Jennifer Friderici, MS

METHODS

RESULTS

DISCUSSION

CONCLUSION

METHODS

RESULTS

DISCUSSION

CONCLUSION

METHODS

RESULTS

DISCUSSION

CONCLUSION

Decompensated cirrhosis (DC) is defined as cirrhosis with at least 1 of the following complications: ascites, hepatocellular carcinoma, bleeding from portal hypertension, or hepatic encephalopathy. Patients with DC have a median survival estimated at 2 years compared to the 12‐year median survival of compensated cirrhotics.[1] In an era where quality of hospital care is being measured, and where progress is being made in the management of several conditions including congestive heart failure and nosocomial infections, little attention has been paid to DC. The burden of chronic liver failure is clear in the United States, where DC leads to more than 150,000 annual admissions to the hospital and accounts for 40,000 deaths annually.[2]

This burden of disease spurred quality improvement efforts in 2010, when a team of experts identified a set of literature‐based parameters or quality indicators (QI) for patients with cirrhosis.[3] We have demonstrated that adherence to these indicators fell far short of desired targets.[4] A year before their publication, an overall compliance of <50% with these metrics was measured at a single medical center.

We sought to improve the quality of care for patients with DC through implementation of mandatory consultation (MC) with a gastroenterologist for all patients admitted with DC. We assessed whether MC was associated with better care and improved outcomes (hospitalization length of stay [LOS], 30‐day readmission, and inpatient mortality) when compared to usual care (UC).[4]

MATERIALS AND METHODS

RESULTS

A total of 303 patients were observed in 695 hospitalizations;149 patients in 379 admissions were observed in the UC cohort, and 154 patients in 316 admissions were observed in the MC cohort. Baseline demographics of all study admissions appear in Table 1. Patients seen in the MC cohort were younger, more likely to speak English, and less likely to be male or have comorbid diabetes mellitus. Most admissions (n=217, 57.2%; 95% confidence interval: 52.3%‐62.3%) were not evaluated by a gastroenterologist in the UC cohort but all were in the MC cohort.

DISCUSSION

In this evaluation of an MC intervention for patients with DC cared for at a large tertiary academic medical center, we found that the implementation of a routine consultation by a gastroenterologist led to greater adherence to recommended care processes when compared to UC. Overall, the management of ascites and the documentation of evaluation for liver transplantation were statistically superior in the intervention (MC) group. UC and MC were similar with respect to treatment of variceal bleeding and hepatic encephalopathy. Although we did not demonstrate changes in mortality, readmission, or LOS as a result of the MC intervention, our study was underpowered to detect clinically meaningful effects.

The gaps in care of patients with cirrhosis were reported before and after the publication of the formal QIs.[7, 8, 9, 10] These gaps remain relevant in the face of an increasing prevalence of DC along with a recent publication suggesting an underestimation of the burden of liver disease in the United States.[11] Ours is the first study to evaluate the impact on inpatients with DC of a liver service with a systematic, mandatory, specialist consultation. A previous study[12] had shown that a GI consultation would improve the care of patients with DC, but excluded patients with variceal bleeding, did not specifically measure the compliance with QIs, and more important, the GI consult was not mandatory.

Our study has several limitations that must be considered while weighing its findings. The patients were not randomly assigned but followed a pre‐established distribution depending on the call schedule. Some of the improvement we noted might be the result of secular trends; however, this remains unlikely given the lack of national initiatives or pay for performance programs. In the UC cohort, patients who were nonEnglish‐speaking were associated with a lower QI score, which could account for part of the improvement seen in the MC group that has a more prominent English‐speaking cohort. Readmissions could have occurred at other hospitals, and patients were not monitored in an outpatient setting. We did not observe a change in the secondary outcomes (30‐day readmission, LOS, in‐hospital death); however, our study was underpowered for that purpose. Given the complexity of the billing process we did not collect the costs of the MC, which is another limitation of our work. Future studies are needed to determine the cost‐effectiveness of the intervention.

This study shows that a dedicated team of physicians focused on compliance with QIs can achieve a rapid improvement, over a year, in providing higher‐quality care. This may be relevant at other institutions. The strength of our study is that our large tertiary academic medical center serves a large catchment area, with a mix of patients from both rural and urban communities. It is located in Massachusetts, where most of the population has had access to healthcare since 2006. Therefore, although this is a single‐center study, we expect our findings to be more generalizable and less subject to selection bias than other single‐center studies.

Importantly, the compliance with QIs was often far from being perfect in the MC group and was different across type of employment of providers, reflecting the challenges in changing practice among physicians.[13] In fact the QI scores of the private practice group did not change, and mirror the compliance observed at our institution in the previous study, before the implementation of the MC.[4] The difference in performance according to the type of employment of providers stems from 2 factors. First, a better documentation of the need of formal evaluation for liver transplantation by the employed gastroenterologists resulted in better compliance with this QI. Second, and more important, among the employed physicians, there was a readiness to assist the hospitalist with diagnostic/therapeutic paracentesis without relying on, for example, an interventional radiologist. This is reflected by the higher score in the management of ascites. Although our study was not designed to answer this directly, employed physicians may have been more engaged in the project and showed a greater willingness to change practice. In the future, linking reimbursement to quality of care will lead to improved accountability of consultants.

In this study we show that a direct involvement of a gastroenterologist improves the care of inpatients as measured by QIs. We theorize that a better coordination of the transition to outpatient care involving the specialist should lead to better outcomes, specifically a reduction in the 22% observed readmission rate within 30 days of patients with DC.[14, 15] As we move forward, a broader definition of outcomes should be addressed, taking into account patient‐related outcomes and preferences.[16] Future studies should define the relationship between the gastroenterologist and the hospitalist service, the role of physician assistants and nurse practitioners in implementing and monitoring compliance with QIs, and define how physicians and patients can be made accountable in the transition to the outpatient setting.

Decompensated cirrhosis (DC) is defined as cirrhosis with at least 1 of the following complications: ascites, hepatocellular carcinoma, bleeding from portal hypertension, or hepatic encephalopathy. Patients with DC have a median survival estimated at 2 years compared to the 12‐year median survival of compensated cirrhotics.[1] In an era where quality of hospital care is being measured, and where progress is being made in the management of several conditions including congestive heart failure and nosocomial infections, little attention has been paid to DC. The burden of chronic liver failure is clear in the United States, where DC leads to more than 150,000 annual admissions to the hospital and accounts for 40,000 deaths annually.[2]

This burden of disease spurred quality improvement efforts in 2010, when a team of experts identified a set of literature‐based parameters or quality indicators (QI) for patients with cirrhosis.[3] We have demonstrated that adherence to these indicators fell far short of desired targets.[4] A year before their publication, an overall compliance of <50% with these metrics was measured at a single medical center.

We sought to improve the quality of care for patients with DC through implementation of mandatory consultation (MC) with a gastroenterologist for all patients admitted with DC. We assessed whether MC was associated with better care and improved outcomes (hospitalization length of stay [LOS], 30‐day readmission, and inpatient mortality) when compared to usual care (UC).[4]

MATERIALS AND METHODS

RESULTS

A total of 303 patients were observed in 695 hospitalizations;149 patients in 379 admissions were observed in the UC cohort, and 154 patients in 316 admissions were observed in the MC cohort. Baseline demographics of all study admissions appear in Table 1. Patients seen in the MC cohort were younger, more likely to speak English, and less likely to be male or have comorbid diabetes mellitus. Most admissions (n=217, 57.2%; 95% confidence interval: 52.3%‐62.3%) were not evaluated by a gastroenterologist in the UC cohort but all were in the MC cohort.

DISCUSSION

In this evaluation of an MC intervention for patients with DC cared for at a large tertiary academic medical center, we found that the implementation of a routine consultation by a gastroenterologist led to greater adherence to recommended care processes when compared to UC. Overall, the management of ascites and the documentation of evaluation for liver transplantation were statistically superior in the intervention (MC) group. UC and MC were similar with respect to treatment of variceal bleeding and hepatic encephalopathy. Although we did not demonstrate changes in mortality, readmission, or LOS as a result of the MC intervention, our study was underpowered to detect clinically meaningful effects.

