Doctors and nurses rush to the bed of a patient in cardiac arrest.

Pam Panchak, Post-Gazette Medical Emergency Team Conference participants Anna Banford, Anne Lippert and Stephen Small work on a simulated patient at the Wiser Institute, which specializes in simulation based training. Click photo for larger image.

An EKG machine sounds an endless monotone behind a rapid patter of questions and answers. A doctor presses defibrillator paddles on a still chest and commands, "Clear!" Electricity jolts the patient's body.

The beep-beep of a normal heart rhythm resumes and life goes on.

This scenario is intense and heroic, but probably not the smartest way to save lives, critical care specialists say.

Much of the chaotic, terrifying and often unsuccessful drama of treating cardiac arrest in the hospital can be avoided, and the number of unexpected hospital deaths can be reduced by 30 percent, if a team of specially trained doctors and nurses steps in before the heart has stopped, as soon as the patient takes a turn for the worse.

That's the concept behind medical emergency teams, or MET, which already are in place at most hospitals in the University of Pittsburgh Medical Center system and in many Australian and European centers. Canada's health system is adopting them, too.

"We are really changing the way health care is being delivered," said critical care specialist Dr. Michael DeVita, UPMC assistant medical director. "People are trying to prevent cardiac arrests instead of respond to them."

Experts would like to see MET in wider use in American hospitals, so much so that the Cambridge, Mass., Institute for Healthcare Improvement is promoting the strategy, which it calls rapid response teams, as part of its campaign to save 100,000 lives.

More than 400 people from 10 countries on four continents attended the first MET conference at the David L. Lawrence Convention Center last month. Co-organizer DeVita said one goal was to create some buzz in the medical community.

"We've been singing and looking for an audience," he said. "[We] are looking to make this the new way the world goes about providing hospital care."

A doctor's sick wife

The UPMC program arose out of the 1989 experience of Dr. Richard L. Simmons, then the chairman of surgery, and his hospitalized wife. Her condition suddenly deteriorated, but the medical ward staff was not familiar with the logistics of getting an urgently needed blood product. Simmons wasn't sure, either.

"When you're an administrator, there are lots of things you don't know about the details," he said. So Simmons called Dr. Ake Grenvik, the head of critical care medicine, who quickly arrived with another specialist from the program. They treat patients in crisis every day.

"Within a minute or two, they showed up and took care of the problem," Simmons said. But the episode made him and Grenvik realize that critical care specialists could, and perhaps should, be brought in to respond to emergencies other than cardiac arrests.

So they created teams to respond to what UPMC called a Condition C, for crisis. It was the first MET program in the country, to DeVita's knowledge, but only in recent years has the hospital culture fully embraced it.

Typically in teaching hospitals, medical students and resident doctors at various stages of specialty training deal with the day-to-day care of patients on the medical and surgical wards. Senior physicians, called attendings, provide oversight.

While that hospital hierarchy helps fledgling doctors learn, "you discover that a major problem, a cultural problem ... is that the smartest guy is not at the bedside," said Simmons, now UPMC's medical director. "Everything is delegated to people being trained."

Dr. Ken Hillman, a conference organizer from the University of New South Wales in Australia, began setting up medical emergency teams around the same time the UPMC experts were, although they were unaware of each other's work. The MET system is now in about half of Australia's hospitals.

Historically, medicine has not emphasized team approaches. In Hillman's words, it's like a chain of silos with each specialty, and often individual doctors, operating independently. Also, nurses must work through a hierarchy of junior to senior doctors.

"That's fine for non-life-threatening situations," he said. When a problem comes up that isn't urgent, the patient will get tended to by the appropriate specialist in a day or two.

Yet for the medical emergency team strategy to work, "you have to smash through all the existing silos," Hillman said. "The concept is not rocket science, but to break through traditions that go back centuries is difficult."

Culturally, even junior doctors are discouraged from asking for help.

"You don't ask another authority to take over because you are then viewed as stupid or [incompetent] ... and you might get bawled out," Simmons said.

But being a senior doctor isn't always a guarantee of sufficient knowledge, experience or resources to deal with every possible emergency. All too often, only one doctor and one nurse are available to take care of an unstable patient on a busy ward.

