Medical Emergency Team Review Research Articles

The impact of frailty and rapid response team activation on patients admitted to the intensive care unit: A case-control matched, observational, single-centre cohort study.

Frailty is a multi-dimensional syndrome associated with mortality and adverse outcomes in patients admitted to the intensive care unit (ICU). Further investigation is warranted to explore the interplay among factors such as frailty, clinical deterioration triggering a medical emergency team (MET) review, and outcomes following admission to the ICU. Single-centre, retrospective observational case-control study of adult patients (>18 years) admitted to a medical-surgical ICU with (cases) or without (controls) a preceding MET review between 4 h and 14 days prior. Matching was performed for age, ICU admission diagnosis, Acute Physiology and Chronic Health Evaluation III (APACHE III) score and the 8-point Clinical Frailty Scale (CFS). Cox proportional hazard regression modelling was performed to determine associations with 30-day mortality after admission to ICU. A total of 2314 matched admissions were analysed. Compared to non-frail patients (CFS 1-4), mortality was higher in all frail patients (CFS 5-8), at 31% vs. 13%, and in frail patients admitted after MET review at 33%. After adjusting for age, APACHE, antecedent MET review and CFS in the Cox regression, mortality hazard ratio increased by 26% per CFS point and by 3% per APACHE III point, while a MET review was not an independent predictor. Limitations of medical treatment occurred in 30% of frail patients, either with or without a MET antecedent, and this was five times higher compared to non-frail patients. Frail patients admitted to ICU have a high short-term mortality. An antecedent MET event was associated with increased mortality but did not independently predict short-term survival when adjusting for confounding factors. The intrinsic significance of frailty should be primarily considered during MET review of frail patients. This study suggests that routine frailty assessment of hospitalised patients would be helpful to set goals of care when admission to ICU could be considered.

Patient outcomes following medical emergency team review on general wards: Development of predictive models.

To develop and internally validate risk prediction models for subsequent clinical deterioration, unplanned ICU admission and death among ward patients following medical emergency team (MET) review. A retrospective cohort study of 1500 patients who remained on a general ward following MET review at an Australian quaternary hospital. Logistic regression was used to model (1) subsequent MET review within 48 h, (2) unplanned ICU admission within 48 h and (3) hospital mortality. Models included demographic, clinical and illness severity variables. Model performance was evaluated using discrimination and calibration with optimism-corrected bootstrapped estimates. Findings are reported using the TRIPOD guideline for multivariable prediction models for prognosis or diagnosis. There was no patient or public involvement in the development and conduct of this study. Within 48 h of index MET review, 8.3% (n = 125) of patients had a subsequent MET review, 7.2% (n = 108) had an unplanned ICU admission and in-hospital mortality was 16% (n = 240). From clinically preselected predictors, models retained age, sex, comorbidity, resuscitation limitation, acuity-dependency profile, MET activation triggers and whether the patient was within 24 h of hospital admission, ICU discharge or surgery. Models for subsequent MET review, unplanned ICU admission, and death had adequate accuracy in development and bootstrapped validation samples. Patients requiring MET review demonstrate complex clinical characteristics and the majority remain on the ward after review for deterioration. A risk score could be used to identify patients at risk of poor outcomes after MET review and support general ward clinical decision-making. Our risk calculator estimates risk for patient outcomes following MET review using clinical data available at the bedside. Future validation and implementation could support evidence-informed team communication and patient placement decisions.

The illness severity of ward remaining patients reviewed by the medical emergency team: A retrospective cohort study.

