A Delphi study to obtain consensus on medical emergency team (MET) stand-down decision making

AIM

A medical emergency team (MET) stand-down decision is the decision to end a MET response and hand responsibility for the patient back to ward staff for ongoing management. Little research has explored this decision. This study aimed to obtain expert consensus on the essential elements required to make optimal MET call stand-down decisions and the communication required before MET departure.

DESIGN

A Delphi design was utilised.

METHODS

An expert panel of 10 members were recruited based on their expert knowledge and recent clinical MET responder experience in acute hospital settings. Participants were emailed a consent form and an electronic interactive PDF for each survey. Two rounds were conducted with no attrition between rounds. The CREDES guidance on conducting and reporting Delphi studies was used to report this study.

RESULTS

Consensus by an expert panel of 10 MET responders generated essential elements of MET stand-down decisions. Essential elements comprised of two steps: (1) the stand-down decision that was influenced by both the patient situation and the ward/organisational context; and (2) the communication required before actioning stand-down. Communication after the decision required both verbal discussions and written documentation to hand over patient responsibility. Specific patient information, a management plan and an escalation plan were considered essential.

CONCLUSION

The Delphi surveys reached consensus on the actions and communication required to stand down a MET call. Passing responsibility back to ward staff after a MET call requires both patient and ward safety assessments, and a clearly articulated patient plan for ward staff. Observation of MET call stand-down decision-making is required to validate the essential elements.

IMPLICATION FOR THE PROFESSION AND PATIENT/OR PATIENT CARE

In specifying the essential elements, this study offers clinical and MET staff a process to support the handing over of clinical responsibility from the MET to the ward staff, and clarification of management plans in order to reduce repeat MET calls and improve patient outcomes.

IMPACT

Minimal research has been focussed on the decision to hand responsibility back to ward staff so the MET may leave the ward with safety plan in place. This study provided expert consensus to optimise MET stand-down decision-making and the ultimate decision to end a MET call. Communication of agreed patient treatment and escalation plans is recommended before leaving the ward. This study can be used as a checklist for MET responder staff making these decisions and ward staff responsible for post-MET call care. The aim being to reduce the likelihood of potentially preventable repeat deterioration in the MET patient population.

REPORTING METHOD

The CREDES guidance on conducting and reporting Delphi studies.

PATIENT OR PUBLIC CONTRIBUTION

None.

Vital sign assessment and nursing interventions in medical and surgical patients with rapid response system triggers

AIM(S)

To explore vital sign assessment (both complete and incomplete sets of vital signs), and escalation of care per policy and nursing interventions in response to clinical deterioration.

DESIGN

This cohort study is a secondary analysis of data from the Prioritising Responses of Nurses To deteriorating patient Observations cluster randomised controlled trial of a facilitation intervention on nurses' vital sign measurement and escalation of care for deteriorating patients.

METHODS

The study was conducted in 36 wards at four metropolitan hospitals in Victoria, Australia. Medical records of all included patients from the study wards during three randomly selected 24-h periods within the same week were audited at three time points: pre-intervention (June 2016), and at 6 (December 2016) and 12 months (June 1017) post-intervention. Descriptive statistics were used to summarise the study data, and relationships between variables were examined using chi-square test.

RESULTS

A total of 10,383 audits were conducted. At least one vital sign measurement was documented every 8 h in 91.6% of audits, and a complete set of vital signs was documented every 8 h in 83.1% of audits. There were pre-Medical Emergency Team, Medical Emergency Team or Cardiac Arrest Team triggers in 25.8% of audits. When triggers were present, a rapid response system call occurred in 26.8% of audits. There were 1350 documented nursing interventions in audits with pre-Medical Emergency Team (n = 2403) or Medical Emergency Team triggers (n = 273). One or more nursing interventions were documented in 29.5% of audits with pre-Medical Emergency Team triggers and 63.7% of audits with Medical Emergency Team triggers.

CONCLUSION

When rapid response system triggers were documented, there were gaps in escalation of care per policy; however, nurses undertook a range of interventions within their scope of practice in response to clinical deterioration.

RELEVANCE TO CLINICAL PRACTICE

Medical and surgical ward nurses in acute care wards frequently engage in vital sign assessment. Interventions by medical and nurgical nurses may occur prior to, or in parallel with calling the rapid response system. Nursing interventions are a key but under-recognised element of the organisational response to deteriorating patients.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Nurses engage in a range of nursing interventions to manage deteriorating patients, (aside from rapid response system activation) that are not well understood, nor well described in the literature to date.

IMPACT

This study addresses the gap in the literature regarding nurses' management of deteriorating patients within their scope of practice (aside from RRS activation) in real world settings. When rapid response system triggers were documented, there were gaps in escalation of care per policy; however, nurses undertook a range of interventions within their scope of practice in response to clinical deterioration. The results of this research are relevant to nurses working on medical and surgical wards.

REPORTING METHOD

The trial was reported according to the Consolidated Standards of Reporting Trials extension for Cluster Trials recommendations, and this paper is reported according to the Strengthening the Reporting of Observational Studies in Epidemiology Statement.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Medication-related Medical Emergency Team activations: a case review study of frequency and preventability

OBJECTIVES

Despite recognition of clinical deterioration and medication-related harm as patient safety risks, the frequency of medication-related Rapid Response System activations is undefined. We aimed to estimate the incidence and preventability of medication-related Medical Emergency Team (MET) activations and describe the associated adverse medication events.

