Resuscitation 49 (2001) 135– 141
www.elsevier.com/locate/resuscitation
The evolutionary process of Medical Emergency Team (MET)
implementation: reduction in unanticipated ICU transfers
Yenna Salamonson a,b,*, Angela Kariyawasam a, Brigitte van Heere a,
Catherine O’Connor a
b
a
ICU/CCU Department, Campbelltown Hospital, P.O. Box 149, Campbelltown 2560, NSW, Australia
Di6ision of Nursing, Faculty of Health, Uni6ersity of Western Sydney Macarthur, P.O. Box 555, Campbelltown 2560, NSW, Australia
Received 14 March 2000; received in revised form 13 April 2000; accepted 14 September 2000
Abstract
Objecti6es: To determine whether the introduction of the Medical Emergency Team (MET) system designed to provide
immediate help for seriously ill patients: (i) changed the pattern of ICU patient transfers from the wards; and (ii) improved
hospital survival rates. Methods: Prospective information on MET calls and unanticipated ICU transfers was collected for 3 years
in a suburban metropolitan hospital. Results: A 3-year review of MET showed the number of MET calls doubled in the second
and third year and the team was activated for more than just the most extremely ill patients. Whilst the frequency of calls for
cardiopulmonary arrest remained constant (n=16), increased use of the MET resulted in the proportion of calls for cardiopulmonary arrest dropping from 30% in year 1 to 13% in year 3. A slight decrease in the percentage of in-hospital deaths (0.74% in
year 1 to 0.65% in year 3) was also demonstrated. The incidence of cardiopulmonary arrest per hospital admission also decreased
slightly (0.08–0.07%). Although the overall number of ICU transfers remained constant, more seriously ill patients were
transferred to ICU via the MET system. This was accompanied by a significant fall in unanticipated ICU transfers. Whilst the
reduction in hospital deaths was encouraging, this study could not demonstrate whether the slight improvement in hospital
survival rate over the 3 years was due to the MET system. Conclusion: More information is needed to demonstrate that the MET
system improves patient survival. The study also highlights the importance of taking proactive measures, which should include
providing in-service education on the benefits of early identification and treatment of patients who are at risk of acute
deterioration, raising awareness and changing attitudes in hospitals when introducing system such as the MET. © 2001 Elsevier
Science Ireland Ltd. All rights reserved.
Keywords: Advanced Life Support (ALS); Cardiac arrest; Emergency medical services; Intensive care; Outcome; Resuscitation
Resumo
Para determinar se a introdução de uma equipa de emergência médica (EEM), destinada a fornecer ajuda imediata a doentes
extremamente graves, (i) mudou o padrão de transferência de doentes das enfermarias para cuidados intensivos, e (ii) se melhorou
a taxa de sobrevivência hospitalar. Métodos: Foi recolhida, ao longo de 3 anos, informação prospectiva das chamadas da EEM
e das transferências não antecipadas para cuidados intensivos, num hospital metropolitano periférico. Resultados: Uma revisão de
3 anos de EEM mostrou que o número de chamadas duplicou no segundo e no terceiro ano e que a equipa foi activada para mais
do que doentes extremamente graves. Enquanto que a frequência de chamadas por paragem cardı́aca permaneceu constante
(n= 16) o aumento da utilização da EEM resultou numa queda da percentagem de chamadas por paragem de 30% no primeiro
ano para 13% no terceiro ano. Também foi demonstrada uma ligeira diminuição na percentagem de mortes intra-hospitalar
(0.74% no primeiro ano para 0.65% no terceiro ano). A incidência de paragem cardio-pulmonar por admissão hospitalar também
diminuiu ligeiramente (0.08–0.07%). Apesar do número global das transferências para cuidados intensivos ter permanecido
constante, os doentes mais graves foram transferidos para cuidados intensivos através do sistema de EEM. Isto foi acompanhado
de uma queda significativa nas transferências não programadas. Apesar da redução no numero de mortes ser encorajadora, não
foi possı́vel demonstrar por este estudo se a ligeira melhoria na taxa de sobrevivência hospitalar foi devida ao sistema de EEM.
* Corresponding author. Tel.: + 61-2-46203322; fax: + 61-2-46254252.
0300-9572/01/$ - see front matter © 2001 Elsevier Science Ireland Ltd. All rights reserved.
