Med Emerg Response Teams
crit care 2006;10:121 and R30
Table 1: Calling Criteria for Medical Emergency Teams
- Staff member is worried about the patient
- Airway
- Noisy breathing / stridor
- Breathing
- Acute change in respiratory rate to < 8 or > 30 breaths / min
- Acute change in pulse oximetry saturation to < 90% despite oxygen administration
- Circulation
- Acute change in heart rate to < 40 or > 130 beats / min
- Ischemic chest pain ¶
- Acute change in systolic blood pressure to < 90 mmHg
- Acute change in urinary output to < 50 mL in 4 hrs.
- Conscious state
- Acute change in conscious state
- Multiple seizures¶
¶ Indicates criteria specific for The Northern Hospital
Table 2: Common reasons for MET calls at The Austin Hospital
Cause of the MET call
Number of calls
Hypoxia / Increased respiratory rate
Pulmonary oedema / fluid overload
Pneumonia / aspiration
Exacerbation chronic obstructive airways disease
Sepsis
Pulmonary embolism
Arrhythmia
Sputum plug, narcotized, acidemia, pleural effusion, tracheostomy blocked, atelectasis, intracranial event
No cause documented
218
66
52
16
11
11
12
30
20
Hypotension
Sepsis
Bleeding / hypovolemia
Acute pulmonary oedema / myocardial ischemia
Arrhythmia
Cardiac arrest
Epidural related, Pulmonary embolism, anaphylaxis, vasovagal, Narcosis
No cause documented
112
30
28
15
10
4
13
15
Altered conscious state
Sepsis
Stroke / Transient ischemic attach or Intracranial bleed
Seizure
Hypovolemia
Cardiogenic shock / acute coronary syndrome
Drug related
CO2 narcosis
Vasovagal, arrhythmia, cardiac arrest, encephalopathy, uremia, meningitis
No cause documented
93
13
13
11
8
6
5
5
21
12
Tachcyardia
Arrhythmia
Sepsis
Acute pulmonary oedema / myocardial ischemia
Drug related
Hypovolemia
Respiratory distress
Pulmonary embolism, Epidural related, stroke
No cause documented
77
29
13
10
4
3
3
3
11
Oliguria
Sepsis
Cardiogenic shock
Hypovolemia
Urinary tract obstruction
Drug related, hepatorenal syndrome, stroke
No cause documented
31
7
7
4
2
5
3
Table 3: Proposed minimum criteria for managing a MET call
- Determine the etiology of the deterioration
- Document the events surrounding the MET call
(A pre-formatted fluorescent yellow sticker is used at The Austin Hospital)
- Organize a management plan and appropriate medical follow-up
- Automatic medical referral for surgical patient subject to a MET call for a medical reason in cases where the patient remains on the ward¶
- Communicating with the parent unit (or their cover) that the MET has occurred
- Compulsory review of the patient by an Intensivist for a patient requiring two MET reviews in a seven day period ¶
- Communicating with the intensivist if the following criteria are fulfilled:
- The patient remains unstable following initial resuscitation
- The patient requires ICU or HDU admission
- The patient may require ICU or HDU admission in the future
- The patient has been admitted to ICU or HDU during this hospital admission
- The members of the MET are unsure how to manage the patient (i.e. the members of the MET are worried about the patient).
¶ Criteria specific for Austin Hospital.
MET, Medical Emergency Team; ICU, Intensive Care Unit; HDU, High Dependency Unit.
Table 4: An approach to managing a MET call
Ask and Assess
Ask the staff how you can help themAsk about the reason for the MET call
Assess for the etiology of the deterioration
Begin basic investigations and resuscitation therapy
Call for help / call consultant if needed
Discuss, Decide, and Document
Discuss MET with parent unit / consultant
Discuss advanced care planning if appropriated
Decide where the patient needs to be managed
Document the MET and subsequent frequency of observations
Explain: the cause of the MET, the investigations required and subsequent management plan
Follow-up: which doctor to follow-up the patient? What are the criteria for doctor re-notification?
Graciously thank the staff at the MET
Table 5: Management of the Hypoxic tachypneic MET call
Assess for etiology
- Pulmonary edema / Cardiac failure (Past history of heart disease. Current evidence of myocardial ischemia, raised JVP, oedema, bilateral crepitations, cardiomegaly)
- Dependent atelectasis/collapse (Patient immobile, basal chest signs, recent surgery)
- Asthma / COAD (Wheeze, prolonged expiration, hyper-inflated chest)
- Sepsis anywhere. eg lung, kidney, wound, intra-abdominal.
- Pulmonary embolism immobile, recent surgery, history of thrombo-embolism, tachycardia, ECG changes of right ventricular strain
Begin basic investigations and resuscitation
- Administer oxygen and obtain portable CXR
- ECG, Cardiac enzymes, electrolytes
- Sepsis screen: FBE, CRP, blood, urine, sputum, wound.
- Consider ABG +/- lactate
- Pulmonary edema Loop diuretic, morphine, nitrates, oxygen, posture, consider CPAP
- Dependent atelectasis/collapse chest physiotherapy, humidified oxygen
- Asthma / COAD bronchodilators, steroids, antibiotics ?BiPAP.
- Pulmonary embolism V/Q scan or CTPA. Consider anti-coagulation.
Call for help
- SaO2 < 90% despite 10L inspired oxygen
- RR > 40, elevated PaCO2, altered conscious state
Discuss & Decide
- Is the patient stable or unstable?
- What is the management plan?
- Does the patient need ICU/HDU/surgery?
- Communicate with patient/Next of kin/parent unit/Intensivist
- What is the subsequent follow up plan?
Explain
- Cause of the hypoxia and subsequent management plan.
- Subsequent observations required.
Follow-up
- Who will follow-up the patient?
JVP = jugular venous pressure, COAD = chronic obstructive airways disease, WCC = white cell count, ECG = electrocardiogram, CXR = chest X-ray, ABG = arterial blood gas, FBE = full blood examination, CRP = C-reactive protein, V/Q = ventilation perfusion, CTPA = CT pulmonary angiogram, SaO2 = saturation oxygen, RR = respiratory rate, PaCO2 = partial pressure of carbon dioxide, ICU = Intensive Care Unit, HDU = High dependency Unit.
crit care 2006;10:R30
Full annotated bibliography (Crit Care Med 2006;34:2463)
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