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MET - more information required
- Iain D Drummond (11 December 2007)
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Doing the right thing requires that the right team is called at the right time.
- Paul G Lawler (31 December 2007)
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Iain D Drummond, ST2 ICU Queen Margaret Hospital, Dunfermline, KY12 OSU
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I read with interest the article by Buist et al "Six year audit of cardiac arrests and medical emergency team calls in an Australian outer metropolitan teaching hospital" (1). The article acknowledges that in the multicentre MERIT study(2) there was no significant reduction in the "composite outcome of cardiac arrest, unexpected death, and unplanned admission to the intensive care unit". The authors then make the valid point that in many cases where criteria for calling the medical emergency team (MET) were fulfilled the team were not called. They postulate that this reflects inadequate education for doctors and nurses involved in the management of acutely unwell patients and go on to describe some measures undertaken with the aim of improving staff education, such as an orientation programme for interns, a professional development programme for medical registrars and the introduction of intensive care liaison nurses. They conclude that these measures led to significant annual reductions in cardiac arrest incidence, albeit with the proviso that this may reflect at least to some extent an increase in Do Not Attempt Resuscitation (DNAR) orders. There is no mention, however, in the conclusion to this study of the other two endpoints from the MERIT study - unexpected death and unplanned admission to the intensive care unit. One must speculate as to whether this data was uncollected or whether it was collected but the results did not support the medical emergency team. Moreover, and arguably most significantly, there is no data presented which demonstrates what proportion of patients who fulfilled criteria for calling the team were actually referred to the team. This data is particularly important given that this study arose from a case where there was a failure to call the MET. Admittedly, there is data presented which demonstrates an overall increase in number of calls to the MET, but this coincides with an increase in hospital admissions. In conclusion, this study does suggest that there may yet be a role for the medical emergency team. However, further studies will be required which address the fallibilities outlined above. 1) Buist M, Harrison J, Abaloz E, Van Dyke S. Six year audit of cardiac arress and medical emergency team calls in an Australian outer metropolitan teaching hospital. BMJ 2007; 335: 1210-12 2) MERIT Study Investigators. Introduction of the medical emergency team (MET) system: a cluster randomised controlled study. Lancet 2005; 365: 2091-7. Competing interests: None declared |
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Paul G Lawler, Honorary Consultant in Critical Care Medicine Janes Cook University Hospital. TS4 3BW
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Patients who become acutely ill require firstly, timely recognition of their deterioration; secondly that urgent appropriate help is called; thirdly that the clinical team summoned arrives quickly; and finally that the team does the right thing. Doing all this should result in less morbidity and mortality. The establishment of a critical care “outreach “service alerted by “track and trigger” systems were two integrated recommendations of “Comprehensive Critical Care”, aimed to achieve a reduction in the need for critical care (1). In response to the report, “outreach” and “track and trigger” systems have been rolled out across most of England. The paper by Buist and colleagues (2) examines the effect of the introduction of such proactive care by the right team, the Medical Emergency Team (MET) on the frequency of cardiac arrests. This paper follows and builds on a previous study by the same group (3). Because there are differences in the interface time frames used for each study and also because the denominators used in calculating the incidence of cardiac arrest are different, direct reconciliation of the data cannot be made. Nevertheless, taken together, the studies cover the period 1994-2005, and clearly show a that each year cardiac arrest rate fell, from 3.77/1000 patients in 1996, to 2.05 in 1999/1000 and then to 0.66/1000 in 2005, that is, almost a six-fold reduction. During the period, the number of MET calls rose from a standing start in 1996 to 213/annum in 2000. Call-rate then ranged from 213 to 311 (average 256/annum). The study showed that there was no obvious overall relationship between the MET call-out rate and the fall in the incidence of cardiac arrest. The MET call-out rate in this study appears to be between 4 and 6 calls/week. It seems surprising that this low call-rate had the effect it appears to have had, but a similar effect was seen in another study (4). Not unreasonably, Buist and colleagues suggest that the reduction in cardiac arrests might not be simply or solely due to the introduction of the MET, but that the reduction might at least be partly a consequence of the educational “background” that was put in to support and integrate a MET system into the clinical pathway. It is intuitive that a MET (or the UK equivalent “Critical Care Outreach Service”) should improve patient outcome, of which cardiac arrest is one proxy. Nevertheless the evidence for the effect of a MET on overall patient outcome is, at best, equivocal. A systematic review (5) showed no real effect of a MET (or similar systems) upon patient outcome. It is difficult to reconcile the evidence base with intuition and with Buist’s report indicating that the “presence” of a MET had an effect. What seems to be clear, however, is that the calling for - or the arrival - of the MET does not appear to be the key to improving patient outcome. The evidence that the “track and trigger” systems developed to detect acute illness and then target the MET to the right patient at the right time has also been subject to systematic review (6). Like the evidence for the effectiveness of a MET, the systems so far developed for alerting the team do not stand up to scrutiny. The obvious conclusion is that until these triggering systems are improved, the MET (or any other “outreach” system) will not be able to deliver to its full potential and the educational “halo” surrounding the introduction of the MET may be its main effect. Unless the MET’s main purpose is intended to be educational, then without better “track and trigger” systems, it is difficult to resist the conclusion that an infrequently use MET is an expensive luxury. Unless local audit proves otherwise, or until “track and trigger” systems are better developed, perhaps finances might be better spent on educating clinical staff. PG Lawler FRCP FRCA Retired Medical Director Honorary Consultant in Critical Care Medicine James Cook University Hospital Middlesbrough TS4 3BW 1. Department of Health. Comprehensive Critical Care: a review of adult critical care services. 2000. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4006585 2. Buist M, Harrison J, Abaloz E, Van Dyke S. Six year audit of cardiac arrests and medical emergency team calls in an Australian outer metropolitan teaching hospital. Brit Med J. 2007; 335: 1210-1212. 3. 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. Brit Med J. 2002; 324: 387-390. 4. Bellomo R, Goldsmith D, Uchino S, Buckmaster J, Hart G, Opdam H et al. Prospective controlled trial of the effect of an emergency team on post operative morbidity and mortality rates. Critical Care Med. 2004; 32: 916-921. 5. Esmonde L, McDonnell A, Ball C, Waskett C, Morgan R, Rashidian A et al. Investigating the effectiveness of critical care outreach services: a systematic review. Intensive Care Med. 2006; 32: 1713-1721. 6. Gao H, Mc Donnell A, Harrison DA, Moore T, Adams S, Daly K et al. Systematic review and evaluation of physiological track and trigger warning systems for identifying at-risk patients on the ward. Intensive Care Med. 2007; 33: 667-679. Competing interests: None declared |
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