The gaps in care of patients with cirrhosis were reported before and after the publication of the formal QIs.[7, 8, 9, 10] These gaps remain relevant in the face of an increasing prevalence of DC along with a recent publication suggesting an underestimation of the burden of liver disease in the United States.[11] Ours is the first study to evaluate the impact on inpatients with DC of a liver service with a systematic, mandatory, specialist consultation. A previous study[12] had shown that a GI consultation would improve the care of patients with DC, but excluded patients with variceal bleeding, did not specifically measure the compliance with QIs, and more important, the GI consult was not mandatory.

Our study has several limitations that must be considered while weighing its findings. The patients were not randomly assigned but followed a pre‐established distribution depending on the call schedule. Some of the improvement we noted might be the result of secular trends; however, this remains unlikely given the lack of national initiatives or pay for performance programs. In the UC cohort, patients who were nonEnglish‐speaking were associated with a lower QI score, which could account for part of the improvement seen in the MC group that has a more prominent English‐speaking cohort. Readmissions could have occurred at other hospitals, and patients were not monitored in an outpatient setting. We did not observe a change in the secondary outcomes (30‐day readmission, LOS, in‐hospital death); however, our study was underpowered for that purpose. Given the complexity of the billing process we did not collect the costs of the MC, which is another limitation of our work. Future studies are needed to determine the cost‐effectiveness of the intervention.

This study shows that a dedicated team of physicians focused on compliance with QIs can achieve a rapid improvement, over a year, in providing higher‐quality care. This may be relevant at other institutions. The strength of our study is that our large tertiary academic medical center serves a large catchment area, with a mix of patients from both rural and urban communities. It is located in Massachusetts, where most of the population has had access to healthcare since 2006. Therefore, although this is a single‐center study, we expect our findings to be more generalizable and less subject to selection bias than other single‐center studies.

Importantly, the compliance with QIs was often far from being perfect in the MC group and was different across type of employment of providers, reflecting the challenges in changing practice among physicians.[13] In fact the QI scores of the private practice group did not change, and mirror the compliance observed at our institution in the previous study, before the implementation of the MC.[4] The difference in performance according to the type of employment of providers stems from 2 factors. First, a better documentation of the need of formal evaluation for liver transplantation by the employed gastroenterologists resulted in better compliance with this QI. Second, and more important, among the employed physicians, there was a readiness to assist the hospitalist with diagnostic/therapeutic paracentesis without relying on, for example, an interventional radiologist. This is reflected by the higher score in the management of ascites. Although our study was not designed to answer this directly, employed physicians may have been more engaged in the project and showed a greater willingness to change practice. In the future, linking reimbursement to quality of care will lead to improved accountability of consultants.

In this study we show that a direct involvement of a gastroenterologist improves the care of inpatients as measured by QIs. We theorize that a better coordination of the transition to outpatient care involving the specialist should lead to better outcomes, specifically a reduction in the 22% observed readmission rate within 30 days of patients with DC.[14, 15] As we move forward, a broader definition of outcomes should be addressed, taking into account patient‐related outcomes and preferences.[16] Future studies should define the relationship between the gastroenterologist and the hospitalist service, the role of physician assistants and nurse practitioners in implementing and monitoring compliance with QIs, and define how physicians and patients can be made accountable in the transition to the outpatient setting.

Decompensated cirrhosis (DC) is defined as cirrhosis with at least 1 of the following complications: ascites, hepatocellular carcinoma, bleeding from portal hypertension, or hepatic encephalopathy. Patients with DC have a median survival estimated at 2 years compared to the 12‐year median survival of compensated cirrhotics.[1] In an era where quality of hospital care is being measured, and where progress is being made in the management of several conditions including congestive heart failure and nosocomial infections, little attention has been paid to DC. The burden of chronic liver failure is clear in the United States, where DC leads to more than 150,000 annual admissions to the hospital and accounts for 40,000 deaths annually.[2]

This burden of disease spurred quality improvement efforts in 2010, when a team of experts identified a set of literature‐based parameters or quality indicators (QI) for patients with cirrhosis.[3] We have demonstrated that adherence to these indicators fell far short of desired targets.[4] A year before their publication, an overall compliance of <50% with these metrics was measured at a single medical center.

We sought to improve the quality of care for patients with DC through implementation of mandatory consultation (MC) with a gastroenterologist for all patients admitted with DC. We assessed whether MC was associated with better care and improved outcomes (hospitalization length of stay [LOS], 30‐day readmission, and inpatient mortality) when compared to usual care (UC).[4]

MATERIALS AND METHODS

RESULTS

A total of 303 patients were observed in 695 hospitalizations;149 patients in 379 admissions were observed in the UC cohort, and 154 patients in 316 admissions were observed in the MC cohort. Baseline demographics of all study admissions appear in Table 1. Patients seen in the MC cohort were younger, more likely to speak English, and less likely to be male or have comorbid diabetes mellitus. Most admissions (n=217, 57.2%; 95% confidence interval: 52.3%‐62.3%) were not evaluated by a gastroenterologist in the UC cohort but all were in the MC cohort.

DISCUSSION

In this evaluation of an MC intervention for patients with DC cared for at a large tertiary academic medical center, we found that the implementation of a routine consultation by a gastroenterologist led to greater adherence to recommended care processes when compared to UC. Overall, the management of ascites and the documentation of evaluation for liver transplantation were statistically superior in the intervention (MC) group. UC and MC were similar with respect to treatment of variceal bleeding and hepatic encephalopathy. Although we did not demonstrate changes in mortality, readmission, or LOS as a result of the MC intervention, our study was underpowered to detect clinically meaningful effects.

The gaps in care of patients with cirrhosis were reported before and after the publication of the formal QIs.[7, 8, 9, 10] These gaps remain relevant in the face of an increasing prevalence of DC along with a recent publication suggesting an underestimation of the burden of liver disease in the United States.[11] Ours is the first study to evaluate the impact on inpatients with DC of a liver service with a systematic, mandatory, specialist consultation. A previous study[12] had shown that a GI consultation would improve the care of patients with DC, but excluded patients with variceal bleeding, did not specifically measure the compliance with QIs, and more important, the GI consult was not mandatory.

Our study has several limitations that must be considered while weighing its findings. The patients were not randomly assigned but followed a pre‐established distribution depending on the call schedule. Some of the improvement we noted might be the result of secular trends; however, this remains unlikely given the lack of national initiatives or pay for performance programs. In the UC cohort, patients who were nonEnglish‐speaking were associated with a lower QI score, which could account for part of the improvement seen in the MC group that has a more prominent English‐speaking cohort. Readmissions could have occurred at other hospitals, and patients were not monitored in an outpatient setting. We did not observe a change in the secondary outcomes (30‐day readmission, LOS, in‐hospital death); however, our study was underpowered for that purpose. Given the complexity of the billing process we did not collect the costs of the MC, which is another limitation of our work. Future studies are needed to determine the cost‐effectiveness of the intervention.

This study shows that a dedicated team of physicians focused on compliance with QIs can achieve a rapid improvement, over a year, in providing higher‐quality care. This may be relevant at other institutions. The strength of our study is that our large tertiary academic medical center serves a large catchment area, with a mix of patients from both rural and urban communities. It is located in Massachusetts, where most of the population has had access to healthcare since 2006. Therefore, although this is a single‐center study, we expect our findings to be more generalizable and less subject to selection bias than other single‐center studies.

Importantly, the compliance with QIs was often far from being perfect in the MC group and was different across type of employment of providers, reflecting the challenges in changing practice among physicians.[13] In fact the QI scores of the private practice group did not change, and mirror the compliance observed at our institution in the previous study, before the implementation of the MC.[4] The difference in performance according to the type of employment of providers stems from 2 factors. First, a better documentation of the need of formal evaluation for liver transplantation by the employed gastroenterologists resulted in better compliance with this QI. Second, and more important, among the employed physicians, there was a readiness to assist the hospitalist with diagnostic/therapeutic paracentesis without relying on, for example, an interventional radiologist. This is reflected by the higher score in the management of ascites. Although our study was not designed to answer this directly, employed physicians may have been more engaged in the project and showed a greater willingness to change practice. In the future, linking reimbursement to quality of care will lead to improved accountability of consultants.

