Does a Medical Emergency Team Activation Define a New Paradigm of Mortality Risk?*

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Pediatric cardiac arrest remains a rare but often fatal event (1). Pediatric cardiac arrest outside the PICU has a high risk of mortality (2) with rates reported at 50–67% (3). Thus, over the last 15 years, many pediatric institutions implemented rapid response teams (RRTs) or medical emergency teams (METs) in an effort to reduce cardiac arrest outside the ICU. In 2005, Tibballs et al (4) first described a RRT in a pediatric institution. Several centers have since reported a reduction in cardiac and respiratory arrests after implementation of a RRT (1) and a recent meta-analysis (5) including 29 adult and pediatric studies demonstrated an overall reduction in hospital mortality and cardiopulmonary arrests.
In this issue of Pediatric Critical Care Medicine, McKelvie et al (6) compared the length of stay (LOS) and mortality rate in children evaluated by their hospital’s MET against other hospitalized children who did not have MET evaluation. They also examined the influence of multiple MET activations for the same patient on the risk of mortality and LOS. This study found pediatric patients evaluated by the MET had significantly higher mortality risk and longer LOS compared with patients not evaluated by the MET; patients with multiple MET activations were at even higher mortality risk. Although this conclusion may seem like common sense to critical care physicians, this study represents one of the first investigations to provide objective data on the topic. There are several study limitations that diminish our ability to fully generalize the author’s conclusions. First, although the cohort of patients was large (42,308 admissions among 29,229 patients), the data are from a single institution. Second, the median time from MET review to death was 8 days with a range of 0–104 days. At these variable time periods between MET review and death, it is difficult to ascertain if the patient’s eventual death was attributable to the same disease process which prompted MET evaluation. This is especially important because 73% of patients with multiple MET activations had at least one complex chronic condition. Third, the authors do not describe how many patients who received a MET evaluation were transferred to the PICU compared with those who remained on the general care unit. Was the threshold for PICU transfer too high in the study hospital? As PICU admission criteria vary from institution to institution, if the threshold was lower, would the mortality rate among patients with MET activations be lower? Although these limitations are important, we applaud the authors’ investigation into this question and the results of this study prompt several important topics for discussion.
One of the most interesting questions raised by the authors is—given their findings that patients evaluated by the MET have a higher mortality risk and longer LOS—should we differentiate these patients from other hospitalized patients and if so, how? McKelvie et al (6) suggest a 24–48 hour follow-up (after the initial MET evaluation) of all patients evaluated by the MET. This begins to address the broader question regarding how to differentiate and manage high-risk patients outside critical care areas and specifically, how to identify these patients “proactively” as high risk. Brady et al (7) proposed and implemented a “watchstander” program, which emphasizes situation awareness among physicians and nurses in noncritical care areas. Their system used three times daily inpatient huddles, a safety officer of the day to identify patients at high risk for deterioration, and clearly defined “watcher” mitigation plans and follow-up.

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