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Contents lists available at ScienceDirect

Collegian
journal homepage: www.elsevier.com/locate/coll

Adult Deterioration Detection System (ADDS): An evaluation of the

impact on MET and Code blue activations in a regional healthcare
service
Karen Missen a, , Joanne. E. Porter b , Anita Raymond c , Kerry de Vent d , Jo-Ann Larkins e
a
Federation University, Faculty of Health, School of Nursing, Midwifery and Healthcare, Gippsland Campus, Northways Road, Churchill, Vic 3842, Australia
b
Federation University, Faculty of Health School of Nursing, Midwifery and Healthcare, Gippsland Campus, Northways Road, Churchill, Vic 3842, Australia
c
Federation University, Faculty of Health School of Nursing, Midwifery and Healthcare, Gippsland Campus, Northways Road, Churchill, Vic 3842, Australia
d
Monash University, Faculty of Science & Technology, School of Applied and Biomedical Sciences, Gippsland Campus, Northways Road, Churchill, Vic 3842,
Australia
e
Federation University, Faculty of Science & Technology, School of Applied and Biomedical Sciences, Gippsland Campus, Northways Road, Churchill, Vic
3842, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Aims: To evaluate the impact of Acute Deterioration Detection System (ADDS) charts introduced to a
Received 6 December 2016 regional healthcare service.
Accepted 5 May 2017 Background: To assist health professionals in identifying essential elements for recognizing patient clin-
Available online xxx
ical deterioration, a national initiative introduced track and trigger observation charts, to hospitals in
Australia. This study investigated whether the introduction of ADDS charts had an impact on the number
Keywords:
of Medical Emergency Team (MET) and Code Blue activations at one regional healthcare service, according
Patient deterioration
to their incident recording database.
Medical emergency team
Resuscitation
Method: A retrospective study of all Code Blue and MET activations was undertaken at a regional hospital,
ADDS pre and post the introduction of ADDS charts in a two year period, June 2012 to June 2014.
Code Blue Results: There was a signicant increase in MET activations from 5.91 to 11.27 per 1000 admissions
Regional (p < 0.01) after the implementation of ADDS charts. There was also an unexplained non-signicant
increase from 0.50 to 0.88 per 1000 admissions in the activations of Code Blue during this period (p = 0.05).
It was also found that ADDS charts did not overly inuence the activation criteria for calling a MET/Code
Blue, except for an increase in reports of high heart rate and a decrease in the use of the criteria worried.
Conclusion: The introduction of ADDS charts has provided health professionals with a clear track and
trigger set of criteria, improving the detection of early signs of deterioration in patients. This study demon-
strated an increase in activations as a result of the introduction of ADDS charts in one regional healthcare
service.
2017 Australian College of Nursing Ltd. Published by Elsevier Ltd.

1. Summary of relevance 1.2. What is already known

1.1. Problem Medical Emergency Team (MET) was introduced into healthcare
services in Australia to assist in preventing adverse outcomes by
The recognition and management of deteriorating patients initiating timely interventions for deteriorating patients. The Adult
remains difcult for nurses in busy acute healthcare services. Deterioration Detection System (ADDS) chart assist health profes-
sionals in recognizing early deterioration in patients and prompt
them in activating MET calls sooner in response to physiological
parameters that exceed normal values.
Corresponding author.
E-mail addresses: karen.missen@federation.edu.au
(K. Missen), joanne.porter@federation.edu.au (Joanne.E. Porter),
anita.raymond@federation.edu.au (A. Raymond), kade5@student.monash.edu
(K. de Vent), jo-ann.larkins@federation.edu.au (J.-A. Larkins).

http://dx.doi.org/10.1016/j.colegn.2017.05.002
1322-7696/ 2017 Australian College of Nursing Ltd. Published by Elsevier Ltd.

