Diurnal Variation in Medical Emergency Team Calls at a Tertiary Care Children’s Hospital

Abstract

Introduction: Medical emergency teams (METs) bring critical care expertise to the bedsides of hospital ward patients who may be deteriorating. Diurnal variation in MET activation rates may identify inconsistencies in the detection of patients needing intervention. We aimed to determine whether such variation exists at our tertiary care children’s hospital. Methods: In this retrospective cohort study, we collected data including date and time of MET and disposition following MET for all inpatients at Cincinnati Children’s Hospital Medical Center with a MET call between January 2008 and May 2014. The analysis compared the MET rate between days and nights, weekdays and weekends, and before and after nursing shift change. Results: The number of METs per hour varied throughout the day. More METs were called during the day than at night (0.7 calls/shift ± 0.95 vs 0.6 ± 0.9, P < 0.001). There were also more METs per day on weekdays than weekends (1.4 ± 1 calls/d vs 1.2 ± 1, P < 0.001). Daytime METs were more likely to lead to transfer to the intensive care unit or operating room than those called at night (61.9% vs. 52.9%, P < 0 .001). MET activation rates did not differ significantly in the 2 hours before nursing shift change compared to the 2 hours after. Conclusions: At our large tertiary care children’s hospital, there are both diurnal variations and variations across weekdays versus weekends in the MET activation rate. This difference may indicate variations in our ability to detect deteriorating patients on the wards and be further studied.

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

“…This suggests that health care providers may be missing a critical period of patient deterioration overnight and delaying essential critical care interventions. 29 Consistent with other studies, we found that CDEs most frequently occurred in patients needing respiratory support, specifically, NIV across all time periods. 6 Of interest, our reported rates of invasive mechanical ventilation during CDEs are lower than previous studies, which is likely due to widespread use of NIV at our institution.…”

“…We report a higher rate of unplanned PICU admission following daytime MET activation and a significant increase in the likelihood of unplanned PICU admission at 08:00, immediately following the period of lowest MET dosage overnight (00:00–07:59). 20 29 30 31 Our results suggest that important clinical deterioration may go undetected overnight in hospitalized pediatric patients leading to sicker patients by morning and consequently higher likelihood of unplanned PICU admission in the daytime. This may occur for several reasons.…”

“…Our findings are consistent with a large pediatric study out of Cincinnati Children's (a 634-bed quaternary care hospital with a 35-bed PICU) that reviewed 3,115 MET activations and also described a low MET activation rate in the overnight hours with a peak in the early daytime period. 29 We build on their findings by proving that the MET dosage is significantly lower in the overnight period. More so, we add important clinical knowledge by examining key patient outcomes and their relationship to time of day.…”

“…4 5 6 Possible future initiatives to optimize the afferent limb overnight that have been previously reported may include changes to physician overnight staffing and nursing monitoring policies, implementation of the previously validated Pediatric Early Warning Score, or a formal “Watcher System,” both with mandatory activation criteria. 9 25 29…”

“…However, our findings are similar to major adult studies and the only prior small pediatric studies. 20 29 30 31…”