Although progress has been made in identifying and responding to acutely deteriorating ward patients, judgements about the level of care required for patients after medical emergency team review are complex, rarely including a formal assessment of illness severity. This challenges staff and resource management practices and patient safety. This study sought to quantify the illness severity of ward patients after medical emergency team review. This retrospective cohort study examined the clinical records of 1500 randomly sampled adult ward patients following medical emergency team review at a metropolitan tertiary hospital. Outcome measures were the derivation of patient acuity and dependency scores using sequential organ failure assessment and nursing activities score instruments. Findings are reported using the STROBE guideline for cohort studies. No direct patient contact was made during the data collection and analysis phases of the study. Patients were male (52.6%), unplanned (73.9%) medical admissions (57.5%), median age of 67 years. The median sequential organ failure assessment score was 4% and 20% of patients demonstrated multiple organ system failure requiring non typical monitoring and coordination arrangements for at least 24 h. The median nursing activities score was 86% suggestive of a near 1:1 nurse-to-patient ratio. More than half of all patients required enhanced levels of assistance with mobilization (58.8%) and hygiene (53.9%) activities. Patients who remain on the ward following medical emergency team review had complex combinations of organ dysfunction, with levels of dependency similar to those found in intensive care units. This has implications for ward and patient safety and continuity of care arrangements. Profiling illness severity at the conclusion of the medical emergency team review may help determine the need for special resource and staffing arrangements or placement within the ward environment.

Illness severity characteristics and outcomes of patients remaining on an acute ward following medical emergency team review: a latent profile analysis

BackgroundPatients requiring medical emergency team (MET) review have complex clinical needs, and most remain on the ward after review. Current detection instruments cannot identify post-MET patient requirements, meaning patients remain...

Non-beneficial resuscitation during inhospital cardiac arrests in a metropolitan teaching hospital.

There is increasing recognition that a proportion of hospitalised patients receive non-beneficial resuscitation, with the potential to cause harm. To describe the prevalence of non-beneficial resuscitation attempts in hospitalised patients and identify interventions that could be used to reduce these events. A retrospective analysis was conducted of all adult inhospital cardiac arrests (IHCA) receiving cardiopulmonary resuscitation (CPR) in a teaching hospital over 9 years. Demographics and arrest characteristics were obtained from a prospectively collected database. Non-beneficial CPR was defined as CPR being administered to patients who had a current not-for-resuscitation (NFR) order in place or who had a NFR order enacted on a previous hospital admission. Further antecedent factors and resuscitation characteristics were collected for these patients. There were 257 IHCA, of which 115 (44.7%) occurred on general wards, with 19.8% of all patients surviving to discharge home. There were 39 (15.2%) instances of non-beneficial CPR, of which 28 (72%) of 39 occurred in unmonitored patients on the ward comprising nearly one-quarter (28/115) of all arrests in this patient group. A specialist had reviewed 30 (76.9%) of 39 of these patients, and 33.3% (13/39) had a medical emergency team (MET) review prior to their arrest. Over one in seven resuscitation attempts were non-beneficial. MET reviews and specialist ward rounds provide opportunities to improve the documentation and visibility of NFR status.

Development and Validation of the Medical Emergency Team-Risk Prediction Model for Clinical Deterioration in Acute Hospital Patients, at Time of an Emergency Admission.

To develop and validate a prediction model to estimate the risk of Medical Emergency Team (MET) review, within 48 hours of an emergency admission, using information routinely available at the time of hospital admission. Development and validation of a multivariable risk model using prospectively collected data. Transparent Reporting of a multivariable model for Individual Prognosis Or Diagnosis recommendations were followed to develop and report the prediction model. A 560-bed teaching hospital, with a 22-bed ICU and 24-hour Emergency Department in Melbourne, Australia. A total of 45,170 emergency admissions of 30,064 adult patients (≥18 yr), with an inpatient length of stay greater than 24 hours, admitted under acute medical or surgical hospital services between 2015 and 2017. The outcome was MET review within 48 hours of emergency admission. Thirty candidate variables were selected from a routinely collected hospital dataset based on their availability to clinicians at the time of admission. The final model included nine variables: age; comorbid alcohol-related behavioral diagnosis; history of heart failure, chronic obstructive pulmonary disease (COPD), or renal disease; admitted from residential care; Charlson Comorbidity Index score 1 or 2, or 3+; at least one planned and one emergency admission in the last year; and admission diagnosis and one interaction (past history of COPD × admission diagnosis). The discrimination of the model was comparable in the training (C-statistics 0.82; 95% CI, 0.81-0.83) and the validation set (0.81; 0.80-0.83). Calibration was reasonable for training and validation sets. Using only nine predictor variables available to clinicians at the time of admission, the MET-risk model can predict the risk of MET review during the first 48 hours of an emergency admission. Model utility in improving patient outcomes requires further investigation.

