OBJECTIVES: To describe the characteristics of medical emergency team (MET) events at an Australian pediatric, tertiary-care center in a way that would allow for comparison with other MET systems.
METHODS: A retrospective, single-center, observational study. Consecutive MET events that occurred between January 2013 and July 2014 at Princess Margaret Hospital for Children in Perth, Western Australia, were included.
RESULTS: There were 46 445 hospital admissions during the study period and 197 MET events in children. This gives a rate of 4.2 MET events per 1000 admissions. Out of 197 pediatric MET events analyzed, there were 2 deaths (1.0%) that occurred during the MET events. All 197 patients were actively treated, with none receiving “do not attempt resuscitation” orders. Of pediatric MET events, 24% (48 of 197) were admitted to the PICU, and 75% (149 of 197) stayed in the ward where the call was made.
CONCLUSIONS: In this tertiary-care, pediatric hospital in Australia, the MET event rate and the rate of admission to the PICU because of MET events are lower than those reported for US pediatric hospitals. Despite these differences, Australian data suggest that outcomes are similar to US pediatric hospitals.
Medical emergency teams (MET), also known as rapid response teams, are teams of specially trained doctors and nurses who are mobilized from the ICU to a deteriorating patient in the ward. Their purpose is to decrease adverse events and in-hospital cardiorespiratory arrest.1–3 The MET system is made of 3 parts.2 The afferent limb is the call made from the wards when a patient is identified as deteriorating. The integrating center is the ICU, where the call is received and from where a team is mobilized. The efferent limb is the team reaching out to the deteriorating patient in the ward and initiating treatment as well as deciding on disposition.2,4
MET systems are used by pediatric hospitals in many countries and function in a similar fashion across borders.5–8 This is true despite significant differences in the health systems in which the pediatric hospitals exist.9 There are data that reveal the characteristics of the MET systems in pediatric hospitals in the United States.5,10 By comparing MET systems in different countries, it might be possible to better understand how MET systems function and how they can be improved.
Our objective in this study was to describe the characteristics of MET events in a tertiary-care, pediatric hospital in Australia. In doing this, Australian data can be compared with US pediatric hospital data, which can provide pediatric hospitals with insight on how to improve pediatric MET systems.
This was a hospital-based, retrospective study at Princess Margaret Hospital for Children (PMH) in Perth, Western Australia. This university-affiliated hospital is the main referral center for pediatrics in the state, with >46 000 admissions per year.
Data were collected from consecutive patients who had an MET event between January 1, 2013, and July 31, 2014. Information regarding age, sex, time of the call, activation triggers, interventions by the MET, and outcomes was collected. Descriptive statistics with percentages and fractions were used. When these data are compared, it is done so against previously published data from US hospitals, mainly the American Heart Association’s Get With The Guidelines-Resuscitation (GWTG-R) registry,10 which is a large report of 3647 MET events that included hospitals that look after sick children.
Missing data from PMH are likely to have occurred at random, and this was dealt with by analyzing only the data that were available. Ethics approval was sought from the hospital’s human research ethics committee. Approval was given after an abridged review, and the requirement for consent was waived.
During the 19-month study period, there were a total of 46 445 admissions to the hospital and 1901 admissions to the PICU.
There were 210 MET events; 13 of these were for adults and therefore excluded, leaving 197 MET events for admitted pediatric patients. This gives a rate of 4.2 MET review calls per 1000 patient admissions.
PMH uses a 2-tier MET system. The first tier is called an “MET call” and refers to children who have vital signs outside the normal range for their age and are in need of medical review but are otherwise still stable. This triggers review by the PICU team and the attending medical team. The second tier is called a Code Blue and refers to children who are in a peri-arrest situation or have arrested, and they commonly require airway management or cardiopulmonary resuscitation. This triggers a response from the PICU, the admitting medical team, as well as emergency department and anesthetics medical officers.
In this cohort, 71% (139 of 197) of MET events were first tier, and 29% (58 of 197) were second tier. There were 2 deaths (1.0%) that occurred during the MET events, with both of these being second-tier calls. All 197 patients were actively treated, with none being offered end-of-life care.
Of pediatric MET events, 24% (48 of 197) were admitted to the PICU, and 76% (149 of 197) stayed in the ward where the call was made.
Data about patient demographics, the time of the event, event triggers, and treatment provided during the MET event were collected and are presented and compared with the GWTG-R registry data in Table 1.
To help put the results of this study in perspective, a description of how PMH compares with the hospitals that contributed data to the GWTG-R registry can be seen in Table 2.
