A multi-facetted patient safety resource-A qualitative interview study on hospital managers' perception of the nurse-led Rapid Response Team.

AIM: To explore hospital managers' perceptions of the Rapid Response Team. DESIGN: An explorative qualitative study using semi-structured individual interviews. METHODS: In September 2019, a qualitative interview study including nineteen hospital managers at three managerial levels in acute care hospitals was conducted. Interview transcripts were analysed with an inductive content analysis approach, involving researcher triangulation in data collection and analysis processes. FINDINGS: One theme, 'A resource with untapped potential, enhancing patient safety, high-quality nursing, and organisational cohesion' was identified and underpinned by six categories and 30 sub-categories. CONCLUSION: The Rapid Response Team has an influence on the organization that goes beyond the team's original purpose. It strengthens the organization's dynamic cohesion by providing clinical support to nurses and facilitating learning, communication and collaboration across the hospital. Managers lack engagement in the team, including local key data to guide future quality improvement processes. IMPLICATIONS: For organizations, nursing, and patients to benefit from the team to its full potential, managerial engagement seems crucial. IMPACT: This study addressed possible challenges to using the Rapid Response Team optimally and found that hospital managers perceived this complex healthcare intervention as beneficial to patient safety and nursing quality, but lacked factual insight into the team's deliverances. The research impacts patient safety pointing at the need to re-organize managerial involvement in the function and development of the Rapid Response Team and System. REPORTING METHOD: We have adhered to the COREQ checklist when reporting this study. "No Patient or Public Contribution".

Critical care nurses' role in rapid response teams: A qualitative systematic review.

AIM: To analyse the qualitative evidence on the role of critical care nurses in rapid response teams. DESIGN: Qualitative systematic review. METHODS: This qualitative systematic review employed Bettany-Saltikov and McSherry's guidelines and is reported according to the Enhancing Transparency in Reporting the Synthesis of Qualitative Research checklist. Two pairs of blinded researchers screened the articles. The data were synthesised using a thematic analysis approach. DATA SOURCES: A systematic literature search was conducted using the CINAHL, Embase and MEDLINE databases. RESULTS: Seven studies were included, and three main roles were identified: (1) balancing between confidence and fear in clinical encounters, (2) facilitating collaboration and (3) managing challenging power dynamics in decision-making. CONCLUSION: Critical care nurses possess extensive knowledge and skills in providing critical care to patients experiencing deterioration on general wards. They play a vital role in facilitating collaboration between team members and ward staff. Furthermore, within the rapid response team, critical care nurses assume leadership responsibilities by overseeing the comprehensive coordination of patient care and actively engaging in the decision-making process concerning patient care. IMPLICATIONS FOR THE PROFESSION: Highlighting the central role of critical care nurses in rapid response teams as well such a team's benefits in healthcare organisations can promote applications for funding to support further quality assurance of rapid response teams and thus enhance patient safety. IMPACT: Health care organisations can assure the quality of rapid response team by providing economical resources and training. The education providers should facilitate and standardise curriculum for critical care nursing students to achieve necessary knowledge and skills as members in rapid response teams. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Effectiveness of Implementing Modified Early Warning System and Rapid Response Team for General Ward Inpatients.

This retrospective study assessed the effectiveness and impact of implementing a Modified Early Warning System (MEWS) and Rapid Response Team (RRT) for inpatients admitted to the general ward (GW) of a medical center. This study included all inpatients who stayed in GWs from Jan. 2017 to Feb. 2022. We divided inpatients into GWnon-MEWS and GWMEWS groups according to MEWS and RRT implementation in Aug. 2019. The primary outcome, unexpected deterioration, was defined by unplanned admission to intensive care units. We defined the detection performance and effectiveness of MEWS according to if a warning occurred within 24 h before the unplanned ICU admission. There were 129,039 inpatients included in this study, comprising 58,106 GWnon-MEWS and 71,023 GWMEWS. The numbers of inpatients who underwent an unplanned ICU admission in GWnon-MEWS and GWMEWS were 488 (.84%) and 468 (.66%), respectively, indicating that the implementation significantly reduced unexpected deterioration (p < .0001). Besides, 1,551,525 times MEWS assessments were executed for the GWMEWS. The sensitivity, specificity, positive predicted value, and negative predicted value of the MEWS were 29.9%, 98.7%, 7.09%, and 99.76%, respectively. A total of 1,568 warning signs accurately occurred within the 24 h before an unplanned ICU admission. Among them, 428 (27.3%) met the criteria for automatically calling RRT, and 1,140 signs necessitated the nursing staff to decide if they needed to call RRT. Implementing MEWS and RRT increases nursing staff's monitoring and interventions and reduces unplanned ICU admissions.

