Risk of clinical deterioration and Medical Emergency Team activation in patients admitted to hospital via the Emergency Department compared to elective admission.

Abstract

Background Medical Emergency Team (MET) and Clinical Review (CRC) criteria are abnormal vital signs indicative of clinical deterioration. CRC are used to trigger rapid review and, at Epworth, general hospital wards and the ED have slightly different trigger criteria. The aims of this study were to: (i) compare the prevalence and median time to MET activation within 24 hours of admission, between patients admitted electively and via the ED, and (ii) compare the prevalence of CRC antecedent to MET activation between the same cohorts. Methods Two-phase retrospective, descriptive study using electronic patient database of all patients admitted to Epworth Richmond in the 2016 calendar year (Phase 1) and medical record audit of 100 randomly selected patients (n=50 elective, n=50 ED) to evaluate prevalence of CRC antecedent to MET activation and the nature of MET criteria achieved (Phase 2). Results ED-admission patients were three times more likely to achieve MET activation (n=556/9,222,6.03%) than elective admissions (n=1,007/52,601,1.91%) during their admission overall. For MET activation within 24-hours of admission (n=560), time to MET activation was longer for ED (Med-14,Q1,Q3=8,19hrs) than elective (Med-9, Q1,Q3=1 6,16hrs) admissions (p<0.001). Hypotension was the most common MET activator (elective:39.9%;ED:27.8%). ‘Nurse worried’ (26%) and pain (22%) were next for the ED cohort compared to hypertension for elective admissions (18%). Phase 2: 72% (n=36) of elective and 74% (n=37) of ED-admissions experienced one or more CRC prior to MET activation. Hypotension (38%), nurse worried (19%), pain (16%) and hypertension (9%) were the most prevalent. Summary Patients admitted via ED are more likely to achieve MET activation during admission and experience later deterioration than elective admissions. Standardised CRC is recommended hospital-wide. Uncontrolled pain contributed significantly to MET activation in the ED cohort, suggesting inadequate analgesia at the ED-ward interface. Further research of the ‘nurse worried’ criterion is recommended.