METHODS

A case review study of consecutive MET activations at two acute, academic teaching hospitals in Melbourne, Australia with mature Rapid Response Systems was conducted. All MET activations during a 3-week study period were assessed for a medication cause including identification of the contributing adverse medication event and its preventability, using validated tools and recognised classification systems.

RESULTS

There were 9439 admissions and 628 MET activations during the study period. Of these, 146 (23.2%) MET activations were medication related: an incidence of 15.5 medication-related MET activation per 1000 admissions. Medication-related MET activations occurred a median of 46.6 hours earlier (IQR 22-165) in an admission than non-medication-related activations (p=0.001). Furthermore, this group also had more repeat MET activations during their admission (p=0.021, OR=1.68, 95% CI 1.09 to 2.59). A total of 92 of 146 (63%) medication-related MET activations were potentially preventable. Tachycardia due to omission of beta-blocking agents (10.9%, n=10 of 92) and hypotension due to cumulative toxicity (9.8%, n=9 of 92) or inappropriate use (10.9%, n=10 of 92) of antihypertensives were the most common adverse medication events leading to potentially preventable medication-related MET activations.

CONCLUSIONS

Medications contributed to almost a quarter of MET activations, often early in a patient's admission. One in seven MET activations were due to potentially preventable adverse medication events. The most common of these were omission of beta-blockers and clinically inappropriate antihypertensive use. Strategies to prevent these events would increase patient safety and reduce burden on the MET.

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

AIMS

The aim of this study was to explore clinician-patient engagement during, and patient experience of, medical emergency team (MET) reviews.

DESIGN

This study involved a convergent mixed-methods design.

METHODS

This 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.

RESULTS

In 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?

CONCLUSION

Clinician-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.

Indications and measures of medical emergency teams: a retrospective evaluation of in-hospital emergency operations of the German Resuscitation Register

BACKGROUND

The present study examines characteristics and interventions of medical emergency teams (MET) in in-hospital emergency care.

METHODS

Analysis of all in-hospital emergencies in patients ≥18 years at 62 hospitals with established MET from the database of the German Resuscitation Registry between 2014-2019. The evaluation covered indications for activation using the ABCDE-scheme, time intervals of arrival and patient care as well as the performed invasive/medical interventions.

RESULTS

Out of 62 hospitals 14,166 in-hospital emergencies (male: 8033 [56.7%]; mean age: 64±18 years) were included. Causes of activation were circulation (5760 [40.7%]), disability (4076 [28.8%]), breathing (3649 [25.8%]) and airway-problems (1589 [11.2%]). Average arrival time at the emergency scene was 4±3 minutes, supply time of MET was 24±23 minutes. Endotracheal intubation was required in 1757 (12.4%) and difficult intubation occurred in 201 (11.4%) patients with the necessity for cricothyroidotomy in eight cases (3.9%). Invasive blood-pressure-measurement was indicated in 1074 (7.6%) patients. Catecholamines were required for hemodynamic stabilization in 2421 (17.1%) patients (norepinephrine: 1520 [10.7%], epinephrine: 430 [3.0%], dobutamine: 26 [0.2%]).

CONCLUSIONS

Current in-hospital emergency care requires special skills in invasive hemodynamic and airway interventions. Recommendations from professional societies are necessary to optimize equipment (e.g. videolaryngoscopy, invasive blood pressure management), training, care algorithms and staff composition against the background of an increasing shortage of resources in the healthcare system.

Characteristics and outcomes of medical emergency team calls in a Swiss tertiary centre - a retrospective observational study

AIMS OF THE STUDY

To describe reasons for medical emergency team (MET) activation over time, to analyse outcomes, and to describe the circadian distribution of MET calls and Intensive Care Unit (ICU) admissions following MET activation.

METHODS

Monocentric retrospective observational study of prospectively collected data on all MET calls between 1^st of January 2012 until 31^st of May 2019. We analysed data on baselines, referring wards, and disposition of all MET patients. In addition, we allocated all MET calls to the hourly intervals over the 24-hour cycle of the day in order to identify peak times of team activation.

RESULTS

A total of 4068 calls in 3277 patients (37% female, n = 1210) were analysed. The mean age was 65.9 years (± 15.7). The MET dose (defined as MET calls/1000 hospital admissions) remained relatively stable over the years with a median of 8.0 calls/1000 hospitalisations (interquartile range [IQR] 7.0-10.0). A total of 2526 calls (62%) occurred out of hours (17:00 to 8:00). The hourly rate of MET activations was greatest during the evening shift (33.8% of calls in seven hours), followed by the day shift (35.8% calls in nine hours) and night shift (30.4% in eight hours). Over the years, staff concern was the main reason for a MET call (n = 1192, 34%), followed by low peripheral oxygen saturation (SpO₂) not responding to oxygen therapy (n = 776, 22%). Abnormal respiratory rate was a trigger to call the MET in 44 cases (1.3%), and was not documented prior to 2017. Overall, in-hospital mortality was 22%.

CONCLUSION

While most common reasons for MET calls over the years were staff concern and low SpO₂, abnormal respiratory rate was the least frequent, but increased after the introduction of the quick sequential organ failure assessment (qSOFA) in 2016. Most MET calls occurred out of hours with peak hours during the evening shift, highlighting the importance of resource allocation during this shift when planning to introduce a MET system in a hospital. In-hospital mortality after a MET call was 22%.