Instead, "We want very sick patients to be managed by not only more people but also critical care specialists," DeVita said. "So it's not a measure of the person at the bedside's capabilities anymore."

The team members

Enter the medical emergency team.

At UPMC Presbyterian, for example, it includes a pair each of critical care physicians, intensive care nurses and respiratory therapists, drawn from multiple ICUs. When a Condition C is called, about 60 pagers go off. The handful who respond know ahead of time which wards they must cover.

This hospital version of 911 now happens about four times a day, DeVita said. In half the cases, the patient can be stabilized on the ward, and the remainder get transferred to an intensive care unit. Sometimes, patients got sicker because of the disease process or medical error.

Helen Haskell, of Columbia, S.C., attended the Pittsburgh conference because the MET concept ties into her efforts to improve hospital care.

She successfully advocated for passage of her state's Lewis Blackman Hospital Patient Safety Act, which requires clear identification of resident doctors and a means for patients and families to see attending physicians upon request.

Haskell's son, Lewis, died in 2000, four days after the 15-year-old had elective surgery to correct a birth defect. Despite several requests, she said, attending physicians never examined Lewis as his condition deteriorated to the point that he couldn't walk unaided. Finally, his heart stopped, and he could not be resuscitated.

Before the cardiac arrest, "he declined for about 30 hours," Haskell said. "Nobody recognized he was even in trouble" while a perforated gastric ulcer bled and spread infection through his system.

Emergency teams are "the best idea that's come along in patient safety since I've been working in it. I can't think of a better one," Haskell said. After all, "if you have a cardiac arrest team, why are they not coming soon enough to do some good? It's a system that really is set up to fail."

A decade ago at UPMC, ward staff still tended to calls for help only when the patient went into cardiac arrest.

"The dogma then ... was that cardiac arrests are random events that occur to sick people suddenly," DeVita said. But research has since shown that these patients often took a turn for the worse minutes or even hours before their hearts stopped.

"If intervention had been taken, those events might have been prevented," DeVita said.

First, hospital staff had to learn to recognize a patient's downturn. So a set of criteria was created to tell staff, medical and nonmedical, when to call a Condition C.

The danger indicators rely on simple vital signs, such as abnormal temperature, heart rate, blood pressure or breathing rate. Unexpected or dangerous bleeding, and seizures or acute mental changes are also on the list.

"If your patient meets any of these criteria and you can't fix it within five or 10 minutes, then you need to call for help," DeVita said. "It's not because you can't do it. It's because the hospital wants to give you extra resources."

Ward staff is praised for recognizing an imminent problem and asking for help. As Simmons put it, Condition C is like a fire department where there are no false alarms.

Also, the helping hands allow the work with other patients on the ward continue with less disruption. That reduces "domino codes," which occasionally happen when the focus on one very sick patient pulls attention from another who also is on the brink of a crisis.

The establishment of the criteria inspired a culture change.

"We very quickly had a tripling in the rate of Condition Cs being called," DeVita said. "And as the rate of Condition Cs being called went up, our rate of Condition As, which is cardiac arrest, went down."

Data from UPMC and several Australian groups show that MET programs led to a 30 percent drop in unexpected hospital mortality, meaning deaths among patients who should have gone home, DeVita said.

And, "we have reduced our cardiac arrest rate very considerably," Hillman said. "It's almost down to zero."

That kind of success prompted the Institute for Healthcare Improvement to make in-hospital crisis teams one of six components in its 100,000 Lives campaign, which aims to reduce the number of avoidable deaths.

More than 2,300 hospitals have joined the effort, the institute's Kathy Duncan said. About a third of them plan to use some version of METs.

"Smaller hospitals, especially nonacademic hospitals, can't provide a handful of doctors at the bedside," Duncan said. "Some have teams that are just two people, an ICU nurse and a respiratory therapist."

Still, a few experienced and well-trained extra hands can make the difference between life and death.

There are many response team models and criteria sets in use worldwide. One goal of the recent conference was to develop some consensus and consistency, DeVita said. He and other experts are working on a textbook, as well.

DeVita knows that Condition C is having an impact at UPMC, which houses the world's largest fellowship program for critical care specialists. Last year, one graduate noted that during his training, he hadn't taken care of a single patient who had a cardiac arrest while in the hospital.