Recommended Guidelines for Monitoring, Reporting, and
Conducting Research on Medical Emergency Team,
Outreach, and Rapid Response Systems: An Utstein-Style
A Scientific Statement From the International Liaison Committee on
Resuscitation (American Heart Association, Australian Resuscitation Council,
European Resuscitation Council, Heart and Stroke Foundation of Canada,
InterAmerican Heart Foundation, Resuscitation Council of Southern Africa,
and the New Zealand Resuscitation Council); the American Heart Association
Emergency Cardiovascular Care Committee; the Council on
Cardiopulmonary, Perioperative, and Critical Care; and the Interdisciplinary
Working Group on Quality of Care and Outcomes Research
Mary Ann Peberdy, MD, Co-Chair; Michelle Cretikos, MBBS, MPH, PhD, Co-Chair;
Benjamin S. Abella, MD, MPhil; Michael DeVita, MD; David Goldhill, MBBS, FRCA, MD;
Walter Kloeck, MB, BCh, FCEM; Steven L. Kronick, MD, MS; Laurie J. Morrison, MD, MSc;
Vinay M. Nadkarni, MD, FAHA; Graham Nichol, MD, MPH, FRCPC, FAHA;
Jerry P. Nolan, FRCA, FCEM; Michael Parr, MB, BS, FRCP, FRCA, FANZCA, FJFICM;
James Tibballs, MBBS, BMedSc, MEd, MBA, MD, FJFICM, FANZCA;
Elise W. van der Jagt, MD, MPH; Lis Young, MD, FFPHM
have abnormal physiological values recorded in the hours
preceding the event.1–11Many studies document that physio-
logical measurements often are not made or recorded during
this critical time of clinical deterioration.12–16Such physiological
abnormalities can be associated with adverse outcome.17–20
Measurements of abnormal physiology, including temperature,
he majority of patients hospitalized with a cardiac arrest
or requiring emergency transfer to the intensive care unit
pulse rate, blood pressure, respiratory rate, hemoglobin, oxygen
saturation by pulse oximetry, and deterioration of mental status,
are therefore important to any system designed for early detec-
tion of physiological instability. At a minimum, these measure-
ments must be obtained accurately and recorded with appropri-
ate frequency. A system that both recognizes significantly
abnormal values and triggers an immediate and appropriate
treatment response is required.
The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside
relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required
to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.
This article has been co-published in the December 2007 issue of Resuscitation.
When this document is cited, the American Heart Association requests that the following citation format be used: Peberdy MA, Cretikos M, Abella
BS, DeVita M, Goldhill D, Kloeck W, Kronick SL, Morrison LJ, Nadkarni V, Nichol G, Nolan J, Parr M, Tibballs J, van der Jagt EW, Young L.
Recommended guidelines for monitoring, reporting, and conducting research on medical emergency team, outreach, and rapid response systems: an
Utstein-style scientific statement: a scientific statement from the International Liaison Committee on Resuscitation (American Heart Association,
Australian Resuscitation Council, European Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation,
Resuscitation Council of Southern Africa, and the New Zealand Resuscitation Council); the American Heart Association Emergency Cardiovascular Care
Committee; the Council on Cardiopulmonary, Perioperative, and Critical Care; and the Interdisciplinary Working Group on Quality of Care and Outcomes
Research. Circulation. 2007;116:2481–2500.
This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on July 10, 2007. A single reprint
is available by calling 800-242-8721 (US only) or by writing the American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX
75231-4596. Ask for reprint No. 71-0419. To purchase additional reprints, call 843-216-2533 or e-mail email@example.com.
