ORIGINAL ARTICLE
Rapid response team patients triaged to remain on ward despite deranged vital signs: missed opportunities? J. Tirkkonen1,2
, T. Kontula1,3 and S. Hoppu1
1
Department of Intensive Care Medicine, Tampere University Hospital, Tampere, Finland Department of Anaesthesiology and Intensive Care Medicine, Sein€ajoki Central Hospital, Sein€ ajoki, Finland 3 Department of Emergency Medicine, Jyv€askyl€a Central Hospital, Jyv€ askyl€ a, Finland 2
Correspondence J. Tirkkonen, Department of Intensive Care Medicine, Tampere University Hospital, PO Box 2000, FI-33521 Tampere, Finland E-mail: [email protected] Conflict of interest Authors declare no conflicts of interests. Funding This study was financially supported by the Competitive Research Funding of the Tampere University Hospital (Grant 9S009). Submitted 2 August 2017; accepted 13 August 2017; submission 20 April 2017. Citation Tirkkonen J, Kontula T, Hoppu S. Rapid response team patients triaged to remain on ward despite deranged vital signs: missed opportunities?. Acta Anaesthesiologica Scandinavica 2017 doi: 10.1111/aas.12993
Background: Rapid response teams (RRTs) triage most patients to stay on ward, even though some of them have deranged vital signs according to RRTs themselves. We investigated the prevalence and outcome of this RRT patient cohort. Methods: A prospective observational study was conducted in a Finnish tertiary referral centre, Tampere University Hospital. Data on RRT activations were collected between 1 May 2012 and 30 April 2015. Vital signs of patients triaged to stay on ward without treatment limitations were classified according to objective RRT trigger criteria observed during the reviews. Results: During the study period, 860 patients had their first RRT review and were triaged to stay on ward. Of these, 564 (66%) had deranged vital signs, while 296 (34%) did not. RRT patients with deranged vital signs were of comparable age and comorbidity index as stable patients. Even though the patients with deranged vital signs had received RRT interventions, such as fluids and medications, more often than the stable patients, they required new RRT reviews more often and had higher in-hospital and 30-day mortality. Moreover, the former group had substantially higher 1-year mortality than the latter (37% vs. 29%, P = 0.014). In a multivariate regression analysis, deranged vital signs during RRT review was found to be independently associated with 30-day mortality (OR 1.74; 95% CI 1.12–2.70). Conclusion: Patients triaged to stay on ward despite deranged vital signs are high-risk patients who could benefit from routine follow-up by RRT nurses before they deteriorate beyond salvation.
Editorial Comment
Rapid response teams from ICUs initiate interventions and relocation for some ward patients. This study examined patients without treatment limitations who were visited by the team, had deranged vital signs, but were triaged to stay on the ward. They had higher mortality rates compared to others visited but without derangements, and, thus, represent an important high-risk patient group. Rapid response teams (RRTs) assess deteriorated general ward patients to either provide minor interventions that change the course of
the illness or escalate care to intensive care.1 Alternatively, in appropriate cases, ethically sound limitations of medical treatment (LOMT)
Acta Anaesthesiologica Scandinavica (2017) ª 2017 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd
An international journal of anaesthesiology, intensive care, pain, and critical emergency medicine
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may be implemented.1 A recent systematic review found that a median of 8.1% of RRT reviews result in LOMT, while a median of 23% result in a transfer to an intensive care unit (ICU).2 Thus, over half of RRT patients without LOMT are triaged to stay on ward. Rapid response teams are triggered when the general ward staff observes deranged vital signs in a ward patient, as defined by the hospital’s objective RRT activation criteria.1,3 However, a RRT may also be triggered by a subjective ‘worried’ criterion if a patient is deemed at risk despite not fulfilling the objective trigger criteria.3 It should also be noted that it is rare for all vital signs to be measured in general wards.4,5 The percentage of RRT patients who actually fulfil the objective RRT criteria when the RRT arrives and conducts the patient assessment has not been studied. The outcomes of patients who are triaged to stay on ward despite deranged vital signs being noted by the RRT is also unknown. In this prospective observational trial, we aim to investigate the outcomes of RRT patients triaged to stay on ward, and we assess RRT triage performance by applying the very criteria used to summon the team in the first place. If the patients who are triaged to stay on ward with deranged vital signs have substantially worse outcomes, they could benefit from routine follow-up by RRT nurses in the future. Methods Ethics The Ethics Committee of the Tampere University Hospital (TAYS) approved the study protocol (Approval no: R10111, 13.9.2010) and the general data collection process is stated at inclinicaltrials.gov (https://clinicaltrials.gov/ct2/show/ NCT01214460). Setting TAYS is a tertiary referral centre in southern Finland that provides the most advanced care for 67 municipalities (catchment population: 1,100,000). Excluding the ICU, the emergency department and obstetric & paediatric wards, the hospital has 538 somatic general ward beds.
The mixed adult surgical-medical ICU has 22 beds (3.9% of adult somatic beds). During the last years, the ICU occupancy has constantly been under 70%. A rapid response system (RRS) was implemented in 2009 and it operates 24/7 from the ICU. The hospital’s RRT is physician-led (attending or resident) and the physician is accompanied by two ICU nurses. The RRT physician has no clinical duties in ICU, but responds to RRT calls and provides intensive care level consultation in emergency room if needed. The afferent limb utilises dichotomised objective trigger criteria (heart rate < 40/min or > 140/min, systolic blood pressure < 90 mmHg, peripheral arteriolar oxygen saturation < 90%, respiratory rate < 5/min or > 24/min and decrease in state of consciousness) in addition to the ‘worried’ criterion. The RRT also attends all cardiac arrest calls, and RRT nurses provide predetermined outreach visits to discharged ICU patients if deemed appropriate by the treating ICU physician. Data collection and exclusion criteria Data on all RRT activations were prospectively collected from 1 May 2012 to 30 April 2015 in line with the Utstein scientific statement.6 Data on long-term outcomes were retrieved from the Finnish Population Register Centre, which is able to provide accurate mortality data based on unique personal identity code issued for every citizen at birth, but only under a license and after an approved application process and proper authorisation. RRT may on rare occasions attend ICU patients, paediatric patients, patients in operation theatre and outpatients; these RRT activations were excluded from the analyses. As we intended to study the outcomes of RRT patients triaged to stay on ward, cardiac arrest reviews, repeat reviews, reviews of patients with pre-existing LOMTs and reviews resulting in ICU transfers or new LOMTs were further excluded. Definitions Here, ‘RRT activation’ refers to calls which are triggered by the ward staff; scheduled outreach visits for preselected ICU patients were not regarded as RRT activations. In cases in which a Acta Anaesthesiologica Scandinavica (2017)
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RRT PATIENTS TRIAGED TO REMAIN ON WARD
patient required CPR conducted by ward staff and/or the RRT, the activation was considered a cardiac arrest review. Vital signs were defined as ‘deranged’ during a RRT review if the RRT staff measured vital signs that fulfilled the objective RRT criteria after arriving to the scene. An alert, voice, pain, unresponsive (AVPU) assessment score ≤ 3 was considered to indicate deranged vital signs, as preceding level of consciousness could not be reliably determined for comparison. A delayed activation of the RRT, also known as afferent limb failure,7 was defined as follows in this study: even though ward staff have recorded objective positive activation criteria 20 360 min before the RRT activation, they do not activate the RRT.
