ORIGINAL ARTICLE

Postoperative Emergency Response Team

Activation at a Large Tertiary Medical Center
Toby N. Weingarten, MD; Sam J. Venus, MD; Francis X. Whalen, MD;
Brittany J. Lyne, SRNA; Holly A. Tempel, SRNA; Sarah A. Wilczewski, SRNA;
Bradly J. Narr, MD; David P. Martin, MD, PhD; Darrell R. Schroeder, MS; and
Juraj Sprung, MD, PhD
Abstract

Objective: To study characteristics and outcomes associated with emergency response team (ERT) activation in post-
surgical patients discharged to regular wards after anesthesia.
Patients and Methods: We identified all ERT activations that occurred within 48 hours after surgery from June 1,
2008, through December 31, 2009, in patients discharged from the postanesthesia care unit to regular wards. For each
ERT case, up to 2 controls matched for age (⫾10 years), sex, and type of procedure were identified. A chart review was
performed to identify factors that may be associated with ERT activation.
Results: We identified 181 postoperative ERT calls, 113 (62%) of which occurred within 12 hours of discharge from
the postanesthesia care unit, for an incidence of 2 per 1000 anesthetic administrations (0.2%). Multiple logistic
regression analysis revealed the following factors to be associated with increased odds for postoperative ERT activation:
preoperative central nervous system comorbidity (odds ratio [OR], 2.53; 95% confidence interval [CI], 1.20-5.32;
P⫽.01), preoperative opioid use (OR, 2.00; 95% CI, 1.30-3.10; P⫽.002), intraoperative use of phenylephrine infusion
(OR, 3.05; 95% CI, 1.08-8.66; P⫽.04), and increased intraoperative fluid administration (per 500-mL increase, OR,
1.06; 95% CI, 1.01-1.12; P⫽.03). ERT patients had longer hospital stays, higher complication rates, and increased
30-day mortality compared with controls.
Conclusion: Preoperative opioid use, history of central neurologic disease, and intraoperative hemodynamic
instability are associated with postoperative decompensation requiring ERT intervention. Patients with these
clinical characteristics may benefit from discharge to progressive or intensive care units in the early postoperative
period.
© 2012 Mayo Foundation for Medical Education and Research 䡲 Mayo Clin Proc. 2012;87(1):41-49

missal to regular wards.5 It is unknown whether

E
mergency response teams (ERTs) have been
introduced by hospitals to evaluate and man-
age hospitalized patients whose condition is
acutely deteriorating. Patients assessed as clini-
cally stable and able to be managed on regular
wards (ie, standard nursing wards) may experi-
ence acute deterioration,1,2 and the ERT is de-
signed to promptly deliver care to these patients.
Identification of characteristics that can predict
postoperative adverse events would be desirable
because early intervention may prevent more se-
vere complications.2 Critical analysis of types and
causes of ERT activation may provide clues to ear-
lier identification and, potentially, prevention of
impending complications.
Because ERT systems are costly,3 some authors
have proposed preemptive triage of higher-acuity
patients to intensive care units (ICUs) or progressive
care units (eg, step-down units).4 The problem with
such an approach is that sudden postoperative ad-
verse events can occur even in patients whose con-
dition was stable in the postanesthesia recovery unit
(PACU) and who fulfilled discharge criteria for dis-
postoperative adverse events can be predicted from
patients’ comorbidities or other aspects of perioper- From the Department of
ative management. Anesthesiology (T.N.W.,
Our objective was to examine factors associated F.X.W., B.J.L., H.A.T., S.A.W.,
with the need for ERT activation after dismissal from B.J.N., D.P.M., J.S.) and Divi-
sion of Biomedical Statistics
anesthetic care. Because we were primarily inter- and Informatics (D.R.S.),
ested in perioperative factors, our study was limited Mayo Clinic, Rochester, MN;
to ERTs activated within the first 48 postoperative and Department of Critical
hours. Identification of factors associated with in- Care Medicine, Orlando Re-
gional Medical Center, Or-
creased risk for these events may help to better
lando, FL (S.J.V.).
triage patients and minimize adverse postopera-
tive outcomes.
PATIENTS AND METHODS
The approval for review of medical records was ob-
tained from the Mayo Clinic Institutional Review
Board in Rochester, MN. This study employed a ret-
rospective case-control design that assessed poten-
tial factors associated with the need for an ERT acti-
vation after either surgery or diagnostic procedures
that required anesthesia.