Dynamic early warning scores for predicting clinical deterioration in patients with respiratory disease

Background

The National Early Warning Score-2 (NEWS-2) is used to detect patient deterioration in UK hospitals but fails to take account of the detailed granularity or temporal trends in clinical observations. We used data-driven methods to develop dynamic early warning scores (DEWS) to address these deficiencies, and tested their accuracy in patients with respiratory disease for predicting (1) death or intensive care unit admission, occurring within 24 h (D/ICU), and (2) clinically significant deterioration requiring urgent intervention, occurring within 4 h (CSD).

Methods

Clinical observations data were extracted from electronic records for 31,590 respiratory in-patient episodes from April 2015 to December 2020 at a large acute NHS Trust. The timing of D/ICU was extracted for all episodes. 1100 in-patient episodes were annotated manually to record the timing of CSD, defined as a specific event requiring a change in treatment. Time series features were entered into logistic regression models to derive DEWS for each of the clinical outcomes. Area under the receiver operating characteristic curve (AUROC) was the primary measure of model accuracy.

Results

AUROC (95% confidence interval) for predicting D/ICU was 0.857 (0.852–0.862) for NEWS-2 and 0.906 (0.899–0.914) for DEWS in the validation data. AUROC for predicting CSD was 0.829 (0.817–0.842) for NEWS-2 and 0.877 (0.862–0.892) for DEWS. NEWS-2 ≥ 5 had sensitivity of 88.2% and specificity of 54.2% for predicting CSD, while DEWS ≥ 0.021 had higher sensitivity of 93.6% and approximately the same specificity of 54.3% for the same outcome. Using these cut-offs, 315 out of 347 (90.8%) CSD events were detected by both NEWS-2 and DEWS, at the time of the event or within the previous 4 h; 12 (3.5%) were detected by DEWS but not by NEWS-2, while 4 (1.2%) were detected by NEWS-2 but not by DEWS; 16 (4.6%) were not detected by either scoring system.

Conclusion

We have developed DEWS that display greater accuracy than NEWS-2 for predicting clinical deterioration events in patients with respiratory disease. Prospective validation studies are required to assess whether DEWS can be used to reduce missed deteriorations and false alarms in real-life clinical settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-022-02130-6.

[In-hospital emergency care in the Federal Republic of Germany. A site survey of hospitals in the German Resuscitation Registry]

BACKGROUND

In contrast to prehospital care there is a lack of specifications for the organization and equipment of medical emergency teams for in-hospital emergency care.

OBJECTIVE

Evaluation of the organization, team composition, training, equipment and tasks of medical emergency teams in the Federal Republic of Germany.

MATERIAL AND METHODS

Evaluation of a web-based survey of all hospitals participating in the German Resuscitation Register between February and March2020. The participants were asked about team composition; emergency equipment; type, content and scope of special training or further training as well as other additional tasks in the everyday clinical routine when participating in the medical emergency team. Hospitals with ≤ or >600 beds were compared.

RESULTS

A total of 21 (>600 beds: 10, 48%; ≤600 beds: 11, 52%) hospitals participated in the survey. Team composition requirements were present at 76% (n = 16; ≤600 beds: 8, 72% vs. >600 beds: 8, 80%), training requirements for medical emergency teams at 38% (n = 16; ≤600 beds: 4, 36% vs. >600 beds: 4, 40%) of hospitals, with a focus on cardiac life support (n = 6, 28%; ≤600 beds: 3, 27% vs. >600 beds: 3, 30%) and airway management (n = 4, 19%; ≤600 beds: 3, 27% vs. >600 beds: 1, 10%). A 12-lead electrocardiogram (n = 7, 33%; ≤600 beds: 1, 9% vs. >600 beds: 6, 60%; p = 0.02), video laryngoscope (n = 7, 33%; ≤600 beds: 2, 18% vs. >600 beds: 5, 50%), ventilator without (n = 7, 33%; ≤600 beds: 2, 18% vs. >600 beds: 5, 50%) or with the possibility of non-invasive ventilation was part of the standard equipment in n = 4, 19% (≤600 beds: 1, 9% vs. >600 beds: 3, 30%). A total of 85% (n = 18; ≤600 beds: 10, 100% vs. >600 beds 8, 72%), had additional tasks in the daily clinical routine. While clinics with >600 beds staffed medical emergency teams 100% of the time from the intensive care units, in clinics ≤600 beds medical emergency teams were deployed significantly more often in the emergency department (n = 5, 45%) and in the normal wards (n = 5, 45%, p = 0.03).

CONCLUSION

Training and equipment of medical emergency teams in the Federal Republic of Germany is heterogeneous. They should at least meet the standards commonly used in prehospital emergency medicine and include the availability of a portable 12-lead electrocardiogram, a ventilator with the possibility of noninvasive ventilation and a video laryngoscope. Regardless of the size of the hospital, continuous availability of all members of the medical emergency teams should be ensured.

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

BACKGROUND

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.

OBJECTIVES

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.

METHODS

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).

RESULTS

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.

CONCLUSIONS

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.

A point-of-care thoracic ultrasound protocol for hospital medical emergency teams (METUS) improves diagnostic accuracy

Background

Point-of-care ultrasound (POCUS) has proven itself in many clinical situations. Few data on the use of POCUS during Medical Emergency Team (MET) calls exist. In this study, we hypothesized that the use of POCUS would increase the number of correct diagnosis made by the MET and increase MET’s certainty.

