Pediatric Medical Emergency Team Research Articles

Pediatric intraoperative cardiopulmonary arrests: A survey to evaluate if Medical Emergency Teams are utilized in pediatric operating rooms.

Studies have shown that standardized code teams may improve outcomes following cardiac arrests. Pediatric intra-operative cardiac arrests are rare events and are associated with a mortality rate of 18%. There is limited data available regarding use Medical Emergency Team (MET) response to pediatric intra-operative cardiac arrest. The purpose of this study was to identify the use of MET in response to pediatric intraoperative cardiac arrest as an exploratory step in establishing evidence-based standardized practice across the hospital for training and management of this rare event. An anonymous electronic survey was created and sent to two populations: The Pediatric Anesthesia Leadership Council, a section of the Society for Pediatric Anesthesia, and the Pediatric Resuscitation Quality Collaborative, a multinational collaborative group, which works to improve resuscitation care in children. Standard summary and descriptive statistics were used for survey responses. The overall response rate was 41%. The majority of respondents worked in a university affiliated, free-standing children's hospital. Ninety-five percent of respondents had a dedicated pediatric MET at their hospital. In 60% of responses from Pediatric Resuscitation Quality Collaborative and 18% of Pediatric Anesthesia Leadership Council hospitals, the MET responds to pediatric intra-operative cardiac arrest; however, the majority of times MET involvement is requested rather than automatic. The MET was found to be activated intraoperatively for situations other than cardiac arrest such as, massive transfusion events, need for extra staff, and for specialty expertise. In 65% of institutions, simulation-based training for cardiac arrest is supported but lacking pediatric intra-operative focus. This survey revealed heterogeneity in the composition and response of the medical response teams responding to pediatric intra-operative cardiac arrests. Improved collaboration and cross training among MET, anesthesia, and operating room nursing may improve outcomes of pediatric intra-operative code events.

Changing patterns in paediatric medical emergency team (MET) activations over 20 years in a single specialist paediatric hospital

BackgroundThe Medical Emergency Team (MET) model was first introduced in the early 1990s and aimed to intervene at an earlier stage of patient clinical deterioration. This study aimed to describe the changes in patient demographics, patterns of activation and clinical outcomes of MET activations at our specialist paediatric hospital across a 20-year period providing the longest duration Medical Emergency Team data set published to date. MethodsThis single-centre observational study prospectively collected data about MET events at a single specialist paediatric hospital in Australia from 1995 to 2014. Patient demographics, activation patterns and clinical outcomes from MET activations were analysed for the 20-year period. Results771 MET events were included in analysis. Most MET events involved children aged <5 years (median age 36 months) with decreased incidence on weekends and night shift. The most frequent reasons stated for MET activation were seizure and respiratory compromise and the most commonly recorded MET interventions were bag-valve-mask ventilation and intravascular access. There was an increase in MET event frequency (MET events per 1000 hospital separations) in the second decade of the service compared to the first (3.25 vs 1.42, p ​< ​0.001) with fewer events for cardiopulmonary arrest but more for respiratory, cardiovascular or neurological compromise. ConclusionsThis study describes the longest duration MET data set published to date. The 20-year span of data demonstrates increased utilisation of the MET system and activation for patients earlier in their deterioration. The data should inform both health service planning and educational requirements for MET providers.

Medical Emergency Team Event Characteristics from an Australian Pediatric Hospital: A Single-Center, Retrospective Study

To describe the characteristics of medical emergency team (MET) events at an Australian pediatric, tertiary-care center in a way that would allow for comparison with other MET systems. A retrospective, single-center, observational study. Consecutive MET events that occurred between January 2013 and July 2014 at Princess Margaret Hospital for Children in Perth, Western Australia, were included. There were 46 445 hospital admissions during the study period and 197 MET events in children. This gives a rate of 4.2 MET events per 1000 admissions. Out of 197 pediatric MET events analyzed, there were 2 deaths (1.0%) that occurred during the MET events. All 197 patients were actively treated, with none receiving "do not attempt resuscitation" orders. Of pediatric MET events, 24% (48 of 197) were admitted to the PICU, and 75% (149 of 197) stayed in the ward where the call was made. In this tertiary-care, pediatric hospital in Australia, the MET event rate and the rate of admission to the PICU because of MET events are lower than those reported for US pediatric hospitals. Despite these differences, Australian data suggest that outcomes are similar to US pediatric hospitals.