PII: S 0 3 0 0 - 9 5 7 2 ( 0 0 ) 0 0 3 5 3 - 1
136
Y. Salamonson et al. / Resuscitation 49 (2001) 135–141
Conclusão: E necessária mais informação para demonstrar que o sistema de EEM melhora a sobrevivência. Este estudo também
sublinha a importância de tomar medidas pró-activas que deveriam incluir formação dentro dos serviços sobre os benefı́cios da
identificação e do tratamento precoce dos doentes em risco de deterioração aguda, aumentando a atenção para estes e mudando
atitudes no hospital aquando da introdução de um sistema de EEM. © 2001 Elsevier Science Ireland Ltd. All rights reserved.
Pala6ras cha6e: Suporte de vida avançado; Paragem cardı́aca; Serviço de emergência médica; Cuidados intensivos; Ressuscitação
1. Introduction
The high mortality rate and poor outcomes after
in-hospital cardiac arrest are well known [1– 3]. However, cardiac arrest is commonly preceded by premonitory signs and symptoms [4,5], which, if acted upon
early, might result in better outcomes [6]. The Medical
Emergency Team (MET) concept subscribes to the
hypothesis that early identification of the seriously ill
will result in improved patient outcome [7– 10]. In
essence, the MET system ‘takes intensive care expertise
to the wards’ [8] where early intervention in seriously ill
patients may prevent some intensive care unit (ICU)
admissions, deaths and cardiac arrests [8]. The MET
system might also help remedy the recently reported
problem of suboptimal care in the general wards [11],
which has been widely acknowledged and debated by
physicians and experts in acute care [6,12,13].
The MET system of medical emergency intervention
was introduced by Liverpool Hospital, NSW, Australia
in 1990 [7,14], to enable early identification and aggressive management of seriously ill patients before the
advent of a cardiac arrest. In addition to a number of
hospitals within the South West Sydney region, the
MET system has also been adopted and reported in a
hospital in Perth, WA [9]. A number of studies of the
MET concept have examined the use of the MET [7,14]
as well as nurses knowledge and use of the system
[15,16].
The MET system is based on standardised calling
criteria that encompass a broader response to medical
emergencies than the Cardiac Arrest Team system.
These standardised calling criteria (Appendix A) identify key pathological and physiological abnormalities
and indicate acute deterioration of the patient [14]. Any
staff member may activate the MET via the established
emergency paging system at any time using the predetermined calling criteria, if they become concerned
about the patient’s condition.
The main aims of this study were to examine the
effects of the MET system on admission to ICU and on
hospital mortality rate over a 3-year period.
2. Methods
2.1. Setting
Campbelltown Hospital is a 200-bed non-teaching
hospital in the South West Sydney region of NSW,
Australia. The MET system was introduced in July
1996. The hospital has a busy emergency department
and an eight bed intensive care/coronary care unit. The
24 h MET system consists of one physician and one
nursing staff member from the intensive care/coronary
care unit, a medical registrar from the emergency department, and two other non-clinical staff. The intensive care registrar is skilled in advanced resuscitation
and leads the team. Liverpool Hospital, (the regional
tertiary referral hospital and the initiator of the MET
concept) offers formal training in all aspects of advanced resuscitation to both medical and nursing staff
in this hospital.
2.2. Method
Prospective information was collected on a standardised form for each MET call over a 3-year period, from
the introduction of this system in July 1996 until June
1999. The data collected included: age and gender of
patient, date, time of the call, reason for calling, therapeutic intervention initiated by the team, immediate
patient outcome, and outcome at hospital discharge.
The patient died in hospital, we reviewed the records
for clinical antecedents during the 24 h prior to the call
to see if the team should have been summoned earlier.
Similar information was also collected on all unanticipated patient transfers from the wards to the Intensive
Care Unit over the same period. These were critically ill
patients for whom the team was not called but who
fulfilled at least one of the MET predetermined criteria
during the 24 h prior to their transfer to the unit. In
short, the unanticipated ICU transfers were patients
where the ward staff ‘could have called the MET, but
did not’.
3. Data analysis
Data was coded and entered into SPSS for Windows
version 7.5 [17]. Descriptive analyses statistics were
used to summarise the sample characteristics: percentages for discrete variables and mean and standard
deviation for continuous variables.  2 tests were used to
compare categorical data. The level of statistical significance for analyses was set at PB 0.05. All significance
tests were two-tailed.
