Published online before print November 9, 2007, doi: 10.1161/CIRCULATIONAHA.107.186227
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(Circulation. 2007;116:2481-2500.)
© 2007 American Heart Association, Inc.
ILCOR Consensus Statements |
Recommended Guidelines for Monitoring, Reporting, and Conducting Research on Medical Emergency Team, Outreach, and Rapid Response Systems: An Utstein-Style Scientific Statement
A Scientific Statement From the International Liaison Committee on Resuscitation (American Heart Association, Australian Resuscitation Council, European Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, and the New Zealand Resuscitation Council); the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiopulmonary, Perioperative, and Critical Care; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research
Key Words: AHA Scientific Statement • emergency medical services • death, sudden
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Introduction |
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 Top Introduction The Consensus ProcessUtstein Reporting TemplatesData Elements and DefinitionsDiscussionSummaryConclusionsReferences |
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The majority of patients hospitalized with a cardiac arrest or requiring emergency transfer to the intensive care unit have abnormal physiological values recorded in the hours preceding the event.1–11 Many studies document that physiological measurements often are not made or recorded during this critical time of clinical deterioration.12–16 Such physiological abnormalities can be associated with adverse outcome.17–20 Measurements of abnormal physiology, including temperature, pulse rate, blood pressure, respiratory rate, hemoglobin, oxygen saturation by pulse oximetry, and deterioration of mental status, are therefore important to any system designed for early detection of physiological instability. At a minimum, these measurements must be obtained accurately and recorded with appropriate frequency. A system that both recognizes significantly abnormal values and triggers an immediate and appropriate treatment response is required.
There is growing evidence that early detection and response to physiological deterioration can improve outcomes for infants, children, and adults.21–29 A variety of response systems have been described, including teams that respond to patients in hospital wards who are critically ill or who are at risk of becoming critically ill. These systems all adhere to the principles of early detection and response to predefined indicators of clinical deterioration. The terms used for these response teams include medical emergency team (MET), rapid response team (RRT), and critical care outreach team (CCOT).25,26,28,30–34 These teams may replace or coexist with traditional cardiac arrest teams, which typically respond to patients already in cardiac arrest. Such teams should possess the required skills and equipment to provide immediate on-site stabilization and management of the patient and to initiate discussions about appropriate limits to medical interventions if indicated. Although the response team is the most obvious component of these systems, these teams are only one part of a much more comprehensive system-wide response. Team-based response systems also require educational, quality improvement, monitoring, and feedback components.35–37
The core data elements identified in the present report should help direct hospitals to collect the most meaningful data to optimize system interventions and improve clinical outcomes. Identification of supplemental data elements should allow enhanced data collection to further scientific knowledge in these system responses. Standardized data elements and definitions will permit aggregate data analysis, as well as create a consistent nomenclature for publications related to these prevention, early intervention, and response systems. Utstein-style data definitions and reporting templates have helped improve the consistency and comparability of data on cardiac arrest, trauma, and drowning and for this reason are proposed for the MET, RRT, and CCOT. The purpose of the present statement is to create consensus-derived key data elements and definitions and to develop a standardized Utstein-style template for the reporting of data related to systems with response teams such as METs, RRTs, and CCOTs.
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The Consensus Process |
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TopIntroductionThe Consensus ProcessUtstein Reporting TemplatesData Elements and DefinitionsDiscussionSummaryConclusionsReferences |
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The need for standardized reporting of MET, RRT, and CCOT data was identified during the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.38 Representatives from the International Liaison Committee on Resuscitation, including scientists and clinicians experienced in rapid response–type systems, were invited to develop a reporting template with consensus-derived data elements and standardized definitions for monitoring and reporting of data related to these systems.