Regular in-situ simulation training of paediatric Medical Emergency Team leads to sustained improvements in hospital response to deteriorating patients, improved outcomes in intensive care and financial savings

Aim of the studyThe introduction of a paediatric Medical Emergency Team (pMET) was accompanied by weekly in-situ simulation team training. Key ward staff participated in team training, focusing on recognition of the deteriorating child, teamwork and early involvement of senior staff. Following an earlier study [1], this investigation aimed to evaluate the long-term impact of ongoing regular team training on hospital response to deteriorating ward patients, patient outcome and financial implications. MethodsProspective cohort study of all deteriorating in-patients in a tertiary paediatric hospital requiring admission to paediatric intensive care (PICU) the year before, 1year after and 3 years after the introduction of pMET and team training. ResultsDeteriorating patients were recognised more promptly (before/1year after/3years after pMET; median time 4/1.5/0.5h, p<0.001), more often reviewed by consultants (45%/76%/81%, p<0.001) and more rapidly escalated to PICU (median time 10.5/5/3.5h, p=0.02). There was a significant reduction in associated PICU admissions (56/51/32, p=0.02) and PICU bed days (527/336/193, p<0.001). The total annual cost of training (£74,250) was more than offset by savings from reduced PICU bed days (£801,600 per annum). Introduction of pMET coincided with significantly reduced hospital mortality (p<0.001). ConclusionThese results indicate that lessons learnt by ward staff during team training led to sustained improvements in the hospital response to critically deteriorating in-patients, significantly improved patient outcomes and substantial savings. Integration of regular in-situ simulation training of medical emergency teams, including key ward staff, in routine clinical care has potential application in all acute specialties.

Pediatric Medical Emergency Team Events and Outcomes: A Report of 3647 Events From the American Heart Association's Get With the Guidelines-Resuscitation Registry.

To describe the clinical characteristics and outcomes of a large, multicenter cohort of pediatric medical emergency team (MET) events occurring in US hospitals reported to the American Heart Association's Get With the Guidelines-Resuscitation registry. We analyzed consecutive pediatric (<18 years) MET events reported to the registry from January 2006 to February 2012. We identified 3647 MET events from 151 US hospitals: 3080 (84%) ward and 567 (16%) telemetry/step-down unit events; median age 3.0 years (interquartile range: 0.0-11.0); 54% male; median duration 29 minutes (interquartile range: 18-49). Triggers included decreased oxygen saturation (32%), difficulty breathing (26%), and staff concern (24%). Thirty-seven percent (1137/3059) were admitted within 24 hours before MET event. Within 24 hours before the MET event, 16% were transferred from a PICU, 24% from an emergency department, and 7% from a pediatric anesthesia care unit. Fifty-three percent of MET events resulted in transfer to a PICU; 3251 (89%) received nonpharmacologic interventions, 2135 (59%) received pharmacologic interventions, 223 (6.1%) progressed to an acute respiratory compromise event, and 17 events (0.5%) escalated to cardiopulmonary arrest during the event. Survival to hospital discharge was 93.3% (n=3299/3536). Few pediatric MET events progress to respiratory or cardiac arrest, but most require nonpharmacologic and pharmacologic intervention. Median duration of MET event was 29 minutes (interquartile range: 18-49), and 53% required transfer to a PICU. Events often occurred within 24 hours after hospital admission or transfer from the PICU, emergency department, or pediatric anesthesia care unit and may represent an opportunity to improve triage and other systems of care.

