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:

Same problem in a different health service may need a different solution


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

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.

Competing interests: No competing interests

12 March 2002
Andrew T King
Surgical Research Fellow
Peter G Pockney, Mick Nielsen, Maureen Coombes, Ian S Bailey, and Mike Clancy
University Surgical Unit, Mailpoint 816 Southampton General Hospital, SO16 6YD