Relationship between Time of Day of Medical Emergency Team Activations and Outcomes of Hospitalized Pediatric Patients

Joshua Feder; Christa Ramsay; Anne Tsampalieros; Nick Barrowman; Kara Richardson; Sara Rizakos; Julia Sweet; James Dayre McNally; Anna-Theresa Lobos

doi:10.1055/s-0042-1744297

Journal of Pediatric Intensive Care, Table of Contents

CC BY-NC-ND 4.0 · J Pediatr Intensive Care 2024; 13(04): 379-388
DOI: 10.1055/s-0042-1744297

Original Article

Relationship between Time of Day of Medical Emergency Team Activations and Outcomes of Hospitalized Pediatric Patients

Joshua Feder

¹Department of Pediatrics, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada

,

Christa Ramsay

²Department of Respiratory Therapy, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada

,

Anne Tsampalieros

³Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada

,

Nick Barrowman

³Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada

,

Kara Richardson

²Department of Respiratory Therapy, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada

,

Sara Rizakos

⁴MD Candidate, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada

,

Julia Sweet

⁴MD Candidate, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada

,

James Dayre McNally

²Department of Respiratory Therapy, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada

⁵Division of Critical Care, Children's Hospital of Eastern Ontario, Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada

,

Anna-Theresa Lobos

⁵Division of Critical Care, Children's Hospital of Eastern Ontario, Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada

› Author Affiliations

Abstract

This study was conducted to investigate whether outcomes of medical emergency team (MET) activations differ by time of day of hospitalized pediatric patients. This is a retrospective cohort study conduct at a tertiary pediatric hospital. Data were extracted from the charts of 846 patients (with one or more MET activations) over a 5-year period. Also can remove hospital names and affiliated institution from the body of the text as readers can find this information in the author list. Patients included children <18 years, admitted to a pediatric ward, who experienced a MET activation between January 1, 2016 and December 31, 2020. We excluded patients reviewed by the MET during a routine follow-up, planned pediatric intensive care unit (PICU) admissions from the ward, and MET activation in out-patient settings, post-anesthesia care unit, and neonatal intensive care unit. There was no intervention. A total of 1,230 MET encounters were included as part of the final analysis. Daytime (08:00–15:59) MET activation was associated with increased PICU admission (25.3%, p = 0.04). There was some evidence of a higher proportion of critical deterioration events (CDEs) during daytime MET activation; however, this did not reach statistical significance (24%, p = 0.09). The highest MET dosage occurred during the evening hours, 16:00 to 23:59 (15/1,000 admissions), and it was lowest overnight, 00:00 to 07:59 (8.8/1,000 admissions, p < 0.001). This period of lowest MET dosage immediately preceded the highest likelihood of PICU admission (08:00, 37.5%) and CDE (09:00, 30.2%). Following the period of lowest MET activity overnight, MET activations during early daytime hours were associated with the highest likelihood of unplanned PICU admission and CDEs. This work identifies potential high-risk periods for undetected critical deterioration and targets for future quality improvement.

Keywords

pediatric - critical care - medical emergency team - rapid response system - critical deterioration events - PICU admission