both univariate- and multivariate analyses. Unless otherwise indicated, data are presented as numbers with percentages. Chi-square and Mann–Whitney U-tests were used for comparisons between groups. Factors independently associated with worse 30-day mortality were investigated with multivariate logistic regression. The ‘enter’ model was applied, and a Hosmer-Lemeshow test was conducted to report the goodness-of-fit of the model. All tests were twosided; P < 0.05 was considered significant, and 95% confidence intervals were used in the multivariate regression model. Statistical analyses were conducted using SPSS version 20 for Windows (SPSS Inc., Chicago, IL, USA). Results
Statistics No formal sample size calculation was conducted; based on our previous studies8,9 and other preceding publications on independent factors for worse outcomes among RRT patients,10–12 we estimated that a 3-year trial period would provide an adequate cohort for
RRT activations during the study period and the final cohort A total of 1914 RRT activations potentially meeting the secondary inclusion criteria occurred during the study period. Figure 1 presents the further excluded RRT reviews and the
Fig. 1. Rapid response team activations during the study period with the final cohort. RRT, rapid response team; ICU, intensive care unit; LOMT, limitations of medical treatment. Acta Anaesthesiologica Scandinavica (2017) ª 2017 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd
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final cohort of 860 RRT patients. Two-thirds of the included patients (564, 66%) had deranged vital signs according to the RRT staff, while 296 (34%) did not. Characteristics and outcome of the RRT patients triaged to stay on ward with observed vs. absent derangements in vital signs The backgrounds of patients with deranged vital signs were comparable to those of patients without recorded derangements in vital signs, with a few exceptions: the former were predominantly male and had more often been acutely admitted to the hospital (Table 1). The RRT review characteristics differed between the two sub cohorts (Table 1). RRT reviews of patients with deranged vital signs according to the RRT criteria occurred more often during on-call hours, took longer, were more often triggered by objective activation criteria and included RRT interventions more often than reviews where no vital sign derangements were observed. Delayed RRT activation was also more common among patients with deranged vital signs during the review. Altogether 168 patients required a repeat RRT review during their hospitalisation, and 86 (51%) of these occurred within 24 h after the initial review. Repeat reviews resulted in ICU transfers in 34 (20%) cases and, on the other hand, new LOMTs in 14 (8.3%) of the cases. Patients with objective vital dysfunctions, but who were nonetheless triaged to stay on ward, required a new RRT review more often (22% vs. 15%, P = 0.012) (Table 2). These patients also had longer hospital stays and higher inhospital, 30-day and one-year mortality rates as compared with patients triaged to stay on ward with normal vital signs (Table 2). Factors independently associated with 30day mortality among RRT patients triaged to remain on ward Table 3 presents the results of the multivariate regression model. Greater age (1.03; 1.02–1.05), non-elective hospital admission (2.74; 1.59– 4.74), higher Charlson comorbidity index (1.18; 1.08–1.29), deranged vital signs recorded by the
RRT (1.74; 1.12–2.70), having a medical reason for hospital admission (1.56; 1.06–2.29) and delayed RRT activation (1.55; 1.05–2.28) were the factors found to be independently associated with increased 30-day mortality. Discussion Major findings The entire concept of the rapid response system is based on deranged vital signs that are (1) noted in time and (2) acted upon swiftly, as it has repeatedly been demonstrated that vital sign abnormalities, defined as RRT trigger criteria, predict a tenuous outcome.1,13,14 We found that no-LOMT RRT patients who have deranged vital signs but are nevertheless triaged to stay on ward are at higher risk for 30-day mortality as compared with the RRT patients with normal vital signs; this finding was confirmed as an independent association in a multivariate regression model. RRT triage performance and comparison to the previous studies In 2013, Schneider et al. published a study on their RRT triage performance in an Australian hospital using 24 h survival as a performance measure.15 Only 0.4% of the patients died during the following 24 h, a percentage clearly lower than in our study (3.0%).15 The percentages of repeat calls during the first 24 h were more comparable (13 for Schneider et al. and 10 here). To our knowledge, no other studies have specifically investigated RRT triage performance. The 24 h mortality rate of RRT patients triaged to stay on ward has been rarely documented; when it has, it has ranged between 3.0% and 9.3%.16,17 Since our study is the first to assess the association of vital signs observed by the RRT itself with short- and long-term outcomes, it is unknown how often patients who fulfil the RRT activation criteria on site are triaged to stay on ward in other institutions. Furthermore, as most repeat activations occur more than 24 h after the first call,10 24-h outcome alone may not be a sufficient measure of triage performance. As suggested by Schneider et al., RRT triage performance could be best investigated by Acta Anaesthesiologica Scandinavica (2017)
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RRT PATIENTS TRIAGED TO REMAIN ON WARD
Table 1 Characteristics of patients triaged to remain on general ward after a RRT review.
