It is more than 15 years since the first Medical Emergency Team (MET) system was introduced to identify patients at risk and prevent serious adverse events in Liverpool Hospital, Sydney, Australia. Since then the MET system has been introduced to many other hospitals in Australia and around the world. Standardised and complete reporting of data related to MET activity is increasingly important to identify the role and benefits of the system and to facilitate quality improvement in health care in general. A uniform method for reporting data related to MET activity will aid interpretation of results, comparisons, review and changes to the MET system. The guidelines for uniform reporting of data in relation to MET activities used in our group of hospitals are presented. Future refinement and consensus agreement on the reporting of MET data internationally should enable comparisons between MET systems in several countries.

Objectives: To evaluate the effectiveness of a medical emergency team (MET) in reducing the rates of selected adverse events.Design: Cohort comparison study after casemix adjustment.Patients and setting: All adult (greater than or equal to 14 years) patients admitted to three Australian public hospitals from 8 July to 31 December 1996.Intervention studied: At Hospital 1, a medical emergency team (MET) could be called for abnormal physiological parameters or staff concern. Hospitals 2 and 3 had conventional cardiac arrest teams.Main outcome measures: Casemix-adjusted rates of cardiac arrest, unanticipated admission to intensive care unit (ICU), death, and the subgroup of deaths where there was no pre-existing "do not resuscitate" (DNR) order documented.Results: There were 1510 adverse events identified among 50 942 admissions. The rate of unanticipated ICU admissions was less at the intervention hospital in total (casemix-adjusted odds ratios: Hospital 1, 1.00; Hospital 2, 1.59 [95% CI, 1.24-2.04] Hospital 3, 1.73 [95% CI, 1.37-2.16]). There was no significant difference rn the Fates of cardiac arrest or total deaths between the three hospitals. However, one of the hospitals with a conventional cardiac arrest team had a higher death rate among patients without a DNR order.Conclusions: The MET hospital had fewer unanticipated ICU/HDU admissions, with no increase in in-hospital arrest rate or total death rate. The non-DNR deaths were Tower compared with one of the other hospitals; however, we did not adjust for DNR practices. We suggest that the MET concept is worthy of further study.

The practice of intensive care medicine is increasingly being seen as extending outside the four walls of the intensive care unit (ICU). Systems are operating for the detection and rapid resuscitation of patients at the earliest possible stage, before and after discharge from the ICU. And yet,current scoring systems used for evaluating intensive care outcomes assume the interventions occur only within the geographical boundaries of the unit. Broader indicators that measure the continuum of care for seriously ill patients across the entire hospital include deaths, cardiorespiratory arrests and unexpected admission to the ICU. Analysis of these indicators can identify potentially preventable cases, where early identification and resuscitation may have prevented their occurrence. Hospital deaths and cardiorespiratory arrests can be further categorized into unexpected events by excluding patients with 'do not resuscitate' orders. This, in itself, assists in changing the culture of a hospital to being more explicit about dying patients. Unless global measurements of care of the seriously ill occurs it is difficult to estimate the impact of care before and after ICU admission; to evaluate ICU admission and discharge policies; to estimate the need for high dependency beds; or to evaluate care of the seriously ill in sites other than the ICU. The system must also develop targeted methods of distributing the data in order to have a maximum impact. Indicators which estimate the quality of care of the seriously ill across the whole hospital are a critical part of any system designed to improve management.

The medical emergency team (MET) at Liverpool Hospital superseded the cardiac arrest team in 1990 and can be summoned by any staff member who identifies a patient at risk according to preset criteria; for example, severe hypotension. Weekly reviews of MET calls have identified clinical antecedents present prior to the patient's condition deteriorating to a critical level. This study assessed the responses of nurses in the presence of these warning signs. Medical records of 178 patients who required MET assistance during 1994 were retrospectively reviewed. A data collection form designed for the study sought demographic information, time and location off the MET call and documented patient complaints for the 24 hours preceding the MET call. Also collected was information on who was contacted as a result of the critical observation. Analysis included frequencies, percentages, means and standard deviations, including location, type and timing of the MET call. MET calls occurred in the general wards (50 per cent), emergency department (42.3 per cent) and other areas (7.7 per cent). The four main categories of emergency comprised cardiac arrest (25.6 per cent), airway/breathing problems (22 per cent), decreased level of consciousness (20.8 per cent) and 'other', including prolonged chest pain, fitting and hypotension (31.6 per cent). The predominant response to a clinical antecedent was to call the MET (68.4 per cent). Other responses resulted in delays of 1 hour (18 per cent) and up to 3 hours (8 per cent) on some wards before treatment specific to the clinical antecedent commenced. A need to educate health professionals regarding the warning signs of acute severe illness and when to summon assistance has been identified.

