Improving the pre-medical emergency team: the case for a behavioural theoretical lens.

There is mounting evidence that the pre-medical emergency team (pre-MET) of rapid response systems is underutilised in clinical practice due to suboptimal structures and processes and resource constraints. In this perspective article, we argue for examining the pre-MET through a 'Behaviour Change Wheel' lens to improve the pre-MET and maximise the associated patient safety benefits. Using pre-MET communication practices as an example, we illustrate the value of the COM-B model, where clinicians' 'capability', 'opportunity', and 'motivation' drive 'behaviour'. Optimising clinicians' behaviours and establishing failsafe rapid response systems is a complex undertaking; however, examining clinicians' behaviours through the COM-B model enables reframing barriers and facilitators to develop multifaceted and coordinated solutions that are behaviourally and theoretically based. The COM-B model is recommended to clinical governance leaders and health services researchers to explore the underlying causes of behaviour and successfully enact change in the design, implementation, and use of the pre-MET to improve patient safety.

Exploring interdisciplinary communication pathways for escalating pre-medical emergency team deterioration: a mixed-methods study.

Objective To explore clinicians' use and perceptions of interdisciplinary communication pathways for escalating care within the pre-medical emergency team (pre-MET) tier of rapid response systems. Method A sequential mixed-methods study was conducted using observations and interviews. Participants were clinicians (nurses, allied health, doctors) caring for orthopaedic and general medicine patients at one hospital. Descriptive and thematic analyses were conducted. Results Escalation practices were observed for 13 of 27 pre-MET events. Leading communication methods for escalating pre-MET events were alphanumeric pagers (61.5%) and in-person discussions (30.8%). Seven escalated pre-MET events led to bedside pre-MET reviews by doctors. Clinician interviews (n = 29) culminated in two themes: challenges in escalation of care, and navigating information gaps. Clinicians reported deficiencies in communication methods for escalating care that hindered interdisciplinary communication and clinical decision-making pertaining to pre-MET deterioration. Conclusion Policy-defined escalation pathways were inconsistently utilised for pre-MET deterioration. Available communication methods for escalating pre-MET events inadequately fulfilled clinicians' needs. Variable perceptions of escalation pathways illuminated a lack of of a shared mental model about clinicians' roles and responsibilities. To optimise timely and appropriate management of patient deterioration, communication infrastructure and interdisciplinary collaboration must be enhanced.

Clinicians' use and perceptions of the pre-medical emergency team tier of one rapid response system: A mixed-methods study.

BACKGROUND: The pre-medical emergency team (pre-MET) tier of rapid response systems facilitates early recognition and treatment of deteriorating ward patients using ward-based clinicians before a MET review is needed. However, there is growing concern that the pre-MET tier is inconsistently used. OBJECTIVE: This study aimed to explore clinicians' use of the pre-MET tier. METHODS: A sequential mixed-methods design was used. Participants were clinicians (nurses, allied health, doctors) caring for patients on two wards of one Australian hospital. Observations and medical record audits were conducted to identify pre-MET events and examine clinicians' use of the pre-MET tier as per hospital policy. Clinician interviews expanded on understandings gained from observation data. Descriptive and thematic analyses were performed. RESULTS: Observations identified 27 pre-MET events for 24 patients that involved 37 clinicians (nurses = 24, speech pathologist = 1, doctors = 12). Nurses initiated assessments or interventions for 92.6% (n = 25/27) of pre-MET events; however, only 51.9% (n = 14/27) of pre-MET events were escalated to doctors. Doctors attended pre-MET reviews for 64.3% (n = 9/14) of escalated pre-MET events. Median time between escalation of care and in-person pre-MET review was 30 min (interquartile range: 8-36). Policy-specified clinical documentation was partially completed for 35.7% (n = 5/14) of escalated pre-MET events. Thirty-two interviews with 29 clinicians (nurses = 18, physiotherapists = 4, doctors = 7) culminated in three themes: Early Deterioration on a Spectrum, A Safety Net, and Demands Versus Resources. CONCLUSIONS: There were multiple gaps between pre-MET policy and clinicians' use of the pre-MET tier. To optimise use of the pre-MET tier, pre-MET policy must be critically reviewed and system-based barriers to recognising and responding to pre-MET deterioration addressed.