Mayo Clin Proc. 䡲 January 2012;87(1):41-49 䡲 doi:10.1016/j.mayocp.2011.08.003 䡲 © 2012 Mayo Foundation for Medical Education and Research 41
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The Department of Anesthesiology at Mayo
Clinic prospectively maintains a log of all ERT acti-
vations that occur at 2 Mayo Clinic-affiliated hospi-
tals in Rochester: Saint Marys and Methodist. Using
this log, we identified adult patients who required
ERT activation within 48 hours of discharge from
the PACU to regular wards from June 1, 2008, to
December 31, 2009. (Regular ward refers to a stan-
dard nursing ward where patient vital signs are as-
sessed at protocol-defined intervals as well as when
clinically indicated. Care may include continuous
pulse oximetry but not invasive monitoring as in an
ICU or progressive care unit setting.) By June 1,
2008, the ERT activation log system had been fully
implemented and was capturing 100% of events.
The 48-hour time window was selected to allow
identification of factors directly related to the intra-
operative course. Surgical patients discharged to
monitored wards were excluded. (Monitored ward is
defined as an advanced patient care ward where pa-
tient vital signs are continually monitored as in an
ICU or other specialized patient care areas where
continual monitoring is indicated, eg, progressive
care unit.) Patients who underwent cardiac catheter-
ization, bronchoscopy, or childbirth were excluded.
For each patient who required ERT activation, we
used the Mayo Clinic medical record database to
identify potential controls of the same sex and sim-
ilar age (⫾10 years) who underwent the same pro-
cedure (as determined from International Classifica-
tion of Diseases, Ninth Revision procedure codes)
during the study period and did not have ERT acti-
vation in the first 48 postoperative hours. From
these pools of potential controls, we randomly se-
lected up to 2 controls for each ERT patient. For
cases in which fewer than 2 potential controls could
be identified, we did not select alternative controls.
Indications for ERT Activations
At our institution an ERT consists of either a rapid
response team (RRT) or code team. An RRT call can
be initiated by any health care team member con-
cerned about the acutely deteriorating medical con-
dition of a patient. Typically at our institution, RRT
calls are prompted as described by others,6 and in-
dications include the following: decline in oxyhe-
moglobin saturation (assessed by either pulse oxim-
etry or clinical assessment), bradypnea, tachypnea,
profound bradycardia or tachycardia, hypotension,
concern for possible heart attack (“chest pain”),
stroke (acute neurologic deficits), or acute mental
status changes (agitation, delirium). However, an
RRT call can be initiated for any other indication at
the discretion of the health care team member. The
RRT consists of an attending physician board-certi-
fied in critical care medicine, a critical care fellow or
senior anesthesia resident, a respiratory therapist,
42 Mayo Clin Proc. 䡲 January 2012;87(1):41-49 䡲 doi:10.1016/j.mayocp.2011.08.003
MAYO CLINIC PROCEEDINGS
and a critical care registered nurse. Code team acti-
vations are reserved for immediate life-threatening
events (cardiopulmonary arrest, severe respiratory
compromise that is assessed to require tracheal in-
tubation and mechanical ventilation) or profoundly
unstable cardiac conditions (possibly requiring car-
dioversion, defibrillation). The code team is similar
in structure to the RRT but consists of an additional
critical care registered nurse, an internal medicine
resident, and a pharmacist. The level of ERT (RRT or
code team) activation is left to the discretion of the
individual health care team member (ie, nurse car-
ing for an unstable patient); thus it is prone to sub-
jectivity. Therefore, the level of activation occasion-
ally is erroneous (making a “mistake on the safe
side” by activating the code team when the RRT
would have been more appropriate). Regardless, the
roles and capabilities of these 2 teams are closely
interrelated. Because our interest was to examine
patients who had an acute postoperative deteriora-
tion, we analyzed all ERT interventions, regardless
of the level of activation.
Data Abstraction
Electronic medical records were abstracted for de-
mographics; comorbid conditions; preoperative, in-
traoperative, and postoperative variables; postoper-
ative course and complications; and details of the
ERT activation. Comorbid conditions were defined
according to definitions used for numerous out-
come studies at Mayo Clinic,7 including cardiovas-
cular disease (coronary artery disease [myocardial
infarction, coronary stent placement, or cardiac by-
pass surgery], congestive heart failure or cardiomy-
opathy [ejection fraction ⬍40%], the potential for
cardiac dysrhythmia [atrial fibrillation or flutter, im-
planted pacemaker and/or automated defibrillator],
arterial hypertension [medically treated], peripheral
vascular disease), central neurologic disease (history
of seizures, dementia, stroke, or transient ischemic
attacks), pulmonary disease (asthma, chronic ob-
structive or restrictive pulmonary disease, pulmo-
nary hypertension, obstructive sleep apnea), diabe-
tes mellitus (medically treated), kidney disease, and
preoperative scheduled use of opioids and/or ben-
zodiazepines. Overall physical status was assessed
from the American Society of Anesthesiologists
(ASA) Physical Status score.
The anesthetic record was reviewed for anesthe-
sia duration, anesthetic method (general, regional),
urgency (elective, emergent), muscle relaxant use,
blood transfusion, fluid administration, and periop-
erative complications. Complications included he-
modynamic instability or systemic arterial hypoten-
