Clinical paperThe epidemiology and outcome of medical emergency team call patients treated with non-invasive ventilation☆
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.
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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.