The task force held a series of teleconferences from June 2005 to August 2006. The initial calls reviewed evidence and identified consensus on the type of data elements necessary for optimal program management (core elements), as well as data elements that would be beneficial for research related to MET systems (supplemental elements). A draft set of data elements was developed and divided into 6 categories. Task force members were each assigned a group of data elements, and a virtual modified Delphi method was used to complete the consensus process.39 All documents used during conference calls were available on the Internet, and all authors had continuous access to documents to provide individual input. A face-to-face conference was not necessary to complete the document. To the best of our knowledge, this is the first time an Utstein-style consensus statement has been generated in this fashion.
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Utstein Reporting Templates |
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TopIntroductionThe Consensus ProcessUtstein Reporting TemplatesData Elements and DefinitionsDiscussionSummaryConclusionsReferences |
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In June 1990, representatives from the American Heart Association, European Resuscitation Council, Heart and Stroke Foundation of Canada, and the Australian Resuscitation Council met at Utstein Abbey on the island of Mosteroy in Norway. The purpose of the meeting was to discuss problems with resuscitation nomenclature and the lack of standardized definitions in reports of adult prehospital cardiac arrest. At a follow-up meeting, the decision was made to adopt the term "Utstein style" for the uniform reporting of data from prehospital cardiac arrests.40 Many other Utstein-style international consensus statements have been published over the past 15 years, including the uniform reporting of pediatric advanced life support,41 laboratory cardiopulmonary resuscitation research,42 in-hospital resuscitation,43 neonatal life support,44 drowning,40 cardiopulmonary resuscitation registries,40 and trauma data.45 These comprehensive documents are aimed at both the clinical and academic communities. The standardized definitions found in the Utstein scientific statements enable comparative analysis between resuscitation studies and healthcare systems.
The challenges associated with collecting MET, RRT, and CCOT data are similar to those associated with the collection of cardiopulmonary resuscitation data. The task force considered a balance between the inclusion of data elements that are important in determining clinical and process outcomes but may be difficult to collect with variables that may be easy to collect but add little to the overall usefulness of the data set. For consistency with previous Utstein-style reports, the task force agreed that data should be classified as core or supplemental. Core data elements are defined as the absolute minimum required for continuous quality improvement and are necessary to accurately track process and outcomes variables. These include facility, patient, event, and outcomes information. The collection of these data elements is sufficient to enable the comparison of process and outcome between different institutions, both nationally and internationally.40 Supplemental data elements are defined as elements required for research or to advance the understanding of process-related issues to drive best clinical practice. Standardized definitions for all data elements will enable comparisons between MET-type programs and will permit the aggregation of data to rapidly advance the science of various rapid response systems. Institutional demographics will enable comparisons and establishment of best practices.
Because there is no single comprehensive, evidence-based set of physiological triggers to initiate an MET response, hospitals may develop their own criteria for initiating an MET call. The criteria for activation are core data elements. With the use of a standardized data set that includes outcomes, it may be possible to determine which calling criteria might be the most useful. To prevent sampling bias, all patient events that occur at or immediately after activation of response teams, as defined by activation criteria, should be included in data reporting. Key patient-level and hospital-level outcomes must be included. Interested individuals or institutions can use these data elements to identify critical factors to consider when these systems are implemented, to monitor system performance, or to compare the rates of team activation and adverse patient outcomes between different institutions.
Figures 1 and 2
are template data collection forms for collection of facility and event data. These forms can be used to assist individual hospitals in creating an efficient, comprehensive data collection tool.
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Data Elements and Definitions |
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TopIntroductionThe Consensus ProcessUtstein Reporting TemplatesData Elements and DefinitionsDiscussionSummaryConclusionsReferences |
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Tables 1 through 5
present data elements and their definitions for the response team data collection: hospital data form (Figure 1
), and Tables 6 through 10 present data elements and their definitions for the response team data collection: case form (Figure 2).