Expert peer review of AHA Scientific Statements is conducted at the AHA National Center. For more on AHA statements and guidelines development,
Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express
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© 2007 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.orgDOI: 10.1161/CIRCULATIONAHA.107.186227
ILCOR Consensus Statement
by guest on December 21, 2015http://circ.ahajournals.org/Downloaded from
There is growing evidence that early detection and re-
sponse to physiological deterioration can improve outcomes
for infants, children, and adults.21–29A variety of response
systems have been described, including teams that respond to
patients in hospital wards who are critically ill or who are at
risk of becoming critically ill. These systems all adhere to the
principles of early detection and response to predefined
indicators of clinical deterioration. The terms used for these
response teams include medical emergency team (MET),
rapid response team (RRT), and critical care outreach team
(CCOT).25,26,28,30–34These teams may replace or coexist with
traditional cardiac arrest teams, which typically respond to
patients already in cardiac arrest. Such teams should possess
the required skills and equipment to provide immediate
on-site stabilization and management of the patient and to
initiate discussions about appropriate limits to medical inter-
ventions if indicated. Although the response team is the most
obvious component of these systems, these teams are only
one part of a much more comprehensive system-wide re-
sponse. Team-based response systems also require educa-
tional, quality improvement, monitoring, and feedback
The core data elements identified in the present report
should help direct hospitals to collect the most meaningful
data to optimize system interventions and improve clinical
outcomes. Identification of supplemental data elements
should allow enhanced data collection to further scientific
knowledge in these system responses. Standardized data
elements and definitions will permit aggregate data analysis,
as well as create a consistent nomenclature for publications
related to these prevention, early intervention, and response
systems. Utstein-style data definitions and reporting tem-
plates have helped improve the consistency and comparabil-
ity of data on cardiac arrest, trauma, and drowning and for
this reason are proposed for the MET, RRT, and CCOT. The
purpose of the present statement is to create consensus-
derived key data elements and definitions and to develop a
standardized Utstein-style template for the reporting of data
related to systems with response teams such as METs, RRTs,
The Consensus Process
The need for standardized reporting of MET, RRT, and
CCOT data was identified during the 2005 International
Consensus Conference on Cardiopulmonary Resuscitation
and Emergency Cardiovascular Care Science With Treatment
Recommendations.38Representatives from the International
Liaison Committee on Resuscitation, including scientists and
clinicians experienced in rapid response–type systems, were
invited to develop a reporting template with consensus-
derived data elements and standardized definitions for mon-
itoring and reporting of data related to these systems.
The task force held a series of teleconferences from June
2005 to August 2006. The initial calls reviewed evidence and
identified consensus on the type of data elements necessary
for optimal program management (core elements), as well as
data elements that would be beneficial for research related to
MET systems (supplemental elements). A draft set of data
elements was developed and divided into 6 categories. Task
force members were each assigned a group of data elements,
and a virtual modified Delphi method was used to complete
the consensus process.39All documents used during confer-
ence calls were available on the Internet, and all authors had
continuous access to documents to provide individual input.
A face-to-face conference was not necessary to complete the
document. To the best of our knowledge, this is the first time
an Utstein-style consensus statement has been generated in
Utstein Reporting Templates
In June 1990, representatives from the American Heart
Association, European Resuscitation Council, Heart and
Stroke Foundation of Canada, and the Australian Resuscita-
tion Council met at Utstein Abbey on the island of Mosteroy
in Norway. The purpose of the meeting was to discuss
problems with resuscitation nomenclature and the lack of
standardized definitions in reports of adult prehospital cardiac
arrest. At a follow-up meeting, the decision was made to
adopt the term “Utstein style” for the uniform reporting of
data from prehospital cardiac arrests.40Many other Utstein-
style international consensus statements have been published
over the past 15 years, including the uniform reporting of
pediatric advanced life support,41laboratory cardiopulmonary
resuscitation research,42in-hospital resuscitation,43neonatal
life support,44drowning,40cardiopulmonary resuscitation reg-
istries,40and trauma data.45These comprehensive documents
are aimed at both the clinical and academic communities. The
standardized definitions found in the Utstein scientific state-
ments enable comparative analysis between resuscitation
studies and healthcare systems.
The challenges associated with collecting MET, RRT, and
CCOT data are similar to those associated with the collection
of cardiopulmonary resuscitation data. The task force consid-
ered a balance between the inclusion of data elements that are
important in determining clinical and process outcomes but
may be difficult to collect with variables that may be easy to
collect but add little to the overall usefulness of the data set.
For consistency with previous Utstein-style reports, the task
force agreed that data should be classified as core or supple-
mental. Core data elements are defined as the absolute
minimum required for continuous quality improvement and
are necessary to accurately track process and outcomes
variables. These include facility, patient, event, and outcomes
information. The collection of these data elements is suffi-
cient to enable the comparison of process and outcome
between different institutions, both nationally and interna-
tionally.40Supplemental data elements are defined as ele-
ments required for research or to advance the understanding
of process-related issues to drive best clinical practice.
Standardized definitions for all data elements will enable
comparisons between MET-type programs and will permit
the aggregation of data to rapidly advance the science of
various rapid response systems. Institutional demographics
will enable comparisons and establishment of best practices.
Because there is no single comprehensive, evidence-based
set of physiological triggers to initiate an MET response,
hospitals may develop their own criteria for initiating an
MET call. The criteria for activation are core data elements.
November 20, 2007
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With the use of a standardized data set that includes out-
comes, it may be possible to determine which calling criteria
might be the most useful. To prevent sampling bias, all
patient events that occur at or immediately after activation of
response teams, as defined by activation criteria, should be
included in data reporting. Key patient-level and hospital-
level outcomes must be included. Interested individuals or
institutions can use these data elements to identify critical
factors to consider when these systems are implemented, to
monitor system performance, or to compare the rates of team
activation and adverse patient outcomes between different
Figures 1 and 2 are template data collection forms for
collection of facility and event data. These forms can be used
to assist individual hospitals in creating an efficient, compre-
hensive data collection tool.