sion (inferred by use of vasopressor infusion as a
surrogate for recalcitrant hypotension), need for car-
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ANESTHESIA AND EMERGENCY TEAM ACTIVATION
dioversion, adverse respiratory events, or other se-
vere perioperative complication.
All data were collected and managed using
REDCap electronic data capture tools hosted at
Mayo Clinic.8 ERT notes were abstracted and sup-
plemented by review of the medication administra-
tion record, ICU admission note, subsequent progress
notes, and discharge summaries. Data abstracted in-
cluded the probable primary cause of the ERT activa-
tion: hypotension from hypovolemia or distributive
shock, respiratory cause, cardiac cause, hyperten-
sive crisis, neurologic causes such as mental status
changes, uncontrolled pain, psychiatric reasons, or
drug reactions. The following interventions were re-
corded: respiratory (tracheal intubation, applica-
tion of a noninvasive ventilatory device such as a
continuous positive airway pressure device, bron-
chodilator administration), cardiac (cardiopulmo-
nary resuscitation, defibrillation or cardioversion,
administration of vasoactive drugs, nitroglycerin,
antiarrhythmic drugs, or diuretics), intravenous
fluid bolus or blood product administration, glu-
cose administration, or administration of analgesics,
sedatives, naloxone, flumazenil, or antipsychotics.
Immediate outcome of the ERT was categorized as
follows: remained in the previous hospital setting
with or without intervention, transfer to a moni-
tored ward, transfer to the operating room for ex-
ploration or treatment, or death.
Outcomes
Postoperative complications that occurred within
the first 30 postoperative days were reported. Infor-
mation was obtained from the medical records from
the index hospitalization, rehospitalization, or out-
patient visits. A 30-day mortality rate was calcu-
lated. Postoperative complications included myo-
cardial infarction, cerebrovascular event, respiratory
failure requiring tracheal reintubation, acute kidney
injury (serum creatinine increase ⬎1 mg/dL and
above 1.5 mg/dL [to convert to ␮mol/L, multiply by
88.4]), thromboembolic event, sepsis or multiorgan
failure, blood transfusion requirement, or death.
Causes of death were recorded. Total days in the
ICU and hospital were recorded.
Statistical Analyses
Data are summarized using mean ⫾ SD or median
with interquartile range (IQR) for continuous vari-
ables and frequency percentage for nominal vari-
ables. To estimate the incidence of ERT activation, a
denominator was obtained using information pro-
vided by the revenue accounting office; it was based
on patient counts after excluding all surgical or pro-
cedural categories of patients expected to be admit-
ted to monitored wards (eg, cardiac, major vascular,
Mayo Clin Proc. 䡲 January 2012;87(1):41-49 䡲 doi:10.1016/j.mayocp.2011.08.003
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thoracic). Of note, this denominator was not re-
duced to account for other planned or unplanned
admissions to monitored wards in patients under-
going operations that do not routinely require this
level of postoperative care. Two sets of analyses
comparing characteristics between ERT cases and
controls were performed. One analysis included all
ERT cases and compared characteristics between
cases and controls using the 2-sample t test for con-
tinuous variables and the Fisher exact test for cate-
gorical variables. The other analysis excluded ERT
cases for which no matched controls could be iden-
tified and was performed using conditional logistic
regression, taking into account the matched study
design. Characteristics found to have evidence
(P⬍.05) of an association in univariate analyses
were included as explanatory variables in a multiple
logistic regression model with ERT activation as the
dependent variable. In all cases, 2-tailed P values of
.05 or less were considered statistically significant.
Analyses were performed using SAS statistical soft-
ware (Version 9.2, SAS Institute, Inc., Cary, NC).
RESULTS
During the study period approximately 95,000 pa-
tients underwent surgery or diagnostic procedures
requiring anesthesia and were discharged to a regu-
lar ward. Of those, 181 patients required ERT acti-
vation within 48 hours; therefore, the estimated rate
of ERT activation in this population was 2 per 1000
anesthetic administrations (0.2%). Of these events,
168 (93%) were RRT, and 13 (7%) were code team
activations. Of the code team activations, 6 met the
institutional definition of a code (5 patients received
cardiopulmonary resuscitation, and in one patient
the trachea was intubated to protect the airway in
the context of acute mental status changes). In the
other 7 patients, the code team was activated for
reasons other than cardiopulmonary collapse (eg,
transient syncope, hypotension). Of the entire co-
hort, 81 patients (45%) underwent general or uro-
logic surgery; 62 (34%), orthopedic surgery; 19
(10%), gynecologic surgery; 11 (6%), otolaryngo-
logical surgery; 5 (3%), neurosurgery; and l3 (7%),
diagnostic procedures or minor operations requir-
ing anesthetic care outside the operating room.
The majority (N⫽113; 62.4%) of ERT interven-
tions occurred during the first 12 hours after sur-
gery, and more than three-fourths (142; 78.5%) oc-
curred within the first 24 hours (Figure). The mean
time from ERT activation to team arrival was 4⫾2
minutes. Table 1 describes the reasons for ERT acti-
vation and types of interventions. The most frequent
reasons for ERT activation were hypotension in 58
patients (32%), cardiac in 36 (20%), and pulmonary
in 31 (17%). In all cases a physician on the ERT
assessed the patient and made decisions regarding
43