In this study we show that a direct involvement of a gastroenterologist improves the care of inpatients as measured by QIs. We theorize that a better coordination of the transition to outpatient care involving the specialist should lead to better outcomes, specifically a reduction in the 22% observed readmission rate within 30 days of patients with DC.[14, 15] As we move forward, a broader definition of outcomes should be addressed, taking into account patient‐related outcomes and preferences.[16] Future studies should define the relationship between the gastroenterologist and the hospitalist service, the role of physician assistants and nurse practitioners in implementing and monitoring compliance with QIs, and define how physicians and patients can be made accountable in the transition to the outpatient setting.

Ascites is the most common complication of cirrhosis leading to hospital admission.[1] Approximately 12% of hospitalized patients who present with decompensated cirrhosis and ascites have spontaneous bacterial peritonitis (SBP); half of these patients do not present with abdominal pain, fever, nausea, or vomiting.[2] Guidelines published by the American Association for the Study of Liver Diseases (AASLD) recommend paracentesis for all hospitalized patients with cirrhosis and ascites and also recommend long‐term antibiotic prophylaxis for survivors of an SBP episode.[3] Despite evidence that in‐hospital mortality is reduced in those patients who receive paracentesis in a timely manner,[4, 5] only 40% to 60% of eligible patients receive paracentesis.[4, 6, 7] We aimed to describe clinical predictors of paracentesis and use of antibiotics following an episode of SBP in patients with decompensated cirrhosis and ascites.

METHODS

We conducted a retrospective cohort study of adults admitted to a single tertiary care center between January 1, 2009 and December 31, 2009.⁷ We included patients with an International Classification of Diseases, Ninth Revision discharge code consistent with decompensated cirrhosis who met clinical criteria for decompensated cirrhosis (see Supporting Figure 1 in the online version of this article) [7] and had enough ascitic fluid to be sampled under imaging guidance. We collected presenting vital signs, laboratory data (within 24 hours of admission), evidence of infection other than SBP (eg, urinary infection, pneumonia), results of peritoneal fluid analysis (defining SBP as 250 polymorphonuclear leukocytes), and use of antibiotic therapy. Our statistical analysis calculated summary statistics as means, medians, and proportions. Furthermore, we used multiple logistic regression to examine the association between predictors and receipt of paracentesis, including age, sex, and clinical measures associated with paracentesis at P0.20 using the Fisher exact test. Alpha was set at 0.05 (2‐sided) for all comparisons.

RESULTS

We identified 193 admissions for 103 patients with decompensated cirrhosis and ascites (Table 1). Of these, 41% (80/193) received diagnostic paracentesis. Mean/standard deviation for age was 53.6/12.4 years; 71% of patients were male and 63% were English speaking. Common comorbidities included diabetes mellitus (33%), psychiatric diagnosis (29%), substance abuse (18%), and renal failure (17%). Excluding SBP, 31% of patients had another documented infection. Gastroenterology was consulted in 50% of the admissions. Fever was present in 27% of patients, elevated white blood cell (WBC) count (ie, WBC >11 k/mm³) was present in 27% of patients, International Normalized Ratio (INR) was elevated (>1.1) in 92% of patients, and 16% of patients had a platelet count of <50,000/mm³. Patients who received paracentesis were less likely to have a fever on presentation (19% vs 32%, P=0.06), low (ie, <50,000/mm³) platelet count (11% vs 19%, P=0.14), or concurrent gastrointestinal (GI) bleed (6% vs 16%, P=0.05). In a multiple logistic regression model including characteristics associated at P0.2 with paracentesis, fever, low platelet count, and concurrent GI bleeding were associated with decreased odds of receiving paracentesis (Appendix 1).

Of the patients who received paracentesis (n=80), 14% were diagnosed with SBP. Of these, 55% received prophylaxis on discharge. Among the patients who did not receive paracentesis (n=113), 38 (34%) received antibiotics for another documented infection (eg, pneumonia), and 25 patients (22%) received antibiotics with no other documented infection or evidence of variceal bleeding. Of these 25 patients who were presumed to be empirically treated for SBP (Figure 1), only 20% were prescribed prophylactic antibiotics on discharge.

Figure 1

CONCLUSION

We found that many patients with decompensated cirrhosis and ascites did not receive paracentesis when hospitalized, which is similar to previously published data.[4, 6, 7] Clinical evidence of infection, such as fever or elevated WBC count, did not increase the odds of receiving paracentesis. Many patients treated for SBP were not discharged on prophylaxis.

This study is limited by its small single‐center design. We could only use data from 1 year (2009), because study data collection was part of a quality‐improvement project that took place for that year only. We did not adjust for the number of red blood cells in the ascitic fluid samples. We were also unable to determine the timing of gastroenterology consultation (whether it was done prior to paracentesis), admission venue (floor vs intensive care), or patient history of SBP.

Despite these limitations, there are important implications. First, the decision to perform paracentesis was not associated with symptoms of infection, although some clinical factors (eg, low platelets or GI bleeding) were associated with reduced odds of receiving paracentesis. Second, a majority of patients treated for SBP did not receive prophylactic antibiotics at discharge. These findings suggest a clear opportunity to increase awareness and acceptance of AASLD guidelines among hospital medicine practitioners. Quality‐improvement efforts should focus on the education of providers, and future research should identify barriers to paracentesis at both the practitioner and system levels (eg, availability of interventional radiology). Checklists or decision support within electronic order entry systems may also help reduce the low rates of paracentesis seen in our and prior studies.[4, 6, 7]

Disclosures: Dr. Lagu is supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award number K01HL114745. Drs. Lagu, Ghaoui, and Brooling had full access to all of the data in the study. They take responsibility for the integrity of the data and the accuracy of the data analysis. Drs. Lagu, Ghaoui, and Brooling conceived of the study. Dr. Ghaoui acquired the data. Ms. Friderici carried out the statistical analyses. Drs. Lagu, Ghaoui, Brooling, Lindenauer, and Ms. Friderici analyzed and interpreted the data, drafted the manuscript, and critically reviewed the manuscript for important intellectual content. The authors report no conflicts of interest.

Ascites is the most common complication of cirrhosis leading to hospital admission.[1] Approximately 12% of hospitalized patients who present with decompensated cirrhosis and ascites have spontaneous bacterial peritonitis (SBP); half of these patients do not present with abdominal pain, fever, nausea, or vomiting.[2] Guidelines published by the American Association for the Study of Liver Diseases (AASLD) recommend paracentesis for all hospitalized patients with cirrhosis and ascites and also recommend long‐term antibiotic prophylaxis for survivors of an SBP episode.[3] Despite evidence that in‐hospital mortality is reduced in those patients who receive paracentesis in a timely manner,[4, 5] only 40% to 60% of eligible patients receive paracentesis.[4, 6, 7] We aimed to describe clinical predictors of paracentesis and use of antibiotics following an episode of SBP in patients with decompensated cirrhosis and ascites.

METHODS

We conducted a retrospective cohort study of adults admitted to a single tertiary care center between January 1, 2009 and December 31, 2009.⁷ We included patients with an International Classification of Diseases, Ninth Revision discharge code consistent with decompensated cirrhosis who met clinical criteria for decompensated cirrhosis (see Supporting Figure 1 in the online version of this article) [7] and had enough ascitic fluid to be sampled under imaging guidance. We collected presenting vital signs, laboratory data (within 24 hours of admission), evidence of infection other than SBP (eg, urinary infection, pneumonia), results of peritoneal fluid analysis (defining SBP as 250 polymorphonuclear leukocytes), and use of antibiotic therapy. Our statistical analysis calculated summary statistics as means, medians, and proportions. Furthermore, we used multiple logistic regression to examine the association between predictors and receipt of paracentesis, including age, sex, and clinical measures associated with paracentesis at P0.20 using the Fisher exact test. Alpha was set at 0.05 (2‐sided) for all comparisons.

RESULTS

We identified 193 admissions for 103 patients with decompensated cirrhosis and ascites (Table 1). Of these, 41% (80/193) received diagnostic paracentesis. Mean/standard deviation for age was 53.6/12.4 years; 71% of patients were male and 63% were English speaking. Common comorbidities included diabetes mellitus (33%), psychiatric diagnosis (29%), substance abuse (18%), and renal failure (17%). Excluding SBP, 31% of patients had another documented infection. Gastroenterology was consulted in 50% of the admissions. Fever was present in 27% of patients, elevated white blood cell (WBC) count (ie, WBC >11 k/mm³) was present in 27% of patients, International Normalized Ratio (INR) was elevated (>1.1) in 92% of patients, and 16% of patients had a platelet count of <50,000/mm³. Patients who received paracentesis were less likely to have a fever on presentation (19% vs 32%, P=0.06), low (ie, <50,000/mm³) platelet count (11% vs 19%, P=0.14), or concurrent gastrointestinal (GI) bleed (6% vs 16%, P=0.05). In a multiple logistic regression model including characteristics associated at P0.2 with paracentesis, fever, low platelet count, and concurrent GI bleeding were associated with decreased odds of receiving paracentesis (Appendix 1).

