In-hospital cardiac arrest epidemiology in a mature rapid response system.

An audit examined the epidemiology of in-hospital cardiac arrests 5 years after a rapid response system was introduced, exploring the frequency of arrests in monitored and unmonitored areas. Details of the initial cardiac rhythm and what proportion of events were preceded by a medical emergency team call were also assessed.

The epidemiology of respiratory arrests in a teaching hospital.

AIMS: We aimed to characterise antecedent causes and outcomes of respiratory arrests occurring within a metropolitan tertiary teaching hospital in Melbourne, Australia. METHODS: We conducted a retrospective audit of respiratory arrests within our hospital over a 6-year period. Data were collected regarding patient characteristics, preceding clinical state, presumed causes and outcomes of arrests. We also compared outcomes of respiratory arrests to that of cardiac arrests occurring over the same period. RESULTS: We identified 82 respiratory arrests, occurring at a rate of 0.57/1000 inpatient admissions. Pre-existing respiratory, neurologic and cardiac disease was common, as was multi-morbidity. Preceding clinical instability was evident in 39% of arrests, most commonly elevated respiratory rate or progressive hypoxia. Pulmonary oedema was the most common cause of respiratory arrest followed by aspiration, neurologic events, medication side-effects, and tracheostomy-tube complications. In-hospital mortality for respiratory arrests was 25.1%, compared with 74.9% for cardiac arrests (p<0.001) over the same time period. CONCLUSIONS: Although rare, respiratory arrests are associated with significantly lower in-hospital mortality than cardiac arrests. Further studies are needed to better predict respiratory arrests and identify interventions to reduce incidence and improve outcomes.

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.

The epidemiology and outcome of medical emergency team call patients treated with non-invasive ventilation.

INTRODUCTION: Use of non-invasive ventilation (NIV) is normally limited to the Emergency Department, Intensive Care Unit (ICU), Coronary Care Unit (CCU) or High Dependency Unit (HDU). However, NIV is sometimes used by the Medical Emergency Team (MET) as respiratory support for ward patients. OBJECTIVES: We reviewed the characteristics and outcome of ward patients treated with NIV in the setting of a MET Call and determined the clinical and prognostic significance of such treatment. METHODS: We used our MET database to assess the characteristics and outcome of patients treated with NIV and compared them to a control group of patients with similar MET diagnoses but not treated with NIV. RESULTS: We studied 5389 calls in 3880 patients. NIV was delivered during 483 (9.0%) calls to 426 patients (11% of the total). The four most common MET diagnoses associated with NIV were acute pulmonary edema (156 calls, 32.3%), pneumonia (84 calls, 17.4%), acute respiratory failure of unclear origin (59 calls, 12.2%) and exacerbation of chronic obstructive pulmonary disease (32 calls, 6.6%). Limitations of medical therapy (LOMT) were documented in 151 (35.4%) patients. Among NIV patients without LOMT, 115 (41.8%) were transferred to ICU and 50 (18.2%) to the coronary care or high dependency unit (CCU/HDU) compared with only 50 (18.0%) and 16 (5.8%) respectively in the control group (p<0.001). Overall, 76 NIV patients (27.6%) received endotracheal intubation (ETT) compared with 61 (21.9%) in controls. Mortality was 23.6% in the NIV group versus 18.8% in the control group. CONCLUSION: One in ten MET call patients received NIV. In those without LOMT, two thirds were transferred to ICU/HDU/CCU, one in four received ETT, and one in four died. NIV use at the time of a MET call identified high risk patients for whom admission to ICU/HDU/CCU should be strongly considered.

Features and outcome of patients receiving multiple Medical Emergency Team reviews.

BACKGROUND AND OBJECTIVES: There is no information on the clinical features and outcome of patients receiving multiple Medical Emergency Team (MET) reviews. Accordingly, we studied the characteristics and outcome of patients receiving one MET call and compared them with those receiving multiple MET reviews. DESIGN: Retrospective observational study using prospectively collected data. SETTING: Tertiary hospital. PATIENTS: Cohort of 1664 patients receiving 2237 MET reviews over a 2-year period. MEASUREMENTS AND MAIN RESULTS: We retrieved information about patient demographics, reasons for MET review, procedures performed by the MET and hospital outcome. We found that 1290 (77.5%) patients received a single MET review and 374 (22.5%) received multiple MET reviews (mean 2.5 reviews, median 2.0). Multiple MET reviews were more likely to be in surgical patients (p < 0.001) and to be due to arrhythmias (p = 0.016). Multiple MET review patients were more likely to be admitted for gastrointestinal diseases (p < 0.001), had a 50% longer hospital stay (p < 0.001) and a 34.6% increase in hospital mortality (p < 0.001) compared to single MET review patients. Their odds ratio (OR) for mortality was 2.14 (95% C.I.: 1.62-2.83; p < 0.001). After exclusion of patients with not for resuscitation (NFR) orders, the OR for mortality was 2.92 (95% C.I.: 2.10-4.06; p < 0.001). The in-hospital mortality of patients subject to multiple MET reviews who were not designated NFR was 34.1%, but only 9.7% of these deaths occurred within 48 h of the initial MET review. CONCLUSION: In our hospital, one fifth of patients receiving MET calls are subject to multiple MET calls. Such patients have identifiable features and have an increased risk of morbidity and mortality. Within any rapid response system, such patients should be recognized as a higher risk group and receive specific additional attention.

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.