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Met event Record 2


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Patient Stamp

Patient Name ___________________________

Medical Record # ________________________


MET Event Record 2

Date:______________ Time MET called:___________

1st Member Arrival Time: _____________

Last Member Departure Time: _______________

Date of birth: ___________________________________

Gender: _____ Age:_________ Weight: ___________

Race: ___________  Hispanic Origin

ICU Discharge prior to MET call? Yes No



If Yes, date admitted to non-ICU unit (after ICU disch.): ____/____/____

Discharged from PACU within 24 hrs of MET call? Yes No

Sedation/anesthesia within 24 hrs of MET call? Yes No

In ED 24 hours prior to MET call? Yes No


All vital sign signs taken in the 4 hrs prior to MET activation

(if none, enter last documented vital signs prior to the MET activation):

Date/Time___ HR___ BP______ Resp Rate SpO2 Temp./Units_

____________ _______ __________ ________ ______ ________ C | F

____________ _______ __________ ________ ______ ________ C | F

____________ _______ __________ ________ ______ ________ C | F



At Time of Event: Heart Rate: ________ BP _____/_____ Respiratory Rate: _______ SpO2: _______ Temp/Units: _______ C | F


Illness Category:

 Medical – Cardiac

 Medical – Non-Cardiac

 Surgical – Cardiac

 Surgical – Non-Cardiac

 Newborn

 Obstetric

 Trauma


 Other (Visitor/Employee)

MET Activation Triggers – Check all that apply


Trigger Unknown

Cardiac:

 Bradycardia

 Tachycardia

 Hypotension

 Symptomatic

Chest pain unresponsive to NTG



Respiratory:

 Respiratory Depression

 Tachypnea

 New onset of difficulty breathing

 Reversal agent without response

Bleeding into airway

 Decreased oxygen saturation

Neurological:

 Mental status change

 Acute Loss of Consciousness (LOC)

 Seizure

 Suspected acute stroke

 Unexplained agitation or delirium



Medical:

Acute decrease in urine output

 Rising lactate to > 4 mEq/L

 Uncontrolled bleeding



Other:

 Staff member concern

 > 1 stat page

 Other: _________________


Drug Interventions – Check all given during MET event


None

 Aspirin

Antiarrhythmic Agent

 Anti-epileptic

 Atropine

 Calcium

 Diuretic (IV)

 Fluid Bolus (IV)


 Glucose Bolus

 Heparin/(LMH)

 Inhaled Bronchodialator

 Insulin/Glucose

 Magnesium

 Mannitol

 Nitroglycerin (IV)

 Nitroglycerin (SL)

Reversal agent

 Sodium bicarbonate

 Thrombolytic

 Vasoactive Agent Infusion (not bolus)

Other: ___________________________

Non-Drug Interventions (Diagnostic and Therapeutic) – Check all done or ordered during MET event


None

 Bedside Cardiac Ultrasound

 Bronchoscopy

 Cardioversion

Chest Tube

 Chest X-ray

 Coma position

Consult (Stat):

 Cardiology

 Critical Care

Neurology

 Pulmonary

 Surgery

 Other: _____________

 CPR

 Crichothyrotomy



 Defibrillation

 Electroencephalogram (EEG)

Foley catheter

 Gastric lavage

 GI - Lower

 GI - Upper

 Head CT (stat)

 Hyperventilation

Monitoring:

 Apnea/Brady.. (stand alone)

ECG Monitor

 Non-Invasive BP (NIBP)

 Pulse Oximeter

 12-lead ECG

 Nasogastric (NG) Tube

 Neonatal Head Ultrasound (echo)

 Pacemaker

 Pericardiocentesis

Respiratory Management:

 Elective intubation (airway protection)

 Mechanical Ventilation

Supplemental O2

 Suctioning

 Tracheostomy Care/Replacement



Ventilation:

 Bag-Valve-Mask

 Mask CPAP/BiPAP

 Nasal Airway

 Oral Airway

 Endotracheal Tube (ET)

 Laryngeal Mask Airway (LMA)

 Combitube

 Other: ________________________

Serum Lactate

 Thoracentesis

Transfusion:

 Albumin

 Fresh frozen plasma

 Packed red blood cells

 Platelets

 Other: __________________

Vascular Access:

Central Vein

 Peripheral Vein

 Intraosseous (IO)

 Umbilical Artery (UAC)

 Umbilical Vein (UVC)

Other Non-Drug Interventions ____________________________ ____________________________


MET Outcome


Did event progress to Acute Respiratory Compromise (ARC) OR (CPA during the MET event?  No  ARC Event  CPA Event

Pt. Transferred To:  Morgue  Not Transf.  ICU  Cath Lab  OR  Telemetry/Step-Down  Other Hosp.  Other: ____________



Was MET response scope of care limited by patient/family end of life decisions or physician decision of medical futility?  Yes  No

Review of MET Response


 MET trigger(s) present, but team not immediately activated

 MET Response Delay:

 MET criteria / process not known or misunderstood by those calling MET

 MET communication system not working (e.g., phone, operator, pager)

 Incomplete or inaccurate information communicated

 Other Specify: ____________________________________

 Essential Patient Data Not Available

Medication Delay

 Equipment Issue  Availability Function

Specify Equipment:_____________________________________

 Issues Between MET team and Other Caregivers/Departments

 Prolonged MET Event Duration


MET Member Signature: _____________________________________

MET Member ID #: __________________________________________



Rev 2 11/01/10 Pg. of 1


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