Patient characteristics Age (median; Q1, Q3) Sex (male) Medical patient CCI (median; Q1, Q3) Coronary artery disease Chronic heart failure Peripheral artery disease Cerebrovascular disease Diabetes Chronic obstructive pulmonary disease Renal insufficiency Malignancy Elective hospital admission Total length of hospital admission (days, median; Q1, Q3) Preceding ICU admission Surgery 0–24 h before the review RRT review characteristics Review during on-call time* Delayed RRT activation† Length of RRT review (min) (median; Q1, Q3) Reason for RRT activation Respiratory Circulatory Neurological Multiple Other‡ RRT intervention Fluids Oxygen§ Medications
Deranged vital signs recorded by RRT (n = 564)
Normal vital signs recorded by RRT (n = 296)
P-value
69 348 226 2.0 80 88 56 90 137 62 46 139 449 11 112 73
68 159 102 2.0 38 42 27 35 76 22 31 73 194 8 56 47
0.452 0.024 0.107 0.133 0.586 0.582 0.703 0.102 0.635 0.095 0.258 0.996 < 0.001 0.001 0.741 0.238
(59, 78) (62) (40) (1.0, 3.0) (14) (16) (10) (16) (24) (11) (8.2) (25) (80) (5, 20) (20) (13)
(55, 78) (53) (35) (0.0, 3.0) (13) (14) (9.1) (12) (26) (7.4) (11) (25) (66) (4, 16) (19) (16)
448 (80) 239 (42) 30 (22, 43)
210 (71) 59 (20) 22 (14, 32)
254 115 80 31 84 91 188 389 200
79 56 46 11 104 87 77 144 43
(45) (20) (14) (5.5) (15) (65) (33) (69) (36)
(27) (19) (16) (3.7) (35) (63) (26) (49) (15)
0.005 < 0.001 < 0.001
< 0.001
0.027 < 0.001 < 0.001
Data are presented as numbers (percentages) if not otherwise indicated. RRT, rapid response team; CCI, Charlson comorbidity index; Malignancy, malignant solid tumour or haematological malignancy; ICU, intensive care unit. *On-call time: Other than Monday Friday 8:00 hours to 15:00 hours. †Delayed RRT activation (also known as afferent limb failure):7 documented positive RRT activation criteria 20 360 min before the RRT activation. ‡Includes the calls triggered by ‘staff worried’ criterion. §Includes all interventions related to oxygenation (oxygen mask, increase in oxygen flow, continuous positive airway pressure).
combining documented vital sign data and both short- and long-term outcomes.15 Retrospectively, we may conclude that some triage errors likely occurred in our cohort, as the RRT patients who were triaged to stay on ward despite deranged vital signs required repeat reviews more frequently and had higher shortand long-term mortality. Deranged vital signs during RRT activation Doesn’t every RRT patient, by definition, have deranged vital signs? To our knowledge, this is
the first study to investigate this topic, but the answer is most likely ‘no’ for other institutions as well. In survey studies, 48% to 56% of ward nurses would trigger an RRT if they were worried about their patient even if the patient’s vital signs were within the normal range according to the hospital’s objective trigger criteria.18,19 This practice is encouraged by the 2006 consensus statement,20 and indeed, 5.0% to 29% of all RRT activations are triggered because of the ‘worried’ criterion.3,10 On the other hand, vital signs may often be inadequately measured and/ or interpreted by the ward nurses.21,22
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Table 2 Outcome of patients triaged to remain on general ward after a RRT review.
Patient outcome New RRT review 24 h mortality Hospital mortality 30-day mortality One-year mortality
Deranged vital signs recorded by RRT (n = 564)
Normal vital signs recorded by RRT (n = 296)
P-value
124 21 87 118 211
44 5 18 33 86
0.012 0.098 < 0.001 < 0.001 0.014
(22) (3.7) (15) (21) (37)
(15) (1.7) (6.1) (11) (29)
Data are presented as numbers (percentages) if not otherwise indicated. RRT, rapid response team.
Table 3 Multivariate logistic regression analysis of factors independently associated with 30-day mortality of patients remaining on general ward after RRT review. Multivariate analysis
Age Non-elective hospital admission CCI Deranged vital signs recorded by the RRT Medical patient Delayed RRT activation Surgery 0–24 h before the review Preceding ICU admission Sex (female) Review during on-call time*
Odds ratio
95% CI
P-value
1.03 2.74 1.18 1.74
1.02–1.05 1.59–4.74 1.08–1.29 1.12–2.70
< 0.001 < 0.001 < 0.001 0.014
1.56 1.55 0.75
1.06–2.29 1.05–2.28 0.41–1.39
0.024 0.026 0.360
0.89 1.08 1.00
0.53–1.51 0.74–1.58 0.64–1.57
0.668 0.702 0.995
RRT studies challenging. We applied our hospital’s own trigger thresholds to define abnormal vital signs, since these are the same thresholds the ward staff are expected to follow. Not all patients with deranged vital signs observed by the RRT can be admitted to intensive care, and the RRT assesses whether the patient can be left on ward with (or without) minor interventions. Our results show that patients with and without deranged vital signs were of similar backgrounds, but those with deranged vital signs had worse outcomes, independent of confounding factors. One could therefore consider issuing routine follow-up visits to no-LOMT RRT patients triaged to stay on ward despite deranged vital signs, especially because, as we have demonstrated, every fifth of these patients require a repeat RRT review in any case. In our cohort, routine follow-up visits would have allowed 564 patients to be re-evaluated during the 3-year period (= the equivalent of one follow-up every other day). At our institution, this could be relatively easy to organise. With routine follow-up visits it could be reliably observed, that either stabilisation has occurred or patient requires further interventions. Study implications
The Hosmer-Lemeshow goodness-of-fit Chi-square (8) with P = 0.910 indicated a good fit of the model. RRT, rapid response team; CI, confidence interval; CCI, Charlson comorbidity index; ICU, intensive care unit. *On-call time: Other than Monday Friday 8:00 hours to 15:00 hours.
The portion of RRT patients triaged to stay on ward despite deranged vital signs, as well as the outcomes of patients triaged to stay on ward, should be documented in future studies reporting on RRT cohorts from different institutions. Furthermore, it should be investigated whether such patients would benefit from routine liaison nurse follow-up in vivo, as their outcome is currently poor when compared to that of patients triaged to stay on ward with normal vital signs. Study strengths and limitations
Therefore, it is clearly crucial that RRTs measure and interpret vital signs upon arrival as is done by emergency medical services in out-of-hospital situations. The definition of ‘deranged vital signs’ depends on the thresholds set for systolic blood pressure, heart rate, respiratory rate, etc. There is great variation in the thresholds used in different centres,23,24 making comparison between
This study was conducted in a large tertiary referral centre that admits patients from all specialties. The hospital’s RRT had already been in place for over 3 years when the study period began, so the RRS should have already matured to some degree. In addition to short-term outcomes (24-h and in-hospital mortality), fixed long-term outcomes were also documented, and 30-day mortality was used in the multivariate Acta Anaesthesiologica Scandinavica (2017)
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RRT PATIENTS TRIAGED TO REMAIN ON WARD
regression model. Importantly, patients with preceding or new treatment limitations were excluded and the ‘expected’ deaths were ruled out from the analyses. These strengths should be weighed against the limitations of this study. First, our study was conducted in a single centre in a Nordic country. Second, our RRS has several specific features that may not apply to other institutions: the afferent limb utilises hospital-specific dichotomised trigger criteria; our RRT is led by an ICU physician; and our RRT also responds to cardiac arrests. These factors limit the generalisability of our results. Third, although our RRT admitted patients to the ICU at rates comparable to other studies, we are unable to comment on whether a small number of patients were triaged to stay on ward partly because of a momentary shortage of ICU resources. Fourth, some RRT patients may have been triaged to stay on ward because their vital signs stabilised substantially during the review, but unfortunately full data on the ‘last measured vital signs’ before RRT departure were recorded too infrequently for this to be examined here. Fifth, sufficient sample size was estimated using the results of previous observational studies; no formal sample size calculations were conducted. Conclusions Rapid response teams patients triaged to stay on ward despite deranged vital signs have longer hospital stays, require repeat RRT reviews more often and have higher short- and long-term mortality rates. Deranged vital signs observed by the RRT during a review is an independent risk factor for 30-day mortality. Acknowledgements None. References 1. Jones D, DeVita M, Bellomo R. Rapid-response teams. N Engl J Med 2011; 365: 139–46. 2. Tirkkonen J, Tamminen T, Skrifvars MB. Outcome of adult patients attended by rapid response teams: a systematic review of the literature. Resuscitation 2017; 112: 43–52.