Y. Salamonson et al. / Resuscitation 49 (2001) 135–141
4. Results
Between July 1996 and June 1999, 299 calls were
made to the Medical Emergency Team. In the first year,
calls averaged one per week and had risen to two per
week by the second year (Table 1). Of these calls, 88%
were from hospital wards, 9% from Emergency and
ICU/CCU departments, and 3% from the Operating
Theatres. The mean age was 60.5 years (range: 0–97
years). The gender mix was approximately equal (51%
female and 49% male). Seventy-one percent of patients
survived to hospital discharge.
137
The reasons given for alerting the MET changed
significantly over the 3 years. Although the frequency
of calls for cardiopulmonary arrest remained constant
(n= 16), the proportion involving cardiopulmonary arrest dropped from 30% in year 1 to 12% in year 3
(Table 1). The proportion of patients transferred for
intensive care also dropped from 44% in year 1 to 31%
in year 3 (Table 3). However, the proportion of patients
requiring advanced life support intervention (i.e. artificial ventilation support, external cardiac massage and
cardiac defibrillation) did not change significantly
(Table 2). The immediate survival rate following inter-
Table 1
Increasing use of the MET system over a 3 year period
Year 1
(July 1996–June 1997)
Year 2
(July 1997–June 1998)
Year 3
(July 1999–June 1999)
Number of MET calls, n
Time of day of MET call
Day shift (0701–1530), n(%)
54
115
130
23 (43)
51 (44)
55 (42)
Evening shift (1531–2259),
n(%)
Night shift (2300–0700),
n(%)
33 (43)
48 (42)
44 (34)
8 (14)
16 (14)
31 (24)
16 (14)
16 (12)
35
14
25
25
35
31
25
23
Reason for MET call
Cardiopulmonary arrest,
16 (30)
n(%)
Breathing problems, n(%)
9 (17)
Circulatory problems, n(%)
5 (9)
Neurological problems, n(%) 14 (26)
Concerned, %
10 (18)
(30)
(12)
(22)
(22)
P-value
 2 =6.628, df =6,
P =0.357
 2 =18.839, df = 8,
P=0.016
(27)
(24)
(19)
(18)
Table 2
Interventions performed by the MET system over a 3 year period
Year 1
(July 1996–June 1997)
Year 2
(July 1997–June 1998)
Year 3
(July 1998–June 1999)
Inter6entions
Bag-Mask ventilation
Yes, n(%)
18 (33)
30 (26)
32 (25)
No, n(%)
36 (67)
85 (74)
98 (75)
Endotrachael intubation
Yes, n(%)
10 (18)
12 (10)
21 (16)
No, n(%)
44 (82)
103 (90)
109 (84)
Cardiac massage
Yes, n(%)
12 (22)
10 (9)
21 (16)
No, n(%)
42 (78)
105 (105)
109 (84)
5 (9)
7 (6)
9 (7)
49 (91)
108 (94)
121 (92)
Cardiac defibrillation
Yes, n(%)
No, n(%)
P-value
 2 =1.522,
df=2
P=0.467
 2 =2.537,
df= 2
P =0.281
 2 =6.047,
df=2
P=0.049
 2 =0.570,
df= 2
P =0.752
Y. Salamonson et al. / Resuscitation 49 (2001) 135–141
138
Table 3
Outcome of patients with the MET system over a 3 year period
Year 1
(July 1996–June 1997)
Year 2
(July 1997–June 1998)
Year 3
(July 1998–June 1999)
P-value
Patient transfer to
intensive care unit, %
24 (44)
36 (31)
40 (31)
 2 =3.590, df = 2,
P= 0.166
Survival rate of patients transferred
to intensive care unit, %
17 (71)
29 (81)
31 (78)
 2 =0.765, df = 2,
P= 0.682
Percentage of patients who
survived immediately after MET
interventions, %
44 (82)
105 (91)
113 (87)
 2 =3.374,df =2,
P =0.185
Percentage of patients who survived
to hospital discharge, %
36 (67)
89 (77)
92 (71)
 2 =2.500, df = 2,
P= 0.286
149 (0.74)
133 (0.66)
151 (0.65)
 2 =0.182, df = 2,
P=0.913
In-hospital deaths,
N (% per hospital admission)
ventions by the MET and the survival rate to hospital
discharge did not increase significantly over the 3 years
of study (Table 3). A review of the clinical records of
MET call patients who died in hospital showed that 26%
of these patients fulfilled at least one of the MET calling
criteria during the 24 h before to the eventual MET call.
There was a 15% increase in hospital admissions over
the 3-year study period (annual hospital admissions
increased from 20 265 in 1996/1997 to 23 221 in 1998/
1999). There was a slight reduction in percentage of
in-hospital deaths, from 0.74% in 1996/1997 to 0.65% in
1998/1999 and a very slight drop in the percentage of
cardiopulmonary arrest (from 0.08 to 0.07%) (Fig. 1).
