Most literature on the medical emergency team (MET) relates to its effects on patient outcome. We reviewed the calling criteria and clinical causes of 400 MET calls in a teaching hospital. The underlying reasons for initiating MET calls were hypoxia (41%), hypotension (28%), altered conscious state (23%), tachycardia (19%), increased respiratory rate (14%) and oliguria (8%).
A suggested approach permits audit and standardization of the management of MET calls and provides an educational framework for the management of acutely unwell ward patients. IntroductionMedical emergency team (MET) systems have been introduced into hospitals to identify, review and treat acutely unwell ward patients.
MethodsThe hospitalsThe Northern and Austin Hospitals are both situated in the north of Melbourne and are affiliated with the University of Melbourne.
ResultsCharacteristics of 400 MET callsOf the 400 MET calls, 23 had only the 'staff worried' criterion. DiscussionWe conducted a study to determine the most common reasons for initiating 400 MET calls in a teaching hospital. ConclusionWe reviewed 400 MET calls and found that five syndromes accounted for essentially all MET calls observed; More than 90% of calls were associated with hypoxia, hypotension or altered conscious state.
Little information is currently available on what conditions trigger medical emergency team (MET) calls. Sepsis, pulmonary oedema and arrhythmias were the most common underlying triggers for MET calls.
Given the above observations, we propose minimum standards of response and a structured approach to managing MET calls.
Competing interestsThe authors declare that they have no competing interests.Authors' contributionsDJ, GD, JG, JB, AC and RB were responsible for the design of the study. An important and highly actionable blueprint for optimum workplace safety Health and safety management is an ongoing concern in today's workplace. Effective Environmental, Health, and Safety Management Using the Team Approach PDF (Adobe DRM) can be read on any device that can open PDF (Adobe DRM) files. Less information exists on the most common causes of MET calls or on possible approaches to their management.
We propose a set of minimum standards for managing a MET review and developed an approach for managing common problems encountered during MET calls. Infection, pulmonary oedema, and arrhythmias featured as prominent causes of all triggers for MET calls.
Most of the literature related to METs has concentrated on their effects in reducing cardiac arrests and serious adverse events [1], primarily in single-centre studies.
The Northern Hospital provides acute and elective medical services, except cardiac surgery, neurosurgery and organ transplantation. Of the remainder, 248 had one listed physiological MET criterion, 105 had two, 23 had three and one patient had four criteria. Sepsis, pulmonary oedema and arrhythmias were the most common triggers of MET calls and of the above syndromes. Effective Environmental, Health, and Safety Management Using the Team Approach provides today's safety professionals with an excellent resource for protecting their organizations' most important resource-their employees. The proposed minimum requirements for managing a MET review included determining the cause of the deterioration, documenting the events surrounding the MET, establishing a medical plan and ongoing medical follow-up, and discussing the case with the intensivist if certain criteria were fulfilled. However, a recent Australian multi-centre cluster-randomized trial failed to confirm that the introduction of METs into hospitals was able to improve these outcomes [2].
The Austin Hospital provides all acute and elective medical services and is the referral centre for liver transplantation and spinal cord injuries for the state of Victoria.


