title: The medical emergency team call: a sentinel event that triggers goals of care discussion.
abstract: OBJECTIVE
  Several studies have questioned the effectiveness of rapid-response systems when measured by outcomes such as decreased overall hospital mortality or cardiac arrest rates. We studied an alternative outcome of rapid-response system implementation, namely, its effect on goals of care and designation of do not resuscitate.
  
  
  METHODS
  Retrospective chart review.
  
  
  METHODS
  Veterans Administration Hospital in New York City.
  
  
  METHODS
  All patients requiring a medical emergency team call.
  
  
  METHODS
  None
  
  
  RESULTS
  : Monthly hospital census and discharge data, death occurrences, and do-not-resuscitate order placements were collected over an 8-year pre-medical emergency team and 5-year post-medical emergency team period. All medical emergency team calls and subsequent transfers to a critical care unit were reviewed and correlated to the placement and timing of do-not-resuscitate orders. Interrupted time-series analysis was used to evaluate the impact of the medical emergency team implementation on the change in trend of do-not-resuscitate orders and the hospital mortality. A total of 390 medical emergency team calls were associated with 109 do-not-resuscitate orders (28%). Of the 209 medical emergency team calls (54%) resulting in transfer to a critical care unit, 66 were associated with do-not-resuscitate orders, 73% of which were obtained after transfer. The odds of becoming do not resuscitate for a patient going to the ICU after the medical emergency team call were 2.9 (95% CI, 1.6-5.5; p = 0.001) times greater than for patients staying on the floors after the medical emergency team call. The medical emergency team implementation significantly changed the trend of do-not-resuscitate orders (p < 0.001) but had no impact on hospital mortality rate (p = 0.638).
  
  
  CONCLUSIONS
  Implementation of a rapid-response system was associated with an increase in do-not-resuscitate order placement. As a sentinel event, medical emergency team activation and transfer to a critical care unit foster consideration of goals of care and frequently results in a transition to a palliative care strategy.
authors.affiliation: 1Pulmonary and Critical Care Sections of the VA NY Harbor Healthcare System, New York, NY. 2Division of Pulmonary and Critical Care Medicine of the New York University School of Medicine, New York, NY. 3Primary Care Section of the VA NY Harbor Healthcare System, New York, NY. 4Division of General Internal Medicine of the New York University School of Medicine, New York, NY. 5Patient Services of the VA NY Harbor Healthcare System, New York, NY.
authors.forename: Robert L
authors.initials: RL
authors.lastname: Smith
authors.forename: Vivian N
authors.initials: VN
authors.lastname: Hayashi
authors.forename: Young Im
authors.initials: YI
authors.lastname: Lee
authors.forename: Leonila
authors.initials: L
authors.lastname: Navarro-Mariazeta
authors.forename: Kevin
authors.initials: K
authors.lastname: Felner
mesh_terms: D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D004638:Emergency Treatment / Q000706:statistics & numerical data*; D017052:Hospital Mortality; D057209:Hospital Rapid Response Team / Q000706:statistics & numerical data*; D006801:Humans; D008875:Middle Aged; D016414:Resuscitation Orders; D012189:Retrospective Studies