Frequency of and associations with alterations of medical emergency team calling criteria in a teaching hospital emergency department.

BACKGROUND: Medical emergency team (METs), activated by vital sign-based calling criteria respond to deteriorating patients in the hospital setting. Calling criteria may be altered where clinicians feel this is appropriate. Altered calling criteria (ACC) has not previously been evaluated in the emergency department (ED) setting. OBJECTIVES: The objectives of this study were to (i) describe the frequency of ACC in a teaching hospital ED and the number and type of vital signs that were modified and (ii) associations between ACC in the ED and differences in the baseline patient characteristics and adverse outcomes including subsequent MET activations, unplanned intensive care unit (ICU) admissions and death within 72 h of admission. METHODS: Retrospective observational study of patients presenting to an academic, tertiary hospital ED in Melbourne, Australia between January 1st, 2019 and December 31st, 2019. The primary outcome was frequency and nature of ACC in the ED. Secondary outcomes included differences in baseline patient characteristics, frequency of MET activation, unplanned ICU admission, and mortality in the first 72 h of admission between those with and without ACC in the ED. RESULTS: Amongst 14 159 ED admissions, 725 (5.1%) had ACC, most frequently for increased heart or respiratory rate. ACC was associated with older age and increased comorbidity. Such patients had a higher adjusted risk of MET activation (odds ratio [OR]: 3.14, 95% confidence interval [CI]: 2.50-3.91, p = <0.001), unplanned ICU admission (OR: 1.97, 95% CI: 1.17-3.14, p = 0.016), and death (OR: 3.87, 95% CI: 2.08-6.70, p = 0.020) within 72 h. CONCLUSIONS: ACC occurs commonly in the ED, most frequently for elevated heart and respiratory rates and is associated with worse patient outcomes. In some cases, ACC requires consultant involvement, more frequent vital sign monitoring, expeditious inpatient team review, or ICU referral.

Are we deskilling or reskilling our hospital ward clinicians?

Rapid reponse teams emerged 27 years ago to identify deteriorating patients and reduce preventable harm. There are concerns that such teams have deskilled hospital staff. However, over the past 20 years, there have been marked changes in hospital care and workplace requirements for hospital staff. In this article, we contend that hospital staff have been reskilled rather than deskilled.

Modifications to rapid response team (medical emergency team) activation criteria and its impact on patient safety.

BACKGROUND: Modifications to rapid response team (RRT) activation criteria occur commonly in Australian hospitals without evidence to define their use. AIMS: To evaluate the effectiveness of RRT activation criteria modifications in preventing RRT activation and differences in adverse events associated with treatment delays caused by modifications. METHODS: A prospective chart audit of hospital patients with RRT activation criteria modifications admitted during a 12-month period in a large regional hospital in Toowoomba, Australia. The incidence of RRT activation criteria modifications, RRT activations and rates of adverse events following criteria modifications were investigated. Adverse events were defined as a delayed treatment on the ward, unplanned intensive care unit admission, cardiac arrest and unexpected death. Differences in patient outcomes among medical and surgical patients were also investigated. RESULTS: A total of 271 patients out of 4009 admitted patients had modifications to their RRT activation criteria. There was no difference in rates of RRT activation in patients with modified criteria compared with patients with unmodified criteria (P = 0.37). In patients with RRT activation criteria modifications, rates of adverse events were higher in patients who met their modified RRT criteria (93.3%) compared with those who did not meet modified RRT criteria (3.8%; P < 0.001). Additionally, in patients with modifications, rates of adverse events were higher in medical patients (27.6%; n = 50) compared with surgical patients (15.6%; n = 14; P = 0.03). CONCLUSIONS: The results strongly suggest that RRT criteria modification is associated with no difference in rates of RRT activation and with detrimental impacts on patient safety, particularly in medical patients.

Epidemiology of in-hospital cardiac arrest patients admitted to the intensive care unit in Australia: a retrospective observational study.