Of the patients who received paracentesis (n=80), 14% were diagnosed with SBP. Of these, 55% received prophylaxis on discharge. Among the patients who did not receive paracentesis (n=113), 38 (34%) received antibiotics for another documented infection (eg, pneumonia), and 25 patients (22%) received antibiotics with no other documented infection or evidence of variceal bleeding. Of these 25 patients who were presumed to be empirically treated for SBP (Figure 1), only 20% were prescribed prophylactic antibiotics on discharge.

Figure 1

CONCLUSION

We found that many patients with decompensated cirrhosis and ascites did not receive paracentesis when hospitalized, which is similar to previously published data.[4, 6, 7] Clinical evidence of infection, such as fever or elevated WBC count, did not increase the odds of receiving paracentesis. Many patients treated for SBP were not discharged on prophylaxis.

This study is limited by its small single‐center design. We could only use data from 1 year (2009), because study data collection was part of a quality‐improvement project that took place for that year only. We did not adjust for the number of red blood cells in the ascitic fluid samples. We were also unable to determine the timing of gastroenterology consultation (whether it was done prior to paracentesis), admission venue (floor vs intensive care), or patient history of SBP.

Despite these limitations, there are important implications. First, the decision to perform paracentesis was not associated with symptoms of infection, although some clinical factors (eg, low platelets or GI bleeding) were associated with reduced odds of receiving paracentesis. Second, a majority of patients treated for SBP did not receive prophylactic antibiotics at discharge. These findings suggest a clear opportunity to increase awareness and acceptance of AASLD guidelines among hospital medicine practitioners. Quality‐improvement efforts should focus on the education of providers, and future research should identify barriers to paracentesis at both the practitioner and system levels (eg, availability of interventional radiology). Checklists or decision support within electronic order entry systems may also help reduce the low rates of paracentesis seen in our and prior studies.[4, 6, 7]

Disclosures: Dr. Lagu is supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award number K01HL114745. Drs. Lagu, Ghaoui, and Brooling had full access to all of the data in the study. They take responsibility for the integrity of the data and the accuracy of the data analysis. Drs. Lagu, Ghaoui, and Brooling conceived of the study. Dr. Ghaoui acquired the data. Ms. Friderici carried out the statistical analyses. Drs. Lagu, Ghaoui, Brooling, Lindenauer, and Ms. Friderici analyzed and interpreted the data, drafted the manuscript, and critically reviewed the manuscript for important intellectual content. The authors report no conflicts of interest.

Ascites is the most common complication of cirrhosis leading to hospital admission.[1] Approximately 12% of hospitalized patients who present with decompensated cirrhosis and ascites have spontaneous bacterial peritonitis (SBP); half of these patients do not present with abdominal pain, fever, nausea, or vomiting.[2] Guidelines published by the American Association for the Study of Liver Diseases (AASLD) recommend paracentesis for all hospitalized patients with cirrhosis and ascites and also recommend long‐term antibiotic prophylaxis for survivors of an SBP episode.[3] Despite evidence that in‐hospital mortality is reduced in those patients who receive paracentesis in a timely manner,[4, 5] only 40% to 60% of eligible patients receive paracentesis.[4, 6, 7] We aimed to describe clinical predictors of paracentesis and use of antibiotics following an episode of SBP in patients with decompensated cirrhosis and ascites.

METHODS

We conducted a retrospective cohort study of adults admitted to a single tertiary care center between January 1, 2009 and December 31, 2009.⁷ We included patients with an International Classification of Diseases, Ninth Revision discharge code consistent with decompensated cirrhosis who met clinical criteria for decompensated cirrhosis (see Supporting Figure 1 in the online version of this article) [7] and had enough ascitic fluid to be sampled under imaging guidance. We collected presenting vital signs, laboratory data (within 24 hours of admission), evidence of infection other than SBP (eg, urinary infection, pneumonia), results of peritoneal fluid analysis (defining SBP as 250 polymorphonuclear leukocytes), and use of antibiotic therapy. Our statistical analysis calculated summary statistics as means, medians, and proportions. Furthermore, we used multiple logistic regression to examine the association between predictors and receipt of paracentesis, including age, sex, and clinical measures associated with paracentesis at P0.20 using the Fisher exact test. Alpha was set at 0.05 (2‐sided) for all comparisons.

RESULTS

We identified 193 admissions for 103 patients with decompensated cirrhosis and ascites (Table 1). Of these, 41% (80/193) received diagnostic paracentesis. Mean/standard deviation for age was 53.6/12.4 years; 71% of patients were male and 63% were English speaking. Common comorbidities included diabetes mellitus (33%), psychiatric diagnosis (29%), substance abuse (18%), and renal failure (17%). Excluding SBP, 31% of patients had another documented infection. Gastroenterology was consulted in 50% of the admissions. Fever was present in 27% of patients, elevated white blood cell (WBC) count (ie, WBC >11 k/mm³) was present in 27% of patients, International Normalized Ratio (INR) was elevated (>1.1) in 92% of patients, and 16% of patients had a platelet count of <50,000/mm³. Patients who received paracentesis were less likely to have a fever on presentation (19% vs 32%, P=0.06), low (ie, <50,000/mm³) platelet count (11% vs 19%, P=0.14), or concurrent gastrointestinal (GI) bleed (6% vs 16%, P=0.05). In a multiple logistic regression model including characteristics associated at P0.2 with paracentesis, fever, low platelet count, and concurrent GI bleeding were associated with decreased odds of receiving paracentesis (Appendix 1).

Of the patients who received paracentesis (n=80), 14% were diagnosed with SBP. Of these, 55% received prophylaxis on discharge. Among the patients who did not receive paracentesis (n=113), 38 (34%) received antibiotics for another documented infection (eg, pneumonia), and 25 patients (22%) received antibiotics with no other documented infection or evidence of variceal bleeding. Of these 25 patients who were presumed to be empirically treated for SBP (Figure 1), only 20% were prescribed prophylactic antibiotics on discharge.

Figure 1

CONCLUSION

We found that many patients with decompensated cirrhosis and ascites did not receive paracentesis when hospitalized, which is similar to previously published data.[4, 6, 7] Clinical evidence of infection, such as fever or elevated WBC count, did not increase the odds of receiving paracentesis. Many patients treated for SBP were not discharged on prophylaxis.

This study is limited by its small single‐center design. We could only use data from 1 year (2009), because study data collection was part of a quality‐improvement project that took place for that year only. We did not adjust for the number of red blood cells in the ascitic fluid samples. We were also unable to determine the timing of gastroenterology consultation (whether it was done prior to paracentesis), admission venue (floor vs intensive care), or patient history of SBP.

Despite these limitations, there are important implications. First, the decision to perform paracentesis was not associated with symptoms of infection, although some clinical factors (eg, low platelets or GI bleeding) were associated with reduced odds of receiving paracentesis. Second, a majority of patients treated for SBP did not receive prophylactic antibiotics at discharge. These findings suggest a clear opportunity to increase awareness and acceptance of AASLD guidelines among hospital medicine practitioners. Quality‐improvement efforts should focus on the education of providers, and future research should identify barriers to paracentesis at both the practitioner and system levels (eg, availability of interventional radiology). Checklists or decision support within electronic order entry systems may also help reduce the low rates of paracentesis seen in our and prior studies.[4, 6, 7]

Disclosures: Dr. Lagu is supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award number K01HL114745. Drs. Lagu, Ghaoui, and Brooling had full access to all of the data in the study. They take responsibility for the integrity of the data and the accuracy of the data analysis. Drs. Lagu, Ghaoui, and Brooling conceived of the study. Dr. Ghaoui acquired the data. Ms. Friderici carried out the statistical analyses. Drs. Lagu, Ghaoui, Brooling, Lindenauer, and Ms. Friderici analyzed and interpreted the data, drafted the manuscript, and critically reviewed the manuscript for important intellectual content. The authors report no conflicts of interest.