Please cite this article in press as: Missen, K., et al. Adult Deterioration Detection System (ADDS): An evaluation of the impact on MET
and Code blue activations in a regional healthcare service. Collegian (2017), http://dx.doi.org/10.1016/j.colegn.2017.05.002
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1.3. What this paper adds
Using track and trigger charts, such as the ADDS, has improved
the detection of deterioration in patients demonstrated by the
increase in MET activations at a regional healthcare service.
2. Introduction & background
Nurses on general wards are now responsible for the care of
acutely unwell patients with multiple complex needs, increas-
ing the possibility of showing signs of deterioration and requiring
urgent medical interventions. Research has demonstrated that the
recognition and management of deteriorating patients remains dif-
cult for nurses which may result in an increase in the morbidity
and mortality of patients in Australia (Chen et al., 2015). To assist
nurses with recognizing the early deterioration of patients in their
care, the Adult Deterioration Detection System (ADDS) chart was
developed as a national initiative by Preece, Horswill, Hill, and
Watson (2010), in line with the National Safety and Quality Health
Service Standard 9: Recognizing and Responding to clinical deteri-
oration in Acute Health Care (Australian Commission of Safety and
Quality in Health Care [ACSQHC], 2009). The ADDS chart is a tiered
track and trigger system that enables early detection and inter-
vention for physiological parameters that exceed normal values
(Preece, Hill, Horswill, & Watson, 2012). This chart was developed
and implemented in various hospitals in Australia in 2012.
The ADDS chart incorporates both single and multiple parame-
ter systems in which the patients physiological observations such
as; respiratory rate, oxygen saturations, blood pressure, heart rate,
temperature, pain and level of consciousness are documented and
then scored using a color-coded key (Preece et al., 2010). Scores
are summed each time vital signs are recorded to give an over-
all indication of the patients condition, the chart documents the
escalation cues required for scores ranging from 1 to 8 (Horswill,
Preece, Hill, & Watson, 2010). Another feature of the ADDS chart
is the single parameter system, in that if a patients single vital
sign is recorded in the purple zone indicating a deviation/decline
from normal parameters, the immediate action requires the nurse
to activate the Medical Emergency Team (MET) (Preece et al., 2012).
The MET system was rst introduced into this regional health ser-
vice in February 2002. The MET is a rapid medical response team
called to facilitate timely and appropriate management of clini-
cally deteriorating patients. This system allows health professionals
in any ward in the health service to activate the assistance of
the expertise of this team, when a patient has been identied as
clinically unstable and meets a pre-set clinical instability criteria.
This team is made up of emergency and critical care nurses and
doctors with advanced life support skills. The MET system aims
to prevent adverse outcomes by initiating timely interventions in
patients whose condition may not be classied as immediately life
threatening (Herod, Frost, Parr, Hillman, & Aneman, 2014).
The pre-set clinical instability criteria for calling a MET varies
slightly between health services in Australia, but essentially the
triggers are: threatened airway, a change in respiratory rate (<8 or
>30 per minute), decrease in Oxygen Saturation (<90%) despite high
ow oxygen, acute change in systolic blood pressure (<90 mmHg),
acute change in heart rate (<40 or > 140 beats/min), acute change
in level of consciousness, seizure, acute change in urine output
(<50 mL over 4 h) (Austin Health, 2016; WA Department of Health,
2014; Santiano et al., 2009) or that the nurse is seriously worried
about the patient and they do not t into this physiological criteria
mentioned (Douw, Huisman-de Waal, van Zanten, van der Hoeven,
