Antecedents to hospital deaths: all in good time (2001)

History shows us that most of the major and most cost-effective medical interventions have been based on good epidemiological study and the use of preventative measures appropriately targeted and applied in good time. The effective prevention of mass communicable diseases such as cholera, smallpox and HIV can be traced to effective scientific and epidemiological study of causation and dissemination. Subsequent breaks in the pattern of transmission by reservoir reduction, immunization or behavioural change have been highly effective. In many ways, the work of Hillman’s team, as reported in this issue of the Journal on page 343,1 builds on these classical epidemiological and public health techniques. One can relate the complex and often chaotic modern acute health system as a care process that can be studied for its effects on health outcomes, both good and bad. The management of patients in acute hospital environments has evolved over that last century without any randomized controlled study of the best way to provide such care. Many of the inpatient models have remained largely unchanged, despite major changes in staffing levels and funding, throughput, training methods and increased numbers of shifts through safe working hours and staffing employment awards. Results of such changes are usually financially driven and are rarely studied for their effects on patients’ outcome. The extensive list of cited international references in the paper by Hillman et al.1 attests to the universal shortcomings in the ward management of acutely ill and deteriorating patients. The sickest patients are usually initially assessed by the most junior of medical and nursing staff. There are many personality and system-based reasons why senior assistance is not obtained in a timely manner. In our highly specialized and subspecialized style of clinical practice, senior medical and nursing staff may not be experienced in the assessment and resuscitation of acutely deteriorating patients. The paper by Hillman et al. describes a patient cohort from 1996 that was part of a larger study in three acute hospitals.1 This study examined the ability of Medical Emergency Teams (MET) to reduce serious adverse events. The study showed that a high proportion of the actively managed patients who died had major derangements in physiological parameters for up to 48 h prior to death. In many cases, junior staff had noted their concerns in the history. What is not clear from the paper is why the next step ‘adequate management and or referral to the intensive care unit (ICU)’ did not occur. Even allowing for attempted ward-based resuscitation, if this was unsuccessful, why were the patients not referred to the ICU or made ‘do not resuscitate’? Many intensivists see the logic in the preventative (MET style) approach, but thus far hard evidence of efficacy is scant. A 2-year study in our hospital of the implementation of a high-dependency unit and subsequently a MET has shown an 80% reduction in cardiac arrests and a 38% reduction in ‘all causes’ mortality in surgical patients expected to stay in hospital longer than 48 h (R. Bellomo, pers. comm., 2001). The criteria used for activation of the MET were those described by Hillman et al.1 If medical care systems design was as patentable and politics-free as studies into endotoxin antibodies, we may have progressed this work further. Hopefully, continued efforts by groups such as Hillman’s will help us to re-engineer our acute care delivery system, all in good time for the next generation of patients.