Editorial II

Not waving, but drowning

D. W. McKeown

University of Edinburgh, Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK E-mail: dermot.mckeown{at}ad.ac.uk

Modern hospitals can be dangerous. Reduced numbers of staff, inexperienced staff, and staff working for limited hours can allow a patient to become unwell without being noticed or treated properly. Reductions in the number of hospital beds mean that the patients in these beds are sicker and have more things wrong with them.1 If patients deteriorate without changes being noticed and treated, then serious consequences develop, such as cardiac arrest.2 The most pressing interventions required to prevent severe deterioration may be relatively simple3 and early response to certain conditions can reduce mortality and morbidity,4 but most hospitals do not have a system to ensure an adequate response to acute illness.

To identify deteriorating patients and start treatment promptly, solutions have been proposed, introduced, developed and promoted. An ideal system would rapidly:

identify patients at risk accurately

summon a team with suitable skills

resuscitate the patient systematically, and

establish a plan for the patient’s own care team to provide further treatment.

Hillman and colleagues introduced one of the first systems, the Medical Emergency Team (MET), in 1990.5 This system has been developed and evaluated by them and other users.6 They, and colleagues using the MET system, have shown reductions in unexpected cardiac arrests7 and emergency intensive care unit (ICU) admissions.8 The introduction of an MET also leads to more formal planning of patient care and declaration of resuscitation status,9 and an improvement in education of all non-critical care staff in the application of resuscitation techniques.10

The contributions of individual components of the system are still being investigated. The aim of an MET is to apply ICU care to those who will benefit from it at an early, planned stage. This should reduce the number of patients who deteriorate in the ward and suffer cardiorespiratory arrests. In addition, the MET can identify those patients who will not benefit from escalation of care. If a not-for-resuscitation (NFR) decision is made, futile cardiopulmonary resuscitation is prevented and more appropriate symptom control or palliative care can be given. The MET concept has been taken up by some other Australasian hospitals, although many await the results of a multicentre trial of the concept. This is being carried out in association with the Australian and New Zealand Intensive Care Society, and is known as the Medical Early Response Intervention and Therapy (MERIT) study. The results are expected this year, and should show if an MET affects three primary outcome measures: NFR deaths; cardiorespiratory arrests; and unanticipated admissions to the ICU.11 The most enthusiastic of its supporters argue that the MET concept should be widely introduced, despite a lack of conclusive evidence of its effectiveness, and contend that delay in setting up METs could already have resulted in preventable deaths.12

A report in the UK, entitled ‘Comprehensive Critical Care’,13 promoted the use of outreach critical care as part of increased critical care funding. Although there was no prescribed model, many hospitals introduced solutions based on the MET system, with varied emphasis on the staffing, education and calling components. It has been said that these developments were funded and promoted without sufficient evidence.14 Encouragingly, some of the results of this relatively uncontrolled development have recently been reported in the National Outreach Report 2003,15 which calls for continued data collection and audit. The NHS Service Delivery and Organisation Research and Development programme is considering proposals for more detailed and longer term evaluation of outreach critical care.16

Early recognition of the patient at risk is crucial to the success of outreach. Activation of the team in nearly all systems includes permission for even junior members of the ward staff to call for help if they are worried about a patient. They must know that this action will not provoke criticism or blame. Rather, the attendance of a more senior and experienced team will continually reinforce education of the ward staff. This is crucial to development of the educational and cultural aspects of improved care.

Activation may also be based on physiological ‘Track and Trigger’ systems (TTS). These have physiological criteria similar to those of the MET, but the normal values, measurements used, and thresholds for team activation differ. At least 95 units in England are using varieties of these along with an outreach service.15 TTSs are also used by hospitals without a formal outreach service. This means that it is difficult to study the performance of TTSs.

In this issue of the journal, Goldhill and McNarry17 present the results of a study of all non-ICU inpatients who were not documented as NFR in a modern urban hospital on a single day. All were assessed for physiological derangements. Results were based on a single assessment, usually routine observations obtained by ward staff. Even this simple technique showed that many patients had results outwith the defined normal values used by the local outreach critical care team. For example, 31% of assessed patients had two or more abnormal results. Patients with the most abnormal measurements had the highest mortality. Only six of 47 patients with three or more physiological abnormalities, a group with a 30-day mortality of 21.3%, and whose scores could trigger a response from the Patient at Risk Team (PART),18 were receiving level 1 or 2 critical care. The remainder were being cared for in standard ward areas.

This confirms that a TTS based on simple measurements, in Goldhill and McNarry’s hospital, identifies a high-risk group of patients, although it does not necessarily identify those patients who will deteriorate further or benefit from a higher level of care. It is worrying that so many patients have abnormal values. This clearly needs further research, as too low a threshold for activation may lead to an unacceptably high workload for teams, and some patients may tolerate abnormal values without detriment. If items with more discrimination were identified, attention could be directed to ensuring that these are reliably measured and charted, as in practical terms, unfortunately, even simple data may be unavailable or inaccurate, or be misinterpreted.1921

Individual parts of physiological scoring systems may have different predictive abilities at different times or in varied conditions.22 23 Continuous monitoring of patients receiving level 1 or 2 care might reveal which sorts of patient are most vulnerable, and which changes indicate important worsening. Such changes and patterns may be interpreted in other ways by experienced ward staff, and the relationship between the ‘worried’ calls and these observations would bear further examination.

Studies of the larger numbers of ward patients are more problematic. Certainly, to increase the use of continuous monitoring changes current practice, but even analysing simple ward-acquired data might show which parts of the TTS contribute most to discrimination and calibration, or are practically easier to collect and more useful.24 Even these studies may have an effect, as introduction of a TTS has been reported to improve the quality of routinely recorded observations.15

The background against which these changes are being introduced is also changing. Legally required reductions in working hours for trainees in the UK could increase critical care involvement in management of all ill patients in hospital, particularly at night. Training in recognition of the critically ill patient and early, effective treatment is being encouraged by intensive care doctors,25 and introduced or expanded in all specialities through courses such as Care of the Critically Ill Surgical Patient (CCrISP), Fundamental Critical Care Support (FCCS), and Acute Life-threatening events Recognition and Treatment (ALERT) courses. The originators of the MET system have always stressed the need to change the skills and attitudes of those caring for patients, with a major emphasis on education.

We have started to think more clearly about using simple observations to prompt urgent treatment of those patients who need it, and this process is unlikely to stop (and should not be stopped). We should take the chance to work out how best to do this, by determining which of our patients with abnormal recordings are most at risk.

D. W. McKeown

University of Edinburgh

Anaesthesia, Critical Care and Pain Medicine

Royal Infirmary of Edinburgh

51 Little France Crescent

Edinburgh EH16 4SA

UK

E-mail: dermot.mckeown{at}ed.ac.uk

References

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