Methods

Single-center prospective observational study on adult patients in need for MET assistance. Patients were included in blocks (weeks). During even weeks, the MET physician performed a clinical assessment and registered an initial diagnosis. Subsequently, the POCUS protocol was performed and a second diagnosis was registered (US+). During uneven weeks, no POCUS was performed (US−). A blinded expert reviewed the charts for a final diagnosis. The number of correct diagnoses was compared to the final diagnosis between both groups. Physician’s certainty, mortality and possible differences in first treatment were also evaluated.

Results

We included 100 patients: 52 in the US + and 48 in the US−  group. There were significantly more correct diagnoses in the US+ group compared to the US− group: 78 vs 51% (P  = 0.006). Certainty improved significantly with POCUS (P  <  0.001). No differences in 28-day mortality and first treatment were found.

Conclusions

The use of thoracic POCUS during MET calls leads to better diagnosis and increases certainty.

Trial registration. ClinicalTrials.gov. Registered 12 July 2017, NCT03214809 https://www.clinicaltrials.gov/ct2/show/NCT03214809?term=metus&cntry=NL&draw=2&rank=1

Supplementary Information

The online version contains supplementary material available at 10.1186/s13089-021-00229-3.

Implementation of extended possibility for CPAP in general wards: A quality inter-professional intervention project

INTRODUCTION AND OBJECTIVES

In a Danish Hospital, 70% of all activations of the rapid response team (RRT) in 2016 were related to adult patients with respiratory insufficiency. The most frequent RRT intervention was continuous positive airway pressure (CPAP). However, there was no systematic follow-up and patients could not receive CPAP outside of daytime hours. The aim of the study was to implement and evaluate a CPAP intervention to improve healthcare.

PATIENTS AND METHODS

A quality inter-professional intervention project was conducted. The interventions consisted of: theoretical and practical education in respiratory insufficiency (including use of CPAP) of nurses and physicians from the general wards, physiotherapists and staff from the RRT; development of an instruction leaflet and video; an update of the existing guidelines. The interventions entailed patients being able to receive CPAP a minimum of 3 times for 5-10min within a 24-h period. All RRT activations were registered and compared in a before-after evaluation of the intervention. Additionally, all staff groups received an electronic questionnaire after implementation.

RESULTS

After implementation, respiratory insufficiency was still the highest primary course for RRT activation. The use of CPAP increased, and the number of patients needing a transfer to the intensive care unit decreased. The response rate for the questionnaire was 44% (203 out of 465), and staff experienced new competences, improved inter-professional cooperation and improved healthcare. However, a substantial number of staff did not feel sufficiently trained or that the intervention was well-implemented.

CONCLUSION

The intervention entailed new competences for the staff, as well as improved system performance, inter-professional cooperation and healthcare. However, there is a need for continuous focus on the intervention.

Clinical Outcomes of patients triggering Medical Emergency Team calls for sinus tachycardia

BACKGROUND

Medical emergency team (MET) calls allow unstable patients to be identified earlier and enables clinicians to institute timely management to ameliorate physiological stress. Sinus tachycardia is a common cause for triggering MET calls. In this study, outcome measures relating to patients who have a MET call for sinus tachycardia were analysed.

METHODS

Two hundred and ninety-three consecutive patients who had MET calls as a result of sinus tachycardia were included in the study. Outcome measures assessed included inpatient mortality, duration of hospital stay, change in disposition of patient care, change in goals of care, and underlying aetiology. Comparison between medical and procedural patients was also performed.

RESULTS

There were 154 patients in the medical group compared to 139 patients in the procedural group. Inpatient mortality was 13% and 6% respectively (p-value= 0.065). The duration of hospital stay was longer in the medical group (11 vs. 8 days, p-value= 0.295). Sepsis accounted for about 50% of MET call diagnoses in both groups. Around 20% of patients in both groups did not have a clear cause identified for the sinus tachycardia. About one-fifth of the patients in both groups were transferred to intensive care following the MET call (17% vs. 16%; p-value= 0.823).

CONCLUSIONS

Sinus tachycardia triggering MET call is not a benign condition. It not infrequently requires escalation of care and is associated with significant inpatient mortality. Clinicians should have a high index of suspicion for sepsis as the underlying cause. This article is protected by copyright. All rights reserved.

Characteristics and outcomes of rapid response team activations for hypotension in orthopaedic patients

BACKGROUND

Hypotension following orthopaedic surgery has been associated with increased morbidity and mortality. Rapid response teams (RRT) review patients on hospital wards with hypotension.

AIM

To evaluate the epidemiology of hypotensive RRT activations in adult orthopaedic patients to identify contributing factors and areas for future quality improvement.

METHODS

Timing of RRT activations, presumed causes of hypotension and associated treatments were assessed.

RESULTS

Among 963 RRT activations in 605 patients over 3 years, the first calls of 226 of 605 patients were due to hypotension, and 213 (94.2%) of 226 had sufficient data for analysis. The median age was 79 (interquartile range 66-87) years; 58 (27.2%) were male, and comorbidities were common. Most (68%) surgery was emergent, and 75.1% received intraoperative vasopressors for hypotension. Most activations occurred within 24 h of surgery, and hypovolaemia, infection and arrhythmias were common presumed causes. Fluid boluses occurred in 173 (81.2%), and the time between surgery and RRT activation was 10 (4.0-26.5) h. in cases where fluid boluses were given, compared with 33 (15.5-61.5) h. where they were not (P < 0.001). Blood transfusion (30, 14.1%) and withholding of medications were also common. Hospital mortality was 8.5% (18), and 13.6% (29) were admitted to critical care at some stage. In-hospital death was associated with older age, functional dependence, arrhythmia and presumed infection.

