Abstract
We read with interest the study by Douglas et al. on triggers for medical emergency team (MET) call activation in non-cardiac surgery within 48 h 1 in a large tertiary public hospital and wholeheartedly agree there is a pressing need to reduce the risk of hypotension, which accounted for 41.4% of their MET calls.
Similar audits have been performed, and solutions for MET prevention of hypotension have been proposed and implemented at two other large tertiary hospitals in Victoria. Hence, it is interesting to compare the results of the MET calls to see the similarities and consider whether the solutions proposed elsewhere may benefit their institution.
A year-long audit of MET calls within 24 h of surgery was performed at Epworth Hospital, a large tertiary private hospital. The audit was approved by the Ethics Committee of Epworth Health Care (EH2017-200) and the requirement for written informed consent was waived.
Our audit found comparable results to those of Douglas et al. Two hundred and ninety-seven MET calls occurred after 29,869 surgical procedures, a rate of 0.99%, accounting for 15.4% of all MET calls over the study period.
Similarly, it was found the MET call triggers were hypotension (45.8%), syncope (12.5%), arrhythmias (8.1%), chest pain (6.7%), pain (6.1%), hypertension (3.4%), hypoxia (3.0%), low urine output (3.0%), bradypnoea (2.4%) and tachypnoea (2.0%).
The median interval between post-anaesthetic care unit discharge and the MET call was 6 h 25 min. No patient has a repeat MET call within this cohort. Two hundred and eighty-six patients (96.3%) remained on the ward, six went to Intensive Care (2.0%), four to Coronary Care (1.3%) and one returned to theatre (0.3%).
On further subgroup analysis, in the patients who reached the hypotension criteria for activation of the MET call, the only treatment required in 119 (87.5%) cases was a fluid bolus with no further escalation in their level of care. Orthopaedics and spinal surgery accounted for 72.1% of all the hypotension MET calls.
As part of the MET prevention plan for hypotension, a single once-only nurse-initiated intravenous fluid bolus of 500 ml Hartmann’s solution was authorised if the systolic blood pressure fell below 100 mmHg, and provided the oxygen saturation on pulse oximetry was above 94%. 2
Similarly, The Alfred, another large tertiary centre public hospital, found that hypotension was the most common trigger when looking at all triggers of MET calls 3 and developed a similar proposed solution but with three exclusion criteria rather than an oxygen saturation-based approach.
Their exclusion criteria were:
The patient is on a respiratory ward. The patient had a cardiac cause for admission. The patient is under the heart failure team.
They estimated there would be a 68.7% reduction in MET calls for hypotension and an absolute reduction of 19.6% in the total MET calls for the hospital at the time of their audit.
The benefits of pre-authorising a single fluid bolus for hypotension would allow for prompt treatment without necessarily needing a MET call, thus reducing the workload of the MET team.
Footnotes
Author Contribution(s)
Acknowledgements
Thanks to Associate Professor Julian Hunt-Smith and Associate Professor Jonathan Barrett for their work, Dr Steven McConchie for his help in extracting the data and Professor Paul Myles for his advice on the audit.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
