Elsevier

Resuscitation

Volume 80, Issue 1, January 2009, Pages 35-43
Resuscitation

Clinical paper
The impact of introducing medical emergency team system on the documentations of vital signs

https://doi.org/10.1016/j.resuscitation.2008.10.009Get rights and content

Abstract

Objective

To study the rate of documentation of vital signs in the period before the occurrence of an adverse event or emergency team call and to measure the effect of introducing the medical emergency team (MET) system on the rate of such documentation.

Methods

During a cluster, randomised trial of the MET in 23 Australian hospitals, we collected the data on lowest systolic blood pressure, highest and lowest respiratory rate and heart rate from 15 min to 24 h before an adverse event (cardiac arrest, death or unexpected intensive care unit admission) or emergency team call. We derived the document of these vital signs (yes/no) from the numerical values recorded. We used analytically weighted and random-effect regression models to examine the association between non-documented (missing) vital signs, hospital characteristics and MET allocation, and to examine their trend over time.

Results

We found marked variability in documentation, with a high proportion of missing vital signs in some hospitals. Close to 77% of patients suffering adverse events had at least one vital sign missing immediately before the event. Allocation to a MET system was associated with significantly increased documentation of respiratory rate and blood pressure before emergency team review (P < 0.01) as well as an improvement in documentation over time (P < 0.01). At all stages and for both MET and control hospitals, the respiratory rate was the least commonly documented vital sign (P < 0.01).

Conclusions

The documentation of vital signs in the period before adverse events was commonly incomplete with a particular deficiency in the documentation of the respiratory rate. Introduction of a MET system was associated with improvement in the rate of documentation of vital signs.

Introduction

The medical emergency team (MET) systems is part of a rapid response team (RRT) concept that aims to provide timely critical care support to ward patients at risk of serious adverse events.1 An effective RRT system is dependent upon doctors and/or nurses activating the team for at risk patients. Activation is typically triggered by concern about the patient's clinical condition and/or the presence of abnormal vital signs. Activation based on abnormal vital signs depends on their measurement, the recognition of abnormal values and timely communication. There is evidence that activation of the MET system is frequently sub-optimal because of failures in measurement, documentation, understanding and communication of vital sign abnormalities.1

The MERIT study, a 23-hospital cluster randomised clinical trial evaluated the effectiveness of the MET system.1 As part of the study, investigators collected information on the value of three vital signs (blood pressure, respiratory rate and heart rate), within the 24 h prior to an adverse event or emergency team call. The adverse events were unplanned intensive care admissions unexpected cardiac arrests, and unexpected deaths defined as a cardiac arrests or a death without a do not resuscitate (DNR) order.

We used the data collected during the MERIT study to investigate the relationship between the rate of documentation of three vital signs (blood pressure, respiratory rate and heart rate) in Australian hospitals and the occurrence of adverse events and emergency team calls, and to examine the effect, if any, of the introduction of a MET system on the rate of vital sign documentation.

Section snippets

Study design

The MERIT study was a cluster randomised controlled trial of 23 Australian hospitals that tested the effectiveness of introducing a MET system. The method of hospital recruitment, randomisation and implementation of the MET during the MERIT study has been described previously.1 All participating hospitals received approval from their Human Research Ethics Committees to conduct the study. We collected data for a 2-month baseline period, a 4-month standardised implementation period (during which

Results

We examined the rate of missing respiratory rate, heart rate and blood pressure for 881 unexpected deaths; 3021 unplanned ICU admissions; 1348 unexpected cardiac arrests; 1754 emergency team calls; and 5988 events in total. The sum of the individual types of event (7004) was greater than the total number of event (5988). This was due to overlap in some definitions of the individual event types. For example, a patient who had a cardiac arrest and died without a pre-existing NFR order was

Discussion

We used collected data from the MERIT study to assess the completeness of documentation of three vital signs (blood pressure, respiratory rate and heart rate) before an adverse event or emergency team call not associated with an adverse event. We found marked variability in levels of documentation from hospital to hospital, and a very high proportion of missing documentation of vital signs. Allocation to the MET system was associated with a statistically significant improvement in documentation

Conflicts of interest statement

All authors stated that they had no conflicts of interest to declare.

Acknowledgements

The study was funded by grants from the National Health and Medical Research Council of Australia, the Australian Council for Safety and Quality in Health Care and the Australian and New Zealand Intensive Care Foundation as part of the MERIT study.

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    A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2008.10.009.

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