Electronic Supplementary Material
“Reducing in-hospital cardiac arrests and hospital mortality
by introducing a Medical Emergency Team”
Intensive Care Medicine 2009
Authors: David Konrad1 MD PhD, Gabriella Jäderling1 MD, Max Bell1 MD PhD,
Fredrik Granath2 PhD, Anders Ekbom2 MD PhD and Claes-Roland Martling1 MD PhD
1Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care, Karolinska Institute, SE171 76 Stockholm, Sweden and
2Department of Medicine, Clinical Epidemiology Unit, Karolinska Institute, SE171 76 Stockholm, Sweden
Correspondence:
David Konrad, MD PhD, Dept Anesthesiology and Intensive care, KarolinskaUniversityHospital, SE17176 Stockholm, Sweden. Phone: +46-8-5177 3140, Fax: +46-8-5177 5810
Mail to:
The MET patients with DNR
When assessing effects of implementing a Medical Emergency Team (MET) or other forms of rapid response teams, it is important to look at effects on DNR (do not resuscitate). In most reports on MET, DNR frequency increases. This was also the case in the present study. During the control period, a prevalence study was performed [1]with the main objective to test our MET criteria. We also checked whetherpatients fulfilling the MET criteria had pre-existing DNR-orders, 4.5% did. In the current study 26% of the MET patients were made DNR, either in direct conjunction with the MET call or at times days later.
Total MET / DNR-METNumber of MET calls / 689 / 179
DNR (%) / 26
Female (%) / 42 / 46
Male (%) / 58 / 54
Mean age, years (SD) / 65.8 (16) / 72 (12)
Response time, min (SD) / 12.3 (14) / 14.5 (14)
Time spent, min (SD) / 33.1 (22) / 36.4 (21)
30-day mortality (%) / 7.9 / 71.5
180-day mortality (%) / 15.8 / 89.7
Table. DNR in MET patients compared with totalMET patients
The comparison with the prevalence study regarding DNR frequencies may not be valid since the issue of DNR would regularly be raised as a consequence of MET involvement whereas in the control period there was no such systematic way of addressing the DNR subject. The DNR orders were issued by the consultant at the ward where the patient was being treated.
As can be seen from Table 1 the patients receiving DNR were older, had a slightly longer response time and naturally much higher short- and long-term mortality. Medical MET patients had a higher DNR frequency: 30.2% vs. 22.2% for the surgical MET patients. In a recent study, Calzavacca and coworkers [2] reported similar overall DNR figures for MET patients.
Mortality rates after CA are still very high in hospitalized patients [3] and show very little, if any, tendency to improve. Thus the MET may serve to both avert CA that are preventable and also to withhold CPR therapy to patients with very poor prognosis, For ethical reasons, the latter effect is very important, as well as providing support in end-of-life care.
It should be noted that the calculations for hospital mortality in the current study does not take DNR into account, i.e. the reductions in hospital mortality both overall and for the respective subgroups cannot be explained by the increase in DNR orders.
References:
1. Bell MB, Konrad D, Granath F, Ekbom A, Martling CR. (2006) Prevalence and sensitivity of MET-criteria in a Scandinavian University Hospital. Resuscitation. 70(1): 66-73.
2. Calzavacca P, Licari E, Tee A, Egi M, Haase M, Haase-Fielitz A, Bellomo R. (2008) A prospective study of factors influencing the outcome of patients after a Medical Emergency Team review. Intensive Care Med. 34(11): 2112-2116.
3. Peberdy MA, Kaye W, Ornato JP, Larkin GL, Nadkarni V, Mancini ME, Berg RA, Nichol G, Lane-Trultt T. (2003) Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation. 58(3): 297-308.