Utility of Pediatric Early Warning System (PEWS) Score and Medical Emergency Team (MET) Activations on Decisions to Implement Critical Care

Utility of Pediatric Early Warning System (PEWS) Score and Medical Emergency Team (MET) Activations on Decisions to Implement Critical Care

Patient Characteristics and Disposition After Pediatric Medical Emergency Team (MET) Activation: Disposition Depends on Who Activates the Team

This study focused on health care staff (HCS) responsible for activating the medical emergency team (MET) at a pediatric tertiary hospital using a well-established rapid response system. Our goals were to report the patient characteristics, MET interventions, and disposition by activating HCS. This is a retrospective cohort study of pediatric patients who received MET activation at the Children's Hospital of Eastern Ontario in Ottawa, Canada. Data were obtained from a prospectively maintained rapid response system database. The primary outcome was PICU admission, with the number and type of interventions performed as secondary outcomes. The most common MET activators were physicians (410, 53.3%) with nurses generating a comparable number (367, 47.7%). Significant differences in PICU admission rates were observed between activator groups, with physicians having statistically higher PICU admission rates when compared with nurses (25.2% vs 15.0%, P = .001). Compared with physicians, nursing-led activations on surgical patients had significantly lower odds of PICU admission relative to medical patients (odds ratio 0.19 vs 0.67; P = .03). No significant difference was observed in the type or number of interventions between any subgroup based on patient (surgery vs medical) or activator type. This study suggests that when nurses activate MET, patients are less likely to be transferred to the PICU despite receiving similar type and number of interventions. Our study results may help direct education initiatives aimed at enhancing the effectiveness of the afferent limb through informing specific HCS as to the importance of their role in using the MET.

Abstract 188: Pediatric Medical Emergency Team Response and Outcomes: A Report of 4,181 Events From the AHA Get With the Guidelines®-Resuscitation Registry

Background: In-hospital cardiac arrest (CA) is often preceded by signs and symptoms that predict subsequent deterioration. In response, hospitals created Medical Emergency Teams (METs) to bring skilled resources to the bedside with the aim of improving outcomes. Objective: Describe a cohort of pediatric MET events from the AHA Get With the Guidelines-Resuscitation (GWTG-R) registry. Methods: We analyzed consecutive pediatric (&lt; 18 yrs) MET events submitted to the AHA GWTG-R from Jan 2006 - Feb 2012. We excluded MET events in outpatient, critical care, newborn nurseries, delivery rooms, emergency departments (ED) and interventional/diagnostic areas. Results: We identified 4,181 MET events from 170 U.S. hospitals: median age 3.0 yrs (IQR = 0.0-13.0) with 52% male. Majority of MET events were in general inpatient wards (N = 3136, 75%) and telemetry/step-down units (N = 580, 13%). Medical (71%) and surgical (15%) non-cardiac patients were most frequent. Median length of MET event was 29.0 mins (IQR = 17.0-47.0). Most frequent triggers included: decreased oxygen saturation (30%), difficulty breathing (24%), staff concern (23%), tachypnea (21%), mental status changes (16%), and respiratory depression (12%). Within 24 hrs prior to MET call, 15% were transferred from an ICU, and 22% were admitted from the ED. Frequent non-drug interventions included: oxygen (58%), peripheral IV placement (30%), CXR (16%), suctioning (15%), and ICU consult (12%). Frequent drug interventions included: fluid bolus (21%), inhaled bronchodilators (16%), and anti-epileptics (7%). Almost half were transferred to the ICU (n = 2022, 48%), 236 (6%) progressed to require emergency assisted ventilation, and 18 patients (0.43%) progressed to CA. Survival to discharge was 92% (N = 3789). Conclusions: MET events occurred in general inpatient wards for objective indications, included assisted ventilation or CPR in 6.4%, and were associated with 8% hospital mortality. After treatment in 87% of events, 39% remained on inpatient wards, suggesting MET associated treatments may have stabilized or improved the condition of children judged to be clinically deteriorating by ward staff. Frequent events after ED admission or ICU transfer may represent an opportunity to improve the system of care.

