in 1994 , franklin and mathew   recognized that cardiac arrests in hospitals are often preceded by prolonged physiologic deteriorations .
these deteriorations not only presage patient deaths but they also offer an opportunity to recognize the crisis and trigger interventions that might be life saving . since then , medical emergency team ( met ) responses have been described by many authors , most notably several groups from australia . although there are no randomized clinical trials showing benefit from introduction of mets , many single center reports [ 2 - 4 ] support the notion that timely intervention may interrupt crisis events and decrease unexpected hospital mortality . as a result of these reports and of the potential for improved outcomes they offer ,
organizations such as the institute for healthcare improvement and the society for critical care medicine have been promoting rapid response teams and mets . in north america and in europe , there now appears to be a rapid increase in number of organizations that have implemented a met program , following a trend set in australia .
the medical literature is now rapidly growing as well , but it has been focused almost exclusively on either the benefits of mets in terms of reducing unexpected mortality or on the processes impacted on by mets ( e.g. improved detection of process errors ) .
what has not occurred is a characterization of the met patient ; for example , who is at risk , and what conditions and settings are dangerous ? in other words , we do not understand the epidemiology of the met patient .
the syndrome(s ) could be related to patient physiology during a dangerous time in their illness ; perhaps each disease entity has an at - risk time for developing a medical crisis requiring a met if no action is taken to prevent it . on the other hand , the met patient may be instead a symptom of a hospital in crisis . in other words ,
the met patient may be created by the environment and not the disease . to be sure
, being ' sick ' is a prerequisite for a met , but at least one review of met events seems to support the conclusion that mets prevent death because they intercept ' system ' errors that lead to cardiac arrest .
future analyses of met events may provide the answer to the question , are hospitals sick ? jones and colleagues , in their report in this issue of critical care , provide an early clue with their epidemiologic analysis of met events .
they describe data to support a commonly suspected association between time of day and the incidence of crisis recognition in hospitals .
their review of over 2000 events revealed an increase in events at certain times of the day , notably near nursing handoffs and physician rounding . their data ,
although observational , strongly suggest a ' sick hospital ' syndrome . although it is possible that subsets of their patient population all happened to deteriorate
a diurnal pattern for physiologic deteriorations would be unexpected , given the diverse causation of met events .
a more reasonable explanation for the observation is that the more care givers that visit a patient , the more likely they are to detect patient deteriorations .
although jones and his coauthors describe an increase in the number of events during ' off hours ' as noted in their fig .
2 , their fig . 1 tells a different story ; the hourly rate of met events is lower during the off hours .
instead , they may accumulate , only to be found at the end , or beginning , of work shifts or during scheduled visits .
if the findings of jones and coworkers are correct , then the conclusion one must draw is that hospitals may have a design flaw  they do not reliably find patients who are exhibiting clinical deterioration .
an alternative hypothesis is that met calls increase during daylight hours because of an increase in inappropriate met activations .
jones and co - authors describe their findings in a hospital with a long history of met responses . it is doubtful that their findings are the result of inadequately trained staff ( and inappropriate activations of the met ) . their hospital has overcome two of the biggest obstacles to met implementation : teaching staff to recognize crisis and motivating staff to call for help when they find one .
they have developed crisis criteria and created mnemonic tools such as pocket cards and wall posters .
they have created a culture that rewards those who utilize the met system , and a culture that reliably recognizes and utilizes a standardized response to crisis .
even so , there is evidence in the report that workers at night are unable to find the crisis as frequently as are staff during the day .
if other authors corroborate these findings , then the inescapable conclusion will be that hospitals do not reliably find patients in crisis , which is an obviously dangerous situation . to respond to this finding ,
hospitals need some form of improved detection system , involving increased staffing , more frequent visits , or more frequent use of monitoring , perhaps in every hospitalized patient .
it is unlikely that staffing will increase because of cost considerations , although a work redesign is possible .
however , it is obvious that care givers can not remain with patients all the time .
the alternative , continuous monitoring of all hospitalized patients ( e.g. with pulse oximetry ) is less expensive and may be life saving .
if continuous monitoring detects crisis situations better , then one would expect the diurnal variation curve to flatten out , and it would prove to be a remedy to the sick hospital syndrome . a third option is to study rigorously the met syndrome and apply findings by better selection of patient monitoring . in any case ,
. a met response addresses one half of the need  it is a process to save reliably those patients who are in crisis .
our challenge is to create an around - the - clock system that efficiently finds deteriorating patients .
 cardiac arrest in hospitals is usually preceded by prolonged deterioration . if the deterioration is recognized and treated , often death can be prevented . 
 medical emergency teams ( met ) are a mechanism to fill this need . 
 the epidemiology of patient deteriorations is not well understood . 
 jones and colleagues provide data regarding the temporal pattern of mets . 
 they describe a diurnal variation to crises that strongly suggests hospital processes may systematically ignore ( and find ) patient deterioration . 
 hospitals in the future must develop methodologies to find more reliably patients who are in crisis , and then respond to them swiftly and effectively to prevent unnecessary deaths . 
None
Competing interests