In‐hospital cardiopulmonary arrests are often preceded by signs of clinical instability, such as changes in vital signs or mental status.1 Nearly 85% of patients who suffer from cardiopulmonary arrests have documented observations of deterioration in the 8 hours before arrest.2 A Medical Emergency Team (MET), sometimes known as Rapid Response Team (RRT), can rapidly assess and manage unstable patients, with the goal that early intervention will prevent adverse outcomes. In 2004, the Institute for Healthcare Improvement (IHI), as part of its 100,000 Lives Campaign, called for hospitals to implement rapid response systems as 1 of 6 strategies to reduce deaths in hospital.3 Since this recommendation, hundreds of hospitals in the United States have invested substantial financial and personnel resources to implement some form of a rapid response system, which is comprised of a varying array of healthcare providers who bring critical care expertise to the patient's bedside.4, 5

Despite the intuitive appeal of the approach, and early observational data which suggested that METs could reduce both codes and unexpected in‐hospital mortality,2, 6 the largest randomized controlled trial found that METs failed to reduce unplanned intensive care unit (ICU) admissions, cardiac arrests, or unexpected deaths.7 More recently, in a prospective observational cohort study at 1 US hospital, Chan et al. found that a nurse‐led RRT did not impact hospital‐wide code rates or mortality.4

The study of rapid response systems is further complicated by a lack of standard definition, and the many types of hospitals in which they may be implemented. In 2006, a consensus conference suggested that MET be used to refer to teams led by physicians (usually intensivists), and RRT be used for teams led by nurses.8 Many studies have been conducted at non‐US institutions, and follow‐up periods have generally been 1 year or less. We report on almost 4 years of experience with a hospitalist‐led MET implemented in a major US academic medical center, and examine the subsequent changes in code calls, cardiac arrests, deaths following cardiopulmonary resuscitation, and overall hospital mortality. Because the MET did not operate in the critical care units, and because cardiac arrest may occur without prior signs of deterioration, we hypothesized that implementation of the MET would correspond to a small drop in total code calls, no change in codes called inside of critical care units, no change in cardiac arrest outside of critical care, and a marked drop in other medical crises (mostly respiratory distress) outside critical care. We also hypothesized that there would be no change in the rate of fatal codes, because most deaths occur in patients who were found to be pulseless on arrival of the code team.

METHODS

RESULTS

Implementation of the MET

The MET was introduced in the first and second quarters of 2006, with 2717 calls logged through the end of 2009 (out of 154,382 admissions). The rate of MET calls increased during the first 6 months of implementation from 5.95 per 1000 admissions in the first quarter of the intervention, to 15.8 calls per 1000 admissions in the second quarter. Call rates peaked in the first half of 2009, at 20.9 calls per 1000 admissions, leveling off to 17.9 calls per 1000 admissions in the last half of 2009 (Figure 1). Of calls with time recorded, 40% occurred on the day shift, 35% on the evening shift, and 25% on the night shift. The most common reason to call the MET was respiratory distress (33%), followed by cardiovascular instability (25%), and neurological abnormality (20%). In 15% of cases, concern about a patient's condition prompted the nurse to call. Calls came primarily from medical floors (75%) and surgical units (20%). The median response time was 4 minutes (interquartile range [IQR], 2.8 to 5.2 minutes) with no meaningful trend during the study period. The median call duration was 50 minutes (IQR, 38 to 72 minutes). Again, there was no trend over time. The most common interventions were arterial blood gas, fluid resuscitation, and electrocardiogram (see Supporting Web Appendix Table 1 in the online version of this article). A physician was present at 52% of the calls in the first year, which rose to 93% of calls in the final year. Approximately 25% of calls resulted in the patient being transferred to a critical care unit. Staff evaluations were overwhelmingly positive. Nurses rated the teams on the following points: whether the critical care nurse and respiratory therapist were efficient and respectful (mean rating 98%, SD 5.6%); promptness (98%, SD 5.6%); whether the patient's needs were addressed appropriately (mean 98%, SD 4.2%); whether the nurse felt supported by the MET (99.5%, SD 1.7%); and whether they would call the MET again (99.7%, SD 1.4%).

Figure 1

Effect of MET on Code Calls and Mortality

Between January 2004 and December of 2009, the hospital case mix index remained constant, and there were a total of 1202 codes called. The majority (62%) took place outside of critical care units. Linear contrasts of pre‐piecewise and post‐piecewise intercepts revealed that overall code calls declined significantly between pre‐implementation and post‐implementation of the MET from 7.30 (95% CI 5.81, 9.16) codes called per 1000 admissions to 4.21 (95% CI 3.42, 5.18) calls per 1000 admissions (Figure 1; also see Supporting Web Appendix Table 2 in the online version of this article). Outside of critical care, code calls declined from 4.70 (95% CI 3.92, 5.63) before the MET was implemented to 3.11 (95% CI 2.44, 3.97) afterwards (Figure 2); this was due primarily to a decrease in medical crises, which averaged 3.29 events per 1000 admissions (95% CI 2.70, 4.02) before implementation and decreased to 1.72 (95% CI 1.28, 2.31) afterwards, whereas cardiac arrests did not change significantly (Figure 3). Following implementation, code calls within critical care also declined significantly, from 2.59 events per 1000 admissions (95% CI 1.82, 3.69) before to 1.24 events per 1000 admissions (95% CI 0.94, 1.63) afterwards. The change in codes called within critical care was smaller, however, and included reductions in both cardiac arrests ( 0.84 events, P = 0.01) and medical crises ( 0.55, P = 0.08). There was no significant change in the rate of fatal codes per 1000 admissions ( +0.06, P = 0.65) (Figure 4). Overall hospital mortality remained steady at 22.0 deaths per 1000 admissions throughout the study period.

Figure 2

Figure 3

Figure 4

DISCUSSION

In this report, we detail the implementation of a novel hospitalist‐led medical emergency team at a large academic medical center over a period of 4 years. The team, which consisted of the patient's physician, a critical care nurse, a respiratory therapist, and an intravenous therapist, achieved full implementation within 6 months, was well received by the nursing staff, and was associated with a 42% decrease in code calls hospital‐wide. Most of the overall reduction was due to a reduction in codes called for medical crises outside of critical care, accompanied by a lesser reduction in codes called for cardiac arrests and medical crises within critical care units. There was no significant effect on the rate of cardiac arrest outside critical care. More importantly, there was no change in the rate of fatal codes or overall hospital mortality.

The idea of early intervention to prevent deterioration among hospitalized patients appeals to the concept that an ounce of prevention is worth a pound of cure. Like many other preventive interventions, rapid response systems have not always delivered on this promise. Since several early reports from Australia2 suggested that medical emergency teams could reduce not only cardiopulmonary arrests, but overall hospital mortality, there has been a rapid proliferation in their implementation, spurred on by the IHI's 100,000 Lives Campaign, which incorporated rapid response systems as one of 6 hospital‐wide interventions aimed at reducing harm and mortality.13 Subsequent randomized trials have both reproduced and refuted the early observational results. A ward‐randomized trial within 1 British hospital found a 50% reduction in hospital mortality for wards assigned to have an RRT,14 while a cluster randomized trial conducted at 23 Australian hospitals found no difference in rates of cardiac arrest or mortality between hospitals implementing METs and those continuing with usual care.7 Interestingly, in the Australian trial, the rates of cardiac arrest and mortality declined for both groups compared to historical controls, an important limitation to observational trials. Reports from single‐institution observational trials are also divided between those that found a reduction in mortality following implementation and those that did not. A recent meta‐analysis reported that there was too much heterogeneity among these trials to reach a conclusion about the benefits of rapid response systems.15

Our study adds to this literature in several ways. First, our MET design, which included the patient's physician (as opposed to an intensive care physician), was different from those previously studied. Including the patient's physician increases the team's knowledge of the patient and disease, and may improve physician acceptance of METs. In addition, our study provides 4 full years of follow‐up. Second, our rate of MET activation (18 calls/1000 admissions) was 2 to 3 times higher than that seen in most other studies,16 thus, the lack of mortality benefit was not likely the result of underuse. Third, our hospital employs a large number of hospitalists whose continuous presence might be expected to attenuate the benefits of an MET. Indeed, our initial rate of codes (7.5/1000 admissions) was similar to the post‐intervention rate in other studies.4 Nevertheless, the decrease in the overall rate of code calls following implementation of our MET was similar to that observed by others.17 Finally, our stratification of code calls inside critical care (where the MET was not deployed) and outside critical care, as well as the division of codes into cardiac arrest (where intervention is often unsuccessful) and other medical crises (primarily respiratory distress), gives further insight into how METs might work. As expected, we found that outside critical care only, codes called for medical crises declined, implying that the main effect of the MET was to provide early interventions for patients who were not likely to die anyway (eg, respiratory care for patients with respiratory distress or intravenous fluids for hypotensive patients). Instead of intervening to prevent death, MET may avoid emergent intubation by providing respiratory therapy and/or urgent intubation. In addition, it represents a less‐intense option for responding to nonlife‐threatening emergencies, such as seizures or syncope. As codes were no longer called for these types of crises, the rate of code calls necessarily fell. The reason that code calls declined inside critical care is less clear. It could be that patients transferred to critical care by the MET were less likely to code than those transferred before implementation, or the decline might be due to other factors that were not evaluated. Regardless, it is clear that the MET did not simply relocate codes to critical care units.

