Impact of implementing pre-Medical Emergency Team tier and digital Code Blue monitoring on cardiac arrest outcomes: A clinical audit at an Indian tertiary care center
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Abstract
Background: In-hospital cardiac arrest contributes significantly to inpatient mortality. Code Blue systems vary globally, and data from India are limited. Recent evidence supports integrating pre-medical emergency team (pre-MET) reduce MET call (activated via early warning scores) and Code Blue events. Our hospital is among the first in India to implement a pre-MET system. Additionally, we developed a digital platform to monitor Code Blue performance that tracks key resuscitation step timings.
Aims: To evaluate impact of pre-MET implementation on MET and Code Blue incidence, and to assess efficacy of our digital tool in enhancing response team performance and patient outcomes.
Methods: This retrospective observational study was conducted between January 2022 and May 2025 at a tertiary hospital in Mumbai, India. All adult patients experiencing Code Blue, MET, and pre-MET calls were included. Data for Code Blue events, including chest compression fraction, were collected using the digital software. Primary outcome was return of spontaneous circulation (ROSC).
Results: We analyzed 1016 Code Blue and 1332 MET/pre-MET events. Post-implementation of pre-MET criteria, pre-MET calls significantly increased with corresponding decrease in MET calls (χ²=10.98, p=0.012). With digital Code Blue monitoring, ROSC rates improved from 37.5% (2022) to 56.5% (2025), with ward-specific rates rising from 63.2% to 85.7%. Chest compression fraction improved over time, indicating enhanced cardiopulmonary resuscitation (CPR) quality.
Conclusion: Implementation of pre-MET tier facilitated early identification of clinical deterioration, reducing MET activations. Real-time digital Code Blue assessment, particularly of chest compression fraction, enhanced CPR quality. Our findings support wider implementation of structured escalation protocols and digital Code Blue monitoring to improve patient outcomes in similar healthcare settings.
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References
2. Penketh, J., Nolan, J.P. In-hospital cardiac arrest: the state of the art. Crit Care 2022;26: 376.
https://doi.org/10.1186/s13054-022-04247-y.
3. Chan PS, Tang Y; American Heart Association's Get With the Guidelines®‐Resuscitation Investigators. Risk-Standardizing Rates of Return of Spontaneous Circulation for In-Hospital Cardiac Arrest to Facilitate Hospital Comparisons. J Am Heart Assoc 2020;9: e014837. doi:10.1161/JAHA.119.014837
4. Jones DA, DeVita MA, Bellomo R. Rapid-response teams. N Engl J Med 2011;365:139–46.
5. Devita MA, Bellomo R, Hillman K, et al. Findings of the first consensus conference on medical emergency teams. Crit Care Med 2006;34:2463–78.
6. Audit Commission. Critical to success: the place of efficient and effective critical care services within the acute hospital. London, UK; 1999.
7. Gardner-Thorpe J, Love N, Wrightson J, Walsh S, Keeling N. The value of Modified Early Warning Score (MEWS) in surgical in-patients: a prospective observational study. Ann R Coll Surg Engl 2006;88: 571–5. doi:10.1308/003588406X130615
8. Sprogis SK, Currey J, Jones D, Considine J. Use of the pre-medical emergency team tier of rapid response systems: A scoping Review. Intensive Crit Care Nurs 2021;65:103041. doi:10.1016/j.iccn.202 1.103041
9. Chan PS, Jain R, Nallmothu BK, Berg RA, Sasson C. Rapid response teams: a systemic review and meta-analysis. Arch Intern Med 2010;170:18–26.
10. De Jong A, Jung B, Daurat A, et al. Effect of rapid response systems on hospital mortality: a systemic review and meta-analysis. Intensive Care Med 2016;42:615–7.
11. Maharaj R, Raffaele I, Wendon J. Rapid response systems: a systemic review and meta-analysis. Crit Care 2015;19:254.
12. Subbe CP, Kruger M, Rutherford P, Gemmel L. Validation of a modified Early Warning Score in medical admissions. QJM 2011;10:521–6.
13. Jones D, Orosz J, Psirides A, Pilcher D. Potential metrics for rapid response systems in Australia and New Zealand. Crit Care Resusc 2023; 25:116-7. doi:10.1016/j.ccrj.2023.06.006
14. American Heart Association. High-quality CPR performance metrics [Internet]. American Heart Association; [cited 2025 Jun 17]. Available from: https://cpr.heart.org/en/resuscitation-science/high-quality-cpr
15. Subbe CP, Kruger M, Rutherford P, Gemmel L. Validation of a modified Early Warning Score in medical admissions. QJM 2011;10:521–6.
16. Schluep M, Gravesteijn BY, Stolker RJ, Endeman H, Hoeks SE. One-year survival after in-hospital cardiac arrest: A systematic review and meta-analysis. Resuscitation 2018;132:90–100. doi:10.1016/j.resu scitation.2018.09.001
17. Ocen D, Kalungi S, Ejoku J, et al. Prevalence, outcomes and factors associated with adult in hospital cardiac arrests in a low-income country tertiary hospital: a prospective observational study. BMC Emerg Med 2015;15:23. doi:10.1186/s12873-015-0047-0
18. Nallamothu BK, Greif R, Anderson T, et al. Ten steps toward improving in-hospital cardiac arrest quality of care and outcomes. Circ Cardiovasc Qual Outcomes 2023;16:e010491. doi:10.1161/CIRCO UTCOMES.123.010491
19. Spearpoint KG, Gruber PC, Brew SJ. Impact of the immediate life support course on the incidence and outcome of in-hospital cardiac arrest calls: An observational study over 6 years. Resuscitation 2009;80:638–43.
