Clinical Deterioration and Repeat Emergency Team Activation
Clinical Deterioration and Repeat Emergency Team Activation
We asked four specific study questions regarding the epidemiology of patients with recurrent clinical deterioration and repeat MET activation.
We identified consecutive adult patients (excluding cardiac surgery and coronary care units as some of these units are not serviced by METs) admitted to four hospitals (two tertiary academic, two community) in Alberta, Canada, with sudden clinical deteriorations identified by the RRS and triggering a MET activation from January 1, 2007, to December 31, 2009. Patients were eligible for inclusion if they were not admitted to an ICU within 2 hours of the MET activation (local policy is to decide on patient disposition within 30 minutes of MET arrival) and their goals of care designation (i.e., resuscitative care vs medical care vs comfort care) upon completion of the MET activation allowed for ICU-level care (i.e., resuscitative care). Cardiac arrest activations (separate activation) and planned MET follow-up visits (e.g., scheduled MET follow-up of patients discharged from ICU) were not included. The cohort was purposefully defined to comprise patients who had experienced a sudden clinical deterioration triggering an initial MET activation and were managed on a hospital ward and left under the care of their admitting physician with goals of care designations that allowed for ICU-level care.
The four study hospitals were managed by Alberta Health Services and included Foothills Medical Centre (tertiary care hospital with 1,088 hospital beds, [almost equal to] 42,000 annual admissions, and 25 medical-surgical ICU beds), University of Alberta Hospital (tertiary care hospital with 650 beds, [almost equal to] 30,000 annual admissions, and 30 medical-surgical ICU beds), Rockyview General Hospital (community hospital with 616 beds, [almost equal to] 33,000 annual admissions, and 10 medical-surgical ICU beds), and Peter Lougheed Centre (community hospital with 577 beds, [almost equal to] 30,000 annual admissions, and 18 medical-surgical ICU beds). Each hospital's MET comprised an ICU physician (attending, fellow, resident, or physician extender), nurse, and respiratory therapist, and it provided services 24 hours per day 7 days per week. The Alberta Health Services RRS employs criteria based on respiratory status, heart rate, blood pressure, mental status changes, or provider "worried" to trigger MET activation. Physicians make management decisions for patients with MET activation (including patient disposition) on a case-by-case basis without a guideline, protocol, or decision-making support.
We used data from Alberta Health Services clinical and administrative databases that have previously been successfully used for program evaluation and research. The MET databases capture reason for assessment, vital signs, diagnostic and therapeutic interventions, and patient disposition, with data acquired at the time of patient assessment. The ICU databases are electronic patient information systems that capture demographic, clinical, and outcome data for all patients admitted to ICU. Alberta Health Services administrative databases capture data on all hospitalized patients, including vital status at discharge, dates of admission and discharge, up to 25 International Classification of Diseases, 10th Edition (ICD-10), diagnostic codes, and up to 20 Canadian Classification of Health Interventions procedure codes.
We identified patient, provider, and institutional factors that may impact processes and outcomes of care for patients with clinical deterioration and MET activation. Patient factors included demographic variables, comorbid conditions, and reason for MET activation. Presence of comorbid conditions was derived using the Deyo classification of Charlson comorbidities and validated ICD-10, coding algorithms (summarized as a single comorbidity score for multivariable analyses). Physician factors included whether an ICU attending physician was present at the MET activation. Hospital factors included ICU occupancy (percentage of ICU beds occupied), the day of the week (weekday [Monday 08:00 to Friday 17:00] vs weekend [Friday 17:01 to Monday 07:59]), and time of day (daytime [08:00 to 17:00] vs night time [17:01 to 07:59]) of the MET activation.
The primary outcome was admission to ICU during the remainder of hospitalization, defined as more than 2 hours following initial MET activation, but prior to hospital discharge. We examined three secondary outcome measures: 1) use of healthcare resources, evaluated by investigations and interventions performed during MET activation, 2) ICU and hospital length of stays, and 3) in-hospital mortality.
The strategy for the primary analysis was to answer each of the four study questions. The unit of analysis was MET activation. We adjusted for patient, physician, and hospital covariates (all baseline variables measured at the time of the initial MET) when analyzing outcome measures. We selected a generalized estimating equations model as it is an extension of standard logistic regression which adjusts for correlation among observations (i.e., patients with more than one hospitalization with a MET activation during the study period and patients clustered within hospitals) and provides "population-average" effect (average response for observations sharing the same covariates) that has familiar interpretation and is more useful when estimating effects at a population level. Statistical analyses were performed with the SAS system (SAS version 9.2; SAS Institute, Cary, NC), and a two-sided p value of less than 0.05 was considered significant. The Health Research Ethics Boards at the University of Calgary and University of Alberta approved this study and waived the need for informed consent from patients and physicians.
Materials and Methods
Study Questions
We asked four specific study questions regarding the epidemiology of patients with recurrent clinical deterioration and repeat MET activation.
What is the incidence of recurrent clinical deterioration and repeat MET activation?