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.

Breaches of pre-medical emergency team call criteria in an Australian hospital.

Objectives and outcomes: To evaluate the 24hrs before medical emergency team (MET) calls to examine: 1) the frequency, nature, and timing of pre-MET criteria breaches; 2) differences in characteristics and outcomes between patients who did and didn't experience pre-MET breaches. Design: Retrospective observational study November 2020-June 2021. Setting: Tertiary referral Australian hospital. Participants: Adults (≥18 years) experiencing MET calls. Results: Breaches in pre-MET criteria occurred prior to 1886/2255 (83.6%) MET calls, and 1038/1281 (81.0%) of the first MET calls. Patients with pre-MET breaches were older (median [IQR] 72 [57-81] vs 66 [56-77] yrs), more likely to be admitted from home (87.8% vs 81.9%) and via the emergency department (73.0% vs 50.2%), but less likely to be for full resuscitation after (67.3% vs 76.5%) the MET. The three most common pre-MET breaches were low SpO2 (48.0%), high pulse rate (39.8%), and low systolic blood pressure (29.0%) which were present for a median (IQR) of 15.4 (7.5-20.8), 13.2 (4.3-21.0), and 12.6 (3.5-20.1) hrs before the MET call, respectively. Patients with pre-MET breaches were more likely to need intensive care admission within 24 h (15.6 vs 11.9%), have repeat MET calls (33.3 vs 24.7%), and die in hospital (15.8 vs 9.9%). Conclusions: Four-fifths of MET calls were preceded by pre-MET criteria breaches, which were present for many hours. Such patients were older, had more limits of treatment, and experienced worse outcomes. There is a need to improve goals of care documentation and pre-MET management of clinical deterioration.

Recognizing and responding to clinical deterioration in adult patients in isolation precautions for infection control: a retrospective cohort study.

BACKGROUND: Patient isolation is widely used as a strategy for prevention and control of infection but may have unintended consequences for patients. Early recognition and response to acute deterioration is an essential component of safe, quality patient care and has not been explored for patients in isolation. OBJECTIVE: The primary aims of this study were to (i) describe the timing, frequency and nature of clinical deterioration during hospital admission for patients with isolation precautions for infection control and (ii) compare the characteristics of patients who did and did not deteriorate during their initial period of isolation precautions for infection control. METHODS: This retrospective cohort study was conducted across three sites of a large Australian health service. The study sample were adult patients (≥18 years) admitted into isolation precautions within 24 h of admission from 1 July 2019 to 31 December 2019. RESULTS: There were 634 patients who fulfilled the study inclusion criteria. One in eight patients experienced at least one episode of clinical deterioration during their time in isolation with most episodes of deterioration occurring within the first 2 days of admission. Timely Medical Emergency Team calls occurred in almost half the episodes of deterioration; however, the same proportion (47.2%) of deterioration episodes resulted in no Medical Emergency Team activation (afferent limb failure). In the 24 h preceding each episode of clinical deterioration (n = 180), 81.6% (n = 147) of episodes were preceded by vital signs fulfilling pre-Medical Emergency Team criteria. Patients who deteriorated during isolation for infection control were older (median age 74.0 vs 71.0 years, P = 0.042); more likely to live in a residential care facility (21.0% vs 7.2%, P = 0.006); had a longer initial period of isolation (4.0 vs 2.9 days, P = < 000.1) and hospital length-of-stay (median 4.9 vs 3.2 days, P = < 0.001) and were more likely to die in hospital (12.3% vs 4.3%, P < 0.001). CONCLUSION: Patients in isolation precautions experienced high Medical Emergency Team afferent limb failure and most fulfilled pre-Medical Emergency Team criteria in the 24 h preceding episodes of deterioration. Timely recognition and response to clinical deterioration continue to be essential in providing safe, quality patient care regardless of the hospital-care environment.

Specific Elements of Team-Based Learning Used in Nursing Education: A Scoping Review.