100
80
Percentage of ERT calls
60
40
20
0 wards with supplemental oxygen (188 ERT patients
0 6 12 18 24 30 36 42 48
Time from end of anesthesia (h)
FIGURE. Cumulative frequency of time to emergency response team
(ERT) activation.
treatment and disposition. Immediate outcomes of
ERT activation are summarized in Table 1.
The median ICU length of stay of patients
transferred to a monitored ward was 2 days (IQR,
2-4 days). Two patients died during code team
calls, both from massive saddle pulmonary em-
boli associated with a cardiac arrest. The admin-
istration of a fluid bolus (N⫽63; 35%) was the
most common overall intervention, followed by
naloxone administration (N⫽16; 9%) and opioid
administration (N⫽12; 7%) (Table 1).
Using previously described matching criteria,
we identified 318 controls for these 181 ERT pa-
tients. For 154 ERT patients (85%) we identified 2
matched controls; for 10 ERT patients (6%) only 1
control could be identified, and for 17 ERT patients
(9%) no controls could be identified because the
patient underwent an operation that was uncom-
mon or that rarely requires anesthesia. Clinical and
demographic features of ERT cases and controls are
summarized in Table 2. ERT and control groups
were similar with the exceptions of higher rates of
central neurologic diseases and preoperative use of
opioid analgesics in ERT patients. Among 18 ERT
patients (10%) with preexisting central neurologic
diseases, 5 (28%) had an ERT activation for worsen-
ing neurologic status. Among 55 ERT patients
(30%) who used opioids, 7 (13%) received nalox-
one during the ERT intervention.
Surgical characteristics in the control and ERT
groups are shown in Table 3. The perioperative
course was similar between groups except that more
ERT patients had intraoperative hemodynamic in-
44 Mayo Clin Proc. 䡲 January 2012;87(1):41-49 䡲 doi:10.1016/j.mayocp.2011.08.003
MAYO CLINIC PROCEEDINGS
stability as reflected by an increased use of phenyl-
ephrine infusion and greater intravenous fluid to-
tals. Of the 10 ERT patients (6%) who received
intraoperative phenylephrine infusion, 8 required
ERT intervention for later hemodynamic instability
(5, hypotension; 3, cardiac).
The intraoperative course in both groups was
devoid of any serious complications. The PACU
course was generally unremarkable, except for 1
ERT patient who required a transient phenylephrine
infusion and fluid bolus but was subsequently dis-
charged to the regular nursing ward. No complica-
tions (tracheal intubation, aspiration, laryngo-
spasm, pulmonary edema, or seizures) occurred in
the PACU, and all patients were transferred to reg-
ular wards. Most patients were discharged to regular
[61%] and 110 controls [50%]; P⫽.78).
From multivariate analysis, the following fac-
tors were found to be significantly associated with
ERT activation (Table 4): preoperative central ner-
vous system comorbidity (odds ratio [OR], 2.53;
95% confidence interval [CI], 1.20-5.32; P⫽.01),
preoperative scheduled opioid use (OR, 2.00; 95%
CI, 1.30-3.10; P⫽.002), intraoperative use of phen-
ylephrine infusion (OR, 3.05; 95% CI, 1.08-8.66;
P⫽.04), and greater intraoperative fluid adminis-
tration (per 500-mL fluid bolus, OR, 1.06; 95%
CI, 1.01-1.12; P⫽.03). Similar results were ob-
tained from the matched-set analysis that ex-
cluded the 17 ERT cases (9%) with no matched
controls (Table 4).
The length of stay was longer for patients who
required ERT activation (median, 4 days [IQR, 3-8
days] vs 3 days (IQR, 1-4 days); P⬍.001). Compli-
cation rates during hospitalization, including 30-
day mortality rates, were higher among patients
who required ERT activation compared with con-
trols (Table 5).
DISCUSSION
Recovery from surgery or diagnostic procedures re-
quiring anesthesia may be associated with compli-
cations. To avoid serious morbidities, it is important
to anticipate potential problems so that preemptive
measures can be implemented. Our study demon-
strated that preoperative scheduled use of opioids,
history of central neurologic disease, and hemody-
namic instability during surgery were characteristics
independently associated with unexpected deterio-
ration within the first 48 postoperative hours. The
majority of ERT calls occurred within the first 24
postoperative hours, most often for hypotension,
mental status changes, or respiratory problems. De-
spite the fact that some patients in the ERT cohort
required minimal to no intervention, ERT patients
had more severe in-hospital complications.
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ANESTHESIA AND EMERGENCY TEAM ACTIVATION

