Characteristics and outcomes of patients receiving review requests for pre-medical emergency team deterioration: a cohort study
Judy Currey A B C H , Matthew Macaulay A D , Daryl Jones D E F and Julie Considine A B GA Deakin University, School of Nursing and Midwifery, 1 Gheringhap Street, Geelong, Vic. 3220, Australia.
B Deakin University, Centre for Quality and Patient Safety in the Institute for Health Transformation, 1 Gheringhap Street, Geelong, Vic. 3220, Australia.
C Deakin University, Office of the Deputy Vice Chancellor (Education), 1 Gheringhap Street, Geelong, Vic. 3220, Australia.
D Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Vic. 3084, Australia.
E School of Public Health and Preventive Medicine, Monash University, Wellington Road, Clayton, Vic. 3800, Australia.
F Department of Surgery, The University of Melbourne, Parkville, Vic. 3010, Australia.
G Centre for Quality and Patient Safety Research–Eastern Health Partnership, 2/5 Arnold Street, Box Hill, Vic. 3128, Australia.
H Corresponding author. Email: judy.currey@deakin.edu.au
Australian Health Review 46(1) 28-34 https://doi.org/10.1071/AH21212
Submitted: 29 June 2021 Accepted: 20 July 2021 Published: 24 December 2021
Journal Compilation © AHHA 2022 Open Access CC BY-NC-ND
Abstract
Objective The aim of this study was to describe the epidemiology of pre-medical emergency team (pre-MET) reviews, including patient characteristics, the frequency and nature of triggers and interventions and in-hospital outcomes.
Methods An exploratory retrospective cohort study was performed using a medical record audit. Fifty orthopaedic and general medicine patients at a hospital in Melbourne, Australia, with requests for pre-MET reviews in 2016 were included. Descriptive analyses were performed.
Results The median patient age was 80 years (interquartile range 19 years). Most patients were female (64%), general medical patients (82%), with limitation of medical treatment orders (52%) and modified pre-MET triggers (42%). Documented pre-MET reviews occurred for 68% of requests. Tachypnoea (24%) and staff worry (24%) were the most common pre-MET triggers. One-third of patients received two clinical interventions. One in five patients had repeat requests for a pre-MET review within 12 h. In-hospital mortality was 12%.
Conclusions Most requests for pre-MET reviews related to older female patients. Clinician adherence to pre-MET policy was variable. Multicentre studies are needed to inform improvements to pre-MET strategies.
What is known about the topic? Australian hospitals have introduced multi-tiered rapid response systems (RRSs) that consist of pre-MET review to comply with accreditation standards. Pre-MET reviews are triggered by early signs of clinical deterioration and are provided by admitting medical teams or senior nurses. There is limited understanding of the characteristics and outcomes of patients receiving pre-MET reviews for early clinical deterioration.
What does this paper add? In a cohort of orthopaedic and general medicine patients, most patients receiving requests for pre-MET reviews were older, female medical patients, with existing modifications to pre-MET triggers. Most requests for pre-MET review were for tachypnoea or staff worry; the latter included clinical problems not addressed by predefined organisational triggers. One in five patients continued to deteriorate within 12 h of the pre-MET request. Clinician adherence to pre-MET policy varied.
What are the implications for practitioners? Patients in this study frequently deteriorated in ways that did not breach predefined pre-MET triggers, demonstrating that pre-MET requests are made for a range of clinical concerns. Doctors and nurses must be vigilant for ongoing clinical deterioration in patients receiving requests for pre-MET reviews. Reflecting the timing of the recent introduction of the pre-MET review system, variable adherence to pre-MET policy raises questions about clinicians’ awareness of and responsibilities in this RRS tier, the impact of workloads on RRS response capability and the suitability of existing escalation policies. Evaluation of the implementation of pre-MET review is warranted.
