1.4 to 3.6, P = 0.001), nasogastric nutrition (OR 2.0, 95% CI 1.0 to 4.0, P = 0.041), a white cell count > 15 x 10(9)/l (OR 2.0, 95% CI 1.2 to 3.4, P = 0.012) and non-weekend intensive care unit discharge (OR 1.9, 95% CI 1.1 to 3.5, P = 0.029). Physiological derangement on the ward (OR 26, 95% CI 8.0 to 81, P < 0.001) strongly predicted readmission, although only 20% of patients meeting medical emergency team criteria had a medical emergency team call made. Risk of readmission is associated with both patient and intensive care factors. Physiological derangement on the ward predicts intensive care unit readmission, however, clinical response to this appears suboptimal.

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.

Abnormal vital signs are associated with an increased risk for critical events in US veteran inpatients

Aim Establish the frequency of abnormal vital signs in medical and surgical ward patients; study their association with “critical events,” which for the purposes of this study, were mortality, cardiac arrests and unplanned ICU transfers. Design and methods Four-month prospective, observational cohort study; University-affiliated US Veteran's hospital. Vital signs from all regular ward medical and surgical inpatients were recorded over the study period and compared with records of cardiac arrests, mortality and ICU admissions. Results Using the Hospital's Medical Emergency Team criteria to define normal/abnormal thresholds for vital signs, abnormal vital signs (VS MET) were found in 16% of patients; of these; 35% experienced a critical event vs. 2.5% in the patients with normal vital signs (OR 21, 95% CI 12–35, p < 0.001). The sensitivity of VS MET to predict a critical event was 0.72 and the positive predictive value was 0.35; sensitivity decreased to 0.28 and positive predictive value increased to 0.78 for patients that had two different VS MET. Survival was significantly lower in both medical and surgical patients with VS MET at both 30 days and at 1 year following discharge ( p < 0.02). Both medical and surgical patients with VS MET had twice the length of stay of patients with normal vitals (3 vs. 7 days; p < 0.001). Conclusions Even single recordings of VS MET signaled increased risk for critical events in hospital ward patients. Use of vital signs as criteria for additional patient assessment and possible ICU admission appears justified. Development of abnormal vitals during hospitalization may signify impaired physiologic reserve that places a patient at higher risk for mortality after discharge.

Abstract 75: Electronic Integrated Monitoring of Medical Emergency Team Calls to a Step Down Unit

Purpose: Early discharge from intensive care units (ICU) to lower acuity monitoring units (step-down units or SDU) is increasing to improve care throughput. However, the ability of minimally invasive monitoring via electronic integrated monitoring systems (IMS) in SDUs to identify cardiopulmonary deterioration in order to activate Medical Emergency Team (MET) response is unknown. We evaluated the ability of an IMS index value to detect clinically significant events which might trigger activation of the MET earlier than called. Methods: Patients were monitored on a 24 bed trauma SDU according to prevailing policy and bedside decision making. An IMS (BioSign TM ) was inserted into the monitoring system and IMS data were collected in a blinded fashion for 8 weeks from all patients. The IMS uses 4 parameters (heart rate [HR], respiratory rate [RR], blood pressure [BP], peripheral oxygen saturation [SpO 2 ]) to develop a single neural networked signal known as the BioSign Index (BSI). Data were analyzed for patient deterioration according to both BSI trigger value and local MET criteria (DeVita, Qual Safety Health Care 2004). Results: Data from 333 patient admissions were evaluated reflecting 18,692 hours of continuous monitoring. SpO 2 monitoring data were absent in 38.5% of monitored hours, despite being mandatory. Most patients were stable throughout their SDU stay. MET activation occurred on 10 occasions (4 respiratory cause [2 SpO 2 , 2 SpO 2 +RR], 2 cardiac (BP), 1 mixed respiratory + cardiac, and 3 other (1 chest pain, 2 acute mental status change). All 7 MET events of respiratory and/or cardiac cause were detected by BSI in advance (mean advanced detection time prior to MET activation was 6.33 hours). Cardiopulmonary deterioration was generally characterized by progressive increases in BSI over time, not step increases. Conclusion : In this population, cardiopulmonary deterioration requiring MET activation was uncommon but always preceded by IMS index elevations which would have alerted the nursing staff in advance. Continuous monitoring of physiological variables may be augmented by integrating information from multiple parameters to create a new variable. The new index parameter may detect patient deterioration earlier than single parameter monitoring.

