Evaluation of a medical emergency team one year after implementation.

AIM: To evaluate the activity and impact of a Medical Emergency Team (MET) one year after implementation. SETTING AND POPULATION: A 700-bed District General Hospital (DGH) in Southeast England with approximately 53,500 adult admissions per annum. The population studied included all adult admissions receiving intervention by the MET during a 12-month period between 1 October 2000 and 30 September 2001. METHODS: Analysis of the activation of the MET using both prospective and retrospectively acquired data. Routinely collected hospital data for admissions, discharges and deaths was used to compare outcomes for the 12 months before and after the introduction of the MET. RESULTS: There were 136 activations of MET over 1-year. Six cases were excluded. Mean age of patients was 73 years (range 20-97 years). 40% (52/130) survived to discharge following MET intervention. Of those who died 22% (28/130) were designated 'not for resuscitation'. Patients that died were more likely to have three or more physiological abnormalities present (odds ratio, OR 6.2, Chi-square (chi(2)) P = 0.004) and had higher MET scores (P = 0.004). Commonest interventions by the MET were initiation or increase of oxygen therapy or ventilatory support (80%), with or without the administration of intravenous fluids or medications. In 10% of cases, oxygen therapy was the sole intervention. One year after implementation of the MET a reduction in cardiac arrest rate and overall mortality was noted but this was not statistically significant. CONCLUSION: Often only simple interventions are only required to reverse deterioration. Initiating 'do not attempt resuscitation' (DNAR) decisions is a key part of MET activity. Multiple physiological abnormalities are associated with increased mortality and therefore wider and earlier application of the MET to the hospital population may save lives or expedite DNAR decisions. New systems need time to develop ("bed in") and further research is needed to observe significant reductions in cardiac arrests and overall mortality.

The identification of risk factors for cardiac arrest and formulation of activation criteria to alert a medical emergency team.

AIM: (1) To identify risk factors for in-hospital cardiac arrest; (2) to formulate activation criteria to alert a clinical response culminating in attendance by a Medical Emergency Team (MET); (3) to evaluate the sensitivity and specificity of the scoring system. METHODS: Quasi-experimental design to determine prevalence of risk factors for cardiac arrest in the hospitalised population. Weighting of risk factors and formulation of activation criteria to alert a graded clinical response. ROC analysis of weighted cumulative scores to determine their sensitivity and specificity. SETTING: An acute 700 bed district general hospital with 32,348 adult admissions in 1999 and a catchment population of around 365,000. SUBJECTS: 118 consecutive adult patients suffering primary cardiac arrest in-hospital and 132 non-arrest patients, randomly selected according to stratified randomisation by gender and age. RESULTS: Risk factors for cardiac arrest include: abnormal respiratory rate (P = 0.013), abnormal breathing indicator (abnormal rate or documented shortness of breath) (P < 0.001), abnormal pulse (P < 0.001), reduced systolic blood pressure (P < 0.001), abnormal temperature (P < 0.001), reduced pulse oximetry (P < 0.001), chest pain (P < 0.001) and nurse or doctor concern (P < 0.001). Multivariate analysis of cardiac arrest cases identified three positive associations for cardiac arrest: abnormal breathing indicator (OR 3.49; 95% CI: 1.69-7.21), abnormal pulse (OR 4.07; 95% CI: 2.0-8.31) and abnormal systolic blood pressure (OR 19.92; 95% CI: 9.48-41.84). Risk factors were weighted and tabulated. The aggregate score determines the grade of clinical response. ROC analysis determined that a score of 4 has 89% sensitivity and 77% specificity for cardiac arrest; a score of 8 has 52% sensitivity and 99% specificity. All patients scoring greater than 10 suffered cardiac arrest. CONCLUSION: Risk factors for cardiac arrest have been identified, quantified and formulated into a table of activation criteria to help predict and avert cardiac arrest by alerting a clinical response. A graded clinical response has resulted in a tool that has both sensitivity and specificity for cardiac arrest.

Incidence, location and reasons for avoidable in-hospital cardiac arrest in a district general hospital.

AIMS: To determine the incidence of avoidable cardiac arrest among patients who had received resuscitation in a district general hospital. To establish how location and individual or system factors influence avoidable cardiac arrest in order to develop an evidence-based preventive strategy. METHODS: Expert panel review of case-notes from 139 consecutive adult in-hospital cardiac arrests over 1 year. RESULTS: There were 32,348 adult admissions in 1999 with 1,023 deaths. The cardiac arrest team was activated 139 times: 118 were for primary in-hospital cardiac arrest. The cardiac arrest rate excluding 'do not attempt resuscitation' (DNAR) cases was 3.8/1000 admissions. In 88.5% of deaths there was a DNAR policy. Survival to hospital discharge following resuscitation was 14%. Among the 118 cases, the panel unanimously agreed that 61.9% of arrests were potentially avoidable, rising to 68% when emergency department arrests were excluded (66 and 73% for majority opinion). Cardiac arrests were more likely at the weekend than during the week (P = 0.02). The odds of potentially avoidable cardiac arrest was 5.1 times greater for patients in general wards than critical care areas (P < 0.001); patients in critical care areas were more likely to survive (P < 0.001). The odds of potentially avoidable cardiac arrest was 12.6 times greater for patients nursed in a clinical area judged 'inappropriate' for their main complaint (P < 0.002, Fisher's exact test) compared to those nursed in 'appropriate' areas. The panel agreed that 100% of potentially avoidable arrests were judged to have received inadequate prior treatment. Clinical signs of deterioration in the preceding 24 h were not acted upon in 48%, and review was confined to a house officer in 45%. CONCLUSION: The majority of treated in-hospital cardiac arrests are potentially avoidable. Multiple system failures include delays and errors in diagnosis, inadequate interpretation of investigations, incomplete treatment, inexperienced doctors and management in inappropriate clinical areas.