In our hospital, the occurrence of cardiac arrest often indicates delayed or suboptimal clinical management of the patient.1
The outcome from in-hospital cardiac arrest is universally poor,2,3,4,5,6
and regardless of outcome the patient’s clinical experience is often catastrophic. Our hospital implemented a medical emergency team in 1996, and within three years the incidence of cardiac arrests (adjusted for case mix) dropped by 50%.7
Three other studies have since reported similar findings,8,9,10
but they have been criticised because they used a historical control, before-after methodology.11 12
Recently in the MERIT study, a large randomised prospective study of medical emergency team implementation,13
a composite outcome of cardiac arrest, unexpected death, and unplanned admission to the intensive care unit was not significantly reduced (5.86 v
5.31, P=0.64). However, in both the intervention and control hospitals the overall calls for an emergency team increased(3.1 v
8.7 calls per 1000 admissions, P=0.0001). Both control and intervention hospitals had a reduction in cardiac arrests (2.08 v
1.47, P=0.003) and unexpected deaths (1.63 v
1.11,P=0.01). The MERIT authors listed several reasons to explain the findings: the intervention was ineffective; the medical emergency team was effective but was poorly implemented in the intervention hospitals; the study’s time frame of 12 months was too short for effective implementation; clinical cross contamination between the two groups; the study was underpowered; the study was impossible to blind; the study could not control for overall system-wide improvement; and in the control hospitals the cardiac arrest team often functioned as a de facto medical emergency team.
Despite the results of the MERIT study, more and more hospitals have set up medical emergency or rapid response teams. In 2005, the US Institute for Healthcare Improvement made hospital implementation of rapid response teams one of six platforms for nationwide roll-out as part of their campaign to save 100
000 lives from adverse events in hospital (www.ihi.org/IHI/Programs/Campaign
). In Australia, the Quality Council has largely replicated this initiative for roll-out in 50 hospitals throughout the country under the Safer Systems Saving Lives Campaign (www.health.vic.gov.au/sssl
). In June 2005, although the MERIT study had just been published, the first consensus conference on medical emergency teams found that hospitals should implement such systems.14
Furthermore, none of the hospitals randomised to using medical emergency teams in the MERIT study has subsequently abandoned their use (K Hillman, personal communication 2006).
In the MERIT study, table 2 gives a clue to the discrepancy in results between the single centre studies using historical controls7,8,9,10
and the MERIT study.13
In a large number of instances where the composite outcome occurred, although the patient had had the criteria for calling the medical emergency team, for whatever reason the staff did not call the team. In intervention hospitals, the medical emergency team was not called before cardiac arrest in 30% of instances when patients had the calling criteria for more than 15 minutes before the arrest occurred. The team was not called in half the incidents leading to unplanned admission to the intensive care unit or unexpected death in hospital. The MERIT study could not measure the effectiveness of the medical emergency team because the randomised intervention was often not received by the patient.
In our hospital the vital importance of ensuring that patients with calling criteria are actually responded to arose largely through the unexpected in-hospital death of a previously well 47 year old man after a thoracotomy in 2001. The family asked the coroner to investigate why a medical emergency team call was not put into place when blood pressure fell and remained low, and also what criteria or symptoms would instigate the medical emergency team process. Part of the cause of death, the coronial inquiry found, was the failure to call the medical emergency team during the 14 hours immediately after the operation, when the patient was tachycardic and hypotensive.15
We recognised that despite our best efforts at hospital-wide education about and implementation of the medical emergency team, patients could die in our hospital because of delayed resuscitation.
Analysis of this death showed a typical example of a clinical futile cycle (fig1) in which a lot of clinical activity is directed at the patient, but little of this activity relieves the dire circumstances. The bedside nurses did recognise and document the abnormal observations, they did contact the on-call second year doctor, the doctor did attend promptly, and the doctor did recognise that the patient was hypovolaemic and start resuscitation. The junior doctor did discuss the case with the on-call registrar. The nursing staff and the junior doctor were satisfied that the appropriate actions were being taken and that there was no need to call the medical emergency team or other senior assistance.
Fig 1 Clinical futile cycles
We identified several important barriers to staff calling for higher order assistance. Firstly, nursing staff were still reluctant to breech the traditional hierarchical referral model of care, even though they knew the patient fulfilled the calling criteria. The junior doctor had responded promptly and started treatment, and also communicated with the registrar, so the nurses were reassured that the situation was in hand. Secondly, over the 14 hour postoperative period, the four different junior doctors who had responsibility for the patient all identified that they were concerned about the patient’s condition, but rather than call the medical emergency team (though they knew that this patient fulfilled the criteria) they all opted to hand the problem either to the next shift or up the hierarchy to the registrar. Finally, although the patient’s physiological variables were abnormal, all staff commented that he looked “too well” to call for the medical emergency team.
This case highlighted that having a medical emergency team based in the intensive care unit, along with telling ward staff about the team and in-service education, was not sufficient. Our two main problems were that ward nurses needed more support for appropriate use of the medical emergency team in our hospital, and that junior medical staff could not consistently recognise and manage appropriately patients who were clinically unstable.16