BACKGROUND: Team-based learning (TBL) is an evidence-based, highly structured teaching strategy. PURPOSE: The purpose of this review was to explore the specific TBL structure and process design elements reported in nursing education studies. METHODS: A scoping review was undertaken according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. Databases were searched on February 15, 2021, using search terms related to nursing, education, and TBL. RESULTS: Of 226 potentially relevant citations, 45 studies were included. The specific TBL design elements reported were team size (n = 41), team formation (n = 24), readiness assurance process (n = 45), immediate feedback (n = 42), activity sequencing (n = 42), 4S application design (n = 13), incentive structure(s) (n = 22), and peer evaluation (n = 13). CONCLUSIONS: There was variability in the reporting of TBL design elements. Preclass preparation and individual and team Readiness Assurance Tests were well reported. Application exercise design and approach to peer evaluation were gaps in the included studies.

Use of the pre-medical emergency team tier of rapid response systems: A scoping Review.

OBJECTIVE: The aim of this review was to explore use of the pre-Medical Emergency Team (pre-MET) tier of Rapid Response Systems to recognise and respond to adult ward patients experiencing early clinical deterioration. METHODS: A scoping review of studies published in English reporting on use of a pre-MET tier in adult ward patients was conducted. Three databases were searched (Medline, CINAHL, EMBASE) for studies published between January 1995 and September 2020. Two researchers independently performed screening and quality assessments. Findings were synthesised thematically. Reporting of the review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. RESULTS: Six of 1669 studies were included in this review. All were single-site studies of single-parameter Rapid Response Systems in Australian hospitals. Five were quantitative studies; one had a qualitative design. Studies fulfilled 50-100% of quality criteria. Two themes were constructed: Afferent processes - Recognising and escalating pre-MET events; and Efferent processes - Pre-MET reviews and associated interventions. There was disparity between clinical practice and pre-MET escalation protocols, and reports of nurse-initiated management of early deterioration. Prospective methods and exploration of multidisciplinary perspectives were notable research gaps. CONCLUSION: Use of the pre-MET tier of Rapid Response Systems is under-researched. Further research is needed to understand barriers and facilitators influencing use of pre-MET strategies to address patient deterioration.

Modifications to medical emergency team activation criteria and implications for patient safety: A point prevalence study.

BACKGROUND: Medical emergency team (MET) activation criteria are sometimes modified to minimise unnecessary MET calls in patients who have chronic physiological derangements, have limitation of medical treatment orders in place, or have recently received treatment for clinical deterioration. However, the safety implications of modifying MET activation criteria are poorly understood. OBJECTIVES: The aim of the study was to examine the safety of modifying MET activation criteria. Specifically, we aimed to examine the frequency and nature of modifications to MET activation criteria and compare characteristics and outcomes of patients with and without modifications to MET activation criteria. METHODS: This was a point prevalence study using a retrospective medical record audit. Patients admitted to 14 wards on November 7, 2018, at two acute-care hospitals of one health service in Melbourne, Australia, were included (N = 430). Data were analysed using descriptive and inferential statistics. The main outcome measures included frequency and nature of modifications to MET activation criteria on a specified date, MET calls, intensive care unit admission, in-hospital cardiac arrest, and in-hospital death. RESULTS: Amongst 430 inpatients, there were 30 modifications to MET activation criteria in 26 (6.0%) patients. All modifications were intended to trigger METs at more extreme levels of physiological derangement. Most modifications pertained to tachypnoea (26.7%; n = 8/30) and bradycardia (23.3%; n = 7/30). Patients with modifications were more likely to have documented physiological deterioration that fulfilled MET (47.8%, n = 11; p < 0.001) or pre-MET (87.0%, n = 20; p < 0.001) criteria in the preceding 24-h period than patients without modifications. Of patients with modifications, none were admitted to an intensive care unit, had a cardiac arrest, or died in the hospital. There were no differences in hospital length of stay or discharge destination between patients with and without modifications. CONCLUSIONS: In this point prevalence study, modifications to MET activation criteria were infrequent and not associated with negative patient safety outcomes.

Understanding the pre-medical emergency team tier of a mature rapid response system: A content analysis of guidance documents.