To our knowledge, no information exists on a systematic approach to the management of such episodes.Our analysis of 400 recent MET calls at the Austin Hospital revealed initial evidence supporting previous opinion that MET calls are likely to be made for a limited number of conditions [3] and that a MET syndrome or several MET syndromes exist [1]. In response to these observations, we propose an approach that permits audit and standardization of the management of MET calls and provides an educational framework for the management of acutely unwell ward patients. The author, a seasoned health and safety professional, provides a blueprint for installing a system that's been proven to reduce illness and injury on any job, in any industry, with a simple, logical approach that compares safety management to production and quality control-issues today's managers readily understand. Despite this negative result, substantial interest in the utility of METs has developed in both the USA and the UK.Limited information exists on the causes and outcomes of episodes of MET reviews. The Northern Hospital has a 10-bed intensive care unit (ICU) that is staffed by an intensive care registrar during the day, and a senior hospital medical officer and anaesthetic registrar overnight. Of the 531 calling criteria for the 400 MET calls, 61 had no documented provisional diagnosis.
Infections, pulmonary oedema, and arrhythmias featured as prominent causes of the 400 MET calls analysed.
The system uses a team approach to get every level of an organization involved in the process of managing safety issues, with the ultimate goal being the development of a safety culture in which every employee has a personal interest in protecting their lives, their property, and their environment. This approach was then adapted to provide a management plan for episodes of tachycardia, hypotension, hypoxia and dyspnoea, reduced urinary output, and altered conscious state. There is even less information on the process of assessment and management undertaken by the MET during an episode of MET review. The Austin Hospital has a 21-bed ICU that is staffed by intensive care registrars at all times.
These syndromes have defined aetiologies and treatments.At least two other studies have assessed the abnormalities leading to the activation of a MET service.
The traditional 'Code Blue' call is intended for the resuscitation of cardiac arrests and other acute life-threatening emergencies. Requirements specific to the Austin Hospital also included automatic medical referral for surgical patients who remained on the ward after a MET call for a medical reason, and compulsory review of the patient by an intensivist for a patient requiring two MET reviews in a seven-day period.Approach to the management of a MET callAn approach to the management of a MET call was developed with the acronym 'A to G' (Table 4 in Additional file 1).
It consists of an anaesthetic registrar, a coronary care registrar and nurse, an ICU registrar and nurse, and the medical registrar of the receiving unit of the day. The members of the MET are encouraged to a sk the nurses the reason for the MET call (that is, what calling criteria initiated the MET call) and a ssess the patient for the aetiology of the deterioration before b eginning b asic resuscitation.
The most common causes of MET calls in this study were acute respiratory failure, status epilepticus, coma, and severe drug overdose. The MET is intended to review all medical emergencies other than cardiac arrests; it has been described in detail previously [4].
It can be activated by any member of hospital staff according to predetermined criteria that are based primarily on abnormalities of vital signs and clinical status (Table 1 in Additional file 1).At the Austin hospital the MET consists of an ICU registrar and nurse, as well as the Medical registrar of the receiving unit of the day. After initial resuscitation and assessment, the staff are instructed to d iscuss the case with appropriate medical staff, d ecide where the patient should be managed, and d ocument the events surrounding the MET. Previously, activation of the MET at the Northern Hospital resulted in notification of only the patient's parent unit doctors.
Issues surrounding the resuscitation status of the patient should also be d iscussed if appropriate. An audit of 80 MET calls at the Northern Hospital in 2001 revealed that alteration in conscious state, hypotension, and noisy breathing were the commonest precipitants (Duke, G; unpublished data).
As part of an ongoing programme to improve the use of the MET at the Northern Hospital, activation of the MET now results in notification of the medical registrar and the intensive care registrar or hospital medical officer.Details of MET callsA detailed log book is maintained by the switchboard operators at both hospitals that records all medical emergency calls.
These findings highlight the need to assess regional variations in the epidemiology of MET calls.At least two other approaches exist that teach junior medical staff to manage acutely unwell hospital patients. At the Austin Hospital, case report forms are also completed by the ICU registrar at the end of each call.


The subsequent frequency of monitoring of vital signs should also be discussed, as should the criteria for doctor re-notification. The ALERTaā€˛? course was developed by staff affiliated with the University of Portsmouth [7, 8]. These forms document the parent unit of the patient as well as the indications for the MET call.
The course provides an overall plan of assessment as well as approaches to the 'blue and breathless patient', 'the patient with a disordered conscious level' and 'the oliguric patient'. Since March 2002 the registrar has also recorded a provisional diagnosis of what medical condition is thought to have caused the MET call. Similar plans were developed for the management of the 'hypotensive MET call', the 'tachycardic MET call', the 'oliguric MET call' and, finally, the 'altered conscious state MET call'.The aetiology and features of the common causes of the call are listed, as well as an approach to the management of each cause. The 'A to G' approach outlined in this article provides information about the aetiology, management and recommendations for referral and follow-up of patients with these and other syndromes.The CCrISP course was developed by the Royal College of Surgeons (England) and is a two-day course aimed at surgical house officers [9]. Details of 400 calls that occurred between April and October 2004 were manually entered into an Excel spreadsheet to provide details on the trigger and the presumed aetiology of the call. The 'A to G' approach outlined in this article is aimed primarily at medical and intensive care registrars and fellows, and incorporates acute deteriorations of both medical and surgical patients. It emphasizes the need to establish a diagnosis of the aetiology of the call and to establish a management and follow-up plan for the patient.
No assumptions are made in cases in which data on presumed diagnosis were missing.Proposed minimum standards for managing a MET callThe proposed minimum standards were developed after a series of meetings and electronic communications between all the authors of this manuscript.
In addition, we have included strategies to facilitate communication between members of the MET and the parent unit of the patient. The 'A to G' approach to managing a MET call was subsequently developed to achieve these minimal standards.
Finally, we have emphasized the importance of not criticizing ward staff for initiating the call. Finally, the 'A to G' approach was adapted to provide a plan for the management of the five most common 'MET syndromes': tachycardia, hypotension, dyspnoea and hypoxia, altered conscious state, and oliguria. Fear of criticism has been shown to be an obstacle for the activation of MET services [10, 11].Our study has several strengths and limitations.
Our approach lends itself to education of the members of the MET and auditing of the MET review process. It is tailored for the team approach of the MET that involves an initial assessment and coordination of ongoing care.
The other major strength of the approach is the ability to adapt it to the requirements of different hospitals. First, the 'MET syndromes' can be adapted according to the case mix and demographics of the patients at a given hospital to reflect the most common criteria and causes for the initiation of a MET call. Second, the details of the management plans can be altered according to local medical opinion and to reflect the level of experience of members of the MET.
Third, it is possible to apply more objective and specific criteria for the notification of senior members of medical staff (for example, call the intensivist if the patient remains hypotensive despite receiving 3 litres of fluid).The major limitation of the approach is that it has not been validated. We are currently implementing a detailed education programme at the Northern Hospital based on these recommendations that seeks to improve the documentation and outcome of patients who receive a MET review.



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