Advertisement

The objective medical emergency team activation criteria: A case–control study

      Summary

      Objective

      To evaluate the ability of pre-defined clinical criteria to identify patients who subsequently suffer cardiac arrest, unplanned intensive care unit admission or unexpected death; to determine the ability of modified criteria to identify these patients.

      Design

      Nested, matched case–control study.

      Setting

      Seven Australian public hospitals.

      Patients and participants

      Four hundred and fifty cases and 520 controls matched for age, sex, hospital, and hospital ward.

      Interventions

      None.

      Measurements and results

      Highest and lowest respiratory and heart rates, lowest systolic blood pressure, presence of threatened airway, seizures or decrease in Glasgow Coma Scale score of greater than two points and incidence of the three adverse events were measured. Combining a heart rate greater than 140, respiratory rate greater than 36, a systolic blood pressure less than 90 mmHg and a greater than two point reduction in the Glasgow Coma Scale identified adverse events with a sensitivity of 49.1% (44.4–53.8%), specificity of 93.7% (91.2–95.6%), and positive predictive value of 9.8% (8.7–11.1%). Adding threatened airway, seizures, low respiratory rate and low heart rate did not substantially improve sensitivity (50.4%; 45.7–55.2%). After modifying the cut-off values for respiratory rate, heart rate and systolic blood pressure, the best achievable positive predictive value remained below 16%.

      Conclusions

      In combination, the respiratory rate, heart rate, systolic blood pressure, and level of consciousness identify patients at risk of cardiac arrest, unplanned intensive care admission or unexpected death with high specificity; however the sensitivity and positive predictive value are relatively low, even after modification of the activation criteria cut-off values.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Resuscitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Brennan T.A.
        • Leape L.L.
        • Laird N.M.
        • Hebert L.
        • Localio A.R.
        • Lawthers A.G.
        Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard Medical Practice Study I.
        N Engl J Med. 1991; 324: 370-376
        • Wilson R.M.
        • Runciman W.B.
        • Gibberd R.W.
        • Harrison B.T.
        • Newby L.
        • Hamilton J.D.
        The quality in Australian Health Care Study.
        Med J Aust. 1995; 163: 458-471
        • Leape L.L.
        • Berwick D.M.
        Five years after to Err is human: what have we learned?.
        JAMA. 2005; 293: 2384-2390
        • Baker G.R.
        • Norton P.G.
        • Flintoft V.
        • et al.
        The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada.
        CMAJ. 2004; 170: 1678-1686
      1. Institute of Medicine. To Err is human: building a safer health system: Committee on Quality of Health Care in America. Washington DC: National Academies Press; 1999.

        • McGloin H.
        • Adam S.K.
        • Singer M.
        Unexpected deaths and referrals to intensive care of patients on general wards. Are some cases potentially avoidable?.
        J R Coll Phys Lond. 1999; 33: 255-259
        • Hodgetts T.J.
        • Kenward G.
        • Vlachonikalis I.
        • et al.
        Incidence, location and reasons for avoidable in-hospital cardiac arrest in a district general hospital.
        Resuscitation. 2002; 54: 115-123
        • Peberdy M.
        • Kaye W.
        • Ornato J.
        • et al.
        Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation.
        Resuscitation. 2003; 58: 297-308
        • Gwinnutt C.
        • Columb M.
        • Harris R.
        Outcome after cardiac arrest in adults in UK hospitals: effect of the 1997 guidelines.
        Resuscitation. 2000; 47: 125-135
        • Goldhill D.R.
        • Sumner A.
        Outcome of intensive care patients in a group of British intensive care units.
        Crit Care Med. 1998; 26: 1337-1345
        • Buist M.D.
        • Jarmolowski E.
        • Burton P.R.
        • Bernard S.A.
        • Waxman B.P.
        • Anderson J.N.
        Recognising clinical instability in hospital patients before cardiac arrest or unplanned admission to intensive care: a pilot study in a tertiary hospital.
        Med J Aust. 1999; 171: 22-25
        • Parkhe M.
        • Myles P.S.
        • Leach D.S.
        • Maclean A.V.
        Outcome of emergency department patients with delayed admission to an Intensive Care Unit.
        Emergency Med. 2002; 14: 50-57
        • Goldhill D.R.
        • White S.A.
        • Sumner A.
        Physiological values and procedures in the 24 h before ICU admission from the ward.
        Anaesthesia. 1999; 45: 529-534
        • Lee A.
        • Bishop G.
        • Hillman K.
        • Daffurn K.
        The Medical Emergency Team.
        Anaesth Intens Care. 1995; 23: 183-186
      2. Institute for Healthcare Improvement. 100 K lives campaign; 2005.