BACKGROUND: The pre-medical emergency team (pre-MET) tier of rapid response systems (RRSs) includes extended activation criteria to identify earlier clinical deterioration and a ward-based patient review that is undertaken by the affected patient's admitting team or covering doctors. There is limited understanding of the structure and processes of the pre-MET RRS tier that are expected to guide clinicians' actions and subsequent patient safety outcomes. OBJECTIVE: The aim of the study was to describe the structure and processes of the pre-MET RRS tier in one acute care setting. METHODS: An exploratory descriptive design involving document analysis was used. Guidance documents (policies, procedures, guidelines, charts, educational materials) were obtained from one health service with a mature, multitiered RRS in Melbourne, Australia. Documents were analysed using content analysis. Concept- and data-driven approaches were used to construct a coding frame. RESULTS: Nineteen guidance documents supporting the pre-MET RRS tier on general wards were analysed. The coding frame consisted of seven main categories: Defining the Pre-MET RRS Tier, Essential Resources for Operationalisation, Recognising Pre-MET Events, Pathways for Activation, Exceptions to the Rule, Clinician Responses to Pre-MET Events, and Recording Pre-MET Events. The structures and processes of the pre-MET RRS tier were largely consistent with national guidelines, but there were internal inconsistencies in pre-MET activation criteria and unclear recommendations for modifying criteria. Pathways for activating the pre-MET RRS tier were complex and involved many steps, including validation processes before escalation of care to doctors. Responses to pre-MET events were seldom aligned to specific clinician types or groups, with nurses and allied health clinicians being under-represented. CONCLUSIONS: We identified opportunities to improve guidance documents supporting the pre-MET RRS tier that may assist other health services engaged in planning or evaluating pre-MET strategies. Further research is needed to understand clinicians' use of the pre-MET RRS tier to inform targeted strategies to optimise its design and implementation.

Team-based learning in nursing education: A scoping review.

AIMS AND OBJECTIVES: To explore the use and student outcomes of Team-Based Learning in nursing education. BACKGROUND: Team-Based Learning is a highly structured, evidence-based, student-centred learning strategy that enhances student engagement and facilitates deep learning in a variety of disciplines including nursing. However, the breadth of Team-Based Learning application in nursing education and relevant outcomes are not currently well understood. DESIGN: A scoping review of international, peer-reviewed research studies was undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. METHODS: The following databases were searched on 7 May 2020: Cumulative Index of Nursing and Allied Health Literature, MEDLINE Complete, PsycINFO and Education Resources Information Center. Search terms related to nursing, education and Team-Based Learning. Original research studies, published in English, and reporting on student outcomes from Team-Based Learning in nursing education programmes were included. RESULTS: Of the 1081 potentially relevant citations, 41 studies from undergraduate (n = 29), postgraduate (n = 4) and hospital (n = 8) settings were included. The most commonly reported student outcomes were knowledge or academic performance (n = 21); student experience, satisfaction or perceptions of Team-Based Learning (n = 20); student engagement with behaviours or attitudes towards Team-Based Learning (n = 12); and effect of Team-Based Learning on teamwork, team performance or collective efficacy (n = 6). Only three studies reported clinical outcomes. CONCLUSIONS: Over the last decade, there has been a growing body of knowledge related to the use of Team-Based Learning in nursing education. The major gaps identified in this scoping review were the lack of randomised controlled trials and the dearth of studies of Team-Based Learning in postgraduate and hospital contexts. RELEVANCE TO CLINICAL PRACTICE: This scoping review provides a comprehensive understanding of the use and student outcomes of Team-Based Learning in nursing education and highlights the breadth of application of Team-Based Learning and variability in the outcomes reported.

Stakeholder acceptance of digital team-based learning.