The patient experience of a medical emergency team review: A convergent mixed-methods study

AimsThe aim of this study was to explore clinician–patient engagement during, and patient experience of, medical emergency team (MET) reviews. DesignThis study involved a convergent mixed-methods design. MethodsThis three-phase study was conducted at two hospitals of one Australian health service. Reviews by the MET were observed for clinician–patient engagement behaviours; medical records were audited to confirm patient demographics and clinical characteristics; and patients who received a MET review were interviewed. Quantitative data were analysed using descriptive statistics, and thematic analysis of qualitative interview data was conducted. ResultsIn total, 26 MET reviews were observed for 22 patients (median age = 81.5 years and 68.2% females). Between 8 and 13 clinicians and other staff members were present during each review, with a total of 209 clinicians present during the 26 reviews. Clinicians were not observed to speak directly or indirectly to the patient about their care in 38.5% (n = 10/26) of the MET reviews, and 58.3% (n = 56/96) of interventions were performed without explanation. Four themes were identified from the interviews: An unexpected event; A lack of understanding; In good hands, and What happens next? ConclusionClinician–patient engagement was infrequent during and after MET reviews. Patients experienced surprise from the sudden arrival of clinicians in their room and had poor levels of understanding about the review. However, most patients felt supported and safe. MET reviews are frequent safety-critical events, and this study identified the patient experience of these events. Clinicians should be aware that patients expressed they were surprised and shocked by the review and that an explanation of what was being done by the clinical team was rarely offered. These findings can be used to inform strategies to improve their patient-engagement behaviours and patient-centred care.

Triggers and Interventions of Patients Who Require Medical Emergency Team Reviews: A Cross-Sectional Analysis of Single Versus Multiple Reviews.

Medical emergency teams constitute part of the escalation protocol of early warning systems in many hospitals. The literature indicates that medical emergency teams may reduce hospital mortality and cardiac arrest. A greater understanding of pathways of patients who experience multiple medical emergency team reviews will inform clinical decision-making. To explore differences between patients who require a single medical emergency team review and those who require multiple reviews, and to identify any differences between patients who were reviewed only once during admission and patients who required multiple reviews. Data for this retrospective cross-sectional review, including demographic data, call triggers, outcomes, and interventions, were routinely collected from January 2013 through December 2015. The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) collaborative's cross-sectional studies checklist (version 4). Of 54 787 admitted patients, 1274 (2%) required a call to a medical emergency team; of those, 260 patients (20%) needed multiple calls. Patients requiring multiple calls demonstrated higher mortality (odds ratio, 1.49 [95% CI, 1.12-1.98]). A logistic regression model identified surgical patients and those receiving antibiotics and respiratory interventions at the first medical emergency team review as being more likely to require multiple reviews. Patients transferred to a higher level of care after the first review were less likely to require another review. Patients requiring multiple medical emergency team reviews have higher mortality. Surgical patients have a higher risk of requiring multiple reviews. Hospitals need to include more details on surgical patients when auditing medical emergency team activation.