BACKGROUND: In-hospital cardiac arrest (IHCA) affects approximately 3000 patients annually in Australia. Introduction of the National Standard for Deteriorating Patients in 2011 was associated with reduced IHCA-related intensive care unit (ICU) admissions and reduced in-hospital mortality of such patients. AIMS: To assess whether the reduction in IHCA-related ICU admissions from hospital wards seen following the implementation of the national standard (baseline period 2013-2014) was sustained over the follow-up period (2015-2019) in Australia. METHODS: A multi-centre retrospective cohort study to compare the characteristics and outcomes of IHCA admitted to the ICU between baseline and follow-up periods. The primary outcome was the proportion of patients admitted to ICU from the ward following IHCA. Secondary outcomes included ICU and hospital mortality of IHCA-related ICU admissions. Data were analysed using hierarchical multivariable logistic regression. RESULTS: The proportion of cardiac arrest-related admissions from the ward was lower in the follow-up period when compared to baseline (4.1 vs 3.8%; P = 0.04). Such patients had lower illness severity and were more likely to have limitations of medical treatment at admission. However, after adjustment for severity of illness, the likelihood of being admitted to ICU following cardiac arrest on the ward increased in the follow-up period (odds ratio (OR) 1.13 (1.05-1.22); P = 0.001). Hospital mortality was lower in the follow-up period (50.3 vs 46.3%; P = 0.02), but after adjustment the likelihood of death did not differ between the periods (OR 1.0 (0.86-1.17); P = 0.98). CONCLUSION: After adjustment for the severity of illness, the likelihood of being admitted to ICU after IHCA slightly increased in the follow-up period.

In-hospital outcomes among older medical inpatients admitted to aged care wards after activation of a 2-tier rapid response system.

BACKGROUND: The outcomes of rapid response systems (RRS) are poorly established in older people. We examined the outcomes in older inpatients at a tertiary hospital that uses a 2-tier RRS, including the outcomes of each tier. METHODS: The 2-tier RRS comprised the clinical review call (CRC) (tier one) and the medical emergency team call (MET) (tier two). We compared the outcomes in four configurations of MET and CRC (MET with CRC; MET without CRC; CRC without MET; neither MET nor CRC). The primary outcome was in-hospital death, and secondary outcomes were length of stay (LOS) and new residential facility placement. Statistical analyses were carried out using Fisher's exact tests, Kruskal-Wallis tests, and logistic regression. RESULTS: A total of 433 METs and 1,395 CRCs occurred among 3,910 consecutive admissions of mean age 84 years. The effect of a MET on death was unaffected by the occurrence of a CRC. The rates of death for MET ± CRC, and CRC without MET, were 30.5% and 18.5%, respectively. Patients having one or more MET ± CRC (adjusted odds ratio [aOR] 4.04, 95% confidence interval [CI] 2.96-5.52), and those having one or more CRC without MET (aOR 2.22, 95% CI 1.68-2.93), were more likely to die in adjusted analysis. Patients who required a MET ± CRC were more likely to be placed in a high-care residential facility (aOR 1.52, 95% CI 1.03-2.24), as were patients who required a CRC without MET (aOR 1.61, 95% CI 1.22-2.14). The LOS of patients who required a MET ± CRC, and CRC without MET, was longer than that of patients who required neither (P < 0.001). CONCLUSIONS: Both MET and CRC were associated with increased likelihood of death and new residential facility placement, after adjusting for factors such as age, comorbidity, and frailty. These data are important for patient prognostication, discussions on goals of care, and discharge planning. The high death rate of patients requiring a CRC (without a MET) has not been previously reported, and may suggest that CRCs among older inpatients should be expediated and attended by senior medical personnel.

Pediatric intraoperative cardiopulmonary arrests: A survey to evaluate if Medical Emergency Teams are utilized in pediatric operating rooms.