Team-Based Learning (TBL) can be associated with administrative processes that are labour intensive. A commercially-available online system offered an opportunity to reduce this burden. The aims of this study were to test the feasibility of integrating digital TBL into health curricula, and to explore the experiences and perspectives of students and educators participating in digital TBL. A prospective mixed methods design was used to survey postgraduate nursing and optometry students (n = 162), and educators (n = 8) at an Australian university. Student and educator perceptions of digital TBL collected were: usability (System Usability Scale); level of student engagement (Student Self-Report of Engagement); and user satisfaction post-participation in digital TBL (Post-Study System Usability Questionnaire). Mean Student Self-Report of Engagement Scores reflected high student engagement with significantly higher levels of engagement reported for digital (x‾=4.16, SD = 0.199) over paper-based (x‾=3.97, SD = 0.267) TBL (p = 0.001). System Usability Scores revealed students (during: x‾ = 72.35, SD = 15.70; post: x‾ = 74.02, SD = 14.00) and educators (x‾=75.0, SD = 15.12) perceived usability of digital TBL to be above average for systems on this scale. Students (x‾=2.40, SD = 0.19) and educators (x‾=2.36, SD = 0.80) were highly satisfied with digital TBL (Post-Study System Usability Questionnaire). High satisfaction and engagement outcomes suggest digital TBL is feasible, efficient, engaging and well accepted by stakeholders.

Understanding the patient experience of early unplanned hospital readmission following acute care discharge: a qualitative descriptive study.

OBJECTIVES: To understand from a patient and carer perspective: (1) what features of the discharge process could be improved to avoid early unplanned hospital readmission (within 72 hours of acute care discharge) and (2) what elements of discharge planning could have enhanced the discharge experience. DESIGN: A qualitative descriptive design was used. Study data were collected using semi-structured interviews that were transcribed verbatim and analysed using inductive thematic analysis. Data related to participant characteristic were collected by medical record audit and summarised using descriptive statistics. SETTING: Three acute care hospitals from one health service in Australia. PARTICIPANTS: Patients who had an early unplanned hospital readmission and/or their carers, if present during the interviews and willing to participate, with patient permission. FINDINGS: Thirty interviews were conducted (23 patients only; 6 patient and carer dyads; 1 carer only). Five themes were constructed: 'experiences of care', 'hearing and being heard', 'what's wrong with me', 'not just about me' and 'all about going home'. There was considerable variability in patients' and carers' experiences of hospital care, discharge processes and early unplanned hospital readmission. Features of the discharge process that could be improved to potentially avoid early unplanned hospital readmission were better communication, optimal clinical care including ensuring readiness for discharge and shared decision-making regarding discharge timing and goals on returning home. The discharge experience could have been enhanced by improved communication between patients (and carers) and the healthcare team, not rushing the discharge process and a more coordinated approach to patient transport home from hospital. CONCLUSIONS: The study findings highlight the complexities of the discharge process and the importance of effective communication, shared decision-making and carer engagement in optimising hospital discharge and reducing early unplanned hospital readmissions.

Specialty cardiac nurses' work satisfaction is influenced by the type of coronary care unit: A mixed methods study.

BACKGROUND: Many dedicated Coronary Care Units (CCUs) in Victoria, Australia, have been decommissioned and replaced with larger combined generic medical/cardiac precincts called hybrid units. Hybrid units are staffed with a low proportion of specialist critical care nurses. These changes may pose risks to nurse satisfaction and retention, and quality of patient care. The aims of this study were to explore specialist cardiac nurses' perceived work satisfaction across four CCUs, and differences in satisfaction between dedicated and hybrid CCUs. METHODS: This concurrent mixed methods study comprised two Phases in four Victorian CCUs (2 dedicated, 2 hybrid). In Phase 1, 74 specialist cardiac nurses completed the Professional Practice Environment (PPE) Scale. In Phase 2, 17 specialist cardiac nurses were interviewed to further explore elements of the PPE subscales. Descriptive, inferential (Phase 1), and content analyses (Phase 2) were performed. RESULTS: Survey participants' median age was 38 years (IQR 30, 45). The median PPE Scale score was 3.10 (IQR 2.90, 3.10) indicating high levels of satisfaction with their workplaces. Specialist cardiac nurses in one hybrid unit were significantly less satisfied compared with each of the other three units (p < 0.05). There were no significant differences in overall satisfaction or in any subscale of the PPE Scale between dedicated and hybrid units. Qualitative data revealed nurses in hybrid units felt they had less control over practice, lacked autonomy, had poor relationships with physicians, and experienced inadequate nurse leadership. CONCLUSIONS: Specialist cardiac nurses' workplace satisfaction overall is high, with no significant differences between dedicated and hybrid CCUs. However, the structure of specialist cardiac units and NUM leadership skill level can impact nurses' satisfaction with their workplace and collegial relationships. Strong nursing leadership that is respectful of nursing expertise and places patient safety foremost positively impacts nurses' satisfaction. Further studies should assess the impact of the types of CCUs and NUM leadership on workforce factors such as nurse retention rates and patient outcomes such as adverse events.