Objective : Compare the health related quality of life of intensive care patients with a community sample. Design : Self-completed questionnaire posted to a consecutive sample of 238 patients 16 months after discharge from an intensive care unit (ICU) and to a random community sample ( n = 242). Setting : The Liverpool Hospital is the main referral and teaching hospital in a community of 620,000 people. It has a ten-bed general ICU. Patients and participants : All patients admitted to the ICU over 8 months with a length of stay ≥ 24 h and a sample drawn from the community telephone directory. Measurements and main results : The self completed questionnaire contained physical and psychosocial health and quality of life (QOL) scales. Analysis of variance indicated that ICU patients were more physically ill and anxiously depressed than the community sample. Sixty-three per cent of patients had not attained full health, were functionally impaired and had a poorer QOL than those patients who had returned to full health and the community. Psychosocial health (apart from anxious depression) was related to the level of perceived physical health rather than to whether or not they had been admitted to the ICU. Those subjects not in full health had poorer interpersonal relationships, less positive attitudes about life, more anxious depression and more suicidal depression. Conclusions : ICU patients following discharge have worse perceived health and more anxiety than others in the community. Sixty-three per cent of patients had a poorer QOL and functional health than those who returned to full health and those in the community.

Objective: A study was undertaken to determine the incidence of antecedent factors leading to hospital inpatient cardiorespiratory arrests. Design: Review of medical records over five randomly selected 24-hour periods to identify signs known to be antecedents to cardiorespiratory arrest. Setting: General wards of a 460-bed Australian teaching hospital. Interventions: None. Measurements and main results: Of the 1,027 charts reviewed, nine (0.88%) were identified as having signs thought to proceed to cardiac arrest. Systolic blood pressure was less than 90 mmHg in three cases, pulse rate was <40 or >140 bpm in one patient and respiratory rate was <5 or >36 breaths/min in five patients. Conclusions: Signs which have been reported as antecedent factors leading to cardiorespiratory arrest are of sufficient frequency in the general hospital population to make it feasible to institute a standardised, team-based urgent response.

Objective: To describe the utilisation of an emergency team that employs standardised calling criteria to facilitate the early identification and resuscitation of patients who are at risk of cardiorespiratory arrest. Design: A prospective study of all Medical Emergency Team calls over a six-month period in 1994. Setting: A 460-bed university teaching hospital in Sydney, Australia. Subjects: Inpatients and outpatients who required Medical Emergency Team intervention. Interventions: None. Endpoints: Unplanned admission to critical care units, mortality. Measurements and main results: There was a total of 294 calls, of which 53% occurred on the wards and 31% in the Emergency Department. Cardiac arrests accounted for 24% of responses. Abnormal physiological variables were a factor in 60% of calls. Decreased level of consciousness occurred in 46% of cases. Fifty-three calls necessitated admission of patients to critical care units, of which 32 (60%) survived to hospital discharge. The mortality rate at hospital discharge was higher in cardiac arrests (84%) than other medical emergencies (27%)(χ2=51.24; p<0.01). Conclusions: The Medical Emergency Team is well employed as an early intervention team, with abnormal physiological variables alerting the team in many cases. A standardised team approach encouraging early medical intervention in 'at-risk' patients may potentially reduce the high morbidity and mortality associated with the seriously ill and those at risk from cardiac arrest.

The concept of a Medical Emergency Team was developed in order to rapidly identify and manage seriously ill patients at risk of cardiopulmonary arrest and other high-risk conditions. The aim of this study was to describe the utilization and outcome of Medical Emergency Team interventions over a one-year period at a teaching hospital in South Western Sydney. Data was collected prospectively using a standardized form. Cardiopulmonary resuscitation occurred in 148/522 (28%) calls. Alerting the team using the specific condition criteria occurred in 253/522 (48%) calls and on physiological/pathological abnormality criteria in 121/522 (23%) calls. Survival rate to hospital discharge following cardiopulmonary arrest was low (29%), compared with other medical emergencies (76%).