      3. Department of Health and National Health Service Modernization Agency. Critical Care Outreach: progress in developing services. The National Outreach Report. London: Department of Health (UK); 2003. Available at www.modern.nhs.uk/criticalcare/5021/7117/78001-DoH-CareOutreach.pdf.

      4. Canadian Patient Safety Institute. Safer healthcare now!; 2005.

        • The Merit study investigators
        Introduction of the Medical Emergency Team (MET) system: a cluster randomised controlled trial.
        Lancet. 2005; 365: 2091-2097
        • Hodgetts T.J.
        • Kenward G.
        • Vlachonikalis I.G.
        • Payne S.
        • Castle N.
        The identification of risk factors for cardiac arrest and formulation of activation criteria to alert a medical emergency team.
        Resuscitation. 2002; 54: 125-131
        • Schein R.M.
        • Hazday N.
        • Pena M.
        • Ruben B.H.
        • Sprung C.L.
        Clinical antecedents to in-hospital cardiopulmonary arrest.
        Chest. 1990; 98: 1388-1392
        • Buist M.
        • Bernard S.
        • Nguyen T.V.
        • Moore G.
        • Anderson J.
        Association between clinically abnormal observations and subsequent in-hospital mortality: a prospective study.
        Resuscitation. 2004; 62: 137-141
        • Fieselmann J.F.
        • Hendryx M.S.
        • Helms C.M.
        • Wakefield D.S.
        Respiratory rate predicts cardiopulmonary arrest for internal medicine patients.
        J Gen Intern Med. 1993; 8: 354-360
        • Goldhill D.R.
        • McNarry A.F.
        Physiological abnormalities in early warning scores are related to mortality in adult inpatients.
        Br J Anaesth. 2004; 92: 882-884
        • Bellomo R.
        • Goldsmith D.
        • Uchino S.
        • et al.
        A prospective before-and-after trial of a medical emergency team.
        Med J Aust. 2003; 179: 283-287
        • Subbe C.P.
        • Kruger M.
        • Rutherford P.
        • Gemmel L.
        Validation of a modified Early Warning Score in medical admissions.
        QJM. 2001; 94: 521-526
        • Prasad V.
        • Morgan R.J.M.
        Pre-emptive care on acute surgical wards—early warning scoring.
        Cpd Anaesth. 2002; 4: 56-60
        • Wright M.M.
        • Stenhouse C.W.
        • Morgan R.J.M.
        Early detection of patients at risk (PART).
        Anaesthesia. 2000; 55: 391-392
        • Goldhill D.R.
        The critically ill: following your MEWS.
        Q J Med. 2001; 94: 507-510
      5. Stata Corporation. Stata base reference manual: release 8. College Station, Texas: Stata Press; 2003.

      6. StataCorp. Stata statistical software: release 8.2. College Station, Texas: Stata Corporation; 2003.

        • Parr M.J.A.
        • Hadfield J.H.
        • Flabouris A.
        • Bishop G.
        • Hillman K.
        The Medical Emergency Team: 12 month analysis of reasons for activation, immediate outcome and not-for-resuscitation orders.
        Resuscitation. 2001; 50: 39-44
        • Husum H.
        • Gilbert M.
        • Wisborg T.
        • Van Heng Y.
        • Murad M.
        Respiratory rate as a prehospital triage tool in rural trauma.
        J Trauma. 2003; 55: 466-470
        • Goldhill D.
        Medical Emergency Teams.
        Care Crit Ill. 2000; 16: 209-212
        • Smith A.F.
        • Wood J.
        Can some in-hospital cardio-respiratory arrests be prevented? A prospective survey.
        Resuscitation. 1998; 37: 133-137
        • McNarry A.F.
        • Goldhill D.R.
        Simple bedside assessment of level of consciousness: comparison of two simple assessment scales with the Glasgow Coma scale*.
        Anaesthesia. 2004; 59: 34-37