The epidemiology of Medical Emergency Team calls for orthopedic patients in a teaching hospital: A retrospective cohort study

BackgroundPatients undergoing orthopedic surgery are at risk of post-operative complications and needing Medical Emergency Team (MET) review. We assessed the frequency of, and associations with MET calls in orthopedic patients, and whether this was associated with increased in-hospital morbidity and mortality. MethodsRetrospective cohort study of patients admitted over four years to a University teaching hospital using hospital administrative and MET call databases. ResultsAmongst 6344 orthopedic patients, 55.8% were female, the median (IQR) age and Charlson comorbidity index were 66 years (47–79) and 3 (1–5), respectively. Overall, 54.5% of admissions were emergency admissions, 1130 (17.8%) were non-operative, and 605 (9.5%) patients received a MET call. The strongest independent associations with receiving a MET call was the operative procedure, especially hip and knee arthroplasty. Common MET triggers were hypotension (37.5%), tachycardia (25.0%) and tachypnoea (9.1%). Patients receiving a MET call were at increased risk of anemia, delirium, pressure injury, renal failure and wound infection. The mortality of patients who received a MET call was 9.8% compared with 0.8% for those who did not. After adjusting for pre-defined co-variates, requirement for a MET call was associated with an adjusted odd-ratio of 9.57 (95%CI 3.1–29.7) for risk of in-hospital death. ConclusionsApproximately 10% of orthopedic patients received a MET call, which was most strongly associated with major hip and knee arthroplasty. Such patients are at increased risk of morbidity and in-hospital mortality. Further strategies are needed to more pro-actively manage at-risk orthopedic patients.

Associations between patient and system characteristics and MET review within 48 h of admission to a teaching hospital: A retrospective cohort study

The Medical Emergency Team (MET) has enhanced the recognition and response to clinical deterioration in acute healthcare. However, patients reviewed by the MET are at increased risk of in-hospital death. Identifying patients at risk of deterioration may improve patient outcomes. AimTo identify patient demographic, medical characteristics and healthcare systems and processes at the time of admission (baseline), associated with Medical Emergency Team (MET) review within 48 h (MET-48 h) of admission. MethodsSingle-site, year-long, retrospective cohort comprising patients admitted for at least 24 h, using routinely collected hospital data. A three-stage modelling approach was used to identify baseline factors associated with MET-48 h ResultsThe study included 15,695 patients with mean age 62.1 years (SD 19.6), male (53.5%), born in Australia or New Zealand (60.9%) and 51.6% held a low-income concession card. A total of 4.3% of patients received a MET review within 48 h of admission. Variables independently associated with MET-48 h in a fully adjusted logistic model included age of 80 years or more (OR = 1.37); ≥3 previous emergency admissions (OR = 1.59); Charlson Comorbidity Index 1 or 2 (OR = 1.47), or ≥ 3 (OR = 1.99); history of alcohol-related behaviour concerns (OR = 2.04), chronic heart failure (OR = 1.48); chronic obstructive pulmonary disease (OR = 1.35); admission for colorectal (OR = 2.66) or upper gastro-intestinal (OR = 1.94) surgery, respiratory or tracheostomy (OR = 2.24); immunology and infections (OR = 1.90); emergency admission (OR = 1.36); admission at night (OR = 1.74), or summer (OR = 1.41) ConclusionsThis is the first study to demonstrate the potential to predict clinical deterioration using data that is readily accessible at the time of admission to hospital.

End-of-life care of oncology inpatients: Are we getting it right?

To examine the current patterns of end-of-life care of medical oncology patients dying in an Australian tertiary acute hospital setting in order to determine potential areas for improvement. A retrospective observational study was undertaken of 295 consecutive adult medical oncology inpatients dying between 2010 and 2015. Charts were reviewed for evidence of (1) resuscitation plans, (2) acute interventions in the 48-h period prior to death, (3) palliative care involvement and (4) recognition of the dying patient and comfort care plans. At the time of death, 98% of patients had a resuscitation plan, 71% of which were completed by the medical oncology team. Fifty-nine percent of medical emergency team reviews occurred in patients without a documented resuscitation plan. Within 48 h of death, active interventions were still being given to 64% of patients in the total patient population. Comfort care plans were documented in 86% of patients; however, 62% of these were only documented within 48 h of death and 20% of patients with a documented comfort care plan still received noncomfort measures. There was a high level of documented resuscitation plans, comfort care plans and recognition of dying. However, active interventions were common within 48 h of death, and comfort care plans and recognition of dying often occurred late. These data indicate a gap between documenting a resuscitation plan and providing timely and appropriate end-of-life care. Understanding the gaps in delivering appropriate care provides an opportunity for improving end-of-life care.