Urgent Ultrasound Guided Hemodynamic Assessments by a Pediatric Medical Emergency Team: A Pilot Study

PurposeTo determine the feasibility of using the Ultrasound Cardiac Output Monitor (USCOM) as an adjunct during hemodynamic assessments by a pediatric medical emergency team (PMET).MethodsPediatric in-patients at McMaster Children’s Hospital aged under 18 years requiring urgent PMET consultation, were eligible. Patients with known cardiac outflow valve defects, Pediatric Critical Care Unit in-patients, and those in cardiorespiratory arrest, were excluded. The primary outcome was feasibility, and the ease of USCOM transport and application as assessed by a self-administered user questionnaire. Secondary outcomes included the quality of USCOM measurements, and agreement in clinical versus USCOM-derived assessments.ResultsForty-one patients from 85 eligible PMET consultations were enrolled between March and August 2011. A total of 55 USCOM assessments were performed on 36 of 41 (87.8%) participants. USCOM could not be completed in 5 (12.2%) participants due to patient agitation (n = 4) and emergent care (n = 1). USCOM was reported as easy to transport and apply by 97.4% and 94.7% of respondents respectively, not obstructive to patient care by 94.7%, and yielded timely measurements by 84.2% respondents. USCOM tracings were of good quality in 41 (75.9%) assessments. Agreement between clinical and USCOM-derived hemodynamic assessments by two independent raters was poor (Rater 1: κ = 0.094; Rater 2: κ = 0.146).ConclusionUSCOM can be applied by a PMET during urgent hemodynamic assessments in children. While USCOM has been validated in stable children, its role in guiding hemodynamic resuscitation and informing therapeutic goals in a hemodynamically unstable pediatric population requires further investigation.

Characteristics of Medication Use During Pediatric Medical Emergency Team Events and the Role of a Pharmacist-Provided Medication Supply

To determine the type and frequency of and indications for medications used during pediatric medical emergency team (PMET) events and to describe a PMET pharmacist training model, creation of a standardized "pharmacist PMET supply," and the pharmacist's role in implementation and ongoing improvement of a PMET. This is a retrospective observational cohort study of 210 PMET events in 172 patients in a tertiary care, academic pediatric hospital, from September 15, 2005, to September 15, 2007. We focused on the types and sources of medications used during PMET events. The medications most commonly used were lorazepam (11%), neuromuscular blockers (10.5%), atropine (9.5%), epinephrine bolus (9%), and albuterol or levalbuterol (9%). However, 49 distinct medications were used in 53.8% of all PMET events. Of all medications requested during a PMET event, only 40% originated from an institutionally standardized emergency medication box, while an additional 35% were readily available at the patient's bedside as part of the "pharmacist PMET supply." A wide variety of medications are required to care for children who suffer acute in-hospital deterioration. The pharmacist's medication supply and expertise ensured immediate availability of therapies for clinical entities ranging from seizures and anaphylaxis to rapid sequence intubation, regardless of the PMET event location.

Regular in situ simulation training of paediatric Medical Emergency Team improves hospital response to deteriorating patients

Aim of the studyThe introduction of a paediatric Medical Emergency Team (pMET) was accompanied by integration of weekly in situ simulation team training into routine clinical practice. On a rotational basis, all key ward staff participated in team training, which focused on recognition of the deteriorating child, teamwork and early consultant review of patients with evolving critical illness. This study aimed to evaluate the impact of regular team training on the hospital response to deteriorating in-patients and subsequent patient outcome. MethodsProspective cohort study of all deteriorating in-patients of a tertiary paediatric hospital requiring admission to paediatric intensive care (PICU) the year before, and after, the introduction of pMET and concurrent team training. ResultsDeteriorating patients were: recognised more promptly (before/after pMET: median time 4/1.5h, p<0.001), more often reviewed by consultants (45%/76%, p=0.004), more often transferred to high dependency care (18%/37%, p=0.021) and more rapidly escalated to intensive care (median time 10.5/5h, p=0.024). These improved responses by ward staff extended beyond direct involvement of pMET.There was a trend towards fewer PICU admissions, reduced level of sickness at the time of PICU admission, reduced length of PICU stay and reduced PICU mortality. Introduction of pMET coincided with significantly reduced hospital mortality (p<0.001). ConclusionsThese results indicate that lessons learnt by ward staff during regular in situ team training led to significantly improved recognition and management of deteriorating in-patients with evolving critical illness. Integration of in situ simulation team training in clinical care has potential applications beyond paediatrics.