3. Santiano N, Young L, Hillman K, Parr M, Jayasinghe S, Baramy LS, Stevenson J, Heath T, Chan C, Claire M, Hanger G. Analysis of Medical Emergency Team calls comparing subjective to “objective” call criteria. Resuscitation 2009; 80: 44–9. 4. Leuvan CH, Mitchell I. Missed opportunities? An observational study of vital sign measurements. Crit Care Resusc 2008; 10: 111–5. 5. McGain F, Creticos MA, Jones D, Van Dyk S, Buist MD, Opdam H, Pellegrino V, Robertson MS, Bellomo R. Documentation of clinical review and vital signs after major surgery. Med J Aust 2008; 189: 380–3. 6. Peberdy MA, Cretikos M, Abella BS, DeVita M, Goldhill D, Kloeck W, Kronick SL, Morrison LJ, Nadkarni VM, Nichol G, Nolan JP, Parr M, Tibballs J, van der Jagt EW, Young L, International Liaison Committee on Resuscitation; American Heart Association; Australian Resuscitation Council; European Resuscitation Council; Heart and Stroke Foundation of Canada; InterAmerican Heart Foundation; Resuscitation Council of Southern Africa; New Zealand Resuscitation Council; American Heart Association Emergency Cardiovascular Care Committee; American Heart Association Council on Cardiopulmonary, Perioperative, and Critical Care; Interdisciplinary Working Group on Quality of Care and Outcomes Research. Recommended guidelines for monitoring, reporting, and conducting research on medical emergency team, outreach, and rapid response systems: an Utstein-style scientific statement. Circulation 2007; 116: 2481–500. 7. Trinkle RM, Flabouris A. Documenting rapid response system afferent limb failure and associated patient outcomes. Resuscitation 2011; 82: 810–4. 8. Tirkkonen J, Yl€ a-Mattila J, Olkkola KT, Huhtala H, Tenhunen J, Hoppu S. Factors associated with delayed activation of medical emergency team and excess mortality: an Utstein-style analysis. Resuscitation 2013; 84: 173–8. 9. Tirkkonen J, Olkkola KT, Tenhunen J, Hoppu S. Ethically justified treatment limitations in emergency situations? Eur J Emerg Med 2016; 23: 214–8. 10. Calzavacca P, Licari E, Tee A, Mercer I, Haase M, Haase-Fielitz A, Jones D, Gutteridge G, Bellomo R. Features and outcome of patients receiving multiple Medical Emergency Team reviews. Resuscitation 2010; 81: 1509–15. 11. Boniatti MM, Azzolini N, Viana MV, Ribeiro BS, Coelho RS, Castilho RK, Guimar~ aes MR, Zorzi L,
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Schulz LF, Filho EM. Delayed medical emergency team calls and associated outcomes. Crit Care Med 2014; 42: 26–30. Calzavacca P, Licari E, Tee A, Egi M, Haase M, Haase-Fielitz A, Bellomo R. A prospective study of factors influencing the outcome of patients after a Medical Emergency Team review. Intensive Care Med 2008; 34: 2112–6. Bell MA, Konrad D, Granath F, Ekbom A, Martling CR. Prevalence and sensitivity of MET-criteria in a Scandinavian University Hospital. Resuscitation 2006; 70: 66–73. Fuhrmann L, Lippert A, Perner A, Østergaard D. Incidence, staff awareness and mortality of patients at risk on general wards. Resuscitation 2008; 77: 325–30. Schneider AG, Warrilow S, Robbins R, Jones DA, Bellomo R. An assessment of the triage performance of the efferent arm of the rapid response system. Resuscitation 2013; 84: 477–82. Dacey MJ, Mirza ER, Wilcox V, Doherty M, Mello J, Boyer A, Gates J, Brothers T, Baute R. The effect of a rapid response team on major clinical outcome measures in a community hospital. Crit Care Med 2007; 35: 2076–82. Herod R, Frost SA, Parr M, Hillman K, Aneman A. Long term trends in medical emergency team activations and outcomes. Resuscitation 2014; 85: 1083–7. Jones D, Baldwin I, McIntyre T, Story D, Mercer I, Miglic A, Goldsmith D, Bellomo R. Nurses’ attitudes to a medical emergency team service in a teaching hospital. Qual Saf Health Care 2006; 15: 427–32.
19. Bagshaw SM, Monror EE, Scouten C, Montgomery C, Slater-MacLean L, Jones DA, Bellomo R, Gibney RT, Capital Health Medical Emergency Team Investigators. A survey of nurses’ beliefs about the medical emergency team system in a canadian tertiary hospital. Am J Crit Care 2010; 19: 74–83. 20. DeVita MA, Bellomo R, Hillman K, Kellum J, Rotondi A, Teres D, Auerbach A, Chen WJ, Duncan K, Kenward G, Bell M, Buist M, Chen J, Bion J, Kirby A, Lighthall G, Ovreveit J, Braithwaite RS, Gosbee J, Milbrandt E, Peberdy M, Savitz L, Young L, Harvey M, Galhotra S. Findings of the first consensus conference on medical emergency teams. Crit Care Med 2006; 34: 2463–78. 21. Hands C, Reid E, Meredith P, Smith GB, Prytherch DR, Schmidt PE, Featherstone PI. Patterns in the recording of vital signs and early warning scores: compliance with a clinical escalation protocol. BMJ Qual Saf 2013; 22: 719–26. 22. Kolic I, Crane S, McCartney S, Perkins Z, Taylor A. Factors affecting response to national early warning score (NEWS). Resuscitation 2015; 90: 85–90. 23. ANZICS-CORE MET dose Investigators, Jones D, Drennan K, Hart GK, Bellomo R, Web SA. Rapid Response Team composition, resourcing and calling criteria in Australia. Resuscitation 2012; 83: 563–7. 24. Tirkkonen J, Nurmi J, Olkkola KT, Tenhunen J, Hoppu S. Cardiac arrest teams and medical emergency teams in Finland: a nationwide crosssectional postal survey. Acta Anaesthesiol Scand 2014; 58: 420–7.