ERTs have been established to intervene quickly

to mitigate sudden deterioration of patients’ health. TABLE 1. Causes for Emergency Response Team (ERT) Activation and Specific
Although this initiative intuitively appears effective, Interventions During ERT Call
ERT outcomes are difficult to assess. ERT interven- Characteristic Patients (N⫽181)
tion may reduce ICU resource utilization9 and im- Causes for ERT activation
mediate mortality after cardiac arrest.3,6,10-13 How-
Hypotension 58 (32)
ever, a large meta-analysis did not find evidence that
Cardiac 36 (20)
these initiatives reduce the overall in-hospital mor-
tality.14 In contrast, introduction of ERTs was Pulmonary 31 (17)
found to increase long-term survival in surgical Neurologic 23 (13)
patients.15 This discrepancy14,15 may be related Pain/psychiatric issues 17 (9)
to differences in disease complexity between sur- Drug interactions 12 (7)
gical and medical patients. Surgical critical events may Hypertension 3 (2)
be associated with more reversible causes (bleeding, Epistaxis 1 (1)
oversedation, hypotension), whereas medical critical Specific interventions
events may be related to advanced or terminal condi-
Chest compressions 5 (3)
tions. If this is true, then implementation of ERTs, bet-
Defibrillation/cardioversion 2 (1)
ter triage of higher-risk patients, or both may improve
postoperative morbidity and mortality. Tracheal intubation 5 (3)
Characteristics used to predict ERT activation Noninvasive ventilation 9 (5)
have been reported only once.16 A small case-con- Other interventions and medications administered
trol study identified ASA Physical Status class 3 or Intravenous fluid bolus 63 (35)
greater and after-hours surgery as predictors. As in Naloxone 16 (9)
our study, hypotension and decreased level of con- Opioids 12 (7)
sciousness were the main reasons for ERT activa-
Blood transfusion 10 (6)
tion.16 That study used ASA Physical Status as a
Vasopressors (epinephrine, phenylephrine) 5 (3)
surrogate for comorbidity,16 but the small cohort
precluded examining the relationship between spe- Bronchodilator 5 (3)
cific comorbidities and intraoperative events with Benzodiazepine 3 (2)
early postoperative complications. In our larger se- Anticholinergic (atropine) 2 (1)
ries, we identified 3 markers for increased postop- Flumazenil 2 (1)
erative ERT activation. Antiarrhythmic (amiodarone) 2 (1)
The first predictor was preoperative opioid ther- Diuretic (furosemide) 1 (1)
apy that led to respiratory depression and overseda-
50% glucose intravenous bolus 2 (1)
tion (as evidenced by a higher rate of naloxone ad-
Antihypertensive (labetalol, hydralazine) 1 (1)
ministration). Other investigators also reported that
patient-controlled analgesia17 and intravenous mor- Nitroglycerin 1 (1)
phine have been associated with higher rates of ERT Immediate outcome
activation for respiratory depression.18 Further- Death 2 (1)
more, it is known that opioid-tolerant patients post- Transfer to surgery 4 (2)
operatively report greater intensity of pain and use Transfer to monitored ward 71 (39)
more opioid analgesics than opioid-naïve pa- Treatment on regular ward 57 (32)
tients.19 A retrospective case-control series found
Continued observation on regular ward 47 (26)
that 47.8% of opioid-tolerant patients experienced
postoperative moderate to severe sedation com- Data are presented as No. (percentage).
pared with 18.5% of opioid-naïve patients.20 A
higher proportion of these patients in our study re-
ceived naloxone (N⫽7 [13%] vs N⫽9 [7%]), fur- intraoperative fluids (crystalloids and colloids) com-
ther suggesting the need for increased vigilance for pared with the average amounts given to the remain-
signs of oversedation. der of ERT patients (see footnote to Table 3). We
The second predictor was the use of phenyleph- consequently used the initiation of “phenylephrine
rine infusions and greater intravenous fluid admin- infusion” as a surrogate for more pronounced hemo-
istration. At our institution we correct brief episodes dynamic instability. At our institution, phenylephrine
of hypotension with boluses of ephedrine or phen- infusion is considered a temporizing measure to cor-
ylephrine but typically initiate phenylephrine infu- rect for factors associated with perioperative hypoten-
sions, in addition to fluid boluses, when hypoten- sion, and it is widely viewed as a benign intervention.
sion persists. Of note, these patients received more However, among ERT patients who required phenyl-
Mayo Clin Proc. 䡲 January 2012;87(1):41-49 䡲 doi:10.1016/j.mayocp.2011.08.003 45
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 MAYO CLINIC PROCEEDINGS

