Antecedents to cardiac arrests in a hospital equipped with a medical emergency team.

BACKGROUND: Studies conducted before the conception of medical emergency teams (METs) revealed that cardiac arrests were often preceded by deranged vital signs. METs have been implemented in hospitals to review ward patients whose conditions are deteriorating in order to prevent adverse events, including cardiac arrest. Antecedents to cardiac arrests in a MET-equipped hospital have not been assessed. OBJECTIVES: To determine what proportion of patients who had cardiac arrests had documented MET criteria before the arrest, and what proportion had a premorbid status suggesting they were unsuitable resuscitation candidates. DESIGN AND SETTING: Prospective observational study of cardiac arrests at the Austin Hospital, Melbourne, Australia, 1 April - 30 September 2010. Data were obtained from the patients' records and electronic "respond blue" database. MAIN OUTCOME MEASURES: Patients' premorbid medical condition and functional status; prior "not-for-resuscitation" (NFR) order; presence or absence of a MET call before cardiac arrest; time and rhythm of cardiac arrest; and in hospital mortality. RESULTS: 27 patients had a cardiac arrest during the study period, 22 of whom had no prior documented NFR order. Among these 22 patients, 18 (82%) had an initial rhythm of asystole or pulseless electrical activity, and 16 (73%) died in hospital. Fifty per cent of arrests were detected between midnight and 08:00. All six patients classified as unsuitable resuscitation candidates died in hospital, and there were trends for increased age and poorer functional status when compared with suitable candidates. A further six patients had documented MET criteria in the 6 hours before the arrest, but did not receive MET review. CONCLUSIONS: In this 6-month audit, about half the patients with cardiac arrest may have been unsuitable for resuscitation, or had objective warning signs that were not acted on. Further improvements in advanced care planning and optimisation of MET activation may further reduce cardiac arrest calls at our hospital.

Percutaneous versus surgical tracheostomy: A randomized controlled study with long-term follow-up.

OBJECTIVE: To compare the safety, availability, and long-term sequelae of percutaneous vs. surgical tracheostomy. DESIGN: Prospective, randomized, controlled study. SETTING: Combined medical/surgical intensive care unit in a tertiary referral hospital. PATIENTS: Two hundred critically ill mechanically ventilated patients who required tracheostomy. INTERVENTIONS: Tracheostomy by either percutaneous tracheostomy or surgical tracheostomy performed in the intensive care unit. MEASUREMENTS AND MAIN RESULTS: The primary outcome measure was the aggregate incidence of predefined moderate or severe complications. The secondary outcome measures were the incidence of each of the components of the primary outcome. Long-term follow-up included clinical assessment, flow volume loops, and bronchoscopy. Both groups were well matched for age, gender, admission Acute Physiology and Chronic Health Evaluation II score, period of endotracheal intubation, reason for intubation, and admission diagnosis. There was no statistical difference between groups for the primary outcome. Bleeding requiring surgical intervention occurred in three percutaneous tracheostomy patients and in no surgical tracheostomy patient (p = .2). Postoperative infection (p = .044) and cosmetic sequelae (p = .08) were more common in surgical tracheostomy patients. There was a shorter delay from randomization to percutaneous tracheostomy vs. surgical tracheostomy (p = .006). Long-term follow-up revealed no complications in either group. CONCLUSIONS: Both percutaneous tracheostomies and surgical tracheostomies can be safely performed at the bedside by experienced, skilled practitioners.