20. Jones D. The medical emergency team - current status and future directions: a perspective for acute care physicians. Intern Med J 2023;53: 888–91.
21. Abu-Jeyyab M, Al-Jafari M, El Din Moawad MH, et al. The role of clinical audits in advancing quality and safety in healthcare services: A multiproject analysis from a Jordanian hospital. Cureus 2024;16: e54764.
22. Ngunga LM, Yonga G, Wachira B, Ezekowitz JA. Initial rhythm and resuscitation outcomes for patients developing cardiac arrest in hospital: Data from low-middle income country. Glob Heart 2018; 13:255–60. doi:10.1016/j.gheart.2018.07.001
23. Leona DF. Prevalence and determinants of return of spontaneous circulation (ROSC) in in-hospital cardiac arrest patients in Indonesia: A systematic review. International Journal of Research Publication and Reviews 2024;5:2354–8.
24. Topeli A, Cakir B. Evaluation of the blue code system established in the health campus of a university hospital. Turk J Emerg Med 2020;21:14–9. doi:10.4103/2452-2473.301912.
25. Alao DO, Mohammed NA, Hukan YO, et al. The epidemiology and outcomes of adult in-hospital cardiac arrest in a high-income developing country. Resusc Plus 2022;10:100220. doi:10.1016/j.respl u.2022.100220.
26. Hazra D, Nekkanti AC, Jindal A, et al. Code blue: Predictors of survival. J Anaesthesiol Clin Pharmacol 2022;38:208–14. doi:10.4103/joacp.JO ACP_327_20.
27. Rattananon P, Tienpratarn W, Yuksen C, et al. Associated factors of cardiopulmonary resuscitation outcomes; a cohort study on an adult in-hospital cardiac arrest registry. Arch Acad Emerg Med 2024;12:e30. doi:10.22037/aaem.v12i1.2227.
28. Cagino LM, Moskowitz A, Nallamothu BK, McSparron J, Iwashyna TJ; American Heart Association’s Get With The Guidelines-Resuscitation Investigators. Trends in return of spontaneous circulation and survival to hospital discharge for in-intensive care unit cardiac arrests. Ann Am Thorac Soc 2023;20:1012–9. doi:10.1513/AnnalsATS.202205-393OC.
29. McGaughey J, O'Halloran P, Porter S, Blackwood B. Early warning systems and rapid response to the deteriorating patient in hospital: A systematic realist review. J Adv Nurs 2017;73:2877–91. doi:10.1111/jan.13398.
30. Han Y, Hu H, Shao Y, et al. The link between initial cardiac rhythm and survival outcomes in in-hospital cardiac arrest using propensity score matching, adjustment, and weighting. Sci Rep 2024;14:7621. doi:10.1038/s41598-024-58468-y.
31. Grunau B, Reynolds JC, Scheuermeyer FX, et al. Comparing the prognosis of those with initial shockable and non-shockable rhythms with increasing durations of CPR: Informing minimum durations of resuscitation. Resuscitation 2016;101:50–6. doi:10.1016/j.resuscitation.2016.01.021.
32. Allencherril J, Lee PYK, Khan K, Loya A, Pally A. Etiologies of In-hospital cardiac arrest: A systematic review and meta-analysis. Resuscitation 2022;175: 88–95. doi:10.1016/j.resuscitation.2022.03.005.
33. Andersen LW, Holmberg MJ, Berg KM, Donnino MW, Granfeldt A. In-hospital cardiac arrest: A review. JAMA 2019;321:1200–10.
34. Muñoz-Rojas G, García-Lorenzo B, Esteve D, et al. Implementing a Rapid Response System in a tertiary-care hospital. A cost-effectiveness study. J Clin Monit Comput 2022;36:1263–9. doi:10.1007/s 10877-022-00859-5.
35. Chang FC, Hsieh MJ, Yeh JK et al. Longitudinal analysis of in-hospital cardiac arrest: trends in the incidence, mortality, and long-term survival of a nationwide cohort. Crit Care 2025;29:41 doi:10.1186/s13054-025-05274-1.
36. Monangi S, Setlur R, Ramanathan R, Bhasin S, Dhar M. Analysis of functioning and efficiency of a code blue system in a tertiary care hospital. Saudi J Anaesth 2018;12:245–9.
37. Jayasingh IA, Margos RA, Philip S. A clinical audit to assess the adherence of the Code Blue team to advanced cardiac life support protocol and its effect on the patient outcome in a tertiary care hospital in Kochi, Kerala. Indian J Respir Care 2018; 7:46–9.
38. Al-Dury N, Rawshani A, Israelsson J, et al. Characteristics and outcome among 14,933 adult cases of in-hospital cardiac arrest: A nationwide study with the emphasis on gender and age. Am J Emerg Med 2017;35:1839–44. doi:10.1016/j.ajem.2017.06.012
39. Amacher SA, Zimmermann T, Gebert P, et al. Sex disparities in ICU care and outcomes after cardiac arrest: a Swiss nationwide analysis. Crit Care 2025; 29:42. doi:10.1186/s13054-025-05262-5.