& Schoonhoven, 2016; Santiano et al., 2009). A MET response can be
upgraded at any time to a Code Blue should the incident become life
threatening, requiring specialist medical assistance, such as anes-
thetic support. A Code Blue can also be activated on its own by
healthcare personnel for a patient requiring prompt emergency
management, most often the result of either a cardiac or respiratory
arrest (Eroglu, Onur, Urgan, Denizbasi, & Akoglu, 2014).
This study aimed to explore whether the introduction and usage
of the ADDS chart in June 2013, increased or decreased the report-
ing of either MET or Code Blue activations within a single Victorian
regional health service. A health service orientation and education
package accompanied the introduction of these new charts in the
form of face to face interactive training over several weeks to cap-
ture as many staff as possible in the wards where these charts were
introduced. This was followed by regular auditing of the charts to
track progress and compliance. We hypothesized that the use of
the ADDS chart would reect early signs of deterioration in patients
and ultimately more MET activations and less Code Blue calls due
to earlier interventions being initiated.
3. Methods
A retrospective study of all Code Blue and MET call activations,
pre and post the introduction of Adult Deterioration Detection
system (ADDS) chart within a health care service in Victoria was
undertaken. The study period for this research was a two year
time frame; 1st June 2012 to 31st May 2014, a year preceding the
introduction of the ADDS chart in June 2013, and a year post imple-
mentation. An entire year was chosen for both before and after
the implementation of the ADDS chart, to minimize effects of sea-
sonal variation on the sample. The sample included all adult (18
years) in patients for whom a Code Blue or MET call was activated
within the two year period in the wards where the ADDS chart was
introduced within this regional health care service.
The study site was an integrated public regional health care
service with more than 250 beds, providing a broad range of ser-
vices including; critical care, high dependency and emergency. Data
relating to each incident (Code Blue and MET call) was recorded by
a clinician on a clinical instability chart which was entered into the
RiskMan database, a quantitative risk assessment tool which the
hospital uses for incident tracking. Data was extracted manually
from RiskMan to Microsoft Excel which was subsequently entered
into IBM SPSS Version 22 for analysis.
The clinical criteria that clinicians within this health service
identify to trigger a MET call and Code Blue response were different
with the MET Call activation based on deteriorating hemodynamic
ndings and Code Blue response based on an absence of signs of life.
These clinical criteria categories are predetermined within RiskMan
by the entry screens available for record management. The use of
RiskMan as an incident tracking system allowed for consistency of
categorization of clinical indicators regardless of the paper based
charting system used with the hospital environment.
4. Data collection
Data collection took place during the year 2015 at the health
care service by accessing their information management database
for recording and managing incidents called RiskMan (RiskMan,
2015). The data obtained from this database included all MET calls
and Code Blue events occurring since 1st January 2010. As this data
could only by accessed at the health service, the data was extracted,
de-identied, and entered directly into a Microsoft Excel spread-
sheet with twelve prescribed variables, by six members of the
researcher team including two clinicians, 3 academics and a nursing
student. Data retrieved from this system included; date of incident,
gender, date of birth, type of call, reason for calling code, clinical
indicators (triggers), initial heart rhythm and vital signs, treatment
given, outcomes, where patient was transferred to, issues arising