The results of this study reveal a snapshot of how the MET system of pediatric hospitals in Australia functions. With these numerical descriptions, we can compare this MET system to MET systems from pediatric hospitals in the United States.
Firstly, by comparing hospital characteristics of PMH and the hospitals that contributed data to the GWTG-R registry, we can see that there are both similarities and differences. PMH is an urban, teaching hospital like the US hospitals from which a large percentage of GWTG-R registry data came from, but at the same time, PMH is relatively small in overall size and has a small number of PICU beds. This combination of characteristics within PMH might be due to the idiosyncrasy of the state of Western Australia having a relatively small population that is scattered throughout an enormous land area of 252 641 786 hectares (975 455.4 square miles).11 This means that there will be no other referral pediatric hospital in its vicinity, the closest being in the city of Adelaide, South Australia, which is 2697 km (1843 miles) away. PMH needs to be self-sufficient and provide as many of the services that a population will need as possible.
PMH has a much lower rate of MET events, with 4.2 per 1000 patient admissions compared with reports that describe 24.41 per 1000 patient admissions in US pediatric hospitals.2,5 The questions from this are as follows: why is this the case, and does this affect outcomes? Population characteristics and the time distribution of events appear to be similar, and thus are not likely to drive the differing rates.
MET activation triggers are the mostly similar between PMH and US hospitals. Activation triggers depend on physiologic parameters and staff concern. In US hospitals, they seem to be more evenly distributed across all possible triggers, whereas at PMH, it seems more skewed toward tachycardia and tachypnea. This leads us to ask whether the triggers for activating an MET event are more sensitive in US pediatric hospitals, resulting in more MET events.
The use of the Children’s Early Warning Tool (CEWT) score, known in other places as the Pediatric Early Warning Score, was different between PMH and the GWTG-R registry.12 These scoring systems allocate points to changes in physiologic parameters, and when the total score adds up to more than a predetermined value, it triggers an MET event. They have been validated and found to work well in tertiary-care centers.13 At PMH, a CEWT score is calculated every hour and recorded on the vital signs observation charts of every patient. A CEWT score of ≥8 triggers a first-tier MET event, or an MET call. In the GWTG-R registry report, data were not collected about early warning scoring systems, and it is not determined if the hospitals contributing data used or did not use 1 of these scoring systems. It would be difficult to arrive at a conclusion on how these scores are related to outcomes in relation to the data presented here.
There was no large difference between the interventions administered by the MET at PMH and US pediatric hospitals. There were twice as many PICU admissions in US pediatric hospitals than at PMH, whereas more patients stayed in the ward at PMH to continue to be managed there. To try to explain this difference, it is useful to look at the availability of critical-care beds in different countries, which is something that could be playing a role here. The United States is 1 of the countries in the world with the most critical-care beds, with 20.0 to 31.7 ICU beds per 100 000 people, whereas Australia has 8.0 to 8.9 ICU beds per 100 000 people.14 Given this difference, it would seem possible that in Australia, patients would need to be more severely ill and go through more rigorous triaging before they get admitted to an ICU environment to ensure that critical-care beds go to those who need them most. This happens when the demand for critical-care services is high.15,16
Despite this difference in PICU admissions, survival outcomes seem to be similar. The survival-to-discharge rate reported in the GWTG-R registry after an MET event was 93.3%.10 According to the Australia and New Zealand Intensive Care Society’s 2015 Australian and New Zealand Paediatric Intensive Care Registry, the percentage of patients who were discharged from the PICU to the ward or home was 95.9% for all pediatric hospitals in the region.17
The rate of patients who received a “do not attempt resuscitation” order was higher in the United States than at PMH. This is consistent with previous reports that reveal a high incidence of life-support limitations in North America compared with other parts of the world, something that is potentially cultural.18
The strength of this report is that PMH is a tertiary-care hospital with similar characteristics to many of the hospitals included in the GWTG-R registry, so the findings can be compared. The limitations of this report are that it is a single-center study and that statistical analysis against US data could not be performed.
From this study, we can conclude that despite many of the characteristics of MET events being similar between an urban, teaching pediatric hospital in Australia and US pediatric hospitals, the rate of MET events and the rate of admission to the PICU is different, with no obvious difference in survival outcomes. This leads us to ask why that is. Asking these questions can potentially lead us to better understand how different systems function and help us improve our respective systems.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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- Copyright © 2018 by the American Academy of Pediatrics