Intended for healthcare professionals

Rapid response to:


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

BMJ 2002; 324 doi: (Published 16 February 2002) Cite this as: BMJ 2002;324:387

Rapid Response:

EMTs cannot function without enhanced critical care services

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.


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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.

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Competing interests: No competing interests

19 March 2002
Patrick J Neligan
Lecturer and Clinical Fellow, Department of Anesthesia, Division of Critical Care Medicine
University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104