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Rapid response team patients triaged to remain on ward despite deranged vital signs: missed opportunities? J. Tirkkonen1,2
, T. Kontula1,3 and S. Hoppu1
1
Department of Intensive Care Medicine, Tampere University Hospital, Tampere, Finland Department of Anaesthesiology and Intensive Care Medicine, Sein€ajoki Central Hospital, Sein€ ajoki, Finland 3 Department of Emergency Medicine, Jyv€askyl€a Central Hospital, Jyv€ askyl€ a, Finland 2
Correspondence J. Tirkkonen, Department of Intensive Care Medicine, Tampere University Hospital, PO Box 2000, FI-33521 Tampere, Finland E-mail: [email protected] Conflict of interest Authors declare no conflicts of interests. Funding This study was financially supported by the Competitive Research Funding of the Tampere University Hospital (Grant 9S009). Submitted 2 August 2017; accepted 13 August 2017; submission 20 April 2017. Citation Tirkkonen J, Kontula T, Hoppu S. Rapid response team patients triaged to remain on ward despite deranged vital signs: missed opportunities?. Acta Anaesthesiologica Scandinavica 2017 doi: 10.1111/aas.12993
Background: Rapid response teams (RRTs) triage most patients to stay on ward, even though some of them have deranged vital signs according to RRTs themselves. We investigated the prevalence and outcome of this RRT patient cohort. Methods: A prospective observational study was conducted in a Finnish tertiary referral centre, Tampere University Hospital. Data on RRT activations were collected between 1 May 2012 and 30 April 2015. Vital signs of patients triaged to stay on ward without treatment limitations were classified according to objective RRT trigger criteria observed during the reviews. Results: During the study period, 860 patients had their first RRT review and were triaged to stay on ward. Of these, 564 (66%) had deranged vital signs, while 296 (34%) did not. RRT patients with deranged vital signs were of comparable age and comorbidity index as stable patients. Even though the patients with deranged vital signs had received RRT interventions, such as fluids and medications, more often than the stable patients, they required new RRT reviews more often and had higher in-hospital and 30-day mortality. Moreover, the former group had substantially higher 1-year mortality than the latter (37% vs. 29%, P = 0.014). In a multivariate regression analysis, deranged vital signs during RRT review was found to be independently associated with 30-day mortality (OR 1.74; 95% CI 1.12–2.70). Conclusion: Patients triaged to stay on ward despite deranged vital signs are high-risk patients who could benefit from routine follow-up by RRT nurses before they deteriorate beyond salvation.
Editorial Comment
Rapid response teams from ICUs initiate interventions and relocation for some ward patients. This study examined patients without treatment limitations who were visited by the team, had deranged vital signs, but were triaged to stay on the ward. They had higher mortality rates compared to others visited but without derangements, and, thus, represent an important high-risk patient group. Rapid response teams (RRTs) assess deteriorated general ward patients to either provide minor interventions that change the course of
the illness or escalate care to intensive care.1 Alternatively, in appropriate cases, ethically sound limitations of medical treatment (LOMT)
Acta Anaesthesiologica Scandinavica (2017) ª 2017 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd
An international journal of anaesthesiology, intensive care, pain, and critical emergency medicine
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may be implemented.1 A recent systematic review found that a median of 8.1% of RRT reviews result in LOMT, while a median of 23% result in a transfer to an intensive care unit (ICU).2 Thus, over half of RRT patients without LOMT are triaged to stay on ward. Rapid response teams are triggered when the general ward staff observes deranged vital signs in a ward patient, as defined by the hospital’s objective RRT activation criteria.1,3 However, a RRT may also be triggered by a subjective ‘worried’ criterion if a patient is deemed at risk despite not fulfilling the objective trigger criteria.3 It should also be noted that it is rare for all vital signs to be measured in general wards.4,5 The percentage of RRT patients who actually fulfil the objective RRT criteria when the RRT arrives and conducts the patient assessment has not been studied. The outcomes of patients who are triaged to stay on ward despite deranged vital signs being noted by the RRT is also unknown. In this prospective observational trial, we aim to investigate the outcomes of RRT patients triaged to stay on ward, and we assess RRT triage performance by applying the very criteria used to summon the team in the first place. If the patients who are triaged to stay on ward with deranged vital signs have substantially worse outcomes, they could benefit from routine follow-up by RRT nurses in the future. Methods Ethics The Ethics Committee of the Tampere University Hospital (TAYS) approved the study protocol (Approval no: R10111, 13.9.2010) and the general data collection process is stated at inclinicaltrials.gov (https://clinicaltrials.gov/ct2/show/ NCT01214460). Setting TAYS is a tertiary referral centre in southern Finland that provides the most advanced care for 67 municipalities (catchment population: 1,100,000). Excluding the ICU, the emergency department and obstetric & paediatric wards, the hospital has 538 somatic general ward beds.
The mixed adult surgical-medical ICU has 22 beds (3.9% of adult somatic beds). During the last years, the ICU occupancy has constantly been under 70%. A rapid response system (RRS) was implemented in 2009 and it operates 24/7 from the ICU. The hospital’s RRT is physician-led (attending or resident) and the physician is accompanied by two ICU nurses. The RRT physician has no clinical duties in ICU, but responds to RRT calls and provides intensive care level consultation in emergency room if needed. The afferent limb utilises dichotomised objective trigger criteria (heart rate < 40/min or > 140/min, systolic blood pressure < 90 mmHg, peripheral arteriolar oxygen saturation < 90%, respiratory rate < 5/min or > 24/min and decrease in state of consciousness) in addition to the ‘worried’ criterion. The RRT also attends all cardiac arrest calls, and RRT nurses provide predetermined outreach visits to discharged ICU patients if deemed appropriate by the treating ICU physician. Data collection and exclusion criteria Data on all RRT activations were prospectively collected from 1 May 2012 to 30 April 2015 in line with the Utstein scientific statement.6 Data on long-term outcomes were retrieved from the Finnish Population Register Centre, which is able to provide accurate mortality data based on unique personal identity code issued for every citizen at birth, but only under a license and after an approved application process and proper authorisation. RRT may on rare occasions attend ICU patients, paediatric patients, patients in operation theatre and outpatients; these RRT activations were excluded from the analyses. As we intended to study the outcomes of RRT patients triaged to stay on ward, cardiac arrest reviews, repeat reviews, reviews of patients with pre-existing LOMTs and reviews resulting in ICU transfers or new LOMTs were further excluded. Definitions Here, ‘RRT activation’ refers to calls which are triggered by the ward staff; scheduled outreach visits for preselected ICU patients were not regarded as RRT activations. In cases in which a Acta Anaesthesiologica Scandinavica (2017)
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patient required CPR conducted by ward staff and/or the RRT, the activation was considered a cardiac arrest review. Vital signs were defined as ‘deranged’ during a RRT review if the RRT staff measured vital signs that fulfilled the objective RRT criteria after arriving to the scene. An alert, voice, pain, unresponsive (AVPU) assessment score ≤ 3 was considered to indicate deranged vital signs, as preceding level of consciousness could not be reliably determined for comparison. A delayed activation of the RRT, also known as afferent limb failure,7 was defined as follows in this study: even though ward staff have recorded objective positive activation criteria 20 360 min before the RRT activation, they do not activate the RRT.
