Clinical Deterioration and Repeat Emergency Team Activation
Clinical Deterioration and Repeat Emergency Team Activation
Objective. To describe the occurrence of recurrent clinical deterioration and repeat medical emergency team activation and assess its effect on processes and outcomes of care.
Design. Retrospective cohort study.
Setting. Two community hospitals and two tertiary care hospitals, Alberta, Canada.
Patients. Consecutive hospitalized adult patients with sudden clinical deterioration and medical emergency team activation without admission to ICU.
Intervention. None.
Measurement and Main Results. We compared ICU admission rates (admissions > 2 hr following index medical emergency team), hospital length of stay, and hospital mortality for a cohort of 3,200 patients with and without recurrent clinical deterioration following medical emergency team activation adjusting for patient, provider, and hospital characteristics.The cohort consisted of 3,200 patients. Ten percent of patients (n = 337) experienced recurrent clinical deterioration and repeat medical emergency team activation during their hospital stay. Patients more likely to experience recurrent clinical deterioration and repeat medical emergency team activation included those with chronic liver disease (odds ratio, 1.75; 95% CI, 1.14–2.69) or who received airway suctioning (odds ratio, 1.66; 95% CI, 1.23–2.25), noninvasive mechanical ventilation (odds ratio, 1.67; 95% CI, 0.94–2.94), or central IV catheter insertion (odds ratio, 1.81; 95% CI, 1.02–3.21) during the index medical emergency team activation. Patients with recurrent clinical deterioration were more likely than patients without recurrent clinical deterioration to be subsequently admitted to ICU (43% vs 13%; odds ratio, 6.11; 95% CI, 4.67–8.00; p < 0.01), to have longer lengths of hospital stay (median, 31 d vs 13 d; p < 0.01), and to die during their hospital stay (34% vs 23%; odds ratio, 1.98; 95% CI, 1.47–2.67; p < 0.01).
Conclusions. Recurrent clinical deterioration and repeat medical emergency team activation are common and associated with increased risk of subsequent ICU admission, increased length of hospital stay, and increased hospital mortality. It may be possible to identify patients at risk of recurrent clinical deterioration following medical emergency team activation and target interventions to improve patient care.
Rapid response systems (RRS) have been developed to improve the safety of hospital care. They are designed to identify patients with sudden clinical deterioration and activate a medical emergency team (MET) to provide rapid evaluation and treatment. The underlying principle is that early intervention in patients with sudden clinical deterioration may improve patient outcomes.
Although the effectiveness of RRS is controversial, they have been promoted by prominent healthcare organizations and broadly implemented. As a result, each day hospitalized patients around the world with sudden clinical deterioration are identified by RRS and receive a "rapid second opinion" and brief intervention from METs. Most of these patients are not admitted to an ICU and remain under the care of their physician on a medical or surgical hospital unit.
There is a relatively small body of literature describing the epidemiology of recurrent clinical deterioration following an initial MET activation. Although these studies are an important contribution, they were conducted in single tertiary care hospitals and reported conflicting outcomes. For these reasons, we identified a multicenter cohort of hospitalized patients with sudden clinical deterioration and MET activation managed without admission to ICU, but whose goals of care designation allowed for ICU-level care (i.e., cohort of patients that received a rapid second opinion and continued with full medical care under their attending physician). Our objective was to describe the occurrence and determinants of recurrent clinical deterioration and repeat MET reactivation (i.e., patients with multiple MET activations) and its effect on outcome.
Abstract and Introduction
Abstract
Objective. To describe the occurrence of recurrent clinical deterioration and repeat medical emergency team activation and assess its effect on processes and outcomes of care.
Design. Retrospective cohort study.
Setting. Two community hospitals and two tertiary care hospitals, Alberta, Canada.
Patients. Consecutive hospitalized adult patients with sudden clinical deterioration and medical emergency team activation without admission to ICU.
Intervention. None.
Measurement and Main Results. We compared ICU admission rates (admissions > 2 hr following index medical emergency team), hospital length of stay, and hospital mortality for a cohort of 3,200 patients with and without recurrent clinical deterioration following medical emergency team activation adjusting for patient, provider, and hospital characteristics.The cohort consisted of 3,200 patients. Ten percent of patients (n = 337) experienced recurrent clinical deterioration and repeat medical emergency team activation during their hospital stay. Patients more likely to experience recurrent clinical deterioration and repeat medical emergency team activation included those with chronic liver disease (odds ratio, 1.75; 95% CI, 1.14–2.69) or who received airway suctioning (odds ratio, 1.66; 95% CI, 1.23–2.25), noninvasive mechanical ventilation (odds ratio, 1.67; 95% CI, 0.94–2.94), or central IV catheter insertion (odds ratio, 1.81; 95% CI, 1.02–3.21) during the index medical emergency team activation. Patients with recurrent clinical deterioration were more likely than patients without recurrent clinical deterioration to be subsequently admitted to ICU (43% vs 13%; odds ratio, 6.11; 95% CI, 4.67–8.00; p < 0.01), to have longer lengths of hospital stay (median, 31 d vs 13 d; p < 0.01), and to die during their hospital stay (34% vs 23%; odds ratio, 1.98; 95% CI, 1.47–2.67; p < 0.01).
Conclusions. Recurrent clinical deterioration and repeat medical emergency team activation are common and associated with increased risk of subsequent ICU admission, increased length of hospital stay, and increased hospital mortality. It may be possible to identify patients at risk of recurrent clinical deterioration following medical emergency team activation and target interventions to improve patient care.
Introduction
Rapid response systems (RRS) have been developed to improve the safety of hospital care. They are designed to identify patients with sudden clinical deterioration and activate a medical emergency team (MET) to provide rapid evaluation and treatment. The underlying principle is that early intervention in patients with sudden clinical deterioration may improve patient outcomes.
Although the effectiveness of RRS is controversial, they have been promoted by prominent healthcare organizations and broadly implemented. As a result, each day hospitalized patients around the world with sudden clinical deterioration are identified by RRS and receive a "rapid second opinion" and brief intervention from METs. Most of these patients are not admitted to an ICU and remain under the care of their physician on a medical or surgical hospital unit.
There is a relatively small body of literature describing the epidemiology of recurrent clinical deterioration following an initial MET activation. Although these studies are an important contribution, they were conducted in single tertiary care hospitals and reported conflicting outcomes. For these reasons, we identified a multicenter cohort of hospitalized patients with sudden clinical deterioration and MET activation managed without admission to ICU, but whose goals of care designation allowed for ICU-level care (i.e., cohort of patients that received a rapid second opinion and continued with full medical care under their attending physician). Our objective was to describe the occurrence and determinants of recurrent clinical deterioration and repeat MET reactivation (i.e., patients with multiple MET activations) and its effect on outcome.
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