BACKGROUND: Studies have shown that standardized code teams may improve outcomes following cardiac arrests. Pediatric intra-operative cardiac arrests are rare events and are associated with a mortality rate of 18%. There is limited data available regarding use Medical Emergency Team (MET) response to pediatric intra-operative cardiac arrest. The purpose of this study was to identify the use of MET in response to pediatric intraoperative cardiac arrest as an exploratory step in establishing evidence-based standardized practice across the hospital for training and management of this rare event. METHODS: An anonymous electronic survey was created and sent to two populations: The Pediatric Anesthesia Leadership Council, a section of the Society for Pediatric Anesthesia, and the Pediatric Resuscitation Quality Collaborative, a multinational collaborative group, which works to improve resuscitation care in children. Standard summary and descriptive statistics were used for survey responses. RESULTS: The overall response rate was 41%. The majority of respondents worked in a university affiliated, free-standing children's hospital. Ninety-five percent of respondents had a dedicated pediatric MET at their hospital. In 60% of responses from Pediatric Resuscitation Quality Collaborative and 18% of Pediatric Anesthesia Leadership Council hospitals, the MET responds to pediatric intra-operative cardiac arrest; however, the majority of times MET involvement is requested rather than automatic. The MET was found to be activated intraoperatively for situations other than cardiac arrest such as, massive transfusion events, need for extra staff, and for specialty expertise. In 65% of institutions, simulation-based training for cardiac arrest is supported but lacking pediatric intra-operative focus. CONCLUSIONS: This survey revealed heterogeneity in the composition and response of the medical response teams responding to pediatric intra-operative cardiac arrests. Improved collaboration and cross training among MET, anesthesia, and operating room nursing may improve outcomes of pediatric intra-operative code events.

Effect of in situ simulation training for emergency caesarean section on maternal and infant outcomes.

BACKGROUND: Emergency caesarean section (ECS) is an effective method for rapid termination of pregnancy and for saving maternal and foetal life in emergencies. Experts recommend that the interval from decision of operation to the decision to delivery interval (DDI) should be shortened as much as possible. Studies have shown that improving communication skills among staff by performing simulation drills shortens DDI, thus reducing the occurrence of adverse obstetric events and protecting maternal and child safety. In situ simulation (ISS) training is a simulation-based training approach for clinical team members conducted in a real-world clinical setting. In August 2020, Anhui Maternal and Child Health Hospital began ISS training on the rapid obstetric response team (RRT) in our hospital area for emergency caesarean section. This study aimed to investigate the effect of implementing in situ simulation training for emergency caesarean section on maternal and child outcomes by comparing maternal and child-related data on emergency caesarean section in two hospital areas. METHODS: Data on cases of emergency caesarean delivery implemented in two hospital districts from August 2020 to August 2022 were collected: 19 in the untrained group and 26 in the training group. The two groups were compared concerning the interval from the decision of operation to the decision to delivery interval (DDI), the interval from the decision of operation to the initiation of skin incision, the interval from skin incision to the decision to delivery interval, and the neonatal situation. RESULTS: Primary outcome comparison: The training group had a significantly shorter interval between the DDI compared to the untrained group (8.14 ± 3.13 vs. 11.03 ± 3.52, P = 0.006). Secondary outcomes comparison: The training group had a significantly shorter interval between the decision to cut skin compared to the untrained group (6.45 ± 2.21 vs. 9.95 ± 4.02, P = 0.001). However, there was no significant difference in the interval between cutting skin and infant delivery between the two groups (2.24 ± 0.08 vs. 2.18 ± 0.13, P > 0.05). Additionally, the Apgar score at 1 min after birth was higher in the training group compared to the untrained group (7.29 ± 2.38 vs. 6.04 ± 1.46, P < 0.05). CONCLUSIONS: The DDI for emergency caesarean section procedures can be significantly shortened, and neonatal Apgar scores at 1 min improved by implementing in situ simulation training for emergency caesarean section in obstetric rapid response teams. In situ simulation training is an effective tool for training in emergency caesarean section procedures and is worth promoting.

Avoiding Escalation to the Emergency Department by Activating an In-Home Rapid Response Team in the 30 Days After Hospital-at-Home Discharge.

BACKGROUND: Mayo Clinic's virtual hybrid hospital-at-home program, Advanced Care at Home (ACH) monitors acute and post-acute patients for signs of deterioration and institutes a rapid response (RR) system if detected. OBJECTIVE: This study aimed to describe Mayo Clinic's ACH RR team and its effect on emergency department (ED) use and readmission rates. METHODS: This was a retrospective review of all post-inpatient (restorative phase) ACH patients admitted from July 6, 2020 through June 30, 2021. If the restorative patient had a clinical decompensation, an RR was activated. All RR activations were analyzed for patient demographic characteristics, admitting and escalation diagnosis, time spent by virtual team on the RR, and whether the RR resulted in transport to the ED or hospital readmission. RESULTS: Three hundred and twenty patients were admitted to ACH during the study interval; 230 received restorative care. Seventy-two patients (31.3%) had events that triggered an RR. Fifty (69.4%) of the RR events were related to the admission diagnosis (p < 0.001; 95% CI 0.59-0.80). Twelve patients (16.7%) required transport to an ED for further treatment and were readmitted and 60 patients (83.3%) were able to be treated successfully in the home by the RR team (p < 0.001; 95% CI 0.08-0.25). CONCLUSIONS: The use of an ACH RR team was effective at limiting both escalations back to an ED and hospital readmissions, as 83% of deteriorating patients were successfully stabilized and managed in their homes. Implementing a hospital-at-home RR team can reduce the need for ED use by providing critical resources and carrying out required interventions to stabilize the patient's condition.

