Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study

The paper by Burgh and colleagues (1) is an important contribution to
the critical care organisation literature. In spite of flaws, – concerning
use of historical controls in an expanding hospital, lack of blinding and
possible Hawthorne effect (an aggressive educational programme was
undertaken), the paper highlights that the most vulnerable patients are
often looked after by the least experienced doctors and nurses. When an
alternate organisational strategy was employed, lives could be saved.

The term "unexpected cardiac arrest" refers to a condition where a
patient has suffered an unrecognised insult and is being cared for in an
inappropriate place by under-trained professionals (2). Signs of
respiratory distress and altered mental status most frequently precede the
critical event (3). The purpose of the emergency medical team, in this
scenario, is to encourage more rapid recognition of patient deterioration
and instigation of targeted therapy, with or without transfer to a higher
intensity medical and nursing environment. The problem with this system
lies here.

The availability of outreach teams, rather than critical care
gatekeepers, is based on the availability of adequately trained doctors
and nurses, and their ability to stay with the patient, until the acute
problem has resolved. Having worked in a dozen or so intensive care units
on two continents I can say with certainty that it is not feasible for the
intensive care registrar on-call to remain in an outlying ward, treating a
critically ill patient. Consequently, the system that has evolved in the
British Isles, and elsewhere, is a "scoop and run" system. Essentially
this involves a senior doctor "eyeballing" the patient and organizing
immediate transfer to high dependency, or intensive care. Where beds are
limited, a gatekeeper is employed. Patient selection in this situation is
often inappropriate (4).

The problem with employing an EMS is bed availability. In the United
States there are 30.5 intensive care (ICU) beds per 100,000 population
(5); in the UK there are 8.6 per 100,000 (5). Remarkably, the EURICUS-1
study (6) revealed that the bed occupancy rate in the UK was 58.5%
compared with 87% in the USA (5). Bed demands were higher in large
university hospitals in the UK (6). It is difficult to interpret this
data: clearly there are sicker patients on the wards in the UK, a
reluctance to admit patients to ICU, and possibly other mitigating factors
– such as bed blocking for elective surgery.

Spending on intensive care services is 1% of the healthcare budget in
the UK and 10% in the USA. Does this make a difference? Absolutely, a
verification study, by Pappachan and colleagues, of the Apache III scoring
system, revealed a 25% increase in mortality in the UK over what was
expected (from US data). The best interpretation of this data is "lead
time bias"(7) – patients admitted to British intensive care units are
sicker than expected; languishing on wards prior to ICU admission consumes
physiologic reserve and worsens outcomes (8). Further, in a large study of
12,762 admissions to intensive care units in the Thames Valley, Goldhill
and colleagues (9) determined that 30% of deaths were attributable to
admission following cardiopulmonary resuscitation; patients admitted from
the wards had worse outcomes than those admitted from the emergency
department or operating suite.

The solution to unexpected cardiac arrests on wards may well be a
combination of EMS and increased availability of critical care beds.
Rationing of ICU beds has been an important component of cost containment
(10), perhaps at a high cost to society (11). However, many of these
patients may not need organ support or invasive monitoring, merely more
intense nursing care (12). The evolution of "intermediate" or "high
dependency" (HDU) care units may be the answer (13).The development of the
HDU concept arose from two factors: 1. patients who were deteriorating
clinically could be managed in a more cost-effective environment that
avoided intensive care admission (14); patients are at higher risk for
cardiac arrest after discharge from intensive care than other patients
(15). In the Thames Valley study, 27% of all deaths occurred following ICU
discharge (9).

Franklin and colleagues (16) looked at ICU admission and case
fatality rates during the 12 months following the opening of a HDU. Total
admissions to the ICU/CCU decreased by 7.1%, there was a 25.0% decrease in
general ward deaths and a 38.8% decrease in ward cardiac arrests. The
authors concluded that admission the HDU reduced mortality rates and
improved access to ICU.

Pappachan and colleagues (17), have proposed that the perceived
national shortage of intensive care beds could be made up by HDU, and
theirs and other studies have identified clinical parameters that identify
patients most likely to benefit from intermediate care (18). Further, the
removal of patients from intensive care, who do not require ICU
interventions, frees up valuable beds for those who do (12).

How is high dependency care to be regulated? The gatekeeper system
may not work in patients best interest: a study of patients refused
admission to intensive care (4) demonstrated a relative risk of death of
1.6 (95% CI 1.0-2.5) compared to patients with corresponding severity of
illness, admitted to ICU. Hence clear guidelines for admission of patients
to high dependency care units are required and should be available (19).

Bed requirements for both intensive care and high dependency care has
been addressed by Lyons and colleagues (20).