both univariate- and multivariate analyses. Unless otherwise indicated, data are presented as numbers with percentages. Chi-square and Mann–Whitney U-tests were used for comparisons between groups. Factors independently associated with worse 30-day mortality were investigated with multivariate logistic regression. The ‘enter’ model was applied, and a Hosmer-Lemeshow test was conducted to report the goodness-of-fit of the model. All tests were twosided; P < 0.05 was considered significant, and 95% confidence intervals were used in the multivariate regression model. Statistical analyses were conducted using SPSS version 20 for Windows (SPSS Inc., Chicago, IL, USA). Results
Statistics No formal sample size calculation was conducted; based on our previous studies8,9 and other preceding publications on independent factors for worse outcomes among RRT patients,10–12 we estimated that a 3-year trial period would provide an adequate cohort for
RRT activations during the study period and the final cohort A total of 1914 RRT activations potentially meeting the secondary inclusion criteria occurred during the study period. Figure 1 presents the further excluded RRT reviews and the
Fig. 1. Rapid response team activations during the study period with the final cohort. RRT, rapid response team; ICU, intensive care unit; LOMT, limitations of medical treatment. Acta Anaesthesiologica Scandinavica (2017) ª 2017 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd
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final cohort of 860 RRT patients. Two-thirds of the included patients (564, 66%) had deranged vital signs according to the RRT staff, while 296 (34%) did not. Characteristics and outcome of the RRT patients triaged to stay on ward with observed vs. absent derangements in vital signs The backgrounds of patients with deranged vital signs were comparable to those of patients without recorded derangements in vital signs, with a few exceptions: the former were predominantly male and had more often been acutely admitted to the hospital (Table 1). The RRT review characteristics differed between the two sub cohorts (Table 1). RRT reviews of patients with deranged vital signs according to the RRT criteria occurred more often during on-call hours, took longer, were more often triggered by objective activation criteria and included RRT interventions more often than reviews where no vital sign derangements were observed. Delayed RRT activation was also more common among patients with deranged vital signs during the review. Altogether 168 patients required a repeat RRT review during their hospitalisation, and 86 (51%) of these occurred within 24 h after the initial review. Repeat reviews resulted in ICU transfers in 34 (20%) cases and, on the other hand, new LOMTs in 14 (8.3%) of the cases. Patients with objective vital dysfunctions, but who were nonetheless triaged to stay on ward, required a new RRT review more often (22% vs. 15%, P = 0.012) (Table 2). These patients also had longer hospital stays and higher inhospital, 30-day and one-year mortality rates as compared with patients triaged to stay on ward with normal vital signs (Table 2). Factors independently associated with 30day mortality among RRT patients triaged to remain on ward Table 3 presents the results of the multivariate regression model. Greater age (1.03; 1.02–1.05), non-elective hospital admission (2.74; 1.59– 4.74), higher Charlson comorbidity index (1.18; 1.08–1.29), deranged vital signs recorded by the
RRT (1.74; 1.12–2.70), having a medical reason for hospital admission (1.56; 1.06–2.29) and delayed RRT activation (1.55; 1.05–2.28) were the factors found to be independently associated with increased 30-day mortality. Discussion Major findings The entire concept of the rapid response system is based on deranged vital signs that are (1) noted in time and (2) acted upon swiftly, as it has repeatedly been demonstrated that vital sign abnormalities, defined as RRT trigger criteria, predict a tenuous outcome.1,13,14 We found that no-LOMT RRT patients who have deranged vital signs but are nevertheless triaged to stay on ward are at higher risk for 30-day mortality as compared with the RRT patients with normal vital signs; this finding was confirmed as an independent association in a multivariate regression model. RRT triage performance and comparison to the previous studies In 2013, Schneider et al. published a study on their RRT triage performance in an Australian hospital using 24 h survival as a performance measure.15 Only 0.4% of the patients died during the following 24 h, a percentage clearly lower than in our study (3.0%).15 The percentages of repeat calls during the first 24 h were more comparable (13 for Schneider et al. and 10 here). To our knowledge, no other studies have specifically investigated RRT triage performance. The 24 h mortality rate of RRT patients triaged to stay on ward has been rarely documented; when it has, it has ranged between 3.0% and 9.3%.16,17 Since our study is the first to assess the association of vital signs observed by the RRT itself with short- and long-term outcomes, it is unknown how often patients who fulfil the RRT activation criteria on site are triaged to stay on ward in other institutions. Furthermore, as most repeat activations occur more than 24 h after the first call,10 24-h outcome alone may not be a sufficient measure of triage performance. As suggested by Schneider et al., RRT triage performance could be best investigated by Acta Anaesthesiologica Scandinavica (2017)
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Table 1 Characteristics of patients triaged to remain on general ward after a RRT review.
Patient characteristics Age (median; Q1, Q3) Sex (male) Medical patient CCI (median; Q1, Q3) Coronary artery disease Chronic heart failure Peripheral artery disease Cerebrovascular disease Diabetes Chronic obstructive pulmonary disease Renal insufficiency Malignancy Elective hospital admission Total length of hospital admission (days, median; Q1, Q3) Preceding ICU admission Surgery 0–24 h before the review RRT review characteristics Review during on-call time* Delayed RRT activation† Length of RRT review (min) (median; Q1, Q3) Reason for RRT activation Respiratory Circulatory Neurological Multiple Other‡ RRT intervention Fluids Oxygen§ Medications
Deranged vital signs recorded by RRT (n = 564)
Normal vital signs recorded by RRT (n = 296)
P-value
69 348 226 2.0 80 88 56 90 137 62 46 139 449 11 112 73
68 159 102 2.0 38 42 27 35 76 22 31 73 194 8 56 47
0.452 0.024 0.107 0.133 0.586 0.582 0.703 0.102 0.635 0.095 0.258 0.996 < 0.001 0.001 0.741 0.238
(59, 78) (62) (40) (1.0, 3.0) (14) (16) (10) (16) (24) (11) (8.2) (25) (80) (5, 20) (20) (13)
(55, 78) (53) (35) (0.0, 3.0) (13) (14) (9.1) (12) (26) (7.4) (11) (25) (66) (4, 16) (19) (16)
448 (80) 239 (42) 30 (22, 43)
210 (71) 59 (20) 22 (14, 32)
254 115 80 31 84 91 188 389 200
79 56 46 11 104 87 77 144 43
(45) (20) (14) (5.5) (15) (65) (33) (69) (36)
(27) (19) (16) (3.7) (35) (63) (26) (49) (15)
0.005 < 0.001 < 0.001
< 0.001
0.027 < 0.001 < 0.001
Data are presented as numbers (percentages) if not otherwise indicated. RRT, rapid response team; CCI, Charlson comorbidity index; Malignancy, malignant solid tumour or haematological malignancy; ICU, intensive care unit. *On-call time: Other than Monday Friday 8:00 hours to 15:00 hours. †Delayed RRT activation (also known as afferent limb failure):7 documented positive RRT activation criteria 20 360 min before the RRT activation. ‡Includes the calls triggered by ‘staff worried’ criterion. §Includes all interventions related to oxygenation (oxygen mask, increase in oxygen flow, continuous positive airway pressure).
