An Observational Analysis of Medication Use During 5,727 Medical Emergency Team Activations at a Tertiary Referral Hospital

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Background

Medical emergency teams (METs) rescue deteriorating patients as the response arm of hospital rapid response systems. This study aimed to (1) investigate medication use during MET activations by describing the type, frequency and access sources of medications; and (2) assess associations between patient characteristics, MET activation criteria, and outcomes and MET medication use.

Methods

A single-center, retrospective study from a prospective database of MET activations in an Australian tertiary referral hospital was undertaken. Consecutive adult MET activations over a 12-month period were included.

Results

Across the study period, there were 5,727 MET activations with medications used at 33.5% (n = 1,920). Of 2,648 medications used, cardiac system agents (n = 944; 35.6%) were the most common category used, while intravenous electrolytes (n = 341; 12.9%) and opioid analgesics (n = 248; 9.4%).were the most frequently used medications. Most commonly, medications were sourced from ward stocks. High blood pressure, heart or respiratory rate, pain, and multiple activation criteria were associated with MET medication use (p < 0.001). Patients who required medications were less likely to remain on the ward, and immediate admission to the ICU was approximately doubled (odds ratio = 1.90; 95% confidence interval = 1.47–2.45).

Conclusion

Medication use by the MET was common and associated with escalation to intensive care. A wide variety of medications, principally from ward stocks, were used with some predictability based on activation criteria. Local system improvements have demonstrated that by focusing on common MET syndromes and medications, further investigation can refine and improve medication use and management systems for deteriorating patients.

Section snippets

Ethical Considerations

This study received human research ethical approval from the Alfred Hospital Ethics Committee (approval number 240/15) and Monash University Human Research Ethics Committee (CF153762 2015001634). A waiver of participant consent was granted.

Setting

The Alfred is a 500-bed university-affiliated tertiary referral hospital in Melbourne providing a comprehensive range of adult specialist medical, surgical, and mental health services. A mature two-tier RRS was activated by single-parameter derangement as

All MET Activations and Patients

During the study period, there were 64,625 same day and multiday admissions and 5,735 MET activations, which equated to 89 MET activations per 1,000 admissions. After application of exclusion criteria, there were 5,727 MET activations involving 2,955 patients available for analysis (Figure 1). Repeat MET activations for the same patient during the study period were common (42.8%; median = 1; range = 1–29). There were 3,277 first activations, 1,226 second, 532 third, and 692 fourth or greater

Principle Findings

In this single-center study we found that medications were used at one third of 5,727 consecutive MET activations. Cardiac therapies, electrolytes, and analgesics were administered most frequently. Most medications used during MET activations were accessed from ward stocks. MET activation criteria, including high blood pressure, heart rate, respiratory rate, and uncontrolled pain, rather than demographics or repeated activations, would appear to be indicative of predicting the need for and type

Conclusion

Medication use and access during MET activations were common and heterogeneous. This understanding resulted in local initiatives to improve MET practice, which have potential to be more generally applicable. However, associations between medication use and MET activation criteria and outcome warrant exploration. Future research should be prospective, be multicenter, use recognized classification systems, and focus on improving medication management from MET activation, through treatment

Funding

Bianca Levkovich was supported by an Australian Government Research Training Program Scholarship. D. J. (Jamie) Cooper was supported by an Australian National Health and Medical Research Council Practitioner Fellowship.

Acknowledgments

The authors acknowledge the contribution of Dr. Irma Bilgrami to the conception of the study and Dr. Eldho Paul for inferential statistical analyses.

Conflicts of Interest

All authors report no conflicts of interest.

Bianca J. Levkovich, MSc, is Honorary Research Pharmacist, Alfred Health, and PhD Candidate, Centre for Medicine Use and Safety (CMUS), Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne.

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      Citation Excerpt :

      Lack of timely access to antibiotics by the MET is a problem identified by others.15 Studies from three Australian tertiary teaching hospitals described electrolytes, antiarrhythmics, furosemide (frusemide), vasopressors, and opioid analgesics as the most commonly used medications at MET activations.5,14,23 In the present multicentre study, dedicated MET medication supplies often did not include all of these agents.

    Bianca J. Levkovich, MSc, is Honorary Research Pharmacist, Alfred Health, and PhD Candidate, Centre for Medicine Use and Safety (CMUS), Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne.

    Gordon Bingham, PhD, is Chief Nursing Information Officer and ICU Liaison Nurse, Alfred Health.

    Ria E. Hopkins, MPH, is Pharmacy Research Assistant, Alfred Health.

    Daryl Jones, MD, PhD, is Associate Professor, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, and Consultant, ICU, Austin Hospital, Melbourne.

    D. J. (Jamie) Cooper, MD, is Head of ICU Research and Deputy Director, Department of Intensive Care, The Alfred, Melbourne, and Director, ANZIC-RC.

    Carl M. Kirkpatrick, PhD, is Director, CMUS.

    Michael J. Dooley, PhD, is Director of Pharmacy, Alfred Health, and Professor of Clinical Pharmacy, CMUS. Please address correspondence to Biana J. Levkovich, [email protected].

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