The impetus to create Medical Emergency Teams comes from studies examining the quality of care and clinical decision making in patients who experienced cardiopulmonary arrest, or who had unplanned admission to an intensive care unit (ICU).The studies were notable for demonstrating great variations in quality of care, and in particular, the widespread finding of care that was inadequate.
Studies evaluating patterns of ward care prior to ICU admission show a general lack of time urgency in evaluating and treating patients with abnormal vital signs and other forms of deterioration (3-5). Patients initially admitted to hospital wards (as opposed to ICU) had up to a 4-fold increase risk of mortality, suggesting that the nature of the care was a more significant determinant of the ultimate clinical trajectory than the admitting diagnosis (4). Both deterioration in the admitting condition and the development of new problems were key risks for a worse outcome.
In a study done by McQuillan et al., patients considered to have "suboptimal" care had twice the ICU mortality rate of the other groups (6). Areas considered problematic were: timing of admission (late), and management of oxygen therapy, airway, breathing, circulation, and monitoring. Reasons underlying the suboptimal care were "failure of organization, lack of knowledge, failure to appreciate clinical urgency, lack of experience, lack of supervision, and failure to seek advice." Our own experience in examining the dynamic decision making of house staff in a fully simulated ICU revealed similar deficiencies, including non-adherence to established protocols (7).
Two different studies of antecedents to cardiac arrest demonstrated that 75% to 85% of the affected patients had some form of deterioration in the hours prior to the cardiac arrest (3,8). Nearly one-third of such abnormalities persisted for greater than 24 hours prior to cardiac arrest, with a population mean of 6.5 hours (3). In one series, the majority (76%) of the disease processes eventually progressing to cardiac arrest were not considered intrinsically, rapidly fatal (8). In another series, over half of the cardiac arrests presented ample warning of decompensation: the majority of patients had uncorrected hypotension, and half of these had systolic blood pressures less than 80mmHg for more than 24 hours (9). Other patients in this series had severe but correctable abnormalities such as hypokalemia, hypoglycemia, and hypoxemia. This collective experience suggests that quality of care, more so than the disease, may be responsible for the poor immediate survival of these patients. Inattention to or unawareness of a developing serious condition causes the additional problem of hasty decision making at the time of cardiac arrest. Once a cardiac arrest has occurred, the clinician's hand is forced, and ICU admission becomes mandatory for surviving patients in the absence of a do-not-resuscitate order.
Problems with establishing proper care were found to exist at multiple levels: nurses were not calling physicians for patients with abnormal vital signs or changes in sensorium; physicians did not fully evaluate these abnormalities when they were contacted; ICU consultants were not called in routinely, and senior level or consulting ICU caregivers did not obtain routine studies, such as blood gasses, hematocrit and electrolyte studies, that would have defined the patient's problem. In cases when laboratory studies were done, they were not always interpreted correctly, and when they were, therapy was not always initiated (5).All of the aforementioned studies were conducted in academic centers where junior team members are traditionally called to evaluate a patient and there is a varying degree of engagement by more senior staff members. Loss of valuable time in patient evaluation and stabilization may have been further compounded by attending staff that lack knowledge of seriously ill patients and their problems, and who lacked the skills to direct an appropriate resuscitation (6,10). Further, teaching hospitals have also increased their reliance on cross-coverage schemes, which also have been associated with a higher incidence of potentially preventable adverse events (11).
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