Abstract & Commentary
Patients with Multiple Medical Emergency Team Calls Are at High Risk for Adverse Outcomes
By David J. Pierson, MD, Editor
SYNOPSIS: In this large observational study in four hospitals with a standardized rapid response system, among patients with an initial team activation who were not immediately transferred to the ICU, those with one or more additional activations during the hospitalization were more likely to need ICU care and had both longer hospital stays and higher mortality.
- SOURCE: Stelfox HT, et al. Characteristics and outcomes for hospitalized patients with recurrent clinical deterioration and repeat medical emergency team activation. Crit Care Med 2014; Mar 25. [Epub ahead of print.]
This retrospective cohort study was carried out at four institutions in Alberta — two tertiary care hospitals and two community hospitals — in which each hospital’s rapid response system (RRS) for ward patients was activated according to criteria standardized for the province’s health care system,1 with data on all such activations recorded prospectively. A medical emergency team (MET) consisting of an intensivist (attending or fellow, or physician extender), a nurse, and a respiratory therapist responded to all activations, which were triggered by criteria-based changes in vital signs or mental status, or if the ward provider was worried about the patient. By policy, during such "emergency second opinions" a decision is made regarding ICU admission within 30 minutes. The investigators examined all MET records for the four hospitals from 2007 through 2009, focusing on patients whose initial MET call did not trigger an ICU admission, and compared those with only an initial such call to those who had one or more subsequent calls. The study’s primary outcome was the need for admission to the ICU following the initial MET call; secondary outcomes were health care resource utilization, ICU and hospital lengths of stay, and in-hospital mortality among patients.
During the 3-year study period, 5008 patients experienced clinical deterioration and MET activation, of whom 26% were admitted to the ICU, 3% died during the consultation, and 7% had the goals of care changed to exclude ICU admission during the initial MET call. Of the remaining 3200 patients, 337 (10.5%) had one or more subsequent MET calls. Compared to patients who had only a single MET call, more of those with multiple calls had chronic liver disease (odds ratio [OR], 1.75; 95% confidence interval [CI], 1.14-2.69), but they were otherwise indistinguishable demographically. Patients with multiple MET calls were more likely to require subsequent ICU admission (43% vs 13%; OR, 6.11; 95% CI, 4.67-8.00; P < 0.01), to have longer hospital lengths of stay (median, 31 vs 13 days; P < 0.01), and to die during the hospitalization (34% vs 23%; OR, 1.98; 95% CI, 1.47-2.67; P < 0.01). During the initial MET call, patients who received airway suctioning, noninvasive ventilation, or placement of a central IV line were more likely to experience subsequent deterioration and MET activation.
While some controversy continues about the benefits of RRSs, their optimal structure and functioning, and their necessity for improved outcomes among acutely hospitalized patients, such systems have been widely implemented in North America. This study, carried out by an experienced group of investigators in the context of a standardized RRS employed throughout a provincial healthcare system,1 is helpful whatever the ultimate verdict on the RRS concept turns out to be. It shows that the need for a second MET call during a given hospitalization — a common occurrence — appears to identify a patient as at greater risk for adverse outcomes as compared to patients whose initial call does not result in ICU admission and who do not trigger a second call.
Further, patients whose initial MET activation includes airway suctioning, the initiation of noninvasive ventilatory support, and/or placement of a central line may be at increased likelihood of subsequently triggering one or more additional MET calls. As Stelfox and colleagues suggest, it may be possible to identify patients at increased risk of recurrent clinical deterioration once a MET activation has occurred. This information may be helpful even in the absence of proof that interventions based on these observational findings can ameliorate the adverse consequences of such risk.
1. Stelfox HT, et al. Intensive care unit bed availability and outcomes for hospitalized patients with sudden deterioration. Arch Intern Med 2012;172:467-474.