TABLE 2. Demographics and Preoperative Comorbidities in Controls and in Patients Who Subsequently
Required Emergency Response Team (ERT) Activation

Variable Control (N⫽318)a ERT (N⫽181) P valueb

Age (y), mean ⫾ SD 59.4⫾17.0 59.9⫾17.4 .77
Body mass index (kg/m2), mean ⫾ SD 29.0⫾6.3 28.3⫾6.4 .23
Male sex 152 (48) 88 (49) .93
ASA Physical Status .12
1-2 198 (62) 99 (55)
3-4 120 (38) 82 (45)
Preoperative creatinine (mg/dL), mean ⫾ SDc 1.2⫾2.3 1.1⫾0.7 .69
Comorbidities
Cardiovasculard 146 (46) 94 (52) .23
Hypertension 141 (44) 82 (45)
Coronary artery disease 38 (12) 28 (15)
Atrial fibrillation or flutter 20 (6) 12 (7)
Pacemaker/internal defibrillator 5 (2) 10 (6)
Peripheral vascular disease 10 (3) 10 (6)
Congestive heart failure 12 (4) 9 (5)
d
Respiratory 60 (19) 45 (25) .14
Obstructive sleep apnea 31 (10) 21 (12)
Preoperative use of CPAP 18 (6) 4 (2)
Severe chronic lung diseasee 10 (3) 14 (8)
Asthma 24 (8) 16 (9)
Central nervous systemd 14 (4) 18 (10) .02
Stroke or transient ischemic attacks 10 (3) 8 (4)
Seizures 2 (1) 6 (3)
Dementia 2 (1) 6 (3)
Diabetes mellitus 55 (17) 29 (16) .80
Preoperative scheduled medication use
Opioids 57 (18) 55 (30) .002
Benzodiazepines 36 (11) 19 (10) .88
a
Data are presented as No. (percentage) unless indicated otherwise. ASA ⫽ American Society of Anesthesiologists;
CPAP ⫽ continuous positive airway pressure.
b
P values are from t tests and Fisher exact test for categorical variables.
c
Data are missing for 59 patients. To convert mg/dL to ␮mol/L, multiply by 88.4.
d
Patients may have more than one comorbidity within the given category; therefore, the sum of the numbers within the category may
exceed the total for the overall category.
e
Includes chronic obstructive pulmonary disease, pulmonary fibrosis, and pulmonary hypertension.

ephrine infusion, postoperative hypotension was the
most common indication for ERT activation. There-
fore, our perception that a phenylephrine infusion is
not a marker for subsequent instability, even after a
stable hemodynamic course in the PACU, needs to be
reexamined. Another study demonstrated that intra-
operative hypotension predicts postoperative adverse
events.21
A third predictor was a history of central neuro-
logic disease. Preexisting cognitive dysfunction is a
strong predictor of postoperative delirium.22 In our
patients, acute postoperative decline in neurologic
function was a frequent cause for ERT activation. Sim-
ilarly, Lee et al16 reported a decline in mental status as
a common reason for ERT activation; however, they
did not comment on preoperative neurologic disease
as a risk factor. The relatively small number of pa-
tients in our study with this condition precludes
us from making a general recommendation re-
garding preemptive triage of these patients to a
higher level of postoperative care. Furthermore,
the hospital outcomes of these patients were
good; more than 50% did not require transfer to a
higher level of care after ERT activation.