References
[1] Australian Commission on Safety and Quality in Health Care (ACSQHC). Essential elements for recognising and responding to acute physiological deterioration. 2nd edn. Sydney: ACSQHC; 2017. Available at https://www.safetyandquality.gov.au/wp-content/uploads/2017/03/National-Consensus-Statement-clinical-deterioration_2017.pdf [verified 16 December 2020].[2] Jones DA, DeVita MA, Bellomo R. Rapid-response teams. N Engl J Med 2011; 365 139–46.
| Rapid-response teams.Crossref | GoogleScholarGoogle Scholar | 21751906PubMed |
[3] DeVita MA, Bellomo R, Hillman K, et al Findings of the first consensus conference on medical emergency teams. Crit Care Med 2006; 34 2463–78.
| Findings of the first consensus conference on medical emergency teams.Crossref | GoogleScholarGoogle Scholar | 16878033PubMed |
[4] ANZICS-CORE MET dose investigators Rapid response team composition, resourcing and calling criteria in Australia. Resuscitation 2012; 83 563–7.
| Rapid response team composition, resourcing and calling criteria in Australia.Crossref | GoogleScholarGoogle Scholar | 22067975PubMed |
[5] Jones DA, Drennan K, Bailey M, et al Mortality of rapid response team patients in Australia: a multicentre study. Crit Care Resusc 2013; 15 273–8.
[6] Calzavacca P, Licari E, Tee A, et al Features and outcome of patients receiving multiple medical emergency team reviews. Resuscitation 2010; 81 1509–15.
| Features and outcome of patients receiving multiple medical emergency team reviews.Crossref | GoogleScholarGoogle Scholar | 20673606PubMed |
[7] Smith RJ, Santamaria JD, Reid DA, et al The mortality associated with review by the rapid response team for non-arrest deterioration: a cohort study of acute hospital adult patients. Crit Care Resusc 2014; 16 119–26.
| 24888282PubMed |
[8] Jones DA, Dunbar NJ, Bellomo R. Clinical deterioration in hospital inpatients: the need for another paradigm shift. Med J Aust 2012; 196 97–100.
| Clinical deterioration in hospital inpatients: the need for another paradigm shift.Crossref | GoogleScholarGoogle Scholar | 22304591PubMed |
[9] Duke GJ, Graco M, Santamaria J, et al Validation of the hospital outcome prediction equation (HOPE) model for monitoring clinical performance. Intern Med J 2009; 39 283–9.
| Validation of the hospital outcome prediction equation (HOPE) model for monitoring clinical performance.Crossref | GoogleScholarGoogle Scholar | 19292775PubMed |
[10] Jones D, Bhasale A, Bailey M, et al Effect of a national standard for deteriorating patients on intensive care admissions due to cardiac arrest in Australia. Crit Care Med 2018; 46 586–93.
| Effect of a national standard for deteriorating patients on intensive care admissions due to cardiac arrest in Australia.Crossref | GoogleScholarGoogle Scholar | 29293152PubMed |
[11] Considine J, Hutchison AF, Rawson H, et al Comparison of policies for recognising and responding to clinical deterioration across five Victorian health services. Aust Health Rev 2018; 42 412–9.
| Comparison of policies for recognising and responding to clinical deterioration across five Victorian health services.Crossref | GoogleScholarGoogle Scholar | 28538140PubMed |
[12] Sprogis SK, Currey J, Considine J, et al Physiological antecedents and ward clinician responses before medical emergency team activation. Crit Care Resusc 2017; 19 50–6.
| 28215132PubMed |
[13] Bingham G, Fossum M, Barratt M, et al Clinical review criteria and medical emergency teams: evaluating a two-tier rapid response system. Crit Care Resusc 2015; 17 167–73.
| 26282254PubMed |
[14] Concord Medical Emergency Team (MET) Study Investigators Outcomes following changing from a two-tiered to a three-tiered hospital rapid response system. Aust Health Rev 2019; 43 178–87.
| Outcomes following changing from a two-tiered to a three-tiered hospital rapid response system.Crossref | GoogleScholarGoogle Scholar | 29141770PubMed |
[15] Australian Commission on Safety and Quality in Health Care (ACSQHC). National safety and quality health service standards. Sydney: ACSQHC; 2017. Available at https://nationalstandards.safetyandquality.gov.au/sites/default/files/files/media/National-Safety-and-Quality-Health-Service-Standards-second-edition_1.pdf [verified 16 December 2020].