Patient perceptions of deterioration and patient and family activated escalation systems-A qualitative study.

To investigate the experiences of patients who received a medical emergency team review following a period of clinical deterioration and their views about the potential use of a patient and family activated escalation system. Delay or failure by health professionals to respond to clinical deterioration remains a patient safety concern. Patients may sometimes identify subtle cues of early deterioration prior to changes in vital signs. In response to health professional and system failures, patient and family activated escalation systems have been mandated and implemented in Australia. However, little research has evaluated their effectiveness nor taken patients' perspectives into account. Qualitative exploratory descriptive design was used. Purposive sampling was used. Semistructured interviews were undertaken in 2014 with 33 patients who required medical emergency team intervention. Data were collected from one private and one public hospital in Melbourne, Victoria, Australia. The framework method was used to analyse the data. All patients stated that it was the clinician who detected and responded to deterioration. Private patient participants were unaware of the medical emergency team system, and felt escalating care was not their responsibility. These patients reported being too sick to communicate prior to and during medical emergency team review and did not favour a patient and family activated escalation system. Public patients were well informed about the medical emergency team system yet expressed concerns around overriding clinicians if activating a patient and family activated escalation system. Patient participation during a period of deterioration is restricted by their clinical condition and limited medical knowledge. Patients felt comfortable to communicate concerns to clinicians but felt they would not activate the patient and family activated escalation system. This behoves clinicians to actively listen and respond to patient concerns. Clinicians must promote a collaborative relationship and encourage patients to communicate their concerns. Given the perceived barriers to patient and family activated escalation systems use, resources being employed for their implementation could be redistributed to other areas of patient safety.

Designing a more efficient, effective and safe Medical Emergency Team (MET) service using data analysis.

IntroductionHospitals have seen a rise in Medical Emergency Team (MET) reviews. We hypothesised that the commonest MET calls result in similar treatments. Our aim was to design a pre-emptive management algorithm that allowed direct institution of treatment to patients without having to wait for attendance of the MET team and to model its potential impact on MET call incidence and patient outcomes.MethodsData was extracted for all MET calls from the hospital database. Association rule data mining techniques were used to identify the most common combinations of MET call causes, outcomes and therapies.ResultsThere were 13,656 MET calls during the 34-month study period in 7936 patients. The most common MET call was for hypotension [31%, (2459/7936)]. These MET calls were strongly associated with the immediate administration of intra-venous fluid (70% [1714/2459] v 13% [739/5477] p<0.001), unless the patient was located on a respiratory ward (adjusted OR 0.41 [95%CI 0.25–0.67] p<0.001), had a cardiac cause for admission (adjusted OR 0.61 [95%CI 0.50–0.75] p<0.001) or was under the care of the heart failure team (adjusted OR 0.29 [95%CI 0.19–0.42] p<0.001).Modelling the effect of a pre-emptive management algorithm for immediate fluid administration without MET activation on data from a test period of 24 months following the study period, suggested it would lead to a 68.7% (2541/3697) reduction in MET calls for hypotension and a 19.6% (2541/12938) reduction in total METs without adverse effects on patients.ConclusionRoutinely collected data and analytic techniques can be used to develop a pre-emptive management algorithm to administer intravenous fluid therapy to a specific group of hypotensive patients without the need to initiate a MET call. This could both lead to earlier treatment for the patient and less total MET calls.

Increased Mortality and Length of Stay Associated With Medical Emergency Team Review in Hospitalized Pediatric Patients: A Retrospective Cohort Study.