The Effect of Continuous Versus Periodic Vital Sign Monitoring on Disease Severity of Patients with an Unplanned ICU Transfer.

Continuous vital sign monitoring (CM) may detect ward patient's deterioration earlier than periodic monitoring. This could result in timely ICU transfers or in a transfer delay due to misperceived higher level of care on the ward. The primary objective of this study was to compare patient's disease severity upon unplanned ICU transfer, before and after CM implementation. We included a one-year period before and after CM implementation between August 1, 2017 - July 31, 2019. Before implementation, surgical and internal medicine patients' vital signs were periodically monitored, compared to continuous monitoring with wireless linkage to hospital systems after implementation. In both periods the same early warning score (EWS) protocol was in place. Primary outcome was disease severity scores upon ICU transfer. Secondary outcomes were ICU and hospital length of stay, incidence of mechanical ventilation and ICU mortality. In the two one-year periods 93 and 59 unplanned ICU transfer episodes were included, respectively. Median SOFA (3 (2-6) vs 4 (2-7), p = .574), APACHE II (17 (14-20) vs 16 (14-21), p = .824) and APACHE IV (59 (46-67) vs 50 (36-65), p = .187) were comparable between both periods, as were the median ICU LOS (3.0 (1.7-5.8) vs 3.1 (1.6-6.1), p.962), hospital LOS (23.6 (11.5-38.0) vs 19 (13.9-39.2), p = .880), incidence of mechanical ventilation (28 (47%) vs 22 (54%), p.490), and ICU mortality (11 (13%) vs 10 (19%), p.420). This study shows no difference in disease severity upon unplanned ICU transfer after CM implementation for patients who have deteriorated on the ward.

Implementation evaluation of a rapid response system in a regional emergency department: a dual-methods study using the behaviour change wheel.

BACKGROUND: Failure to recognise and respond to clinical deterioration is a major cause of high mortality events in emergency department (ED) patients. Whilst there is substantial evidence that rapid response teams reduce hospital mortality, unplanned intensive care admissions, and cardiac arrests on in-patient settings, the use of rapid response teams in the ED is variable with poor integration of care between emergency and specialty/intensive care teams. OBJECTIVES: The aim of this study was to evaluate uptake and impact of a rapid response system on recognising and responding to deteriorating patients in the ED and identify implementation factors and strategies to optimise future implementation success. METHODS: A dual-methods design was used to evaluate an ED Clinical Emergency Response System (EDCERS) protocol implemented at a regional Australian ED in June 2019. A documentation audit was conducted on patients eligible for the EDCERS during the first 3 months of implementation. Quantitative data from documentation audit were used to measure uptake and impact of the protocol on escalation and response to patient deterioration. Facilitators and barriers to the EDCERS uptake were identified via key stakeholder engagement and consultation. An implementation plan was developed using the Behaviour Change Wheel for future implementation. RESULTS: The EDCERS was activated in 42 (53.1%) of 79 eligible patients. The specialty care team were more likely to respond when the EDCERS was activated than when there was no activation ([n = 40, 50.6%] v [n = 26, 32.9%], p = 0.01). Six facilitators and nine barriers to protocol uptake were identified. Twenty behaviour change techniques were selected and informed the development of a theory-informed implementation plan. CONCLUSION: Implementation of the EDCERS protocol resulted in high response rates from specialty and intensive care staff. However, overall uptake of the protocol by emergency staff was poor. This study highlights the importance of understanding facilitators and barriers to uptake prior to implementing a new intervention.

The epidemiology of rapid response team activation amongst patients undergoing major gastrointestinal surgery.