CONCLUSIONS

Hypotension-related RRT calls in orthopaedic patients are common. Future interventional studies might focus on perioperative fluid therapy and vaso-active medications, as well as withholding of anti-hypertensive medications preoperatively.

Predictors of acute hospital mortality and length of stay in patients with new-onset atrial fibrillation: a first-hand experience from a medical emergency team response provider

BACKGROUND

Atrial fibrillation (AF) occurs frequently following cardiothoracic surgery and treatment decisions are informed by evidence-based clinical guidelines. Outside this setting there are few data to guide clinical management.

AIM

To describe the characteristics, management and outcomes of hospitalised adult patients with new-onset AF.

METHODS

The medical emergency team (MET) database was utilised to identify patients who had a 'MET call' activated for tachycardia between 2015 and 2016. Patients with sinus tachycardia, pre-existing AF/atrial flutter or other known tachyarrhythmia were excluded. Primary outcomes were length of hospital stay and in-hospital mortality.

RESULTS

New-onset AF was identified in 137 patients: 68 medically managed; 38 non-cardiothoracic post-operative; and 31 cardiothoracic post-operative. Mean age was 74 ± 11.6 years and 72 (53%) were male. Of 79 patients who underwent echocardiography, 80% had left atrial dilatation and 14% had reduced left ventricular ejection fraction (LVEF). Mean length of stay (LOS) was 12 days and in-hospital mortality rate was 11%. On multivariable analysis, the odds of death during acute hospitalisation was 7.4 times higher in patients with heart failure with reduced LVEF (odds ratio 7.4, 95% confidence interval (CI) 1.23-44.8, P = 0.028). Length of acute hospital stay increased by 36% if the duration of AF was longer than 48 h (beta coefficient 0.36, 95% CI -0.015 to 0.74, P = 0.059).

CONCLUSION

Left ventricular systolic dysfunction in hospitalised patients with new-onset AF is associated with increased all-cause mortality whereas lower serum potassium levels are associated with an increased LOS. A prospective study is planned to compare outcomes based on in-hospital treatment strategies.

Clinical deterioration in patients with ST-elevation myocardial infarction during and for 24 h after percutaneous coronary intervention: An observational study

BACKGROUND

In-hospital adverse events such as cardiac arrest are preceded by abnormalities in physiological data and are associated with high mortality. Healthcare institutions have implemented rapid response systems such as the medical emergency team for early recognition and response to clinical deterioration. Yet, most cardiac catheterisation laboratories, have yet to formally implement a rapid response system, so the nature and frequency of clinical deterioration is unclear and no published data exist.

OBJECTIVES

To explore the nature and frequency of clinical deterioration in ST- elevation myocardial infarction patients in a cardiac catheterisation laboratory without a Medical emergency team, and 24 hours after percutaneous coronary intervention and the immediate nursing responses to clinical deterioration.

METHOD

An exploratory descriptive study using retrospective medical audit was conducted in a public tertiary teaching hospital in Melbourne, Australia. In 2014, there were 327 ST- elevation myocardial infarction presentations of which 75 were randomly selected. Descriptive statistics were used to analyse the data.

RESULTS

In the cardiac catheterisation laboratory, 82.6% of patients fulfilled medical emergency team activation criteria and deterioration was predominantly cardiovascular. Respiratory rate was not documented for all patients in cardiac catheterisation laboratory. Post percutaneous coronary intervention, 31% of patients fulfilled medical emergency team activation criteria and this deterioration occurred secondary to hypoxia. There were no documented abnormalities in respiratory rate.

CONCLUSION

The ST- elevation myocardial infarction patients admitted to the cardiac catheterisation laboratory are critically ill patients. Failure to monitor for signs of respiratory dysfunction such as respiratory rate in cardiac catheterisation laboratory may delay recognition of clinical deterioration and timely escalation of care. Further research is required to inform changes in the system to improve patient safety.

The frequency and nature of clinician identified medication-related rapid response system calls

AIM

The contribution of adverse medication events to clinical deterioration is unknown. This study aimed to determine the frequency and nature of rapid response system (RRS) calls that clinicians perceived were medication-related using RRS quality arm data.

METHODS

Analysis of routine data prospectively collected by clinicians responding to RRS calls in an Australian acute tertiary academic hospital.

RESULTS

Between January 2013 and June 2017, 12,221 adult patients triggered the RRS for 25,906 medical emergency team (MET) and 512 code blue calls. Clinicians identified 433 medication-related RRS calls (1.6%) involving 406 patients (3.3%). These included 418 MET calls (1.3 medication-related MET calls per 1000 admissions) and 15 code blue calls (0.045 medication-related code blue calls per 1000 admissions). Medication-related calls occurred earlier in the admission (p = 0.002) and were more common for patients triggering multiple calls during the same admission (p < 0.001), compared to non-medication-related calls. Medication-related calls most commonly were triggered by low blood pressure (38.3%) and involved cardiovascular (43.0%) and nervous system medications (36.0%). Dose-related toxicity (n = 178) was the most frequent adverse medication event contributing to medication-related calls.

