The medical emergency team and end-of-life care: a pilot study.

OBJECTIVES: To assess the characteristics of patients who died in a teaching hospital and the role of the medical emergency team (MET) in their end-of-life care. METHODS: This was a retrospective analysis of 105 deaths over the month of May 2005 by a blinded investigator, who documented patient age, parent hospital unit, comorbidities, presence and timing of not-for-resuscitation (NFR) designation, and presence and timing of first MET review. We analysed differences between medical versus surgical patients, NFR versus non-NFR patients, and MET-reviewed versus non-MET-reviewed patients. RESULTS: Of the 105 patients who died, 80 were medical patients and 25 were surgical patients. Five patients were not designated NFR at the time of death, and three of these had antecedent MET criteria in the 24 hours before death. Of the 100 patients who were designated NFR at the time of death, 35 received a MET call during their admission. Of the 35 MET calls, 10 occurred on the same day as the patient's death, and 12 on the same day as the NFR designation. Documentation of NFR status occurred later in the admission for patients who received a MET call than for those who did not receive a MET call (mean +/-SD, 13.3 +/-16.1 versus 5.3 +/-10.8 days after admission; P = 0.003). Hypotension, hypoxia and tachypnoea were the most common MET triggers, and pulmonary oedema, pneumonia and acute coronary syndromes were the most common reasons for the deterioration in the patient's condition. Following the MET review, patients were admitted to the ICU and newly classified as NFR in 15 and nine of the 35 MET calls, respectively. CONCLUSIONS: Most patients who died in our hospital were designated NFR at the time of death. A third of these patients were seen by the MET before death. In about 10% of cases, the MET participated in the decision to designate the patient NFR.

Long-term effect of a Medical Emergency Team on mortality in a teaching hospital.

AIM: To assess the effect of a Medical Emergency Team (MET) service on patient mortality in the 4 years since its introduction into a teaching hospital. METHODS: Using the hospital electronic database we obtained the number of admissions and in-hospital deaths "before-" (September 1998-August 1999), "during education-" (September 1999-August 2000), the "run-in period-" (September 2000-October 2000), and "after-" (November 2000-December 2004) the introduction of a MET service, intended to review and treat acutely unwell ward patients. RESULTS: There were 42,230 surgical and 112,321 medical admissions over the study period. During the education period for the MET the odds ratio (OR) of death for surgical patients was 0.82 compared to the "before" MET period (95% CI 0.67-1.00; p=0.055). During the 2 month "run-in" period it remained statistically unchanged at 1.01 (95% CI 0.67-1.51; p=0.33). In the 4 years "after" introduction of the MET, the OR of death for surgical patients remained lower than the "before" MET period (multiple chi(2)-test p=0.0174). There were 1252 surgical MET calls, and in December 2004 the ratio of surgical MET calls to surgical deaths was 1.76:1. In contrast, in-hospital deaths for medical patients increased during the "education period", the "run-in" period and into the first year "after" the introduction of the MET (multiple chi(2)-test p<0.0001). There were 1278 medical MET calls, and in December 2004 the ratio of medical MET calls to medical deaths was 1:2.47 (0.41:1). For each 12-month period, the relative risk of death for medical patients as opposed to surgical patients ranged between 1.32 and 2.40. CONCLUSIONS: Introduction of an Intensive Care-based MET in a university teaching hospital was associated with a fluctuating reduction in post-operative surgical mortality which was already apparent during the education phase, but a sustained increase in the mortality of medical patients which was similarly already apparent during the education phase. The differential effects on mortality may relate to differences in the degree of disease complexity and reversibility between medical and surgical patients.

Medical emergency team syndromes and an approach to their management.

INTRODUCTION: Most literature on the medical emergency team (MET) relates to its effects on patient outcome. Less information exists on the most common causes of MET calls or on possible approaches to their management. METHODS: We reviewed the calling criteria and clinical causes of 400 MET calls in a teaching hospital. We propose a set of minimum standards for managing a MET review and developed an approach for managing common problems encountered during MET calls. RESULTS: The underlying reasons for initiating MET calls were hypoxia (41%), hypotension (28%), altered conscious state (23%), tachycardia (19%), increased respiratory rate (14%) and oliguria (8%). Infection, pulmonary oedema, and arrhythmias featured as prominent causes of all triggers for MET calls. The proposed minimum requirements for managing a MET review included determining the cause of the deterioration, documenting the events surrounding the MET, establishing a medical plan and ongoing medical follow-up, and discussing the case with the intensivist if certain criteria were fulfilled. A systematic approach to managing episodes of MET review was developed based on the acronym 'A to G': ask and assess; begin basic investigations and resuscitation, call for help if needed, discuss, decide, and document, explain aetiology and management, follow-up, and graciously thank staff. This approach was then adapted to provide a management plan for episodes of tachycardia, hypotension, hypoxia and dyspnoea, reduced urinary output, and altered conscious state. CONCLUSION: A suggested approach permits audit and standardization of the management of MET calls and provides an educational framework for the management of acutely unwell ward patients. Further evaluation and validation of the approach are required.