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

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

OBJECTIVES

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.

DESIGN

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.

SETTING

A 560-bed teaching hospital, with a 22-bed ICU and 24-hour Emergency Department in Melbourne, Australia.

PATIENTS

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.

MEASUREMENTS AND MAIN RESULTS

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.

CONCLUSIONS

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.

Recognising and Responding to Clinical Deterioration in Adult Patients in Isolation Precautions for Infection Control: A Retrospective Cohort Study

BACKGROUND

Patient isolation is widely used as a strategy for prevention and control of infection but may have unintended consequences for patients. Early recognition and response to acute deterioration is an essential component of safe, quality patient care and has not been explored for patients in isolation. Primary aims of this study were to: i) describe the timing, frequency, and nature of clinical deterioration during hospital admission for patients with isolation precautions for infection control and ii) compare the characteristics of patients who did and did not deteriorate during their initial period of isolation precautions for infection control.

METHODS

This retrospective cohort study was conducted across three sites of a large Australian health service. The study sample were adult patients (≥18 years) admitted into isolation precautions within 24-hours of admission from 1 July to 31 December 2019.

RESULTS

There were 634 patients who fulfilled the study inclusion criteria. One in eight patients experienced at least one episode of clinical deterioration during their time in isolation with most episodes of deterioration occurring within the first two days of admission. Timely Medical Emergency Team calls occurred in almost half the episodes of deterioration; however, the same proportion (47.2%) of deterioration episodes resulted in no Medical Emergency Team activation (afferent limb failure). In the 24-hours preceding each episode of clinical deterioration (n=180), 81.6% (n=147) of episodes were preceded by vital signs fulfilling pre-Medical Emergency Team criteria.Patients who deteriorated during isolation for infection control were older (median age 74.0 vs 71.0 years, P=0.042); more likely to live in a residential care facility (21.0% vs 7.2%, P=0.006); had a longer initial period of isolation (4.0 vs 2.9 days, P=<000.1) and hospital length of stay (median 4.9 vs 3.2 days, P=<0.001) and were more likely to die in hospital (12.3% vs 4.3%, P<0.001).

CONCLUSION

Patients in isolation precautions experienced high Medical Emergency Team afferent limb failure and most fulfilled pre-Medical Emergency Team criteria in the 24-hours preceding episodes of deterioration. Timely recognition and response to clinical deterioration continue to be essential in providing safe, quality patient care regardless of the hospital-care environment.