Rapid response systemsThe epidemiology of Medical Emergency Team calls for orthopedic patients in a teaching hospital: A retrospective cohort study
Introduction
Orthopedic surgery frequently involves substantial mechanical and physiological stresses that can be associated with hypovolemia, cardiac dysfunction, and alterations of vasomotor function. These stresses can in turn lead to organ dysfunction, significant morbidity and mortality. Many orthopedic procedures are performed in elderly patients with significant co-morbidities and reduced physiological reserve. Combined, these factors predispose patients to several major post-operative complications including acute kidney injury, major adverse cardiac events, postoperative pulmonary complications and delirium.1, 2
Rapid Response (RRT) or Medical Emergency Teams (MET) are an interdisciplinary team of critical care health professionals who identify and treat deteriorating postoperative patients on the ward.3 The MET is activated when a patient breaches one or more pre-defined criteria based on deteriorations in a patient’s vital signs. The introduction of METs have been associated with reductions in in-hospital cardiac arrests, all-cause hospital mortality, and post-operative complications.4, 5, 6, 7
Although METs have been shown to improve patient outcomes, there remains a paucity of data defining these patients’ baseline characteristics and peri-operative variables. Furthermore, it is desirable to better understand the epidemiology of MET events to further improve patient safety and outcomes.8 Accordingly, we undertook a retrospective study of patients admitted to a high-volume orthopedic unit in a university hospital. Specifically, we assessed the frequency of MET activations, baseline patient characteristics, the physiological trigger for the MET activation and whether requirement for a MET activation was associated with an increased risk of in-hospital complications. Finally, we determined if requirement for a MET activation was associated with an increased risk of in-hospital death.
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Hospital setting
After Human Research Ethics approval (HREC no: LNR/16/Austin/166) we performed a retrospective cross-sectional study of adult patients admitted to the orthopedic unit between January 2012 to December 2015. The need for informed written patient consent was waived due to the observational and retrospective nature of the study. The study was conducted at Austin Health, a tertiary teaching hospital affiliated with the University of Melbourne in Melbourne, Victoria, Australia. Austin Health performs
Details of the patient cohort
Between 2012 to 2015, a total of 6344 patients were admitted under the orthopedic surgical unit. The median (IQR) age was 66 (47–79), 55.8% were female, and the median (IQR) CCI was 3 (1–5). Smoking and alcohol abuse were present in 31.0% and 1.7% of patients, respectively (Table 1). Overall, 54.5% of admissions were emergency admissions and 1130 (17.8%) were classified as non-operative (Table 2).
Details of MET call number and physiological trigger
There were 605 (9.5%) patients who received a MET call during their admission, of which 390 (64.5%)
Discussion
We conducted a retrospective observational study of patients admitted under an orthopedic surgical unit of a university hospital to evaluate the epidemiology of MET activations. We found that patients who received a MET call were older, more likely to be emergently admitted, and had a higher CCI. In addition, such patients were more likely to have an operative procedure, especially hip and knee surgery, require ICU admission, and develop a postoperative complication. Finally, we found that
Conclusions
In our hospital, approximately one in ten patients received a MET call after orthopedic surgery. Increasing age, major lower limb joint arthroplasty, and patients with a high CCI were at increased risk of requiring a MET activation. Patients who received a MET call were at increased risk of subsequently developing postoperative complications and dying in hospital. Further strategies are needed to recognize and respond to clinical deterioration and more pro-actively manage at-risk orthopedic
Conflict of interest statement
None of the authors have any conflicts of interest to declare in relation to this manuscript.
Contributions
DJ and LC conceived the study.
LC and LO conducted the data analysis.
JGRR, RZ, BM and RR conducted the data extraction.
DJ takes responsibility for the integrity of the study.
All authors contributed significantly to the drafting and revision of the manuscript.
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