Our study has a number of limitations. First, it is an observational study and cannot account for other confounders relating to temporal trends in the hospital. However, our long time window allowed us to examine trends over several years. For 2 years prior to implementation of the MET, there was no decline at all in the rate of code calls, followed by an immediate and sustained drop after implementation. Other interventions, including ventilator‐associated pneumonia bundles, sepsis bundles, and advanced cardiac life support simulation training were also implemented at different times during the study period. However, the stark demarcation in code call rates coinciding with MET implementation makes it less likely that these other interventions were responsible for the observed decline. Second, our study was limited to a single institution and a single type of MET. Our findings may not apply to other types of institutions with different staffing arrangements or a different hospital culture, nor would they necessarily apply to different types of MET. Third, our nurse surveys were not collected anonymously, and this may have affected the nurses' responses. Finally, we did not collect physiological parameters on our patients, so we cannot state with certainty what the MET intervention accomplished.

Since initial studies suggested that METs could reduce hospital mortality rates, the Joint Commission has effectively mandated implementation of rapid response systems in all hospitals. Newer evidence, however, has been less convincing of mortality or other benefit. Our study adds to the literature in that we also did not find a mortality benefit. However, there were 2 clear benefits that we did identify. Our MET did appear to substantially reduce total numbers of code calls, particularly codes called for medical crises. Also, our nurses had a very positive response to the MET, which empowered them to get help for a patient when the patient's physician was unavailable or did not take their concerns seriously. Clearly, additional study is needed to better understand the effects of METs on mortality, codes, and other indicators of patient outcomes. However, in the current regulatory environment, such studies will be difficult to perform. Instead, additional studies can clarify which models deliver best outcomes and optimal use of our limited resources.

In‐hospital cardiopulmonary arrests are often preceded by signs of clinical instability, such as changes in vital signs or mental status.1 Nearly 85% of patients who suffer from cardiopulmonary arrests have documented observations of deterioration in the 8 hours before arrest.2 A Medical Emergency Team (MET), sometimes known as Rapid Response Team (RRT), can rapidly assess and manage unstable patients, with the goal that early intervention will prevent adverse outcomes. In 2004, the Institute for Healthcare Improvement (IHI), as part of its 100,000 Lives Campaign, called for hospitals to implement rapid response systems as 1 of 6 strategies to reduce deaths in hospital.3 Since this recommendation, hundreds of hospitals in the United States have invested substantial financial and personnel resources to implement some form of a rapid response system, which is comprised of a varying array of healthcare providers who bring critical care expertise to the patient's bedside.4, 5

Despite the intuitive appeal of the approach, and early observational data which suggested that METs could reduce both codes and unexpected in‐hospital mortality,2, 6 the largest randomized controlled trial found that METs failed to reduce unplanned intensive care unit (ICU) admissions, cardiac arrests, or unexpected deaths.7 More recently, in a prospective observational cohort study at 1 US hospital, Chan et al. found that a nurse‐led RRT did not impact hospital‐wide code rates or mortality.4

The study of rapid response systems is further complicated by a lack of standard definition, and the many types of hospitals in which they may be implemented. In 2006, a consensus conference suggested that MET be used to refer to teams led by physicians (usually intensivists), and RRT be used for teams led by nurses.8 Many studies have been conducted at non‐US institutions, and follow‐up periods have generally been 1 year or less. We report on almost 4 years of experience with a hospitalist‐led MET implemented in a major US academic medical center, and examine the subsequent changes in code calls, cardiac arrests, deaths following cardiopulmonary resuscitation, and overall hospital mortality. Because the MET did not operate in the critical care units, and because cardiac arrest may occur without prior signs of deterioration, we hypothesized that implementation of the MET would correspond to a small drop in total code calls, no change in codes called inside of critical care units, no change in cardiac arrest outside of critical care, and a marked drop in other medical crises (mostly respiratory distress) outside critical care. We also hypothesized that there would be no change in the rate of fatal codes, because most deaths occur in patients who were found to be pulseless on arrival of the code team.

METHODS

RESULTS

Implementation of the MET

The MET was introduced in the first and second quarters of 2006, with 2717 calls logged through the end of 2009 (out of 154,382 admissions). The rate of MET calls increased during the first 6 months of implementation from 5.95 per 1000 admissions in the first quarter of the intervention, to 15.8 calls per 1000 admissions in the second quarter. Call rates peaked in the first half of 2009, at 20.9 calls per 1000 admissions, leveling off to 17.9 calls per 1000 admissions in the last half of 2009 (Figure 1). Of calls with time recorded, 40% occurred on the day shift, 35% on the evening shift, and 25% on the night shift. The most common reason to call the MET was respiratory distress (33%), followed by cardiovascular instability (25%), and neurological abnormality (20%). In 15% of cases, concern about a patient's condition prompted the nurse to call. Calls came primarily from medical floors (75%) and surgical units (20%). The median response time was 4 minutes (interquartile range [IQR], 2.8 to 5.2 minutes) with no meaningful trend during the study period. The median call duration was 50 minutes (IQR, 38 to 72 minutes). Again, there was no trend over time. The most common interventions were arterial blood gas, fluid resuscitation, and electrocardiogram (see Supporting Web Appendix Table 1 in the online version of this article). A physician was present at 52% of the calls in the first year, which rose to 93% of calls in the final year. Approximately 25% of calls resulted in the patient being transferred to a critical care unit. Staff evaluations were overwhelmingly positive. Nurses rated the teams on the following points: whether the critical care nurse and respiratory therapist were efficient and respectful (mean rating 98%, SD 5.6%); promptness (98%, SD 5.6%); whether the patient's needs were addressed appropriately (mean 98%, SD 4.2%); whether the nurse felt supported by the MET (99.5%, SD 1.7%); and whether they would call the MET again (99.7%, SD 1.4%).

Figure 1

Effect of MET on Code Calls and Mortality

Between January 2004 and December of 2009, the hospital case mix index remained constant, and there were a total of 1202 codes called. The majority (62%) took place outside of critical care units. Linear contrasts of pre‐piecewise and post‐piecewise intercepts revealed that overall code calls declined significantly between pre‐implementation and post‐implementation of the MET from 7.30 (95% CI 5.81, 9.16) codes called per 1000 admissions to 4.21 (95% CI 3.42, 5.18) calls per 1000 admissions (Figure 1; also see Supporting Web Appendix Table 2 in the online version of this article). Outside of critical care, code calls declined from 4.70 (95% CI 3.92, 5.63) before the MET was implemented to 3.11 (95% CI 2.44, 3.97) afterwards (Figure 2); this was due primarily to a decrease in medical crises, which averaged 3.29 events per 1000 admissions (95% CI 2.70, 4.02) before implementation and decreased to 1.72 (95% CI 1.28, 2.31) afterwards, whereas cardiac arrests did not change significantly (Figure 3). Following implementation, code calls within critical care also declined significantly, from 2.59 events per 1000 admissions (95% CI 1.82, 3.69) before to 1.24 events per 1000 admissions (95% CI 0.94, 1.63) afterwards. The change in codes called within critical care was smaller, however, and included reductions in both cardiac arrests ( 0.84 events, P = 0.01) and medical crises ( 0.55, P = 0.08). There was no significant change in the rate of fatal codes per 1000 admissions ( +0.06, P = 0.65) (Figure 4). Overall hospital mortality remained steady at 22.0 deaths per 1000 admissions throughout the study period.

