Prevent Avoidable Codes with a Medical Emergency Team

Virginia Mason Medical Center
Seattle, Washington, USA



Michael Westley, MD, Medical Director, Critical Care and Respiratory Therapy
Daniel Hanson, MD, Hospitalist
Laurel G. Tyler, RN, MN, CCRN, Clinical Nurse Specialist, Critical Care and Telemetry
Eileen Dunning, RN, Project Manager, Department of Nursing
Rosemary Tempel, RN, Clinical Practice Improvement



To prevent avoidable codes by using a Medical Emergency Team (MET) to intervene before patients develop cardiopulmonary arrest or other adverse events.


[*NOTE: A Medical Emergency Team is also known as a Rapid Response Team.]



  • Number of Code 4’s (CPR and/or intubation events) per month (in CCU, outside CCU, and total)
  • Rate of preventable codes



Team formed, tools created to support systems and standard work, and process improvement measurement developed.

  • Formed team model: Hospitalist, CCU charge nurse, and Respiratory Therapist
  • Created tools, including online (Cerner) orders, intervention/audit, and communication tools  
  • Revised MET documentation form (user friendly; vital sign prompts; symptoms to activate call to include those of SIRS/sepsis and stroke; prompting for intensivist and sepsis bundle coming in next revision)
Role assignment to document events and coordinate improvements. Hospitalist leads team to assess and stabilize the patient.
  • Critical Care charge nurse coordinates nursing assessment, assists with therapies, facilitates transfers and documents events
  • Respiratory Therapy manages airway, oxygen therapy, and nebulized medications
  • Entire team provides immediate on-site training and education to floor staff as needed
  • CNS reviews forms and communicates need for follow-up to appropriate parties
  • Medical Director reviews all Code 4 calls for failure to recognize and respond to clinical deterioration
  • Project manager enters data into a shared database 
  • Clinical Practice Improvement provides data assistance, graphs and charts for analysis
Celebrate and communicate results widely.
  • Communication and celebration of MET’s first year anniversary to general staff via Nursing Action Forum, Hospital Leadership Team, Professional Medical Staff, and organizational newsletter
  • IHI storyboard session winner – June 2005 First International Summit on Hospital Redesign
  • Annual Hospital Safety Seminar produced










Summary of Results / Lessons Learned / Next Steps

Lessons Learned:

  • MET calls were slow to start; ongoing efforts on multiple levels have increased the number of calls dramatically.
  • STAT respiratory therapy and anesthesia calls continued despite availability of MET. Now all STAT calls converted to MET calls by operator.
  • MET partnered with STROKE Team in November – 2nd round of education; incorporated and focused on our at-risk populations.
  • All RNs required to “Sign Off” stating they know when and how to call the MET; accountability to training.
  • MET calls changed from pager only to Overhead Page – “Free Advertising”; broadened awareness to entire staff and consumers of care in the hospital.
  • Follow-up and feedback required on specific units; successive checks and follow-up, or just-in-time training.
  • MET calls have increased over time with a corresponding decline in cardiopulmonary arrests, moving team toward project goal.


  • Clinicians (RNs and MDs) have difficulty understanding how the MET can help them (lack of awareness of goal/function of MET).
  • Some clinicians (RNs and MDs) do not want MET involved in the care of “their” patient (influence and control issues, as well as lack of awareness).
  • Impact of (negative/neutral) feedback to clinicians has caused decreased use of MET.
  • Lack of standard communication methodology between RN, MET, and primary patient care providers (SBAR not used).
  • Need to improve communication (handoff) of patient care information and high-risk safety issues (lack standard methodology to notify primary team prior to MET, and return care after MET).


Next Steps:
  • Develop handoff strategy to identify patients at risk (safety factors), and to intervene before MET needed.
  • Expand/re-introduce SBAR communication methodology.
  • Explore critical thinking of care providers – lack of planning, communication, and/or rescue.
  • Develop, test/implement interventions to resolve issues identified by Box 4 mortality case reviews.
  • MET case review to identify clinical gaps in communication that could have prevented need for MET call.
  • Expand focus for early recognition of goal-directed sepsis care.
  • Improve timeliness of MET activation and recognition of MET criteria on pilot unit.
  • Use of MET to facilitate care coverage of acute myocardial responses from field to interventional catheterization pending cath team arrival. (Seeking a shorter door-to-balloon time and improved care flow.)
A team of IHI content experts has reviewed this report and determined that it is a compelling example of current results from organizations working with IHI.


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