Elsevier

Resuscitation

Volume 82, Issue 9, September 2011, Pages 1218-1223
Resuscitation

Clinical paper
The epidemiology and outcome of medical emergency team call patients treated with non-invasive ventilation

https://doi.org/10.1016/j.resuscitation.2011.04.009Get rights and content

Abstract

Introduction

Use of non-invasive ventilation (NIV) is normally limited to the Emergency Department, Intensive Care Unit (ICU), Coronary Care Unit (CCU) or High Dependency Unit (HDU). However, NIV is sometimes used by the Medical Emergency Team (MET) as respiratory support for ward patients.

Objectives

We reviewed the characteristics and outcome of ward patients treated with NIV in the setting of a MET Call and determined the clinical and prognostic significance of such treatment.

Methods

We used our MET database to assess the characteristics and outcome of patients treated with NIV and compared them to a control group of patients with similar MET diagnoses but not treated with NIV.

Results

We studied 5389 calls in 3880 patients. NIV was delivered during 483 (9.0%) calls to 426 patients (11% of the total). The four most common MET diagnoses associated with NIV were acute pulmonary edema (156 calls, 32.3%), pneumonia (84 calls, 17.4%), acute respiratory failure of unclear origin (59 calls, 12.2%) and exacerbation of chronic obstructive pulmonary disease (32 calls, 6.6%). Limitations of medical therapy (LOMT) were documented in 151 (35.4%) patients. Among NIV patients without LOMT, 115 (41.8%) were transferred to ICU and 50 (18.2%) to the coronary care or high dependency unit (CCU/HDU) compared with only 50 (18.0%) and 16 (5.8%) respectively in the control group (p < 0.001). Overall, 76 NIV patients (27.6%) received endotracheal intubation (ETT) compared with 61 (21.9%) in controls. Mortality was 23.6% in the NIV group versus 18.8% in the control group.

Conclusion

One in ten MET call patients received NIV. In those without LOMT, two thirds were transferred to ICU/HDU/CCU, one in four received ETT, and one in four died. NIV use at the time of a MET call identified high risk patients for whom admission to ICU/HDU/CCU should be strongly considered.

Introduction

Non-invasive ventilation (NIV) is established in the treatment of acute pulmonary edema and decompensated chronic obstructive pulmonary disease (COPD) where it has been shown to decrease the need for endotracheal intubation and mortality1, 2, 3, 4, 5.

Trained nursing and medical staff in higher acuity wards are needed to apply NIV due to its technical requirements. Such wards include the emergency department (ED), high dependency unit (HDU), coronary care unit (CCU) or intensive care unit (ICU)6, 7. In the setting of a medical emergency call (MET Call), NIV can be applied on the ward as (1) a temporary supportive measure while awaiting transfer to higher acuity wards or (2) initial supportive therapy while definitive treatment is implemented or, (3) palliation to increase patient comfort8, 9, 10.

Medical Emergency Teams (MET's) or Rapid Response Teams (RRT's) are now active in many hospitals11, 12, 13, 14. The MET concept relies on early detection and intervention in deteriorating ward patients15. In an audit of 400 MET calls in our hospital, the most common physiological MET trigger was respiratory distress16. In some of these patients, respiratory distress is life-threatening and endotracheal intubation (ETT) is immediately needed. In others, NIV may represent a reasonable initial therapeutic option. However, little is known about the incidence of NIV use during a MET call, the characteristics of the patients treated, their disposition after MET reviews and their in-hospital outcome. This information would be useful for prognostic reasons and to assist clinicians in making therapeutic and logistic decisions.

We hypothesized that NIV treatment during a MET call would be relatively common and associated with a high need for greater acuity ward care and increased risk of ETT and death. We tested this hypothesis by conducting a retrospective observational study in a large cohort of MET call patients and comparing NIV-treated patients to a control group with similar conditions but not treated with NIV.

Section snippets

Methods

The Human Research Ethics Committee of our hospital approved this retrospective study of “The role of the MET in the management of acutely unwell patients” and waived the need for informed consent.

Results

Between August 2005 and August 2010, there were 6264 MET calls, of which 5389 calls (86%) in 3880 patients had complete data. NIV was delivered during 483 (9.0%) of these calls to 426 patients (11.0% of total). The most common initial MET diagnoses were acute pulmonary edema and pneumonia (Table 1). The characteristics of the patients in both the NIV and control group are presented in Table 1, their disposition after MET review and their outcome is presented in Fig. 2.

Key findings

We conducted a retrospective observational study of patients who received NIV in the setting of a MET call. We found that NIV was applied to one in ten MET calls, with acute pulmonary edema and pneumonia the most common triggers. Application of NIV was generally transient while awaiting transfer to higher acuity wards. Less than a third of patients were remained in their original ward. About one in four patients without LOMT orders required endotracheal intubation (ETT) and a similar proportion

Conclusions

During a MET call, NIV is used in 10% of cases and is typically delivered as a supportive measure prior to transfer to a higher acuity ward. Our observations suggest that, during a MET call, NIV can help identify patients with an increased need for transfer to a higher acuity ward or in need of consideration of LOMT orders. Thus, when confronted with a patient deemed to need NIV, transfer to a higher acuity ward should be strongly considered as the default approach in all patients without LOMT

Conflicts of interests

All authors stated that they had no conflicts of interest to declare.

References (26)

  • C.D. Shee et al.

    Non-invasive ventilation and palliation: experience in a district general hospital and a review

    Palliative Med

    (2003)
  • R.M. Kacmarek et al.

    Should noninvasive ventilation be used with the do-not-intubate patient?

    Resp Care

    (2009)
  • M.D. Buist et al.

    Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study

    BMJ

    (2002)
  • Cited by (0)

    A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2011.04.009.

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