Original ArticleAssociations between patient and system characteristics and MET review within 48 h of admission to a teaching hospital: A retrospective cohort study
Introduction
Rapid response systems (RRSs) were developed to support the recognition and response to clinical deterioration, in order to decrease the high mortality associated with adverse events such as in-hospital cardiac arrest and unplanned Intensive Care Unit (ICU) admissions [1]. RRSs are organisation-wide systems and consist of four parts [2]. First, the afferent limb which comprises the recognition of deterioration and activation of the response system; second, a Rapid Response Team (RRT) to respond to deteriorating patients; third, an administration limb consisting of the day-to-day resourcing and management of the RRS; and finally, a governance limb for monitoring and quality improvement of the RRS [2]. In Australia, the most common model of RRT is the Medical Emergency Team (MET) [3,4], an ICU-specialist led response team, summonsed in response to pre-defined single -parameter criteria for recognising clinical deterioration [2,4].
Although the effectiveness of RRSs has been questioned [5,6], in three meta-analyses RRSs were associated with a decrease in in-hospital cardiac arrests and, to a lesser extent, hospital mortality [[7], [8], [9]]. However, the MET is a reactive approach to recognising and responding to clinical deterioration, is resource intensive and often under-funded, and patients reviewed by the MET are at high risk of in-hospital death [[10], [11], [12]]. This reactive approach may also encourage ward-based clinicians to defer care decisions and abdicate responsibility for patient care [6,13].
Earlier recognition of deterioration may further improve patient outcomes [14,15], and experts have recommended that the focus of researchers and clinicians shifts to predicting and preventing clinical deterioration [11,16]. A better understanding of risk factors for clinical deterioration will assist clinicians to identify high-risk patients and enable proactive, informed clinical care decisions to be made before deterioration occurs. MET review records are currently the earliest, reliable, evidence-based indication of clinical deterioration events in acute care patients. Most MET reviews take place within the first 48 h of an admission [17]. Therefore identifying patient and admission characteristics that have important associations with MET review within 48 h and are readily accessible to clinicians at the time of admission, is a first step towards proactive, preventative care for patients at increased risk of clinical deterioration.
The aim of this study was to identify: i) patient demographic characteristics; ii) patient medical characteristics; and iii) factors related to the healthcare system and processes present at the time of admission to hospital that are associated with clinical deterioration in the first 48 h using routinely collected hospital data.
Section snippets
Study design
This was a retrospective cohort study, using routinely collected hospital data for the period January 1 to December 31, 2016.
Ethics approval
Approval was received from the Human Research Ethics Committee at the study site (LNR/16/Austin/562), and Deakin University (2017–041), prior to study commencement. The requirement to obtain consent from participants was waived according to local and national policy regulations.
Setting
The setting was the major acute care campus of a three-campus health network in the northern
Data sources and management
The demographic, clinical and systems data used in this study were routinely collected by Victorian health services as part of the Victorian Admitted Episodes Dataset (VAED) [27]. Healthcare services report these data to the state government to enable service evaluation and funding decisions. Information is initially entered into an individual's health record by clinicians and hospital clerks contemporaneously, then extracted and coded by professional coders following hospital separation.
Results
A total of 22,241 admissions in 15,695 patients meeting the eligibility criteria occurred during the study period. Of these, 12,209 had a single admission in the study period, while 3486 patients had multiple admissions, of which we selected the last admission in the study period.
The mean age at admission was 62.1 years (SD 19.6), and 53.5% were male. Most held a low-income concession card (51.6%) and only 29.6% were privately insured. The majority were born within Australia or New Zealand
Discussion
The aim of this study was to identify patient and admission characteristics that have important associations with clinical deterioration, and are readily accessible to clinicians at the time of admission. The study included 15,695 patients, representative of an acute inpatient population of a tertiary referral hospital. MET review within 48 h of admission was selected as a surrogate outcome indicating clinical deterioration. One in twelve patients received a MET review at any time during their
Conclusions
This was the first study to demonstrate the potential to use information that is readily accessible at the time of admission to predict clinical deterioration. In this single-site cohort study several factors including previous emergency hospital admissions; Charlson Comorbidity Index score; history of chronic cardiac or respiratory illness; and admission diagnosis, time of day, and season were each independently associated with MET review within 48 h. These results enable the development of
Conflicts of interest
There are no competing interests to declare.
Acknowledgements
We gratefully acknowledge the contribution of Ray Robbins in extracting and collating the data used in this study.
References (40)
- et al.
The mortality associated with review by the rapid response team for non-arrest deterioration: a cohort study of acute hospital adult patients
Crit Care Resusc
(2014) - et al.
Critical care clinician perceptions of factors leading to medical emergency team review
Aust Crit Care
(2018) - et al.
Physiological antecedents and ward clinician responses before medical emergency team activation
Crit Care Resusc
(2017) - et al.
Defining clinical deterioration
Resuscitation.
(2013) - et al.
Characteristics and outcomes of patients receiving a medical emergency team review for respiratory distress or hypotension
J Crit Care
(2008) - et al.
The impact of rapid response system on delayed emergency team activation patient characteristics and outcomes--a follow-up study
Resuscitation.
(2010) - et al.
Features and outcome of patients receiving multiple medical emergency team reviews
Resuscitation.
(2010) - et al.
Incidence, staff awareness and mortality of patients at risk on general wards
Resuscitation.
(2008) - et al.
A retrospective cohort study of age-based differences in the care of hospitalized patients with sudden clinical deterioration
J Crit Care
(2015) - et al.
Rapid response systems
Med J Austr
(2014)
Findings of the first consensus conference on medical emergency teams
Crit Care Med
Introduction of medical emergency teams in Australia and New Zealand: a multi-centre study
Criti Care (London, England)
Rapid-response teams
New Engl J Med
Rapid response team implementation and in-hospital mortality*
Crit Care Med
Rapid response system
J Anesth
Rapid response systems: a systematic review and meta-analysis
Crit Care
Effect of rapid response systems on hospital mortality: a systematic review and meta-analysis
Intensive Care Med
Effectiveness of rapid response teams on rates of in-hospital cardiopulmonary arrest and mortality: a systematic review and meta-analysis
J Hosp Med
On RRTs and ANZICS-CORE. resource use, governance and case load of rapid response teams in Australia and New Zealand in 2014
Crit Care Resusc
Clinical deterioration in hospital inpatients: the need for another paradigm shift
Med J Aust
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