BACKGROUND: Clinical deterioration requiring rapid response team (RRT) review is associated with increased morbidity amongst hospitalised patients. The frequency of and association with RRT calls in patients undergoing major gastrointestinal surgery is unknown. Understanding the epidemiology of RRT calls might identify areas for quality improvement in this cohort. OBJECTIVES: The objective of this study is to identify perioperative risks and outcome associations with RRT review following major gastrointestinal surgery. METHODS: We conducted a retrospective cohort study using electronic databases at a large Australian university hospital. We included adult patients admitted for major gastrointestinal surgery between 1 January 2015 and 31 March 2018. RESULTS: Of 7158 patients, 514 (7.4%) required RRT activation postoperatively. After adjustment, variables associated with RRT activation included the following: hemiplegia/paraplegia (odds ratio [OR]: 8.0, 95% confidence interval [CI]: 2.3 to 27.8, p = 0.001), heart failure (OR: 6.9, 95% CI: 3.3 to 14.6, p < 0.001), peripheral vascular disease (OR: 5.3, 95% CI: 2.7 to 10.4, p < 0.001), peptic ulcer disease (OR: 4.2, 95% CI: 2.2 to 8.0, p < 0.001), chronic obstructive pulmonary disease (OR: 4.0, 95% CI: 2.2 to 7.2, p < 0.001), and emergency admission status (OR: 2.6, 95% CI: 2.1 to 3.3, p < 0.001). Following the index operation, 46% of first RRT activations occurred within 24 h of surgery and 61% had occurred within 48 h. The most common triggers for RRT activation were tachycardia, hypotension, and tachypnoea. Postoperative RRT activation was associated with in-hospital mortality (OR: 6.7, 95% CI: 3.8 to 11.8, p < 0.001), critical care admission (incidence rate ratio: 8.18, 95% CI: 5.23 to 12.77, p < 0.001), and longer median length of hospital stay (12 days vs. 2 days, p < 0.001) compared to no RRT activation. CONCLUSION: After major gastrointestinal surgery, one in 14 patients had an RRT activation, almost half within 24 h of surgery. Such activation was independently associated with increased morbidity and mortality. Identified associations may guide more pre-emptive management for those at an increased risk of RRT activation.

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.

Frequency and nature of medical emergency team afferent limb failure in patients with documented vital sign abnormalities: A retrospective point prevalence study.

BACKGROUND: Medical emergency team (MET) afferent limb failure is the presence of MET triggers and the absence of a documented MET call. OBJECTIVES: The aim of this study was to measure and understand the frequency and nature of MET afferent limb failure in patients with documented vital sign abnormalities in an Australian major teaching hospital. METHODS: A retrospective point prevalence study was conducted at a 600-bed teaching hospital in Melbourne, Australia. Data were collected for all adult inpatients (aged ≥18 years) on 13 wards (three general medicine, three surgical, and seven specialist wards) during a randomly selected 24-h period. Data were extracted from the electronic medical record. RESULTS: There were 357 patients included in the study, with a median age of 72 y. Of the 9716 vital sign measures extracted, 0.9% fulfilled patient-specific MET activation criteria. There were 93 MET triggers documented in 36 patients: 25 patients experienced MET afferent limb failure. The major issues related to MET afferent limb failure were MET trigger modification processes, resolution of vital sign abnormalities, alternative escalation of care, and limitations of medical treatment orders without specific modifications to MET triggers. CONCLUSIONS: Mandating MET activation for one aberrant vital sign at a single point in time warrants further assessment: lack of timely vital sign resolution may be a more appropriate trigger for MET calls and should be formally tested in future research. The frequency and effectiveness of alternative escalation pathways and local management of patients with MET triggers also warrant further investigation.

Pre-medical emergency team activations - Patient characteristics, outcomes and predictors of deterioration.

