Page 111 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 12: Rapid Response Teams 79

TABLE 12-2 Summary of Studies Reporting Antecedents to Serious Adverse Events and In-Hospital Cardiopulmonary Arrests (Continued)
Reference and Year of Inception Study Population and Setting Method of Assessment Major Findings
McQuillan et al, Winter 1992 100 consecutive emergency admissions Opinions of two external assessors on Assessors agreed that 20% received optimal care and 54%
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to adult ICU in England (Portsmouth and quality of care before admission → espe- suboptimal care. ICU mortality of these patients was 25%
Southampton) cially recognition, investigation, monitor- and 48%, respectively. Suboptimal care resulted from
ing and management of abnormalities of lack of organization and knowledge, failure to appreciate
airway, breathing, and circulation. urgency, failure to seek advice
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Buist et al, Jan-Dec 1997 43 cardiac arrests and 79 unplanned ICU Retrospective assessment of medical 76% of patients had instability for >1 hour
admissions in 112 patients records for abnormalities in vital signs and Median duration of instability was 6.5 hours
Dandenong Hospital Victoria blood tests Hemodynamic > respiratory > abnormal laboratory
results > reduced conscious state
Overall mortality = 62%
Accounted for 15% all ICU admissions, one-third ICU
deaths, 18% hospital deaths
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Hodgetts et al, 1999 118 consecutive arrests over 1-year Review by expert panel to determine if Panel unanimously agreed that 61.9% of arrests were
period in all hospital areas except day arrests were potentially avoidable potentially avoidable
units and the emergency department Inadequate treatment included errors in Cardiac arrests more likely on the weekend
700-bed acute district general hospital diagnosis, inadequate interpretation of Odds ratio for potentially avoidable arrest on general ward
in southeast England investigations, incomplete treatment, versus critical care area was 5.1
inexperienced doctors, management in
inappropriate clinical areas 100% of potentially avoidable arrests deemed to receive
inadequate treatment
Hodgetts et al, 1999 118 cardiac arrests as above Compared incidence of abnormal clinical Risk factors for arrest included abnormalities in respira-
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Compared with 132 controls who did criteria tory rate, breathing, pulse rate, systolic blood pressure, or
not suffer cardiac arrest Assessed for risk factors for cardiac arrest temperature, as well as chest pain, hypoxia, or concern by
using clinical criteria the doctor or nurse
Buist et al, May-Dec 1999 6303 patients admitted over 7 months Prospective assessment of patients identi- 8.9% of admissions fulfilled criteria. Oxygen desaturation
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to 320-bed hospital in Dandenong fied by predefined abnormal observations and hypotension comprised 68% of all events. The pres-
Australia ence of any abnormality was associated with a 6.8-fold
increased risk of mortality
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Goldhill et al, 13-month 79 unplanned ICU admissions in 76 Physiological values and interventions in 34% underwent cardiopulmonary resuscitation. Many had
period from May 1995 patients 24 hours prior to ICU admission respiratory deterioration: 75% received oxygen, 37% received
arterial blood gas analysis, 61% had oxygen saturation mea-
< 90%) Overall mortality 58%
sured (63% of these had Sp O 2
Goldhill and McNarry, Recorded vital signs on 433 patients on Measured vital signs within 8 hours of 6% died within 30 days
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Dec 2002 a single day patient review Increased number of abnormal vital signs was associated
with increased risk of death. Patients often died many days
after admission, suggesting there was time to intervene
Nurmi et al, Dec 2001 to 110 cardiac arrests in four Finnish Chart review of vital signs, symptoms, 54% of cardiac arrests had MET criteria in the 8 hours
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May 2003 hospitals and interventions in the 8 hours prior to before the arrest, documented on average 3.8 hours before
cardiac arrest the arrest. Most common abnormalities were “respiratory
distress” and hypoxia, but respiratory rate was docu-
mented in only one of 110 patients
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Bell et al, Two separate days: 1097 patients 50 nursing students recorded vital signs 4.5% of the cohort fulfilled commonly measured criteria
Dec 10, 2003, and Mar 24, 2004 Karolinska University Hospital Solna of 1097 patients between 9 am and 2 pm on used to trigger Medical Emergency Team (MET) review
two separate days These patients had a 30-day mortality of 25% compared
with 3.5% for patients not fulfilling criteria
AMI, acute myocardial infarction; ICU, intensive care unit; OR, odds ratio; MET, Medical Emergency Team.

studies had overestimated the incidence of death due to medical error. they are routinely measured and assessed by treating medical and nurs-
In addition, the authors demonstrated considerable interobserver vari- ing staff (Figs. 12-1 to 12-3). However, the limitation of these studies
ability in estimation of preventability, suggesting that “preventability was is that they fail to demonstrate whether intervention during the course
in the eye of the reviewer.” 14 of deterioration would have altered the patient outcome. In addition,
Other investigators have retrospectively assessed patients’ case his- they do not assess a control group to document the frequency of such
tories for objective signs of physiological or biochemical instability in perturbations in patients not suffering cardiac arrest and unplanned
the hours leading up to the cardiac arrest or unplanned ICU admis- ICU admission.
sion. At least five studies 15-19 have demonstrated that patients develop Three studies have attempted to assess the utility, sensitivity, and
new complaints or deterioration in commonly measured vital signs or prevalence of deranged vital signs in prospective cohort studies. Thus,
laboratory investigations in up to 84% of cases in the 24 hours prior to Goldhill and McNarry conducted a study in which the vital signs of
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the event (Table 12-2). Such perturbations are not only objective, but 433 patients were prospectively recorded on a single day. They reported

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