Background

The Medical Emergency Team (MET) was introduced to Frimley Park Hospital NHS Trust as part of a 2-year research programme funded by the Defence Secondary Care Agency.  The MET is an acute response team activated when patients demonstrate predetermined antecedents to cardiac arrest. The aim of MET is to reduce the rate of avoidable in-hospital cardiac arrest. The team has been operational since 20th September 2000.

Activating The Team

The team is activated via the switchboard, by dialling 333.  A doctor or nurse can activate the MET

The Activation Criteria

The activation criteria allow for a graduated clinical response, determined by the patient’s clinical condition. The level of deterioration determines the score, the higher the score the greater the clinical response, culminating in activation of the MET for a score of 8 or more.

The activation criteria are displayed on posters in all clinical areas and are also found at the back of the MET treatment guidelines booklet.  All nursing staff are issued with a laminated card containing the activation criteria on one side and graded clinical response on the other. All doctors and nurses that attend training are issued with their own copy of the treatment guidelines booklet and encouraged to refer to it.

Who Is On The Team?

  • On call medical SpR/SHO
  • ITU anaesthetic SpR
  • Intensive Care Nurse
  • Resuscitation Officer
  • Porter

Who Is Involved With The Research Project?

Professor Tim Hodgetts is the project supervisor.
Gary Kenward is employed full-time as project leader and co-ordinates the project team.
Sue Payne is database manager and provides administrative support.
Our expert panel consists of: Dr L Sheikh, Dr N Ineson and Mr Nick Castle.
Dr Rob Crouch (Southampton) was involved in the early phase of project design.
Dr Ioannis Vlachonikolis (statistician) and Heather Gage (health economist) from the University of Surrey provide support on a consultancy basis.
Nicky Bianco is an IT consultant who helped design an Access database for data storage and preliminary analysis.
ITU provide clinical staff to support the MET and with effect from November 2001 will be the point of contact for general enquiries.

What Has The Project Team Achieved To Date?

Clinical

A Medical Emergency Team has been introduced to a district general hospital.
A positive change in clinical practice has been observed amongst nursing staff; they are more aware and vigilant at the bedside of changes in physiological variables.

Audit

Prior to implementation of MET an analysis of all in-hospital cardiac arrest events over 1 year determined:

  • Antecedent factors for cardiac arrest
  • The incidence of avoidable cardiac arrest
  • The reasons for avoidable cardiac arrest
  • We are collecting data prospectively on cardiac arrest team activations and MET activations.
    An attitudinal survey of all doctors in the Trust has been conducted to assess attitudes to MET and find ways to improve the system.
    We have undertaken an economic evaluation of the cost of cardiac arrest in a DGH and will compare this to the cost of the MET.
    An attitudinal survey of nursing staff has been conducted to determine the impact of the MET educational programme.

    Innovation

    Activation criteria to alert a MET have been designed:

    • The criteria have been validated using a non-arrest sample


    A graded clinical response has been developed that:

    • Activates the patient’s own doctor (SHO) at a score of 4
    • Fast bleeps the patient’s own doctor (SHO) at a score of 5-7
    • Activates the MET at a score of 8

    Evidence-based treatment guidelines for managing the main problems that lead to cardiac arrest have been devised.
    A laminated pocket size card that shows the activation criteria and graded clinical response has been designed. This has been issued to all Trust nurses and HCAs.
    A TPR chart that contains the MET activation criteria and encourages staff to score patients on a regular basis has been devised.  This improves the early detection of deterioration.
    An analysis of the sensitivity and specificity of the graded clinical response has demonstrated that

  • At a score of 8 all but 1.5% of patients will proceed to cardiac arrest
  • All patients that scored greater than 10 in our sample suffered cardiac arrest
  • Education

    Over 400 Trust doctors, nurses and health care assistants (HCA) have attended formal MET training (correct at October 2001).
    A rolling training programme continues twice monthly.
    Training packs have been designed for ward-based MET cascade trainers.
    All doctors are briefed about MET during their hospital induction package.