However, the reduction in percentage of in-hospital
deaths was not statistically significant (P =0.913)
(Table 3).
The number of unanticipated ICU transfers decreased
from 58 in year 1 to 36 in Year 3 (Table 4). More
unanticipated transfers occurred during the nursing night
shift in year 1, but, by year 3 equal proportions of
unanticipated transfers occurred during each of the three
shifts (Table 4). The mean age of the unanticipated ICU
transfers was 61.6 years (range: 9– 90 years), with
approximately
the
same
proportion
of
fe-
Fig. 1. Percentage of hospital deaths, MET calls and cardiopulmonary arrest over the 3 years.
Y. Salamonson et al. / Resuscitation 49 (2001) 135–141
male to males (52% female and 48% male). Seventy-five
percent of these unanticipated transfers survived to
hospital discharge. There were no changes in immediate
and hospital discharge survival rates in the unanticipated ICU transfers over the 3-year period.
The survival rates for ICU transfers through the
MET system and unanticipated ICU transfers did not
change significantly over the 3 years (Table 4). Despite
the reduction in unanticipated ICU transfers, the number of patients transferred to ICU from the wards
remained fairly constant (Table 4) because the increasing number of transfers through the MET system offset
the reduction in unanticipated transfers. There was no
significant change in the survival rate to hospital discharge in patients transferred via the MET system
compared with the unanticipated ICU transfers.
5. Discussion
This 3-year review of the MET system showed a
more than twofold increase in the number of MET calls
during the second and third year. This was a result of
the MET system being called increasingly for less acute
patients. The evidence for this is the reduction in the
proportion of MET calls for cardiopulmonary arrest,
and the proportion of MET call patients transferred to
intensive care, together with the fall in hospital mortality of patients for whom the MET system was activated. Only 13% of MET calls in the third year were for
cardiopulmonary arrest. A similar proportion of MET
calls for cardiopulmonary arrest was also reported by
Liverpool Hospital [10]. The in-hospital mortality rate
of 30% in the third year was lower compared with
Liverpool Hospital’s 40% [7], however, the illness severity patients admitted to a tertiary referral hospital may
well account for this difference. Increased use of the
139
MET system was a likely factor in the reduction in
unanticipated ICU transfers over the study period. The
demand for ICU beds with the implementation of the
MET system remained fairly constant because the increasing number of ICU transfers via the MET system
was offset by the reduction of unanticipated ICU
transfers.
Whilst a decrease in the proportion of MET call
patients who required ICU transfer was seen during the
3 years of study, the 31% who required ICU transfer in
Year 3 is significantly higher than the 19% reported by
Liverpool Hospital [10]. In addition, the 75% in-hospital survival rate of MET call patients who required
ICU transfers (Table 1) was higher than the 60% reported for 1994 at Liverpool Hospital [7]. Perhaps this
was due to the differences between the two hospitals in
the type of patients deemed necessary for ICU transfer.
Being a tertiary referral hospital, it was very likely that
only the most severely ill patients were transferred to
ICU in Liverpool Hospital. The wards in Liverpool
Hospital may also be better equipped to care for more
critical patients. In contrast, in Campbelltown Hospital,
both acutely ill and high dependency patients were
likely to be transferred to ICU for further management.
During the 3-year period, Campbelltown Hospital ICU
was able to accommodate all MET call patients who
needed an ICU bed.
In the wards following MET calls, staff have often
expressed a sense of relief when the acutely ill patients
under their care were assessed to be ‘too sick’ to remain
in the ward and required transfer to ICU. This may
explain the increase in MET calls over the 3 years.
Although the transfer was often perceived as beneficial
to both patients and ward staff, it is possible that this
practice will lead to the deskilling of ward staff, in their
ability to care for acutely ill patients.