CONCLUSION

One in 30 patients triggering a RRS call experienced medication-related clinical deterioration, most often due to dose related toxicity of cardiovascular system medications. The perceived frequency and potential preventability of this medication-related harm suggest further research is required to increase recognition of medication-related RRS calls by responding clinicians and to reduce the incidence.

Derivation and validation of a risk score for predicting mortality among inpatients following rapid response team activation

PURPOSE OF THE STUDY

Despite mature rapid response systems (RRS) for clinical deterioration, individuals activating RRS have poor outcomes, with up to one in four dying in hospital. We aimed to derive and validate a risk prediction tool for estimating risk of 28-day mortality among hospitalised patients following rapid response team (RRT) activation.

STUDY DESIGN

Analysis of prospectively collected data on 1151 consecutive RRT activations involving 800 inpatients at a tertiary adult hospital. Patient characteristics, RRT triggers and actions, and mortality were ascertained from medical records and death registries. A multivariable risk prediction regression model, derived from 600 randomly selected patients, was validated in the remaining 200 patients. Main outcome was accuracy of weighted risk score (measured by area under receiver operator curve (AUC)) and performance characteristics for various cut-off scores.

RESULTS

At 28 days, 150 (18.8%) patients had died. Increasing age, emergency admission, chronic liver disease, chronic kidney disease, malignancy, after-hours RRT activation, increasing National Early Warning Score, major/intense RRT intervention and multiple RRT activations were predictors of mortality. The risk score (0-105) in derivation and validation cohorts had AUCs 0.86 (95% CI 0.82 to 0.89) and 0.82 (95% CI 0.75 to 0.90), respectively. In the validation cohort, cut-off score of 32.5 or higher maximised sensitivity: 81.6% (95% CI 68.4% to 92.1%), specificity: 56.2% (95% CI 49.4% to 63.6%), positive likelihood ratio (LR): 1.9 (95% CI 1.5 to 2.3) and negative LR: 0.3 (95% CI 0.2 to 0.6).

CONCLUSION

A validated risk score predicted risk of post-RRT death with more than 80% accuracy, helping to identify patients for whom targeted rescue care may improve survival.

An Observational Analysis of Medication Use During 5,727 Medical Emergency Team Activations at a Tertiary Referral Hospital

BACKGROUND

Medical emergency teams (METs) rescue deteriorating patients as the response arm of hospital rapid response systems. This study aimed to (1) investigate medication use during MET activations by describing the type, frequency and access sources of medications; and (2) assess associations between patient characteristics, MET activation criteria, and outcomes and MET medication use.

METHODS

A single-center, retrospective study from a prospective database of MET activations in an Australian tertiary referral hospital was undertaken. Consecutive adult MET activations over a 12-month period were included.

RESULTS

Across the study period, there were 5,727 MET activations with medications used at 33.5% (n = 1,920). Of 2,648 medications used, cardiac system agents (n = 944; 35.6%) were the most common category used, while intravenous electrolytes (n = 341; 12.9%) and opioid analgesics (n = 248; 9.4%).were the most frequently used medications. Most commonly, medications were sourced from ward stocks. High blood pressure, heart or respiratory rate, pain, and multiple activation criteria were associated with MET medication use (p < 0.001). Patients who required medications were less likely to remain on the ward, and immediate admission to the ICU was approximately doubled (odds ratio = 1.90; 95% confidence interval = 1.47-2.45).

CONCLUSION

Medication use by the MET was common and associated with escalation to intensive care. A wide variety of medications, principally from ward stocks, were used with some predictability based on activation criteria. Local system improvements have demonstrated that by focusing on common MET syndromes and medications, further investigation can refine and improve medication use and management systems for deteriorating patients.

Predicting tachycardia as a surrogate for instability in the intensive care unit

Tachycardia is a strong though non-specific marker of cardiovascular stress that proceeds hemodynamic instability. We designed a predictive model of tachycardia using multi-granular intensive care unit (ICU) data by creating a risk score and dynamic trajectory. A subset of clinical and numerical signals were extracted from the Multiparameter Intelligent Monitoring in Intensive Care II database. A tachycardia episode was defined as heart rate ≥ 130/min lasting for ≥ 5 min, with ≥ 10% density. Regularized logistic regression (LR) and random forest (RF) classifiers were trained to create a risk score for upcoming tachycardia. Three different risk score models were compared for tachycardia and control (non-tachycardia) groups. Risk trajectory was generated from time windows moving away at 1 min increments from the tachycardia episode. Trajectories were computed over 3 hours leading up to the episode for three different models. From 2809 subjects, 787 tachycardia episodes and 707 control periods were identified. Patients with tachycardia had increased vasopressor support, longer ICU stay, and increased ICU mortality than controls. In model evaluation, RF was slightly superior to LR, which accuracy ranged from 0.847 to 0.782, with area under the curve from 0.921 to 0.842. Risk trajectory analysis showed average risks for tachycardia group evolved to 0.78 prior to the tachycardia episodes, while control group risks remained < 0.3. Among the three models, the internal control model demonstrated evolving trajectory approximately 75 min before tachycardia episode. Clinically relevant tachycardia episodes can be predicted from vital sign time series using machine learning algorithms.

