Outreach and Early Warning Systems (EWS) for the prevention of intensive care admission and death of critically ill adult patients on general hospital wards.

BACKGROUND Despite the fact that outreach and early warning systems (EWS) are an integral part of a hospital wide systems approach to improve the early identification and management of deteriorating patients on general hospital wards, the widespread implementation of these interventions in practice is not based on robust research evidence. OBJECTIVES The primary objective was to determine the impact of critical care outreach services on hospital mortality rates. Secondary objectives included determining the effect of outreach services on intensive care unit (ICU) admission patterns, length of hospital stay and adverse events. SEARCH STRATEGY The review authors searched the following electronic databases: EPOC Specialised Register, The Cochrane Central Register of Controlled Trials (CENTRAL) and other Cochrane databases (all on The Cochrane Library 2006, Issue 3), MEDLINE (1996-June week 3 2006), EMBASE (1974-week 26 2006), CINAHL (1982-July week 5 2006), First Search (1992-2005) and CAB Health (1990-July 2006); also reference lists of relevant articles, conference abstracts, and made contact with experts and critical care organisations for further information. SELECTION CRITERIA Randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series designs (ITS) which measured hospital mortality, unanticipated ICU admissions, ICU readmissions, length of hospital stay and adverse events following implementation of outreach and EWS in a general hospital ward to identify deteriorating adult patients versus general hospital ward setting without outreach and EWS were included in the review. DATA COLLECTION AND ANALYSIS Three review authors independently extracted data and two review authors assessed the methodological quality of the included studies. Meta-analysis was not possible due to heterogeneity. Summary statistics and descriptive summaries of primary and secondary outcomes are presented for each study. MAIN RESULTS Two cluster-randomised control trials were included: one randomised at hospital level (23 hospitals in Australia) and one at ward level (16 wards in the UK). The primary outcome in the Australian trial (a composite score comprising incidence of unexpected cardiac arrests, unexpected deaths and unplanned ICU admissions) showed no statistical significant difference between control and medical emergency team (MET) hospitals (adjusted P value 0.640; adjusted odds ratio (OR) 0.98; 95% confidence interval (CI) 0.83 to 1.16). The UK-based trial found that outreach reduced in-hospital mortality (adjusted OR 0.52; 95% CI 0.32 to 0.85) compared with the control group. AUTHORS' CONCLUSIONS The evidence from this review highlights the diversity and poor methodological quality of most studies investigating outreach. The results of the two included studies showed either no evidence of the effectiveness of outreach or a reduction in overall mortality in patients receiving outreach. The lack of evidence on outreach requires further multi-site RCT's to determine potential effectiveness.

[1]  C. Sprung,et al.  Clinical antecedents to in-hospital cardiopulmonary arrest. , 1990, Chest.

[2]  C. Franklin,et al.  Developing strategies to prevent inhospital cardiac arrest: Analyzing responses of physicians and nurses in the hours before the event , 1994, Critical care medicine.

[3]  K. Hillman,et al.  The Medical Emergency Team , 1995, Anaesthesia and intensive care.

[4]  R. Morgan,et al.  An early warning scoring system for detecting developing critical illness , 1997 .

[5]  Giles Morgan,et al.  Confidential inquiry into quality of care before admission to intensive care , 1998, BMJ.

[6]  D. Goldhill,et al.  Outcome of intensive care patients in a group of British intensive care units. , 1998, Critical care medicine.

[7]  A. Smith,et al.  Can some in-hospital cardio-respiratory arrests be prevented? A prospective survey. , 1997, Resuscitation.

[8]  M. Singer,et al.  Unexpected Deaths and Referrals to Intensive Care of Patients on General Wards – Are Some Cases Potentially Avoidable? , 1999, Journal of the Royal College of Physicians of London.

[9]  Worthington,et al.  The patient‐at‐risk team: identifying and managing seriously ill ward patients , 1999, Anaesthesia.

[10]  D. Goldhill,et al.  Physiological values and procedures in the 24 h before ICU admission from the ward , 1999, Anaesthesia.