Figure 2

Figure 3

Figure 4

DISCUSSION

In this report, we detail the implementation of a novel hospitalist‐led medical emergency team at a large academic medical center over a period of 4 years. The team, which consisted of the patient's physician, a critical care nurse, a respiratory therapist, and an intravenous therapist, achieved full implementation within 6 months, was well received by the nursing staff, and was associated with a 42% decrease in code calls hospital‐wide. Most of the overall reduction was due to a reduction in codes called for medical crises outside of critical care, accompanied by a lesser reduction in codes called for cardiac arrests and medical crises within critical care units. There was no significant effect on the rate of cardiac arrest outside critical care. More importantly, there was no change in the rate of fatal codes or overall hospital mortality.

The idea of early intervention to prevent deterioration among hospitalized patients appeals to the concept that an ounce of prevention is worth a pound of cure. Like many other preventive interventions, rapid response systems have not always delivered on this promise. Since several early reports from Australia2 suggested that medical emergency teams could reduce not only cardiopulmonary arrests, but overall hospital mortality, there has been a rapid proliferation in their implementation, spurred on by the IHI's 100,000 Lives Campaign, which incorporated rapid response systems as one of 6 hospital‐wide interventions aimed at reducing harm and mortality.13 Subsequent randomized trials have both reproduced and refuted the early observational results. A ward‐randomized trial within 1 British hospital found a 50% reduction in hospital mortality for wards assigned to have an RRT,14 while a cluster randomized trial conducted at 23 Australian hospitals found no difference in rates of cardiac arrest or mortality between hospitals implementing METs and those continuing with usual care.7 Interestingly, in the Australian trial, the rates of cardiac arrest and mortality declined for both groups compared to historical controls, an important limitation to observational trials. Reports from single‐institution observational trials are also divided between those that found a reduction in mortality following implementation and those that did not. A recent meta‐analysis reported that there was too much heterogeneity among these trials to reach a conclusion about the benefits of rapid response systems.15

Our study adds to this literature in several ways. First, our MET design, which included the patient's physician (as opposed to an intensive care physician), was different from those previously studied. Including the patient's physician increases the team's knowledge of the patient and disease, and may improve physician acceptance of METs. In addition, our study provides 4 full years of follow‐up. Second, our rate of MET activation (18 calls/1000 admissions) was 2 to 3 times higher than that seen in most other studies,16 thus, the lack of mortality benefit was not likely the result of underuse. Third, our hospital employs a large number of hospitalists whose continuous presence might be expected to attenuate the benefits of an MET. Indeed, our initial rate of codes (7.5/1000 admissions) was similar to the post‐intervention rate in other studies.4 Nevertheless, the decrease in the overall rate of code calls following implementation of our MET was similar to that observed by others.17 Finally, our stratification of code calls inside critical care (where the MET was not deployed) and outside critical care, as well as the division of codes into cardiac arrest (where intervention is often unsuccessful) and other medical crises (primarily respiratory distress), gives further insight into how METs might work. As expected, we found that outside critical care only, codes called for medical crises declined, implying that the main effect of the MET was to provide early interventions for patients who were not likely to die anyway (eg, respiratory care for patients with respiratory distress or intravenous fluids for hypotensive patients). Instead of intervening to prevent death, MET may avoid emergent intubation by providing respiratory therapy and/or urgent intubation. In addition, it represents a less‐intense option for responding to nonlife‐threatening emergencies, such as seizures or syncope. As codes were no longer called for these types of crises, the rate of code calls necessarily fell. The reason that code calls declined inside critical care is less clear. It could be that patients transferred to critical care by the MET were less likely to code than those transferred before implementation, or the decline might be due to other factors that were not evaluated. Regardless, it is clear that the MET did not simply relocate codes to critical care units.

Our study has a number of limitations. First, it is an observational study and cannot account for other confounders relating to temporal trends in the hospital. However, our long time window allowed us to examine trends over several years. For 2 years prior to implementation of the MET, there was no decline at all in the rate of code calls, followed by an immediate and sustained drop after implementation. Other interventions, including ventilator‐associated pneumonia bundles, sepsis bundles, and advanced cardiac life support simulation training were also implemented at different times during the study period. However, the stark demarcation in code call rates coinciding with MET implementation makes it less likely that these other interventions were responsible for the observed decline. Second, our study was limited to a single institution and a single type of MET. Our findings may not apply to other types of institutions with different staffing arrangements or a different hospital culture, nor would they necessarily apply to different types of MET. Third, our nurse surveys were not collected anonymously, and this may have affected the nurses' responses. Finally, we did not collect physiological parameters on our patients, so we cannot state with certainty what the MET intervention accomplished.

Since initial studies suggested that METs could reduce hospital mortality rates, the Joint Commission has effectively mandated implementation of rapid response systems in all hospitals. Newer evidence, however, has been less convincing of mortality or other benefit. Our study adds to the literature in that we also did not find a mortality benefit. However, there were 2 clear benefits that we did identify. Our MET did appear to substantially reduce total numbers of code calls, particularly codes called for medical crises. Also, our nurses had a very positive response to the MET, which empowered them to get help for a patient when the patient's physician was unavailable or did not take their concerns seriously. Clearly, additional study is needed to better understand the effects of METs on mortality, codes, and other indicators of patient outcomes. However, in the current regulatory environment, such studies will be difficult to perform. Instead, additional studies can clarify which models deliver best outcomes and optimal use of our limited resources.

In‐hospital cardiopulmonary arrests are often preceded by signs of clinical instability, such as changes in vital signs or mental status.1 Nearly 85% of patients who suffer from cardiopulmonary arrests have documented observations of deterioration in the 8 hours before arrest.2 A Medical Emergency Team (MET), sometimes known as Rapid Response Team (RRT), can rapidly assess and manage unstable patients, with the goal that early intervention will prevent adverse outcomes. In 2004, the Institute for Healthcare Improvement (IHI), as part of its 100,000 Lives Campaign, called for hospitals to implement rapid response systems as 1 of 6 strategies to reduce deaths in hospital.3 Since this recommendation, hundreds of hospitals in the United States have invested substantial financial and personnel resources to implement some form of a rapid response system, which is comprised of a varying array of healthcare providers who bring critical care expertise to the patient's bedside.4, 5

Despite the intuitive appeal of the approach, and early observational data which suggested that METs could reduce both codes and unexpected in‐hospital mortality,2, 6 the largest randomized controlled trial found that METs failed to reduce unplanned intensive care unit (ICU) admissions, cardiac arrests, or unexpected deaths.7 More recently, in a prospective observational cohort study at 1 US hospital, Chan et al. found that a nurse‐led RRT did not impact hospital‐wide code rates or mortality.4

The study of rapid response systems is further complicated by a lack of standard definition, and the many types of hospitals in which they may be implemented. In 2006, a consensus conference suggested that MET be used to refer to teams led by physicians (usually intensivists), and RRT be used for teams led by nurses.8 Many studies have been conducted at non‐US institutions, and follow‐up periods have generally been 1 year or less. We report on almost 4 years of experience with a hospitalist‐led MET implemented in a major US academic medical center, and examine the subsequent changes in code calls, cardiac arrests, deaths following cardiopulmonary resuscitation, and overall hospital mortality. Because the MET did not operate in the critical care units, and because cardiac arrest may occur without prior signs of deterioration, we hypothesized that implementation of the MET would correspond to a small drop in total code calls, no change in codes called inside of critical care units, no change in cardiac arrest outside of critical care, and a marked drop in other medical crises (mostly respiratory distress) outside critical care. We also hypothesized that there would be no change in the rate of fatal codes, because most deaths occur in patients who were found to be pulseless on arrival of the code team.