Understanding how medications contribute to clinical deterioration and are used in rapid response systems: A comprehensive scoping review

BACKGROUND

In hospitals, rapid response systems (RRSs) identify patients who deteriorate and provide critical care at their bedsides to stabilise and escalate care. Medications, including oral and parenteral pharmaceutical preparations, are the most common intervention for hospitalised patients and the most common cause of harm. This connection between clinical deterioration and medication safety is poorly understood.

OBJECTIVES

To inform improvements in prevention and management of clinical deterioration, this review aimed to examine how medications contributed to clinical deterioration and how medications were used in RRSs.

REVIEW METHODS

A scoping review was undertaken of medication data reported in studies of clinical deterioration or RRSs in diverse hospital settings between 2005 and 2017. Bibliographic database searches used permutations of "rapid response system," "medical emergency team," and keyword searching with medication-related terms. Independent selection, quality assessment, and data extraction informed mapping against four medication themes: causes of deterioration, predictors of deterioration, RRS use, and management.

RESULTS

Thirty articles were reviewed. Quality was low: limited by small samples, observational, single-centre designs and few primary medication-related outcomes. Adverse drug reactions and potentially preventable medication errors, involving sedatives, analgesics, and cardiovascular agents, contributed to clinical deterioration. While sparsely reported, outcomes included death and escalation of care. In children, administration of antibiotics or nebulised medications appeared to predict subsequent deterioration. Cardiovascular medications, sedatives, and analgesics commonly were used to manage deterioration but further detail was lacking. Despite reported potential for patient harm, evaluation of medication management systems was limited.

CONCLUSIONS

Medications contributed to potentially preventable clinical deterioration, with considerable harm, and were common interventions for its management. When assessing deteriorating patients or caring for patients who require escalation to critical care, clinicians should consider medication errors and adverse reactions. Studies with more specific medication-related, patient-centred end points could reduce medication-related deterioration and refine RRS medication use and management.

The impact of a multimodal education strategy (the DeTER program) on nurses' recognition and response to deteriorating patients

Nurses are ideally positioned to recognise and respond to patient deterioration. However, premonitory signs of patient deterioration are often overlooked, not managed, or not communicated in a timely fashion. Education programs aimed at improving nurses' technical and non-technical skills have been developed, however, the outcomes of these educational strategies remain unclear. A quasi-experimental time series design was used in this study to evaluate the impact of a multi-modal education program (DeTER) on acute care nurses' technical and non-technical skill development and recognition and response to patient deterioration. Participants were asked to complete a survey on four occasions: one month prior to commencement of the DeTER program, immediately prior and post workshop attendance and two-three months' post workshop completion. Pre-intervention, data were collected on participants' demographic profile and their responses to the Clinical Emergency Recognition and Response Survey designed by (Buckley and Gordon, 2011). Post intervention these data were collected again and, in addition, respondents were asked to report on their recent experiences of deteriorating patients and report on their confidence in managing these incidents. Sixty staff consented to participate in the study and all completed the surveys at time 2 and 3. In total 32 staff (45%) responded at all time points. Participants included registered nurses (n = 51; 85%), and enrolled nurses (n = 9; 15%), on average they had worked for 10.4 years (sd = 11.1). Participants rated patient advocacy and assertiveness skills as the most useful aspects of the workshop. Recognition and response to deteriorating patients by ward nurses is a multifaceted process influenced by many factors. Our study supports the importance of multimodal educational strategies in sustaining changes to ward nurses' technical and non-technical skills over time.

Elderly patients are at high risk of night-time admission to the intensive care unit following a rapid response team call

Previous studies have shown that elderly patients (age ≥65 years) are less likely to be admitted to the intensive care unit following a rapid response team call and have high hospital mortality rates. This study has shown that elderly patients have a significantly higher probability of being admitted to an intensive care unit following a rapid response team call at night than during the day. However, at no time are they at greater risk than younger patients of incomplete vital sign recording, a failure to escalate care for acute deterioration or mortality.

Patient characteristics, interventions and outcomes of 1151 rapid response team activations in a tertiary hospital: a prospective study

BACKGROUND

The characteristics of mature contemporary rapid response systems are unclear.

AIM

To determine the patient characteristics, processes and outcomes, both in-hospital and post-discharge, of a well-established rapid response system in a tertiary adult hospital.

METHODS

This is a prospective study of consecutive rapid response team (RRT) activations between 1 July and 25 November 2015. Variables included patient characteristics, timing, location and triggers of RRT activations, interventions undertaken, mortality and readmission status at 28 days post-discharge.

RESULTS

A total of 1151 RRT activations was analysed (69.1 per 1000 admissions), involving 800 patients, of whom 81.5% were emergency admissions. A total of 351 (30.5%) activations comprised repeat activations for the same patient. Most activations (723; 62.8%) occurred out of hours, and 495 (43%) occurred within 48 h of admission. Hypotension, decreased level of consciousness and oxygen desaturation were the most common triggers. Advanced life support was undertaken in less than 7%; 198 (17.2%) responses led to transfer to higher-level care units. Acute resuscitation plans were noted for only 29.1% of RRT activations, with 80.3% stipulating supportive care only. A total of 103 (12.6%) patients died in hospital, equalling 14 deaths per 100 RRT activations. At 28 days, 150 (18.8%) patients had died, significantly more among those with multiple versus single RRT activations (24.9 vs 16.6%; odds ratio 1.66, 95% confidence interval 1.31-2.44; P = 0.013).