Full Text

References

References
1 Krmpotic K, Lobos AT, Chan J. et al. A retrospective case-control study to identify predictors of unplanned admission to pediatric intensive care within 24 hours of hospitalization. Pediatr Crit Care Med 2019; 20 (07) e293-e300
2 Hanson CC, Randolph GD, Erickson JA. et al. A reduction in cardiac arrests and duration of clinical instability after implementation of a paediatric rapid response system. Postgrad Med J 2010; 86 (1015): 314-318
3 Kause J, Smith G, Prytherch D, Parr M, Flabouris A, Hillman K. Intensive Care Society (UK), Australian and New Zealand Intensive Care Society Clinical Trials Group. A comparison of antecedents to cardiac arrests, deaths and emergency intensive care admissions in Australia and New Zealand, and the United Kingdom–the ACADEMIA study. Resuscitation 2004; 62 (03) 275-282
4 El Halal MGDS, Barbieri E, Filho RM, Trotta Ede A, Carvalho PRA. Admission source and mortality in a pediatric intensive care unit. Indian J Crit Care Med 2012; 16 (02) 81-86
5 Odetola FO, Rosenberg AL, Davis MM, Clark SJ, Dechert RE, Shanley TP. Do outcomes vary according to the source of admission to the pediatric intensive care unit?. Pediatr Crit Care Med 2008; 9 (01) 20-25
6 Bonafide CP, Localio AR, Roberts KE, Nadkarni VM, Weirich CM, Keren R. Impact of rapid response system implementation on critical deterioration events in children. JAMA Pediatr 2014; 168 (01) 25-33
7 Jones DA, DeVita MA, Bellomo R. Rapid-response teams. N Engl J Med 2011; 365 (02) 139-146
8 Jones D, Lippert A, DeVita M, Hillman K. What's new with rapid response systems?. Intensive Care Med 2015; 41 (02) 315-317
9 Kotsakis A, Lobos AT, Parshuram C. et al; Ontario Pediatric Critical Care Response Team Collaborative. Implementation of a multicenter rapid response system in pediatric academic hospitals is effective. Pediatrics 2011; 128 (01) 72-78
10 Tibballs J, Kinney S. Reduction of hospital mortality and of preventable cardiac arrest and death on introduction of a pediatric medical emergency team. Pediatr Crit Care Med 2009; 10 (03) 306-312
11 Brilli RJ, Gibson R, Luria JW. et al. Implementation of a medical emergency team in a large pediatric teaching hospital prevents respiratory and cardiopulmonary arrests outside the intensive care unit. Pediatr Crit Care Med 2007; 8 (03) 236-246 , quiz 247
12 McKelvie B, McNally JD, Chan J, Momoli F, Ramsay C, Lobos AT. Increased mortality and length of stay associated with medical emergency team review in hospitalized pediatric patients: a retrospective cohort study. Pediatr Crit Care Med 2017; 18 (06) 571-579
13 DeVita MA, Braithwaite RS, Mahidhara R, Stuart S, Foraida M, Simmons RL. Medical Emergency Response Improvement Team (MERIT). Use of medical emergency team responses to reduce hospital cardiopulmonary arrests. Qual Saf Health Care 2004; 13 (04) 251-254
14 Jones D, Bellomo R, DeVita MA. Effectiveness of the medical emergency team: the importance of dose. Crit Care 2009; 13 (05) 313
15 Sundararajan K, Flabouris A, Thompson C. Diurnal variation in the performance of rapid response systems: the role of critical care services-a review article. J Intensive Care 2016; 4: 15
16 Taenzer AH, Spence BC. The afferent limb of rapid response systems: continuous monitoring on general care units. Crit Care Clin 2018; 34 (02) 189-198
17 Difonzo M. Performance of the afferent limb of rapid response systems in managing deteriorating patients: a systematic review. Crit Care Res Pract 2019; 2019: 6902420
18 Trinkle RM, Flabouris A. Documenting rapid response system afferent limb failure and associated patient outcomes. Resuscitation 2011; 82 (07) 810-814
19 Barbosa V, Gomes E, Vaz S. et al. Failure to activate the in-hospital emergency team: causes and outcomes. Rev Bras Ter Intensiva 2016; 28 (04) 420-426