    Communication

    New research findings are fed back to hospital staff via newsletters and presentations.
    There have been external presentations at conferences (both nationally and internationally) and to other hospitals.
    The DoH and CHI have been briefed about the research undertaken to date.

    IT development

    With the help of an IT consultant an access database has been designed that is:

  • Informed by the Utstein principles
  • Suitable for the collection and analysis of cardiac arrest and MET data
  • May be suitable for outreach data collection and analysis (further details on request)
  • A hospital intranet site will soon be online.

    This Internet site (www.metproject.org).

    Publications

    Kenward G, Hodgetts TJ, Castle N. (2001).
    ‘Putting the R back in TPR’ (Pictured)
    Nursing Times, 97(40): 32-33.

    Turner L, Kenward G, Hodgetts TJ.  (2001).
    ‘The introduction of Medical Emergency Team: the challenge of change.’
    Nursing Times, 97(40): 34-35.

    Hodgetts TJ, Kenward G, Vlackonikolis I, Payne S, Castle N. (2002) ‘Incidence, location and reasons for avoidable in-hospital cardiac arrest in a district general hospital’. Resuscitation, accepted 2002.

    Hodgetts TJ, Kenward G, Vlackonikolis I, Payne S, Castle N. (2002) ‘The identification of risk factors for cardiac arrest and formulation of activation criteria to alert a Medical Emergency Team’.
    Resuscitation, accepted 2002.

     

    Useful references

    Medical Emergency Team

    1. Hourihan F, Bishop G, Hillman KM, Daffurn K, Lee A. The Medical Emergency Team: a new strategy to identify and intervene in high-risk patients. Clinical Intensive Care 1995; 6: 269-272.
    2. Daly FF, Sidney KL, Fatovich DM. The Medical Emergency Team (MET): a model for the district general hospital. Aust NZ J Med 1998; 28: 795-8.
    3. Morgan R, Williams F, Wright M. Early Warning Scoring System for detecting developing critical illness. Clinical Intensive Care 1997; 8: 100.
    4. Goldhill DR, Worthington L, Mulcahy A, Tarling M, Sumner A. The patient-at-risk team: identifying and managing seriously ill ward patients. Anaesthesia 1999; 54: 853-60.
    5. Smith, G.  To M.E.T. or not to M.E.T.  – that is the question. Care of the Critically Ill 2000; 16: 198-199.
    6. Goldhill DR. Medical emergency teams. Care of the Critically Ill 2000;16:209-212.
    7. Lee A, Bishop G, Hillman K, Daffurn K. The Medical Emergency Team. Anaesth Intens Care 1995; 23: 183-186.

    Avoidable cardiac and respiratory arrest

    1. Smith A, Wood J. Can some in-hospital cardio-respiratory arrests be prevented? Resuscitation 1998; 37: 133-137.
    2. Franklin C, Mathew J. Developing strategies to prevent in-hospital cardiac arrest: analyzing responses of physicians and nurses in the hours before the event. Crit Care Med 1994; 22: 244-247.
    3. McGloin H, Adam SK, Singer M. Unexpected deaths and referrals to intensive care units of patients on general wards. Are some cases potentially avoidable? J RCP London 1999; 33:255-259.
    4. Fieselmann J, Hendryx M, Helms C et al. Respiratory rate predicts cardiopulmonary arrest for internal medicine in-patients. J Gen Intern Med 1993; 8: 354-360.
    5. Bedell S, Deitz D, Leeman D, Delbanco T. Incidence and characteristics of preventable iatrogenic cardiac arrests. JAMA 1991; 265: 2815-2820.
    6. Schein R, Hazday N, Pena M, Ruben B, Sprung C. Clinical antecedents to in-hospital cardiopulmonary arrest. Chest 1990; 6: 1388-1392.
    7. George AL, Folk BP, Crecelius PL, Campbell WB. Pre-arrest morbidity and other correlates of survival after in-hospital cardiopulmonary arrest. Am J Med 1989; 87: 28-34.

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