In February 1991, the Intensive Care Unit (ICU) at Liverpool Hospital was extended and relocated to a larger area. It soon became apparent that noise levels within the newly renovated unit were particularly worrying to patients, staff and relatives. A Continuous Quality Improvement (CQI) group was formed to investigate, and develop measures to reduce these noise levels. Through the implementation of various CQI tools a study plan was developed to investigate the noise problem. The study plan included: a patient, relative and staff questionnaire; a literature search; identification of levels of noise using a sound level meter; contracting a noise consultant to visit and review the ICU environment. The results of the CQI investigations revealed that there was an inappropriately high level of noise in the ICU. Several key contributing factors were also identified. These findings provided the basis for several positive measures to be undertaken including: the installation of sound absorbing ceilings; removal of rubbish bin lids; revision of the telephone ringing system; revision of the mobile x-ray machine; prioritisation of audible machine alarms; education of staff in noise level awareness; The application of the Continuous Quality Improvement (CQI) process to the noise problem facilitated the exploration of the source of noise, the effects on staff and patients, and ways to reduce noise levels in the intensive care environment.

(1995). Post-hospital outcome following intensive care. Clinical Intensive Care: Vol. 6, No. 3, pp. 127-127.

Many current nursing activities are performed without regular reviews of their usefulness. The recording of fluid gains and losses on a fluid balance chart is one such activity. This article explores the practice of fluid monitoring on the wards of a university teaching hospital.

Objective To document the process of managing the dying patient in the intensive care unit (ICU) and thus to broaden community debate about an issue that is usually only discussed at a theoretical or philosophical level. Setting A six-bed ICU in Liverpool Hospital, a 419-bed teaching institution in the southwestern area of Sydney. Patients Twenty-seven patients, seen over a nine-month period, who had curative treatment withdrawn or withheld. The mean age of the patients was 68 years and the severity of illness, by the APACHE II scoring system, ranged from 12 to 45. Interventions Twenty-three of the 27 patients Were mechanically ventilated and 11 were receiving inotropic support. Medical staff usually initiated discussions and sought staff consensus that the patient should be allowed to die (on 23 of 27 occasions). Most relatives (25 of 27) accepted this decision. Support therapies and routine care were stopped according to policy guidelines. Sedatives and narcotics were used in some patients (18 of 27). Twenty-one patients died in the ICU and six in the general ward areas. Conclusion Introduction of a policy to guide management of dying patinents in intensive care has been accepted by staff. Most dying patients are now managed in accordance with these guidelines. Further discussion and debate of this important issue, by health professionals and society as a whole, is required.

An inability to attract and retain sufficient numbers of Registered Nurses (RN's), and Resident Medical Officer shortages in 1990 lead to a concern about who would provide services and whether RN's should "extend" their roles. This survey was developed to allow clinical nurses to identify what their role should be and to quantify the degree of role extension already occurring in the Intensive Care Units (ICU's) of New South Wales' hospitals. Surveys (823) were sent to 33 ICU's across New South Wales. Major Teaching (MTH), Suburban (SH) and Country (CH) hospitals were included in equal numbers. Nurse Unit Managers were contacted and agreed to the distribution of the questionnaire to all RN's working in these units. General demographic information was sought regarding experience in ICU, with the remainder of the questions related to whether nurses should take on extra tasks and what nursing duties could be relinquished. Overall return rate was 51.8% with variations in the type of hospital, MTH (35%), SH (57%), CH (68%). Nurses (72%) want to extend or already do have an extended role. However, they are very definite about what tasks they wish to perform and consistently throughout New South Wales do not wish to perform clerical tasks, some invasive procedures such as endotracheal intubation or arterial cannulation or prescribe medications. The majority of RN's want to relinquish non nursing duties such as cleaning, ordering supplies and clerical tasks. The study demonstrated that, a great many nurses working in ICU would like to and/or perceive the need for some role extension. Clearly nurses must be included in all discussions and decisions affecting their future.