Reduction in Hospital Mortality Over Time in a Hospital Without a Pediatric Medical Emergency Team

To determine whether hospital mortality has decreased over time in a hospital that has not introduced a pediatric medical emergency team (PMET). Retrospective observational study. Quaternary children's hospital. All pediatric inpatient separations (defined as any discharge, including death) during 10 fiscal years. We searched our hospital administrative database to determine the number of pediatric inpatient separations and deaths, and we searched the hospital switchboard and pediatric intensive care databases to determine ward code and cardiopulmonary arrest rates. Relative risks (RRs) with 95% confidence intervals (CIs) and logistic regression compared results over time. During the periods of the 2 PMET studies showing a reduction in hospital mortality, we found a decrease in hospital mortality: for 1999-2002 vs 2002-2006, 212 deaths among 14 161 patients (1.50%) vs 219 of 26 767 (0.82%), RR, 0.55 (95% CI, 0.44-0.69); for 2000-2005 vs 2005-2007, 300 deaths among 29 497 patients (1.02%) vs 98 of 14 005 (0.70%), RR, 0.69 (95% CI, 0.55-0.86). During the periods of the 3 PMET studies showing no change in or not examining hospital mortality, we found no significant change in hospital mortality. The annual odds ratio for survival was 1.13 (95% CI, 1.09-1.16). There were no changes in ward code and cardiopulmonary arrest rates over time. We found a reduction in hospital mortality over time in a children's hospital without a PMET. This demonstrates the limitation of before-and-after study designs, and we hypothesize that multiple co-interventions account for the decrease in mortality. Whether a PMET could have reduced mortality further is unknown.

Attitudes and barriers to a Medical Emergency Team system at a tertiary paediatric hospital

Aim To determine the attitudes and barriers to an established paediatric Medical Emergency Team (MET) system among nurses and doctors. Methods Invitation to all clinical staff in a paediatric hospital to complete an electronic 41-item branched survey. Responses were graded on a Likert scale. Results 407 staff completed the survey (280 nurses, 127 doctors). The MET system was highly valued for obtaining urgent assistance for the seriously ill patients by 85% of nurses and 83% of doctors. However, barriers to MET activation included; preference to contact the covering (attending) doctors by 80% of nurses and 45% of doctors, active discouragement to activating a MET by 41% of nurses and 12% of doctors, and fear of criticism by 17% of nurses and 9% of doctors if the patient was not deemed seriously ill by the MET attendees. Less experienced staff were significantly more likely to report barriers to calling a MET. Negative attitudes from MET attendees were reported by nurses (24%) and doctors (6.5%). Failure to recognize serious illness was revealed by unwillingness of 47% of doctors and 32% of nurses to activate MET when activation criteria were attained and by retrospective realization by 30% of doctors and 15% of nurses that they had failed to activate MET when needed. Conclusions Cultural and behavioral barriers to MET activation and inability to recognize serious illness may explain in part the failure of a MET system to completely eliminate unexpected cardiac arrest and death. Unless these issues are addressed, the full benefits of a MET system may not be realised.

Cohort study to test the predictability of the Melbourne criteria for activation of the medical emergency team

ObjectiveTo test the predictability of the Melbourne criteria for activation of the medical emergency team (MET) to identify children at risk of developing critical illness.DesignCohort study.SettingAdmissions to all paediatric wards...