46 Mayo Clin Proc. 䡲 January 2012;87(1):41-49 䡲 doi:10.1016/j.mayocp.2011.08.003

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ANESTHESIA AND EMERGENCY TEAM ACTIVATION

TABLE 3. Anesthetic and Intraoperative Characteristics in Controls and in Patients Who Required Emergency
Response Team (ERT) Activationa

Characteristic Control (N⫽318) ERT (N⫽181) P value

Emergency procedure 16 (5) 7 (4) .66
Type of anesthesia .66
General 257 (81) 145 (80)
Neuroaxial 36 (11) 18 (10)
Peripheral nerve block ⫾ sedation 25 (8) 18 (10)
Airway management .93
Endotracheal intubation 243 (76) 136 (75)
Laryngeal mask airway 14 (4) 9 (5)
Mask or nasal cannula 61 (19) 36 (20)
Intraoperative use
Nondepolarizing muscle blockers 135 (42) 87 (48) .26
Blood transfusion 22 (7) 18 (10) .24
Crystalloids/colloids (L), mean ⫾ SD 2.2⫾1.5 2.6⫾2.0 .04
Phenylephrine infusion 6 (2) 10 (6)b .03
Antihypertensives 31 (10) 12 (7) .23
Adverse intraoperative events
Bronchospasm 6 (2) 6 (3) .32
Hypoxemia 2 (1) 1 (1) .92
Anesthetic duration (h), mean ⫾ SD 3.3⫾1.7 3.4⫾2.1 .57
a
Data are presented as No. (percentage) unless indicated otherwise.
b
ERT patients (n⫽10) who had intraoperative phenylephrine infusion received 3.3⫾1.6 L of fluids intraoperatively.

The PACU course was generally uneventful in
our patients, which is not surprising because to be
included in our study, they needed to be in suffi-
ciently stable condition to warrant discharge to
regular wards.5 A study of respiratory and cardio-
vascular events in the PACU demonstrated that
tachycardia and hypertension were predictive of un-
planned ICU admission and increased mortality,
demonstrating a relationship between early postop-
erative clinical deterioration and long-term out-
comes.23 Furthermore, this study revealed a strong
tendency for patients to exhibit similar cardiovascu-
lar events intraoperatively and in the PACU.23 In
our study, patients with intraoperative hypotension

TABLE 4. Multivariate Analysis of Factors Associated With Emergency Response Team (ERT) Activationa

All ERT cases and controls Matched-set analysis

Odds ratio 95% CI P value Odds ratio 95% CI P value

Preoperative
Central nervous system comorbidityb 2.53 1.20-5.32 .01 2.44 1.07-5.58 .04
Preoperative scheduled opioid use 2.00 1.30-3.10 .002 1.95 1.18-3.24 .01
Intraoperative
Phenylephrine infusion 3.05 1.08-8.66 .04 3.85 1.25-11.84 .02
Crystalloids/colloidsc 1.06 1.01-1.12 .03 1.12 1.04-1.20 .003
a
Characteristics found to have a significant univariate association (see Tables 2 and 3) were included in the multiple logistic regression
model. In addition to an analysis that included all ERT cases and controls, a matched-set analysis was performed that excluded 17 ERT
cases that did not have any matched controls. The matched-set analysis was performed using conditional logistic regression, taking into
account the matched-set study design. CI ⫽ confidence interval.
b
Preoperative central nervous system comorbidities include cerebrovascular disease, seizures, and dementia.
c
Odds ratios are for a 500-mL increase.