CONCLUSION

Relatively few RRT activations are associated with acute resuscitation plans, and most interventions during RRT responses are low level. The high rate of post-RRT deaths and transfers to higher-level care units calls for the prospective identification of such patients in targeting appropriate care.

Association Between Survival and Time of Day for Rapid Response Team Calls in a National Registry

OBJECTIVES

Decreased staffing at nighttime is associated with worse outcomes in hospitalized patients. Rapid response teams were developed to decrease preventable harm by providing additional critical care resources to patients with clinical deterioration. We sought to determine whether rapid response team call frequency suffers from decreased utilization at night and how this is associated with patient outcomes.

DESIGN

Retrospective analysis of a prospectively collected registry database.

SETTING

National registry database of inpatient rapid response team calls.

PATIENTS

Index rapid response team calls occurring on the general wards in the American Heart Association Get With The Guidelines-Medical Emergency Team database between 2005 and 2015 were analyzed.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was inhospital mortality. Patient and event characteristics between the hours with the highest and lowest mortality were compared, and multivariable models adjusting for patient characteristics were fit. A total of 282,710 rapid response team calls from 274 hospitals were included. The lowest frequency of calls occurred in the consecutive 1 AM to 6:59 AM period, with 266 of 274 (97%) hospitals having lower than expected call volumes during those hours. Mortality was highest during the 7 AM hour and lowest during the noon hour (18.8% vs 13.8%; adjusted odds ratio, 1.41 [1.31-1.52]; p < 0.001). Compared with calls at the noon hour, those during the 7 AM hour had more deranged vital signs, were more likely to have a respiratory trigger, and were more likely to have greater than two simultaneous triggers.

CONCLUSIONS

Rapid response team activation is less frequent during the early morning and is followed by a spike in mortality in the 7 AM hour. These findings suggest that failure to rescue deteriorating patients is more common overnight. Strategies aimed at improving rapid response team utilization during these vulnerable hours may improve patient outcomes.

Rapid Response Team activation in New Zealand hospitals—a multicentre prospective observational study

We aimed to describe the epidemiology of Rapid Response Team (RRT) activation in New Zealand public hospitals. We undertook a prospective multicentre observational study of RRT activations in 11 hospitals for consecutive 14-day periods during October–December 2014. A standardised case report form was used to collect data on patient demographics, RRT activation criteria and timing, vital signs on RRT arrival, team composition and intervention, treatment limitation and patient outcome at day 30. Three hundred and thirteen patients received 351 RRT calls during the study period. Patients were admitted under a medical specialty in 177 (56.5%) instances. Median duration from hospital admission to first RRT call was two days. Eighty-six percent of RRT calls were to inpatient wards. A total of 43.4% of RRT calls occurred between 0800 and 1700 hours (38% of the day) and 75.5% of RRT calls were activated by ward nurses. A median of three staff attended each call. Common triggers for RRT activation were increased Early Warning Score (56.2%) and staff concern (25.7%). During the RRT call, 2.8% of patients died; 19.8% died by day 30. New ‘Not For Resuscitation’ orders were written in 22.5% of RRT calls. By day 30, 56.2% of patients had been discharged home alive. In conclusion, RRTs in New Zealand are multidisciplinary, mostly nurse-activated and predominantly respond to deteriorating medical (rather than surgical) patients. Most patients remain on the ward. The RRT frequently implements treatment limitations. Given almost one in five patients die within 30 days, over half of whom die within 72 hours of RRT review, surviving the RRT call may provide false reassurance that the patient will subsequently do well.

Diurnal variation in the performance of rapid response systems: the role of critical care services-a review article

The type of medical review before an adverse event influences patient outcome. Delays in the up-transfer of patients requiring intensive care are associated with higher mortality rates. Timely detection and response to a deteriorating patient constitute an important function of the rapid response system (RRS). The activation of the RRS for at-risk patients constitutes the system’s afferent limb. Afferent limb failure (ALF), an important performance measure of rapid response systems, constitutes a failure to activate a rapid response team (RRT) despite criteria for calling an RRT.

There are diurnal variations in hospital staffing levels, the performance of rapid response systems and patient outcomes. Fewer ward-based nursing staff at night may contribute to ALF. The diurnal variability in RRS activity is greater in unmonitored units than it is in monitored units for events that should result in a call for an RRT. RRT events include a significant abnormality in either the pulse rate, blood pressure, conscious state or respiratory rate. There is also diurnal variation in RRT summoning rates, with most activations occurring during the day. The reasons for this variation are mostly speculative, but the failure of the afferent limb of RRT activation, particularly at night, may be a factor.

The term “circadian variation/rhythm” applies to physiological variations over a 24-h cycle. In contrast, diurnal variation applies more accurately to extrinsic systems. Circadian rhythm has been demonstrated in a multitude of bodily functions and disease states.

For example, there is an association between disrupted circadian rhythms and abnormal vital parameters such as anomalous blood pressure, irregular pulse rate, aberrant endothelial function, myocardial infarction, stroke, sleep-disordered breathing and its long-term consequences of hypertension, heart failure and cognitive impairment. Therefore, diurnal variation in patient outcomes may be extrinsic, and more easily modifiable, or related to the circadian variation inherent in human physiology. Importantly, diurnal variations in the implementation and performance of the RRS, as gauged by ALF, the RRT response to clinical deterioration and any variations in quality and quantity of patient monitoring have not been fully explored across a diverse group of hospitals.