Patient acceptability of wearable vital sign monitoring technologies in the acute care setting: A systematic review.

AIMS AND OBJECTIVES: To examine patient acceptability of wearable vital sign monitoring devices in the acute setting. BACKGROUND: Wearable vital sign monitoring devices may improve patient safety, yet hospital patients' acceptability of these devices is largely unreported. DESIGN: A systematic review. METHODS: Cumulative Index to Nursing and Allied Health Literature Complete, MEDLINE Complete and EMBASE were searched, supplemented by reference list hand searching. Studies were included if they involved adult hospital patients (≥18 years), a wearable monitoring device capable of assessing ≥1 vital sign, and measured patient acceptability, satisfaction or experience of wearing the device. No date restrictions were enforced. Quality assessments of quantitative and qualitative studies were undertaken using the Downs and Black Checklist for Measuring Study Quality and the Critical Appraisal Skills Programme Qualitative Research Checklist, respectively. Meta-analyses were not possible given data heterogeneity and low research quality. Reporting adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and a Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist was completed. RESULTS: Of the 427 studies screened, seven observational studies met the inclusion criteria. Six studies were of low quality and one was of high quality. In two studies, patient satisfaction was investigated. In the remaining studies, patient experience, patient opinions and experience, patient perceptions and experience, device acceptability, and patient comfort and concerns were investigated. In four studies, patients were mostly accepting of the wearable devices, reporting positive experiences and satisfaction relating to their use. In three studies, findings were mixed. CONCLUSION: There is limited high-quality research examining patient acceptability of wearable vital sign monitoring devices as an a priori focus in the acute setting. Further understanding of patient perspectives of these devices is required to inform their continued use and development. RELEVANCE TO CLINICAL PRACTICE: The provision of patient-centred nursing care is contingent on understanding patients' preferences, including their acceptability of technology use.

Physiological antecedents and ward clinician responses before medical emergency team activation.

OBJECTIVES: To investigate the frequency, characteristics and timing of objectively measured clinical instability in adult ward patients in the 24 hours preceding activation of the medical emergency team (MET). We also examined ward clinician responses to documented clinical instability. DESIGN, SETTING AND PARTICIPANTS: A descriptive, exploratory design with a retrospective medical record audit. We descriptively analysed data from 200 ward patients reviewed by the MET at a tertiary teaching hospital in Melbourne, Australia, during 2014. MAIN OUTCOME MEASURES: Frequency and characteristics of urgent clinical review (UCR) criteria breaches in the 24 hours preceding MET activation, and in-hospital mortality. RESULTS: Overall, 78.5% of patients breached UCR criteria at least once in the 24 hours preceding MET activation, with 80.9% having multiple breaches. The most common causes of UCR criteria breaches were hypoxaemia without supplemental oxygen (27.4%, n = 43) and hypoxaemia with supplemental oxygen (21.7%, n = 34) for first UCR criteria breaches, and tachycardia (33.1%, n = 42) for last UCR criteria breaches during the 24 hours we examined. The median time before MET activation for first and last breaches was 17.1 hours and 1.2 hours, respectively. Examination of the clinician documentation suggested a high incidence of pre-MET activation afferent limb failure. In-hospital mortality was 12%. CONCLUSIONS: Patients commonly and repeatedly breached objectively measured UCR criteria in the 24 hours preceding MET activation, providing numerous opportunities for clinicians to recognise and respond to early clinical deterioration. The high incidence of pre- MET afferent limb failure requires further exploration.