Mayo Clin Proc. 䡲 January 2012;87(1):41-49 䡲 doi:10.1016/j.mayocp.2011.08.003 47

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 MAYO CLINIC PROCEEDINGS

TABLE 5. Outcomes for Controls and for Patients Who Had Emergency Response Team (ERT) Intervention
During Hospitalizationa

Control
(N⫽318) ERT (N⫽181)

Complicationsb No. of patients No. of patients P value

Myocardial infarction 1 (⬍1) 5 (3) .03
Stroke 1 (⬍1) 6 (3) .01
Mechanical ventilationc 2 (1) 16 (9) ⬍.001
Renal failure 7 (2) 12 (7) .03
Deep vein thrombosis 1 (⬍1) 3 (2) .14
Pulmonary embolus 1 (⬍1) 2 (1) .30
Sepsis/multiorgan failure 3 (1) 15 (8) ⬍.001
Need for blood transfusion 3 (1) 20 (11) ⬍.001
Mortality at 30 dd .02
Alive 315 (99) 173 (96)
Dead 3 (1) 8 (4)
a
Data are presented as No. (percentage).
b
These complications represent all complications that occurred from the time of postanesthesia recovery unit discharge to hospital
discharge and are not limited to those occurring at the time of the ERT intervention.
c
Mechanical ventilation was implemented for patients who required ventilatory support for respiratory failure arising from cardiopul-
monary arrest, acute lung injury, pneumonia, sepsis, or multisystem organ failure.
d
All deaths in the control group, and 1 death in the ERT group, occurred following hospital discharge. Causes of the 7 in-hospital deaths
in the ERT group included cardiac arrest during the time of the rapid response team activation in 2 patients, due to massive pulmonary
emboli as determined on autopsy; pneumonia in 1; multiorgan failure in 3; and acute hemorrhage in 1. The specific causes of the 4
out-of-hospital deaths were not determined. The 3 control patients were as follows: an 85-year-old woman with non-Hodgkin
lymphoma who had cardiac arrest after readmission following resection of a tongue lesion; a 57-year-old man with advanced
scleroderma (with cardiac and pulmonary involvement) who had undergone a muscle biopsy under monitored anesthetic care; a
62-year-old woman with renal cell carcinoma and multiple pulmonary emboli who died after placement of a pleural catheter for
malignant effusion under anesthesia. The ERT patient who died out of hospital was a 94-year-old woman who previously underwent
a left hemimandibulectomy.

had unremarkable PACU stays, and yet some expe-
rienced subsequent hemodynamic instability. This
suggests that the aggressive volume replacement
combined with intensive monitoring maintained
hemodynamic stability throughout the PACU stay.
However, the underlying comorbidities or condi-
tions that led to subsequent instability after dis-
charge to a regular ward were either not manifest or
not recognized in the PACU.
This is a retrospective study with all inherent
limitations. Because we limited our study to ERT
calls during the first 48 postoperative hours, we
could have missed significant complications that oc-
curred outside that time frame but still were related
to anesthesia and surgery. Despite the existence of
well-defined clinical criteria for ERT activation, con-
siderable subjectivity is involved. More specifically,
activation is triggered typically by allied health care
professionals with varied levels of training; there-
fore, some ERT activations were initiated for non-
critical reasons (eg, epistaxis), which affects the abil-
ity to identify factors associated with increased odds
for more severe events. This is reflected in our data
in that 47 ERT activations (26%) resulted in no in-
tervention by the team. This is also the reason why
we decided to include cases from both RRT and code
team activations; ie, the reasons why one team was
activated over the other are at times arbitrary. Re-
gardless, we think that activation of either team rep-
resents an acute unexpected health decompensation
and thus is relevant for study. We believe our re-
ported incidence represents an underestimate be-
cause invariably some patients were discharged to
the ICU for other reasons but were still included in
the denominator. However, our incidence of 0.2% is
similar to a previous report.16
CONCLUSION
Patients with preoperative central neurologic dis-
ease, scheduled preoperative opioid use, or intraop-
erative hemodynamic instability were found to be at
increased risk for ERT activation within 48 postop-
erative hours. More vigilant monitoring of such pa-
tients may be warranted in the immediate postoper-
ative period.

48 Mayo Clin Proc. 䡲 January 2012;87(1):41-49 䡲 doi:10.1016/j.mayocp.2011.08.003

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ANESTHESIA AND EMERGENCY TEAM ACTIVATION
ACKNOWLEDGEMENT
We are thankful to Andrew Hanson for assistance
with data management and statistical analyses.
Grant Support: This project was supported by the Depart-
ment of Anesthesiology, Mayo Clinic, Rochester, MN, and
National Institutes of Health/National Center for Research
Resources Clinical and Translational Science Awards Grant
Number UL1 RR024150.
Its contents are solely the responsibility of the authors and
do not necessarily represent the official views of the Na-
tional Institutes of Health.
Correspondence: Address to Juraj Sprung, MD, PhD, De-
partment of Anesthesiology, Mayo Clinic, 200 First St SW,
Rochester, MN 55905 (sprung.juraj@mayo.edu).
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