[11]  M. Tivey,et al.  Prospective evaluation of a modified Early Warning Score to aid earlier detection of patients developing critical illness on a general surgical ward , 2000 .

[12]  Tien Chey,et al.  Rates of in‐hospital arrests, deaths and intensive care admissions: the effect of a medical emergency team , 2000, The Medical journal of Australia.

[13]  C. Subbe,et al.  Validation of a modified Early Warning Score in medical admissions. , 2001, QJM : monthly journal of the Association of Physicians.

[14]  K. Hillman,et al.  Antecedents to hospital deaths , 2001, Internal medicine journal.

[15]  K. Hillman,et al.  Duration of life-threatening antecedents prior to intensive care admission , 2002, Intensive Care Medicine.

[16]  Johan P Mackenbach,et al.  Income inequality and population health , 2002, BMJ : British Medical Journal.

[17]  J. Millo,et al.  Reduction in post-ICU, in-hospital mortality following the introduction of an ICU nursing outreach service , 2002, Critical Care.

[18]  G. Moore,et al.  Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study , 2002, BMJ : British Medical Journal.

[19]  An audit of a patient-at-risk trigger scoring system for identifying seriously ill ward patients. , 2002, Nursing in critical care.

[20]  S. Ridley,et al.  Impact of an Outreach team on re‐admissions to a critical care unit , 2003, Anaesthesia.

[21]  Rinaldo Bellomo,et al.  The Medical Journal of Australia ISSN: , 2000 .

[22]  A. Pittard,et al.  Out of our reach? Assessing the impact of introducing a critical care outreach service , 2003, Anaesthesia.

[23]  C. Ball,et al.  Effect of the critical care outreach team on patient survival to discharge from hospital and readmission to critical care: non-randomised population based study , 2003, BMJ : British Medical Journal.

[24]  Editorial II Outreach critical care—cash for no questions? , 2003 .

[25]  C. Subbe,et al.  Effect of introducing the Modified Early Warning score on clinical outcomes, cardio‐pulmonary arrests and intensive care utilisation in acute medical admissions * , 2003, Anaesthesia.

[26]  Gary B. Smith,et al.  Impact of attending a 1-day multi-professional course (ALERT) on the knowledge of acute care in trainee doctors. , 2004, Resuscitation.

[27]  Rinaldo Bellomo,et al.  Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates* , 2004, Critical care medicine.

[28]  D. Berry,et al.  Impact of a critical care outreach team on critical care readmissions and mortality , 2004, Acta anaesthesiologica Scandinavica.

[29]  D. Story,et al.  The effect of critical care outreach on postoperative serious adverse events , 2004, Anaesthesia.

[30]  K. Hillman,et al.  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 , 2004 .

[31]  M. Devita,et al.  Use of medical emergency team responses to reduce hospital cardiopulmonary arrests , 2004, Quality and Safety in Health Care.

[32]  Arash Rashidian,et al.  Introducing Critical Care Outreach: a ward-randomised trial of phased introduction in a general hospital , 2004, Intensive Care Medicine.

[33]  P. Featherstone,et al.  Impact of a one-day inter-professional course (ALERT) on attitudes and confidence in managing critically ill adult patients. , 2005, Resuscitation.

[34]  Daryl A Jones,et al.  Long term effect of a medical emergency team on cardiac arrests in a teaching hospital , 2005, Critical care.

[35]  K. Hillman,et al.  Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial , 2005, The Lancet.

[36]  S. Harvey,et al.  Investigating the effectiveness of critical care outreach services: a systematic review , 2006, Intensive Care Medicine.

[37]  K. Hillman,et al.  Findings of the First Consensus Conference on Medical Emergency Teams* , 2006, Critical care medicine.

[38]  Michael A. DeVita,et al.  Medical Emergency Teams , 2006 .

[39]  D. Berwick,et al.  The 100,000 lives campaign: setting a goal and a deadline for improving health care quality. , 2006, JAMA.

[40]  Can we distinguish patients at risk of deterioration? , 2006, Critical Care.

[41]  Daryl A Jones,et al.  Effect of the medical emergency team on long-term mortality following major surgery , 2007, Critical care.