Please cite this article in press as: Missen, K., et al. Adult Deterioration Detection System (ADDS): An evaluation of the impact on MET
and Code blue activations in a regional healthcare service. Collegian (2017), http://dx.doi.org/10.1016/j.colegn.2017.05.002
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Table 1
Demographics for data set.
ADDS
Pre ADDS
Count % Count
Gender Male 82
Female 109
Age category 1824 years old 7 3.8%
2534 years old 8 4.3%
3544 years old 12
4554 years old 21
5564 years old 26
6574 years old 43
75 years or older 69
and specic observations. The data was then cleaned and checked,
with duplicates removed and any missed data rechecked against
the RiskMan (2015) database prior to being entered into IBM SPSS
Version 22 for statistical analysis. Whilst data was available from
January 2010, for the purpose of this paper only the data extracted
from 1st June 2012 to 31st May 2014 was used with this providing
an adequate timeframe to explore the effects of introduction of the
ADDS chart in June 2013.
5. Ethical considerations
Ethical approval for the study was granted by both the regional
health service and Federation University ethical committees. Data
was de-identied before analysis (project number E14-008).
6. Data analysis
The nature of data was a limiting factor in the choice of methods
used for statistical analysis. Most variables in the data set were cat-
egorical (nominal), meaning that non-parametric procedures such
as the Chi-square test were used extensively in the statistical analy-
sis. Unlike parametric statistical tests, non-parametric tests like the
Chi-Square do not require normally distributed and/or scale data.
To compare two or more independent samples, the Chi-square
(2 ) test of Contingencies was used which assessed whether the
variables were related and whether the relationship was statisti-
cally signicant. The Chi-square (2 ) goodness of t (one sample tation of the ADDS chart, the most common worried call was due
Chi-square) was used to determine whether the observed numbers
differed from expected frequencies in a single category.
7. Results
7.1. Sample and demographics
The clinical data for a total of 590 patients, that were treated
as inpatients in the general, psychiatric, subacute ward areas over
a two year period, were retrospectively extracted from RiskMan
with a total of 191 patient records pre implementation and 399
recorded after the implementation of the ADDS chart. There is a
statistically signicant difference in gender distribution (2 = 5.644,
p = 0.018) (see Table 1) with a higher percentage of female patients
in the pre implementation phase. The age of individuals ranged
from 18 to 100 years of age (mean 67.8 years, SD 17.5). Pediatric
(<18 years of age) cases were not included in this data set, as the
ADDS charting system has been only designed for adult patients
and was used accordingly. Whilst there is a steady trend towards
a greater percentages of older patients in both the pre and post
implementation phases, this has increased post implementation
of the ADDS chart with 46% of patients in the 75 years or older
Please cite this article in press as: Missen, K., et al. Adult Deterioration Detection System (ADDS): An evaluation of the impact on MET
and Code blue activations in a regional healthcare service. Collegian (2017), http://dx.doi.org/10.1016/j.colegn.2017.05.002
3
Post ADDS
%
42.9% 213 53.4%
57.1% 186 46.6%
1 0.3%
13 3.3%
6.5% 29 7.3%
11.3% 35 8.8%
14.0% 74 18.6%
23.1% 62 15.6%
37.1% 46.1%
category. Table 1 summarizes the demographic characteristics of
the data set.
Comparison of MET and Code Blue calls before and after imple-
mentation of the ADDS
When comparing the number of MET call activations per 1000
patients before and after the implementation of the ADDS chart,
there was a signicant increase (p < 0.01) in activations propor-
tional to admissions found in the year after the implementation.
Table 2 summarizes the number of Code Blue and MET call
activations proportional to admissions before and after the imple-
mentation of the ADDS chart.
The two most common activation criteria highlighted for calling
a MET/Code Blue that were consistent before and after the imple-
mentation of the ADDS were low blood pressure and low GCS.
However, there were some differences noted with the criteria of
high heart rate (>140) signicantly increased (p < 0.01) from 6.3%
of all calls before ADDS to 15.3% post implementation. The criteria
worried decreased as a trigger for activating MET/Code Blues fol-
lowing the implementation of the ADDS chart, from 15.7% before
to 11.5% after implementation (see Table 3).
When evaluating the triggers and the selected criteria for call-
ing a MET or Code Blue, before and after the implementation of
the ADDS chart, worried was an often-used criteria. Within the
RiskMan database, there is an opportunity to provide further expla-
nation of the clinical trigger sub category for the criteria Worried.
The results demonstrated a change in the sub category of worried
with the implementation of the ADDS chart. Before the implemen-
to low oxygen saturation or breathing problems (54.3%) followed
by unresponsive (34.3%). After ADDS, the most common marked
worried sub categories were not quite right (33.3%) followed by
chest pain (29.2%) (see Table 4).
A clinical intervention such as a MET Call or Code Blue may result
in patients being transferred within the hospital, for example from
a ward to a higher dependency unit such as critical or intensive care.
This is considered a transferrable outcome. The implementation of
the ADDS chart did not inuence the transferrable outcomes for
patients. When comparing before and after the implementation of
the ADDS chart, the vast majority of patients remained on the ward
where the call was activated. Transferring the patient to the crit-
ical care unit (CCU) was the second-most common outcome (see
Table 5).
8. Discussion
Experiential research investigating the use of ADDS charts is lim-
ited as it is a relatively new initiative in Australia, with the national
rollout taking place, in 2012. This research aimed to explore if the
introduction and use of ADDS charts in a regional acute health
care service had any impact on the number of MET and Code Blues
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Table 2
Comparison of Code Blue and MET Calls before and after ADDS implementation.