combining documented vital sign data and both short- and long-term outcomes.15 Retrospectively, we may conclude that some triage errors likely occurred in our cohort, as the RRT patients who were triaged to stay on ward despite deranged vital signs required repeat reviews more frequently and had higher shortand long-term mortality. Deranged vital signs during RRT activation Doesn’t every RRT patient, by definition, have deranged vital signs? To our knowledge, this is
the first study to investigate this topic, but the answer is most likely ‘no’ for other institutions as well. In survey studies, 48% to 56% of ward nurses would trigger an RRT if they were worried about their patient even if the patient’s vital signs were within the normal range according to the hospital’s objective trigger criteria.18,19 This practice is encouraged by the 2006 consensus statement,20 and indeed, 5.0% to 29% of all RRT activations are triggered because of the ‘worried’ criterion.3,10 On the other hand, vital signs may often be inadequately measured and/ or interpreted by the ward nurses.21,22
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Table 2 Outcome of patients triaged to remain on general ward after a RRT review.
Patient outcome New RRT review 24 h mortality Hospital mortality 30-day mortality One-year mortality
Deranged vital signs recorded by RRT (n = 564)
Normal vital signs recorded by RRT (n = 296)
P-value
124 21 87 118 211
44 5 18 33 86
0.012 0.098 < 0.001 < 0.001 0.014
(22) (3.7) (15) (21) (37)
(15) (1.7) (6.1) (11) (29)
Data are presented as numbers (percentages) if not otherwise indicated. RRT, rapid response team.
Table 3 Multivariate logistic regression analysis of factors independently associated with 30-day mortality of patients remaining on general ward after RRT review. Multivariate analysis
Age Non-elective hospital admission CCI Deranged vital signs recorded by the RRT Medical patient Delayed RRT activation Surgery 0–24 h before the review Preceding ICU admission Sex (female) Review during on-call time*
Odds ratio
95% CI
P-value
1.03 2.74 1.18 1.74
1.02–1.05 1.59–4.74 1.08–1.29 1.12–2.70
< 0.001 < 0.001 < 0.001 0.014
1.56 1.55 0.75
1.06–2.29 1.05–2.28 0.41–1.39
0.024 0.026 0.360
0.89 1.08 1.00
0.53–1.51 0.74–1.58 0.64–1.57
0.668 0.702 0.995
RRT studies challenging. We applied our hospital’s own trigger thresholds to define abnormal vital signs, since these are the same thresholds the ward staff are expected to follow. Not all patients with deranged vital signs observed by the RRT can be admitted to intensive care, and the RRT assesses whether the patient can be left on ward with (or without) minor interventions. Our results show that patients with and without deranged vital signs were of similar backgrounds, but those with deranged vital signs had worse outcomes, independent of confounding factors. One could therefore consider issuing routine follow-up visits to no-LOMT RRT patients triaged to stay on ward despite deranged vital signs, especially because, as we have demonstrated, every fifth of these patients require a repeat RRT review in any case. In our cohort, routine follow-up visits would have allowed 564 patients to be re-evaluated during the 3-year period (= the equivalent of one follow-up every other day). At our institution, this could be relatively easy to organise. With routine follow-up visits it could be reliably observed, that either stabilisation has occurred or patient requires further interventions. Study implications
The Hosmer-Lemeshow goodness-of-fit Chi-square (8) with P = 0.910 indicated a good fit of the model. RRT, rapid response team; CI, confidence interval; CCI, Charlson comorbidity index; ICU, intensive care unit. *On-call time: Other than Monday Friday 8:00 hours to 15:00 hours.
The portion of RRT patients triaged to stay on ward despite deranged vital signs, as well as the outcomes of patients triaged to stay on ward, should be documented in future studies reporting on RRT cohorts from different institutions. Furthermore, it should be investigated whether such patients would benefit from routine liaison nurse follow-up in vivo, as their outcome is currently poor when compared to that of patients triaged to stay on ward with normal vital signs. Study strengths and limitations
Therefore, it is clearly crucial that RRTs measure and interpret vital signs upon arrival as is done by emergency medical services in out-of-hospital situations. The definition of ‘deranged vital signs’ depends on the thresholds set for systolic blood pressure, heart rate, respiratory rate, etc. There is great variation in the thresholds used in different centres,23,24 making comparison between
This study was conducted in a large tertiary referral centre that admits patients from all specialties. The hospital’s RRT had already been in place for over 3 years when the study period began, so the RRS should have already matured to some degree. In addition to short-term outcomes (24-h and in-hospital mortality), fixed long-term outcomes were also documented, and 30-day mortality was used in the multivariate Acta Anaesthesiologica Scandinavica (2017)
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regression model. Importantly, patients with preceding or new treatment limitations were excluded and the ‘expected’ deaths were ruled out from the analyses. These strengths should be weighed against the limitations of this study. First, our study was conducted in a single centre in a Nordic country. Second, our RRS has several specific features that may not apply to other institutions: the afferent limb utilises hospital-specific dichotomised trigger criteria; our RRT is led by an ICU physician; and our RRT also responds to cardiac arrests. These factors limit the generalisability of our results. Third, although our RRT admitted patients to the ICU at rates comparable to other studies, we are unable to comment on whether a small number of patients were triaged to stay on ward partly because of a momentary shortage of ICU resources. Fourth, some RRT patients may have been triaged to stay on ward because their vital signs stabilised substantially during the review, but unfortunately full data on the ‘last measured vital signs’ before RRT departure were recorded too infrequently for this to be examined here. Fifth, sufficient sample size was estimated using the results of previous observational studies; no formal sample size calculations were conducted. Conclusions Rapid response teams patients triaged to stay on ward despite deranged vital signs have longer hospital stays, require repeat RRT reviews more often and have higher short- and long-term mortality rates. Deranged vital signs observed by the RRT during a review is an independent risk factor for 30-day mortality. Acknowledgements None. References 1. Jones D, DeVita M, Bellomo R. Rapid-response teams. N Engl J Med 2011; 365: 139–46. 2. Tirkkonen J, Tamminen T, Skrifvars MB. Outcome of adult patients attended by rapid response teams: a systematic review of the literature. Resuscitation 2017; 112: 43–52.