Rapid response systems using medical emergency teams reduce hospital wide cardiorespiratory arrest and mortality. While rapid response systems improve hospital-wide outcomes, children receiving medical emergency team review may still be at increased risk for morbidity and mortality. The study purpose was to compare the length of stay and mortality rate in children receiving a medical emergency team review with those of other hospitalized children. Retrospective cohort study. Tertiary Pediatric Hospital, Children's Hospital of Eastern Ontario, Ottawa, Canada. Cohort of 42,308 pediatric admissions to the general inpatient ward. Data over 7 years were obtained from a prospectively maintained rapid response systems database. From the cohort, 995 (2.35%) of the admissions had one and 276 (0.65%) had multiple medical emergency team activations. When compared with patients without, children having one or multiple medical emergency team reviews had 13.34 (95% CI, 5.33-33.2) and 50.10 (95% CI, 19.86-126.39) times the odds of death, respectively. Patients experiencing a medical emergency team review stayed in hospital 1.59 times (95% CI, 1.39-1.82) longer, whereas those with multiple medical emergency team reviews stayed 2.44 times (95% CI, 1.85-3.20) longer. The associations remained significant after controlling for important confounders and excluding elective admissions from the analyses. Most repeat medical emergency team reviews occurred within a day of the initial review or involved patients with multiple comorbidities. Our study suggests that pediatric patients reviewed by the medical emergency team are at significantly higher risk of mortality and longer length of stay than general ward inpatients. As well, patients with multiple medical emergency team reviews were at particularly high risk compared with patients with one medical emergency team review. Patients who experience medical emergency team reviews should be recognized as a high-risk group, and future studies should consider how to decrease morbidity and mortality. Based on our findings, we suggest that these patients be followed for 24-48 hours after any medical emergency team activation.

Critical care clinician perceptions of factors leading to Medical Emergency Team review

BackgroundThe introduction of rapid response systems has reduced the incidence of in-hospital cardiac arrest; however, many instances of clinical deterioration are unrecognised. Afferent limb failure is common and may be associated with unplanned intensive care admissions, heightened mortality and prolonged length of stay. Patients reviewed by a Medical Emergency Team are inherently vulnerable with a high in-hospital mortality. ObjectiveTo explore perceptions of intensive care unit (ICU) staff who attend deteriorating acute care ward patients regarding current problems, barriers and potential solutions to recognising and responding to clinical deterioration that culminates in a Medical Emergency Team review. MethodsA descriptive exploratory design was used. Registered intensive care nurses and medical staff (N=207) were recruited during a professional conference using purposive sampling for experience in attending deteriorating patients. Written response surveys were used to address the study aim. Data were analysed using content analysis. ResultsFour major themes were identified: Governance, Teamwork, Clinical Care Delivery and End of Life Care. Participants perceived there was a lack of sufficient and senior staff with the required theoretical knowledge; and inadequate assessment and critical thinking skills for anticipating, recognising and responding to clinical deterioration. Senior doctors were perceived to inappropriately manage End of Life Care issues and displayed Teamwork behaviours rendering ward clinicians feeling fearful and intimidated. A lack of System and Clinical Governance hindered identification of clinical deterioration. ConclusionsTo improve patient safety related to recognising and responding to clinical deterioration, suboptimal care due to professionals’ knowledge, skills and behaviours need addressing, along with End of Life Care and Governance.

Epidemiology of long-stay patients in a university teaching hospital.