In conclusion, the paper by Burgh and colleagues (1) has addressed
the urgent need for more defined care pathways for hospitalized patients
who may develop critical illness. The presence of an EMT is but one arm of
an overall system which requires increased availability of critical care
beds. Moreover, education about appropriate utilization of these beds is
essential. The introduction of high dependency care is a proven, viable,
cost-effective method of providing quality care for deteriorating, post
operative and post intensive care patients.

References

(1) Buist MD, Moore GE, Bernard SA, Waxman BP, Anderson JN, Nguyen
TV. Effects of a medical emergency team on reduction of incidence of and
mortality from unexpected cardiac arrests in hospital: preliminary study.
BMJ 2002; 324(7334):387-390.

(2) McQuillan P, Pilkington S, Allan A, Taylor B, Short A, Morgan G et al.
Confidential inquiry into quality of care before admission to intensive
care. BMJ 1998; 316(7148):1853-1858.

(3) Schein RM, Hazday N, Pena M, Ruben BH, Sprung CL. Clinical antecedents
to in-hospital cardiopulmonary arrest. Chest 1990; 98(6):1388-1392.

(4) Metcalfe MA, Sloggett A, McPherson K. Mortality among appropriately
referred patients refused admission to intensive-care units. Lancet 1997;
350(9070):7-11.

(5) Angus DC, Sirio CA, Clermont G, Bion J. International comparisons of
critical care outcome and resource consumption. Crit Care Clin 1997;
13(2):389-407.

(6) Miranda D, Ryan DW SWFV. Organisation and Management of Intensive
Care: a prospective study in 12 European countries. 1-9-0098. Springer.
Ref Type: Generic

(7) Vincent JL, Ferreira F, Moreno R. Scoring systems for assessing organ
dysfunction and survival. Crit Care Clin 2000; 16(2):353-366.

(8) Rapoport J, Teres D, Lemeshow S, Harris D. Timing of intensive care
unit admission in relation to ICU outcome. Crit Care Med 1990; 18(11):1231
-1235.

(9) Goldhill DR., Sumner A. Outcome of intensive care patients in a group
of British intensive care units. Crit Care Med 2002; 28(8):1337-1345.

(10) Bion J. Cost containment: Europe. The United Kingdom. New Horiz 1994;
2(3):341-344.

(11) Smith GB, Taylor BL, McQuillan PJ, Nials E. Rationing intensive care.
Intensive care provision varies widely in Britain. BMJ 1995;
310(6991):1412-1413.

(12) Fox AJ, Owen-Smith O, Spiers P. The immediate impact of opening an
adult high dependency unit on intensive care unit occupancy. Anaesthesia
1999; 54(3):280-283.

(13) Ryan DW. Rationing intensive care. High dependency units may be the
answer. BMJ 1995; 310(6985):1010-1011.

(14) Byrick RJ, Mazer CD, Caskennette GM. Closure of an intermediate care
unit. Impact on critical care utilization. Chest 1993; 104(3):876-881.

(15) Franklin C, Mathew J. Developing strategies to prevent inhospital
cardiac arrest: analyzing responses of physicians and nurses in the hours
before the event. Crit Care Med 1994; 22(2):244-247.

(16) Franklin CM, Rackow EC, Mamdani B, Nightingale S, Burke G, Weil MH.
Decreases in mortality on a large urban medical service by facilitating
access to critical care. An alternative to rationing. Arch Intern Med
1988; 148(6):1403-1405.

(17) Pappachan JV, Millar BW, Barrett DJ, Smith GB. Analysis of intensive
care populations to select possible candidates for high dependency care. J
Accid Emerg Med 1999; 16(1):13-17.

(18) Zimmerman JE, Wagner DP, Knaus WA, Williams JF, Kolakowski D, Draper
EA. The use of risk predictions to identify candidates for intermediate
care units. Implications for intensive care utilization and cost. Chest
1995; 108(2):490-499.

(19)Nasraway SA, Cohen IL, Dennis RC, Howenstein MA, Nikas DK, Warren J et
al. Guidelines on admission and discharge for adult intermediate care
units. American College of Critical Care Medicine of the Society of
Critical Care Medicine. Crit Care Med 1998; 26(3):607-610.

(20) Lyons RA, Wareham K, Hutchings HA, Major E, Ferguson B. Population
requirement for adult critical-care beds: a prospective quantitative and
qualitative study. Lancet 2000; 355(9204):595-598.