METHODS

RESULTS

Implementation of the MET

The MET was introduced in the first and second quarters of 2006, with 2717 calls logged through the end of 2009 (out of 154,382 admissions). The rate of MET calls increased during the first 6 months of implementation from 5.95 per 1000 admissions in the first quarter of the intervention, to 15.8 calls per 1000 admissions in the second quarter. Call rates peaked in the first half of 2009, at 20.9 calls per 1000 admissions, leveling off to 17.9 calls per 1000 admissions in the last half of 2009 (Figure 1). Of calls with time recorded, 40% occurred on the day shift, 35% on the evening shift, and 25% on the night shift. The most common reason to call the MET was respiratory distress (33%), followed by cardiovascular instability (25%), and neurological abnormality (20%). In 15% of cases, concern about a patient's condition prompted the nurse to call. Calls came primarily from medical floors (75%) and surgical units (20%). The median response time was 4 minutes (interquartile range [IQR], 2.8 to 5.2 minutes) with no meaningful trend during the study period. The median call duration was 50 minutes (IQR, 38 to 72 minutes). Again, there was no trend over time. The most common interventions were arterial blood gas, fluid resuscitation, and electrocardiogram (see Supporting Web Appendix Table 1 in the online version of this article). A physician was present at 52% of the calls in the first year, which rose to 93% of calls in the final year. Approximately 25% of calls resulted in the patient being transferred to a critical care unit. Staff evaluations were overwhelmingly positive. Nurses rated the teams on the following points: whether the critical care nurse and respiratory therapist were efficient and respectful (mean rating 98%, SD 5.6%); promptness (98%, SD 5.6%); whether the patient's needs were addressed appropriately (mean 98%, SD 4.2%); whether the nurse felt supported by the MET (99.5%, SD 1.7%); and whether they would call the MET again (99.7%, SD 1.4%).

Figure 1

Effect of MET on Code Calls and Mortality

Between January 2004 and December of 2009, the hospital case mix index remained constant, and there were a total of 1202 codes called. The majority (62%) took place outside of critical care units. Linear contrasts of pre‐piecewise and post‐piecewise intercepts revealed that overall code calls declined significantly between pre‐implementation and post‐implementation of the MET from 7.30 (95% CI 5.81, 9.16) codes called per 1000 admissions to 4.21 (95% CI 3.42, 5.18) calls per 1000 admissions (Figure 1; also see Supporting Web Appendix Table 2 in the online version of this article). Outside of critical care, code calls declined from 4.70 (95% CI 3.92, 5.63) before the MET was implemented to 3.11 (95% CI 2.44, 3.97) afterwards (Figure 2); this was due primarily to a decrease in medical crises, which averaged 3.29 events per 1000 admissions (95% CI 2.70, 4.02) before implementation and decreased to 1.72 (95% CI 1.28, 2.31) afterwards, whereas cardiac arrests did not change significantly (Figure 3). Following implementation, code calls within critical care also declined significantly, from 2.59 events per 1000 admissions (95% CI 1.82, 3.69) before to 1.24 events per 1000 admissions (95% CI 0.94, 1.63) afterwards. The change in codes called within critical care was smaller, however, and included reductions in both cardiac arrests ( 0.84 events, P = 0.01) and medical crises ( 0.55, P = 0.08). There was no significant change in the rate of fatal codes per 1000 admissions ( +0.06, P = 0.65) (Figure 4). Overall hospital mortality remained steady at 22.0 deaths per 1000 admissions throughout the study period.

Figure 2

Figure 3

Figure 4

DISCUSSION

In this report, we detail the implementation of a novel hospitalist‐led medical emergency team at a large academic medical center over a period of 4 years. The team, which consisted of the patient's physician, a critical care nurse, a respiratory therapist, and an intravenous therapist, achieved full implementation within 6 months, was well received by the nursing staff, and was associated with a 42% decrease in code calls hospital‐wide. Most of the overall reduction was due to a reduction in codes called for medical crises outside of critical care, accompanied by a lesser reduction in codes called for cardiac arrests and medical crises within critical care units. There was no significant effect on the rate of cardiac arrest outside critical care. More importantly, there was no change in the rate of fatal codes or overall hospital mortality.

The idea of early intervention to prevent deterioration among hospitalized patients appeals to the concept that an ounce of prevention is worth a pound of cure. Like many other preventive interventions, rapid response systems have not always delivered on this promise. Since several early reports from Australia2 suggested that medical emergency teams could reduce not only cardiopulmonary arrests, but overall hospital mortality, there has been a rapid proliferation in their implementation, spurred on by the IHI's 100,000 Lives Campaign, which incorporated rapid response systems as one of 6 hospital‐wide interventions aimed at reducing harm and mortality.13 Subsequent randomized trials have both reproduced and refuted the early observational results. A ward‐randomized trial within 1 British hospital found a 50% reduction in hospital mortality for wards assigned to have an RRT,14 while a cluster randomized trial conducted at 23 Australian hospitals found no difference in rates of cardiac arrest or mortality between hospitals implementing METs and those continuing with usual care.7 Interestingly, in the Australian trial, the rates of cardiac arrest and mortality declined for both groups compared to historical controls, an important limitation to observational trials. Reports from single‐institution observational trials are also divided between those that found a reduction in mortality following implementation and those that did not. A recent meta‐analysis reported that there was too much heterogeneity among these trials to reach a conclusion about the benefits of rapid response systems.15

Our study adds to this literature in several ways. First, our MET design, which included the patient's physician (as opposed to an intensive care physician), was different from those previously studied. Including the patient's physician increases the team's knowledge of the patient and disease, and may improve physician acceptance of METs. In addition, our study provides 4 full years of follow‐up. Second, our rate of MET activation (18 calls/1000 admissions) was 2 to 3 times higher than that seen in most other studies,16 thus, the lack of mortality benefit was not likely the result of underuse. Third, our hospital employs a large number of hospitalists whose continuous presence might be expected to attenuate the benefits of an MET. Indeed, our initial rate of codes (7.5/1000 admissions) was similar to the post‐intervention rate in other studies.4 Nevertheless, the decrease in the overall rate of code calls following implementation of our MET was similar to that observed by others.17 Finally, our stratification of code calls inside critical care (where the MET was not deployed) and outside critical care, as well as the division of codes into cardiac arrest (where intervention is often unsuccessful) and other medical crises (primarily respiratory distress), gives further insight into how METs might work. As expected, we found that outside critical care only, codes called for medical crises declined, implying that the main effect of the MET was to provide early interventions for patients who were not likely to die anyway (eg, respiratory care for patients with respiratory distress or intravenous fluids for hypotensive patients). Instead of intervening to prevent death, MET may avoid emergent intubation by providing respiratory therapy and/or urgent intubation. In addition, it represents a less‐intense option for responding to nonlife‐threatening emergencies, such as seizures or syncope. As codes were no longer called for these types of crises, the rate of code calls necessarily fell. The reason that code calls declined inside critical care is less clear. It could be that patients transferred to critical care by the MET were less likely to code than those transferred before implementation, or the decline might be due to other factors that were not evaluated. Regardless, it is clear that the MET did not simply relocate codes to critical care units.

Our study has a number of limitations. First, it is an observational study and cannot account for other confounders relating to temporal trends in the hospital. However, our long time window allowed us to examine trends over several years. For 2 years prior to implementation of the MET, there was no decline at all in the rate of code calls, followed by an immediate and sustained drop after implementation. Other interventions, including ventilator‐associated pneumonia bundles, sepsis bundles, and advanced cardiac life support simulation training were also implemented at different times during the study period. However, the stark demarcation in code call rates coinciding with MET implementation makes it less likely that these other interventions were responsible for the observed decline. Second, our study was limited to a single institution and a single type of MET. Our findings may not apply to other types of institutions with different staffing arrangements or a different hospital culture, nor would they necessarily apply to different types of MET. Third, our nurse surveys were not collected anonymously, and this may have affected the nurses' responses. Finally, we did not collect physiological parameters on our patients, so we cannot state with certainty what the MET intervention accomplished.

Since initial studies suggested that METs could reduce hospital mortality rates, the Joint Commission has effectively mandated implementation of rapid response systems in all hospitals. Newer evidence, however, has been less convincing of mortality or other benefit. Our study adds to the literature in that we also did not find a mortality benefit. However, there were 2 clear benefits that we did identify. Our MET did appear to substantially reduce total numbers of code calls, particularly codes called for medical crises. Also, our nurses had a very positive response to the MET, which empowered them to get help for a patient when the patient's physician was unavailable or did not take their concerns seriously. Clearly, additional study is needed to better understand the effects of METs on mortality, codes, and other indicators of patient outcomes. However, in the current regulatory environment, such studies will be difficult to perform. Instead, additional studies can clarify which models deliver best outcomes and optimal use of our limited resources.