Patients admitted to acute care hospitals may have multiple comorbidities, and a small proportion may stay for a protracted period. To assess the proportion of hospital patients who are long stay (≥14 days) and evaluate associations with baseline variables and subsequent inpatient morbidity and mortality. This is a retrospective observational study of patients aged ≥18 years staying in hospital for at least 24 h between 1 July 2013 and 30 June 2014. There were 22 094 admissions in 15 623 patients. The median (interquartile range (IQR)) length of stay (LOS) was 4 (2-8) days, and 10% had a LOS >16 days. Long-stay admissions comprised 13.1% of admissions but used 49.1% of bed days. Long-stay admissions were more likely to be associated with intensive care unit admission (21.2 vs 6.0%), medical emergency team review (20.5 vs 4.3%) and a longer duration of mechanical ventilation (P < 0.0001 all comparisons). Long-stay patients were more likely to develop in-hospital complications, were more likely to die in hospital (8.2 vs 3.1%) and were less likely to be discharged home (P < 0.001 all comparisons). Multiple variable analysis revealed several associations with prolonged stay, including multiple admissions in the study period, the nature of the admitting unit, the Charlson comorbidity index at admission, admission from another hospital and any history of smoking. Patients staying at least 14 days comprised one seventh of hospital admissions but used half of bed days and suffered increased in-hospital morbidity and mortality. Several pre-admission associations with prolonged stay were identified.

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.

Characteristics and outcomes of patients admitted to ICU following activation of the medical emergency team: impact of introducing a two-tier response system.

To determine the impact of introducing a two-tier system for responding to deteriorating ward patients on ICU admissions after medical emergency team review. Retrospective database review before (2006-2009) and after (2011-2013) the introduction of a two-tier system. Tertiary, university-affiliated hospital. A total of 1,564 ICU admissions. Two-tier rapid response system. The median number of medical emergency team activations/1,000 hospitalizations increased from 22 to 31 (difference [95% CI], 9 [5-10]; p<0.0001) with a decreased rate of medical emergency team activations leading to ICU admission (from median 11 to 8; difference [95% CI], 3 [3-4]; p=0.03). The median proportion of medical emergency team reviews leading to ICU admission increased for those triggered by tachypnoea (from 11% to 15%; difference [95% CI], 4 [3-5]; p<0.0001) and by hypotension (from 27% to 43%; difference [95% CI], 15 [12-19]; p<0.0001) and decreased for those triggered by reduced level of consciousness (from 20% to 17%; difference [95% CI], 3 [2-4]; p<0.0001) and by clinical concern (from 18% to 9%; difference [95% CI], 10 [9-13]; p<0.0001). The proportions of ICU admissions following medical emergency team review did not change significantly for tachycardia, seizure, or cardiorespiratory arrest. The overall ICU mortality for admissions following medical emergency team review for tachypnoea, tachycardia, and clinical concern decreased (from 29% to 9%: difference [95% CI], 20 [11-29]; p<0.0001) but did not change for the other triggers. The Acute Physiology and Chronic Health Evaluation predicted and observed ICU mortality and the proportion of patients dying with a not-for-resuscitation order decreased. The introduction of a two-tier response to clinical deterioration increased ICU admissions triggered by cardiorespiratory criteria, whereas admissions triggered by more subjective criteria decreased. The overall ICU mortality for patients admitted following medical emergency team review decreased, suggesting that the two-tier system led to earlier recognition of reversible pathology or a decision not to escalate the level of care.

Delayed Medical Emergency Team Calls and Associated Outcomes*

To determine whether there was an association between delayed medical emergency team calls and mortality after a medical emergency team review. This was a prospective observational study. A university-affiliated tertiary referral hospital in Porto Alegre, Brazil. All patients were reviewed by the medical emergency team from July 2008 to December 2009. None. There were 1,481 calls for 1,148 patients. Delayed medical emergency team calls occurred for 246 patients (21.4%). The criterion associated with delay was typically the same criterion for the subsequent medical emergency team call. Physicians had a greater prevalence of delayed medical emergency team calls (110 of 246 [44.7%]) than timely medical emergency team calls (267 of 902 [29.6%]; p < 0.001). The mortality at 30 days after medical emergency team review was higher among patients with delayed medical emergency team activation (152 [61.8%]) than patients receiving timely medical emergency team activation (378 [41.9%]; p < 0.001). In a multivariate analysis, delayed medical emergency team calls remained significantly associated with higher mortality. Delayed medical emergency team calls are common and are independently associated with higher mortality. This result reaffirms the concept and need for a rapid response system.

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.