ADDS Admissions Code Blue Code Blue per MET MET call - per Total Total calls per
calls 1000 admissions calls 1000 admissions calls 1000 admissions

Pre ADDS 29,761 15 0.50 176 5.91 191 6.42

(June 20122013)
Post ADDS 32,817 29 0.88 370 11.27 399 12.16
(June 2013 31st
May 2014)

Table 3 period. Previous research undertaken by Kansal and Havill (2012) in

Activation criteria (triggers) for calling a MET or Code Blue before and after ADDS
Australia, found similar results, with a 50% increase in the number
chart implementation.
of rapid response calls after the introduction of a two-tiered rapid-
Triggers for call ADDS response system and new track and trigger observation charts and
activation calling criteria.
Pre ADDS Post ADDS
During the rollout of the ADDS chart at this health care ser-
Count % Count %
vice, all nursing staff attended professional development sessions
Airway 5 2.6% 14 3.5% on how to use this chart effectively and to ensure all clinical staff
SBP < 90 44 23.0% 104 26.1%
were made aware of the parameters for calling a MET. The empow-
Cardiac arrest 9 4.7% 19 4.8%
Low GCS 31 16.2% 79 19.8% erment of nurses through improved education on the effective use
HR < 40 4 2.1% 4 1.0% of ADDs and the escalation cues for a medical emergency may have
HR > 140 12 6.3% 61 15.3% also prompted this elevation in MET calls. A barrier identied by
Obstetric 0 0.0% 3 .8% Massey, Chaboyer, and Aiken (2014) in their Australian study was
Respiratory arrest 3 1.6% 2 .5%
Seizure 11 5.8% 25 6.3%
that nurses misunderstood the criteria and purpose of a MET, which
RR < 5 0 0.0% 1 .3% contributed to the underutilization or incorrect use of MET activa-
RR > 36 9 4.7% 28 7.0% tions at a large public teaching hospital. The nurses in this study did
Stroke 0 0.0% 0 0.0% not view MET as an early intervention strategy, associating it with
Trauma 6 3.1% 0 0.0%
a medical emergency, such as a cardiorespiratory arrest (Massey
Worried 30 15.7% 46 11.5%
BP > 190 8 4.2% 7 1.8% et al., 2014). This resulted in delays in activating a MET, leading to
Low urine output 2 1.0% 0 0.0% further deterioration in patients and ultimately death by not esca-
Low oxygen saturation 7 3.7% 2 .5% lating care sooner (Massey et al., 2014). As professional education
Other 10 5.2% 4 1.0% related to ADDS chart and MET criteria, may have increased clinical
staff awareness initially in activating MET calls, additional research
Table 4 needs to be undertaken to accurately determine if these observa-
The meaning of the criteria worried before and after implementation of the ADDS. tion charts, in the long term, continue to have a positive effect on
the number of MET calls activated.
ADDS
What was interesting in the ndings from this single site study,
Pre ADDS Post ADDS is that not only did the incidence of MET activations increase, there
Count % Count % was also an increase in Code Blue calls following the implementa-
tion of the ADDS. There is no clear explanation for this occurrence
Low oxygen saturation or breathing problem 19 54.3% 4 16.7%
Chest pain 1 2.9% 7 29.2% and is a concern, as signs of clinical deterioration often precede
Not quite right 2 5.7% 8 33.3% cardiac arrest, respiratory arrest and unplanned intensive care unit
Unresponsive 12 34.3% 0 0.0% (ICU) admissions. The main aim of the ADDS chart is to detect
Other 1 2.9% 5 20.8% patient deterioration earlier by prompting recognition and appro-
priate management (Preece et al., 2010). Hence, using a track and
Table 5 trigger observation chart such as the ADDS, should have alerted
Where patients were transferred to before and after the implementation of the ADDS nursing and medical staff to detect patient deterioration sooner,
chart. decreasing the incidence of cardiac/respiratory arrests at this facil-
Transferred to ADDS ity (Preece et al., 2012). There may however be a link to the
increasing age of the patient cohort with nearly half of the patients
Pre ADDS Post ADDS
for whom a Code Blue or MET Call was called after the implemen-
Count % Count % tation of the ADDS Chart were 75 years of age or older and hence
Stayed on ward 128 68.1% 240 60.3% likely to have a range of pre-existing clinical comorbidities. In con-
ICU/CCU 27 14.4% 69 17.3% trast to our ndings, Kansal and Havill (2012) found the number of
ED 10 5.3% 25 6.3% cardiac arrests actually decreased, though not statistically signi-
OT 6 3.2% 2 0.5% cantly, after the implementation of track and trigger observation
Deceased 5 2.7% 20 5.0%
Other hospital 1 .5% 8 2.0%
charts and new calling criteria in an Australian tertiary hospital.
Other 11 5.9% 34 8.5% Further comparative research needs to be undertaken in a variety
of healthcare services to assist in validating ndings regarding the
number of Code Blue activations following the implementation of
activations during this time. The ndings of the present study are track and trigger observation charts such as ADDS.
predictable, in that the use of an observation chart such as the ADDS When comparing activation criteria (triggers) that were docu-
chart, which gives an overall indication by scoring each vital sign mented by health professionals for calling a MET/Code Blue, before
recorded and having escalation cues for the summed score, demon- and after the implementation of ADDS chart, the current study
strated a statistically signicant increase (p < 0.01) in the number found three signicant changes. There was an increase in the
of MET activations at this healthcare service during this study reporting of high heart rate reporting of the respiratory rate and a

