Predictors of Repeat Medical Emergency Team Activation in Deteriorating Ward Patients: A Retrospective Cohort Study.

Recurrent clinical deterioration and repeat medical emergency team (MET) activation are common and associated with high in-hospital mortality. This study assessed the predictors for repeat MET activation in deteriorating patients admitted to a general ward. We retrospectively analyzed the data of 5512 consecutive deteriorating hospitalized adult patients who required MET activation in the general ward. The patients were divided into two groups according to repeat MET activation. Multivariate logistic regression analyses were used to identify the predictors for repeat MET activation. Hematological malignancies (odds ratio, 2.07; 95% confidence interval, 1.54-2.79) and chronic lung disease (1.49; 1.07-2.06) were associated with a high risk of repeat MET activation. Among the causes for MET activation, respiratory distress (1.76; 1.19-2.60) increased the risk of repeat MET activation. A low oxygen saturation-to-fraction of inspired oxygen ratio (0.97; 0.95-0.98), high-flow nasal cannula oxygenation (4.52; 3.56-5.74), airway suctioning (4.63; 3.59-5.98), noninvasive mechanical ventilation (1.52; 1.07-2.68), and vasopressor support (1.76; 1.22-2.54) at first MET activation increased the risk of repeat MET activation. The risk factors identified in this study may be useful to identify patients at risk of repeat MET activation at the first MET activation. This would allow the classification of high-risk patients and the application of aggressive interventions to improve outcomes.

Impact of hospitalization duration before medical emergency team activation: A retrospective cohort study.

BACKGROUND: The rapid response system has been implemented in many hospitals worldwide and, reportedly, the timing of medical emergency team (MET) attendance in relation to the duration of hospitalization is associated with the mortality of MET patients. We evaluated the relationship between duration of hospitalization before MET activation and patient mortality. We compared cases of MET activation for early, intermediate, and late deterioration to patient characteristics, activation characteristics, and patient outcomes. We also aimed to determine the relationship, after adjusting for confounders, between the duration of hospitalization before MET activation and patient mortality. MATERIALS AND METHODS: We retrospectively evaluated patients who triggered MET activation in general wards from March 2009 to February 2015 at the Asan Medical Center in Seoul. Patients were categorized as those with early deterioration (less than 2 days after admission), intermediate deterioration (2-7 days after admission), and late deterioration (more than 7 days after admission) and compared them to patient characteristics, activation characteristics, and patient outcomes. RESULTS: Overall, 7114 patients were included. Of these, 1793 (25.2%) showed early deterioration, 2113 (29.7%) showed intermediate deterioration, and 3208 (45.1%) showed late deterioration. Etiologies of MET activation were similar among these groups. The clinical outcomes significantly differed among the groups (intensive care unit transfer: 34.1%, 35.6%, and 40.4%; p < 0.001 and mortality: 26.3%, 31.5%, and 41.2%; p < 0.001 for early, intermediate, and late deterioration, respectively). Compared with early deterioration and adjusted for confounders, the odds ratio of mortality for late deterioration was 1.68 (1.46-1.93). CONCLUSIONS: Nearly 50% of the acute clinically-deteriorating patients who activated the MET had been hospitalized for more than 7 days. Furthermore, they presented with higher rates of mortality and ICU transfer than patients admitted for less than 7 days before MET activation and had mortality as an independent risk factor.

Predictive powers of the Modified Early Warning Score and the National Early Warning Score in general ward patients who activated the medical emergency team.

BACKGROUND: The current early warning scores may be insufficient for medical emergency teams (METs) to use in assessing the severity and the prognosis of activated patients. We evaluated the predictive powers of the Modified Early Warning Score (MEWS) and the National Early Warning Score (NEWS) for 28-day mortality and to analyze predictors of 28-day mortality in general ward patients who activate the MET. METHODS: Adult general ward inpatients who activated the MET in a tertiary referral teaching hospital between March 2009 and December 2016 were included. The demographic and clinical characteristics and physiologic parameters at the time of MET activation were collected, and MEWS and NEWS were calculated. RESULTS: A total of 6,729 MET activation events were analyzed. Patients who died within 28 days were younger (mean age 60 vs 62 years), were more likely to have malignancy (72% vs 53%), were more likely to be admitted to the medical department rather than the surgical department (93% vs 80%), had longer intervals from admission to MET activation (median, 7 vs 5 days), and were less likely to activate the MET during nighttime hours (5 PM to 8 AM) (61% vs 66%) compared with those who did not die within 28 days (P < 0.001 for all comparisons). The areas under the receiver operating characteristic curves of MEWS and NEWS for 28-day mortality were 0.58 (95% CI, 0.56-0.59) and 0.60 (95% CI, 0.59-0.62), which were inferior to that of the logistics regression model (0.73; 95% CI, 0.72-0.74; P < 0.001 for both comparisons). CONCLUSIONS: Both the MEWS and NEWS had poor predictive powers for 28-day mortality in patients who activated the MET. A new scoring system is needed to stratify the severity and prognosis of patients who activated the MET.

A risk scoring model based on vital signs and laboratory data predicting transfer to the intensive care unit of patients admitted to gastroenterology wards.