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Discussion |
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TopIntroductionThe Consensus ProcessUtstein Reporting TemplatesData Elements and DefinitionsDiscussionSummaryConclusionsReferences |
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For many patients, clinical condition deteriorates during the hospital stay. This deterioration is frequently unrecognized or inappropriately or incompletely treated. Some patients require emergency transfer to an intensive care unit, or their condition deteriorates to cardiac arrest.1,5,6,9,11,46–48 System interventions, including the use of METs, RRTs, and CCOTs, have the potential to decrease cardiac arrest and in-hospital mortality rates.21,23–25,28,49 The precise impact of these interventions remains unclear, because the largest study of METs, a cluster randomized, controlled trial, failed to show an effect of the MET system on rates of cardiac arrest, unexpected death, or unplanned admission to the intensive care unit.12 The failure to demonstrate effect may have been due to a real failure of the intervention but also may have been multifactorial and possibly design related. Plausible reasons for failure include contamination of the control hospitals, a very short baseline period, insufficient time for team implementation and maturation in the intervention hospitals, an insufficient duration of the study period to demonstrate a difference, and lack of power. Given that these possibilities are likely to have influenced the results, these systems require further study.
One recent publication has outlined guidelines for the uniform reporting of data for METs.50 This document was developed by a single health service in Sydney, Australia. The present document was compiled by a task force of international representatives and considered all of the existing types of team-based response systems, rather than focusing solely on the MET system. The present document therefore provides a set of core and supplemental data elements for reporting on these systems that was reached by international consensus and that should be capable of being readily adopted in many institutions around the world. This will encourage more complete data collection and consistency in reporting of findings and will enable comparison of cross-institutional and international outcomes.
The context in which MET systems are implemented is important and may affect outcomes. Many of the core data elements in this statement relate to individual institutional facility and demographic data and were recommended to facilitate greater understanding of the environment in which the system was implemented.
Response Teams
Different hospitals have different capacities for intensive monitoring of patients. A response system that works well in one institution may not work well in another. Data collected from many different types of institutions may enable formulation of guidelines for best practice according to the capability of each hospital. The data elements for team demographics and composition are also considered core elements, because the different skills and experience of response team members may influence patient outcome. It is not known whether an immediate response to a patient’s deteriorating condition by a team of trained and experienced doctors improves outcome compared with a first response with 1 trained nurse who has the ability to mobilize a more comprehensive team response when required. The nature of the intervention may need to be tailored to local resources. The impact of variable team training, composition, and experience on patient and process outcomes is unknown. Given these uncertainties, collection of and reporting on the core data elements for the team demographics and response are strongly recommended.
Patient Demographics
Some patient demographic data, such as name, medical record number, and date of birth, may not be reported in certain locales because of patient confidentiality restraints. These data elements were included as core elements so that individual hospitals can track individual cases for the purposes of quality improvement and feedback.
Ethnicity was not included as a data element because there is no internationally meaningful and easily constructed definition of ethnicity. Some hospitals may wish to track ethnicity independently to obtain information that is meaningful locally.
Pre-Event Data
An understanding of the patient’s pre-event history may be vital to the development of a system that is capable of responding to patients at risk wherever they are in the hospital, because the optimal time for activating a full system response is not known. Identification of high-risk patients for more intensive monitoring and care may assist this process. Therefore, the data elements that provide information about the patient in the 24 hours before activation and at the time of activation constitute important information.
Event Data
A variety of activation criteria have been described for adults. Some systems are quite restrictive, whereas others encompass Text continues on page 16many different criteria, including subjective criteria. Only 1 set of calling criteria has been published for infants and children.28 More information on the patient’s physiological status at the time of the call may be helpful in determining the optimal set of activation criteria by linking the patient’s physiological status at the time of team activation to the patient’s outcome. Alternatively, different sets of activation criteria may be equally useful. These data elements also provide information on how critical the patient’s condition was at the time of activation, which provides an opportunity for more consistent comparison of team responses and impact.