Data Elements and Definitions
Tables 1 through 5 present data elements and their definitions
for the response team data collection: hospital data form
(Figure 1), and Tables 6 through 10 present data elements and
their definitions for the response team data collection: case
form (Figure 2).
For many patients, clinical condition deteriorates during the
hospital stay. This deterioration is frequently unrecognized or
inappropriately or incompletely treated. Some patients re-
quire emergency transfer to an intensive care unit, or their
condition deteriorates to cardiac arrest.1,5,6,9,11,46–48System
interventions, including the use of METs, RRTs, and CCOTs,
have the potential to decrease cardiac arrest and in-hospital
mortality rates.21,23–25,28,49The precise impact of these inter-
ventions remains unclear, because the largest study of METs,
a cluster randomized, controlled trial, failed to show an effect
of the MET system on rates of cardiac arrest, unexpected
death, or unplanned admission to the intensive care unit.12
The failure to demonstrate effect may have been due to a real
failure of the intervention but also may have been multifac-
torial and possibly design related. Plausible reasons for
failure include contamination of the control hospitals, a very
short baseline period, insufficient time for team implementa-
tion and maturation in the intervention hospitals, an insuffi-
cient duration of the study period to demonstrate a difference,
and lack of power. Given that these possibilities are likely to
have influenced the results, these systems require further
One recent publication has outlined guidelines for the
uniform reporting of data for METs.50This document was
developed by a single health service in Sydney, Australia.
The present document was compiled by a task force of
international representatives and considered all of the existing
types of team-based response systems, rather than focusing
solely on the MET system. The present document therefore
provides a set of core and supplemental data elements for
reporting on these systems that was reached by international
consensus and that should be capable of being readily
adopted in many institutions around the world. This will
encourage more complete data collection and consistency in
reporting of findings and will enable comparison of cross-
institutional and international outcomes.
The context in which MET systems are implemented is
important and may affect outcomes. Many of the core data
elements in this statement relate to individual institutional
facility and demographic data and were recommended to
facilitate greater understanding of the environment in which
the system was implemented.
Different hospitals have different capacities for intensive
monitoring of patients. A response system that works well in
one institution may not work well in another. Data collected
from many different types of institutions may enable formu-
lation of guidelines for best practice according to the capa-
bility of each hospital. The data elements for team demo-
graphics and composition are also considered core elements,
because the different skills and experience of response team
members may influence patient outcome. It is not known
whether an immediate response to a patient’s deteriorating
condition by a team of trained and experienced doctors
improves outcome compared with a first response with 1
trained nurse who has the ability to mobilize a more compre-
hensive team response when required. The nature of the
intervention may need to be tailored to local resources. The
impact of variable team training, composition, and experience
on patient and process outcomes is unknown. Given these
uncertainties, collection of and reporting on the core data
elements for the team demographics and response are
Some patient demographic data, such as name, medical
record number, and date of birth, may not be reported in
certain locales because of patient confidentiality restraints.
These data elements were included as core elements so that
individual hospitals can track individual cases for the pur-
poses of quality improvement and feedback.
Ethnicity was not included as a data element because there is
no internationally meaningful and easily constructed definition
of ethnicity. Some hospitals may wish to track ethnicity inde-
pendently to obtain information that is meaningful locally.
An understanding of the patient’s pre-event history may be
vital to the development of a system that is capable of
responding to patients at risk wherever they are in the
hospital, because the optimal time for activating a full system
response is not known. Identification of high-risk patients for
more intensive monitoring and care may assist this process.
Therefore, the data elements that provide information about
the patient in the 24 hours before activation and at the time of
activation constitute important information.
A variety of activation criteria have been described for adults.
Some systems are quite restrictive, whereas others encompass
Text continues on page 16
Peberdy et al Reporting on Medical Emergency Team Systems
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Figure 1. Response team data collection: hospital data form.
November 20, 2007
by guest on December 21, 2015
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KEY WORDS: AHA Scientific Statement ? emergency medical services
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the Council on Cardiopulmonary, Perioperative, and Critical Care; and the
Council); the American Heart Association Emergency Cardiovascular Care Committee;
Resuscitation Foundation, Resuscitation Council of Southern Africa, and the New Zealand
Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart
Resuscitation (American Heart Association, Australian Resuscitation Council, European
Scientific Statement: A Scientific Statement From the International Liaison Committee on
Medical Emergency Team, Outreach, and Rapid Response Systems: An Utstein-Style
Recommended Guidelines for Monitoring, Reporting, and Conducting Research on
Print ISSN: 0009-7322. Online ISSN: 1524-4539
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2007;116:2481-2500; originally published online November 9, 2007;
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