[16] O’Connell A, Flabouris A, Kim SW, et al A newly designed observation and response chart’s effect upon adverse inpatient outcomes and rapid response team activity. Intern Med J 2016; 46 909–16.
| A newly designed observation and response chart’s effect upon adverse inpatient outcomes and rapid response team activity.Crossref | GoogleScholarGoogle Scholar | 27246106PubMed |
[17] Sprogis SK, Currey J, Jones D, et al Use of the pre-medical emergency team tier of rapid response systems: a scoping review. Intensive Crit Care Nurs 2021; 65 103041
| Use of the pre-medical emergency team tier of rapid response systems: a scoping review.Crossref | GoogleScholarGoogle Scholar | 33795182PubMed |
[18] Sprogis SK, Currey J, Jones D, et al Understanding the pre-medical emergency team tier of a mature rapid response system: a content analysis of guidance documents. Aust Crit Care 2021; 34 427–34.
| Understanding the pre-medical emergency team tier of a mature rapid response system: a content analysis of guidance documents.Crossref | GoogleScholarGoogle Scholar | 33685780PubMed |
[19] Guinane JL, Bucknall TK, Currey J, et al Missed medical emergency team activations: tracking decisions and outcomes in practice. Crit Care Resusc 2013; 15 266–72.
| 24289507PubMed |
[20] Lyons PG, Edelson DP, Churpek MM. Rapid response systems. Resuscitation 2018; 128 191–7.
| Rapid response systems.Crossref | GoogleScholarGoogle Scholar | 29777740PubMed |
[21] Flabouris A, Nandal S, Vater L, et al Multi-tiered observation and response charts: revalence and incidence of triggers, modifications and calls, to acutely deteriorating adult patients. PLoS One 2015; 10 e0145339
| Multi-tiered observation and response charts: revalence and incidence of triggers, modifications and calls, to acutely deteriorating adult patients.Crossref | GoogleScholarGoogle Scholar | 26717479PubMed |
[22] Andersen LW, Kim WY, Chase M, et al The prevalence and significance of abnormal vital signs prior to in-hospital cardiac arrest. Resuscitation 2016; 98 112–7.
| The prevalence and significance of abnormal vital signs prior to in-hospital cardiac arrest.Crossref | GoogleScholarGoogle Scholar | 26362486PubMed |
[23] Tirkkonen J, Skrifvars MB, Parr MM, et al In-hospital cardiac arrest in hospitals with mature rapid response systems: a multicentre, retrospective cohort study. Resuscitation 2020; 149 109–16.
| In-hospital cardiac arrest in hospitals with mature rapid response systems: a multicentre, retrospective cohort study.Crossref | GoogleScholarGoogle Scholar | 32114070PubMed |
[24] Kause J, Smith G, Prytherch D, et al A comparison of antecedents to cardiac arrests, deaths and emergency intensive care admissions in Australia and New Zealand, and the United Kingdom: the academia study. Resuscitation 2004; 62 275–82.
| A comparison of antecedents to cardiac arrests, deaths and emergency intensive care admissions in Australia and New Zealand, and the United Kingdom: the academia study.Crossref | GoogleScholarGoogle Scholar | 15325446PubMed |
[25] Harrison GA, Jacques T, McLaws M-L, et al Combinations of early signs of critical illness predict in-hospital death-the SOCCER study (signs of critical conditions and emergency responses). Resuscitation 2006; 71 327–34.
| Combinations of early signs of critical illness predict in-hospital death-the SOCCER study (signs of critical conditions and emergency responses).Crossref | GoogleScholarGoogle Scholar | 17069957PubMed |
[26] Davis T, Nogajski B. Alterations to calling criteria for between the flags (an early warning system). BMJ Qual Improv Rep 2015; 4 u206561.w2638
| Alterations to calling criteria for between the flags (an early warning system).Crossref | GoogleScholarGoogle Scholar | 26734326PubMed |
[27] Ganju A, Kapitola K, Chalwin R. Modifications to predefined rapid response team calling criteria: prevalence, characteristics and associated outcomes. Crit Care Resusc 2019; 21 32–8.