Sir,

We read with interest the article by Buist et al. We too have recognised
that care preceding admission to the intensive care unit (ICU) can be
improved (1). In view of the large number of patients and sparse staffing
levels typical of most UK hospitals we chose instead a combination of a
bedside, physiology-based scoring system (2), increased education of both
nurses and doctors in the recognition of the critically ill and “outreach”
nurses with intensive care expertise who can both support patients on the
ward and help with their admission to the ICU. This initiative was backed
by a protocol that ensured escalation of care if the patient was not
improving and was for resuscitation. This “bottom up” approach, which
contrasts with Buist’s specialists who are parachuted in, was welcomed by
nurses and junior doctors who felt empowered to call for help. This
physiology-based scoring system was applied to 2000 surgical patients and
identified all patients who went on to suffer death in hospital well
before they did so. The clear protocol for responding to these patients
set standards that were easily auditable.

Before and after studies such as Buist et al’s will always be
vulnerable to failure to measure confounders. Were more patients allocated
“do not resuscitate” orders with and without MET involvement, did the ICU
change their admission policy? It would have helped if secular trends in
similar hospitals had been measured. Having said this conducting a
randomised controlled trial of a mixed educational/therapeutic
intervention where one of the treatment outcomes is intensive therapy is
extremely difficult and some would argue unethical.

Surely the question is not should knowledgeable staff see
physiologically deranged patients early and involve more senior staff if
they are not improving (the bleedin’ obvious) but rather how to deliver
such a service that will work in the UK.

Yours sincerely, on behalf of the Critical Care Group.

Andrew King
Surgical Research Fellow

Peter Pockney
Surgical Research Fellow

Mick Nielsen
Consultant in Intensive Care

Maureen Coombes
Nurse Consultant in Intensive Care

Ian Bailey
Consultant General Surgeon

Mike Clancy
Consultant in Emergency Medicine

Southampton University Hospitals Trust, Mailpoint 816,
Tremona Road. Southampton. SO16 6YD

atknrk@hotmail.com

1. Mcquillan P, Pilkington S, Allan A, Taylor B, Short A, Morgan G,
Nielsen M, Barret D, Smith G. Confidential inquiry into quality of care
before admission to intensive care. BMJ. 1998 Jun 20;316(7148):1853-8.

2. Stenhouse C, Coates S, Tivey M, Allsop P, Parker T. Prospective
evaluation of a Modified Early Warning Score to aid earlier detection of
patients developing critical illness on a general surgical ward. Br J
Anaesthesia 2000; 663P.

I read with great interest the paper by Buist et al. showing a
reduction in incidence of unexpected cardiac arrest following the
introduction of a medical emergency team. However I feel that the
accompanying headline "emergency hospital teams halve heart deaths" was
both inaccurate and misleading.

The study showed a 50 per cent reduction in incidence of cardiac
arrest,not mortality. In fact the authors noted that "the new system may
simply have transferred mortality associated with cardiac arrest to
mortality that occurred at other times/places". They have also noted that
calls to the medical emergency team often resulted in a decision to
implement a "do not resuscitate" order. While this may result in more
appropriate care and use of available resources it is not the same as a
reduction in mortality. The observed reduction in mortality was from
1.967 per cent to 1.720 per cent. Although statistically significant this
is a fairly modest change and not what the reader may have expected from
the BMJ headline.

I feel that the transition from cardiac arrest teams to medical
emergency teams will have an important role in the future organisation of
critical care services.As noted in this paper,this requires a considerable
culture change in hospital practice.Such change will not be helped by
misleading and inaccurate reporting of an important study such as this.

The picture in question was chosen by the editorial team including
several qualified doctors.

According to the Science Photo Library, which supplied the image, the
staff
and the patient in the photo are real although the situation may or may
not be.
Personally I think it isn't as the photograph is so close to the action
that if it was a real emergency situation the photographer would have
been very
intrusive.
However, that depends very much on the relationship between the staff,
patients and
photographer. This photographer, Larry Mulvehill, takes many hospital
photos
so I assume he has a good relationship with the staff, and it would not
be in their interest
or his to be photographed making a mistake in any medical procedure.

It was taken in an American hospital (the article is by Australians
and
we are in the UK,
which gives it a rather international flavour)

The image is intentionally blurred - it's a well known technique used
by
photographers
or possibly by a designer on a Mac to suggest speed. It's virtually
impossible to
visually suggest speed in a still picture without either natural or
added blur.

Regarding the patient's colour, all the flesh tones in the image are
rather high
which is another photographer's trick to add contrast.

Perhaps Dr Buist could have supplied a picture, but he would have
needed
to deliver a professional quality image
complete with model releases within a week of request. It's probable
that his work schedule would make this difficult,
and it is of course not viable to obtain model releases during an
emergency
situation.

Finally, cover images need to have impact, and for that reason are
rarely of a purely academic or scientifically descriptive nature. The
idea behind this
image primarily is to convey rush action rather than absolute detail.