Increasing the Use of an Existing Medical Emergency Team in a Teaching Hospital

Cultural barriers in hospital ward staff may limit the use of a Medical Emergency Team (MET) service. In December 2000 the role of the existing Code Blue team in our hospital was expanded to incorporate review of patients fulfilling commonly employed MET criteria. Between January 2001 and June 2003, the average call rate was only 9.8 calls/ 1000 admissions. Anecdotal feedback and a group-administered questionnaire conducted in July 2003 demonstrated a number of obstacles to initiating calls and the system was modified in October 2004. Specifically, emergency response calls were separated into Code Blue calls (for cardiorespiratory arrests) and MET calls (with physiological and worried criteria). Further loud overhead chimes as well as anaesthetist and cardiologist attendance were used only in the case of Code Blue calls (suspected arrests). Finally, the heart rate and respiratory rate criteria for MET service activation were modified. In the 12 months before the intervention (October 2003 to September 2004) there were 817 emergency response calls and 51,963 admissions (15.7 calls/1000 admissions). In the 12 months after the intervention there were 1349 emergency response calls (Code Blue plus MET calls) and 54,593 admissions (24.7 calls/1000 admissions [OR 1.59; 95% CI=1.45-1.73; P<0.0001]). Our findings suggest that increasing the use of an existing service to review patients fulfilling MET criteria requires repeated education and a periodic assessment of site-specific obstacles to utilization.

Observations and warning signs prior to cardiac arrest. Should a medical emergency team intervene earlier?

The Medical Emergency Team (MET) has evolved in some hospitals as a means of delivering effective treatment early enough to prevent cardiac arrests. Our aim was to analyze the effectiveness of observation practice to detect abnormalities in vital signs prior to cardiac arrest and to determine the need for a MET system in Finnish hospitals. The charts of patients who suffered cardiac arrest during 18 months in four hospitals were reviewed. The vital signs, symptoms and interventions during 8 h prior to arrest were recorded and analyzed against trigger criteria of the MET. During the study period, 110 patients suffered cardiac arrest in hospitals, and 56 (51%) of the arrests occurred on the wards. Of those patients, 30 (54%) had an abnormal vital sign fulfilling the MET criteria, documented on average 3.8 h prior to the arrest. During this period, 13 patients did not receive any intervention (e.g. supplemental oxygen or medication), eight received intervention within 1 h and nine received intervention after more than 1 h. Response to the first intervention was not attained in any patient; nevertheless re-interventions took place in one patient only. Significant physiological deterioration seems to be common in the hours before a cardiac arrest on the wards of Finnish hospitals, suggesting that implementation of a MET-system may be worthwhile. However, the practice of vital sign observation by the nursing staff should be improved before maximal benefit of a MET can be achieved.

A clinical model for health services research—the medical emergency team

Health Services Research (HSR) is a relatively recent discipline which describes how health care delivery occurs and the evaluation of that care. The implementation of a Medical Emergency Team (MET) is an example of a health service intervention. The aim of the MET is to extend the expertise of Intensive Care across the hospital to all at-risk patients. The MET criteria for calling are based on simple abnormalities in vital signs with an extra “worried” category to empower junior medical and nursing staff to call for help. The concept is based on early intervention and resuscitation of the seriously ill, hopefully leading to improved outcomes from intensive care and perhaps even avoiding admission to an intensive care unit. The problems of implementing major health service change and evaluating the effectiveness of that change presents a different challenge to evaluating a new drug or procedure and is approached within different research frameworks.