BACKGROUND: Pre-medical emergency team (MET) calls are an increasingly common tier of Rapid Response Systems, but the epidemiology of patients who trigger a Pre-MET is not well understoof. OBJECTIVES: This study aims to examine the epidemiology and outcomes of patients who trigger a pre-MET activation and identify risk factors for further deterioration. METHODS: This is a retrospective cohort study of pre-MET activations in a university-affiliated metropolitan hospital in Australia, between 13 April 2021 and 4 October 2021. A multivariable regression model was used to identify variables associated with further deterioration, defined as a MET call or Code Blue within 24 h of pre-MET activation. RESULTS: From a total of 39 664 admissions, there were 7823 pre-MET activations (197.2 per 1000 admissions). Compared to inpatients that did not trigger a pre-MET, the patients were older (68.8 vs 53.8 years, p < 0.001), were more likely to be male (51.0 vs 47.6%, p < 0.001), had an emergency admission (70.1% vs 53.3%, p < 0.001), and were under a medical specialty (63.7 vs 54.9%, p < 0.001). They had a longer hospital length of stay (5.6 vs 0.4 d, p < 0.001) and higher in-hospital mortality (3.4% vs 1.0%, p < 0.001). A pre-MET was more likely to progress to a MET call or Code Blue if it was activated for fever, cardiovascular, neurological, renal, or respiratory criteria (p < 0.001), if the patient was under a paediatric team (p = 0.018), or if there had been a MET call or Code Blue prior to the pre-MET activation (p < 0.001). CONCLUSION: Pre-MET activations affect almost 20% of hospital admissions and are associated with a higher risk of mortality. Certain characteristics may predict further deterioration to a MET call or Code Blue, suggesting the potential for early intervention via clinical decision support systems.

The role of the intensive care nurse in the medical emergency team: A constructivist grounded theory study.

BACKGROUND: Intensive care nurses are essential members of rapid response systems (RRSs) with little qualitative data available to capture what intensive care nurses do as they navigate their way around the complexity of a medical emergency call. OBJECTIVE: The study aims to describe and explain the role of the intensive care nurse within the medical emergency team (MET) of a tertiary-level hospital to develop an understanding of the intensive care nurse role, the way it is enacted, and their responsibilities within the team. METHOD: A constructivist grounded theory research approach collected qualitative data from intensive care nurses who had experience attending MET calls. Data were collected through participant observation (16 MET calls), followed by 12 semistructured interviews. FINDINGS: A substantive theory was developed that 'keeping patient's safe' is a fundamental role of the intensive care nurse within the MET. This is derived from four key concepts: Systematic framework for decision making, Figuring it out, Directing care, and Patient safety. Each of these concepts was developed from categories that describe the role of the intensive care unit nurse on the MET. They include performing assessments and interventions, figuring it out, critical thinking, prioritising care, directing care, being supportive, and ensuring patient safety. CONCLUSION: This study provides new insights into and an understanding of the ways intensive care nurses work within the MET, making a significant contribution to our existing understanding of the role.

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.

Antecedents to and outcomes for in-hospital cardiac arrests in Australian hospitals with mature medical emergency teams: A multicentre prospective observational study.

BACKGROUND: The epidemiology and predictability of in-hospital cardiac arrests (IHCAs) in hospitals with established medical emergency teams (METs) is underinvestigated. OBJECTIVES: We categorised IHCAs into three categories: "possible suboptimal end-of-life planning" (possible SELP), "potentially predictable", or "sudden and unexpected" using age, Charlson Comorbidity Index, place of residence, functional independence, along with documented vital signs, K+ and HCO3 in the period prior to the IHCA. We also described the differences in characteristics and outcomes amongst these three categories of IHCAs. METHODS: This was a prospective observational study (1st July 2017 to 9th August 2018) of adult (18 years) IHCA patients in wards of seven Australian hospitals with well-established METs. RESULTS: Amongst 152 IHCA patients, 145 had complete data. The number (%) classified as possible SELP, potentially predictable, and sudden and unexpected IHCA was 50 (34.5%), 52 (35.8%), and 43 (29.7%), respectively. Amongst the 52 potentially predictable patients, six (11.5%) had missing vital signs in the preceding 6 hr, 18 (34.6%) breached MET criteria in the prior 24 hr but received no MET call, and 6 (11.5%) had a MET call but remained on the ward. Abnormal K+ and HCO3 was present in 15 of 51 (29.5%) and 13 of 51 (25.5%) of such patients, respectively. The 43 sudden and unexpected IHCA patients were mostly (97.6%) functionally independent and had the lowest median Charlson Comorbidity Index. In-hospital mortality for IHCAs classified as possible SELP, potentially predictable, and sudden and unexpected was 76.0%, 61.5%, and 44.2%, respectively (p = 0.007). Only four of 12 (33.3%) possible SELP survivors had a good functional outcome. CONCLUSIONS: In seven Australian hospitals with mature METs, only one-third of IHCAs were sudden and unexpected. Improving end-of-life care in elderly comorbid patients and enhancing the response to objective signs of deterioration may further reduce IHCAs in the Australian context.