Please cite this article in press as: Missen, K., et al. Adult Deterioration Detection System (ADDS): An evaluation of the impact on MET
and Code blue activations in a regional healthcare service. Collegian (2017), http://dx.doi.org/10.1016/j.colegn.2017.05.002
G Model
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K. Missen et al. / Collegian xxx (2017) xxxxxx
decrease in the criteria worried used. With the single color-coded
parameter system used with the ADDS charts, if a single physi-
ological observation is recorded in the purple zone, the directed
response is to activate a MET call. This could explain the increase
in the reporting of a high heart rate (>140) and high respiratory
rate (>36) as triggers for MET call activations. The charts have been
specically designed with the critical vital signs, listed in decreas-
ing order of importance, displayed on the top-left corner of the page
(Preece et al., 2010), which could account for the decrease use of
the worried criteria. Prior to the implementation of ADDS charts at
this healthcare facility, low O2 saturation and breathing problems
were the most common sub-categories cited for when the worried
criteria was reported. Respiratory rate and oxygen saturations are
listed at the top-left of the chart, indicating their critical importance
and obviously highlighting to the user any immediate deterioration
in these physiological parameters. The location of the critical vital
signs may be one explanation for the change in activation num-
bers however further research is recommended to verify that chart
formatting inuences reporting incidence.
9. Limitations
This study was undertaken at one regional healthcare service,
while the ndings have inferences which are likely to be benecial
to other acute healthcare services, local contexts may differ. This is a
retrospective study and other factors such as stafng levels, atten-
dance at education sessions and environmental conditions could
have affected the number of cases during the two study periods.
10. Conclusions
The evaluation of the impact of the ADDS charting system in a
single Regional healthcare service showed an increase in the num-
ber of MET call activations in the post compared to the pre-ADDS
period. Although it was hypothesized that the introduction of the
ADDS chart would reduce the number of the Code Blue activations
this was not the case in this study. Patients continued to be man-
aged at ward level with only a slight increase in the number of
patients that were subsequently transferred to the Critical care unit.
The introduction of the ADDS chart does seem to have had an impact
on helping to dene the worried category with a signicant reduc-
tion in the number of cases reported as low saturations post ADDS,
which may be explained by the training and clearly dened param-
eters on the ADDS chart. Further research is required to assess the
impact of the introduction of the ADDS charting system to fully
ascertain the benets to patient safety in the early detection of
deterioration.
Please cite this article in press as: Missen, K., et al. Adult Deterioration Detection System (ADDS): An evaluation of the impact on MET
and Code blue activations in a regional healthcare service. Collegian (2017), http://dx.doi.org/10.1016/j.colegn.2017.05.002
5
Acknowledgments
We would like to thank and acknowledge the MET/Code Blue
activation project team members for their assistance with the data
collection process for this research.
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