PURPOSE: To compare the ability of a score based on vital signs and laboratory data with that of the modified early warning score (MEWS) to predict ICU transfer of patients with gastrointestinal disorders. MATERIALS AND METHODS: Consecutive events triggering medical emergency team activation in adult patients admitted to the gastroenterology wards of the Asan Medical Center were reviewed. Binary logistic regression was used to identify factors predicting transfer to the ICU. Gastrointestinal early warning score (EWS-GI) was calculated as the sum of simplified regression weights (SRW). RESULTS: Of the 1219 included patients, 468 (38%) were transferred to the ICU. Multivariate analysis identified heart rate≥105bpm (SRW 1), respiratory rate≥26bpm (SRW 2), ACDU (Alert, Confused, Drowsy, Unresponsive) score≥1 (SRW 2), SpO2/FiO2 ratio<240 (SRW 2), creatinine ≥2.0mg/dL (SRW 2), total bilirubin ≥9.0mg/dL (SRW 2), prothrombin time/international normalized ratio (INR) ≥1.5 (SRW 2), and lactate ≥3.0mmol/L (SRW 2) for inclusion in EWS-GI. The area under the receiver operating characteristic curve of the EWS-GI was larger than that of MEWS (0.76 vs. 0.64; P<0.001). CONCLUSIONS: EWS-GI may predict ICU transfer among patients admitted to gastroenterology wards. The EWS-GI should be prospectively validated.

A combination of early warning score and lactate to predict intensive care unit transfer of inpatients with severe sepsis/septic shock.

BACKGROUND/AIMS: The modified early warning score (MEWS) is used to predict patient intensive care unit (ICU) admission and mortality. Lactate (LA) in the blood lactate (BLA) is measured to evaluate disease severity and treatment efficacy in patients with severe sepsis/septic shock. The usefulness of a combination of MEWS and BLA to predict ICU transfer in severe sepsis/septic shock patients is unclear. We evaluated whether use of a combination of MEWS and BLA enhances prediction of ICU transfer and mortality in hospitalized patients with severe sepsis/septic shock. METHODS: Patients with severe sepsis/septic shock who were screened or contacted by a medical emergency team between January 2012 and August 2012 were enrolled at a university-affiliated hospital with ~2,700 beds, including 28 medical ICU beds. RESULTS: One hundred patients were enrolled and the rate of ICU admittance was 38%. MEWS (7.37 vs. 4.85) and BLA concentration (5 mmol/L vs. 2.19 mmol/L) were significantly higher in patients transferred to ICU than those in patients treated in general wards. The combination of MEWS and BLA was more accurate than MEWS alone in terms of ICU transfer (C-statistics: 0.898 vs. 0.816, p = 0.019). The 28-day mortality rate was 19%. MEWS was the only factor significantly associated with 28-day mortality rate (odds ratio, 1.462; 95% confidence interval, 1.122 to 1.905; p = 0.005). CONCLUSIONS: The combination of MEWS and BLA may enhance prediction of ICU transfer in patients with severe sepsis/septic shock.

Activation of a medical emergency team using an electronic medical recording-based screening system*.

OBJECTIVES: To evaluate the efficacy of a medical emergency team activated using 24-hour monitoring by electronic medical record-based screening criteria followed by immediate intervention by a skilled team. DESIGN: Retrospective cohort study. SETTING: Academic tertiary care hospital with approximately 2,700 beds. PATIENTS: A total of 3,030 events activated by a medical emergency team from March 1, 2008, to February 28, 2010. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: We collected data for all medical emergency team activations: patient characteristics, trigger type for medical emergency team (electronic medical record-based screening vs calling criteria), interventions during each event, outcomes of the medical emergency team intervention, and 28-day mortality after medical emergency team activation. We analyzed data for 2009, when the medical emergency team functioned 24 hours a day, 7 days a week (period 2), compared with that for 2008, when the medical emergency team functioned 12 hours a day, 7 days a week (period 1). The commonest cause of medical emergency team activation was respiratory distress (43.6%), and the medical emergency team performed early goal-directed therapy (21.3%), respiratory care (19.9%), and difficult airway management (12.3%). For patients on general wards, 51.3% (period 1) and 38.4% (period 2) of medical emergency team activations were triggered by the electronic medical record-based screening system (electronic medical record-triggered group). In 23.4%, activation occurred because of an abnormality in laboratory screening criteria. The commonest activation criterion from electronic medical record-based screening was respiratory rate (39.4%). Over half the patients were treated in the general ward, and one third of the patients were transferred to the ICU. The electronic medical record-triggered group had lower ICU admission with an odds ratio of 0.35 (95% CI, 0.22-0.55). In surgical patients, the electronic medical record-triggered group showed the lower 28-day mortality (10.5%) compared with the call-triggered group (26.7%) or the double-triggered group (33.3%) (odds ratio 0.365 with 95% CI, 0.154-0.867, p = 0.022). CONCLUSIONS: We successful managed the medical emergency team with electronic medical record-based screening criteria and a skilled intervention team. The electronic medical record-triggered group had lower ICU admission than the call-triggered group or the double-triggered group. In surgical patients, the electronic medical record-triggered group showed better outcome than other groups.