Elsevier

Resuscitation

Volume 50, Issue 1, July 2001, Pages 39-44
Resuscitation

The Medical Emergency Team: 12 month analysis of reasons for activation, immediate outcome and not-for-resuscitation orders

https://doi.org/10.1016/S0300-9572(01)00323-9Get rights and content

Abstract

Objective: To describe the reasons for, and immediate outcome following Medical Emergency Team (MET) activation. Methods: Retrospective analysis of MET calls in 1998. Results: There were 713 MET calls to 559 in-patients. Of the 559 patients 252 (45%) were admitted to ICU and 49 (6.9%) died during the MET response. The three commonest criteria for calling the MET were a fall in GCS>2 (n=155); a systolic blood pressure<90 mmHg (n=142) and a respiratory rate>35 (n=109). Cardiac arrests accounted for 61 calls and had an immediate mortality of 59%. The most common MET criterion associated with admission to ICU was a respiratory rate >35. Of patients who received MET calls based only on the ‘worried’ criterion 16% were admitted to ICU. The MET felt that a not-for-resuscitation order would have been appropriate in 130 cases (23%). NFR orders were documented during 27 of the MET calls. Conclusions: The MET system provides objective and subjective criteria by which medical and nursing staff can identify patients who become acutely unwell. A high proportion of these patients will require admission to Intensive Care. The MET system also provides the opportunity to identify patients for whom an NFR order should be considered.

Sumàrio

Objectivo: Descrever as razões para a activação de uma Equipa de Emergência Médica (EEM). Métodos: Análise retrospectiva das chamadas da EEM em 1998. Resultados: Houve 713 chamadas para 599 doentes internados. Dos 599 pacientes, 252 (45%) foram admitidos na UCI (Unidade de Cuidados Intensivos) e 49 (6.9%) morreram durante a resposta da EEM. Os três motivos mais comuns para activar a EEM foram diminuição na ECG (Escala de Coma de Glasgow) >2 (n=155); pressão arterial sistólica < 90 mmHg (n=142) e frequência respiratória > 35 (n=109). 61 das chamadas foram por paragem cardı&#x0301;aca e tiveram uma mortalidade imediata de 59%. O critério que mais vezes se associou a internamento na UCI foi uma frequência respiratória >35. Quando as chamadas da EEM foram ditadas apenas nos critérios de ‘preocupação’ só 16% dos doentes foram admitidos na UCI. A EEM sentiu que a Ordem de Não Reanimar (DNR) teria sido apropriada em 130 casos (22%). Existiam ordens DNR foram documentadas em 27 das chamadas da EEM. Conclusão: O sistema EEM define critérios objectivos e subjectivos através dos quais a equipa médica e de enfermagem podem identificar doentes agudizados. Uma proporção elevada destes doentes requerer admissão em Cuidados Intensivos. O sistema da EEM permite identificar doentes para quem a ordem DNR deve ser considerada.

Introduction

The mortality rate following in-hospital cardiac arrest is very high, with only 15% survival at 1 year [1]. The chances of survival are particularly low for those patients with non-ventricular fibrillation(VF)/ventricular tachycardia (VT) arrest rhythms, i.e. asystole or pulseless electrical activity (PEA) [2]. In-hospital cardiac arrest, particularly non VF/VT arrest, is often predictable and preceded by easily recognised physical changes that are present for many hours before the arrest [3]. Intensive care medicine has been largely practised within the four walls of the ICU. However, outcome following intensive care is also determined by the level of care delivered before and after admission to the ICU [4]. The establishment of a hospital-wide system which rapidly detects and responds to the seriously ill in the early stages and which monitors and audits quality should result in improved patient care. One such system is based around the Medical Emergency Team [5]. The MET system was developed at Liverpool Hospital in Sydney, Australia and is an integral part of South Western Sydney Area Health Service (SWSAHS). Liverpool Hospital is a 580 bed tertiary referral centre for SWSAHS and teaching hospital affiliated to the University of New South Wales. The components of the MET system include:

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    the identification of patients at risk based on simple criteria;

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    an emergency response by the MET which replaces the hospital cardiac arrest team;

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    an advanced resuscitation training programme;

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    collecting outcome indicators which allow:

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    measurement of hospital quality;

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    assessment of what is potentially preventable;

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    assessment of end of life decisions;

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    feedback through the Quality Improvement System to advance patient care.


The MET was introduced in 1990 and designed to provide early identification of and rapid response to seriously ill patients at risk of cardiorespiratory arrest or needing admission to the intensive care unit. The MET is lead by an intensive care registrar and includes the medical registrar, and a senior intensive care Nurse. The surgical registrar also attends MET calls to surgical patients. Activation of the MET occurs in response to previously validated and published criteria (Appendix A) [6]. These criteria represent the easily recognised changes in physical signs that may be present for many hours before arrest and can be used as the basis for what can be considered critical illness. The calling criteria are recognised throughout the hospital and the system provides a rapid response by a multi-disciplinary team trained in advanced resuscitation.

This paper is a retrospective analysis of MET calls during the 12 months of January to December 1998. We present the reasons for calling the MET, the immediate outcome following calls, the number of patients where a not-for-resuscitation order was thought to be appropriate by the MET at the time of the call and the number of times a not-for-resuscitation order was documented by the MET team.

Section snippets

Methods

Data on MET calls is collected by means of a scan compatible ‘tick box’ form (Appendix B) completed by the intensive care registrar (MET leader) immediately following each MET. The data is then entered onto a database (Microsoft Access) by the MET coordinator and is updated and validated on a weekly basis. Any missing or incomplete data is followed up within 7 days to maximise data retrieval. A retrospective analysis of the MET database from January to December 1998 was performed. The analysis

Results

During 1998 the MET was activated 800 times. Eighty-seven calls were excluded from the study (40 visitors, 16 out-patients and 31 emergency department patients) leaving a total of 713 MET calls to 559 in patients. Of the 559 patients, 55.2% were male. The mean age was 64.5 years (range 3–98 years). 252 (45%) were admitted to ICU and 49 (6.9%) died whilst the MET were present. More than one MET call was made to 102 patients. The reasons for activation of the MET are shown in Table 1. The

Discussion

The MET system identifies a large number of patients who meet criteria suggestive of critical illness. Some (45%) of these patients require high dependency or intensive care whilst in others the potential for HDU/ICU admission is possibly reduced by the management initiated following the MET call. Some patients who initially respond to the interventions of the MET and who are left in a stable condition on the wards subsequently require another MET call for the same or different reasons,

Conclusions

The MET system provides objective and subjective criteria by which medical and nursing staff can identify patients in need of urgent intervention. A high proportion (45%) of the patients meeting the call criteria required admission to ICU/HDU. The overall immediate mortality of patients meeting the MET call criteria was 6.9%. The MET system also provides the opportunity to identify patients for whom an NFR order should be considered.

Acknowledgements

Carl Thebridge and Rachelle Starkey for their roles as MET coordinators. The data in this paper was presented in abstract form at the Resuscitation 2000 meeting of the European Resuscitation Council, Antwerp, June 2000.

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