Epidemiology and Prognostic Significance of Rapid Response System Activation in Patients Undergoing Liver Transplantation

Abstract

Patients undergoing liver transplantation have a high risk of perioperative clinical deterioration. The Rapid Response System is an intensive care unit-based approach for the early recognition and management of hospitalized patients identified as high-risk for clinical deterioration by a medical emergency team (MET). The etiology and prognostic significance of clinical deterioration events is poorly understood in liver transplant patients. We conducted a cohort study of 381 consecutive adult liver transplant recipients from a prospectively collected transplant database (2011–2017). Medical records identified patients who received MET activation pre- and post-transplantation. MET activation was recorded in 131 (34%) patients, with 266 MET activations in total. The commonest triggers for MET activation were tachypnea and hypotension pre-transplantation, and tachycardia post-transplantation. In multivariable analysis, female sex, increasing Model for End-Stage Liver Disease score and hepatorenal syndrome were independently associated with MET activation. The unplanned intensive care unit admission rate following MET activation was 24.1%. Inpatient mortality was 4.2% and did not differ by MET activation status; however, patients requiring MET activation had significantly longer intensive care unit and hospital length of stay and were more likely to require inpatient rehabilitation. In conclusion, liver transplant patients with perioperative complications requiring MET activation represent a high-risk group with increased morbidity and length of stay.

The transcultural adaptation and validation of the Chinese version of the Attitudes Toward Recognizing Early and Noticeable Deterioration scale

“…As defined by the medical profession, clinical deterioration refers to “a change from a clinically healthy state to an increasingly poor health state that increases the risk of death, disability, organ dysfunction, or illness ( Jones et al, 2013 ; Treacy et al, 2022 ).” The rapid response system (RRS) is a mechanism for the early identification of critically ill patients at potential risk of adverse events using single or multiple early warning values in the setting of a continuing shortage of critical care resources and equipment and then accurately initiating rapid response team, medica emergency teams, or critical care outreach team to provide the targeted response and acute management of ward patients ( McGaughey et al, 2017 ; Robertson et al, 2021 ). The implementation of RRSs has gained increasing attention over the past two decades to identify and respond promptly to deteriorating inpatients as part of the global patient quality and safety agenda ( Winters et al, 2013 ; McGaughey et al, 2021 ).…”

Improving risk stratification and decision support for deteriorating hospital patients

“…Many institutions now have well-established databases that allow determination of which hospitalised patients are at increased risk of rapid response team review. [18][19][20][21][22] In addition, several investigators have attempted to evaluate associations with worse patient outcomes following rapid response team review, including repeat calls and subsequent ICU admission. [23][24][25] In an effort to identify patients at risk of poor outcomes and needing enhanced care following a MET review, in this edition of the journal, Batterbury and colleagues 26 describe a retrospective cohort study with 1500 adult patients who remained on the ward following a MET call at an Australian quaternary hospital.…”

“…Thus, while rapid response teams have improved the outcomes of hospitalised patients, there is a need to develop systems and processes to further improve patient outcomes. Many institutions now have well-established databases that allow determination of which hospitalised patients are at increased risk of rapid response team review 18–22. In addition, several investigators have attempted to evaluate associations with worse patient outcomes following rapid response team review, including repeat calls and subsequent ICU admission 23–25…”

The medical emergency team — current status and future directions: a perspective for acute care physicians

“…Several studies have been conducted to predict which patients are likely to require a MET call to guide the development of strategies that are more proactive in nature. [35][36][37][38] Currently, MET criteria are relatively sensitive but not specific. Thus, only 20% of patients will be admitted to the ICU following MET review.…”

“…A further future goal will be increased use of the electronic health care record and MET databases to improve understanding and management of deteriorating patients. Several studies have been conducted to predict which patients are likely to require a MET call to guide the development of strategies that are more proactive in nature 35–38 . Currently, MET criteria are relatively sensitive but not specific.…”