The core data set discussed here forms part of the most common and widely used sets of activation criteria. Level of consciousness is included in most sets of activation criteria, but level of deterioration is specified or described in many different and sometimes subjective ways. Although there is no universally accepted scoring system to characterize mental status, there was consensus to use either the ACDU (Alert, Confused, Drowsy, Unresponsive) or the AVPU (Alert, responds to Voice, responds to Pain, Unresponsive) scoring system. Both systems are easily used by general ward staff and have been validated as methods for tracking changes in level of consciousness.51 The Glasgow Coma Scale (GCS) is sometimes included in activation criteria, but in practice, it is not often used in general ward environments and may be scored incorrectly by people who do not use it often.52 The ACDU and AVPU systems may therefore be more practical and useful for scoring deterioration in neurological patients.
The location where the patient’s condition deteriorates may be related to outcome. Knowledge of patient location at the time of system activation is essential.18,47 This information may also serve to highlight whether there are areas of the hospital where patients’ conditions commonly deteriorate. This may help institutions provide tailored solutions through increased monitoring or staffing of these areas, or it may stimulate other improvements in quality of care.
Team Activations and Interventions
When studying the potential benefit of an MET or other rapid response system, the cost of providing a team response, measured in terms of time that team members are absent from their usual duties, may be an important consideration. Therefore, collection and reporting of the time of team activation and the time of completion of activation are core data elements. It is widely reported that time reporting that is not centralized or adjusted to a single clock is unreliable, and thus, hospitals that adjust to a single timepiece should be able to compare time-response effects. The interventions provided by the team are crucial for understanding the range and type of interventions that may be required to treat patients with deteriorating conditions. These interventions may also have an impact on patient outcome. The MET commonly undertakes therapies such as providing supplementary oxygen and fluids. These simple interventions may be as important in determining outcome as more invasive therapies.33
After team activation, team members may also consider institution of treatment-limitation orders when escalation of medical support is considered futile or inappropriate. These interventions, or the opening of discussion about treatment limitations, are an important part of response team activities and constitute an indicator of quality of care. In particular, the institution of a do-not-attempt-resuscitation (DNAR)/not-for-resuscitation (NFR) order is an important treatment. Institution of any treatment-limitation order or DNAR/NFR order should be collected and reported in order to understand the contribution of response teams to patient management.
Patient Outcome Measures
Patient outcomes are the most important measures of the effect of a system-wide intervention. Outcomes should be collected accurately to enable quality assurance of existing care and research into the different types of system responses to define future standards of care and to allow comparison between centers. The listed outcomes have been chosen for their simplicity and their importance in understanding system interventions. In particular, the patient’s vital status at time of discharge was selected to enable comparison of rates of serious adverse outcome, including cardiac arrest, because these are central indicators of patient outcome.
Hospital Outcome Measures
The hospital-level data elements related to DNAR/NFR deaths have been defined as core data in recognition of the potential for these system interventions to improve quality of care, particularly for patients at the end of life. It is also important to track the number of DNAR/NFR deaths when the cardiac arrest event rate and other indicators of system effectiveness are being monitored. This will help determine whether any decrease in cardiac arrests is the result of an increase in the rate of assignment of DNAR/NFR orders, and if so, whether this is an appropriate response and what proportion of the reduction in cardiac arrests can be attributed to this change. We anticipate that many institutions may have some difficulty in collecting this information, because it is often recorded poorly or not reported at all, but we urge investigators to make every effort to include information about DNAR/NFR deaths and the location of these deaths in their data collection and reporting. The MET has the best chance of altering outcome for patients who die unexpectedly in areas where the level of care is inappropriately low, and this is where the attention of most of these teams is directed. Unexpected deaths that occur in critical care areas, operating rooms, and emergency departments are not likely to be affected by a system such as the MET, because the level of care should already be optimal.
