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82 PART 1: An Overview of the Approach to and Organization of Critical Care

particularly in surgical patients. Importantly, some of these hospitals 60
45
have demonstrated that these benefits can be sustained over a prolonged
period. 44,46 In one hospital, introduction of an RRS was associated with a 50 MET
progressive reduction in the rates of cardiac arrests with time (Fig. 12-6). 44 Controls
The MERIT study involved a cluster-randomized controlled trial of 40
23 hospitals in Australia and New Zealand. In this study, patients were Percentage of events 30
not randomized to receive or not receive an intervention, because of the
risk of cross-contamination. Instead, after a 2-month period of baseline 20
data collection, 12 of the 23 hospitals were randomized to have an RRT
implemented, while 11 had ongoing care as usual. Data were then col- 10
47
lected for a 4-month period after the introduction of the RRT to assess 0
https://kat.cr/user/tahir99/
the effectiveness of the intervention. Cardiac ICU Unexpected
The study revealed that there was an increase in emergency call rates arrest admission death
in the RRT hospital, when compared with the control hospitals (8.7/1000 76/250 313/611 24/48
admissions versus 3.1/1000; p < 0.001). However, this was not associ- vs vs vs
ated with a statistically significant reduction in the incidence of the com- 109/246 314/568 16/29
posite end point of cardiac arrests, unexpected deaths, and unplanned
ICU admissions (5.86 versus 5.21; p = 0.64). A number of reasons for FIGURE 12-8. Percentage of events in the MERIT trial that had evidence of physiological
instability before an adverse event and yet no call for an emergency team intervention was
the lack of positive outcome have been proposed. These include the
relatively short education period and the short follow-up period after made. In the hospitals allocated to having a MET, there was still a very high incidence of
failure to rescue.
the RRS implementation. Data from other hospitals show that more
time is needed to see full uptake of the RRT service (Fig. 12-7). In
addition, the call rate seen in the MERIT hospital intervention hospi-
tals (8.7/1000 admissions) was low in comparison to that seen at other
hospitals (24.7-56.4/1000 admissions). 48,49 Furthermore, many patients 100
who suffered adverse events in the intervention hospitals had anteced- 90 MET
ent calling criteria, but the team was not called (Figs. 12-8 and 12-9). 80 Controls
Finally, control hospitals displayed a great degree of MET-like activity 70
(contamination) (Fig. 12-10). 60
Recently, there has been recognition that the “dose” of review may Percentage of calls made per event 50
be an important factor as to whether the implementation of the team is 40
30
3.5 3 20 0 Cardiac ICU Unexpected
10
Cardiac arrests/1000 admissions 2.5 2 1 FIGURE 12-9. Percentage of events in the MERIT trial that had evidence of physiological
admission
death
arrest
95/313
2/24
72/76
vs
vs
vs
27/314
4/16
104/109
1.5
instability before an adverse event, where a call for an emergency team intervention was
0.5
in patients who were then admitted to ICU.
0 made. The only increase in preventive activity in hospitals allocated to having a MET occurred
1999 2000 2001 2002 2003 2004
Year
FIGURE 12-6. Changes in the incidence of cardiac arrests in an academic center follow-
ing introduction of an RRT in late 2000. 7
6 MET
90 5 4 Controls
Number of METs per month 60 Calls per 1000 admissions 3 2 1
80
70
50
40
30
20
10
0
associated
associated
(70.5%)
2000 2001 2002 2003 2004 MET = 1329/1886 0 Calls without Calls with
event
event
Control = 194/528
Year (36.7%)
MET calls in 2007: 147/month
FIGURE 12-10. Number of emergency team calls per 1000 admissions in hospitals
FIGURE 12-7. Progressive uptake of RRT calls in an academic center. The number of calls allocated to having a MET or not having one (controls). In the control hospitals, there was a
increased from 25 calls/month to 147 calls/month over 7 years. significant degree of nonevent related (preventive) activity indicating contamination.

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