Paediatric medical emergency team helped cut hospital deaths

Paediatric medical emergency team helped cut hospital deaths

Reduction of hospital mortality and of preventable cardiac arrest and death on introduction of a pediatric medical emergency team*

To determine the effect of a medical emergency team (MET) on the incidence of unexpected cardiac arrest and death. Comparison of retrospective data (pre-MET) before introduction of MET with prospective data after introduction of MET system (post-MET). Tertiary care pediatric hospital. A total of 104,780 admissions during a 41-month period pre-MET; 138,424 admissions during 48 months post-MET. Introduction of a MET. Total hospital deaths decreased from 4.38 to 2.87/ 1000 admissions (risk ratio 0.65, 95% confidence interval [CI] 0.57-0.75, p < 0.0001). Ward unexpected death decreased from 13 (0.12/1000) to 6 (0.04/1000) (risk ratio 0.35, 95% CI 0.13- 0.92, p = 0.03) but unexpected cardiac arrests did not change from 0.19/1000 to 0.17/1000 (risk ratio 0.91, 95% CI 0.50 -1.64, p = 0.75). Thirty-four hospital deaths, including three unexpected deaths (1 out of 72 MET calls), were prevented each year of MET operation. Preventable cardiac arrest (children whose symptoms or signs fulfilled MET calling criteria) decreased from 17 (0.16/ 1000) to 10 (0.07/1000) (risk ratio 0.45, 95% CI 0.20-0.97, p = 0.04) and in whom death decreased from 12 to 2 (0.11/1000 to 0.01/1000) (risk ratio 0.13, 95% CI 0.03-0.56, p = 0.001). Nonpreventable cardiac arrest (children whose symptoms or signs did not fulfill MET calling criteria) increased from 3 to 14 (0.03/1000 to 0.10/1000, p = 0.03) but death did not increase. Survival from cardiac arrest increased from 7 of 20 patients to 17 of 23 (risk ratio 2.11, 95% CI 1.11- 4.02, p = 0.01). Annual calls for urgent assistance were 202 in the post-MET era and 46 during the pre-MET era (ratio 4.4:1). Introduction of a MET was associated with reduction of total hospital death and reduction of preventable cardiac arrest and death with increased survival in wards of a pediatric hospital. MET calling criteria identified some but not all children at risk of unexpected cardiac arrest and death.

Transition From a Traditional Code Team to a Medical Emergency Team and Categorization of Cardiopulmonary Arrests in a Children's Center

To study the effect of an intervention on prevention of respiratory arrest and cardiopulmonary arrest (CPA) and to characterize ward CPAs by preceding signs and symptoms and initial cardiac rhythm. A before-and-after interventional trial (12 months preintervention and 12 months postintervention). A tertiary care, academic children's hospital. Admitted patients who subsequently had either the code team or pediatric medical emergency team (PMET) called or who had a respiratory arrest or CPA on the wards. Intervention Transition from a traditional code team to a PMET that responds to clinically deteriorating children in noncritical care areas. Combined rate of respiratory arrests and CPAs, rate of CPAs, and rate of respiratory arrests on the wards and agreement between independent reviewers on categorization of CPAs. There was no change in the rate of CPAs on the wards. However, there was a 73% decrease in the incidence of respiratory arrests (0.23 respiratory arrests/1000 patient-days pre-PMET vs 0.06 post-PMET, P = .03). There was 100% agreement between reviewers on categorization of CPAs. Transition to a PMET was not associated with a change in CPAs but was associated with a significant decrease in the incidence of ward respiratory arrests. We also describe children who may have benefited from the PMET but whose data were not captured by current outcome measures. Finally, we present a new method for categorization of ward CPAs based on preceding signs and symptoms and initial cardiac rhythm.

A Pediatric Medical Emergency Team Manages a Complex Child with Hypoxia and a Worried Parent

As demonstrated in this case report, parental concern can serve as an important and effective call trigger.

Reduction of paediatric in-patient cardiac arrest and death with a medical emergency team: preliminary results

Aims: To determine the impact of a paediatric medical emergency team (MET) on cardiac arrest, mortality, and unplanned admission to intensive care in a paediatric tertiary care hospital. Methods: Comparison...