| 30857510PubMed |
[28] Kerkham T, Brain M. Rapid response team trigger modifications: are we using them safely? Intern Med J 2020; 50 1513–7.
| Rapid response team trigger modifications: are we using them safely?Crossref | GoogleScholarGoogle Scholar | 31760671PubMed |
[29] Boniatti MM, Azzolini N, Viana MV, et al Delayed medical emergency team calls and associated outcomes. Crit Care Med 2014; 42 26–30.
| Delayed medical emergency team calls and associated outcomes.Crossref | GoogleScholarGoogle Scholar | 23989173PubMed |
[30] Chen J, Bellomo R, Flabouris A, et al Delayed emergency team calls and associated hospital mortality: a multicenter study. Crit Care Med 2015; 43 2059–65.
| Delayed emergency team calls and associated hospital mortality: a multicenter study.Crossref | GoogleScholarGoogle Scholar | 26181217PubMed |
[31] Herod R, Frost SA, Parr M, et al Long term trends in medical emergency team activations and outcomes. Resuscitation 2014; 85 1083–7.
| Long term trends in medical emergency team activations and outcomes.Crossref | GoogleScholarGoogle Scholar | 24769054PubMed |
[32] Olsen SL, Søreide E, Hillman K, et al Succeeding with rapid response systems – a never-ending process: a systematic review of how health-care professionals perceive facilitators and barriers within the limbs of the RRS. Resuscitation 2019; 144 75–90.
| Succeeding with rapid response systems – a never-ending process: a systematic review of how health-care professionals perceive facilitators and barriers within the limbs of the RRS.Crossref | GoogleScholarGoogle Scholar | 31525405PubMed |
[33] Treacy M, Stayt CL. To identify the factors that influence the recognizing and responding to adult patient deterioration in acute hospitals. J Adv Nurs 2019; 75 3272–85.
| To identify the factors that influence the recognizing and responding to adult patient deterioration in acute hospitals.Crossref | GoogleScholarGoogle Scholar | 31241199PubMed |
[34] Santiano N, Young L, Hillman K, et al Analysis of medical emergency team calls comparing subjective to “objective” call criteria. Resuscitation 2009; 80 44–9.
| Analysis of medical emergency team calls comparing subjective to “objective” call criteria.Crossref | GoogleScholarGoogle Scholar | 18952358PubMed |
[35] Douw G, Huisman‐de Waal G, Zanten ARH, et al Capturing early signs of deterioration: the dutch-early-nurse-worry-indicator-score and its value in the rapid response system. J Clin Nurs 2017; 26 2605–13.
| Capturing early signs of deterioration: the dutch-early-nurse-worry-indicator-score and its value in the rapid response system.Crossref | GoogleScholarGoogle Scholar | 27865003PubMed |
[36] Douw G, Schoonhoven L, Holwerda T, et al Nurses’ worry or concern and early recognition of deteriorating patients on general wards in acute care hospitals: a systematic review. Crit Care 2015; 19 230
| Nurses’ worry or concern and early recognition of deteriorating patients on general wards in acute care hospitals: a systematic review.Crossref | GoogleScholarGoogle Scholar | 25990249PubMed |
[37] Victorian Auditor General. Hospital performance: length of stay. 2016. Available at https://www.audit.vic.gov.au/report/results-2016-17-audits-public-hospitals [verified 1 December 2020].
[38] Considine J, Charlesworth D, Currey J. Characteristics and outcomes of patients requiring rapid response system activation within hours of emergency admission. Crit Care Resusc 2014; 16 184–9.
| 25161020PubMed |
[39] Bell MB, Konrad D, Granath F, et al Prevalence and sensitivity of MET criteria in a Scandinavian university hospital. Resuscitation 2006; 70 66–73.
| Prevalence and sensitivity of MET criteria in a Scandinavian university hospital.Crossref | GoogleScholarGoogle Scholar | 16757089PubMed |
[40] Connelly LM. Retrospective chart reviews. Medsurg Nurs 2008; 17 322–3.
| 19051979PubMed |