Table 4
Reduction in unanticipated ICU transfers compared with ICU transfers via the MET system
Year 2
Year 2
Year 2
P-value
(July 1996–June 1997) (July 1997–June 1998) (July 1998–June 1999)
Frequency of all ICU transfers from the wards
(MET transfer+unanticipated ICU transfer), n
Unanticipated ICU transfers, n(%)
82
80
78
58 (71)
46 (58)
36 (46)
 2 =9.969, df =2,
P= 0.007
Proportions of unanticipated ICU transfers:
Time of day
Day shift (0701–1530)%
13 (22)
11 (24)
12 (33)
 2 =1.895, df =4,
P= 0.755
Evening shift (1531–2259)%
Night shift (2300–0700)%
In-hospital patient survival
MET ICU transfers, n(%)
22 (38)
23 (40)
15 (33)
20 (43)
12 (33)
12 (33)
17 (71)
27 (79)
31 (74)
Unanticipated ICU transfers, n(%)
44 (76)
35 (76)
26 (72)
 2 =0.607, df =2,
P= 0.738
 2 =0.200, df =2,
P= 0.905
140
Y. Salamonson et al. / Resuscitation 49 (2001) 135–141
In addition to being used to summon assistance for
critically ill patients in the wards, the MET system
was also used by the ward staff to assist the physician in-charge in making a clear management decision
for the on-going care of critically ill patients who
were likely to die with or without aggressive intensive
care management. Ward staff have activated the
MET system so that a ‘Not for Resuscitation’ order
can be issued for unsalvageable patients who were
not suitable for ICU management.
Although the percentage of cardiopulmonary arrests remained fairly constant over the 3 years, the
reduction in the proportion of hospital deaths along
with the concomitant increase in percentage of MET
calls was reassuring. Without additional evidence, it
would be premature to infer that the reduction of
in-hospital deaths over the 3 years is an indicator of
the effectiveness of the MET system.
Despite the increasing number of calls received by
the MET over the 3 years and the increasing use of
the MET to attend to less acutely ill patients, the
percentage of unanticipated ICU transfers remained
high. This suggests that some ward staff were still
opting not to use the MET system for patients who
fulfilled the predetermined MET calling criteria. Instead, they chose to call the medical resident or medical registrar for assistance. This finding is consistent
with the results reported by Daffurn et al. [15]. The
persistently high frequency of unanticipated ICU
transfers and evidence that some of the MET calls
could have been made earlier suggests that the MET
system was still underutilised in Year 3.
We need to explore why ward staff seem to be
under-using the MET system. It could be that they
are unaware of the MET calling criteria, or, the
benefits of intervention by a specialised medical team
which could prevent the downward spiral to cardiopulmonary arrest. Perhaps some staff believed that
these acutely ill patients who fulfilled the MET calling
criteria were getting an equally high quality of treatment from the medical resident or registrar without
the associated drama activating the MET system.
There seems to be a need to heighten awareness
among the ward staff of the calling criteria and the
benefits of early identification and treatment of patients who are at risk of acute deterioration. If ward
staff are certain of getting superior medical assistance
from the MET system, it is likely that they will use
this system more often and at the first appearance of
premonitory signs and symptoms of cardiopulmonary
arrest.
This study clearly shows a reduction in unanticipated ICU transfers over the 3-year period with the
implementation of the MET system. Although the advocates of the MET system put forward a convincing
case that MET can improve survival [7], our study
was not able to demonstrate conclusively that the reduction in hospital mortality rate over the 3-year period was due to the introduction of the MET system.
This is possibly because information relating to severity of illness was not collected. To demonstrate an
increase in patient survival rate with the introduction
of a MET system, there is a need to adjust mortality
rate for severity of illness (e.g. the acute physiology,
age, chronic health evaluation (APACHE) prognostic
system) [18] on all patients admitted to the hospital
over the period of study. The APACHE prognostic
system has been shown to provide good discrimination of hospital mortality [19] and could have been
used to calculate the risk-adjusted standardised mortality ratio (SMR). This information is necessary to
make accurate comparisons of patient survival rates
over the 3-year period.
Hence, the study was not able to provide conclusive evidence that the MET approach improved patient survival, but it did appear to reduce the number
of unanticipated transfers to intensive care so that
seriously ill patients received earlier specific treatment.
The study also demonstrated the importance of introducing cultural and attitudinal changes for a new system to work optimally, as highlighted in previous
studies [9,20]. An operational change such as the
MET system needs to be supported by extensive inservice education to promote awareness of the MET
concept. Staff are more likely to call the team if they
are aware and convinced of the benefits.
Nevertheless, the implementation of the MET system in a suburban non-teaching hospital since 1996
without the aid of additional resources is a commendable effort. The system owes its success to the support received from Liverpool Hospital and to a
handful of visionary stakeholders who are committed
to the success of this system to improve health outcomes in acutely ill patients.