20 Fernando SM, Reardon PM, Bagshaw SM. et al. Impact of nighttime rapid response team activation on outcomes of hospitalized patients with acute deterioration. Crit Care 2018; 22 (01) 67
21 Molloy J, Pratt N, Tiruvoipati R, Green C, Plummer V. Relationship between diurnal patterns in rapid response call activation and patient outcome. Aust Crit Care 2018; 31 (01) 42-46
22 Galhotra S, DeVita MA, Simmons RL, Schmid A. members of the Medical Emergency Response Improvement Team (MERIT) Committee. Impact of patient monitoring on the diurnal pattern of medical emergency team activation. Crit Care Med 2006; 34 (06) 1700-1706
23 Barwise A, Thongprayoon C, Gajic O, Jensen J, Herasevich V, Pickering BW. Delayed rapid response team activation is associated with increased hospital mortality, morbidity, and length of stay in a tertiary care institution. Crit Care Med 2016; 44 (01) 54-63
24 Sax FL, Charlson ME. Medical patients at high risk for catastrophic deterioration. Crit Care Med 1987; 15 (05) 510-515
25 Parshuram CS, Duncan HP, Joffe AR. et al. Multicentre validation of the bedside paediatric early warning system score: a severity of illness score to detect evolving critical illness in hospitalised children. Crit Care 2011; 15 (04) R184
26 Valiani V, Gao S, Chen Z. et al. In-hospital mobility variations across primary diagnoses among older adults. J Am Med Dir Assoc 2016; 17 (05) 465.e1-465.e8
27 Feudtner C, Christakis DA, Connell FA. Pediatric deaths attributable to complex chronic conditions: a population-based study of Washington State, 1980-1997. Pediatrics 2000; 106 (1, Pt 2): 205-209
28 Sison CP, Glaz J. Simultaneous confidence intervals and sample size determination for multinomial proportions. J Am Stat Assoc 1995; 90 (429) 366-369
29 Conway SR, Tegtmeyer K, Wheeler DS, Loechtenfeldt A, Stalets EL, Brady PW. Diurnal variation in medical emergency team calls at a tertiary care children's hospital. Pediatr Qual Saf 2020; 5 (05) e341
30 Humphreys S, Totapally BR. Rapid response team calls and unplanned transfers to the pediatric intensive care unit in a pediatric hospital. Am J Crit Care 2016; 25 (01) e9-e13
31 Churpek MM, Edelson DP, Lee JY, Carey K, Snyder A. American Heart Association's Get With The Guidelines-Resuscitation Investigators. Association between survival and time of day for rapid response team calls in a national registry. Crit Care Med 2017; 45 (10) 1677-1682
32 Needleman J, Buerhaus P, Pankratz VS, Leibson CL, Stevens SR, Harris M. Nurse staffing and inpatient hospital mortality. N Engl J Med 2011; 364 (11) 1037-1045
33 Wallace DJ, Angus DC, Barnato AE, Kramer AA, Kahn JM. Nighttime intensivist staffing and mortality among critically ill patients. N Engl J Med 2012; 366 (22) 2093-2101
34 Bonafide CP, Localio AR, Song L. et al. Cost-benefit analysis of a medical emergency team in a children's hospital. Pediatrics 2014; 134 (02) 235-241
35 Neuraz A, Guérin C, Payet C. et al. Patient mortality is associated with staff resources and workload in the ICU: a multicenter observational study. Crit Care Med 2015; 43 (08) 1587-1594
36 Sharpe R, Koval V, Ronco JJ. et al. The impact of prolonged continuous wakefulness on resident clinical performance in the intensive care unit: a patient simulator study. Crit Care Med 2010; 38 (03) 766-770
37 Amirian I, Andersen LT, Rosenberg J, Gögenur I. Working night shifts affects surgeons' biological rhythm. Am J Surg 2015; 210 (02) 389-395
38 Bisbal M, Pauly V, Gainnier M. et al. Does admission during morning rounds increase the mortality of patients in the medical ICU?. Chest 2012; 142 (05) 1179-1184
39 Sundararajan K, O'Connell A, Flabouris A, Thompson C. Responding to clinical deterioration: diurnal variation in afferent limb failure. Resuscitation 2021; 160: 14-15
40 McCrory MC, Spaeder MC, Gower EW. et al. Time of admission to the PICU and mortality. Pediatr Crit Care Med 2017; 18 (10) 915-923

Supplementary Material

Supplementary Material