Do patients with recurrent clinical deterioration and repeat MET activation receive similar healthcare resources as patients with a single MET activation?
Do patients with recurrent clinical deterioration and repeat MET activation have similar outcomes of care as patients with a single MET activation?
What patient, provider, and hospital characteristics are associated with recurrent clinical deterioration and repeat MET activation?
Study Cohort
We identified consecutive adult patients (excluding cardiac surgery and coronary care units as some of these units are not serviced by METs) admitted to four hospitals (two tertiary academic, two community) in Alberta, Canada, with sudden clinical deteriorations identified by the RRS and triggering a MET activation from January 1, 2007, to December 31, 2009. Patients were eligible for inclusion if they were not admitted to an ICU within 2 hours of the MET activation (local policy is to decide on patient disposition within 30 minutes of MET arrival) and their goals of care designation (i.e., resuscitative care vs medical care vs comfort care) upon completion of the MET activation allowed for ICU-level care (i.e., resuscitative care). Cardiac arrest activations (separate activation) and planned MET follow-up visits (e.g., scheduled MET follow-up of patients discharged from ICU) were not included. The cohort was purposefully defined to comprise patients who had experienced a sudden clinical deterioration triggering an initial MET activation and were managed on a hospital ward and left under the care of their admitting physician with goals of care designations that allowed for ICU-level care.
The four study hospitals were managed by Alberta Health Services and included Foothills Medical Centre (tertiary care hospital with 1,088 hospital beds, [almost equal to] 42,000 annual admissions, and 25 medical-surgical ICU beds), University of Alberta Hospital (tertiary care hospital with 650 beds, [almost equal to] 30,000 annual admissions, and 30 medical-surgical ICU beds), Rockyview General Hospital (community hospital with 616 beds, [almost equal to] 33,000 annual admissions, and 10 medical-surgical ICU beds), and Peter Lougheed Centre (community hospital with 577 beds, [almost equal to] 30,000 annual admissions, and 18 medical-surgical ICU beds). Each hospital's MET comprised an ICU physician (attending, fellow, resident, or physician extender), nurse, and respiratory therapist, and it provided services 24 hours per day 7 days per week. The Alberta Health Services RRS employs criteria based on respiratory status, heart rate, blood pressure, mental status changes, or provider "worried" to trigger MET activation. Physicians make management decisions for patients with MET activation (including patient disposition) on a case-by-case basis without a guideline, protocol, or decision-making support.
Sources of Data
We used data from Alberta Health Services clinical and administrative databases that have previously been successfully used for program evaluation and research. The MET databases capture reason for assessment, vital signs, diagnostic and therapeutic interventions, and patient disposition, with data acquired at the time of patient assessment. The ICU databases are electronic patient information systems that capture demographic, clinical, and outcome data for all patients admitted to ICU. Alberta Health Services administrative databases capture data on all hospitalized patients, including vital status at discharge, dates of admission and discharge, up to 25 International Classification of Diseases, 10th Edition (ICD-10), diagnostic codes, and up to 20 Canadian Classification of Health Interventions procedure codes.
Patient, Physician, and Hospital Factors
We identified patient, provider, and institutional factors that may impact processes and outcomes of care for patients with clinical deterioration and MET activation. Patient factors included demographic variables, comorbid conditions, and reason for MET activation. Presence of comorbid conditions was derived using the Deyo classification of Charlson comorbidities and validated ICD-10, coding algorithms (summarized as a single comorbidity score for multivariable analyses). Physician factors included whether an ICU attending physician was present at the MET activation. Hospital factors included ICU occupancy (percentage of ICU beds occupied), the day of the week (weekday [Monday 08:00 to Friday 17:00] vs weekend [Friday 17:01 to Monday 07:59]), and time of day (daytime [08:00 to 17:00] vs night time [17:01 to 07:59]) of the MET activation.
Process and Outcome Measures
The primary outcome was admission to ICU during the remainder of hospitalization, defined as more than 2 hours following initial MET activation, but prior to hospital discharge. We examined three secondary outcome measures: 1) use of healthcare resources, evaluated by investigations and interventions performed during MET activation, 2) ICU and hospital length of stays, and 3) in-hospital mortality.
Statistical Analysis
The strategy for the primary analysis was to answer each of the four study questions. The unit of analysis was MET activation. We adjusted for patient, physician, and hospital covariates (all baseline variables measured at the time of the initial MET) when analyzing outcome measures. We selected a generalized estimating equations model as it is an extension of standard logistic regression which adjusts for correlation among observations (i.e., patients with more than one hospitalization with a MET activation during the study period and patients clustered within hospitals) and provides "population-average" effect (average response for observations sharing the same covariates) that has familiar interpretation and is more useful when estimating effects at a population level. Statistical analyses were performed with the SAS system (SAS version 9.2; SAS Institute, Cary, NC), and a two-sided p value of less than 0.05 was considered significant. The Health Research Ethics Boards at the University of Calgary and University of Alberta approved this study and waived the need for informed consent from patients and physicians.
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