Acknowledgements
We wish to acknowledge Julie Kesby-Smith, the
former Nurse Unit Manager of ICU/CCU department, without whom the implementation of the MET
concept in Campbelltown Hospital in 1996 would not
have been possible. We thank the Intensive Care Staff
for completing the MET forms and Clinical Information staff for assisting in clinical record retrievals. We
also wish to extend our sincere thanks to Malcolm
Masso, Director Nursing and Acute Services for his
support and encouragement and Professor Ken Hillman, Director of Critical Care, Liverpool Hospital
for his helpful comments in the preparation of this
manuscript.
Y. Salamonson et al. / Resuscitation 49 (2001) 135–141
Appendix A. Met calling criteria
Acute
change in
Airway
Breathing
Circulation
[6]
Criteria for calling
[7]
Threatened airway
All respiratory arrests
Respiratory rate/minute
Spo2
All cardiac arrests
Pulse rate/minute
Systolic blood pressure
Neurological Sudden change in level
function
of consciousness
Repeated or prolonged
seizures
Other
Any patient whom you
are concerned about
who does not fit into
the above criteria
B6 or \36
B85%
B40 or \
140
B90 mmHg
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
References
[16]
[1] Kaye W, Mancini ME. Improving outcome from cardiac arrest
in the hospital with a reorganized and strengthened chain of
survival: an American view. Resuscitation 1996;31:181 –6.
[2] Jastremski MS. In-hospital cardiac arrest. Ann Emerg Med
1993;22:113 – 7.
[3] Bedell SE, Delbanco TL, Cook F, Epstein FH. Survival after
cardiopulmonary resuscitation in the hospital. N Eng J Med
1983;309:569 – 76.
[4] Schein RM, Hazday N, Pena M, Ruben BH, Sprung CL.
Clinical antecedents to in-hospital cardiopulmonary arrest. Chest
1990;98:1388 – 92.
[5] Franklin C, Matthew J. Developing strategies to prevent inhos-
.
[17]
[18]
[19]
[20]
141
pital cardiac arrest: analyzing responses of physicians and nurses
in the hours before the event. Crit Care Med 1994;22:244 –7.
Wood J, Smith A. Active management should prevent cardiopulmonary arrests. Br Med J 1999;318:51 – 2.
Hourihan F, Bishop G, Hillman KM, Daffurn K, Lee A. The
Medical Emergency Team: a new strategy to identify and intervene in high-risk patients. Clin Intensive Care 1995;6:269 –72.
Mercer M, Fletcher SJ, Bishop GF. Medical emergency teams
improve care. Br Med J 1999;318:54.
Daly FF, Sidney KL, Fatovich DM. The Medical Emergency
Team (MET): a model for the district general hospital. Aust N Z
J Med 1998;28:795 – 8.
Parr M, Bishop G, Hillman K, Daffurn K, Thebridge C. Predicting inhospital cardiac arrest. Resuscitation 1998;38:199.
McQuillan P, Pilkington S, Allan A, Taylor B, Short A, Morgan
G, et al. Confidential inquiry into quality of care before admission to intensive care. Br Med J 1998;316:1853 – 8.
Garrard C, Young D. Suboptimal care of patients before admission to intensive care. Br Med J 1998;316:1841 – 2.
Ringrose T, Garrard C. Doctors don’t review patients that
nurses identify as highly dependent. Br Med J 1999;318:52.
Lee A, Bishop G, Hillman KM, Daffurn K. The Medical
Emergency Team. Anaesth Intensive Care 1995;23:183 –6.
Daffurn K, Lee A, Hillman KM, Bishop GF, Bauman A. Do
nurses know when to summon emergency assistance? Intensive
Crit Care Nurs 1994;10:115 – 20.
Crispin C, Daffurn K. Nurses’ responses to acute severe illness.
Aust Crit Care 1998;11:131 – 3.
SPSS. SPSS. In: Statistical package for social sciences. SPSS/
PC+ V 7.5 ed. Chicago, IL: SPSS; 1997.
Knaus WA, Wagner DP, Draper EA, Zimmerman JE, Bergner
M, Bastos PG, et al. The APACHE III prognostic system. Risk
prediction of hospital mortality for critically ill hospitalized
adults. Chest 1991;100:1619 – 36.
Bastos PG, Sun X, Wagner DP, Knaus WA, Zimmerman JE.
Application of the APACHE III prognostic system in Bralian
intensive care units: a prospective multicenter study. Intensive
Care Med 1996;22:564 – 70.
Hillman KM. Redefining resuscitation. Aust N Z J Med
1998;28:759 – 60.