3. Santiano N, Young L, Hillman K, Parr M, Jayasinghe S, Baramy LS, Stevenson J, Heath T, Chan C, Claire M, Hanger G. Analysis of Medical Emergency Team calls comparing subjective to “objective” call criteria. Resuscitation 2009; 80: 44–9. 4. Leuvan CH, Mitchell I. Missed opportunities? An observational study of vital sign measurements. Crit Care Resusc 2008; 10: 111–5. 5. McGain F, Creticos MA, Jones D, Van Dyk S, Buist MD, Opdam H, Pellegrino V, Robertson MS, Bellomo R. Documentation of clinical review and vital signs after major surgery. Med J Aust 2008; 189: 380–3. 6. Peberdy MA, Cretikos M, Abella BS, DeVita M, Goldhill D, Kloeck W, Kronick SL, Morrison LJ, Nadkarni VM, Nichol G, Nolan JP, Parr M, Tibballs J, van der Jagt EW, Young L, International Liaison Committee on Resuscitation; American Heart Association; Australian Resuscitation Council; European Resuscitation Council; Heart and Stroke Foundation of Canada; InterAmerican Heart Foundation; Resuscitation Council of Southern Africa; New Zealand Resuscitation Council; American Heart Association Emergency Cardiovascular Care Committee; American Heart Association Council on Cardiopulmonary, Perioperative, and Critical Care; Interdisciplinary Working Group on Quality of Care and Outcomes Research. Recommended guidelines for monitoring, reporting, and conducting research on medical emergency team, outreach, and rapid response systems: an Utstein-style scientific statement. Circulation 2007; 116: 2481–500. 7. Trinkle RM, Flabouris A. Documenting rapid response system afferent limb failure and associated patient outcomes. Resuscitation 2011; 82: 810–4. 8. Tirkkonen J, Yl€ a-Mattila J, Olkkola KT, Huhtala H, Tenhunen J, Hoppu S. Factors associated with delayed activation of medical emergency team and excess mortality: an Utstein-style analysis. Resuscitation 2013; 84: 173–8. 9. Tirkkonen J, Olkkola KT, Tenhunen J, Hoppu S. Ethically justified treatment limitations in emergency situations? Eur J Emerg Med 2016; 23: 214–8. 10. Calzavacca P, Licari E, Tee A, Mercer I, Haase M, Haase-Fielitz A, Jones D, Gutteridge G, Bellomo R. Features and outcome of patients receiving multiple Medical Emergency Team reviews. Resuscitation 2010; 81: 1509–15. 11. Boniatti MM, Azzolini N, Viana MV, Ribeiro BS, Coelho RS, Castilho RK, Guimar~ aes MR, Zorzi L,
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Schulz LF, Filho EM. Delayed medical emergency team calls and associated outcomes. Crit Care Med 2014; 42: 26–30. Calzavacca P, Licari E, Tee A, Egi M, Haase M, Haase-Fielitz A, Bellomo R. A prospective study of factors influencing the outcome of patients after a Medical Emergency Team review. Intensive Care Med 2008; 34: 2112–6. Bell MA, Konrad D, Granath F, Ekbom A, Martling CR. Prevalence and sensitivity of MET-criteria in a Scandinavian University Hospital. Resuscitation 2006; 70: 66–73. Fuhrmann L, Lippert A, Perner A, Østergaard D. Incidence, staff awareness and mortality of patients at risk on general wards. Resuscitation 2008; 77: 325–30. Schneider AG, Warrilow S, Robbins R, Jones DA, Bellomo R. An assessment of the triage performance of the efferent arm of the rapid response system. Resuscitation 2013; 84: 477–82. Dacey MJ, Mirza ER, Wilcox V, Doherty M, Mello J, Boyer A, Gates J, Brothers T, Baute R. The effect of a rapid response team on major clinical outcome measures in a community hospital. Crit Care Med 2007; 35: 2076–82. Herod R, Frost SA, Parr M, Hillman K, Aneman A. Long term trends in medical emergency team activations and outcomes. Resuscitation 2014; 85: 1083–7. Jones D, Baldwin I, McIntyre T, Story D, Mercer I, Miglic A, Goldsmith D, Bellomo R. Nurses’ attitudes to a medical emergency team service in a teaching hospital. Qual Saf Health Care 2006; 15: 427–32.
19. Bagshaw SM, Monror EE, Scouten C, Montgomery C, Slater-MacLean L, Jones DA, Bellomo R, Gibney RT, Capital Health Medical Emergency Team Investigators. A survey of nurses’ beliefs about the medical emergency team system in a canadian tertiary hospital. Am J Crit Care 2010; 19: 74–83. 20. DeVita MA, Bellomo R, Hillman K, Kellum J, Rotondi A, Teres D, Auerbach A, Chen WJ, Duncan K, Kenward G, Bell M, Buist M, Chen J, Bion J, Kirby A, Lighthall G, Ovreveit J, Braithwaite RS, Gosbee J, Milbrandt E, Peberdy M, Savitz L, Young L, Harvey M, Galhotra S. Findings of the first consensus conference on medical emergency teams. Crit Care Med 2006; 34: 2463–78. 21. Hands C, Reid E, Meredith P, Smith GB, Prytherch DR, Schmidt PE, Featherstone PI. Patterns in the recording of vital signs and early warning scores: compliance with a clinical escalation protocol. BMJ Qual Saf 2013; 22: 719–26. 22. Kolic I, Crane S, McCartney S, Perkins Z, Taylor A. Factors affecting response to national early warning score (NEWS). Resuscitation 2015; 90: 85–90. 23. ANZICS-CORE MET dose Investigators, Jones D, Drennan K, Hart GK, Bellomo R, Web SA. Rapid Response Team composition, resourcing and calling criteria in Australia. Resuscitation 2012; 83: 563–7. 24. Tirkkonen J, Nurmi J, Olkkola KT, Tenhunen J, Hoppu S. Cardiac arrest teams and medical emergency teams in Finland: a nationwide crosssectional postal survey. Acta Anaesthesiol Scand 2014; 58: 420–7.
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