Pediatric Systems
A special effort has been made to ensure that data on the use of response systems for pediatric inpatient care are also collected. Only 1 study has attempted to assess the impact of an inpatient pediatric MET in preventing serious adverse events, including death.28 More information is necessary to determine whether these systems show a consistent benefit in this population. Although many of the data suggested for collection will be similar for adults and children, specific physiological activation criteria (heart rate, respiratory rate, and blood pressure) will differ depending on the age of the patient. A uniform method of collecting these data should make validation and assessment of the usefulness of activation criteria in infants and children achievable. In addition, the types of serious adverse events experienced by pediatric patients may also be different, because respiratory system–mediated events are more common in these patients than primary cardiac events.53 Data on newborns who receive care in neonatal intensive care settings have been purposely excluded from this effort because intensive care expertise is consistently available to the majority of these neonates.
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Summary |
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TopIntroductionThe Consensus ProcessUtstein Reporting TemplatesData Elements and DefinitionsDiscussionSummaryConclusionsReferences |
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The number of core data elements may be challenging, but every effort has been made to minimize demands on clinicians, quality-improvement staff, and researchers. Where data elements require retrospective review of patient records, careful consideration of the cost-benefit of these data elements was made, and in every case, the additional benefit was thought to outweigh the costs of data collection. We urge clinicians to make every effort to include these data elements in their internal quality-improvement programs, and we urge researchers to include them in their research design.
The level of monitoring of patients in hospitals may increase significantly in the future, and it is possible that many more patients will be monitored continuously rather than intermittently. These changes may affect the activation criteria used and resources required to staff response teams adequately. Increased surveillance may increase the number of response team calls. Optimal methods for monitoring hospitalized patients are not well understood, but the information collected as part of the investigation of these response teams may also contribute to more appropriate monitoring strategies.
The purpose of MET, RRT, and CCOT systems is to improve quality of care and prevent adverse outcomes in hospitalized patients. In particular, the prevention of medical error is a high priority.54,55 Systems such as these are needed to ensure that gaps in quality of care are closed.
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Conclusions |
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TopIntroductionThe Consensus ProcessUtstein Reporting TemplatesData Elements and DefinitionsDiscussionSummaryConclusionsReferences |
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A proportion of hospitalized patients are cared for in areas that are inappropriate for the severity of their illness. There are opportunities to improve patient outcomes and optimize the use of limited healthcare resources by identifying patients at risk of deterioration, cardiac arrest, or death and by intervening early to lower these risks. By consensus, a list of core and supplemental data elements has been developed in the Utstein style for monitoring incidence and outcome of such in-hospital events, and a system intervention has been designed to reduce such events. These data may be used to develop evidence-based recommendations for best clinical practice and to improve outcomes in hospitalized patients.
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Acknowledgments |
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The authors wish to thank Tanya Semenko and Dr Brian Eigel for their unwavering support and assistance in the preparation of this manuscript.
Disclosures
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Footnotes |
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The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.
This article has been co-published in the December 2007 issue of Resuscitation.
When this document is cited, the American Heart Association requests that the following citation format be used: Peberdy MA, Cretikos M, Abella BS, DeVita M, Goldhill D, Kloeck W, Kronick SL, Morrison LJ, Nadkarni V, Nichol G, Nolan J, Parr M, Tibballs J, van der Jagt EW, Young L. Recommended guidelines for monitoring, reporting, and conducting research on medical emergency team, outreach, and rapid response systems: an Utstein-style scientific statement: a scientific statement from the International Liaison Committee on Resuscitation (American Heart Association, Australian Resuscitation Council, European Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, and the New Zealand Resuscitation Council); the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiopulmonary, Perioperative, and Critical Care; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research. Circulation. 2007;116:2481–2500.
This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on July 10, 2007. A single reprint is available by calling 800-242-8721 (US only) or by writing the American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX 75231-4596. Ask for reprint No. 71-0419. To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer.com.
Expert peer review of AHA Scientific Statements is conducted at the AHA National Center. For more on AHA statements and guidelines development, visit http://www.americanheart.org/presenter.jhtml?identifer=3023366.
Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at http://www.americanheart.org/presenter.jhtml?identifier=4431. A link to the "Permission Request Form" appears on the right side of the page.
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