Critical Care Response Teams in Ontario: Rationale, Research and Results

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Critical Care Response Teams in Ontario
Rationale, Research and Results

• Stuart F. Reynolds, M.D.

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Disclosures

• Physician Lead, Ministry of Health and Long Term
  Care, Critical Care Response Team Project

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Outline

• Overview of a Rapid Response System
• Rationale
• Reviewing the evidence
• Snapshot of the Ontario experience

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Rapid Response System Framework
Efferent Limb
Afferent Limb
Administrative Limb
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Afferent Limb

• Event Detection Identifying the patient at risk
• Bedside Clinician
• Empowerment
• Education
• Calling Criteria
• Recognition of the critically ill

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Efferent Limb

• Structure varies with jurisdiction
• U.K. Outreach
• Australia MET
• U.S.A. MET, Hospitalists, RRTs
• Canada CCRTs
• MET during day
• Outreach at night with Intensivist backup
• Patient Assessment Treatment

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Administrative Limb

• Leadership
• Implementation Planning
• Data Collection Analysis Feedback
• Design feedback mechanisms to the team and to the
  teams response areas
• Track data to improve utilization of the team

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Why bother??

• A code does not occur out of the Blue

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• Cardiac arrests over 4 months
• 84 had documented clinical deterioration within
  8 hours pre-arrest

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Recognizing clinical instability in hospital
patients before cardiac arrest or unplanned
admission to intensive care. A pilot study in a
tertiary-care hospital.Buist MD, Jarmolowski E,
Burton PR, Bernard SA, Waxman BP, Anderson J.

• Retrospective review, over one year of all
• cardiac arrests
• unplanned ICU admission
• Median duration of instability 6.5 hours prior to
  Critical Event

Med J Aust. 1999 Jul 5171(1)22-5
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Prospective confidential inquiryReviewed 100
consecutive patients admitted to ICURevealed
that up to 41 of ICU admissions could possibly
be avoided.Related tofailure to appreciate
alterations in the ABCs and delay in ICU
Consultation
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Unexpected deaths and referrals to intensive care
of patients on general wards. Are some cases
potentially avoidable?
J R Coll Physicians Lond. 1999 May-Jun33(3)255-9

McGloin H, Adam SK, Singer M.

• 6 months review of all hospital deaths, unplanned
  ICU admissions
• 4 of deaths were potentially avoidable, early
  warning signs not appreciated.
• ICU Admissions
• 32 of which clinical deterioration was not
  appreciated
• ICU mortality higher 52 vs 35

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Et Tu?
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Is Early Death Following ICU Admission
Preventable?

• Anika Minnes, John T Granton, Wilfrid Demajo,
  Anne Marie Sweeney, Stuart F. Reynolds, Thomas E.
  Stewart, and Niall D. Ferguson
• University Health Network
• University of Toronto

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Vitals within 6 hours of ICU admission
All Early Death No Early Death
Number 120 21 99
Resp Rate 50 38 53
Saturation 76 71 77
Systolic BP 75 71 76
Heart Rate 73 62 75
Urine Output 8 0 10
Drop in LOC 20 14 21
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Rationale

• There is time for intervention
• The evolution of physiological deterioration is
  relatively slow.
• There are warning signs
• Clinical deterioration can be detected utilizing
  common vital signs
• There are effective treatments
• Early Goal Directed Therapy
• ACS therapy
• Oxygen, NIV for COPD, CHF
• Many critical interventions are time dependant.
• Trauma
• Severe Sepsis
• ACS
• CVA
• Expertise exists and can be deployed

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Critical Care Response Teams in Ontario are

• A systematic approach to the early identification
  and facilitation of resuscitation of in-patients
  at risk of deterioration.
• A way to provide Comprehensive Critical Care
  Services
• Prophylactic interventions
• Follow-up of patients recently discharged from
  the ICU to prevent readmission
• Rounds on high-dependency units

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continued

• A way to provide critical care education
• Teaching nursing unit personnel
• Signs and symptoms of an at risk patient
• Utilization of calling criteria
• Teaching medical students and residents how to
  recognize and resuscitate the acutely ill patient
• A way to Support and Coordinate the care of
  patients
• Assistance with end-of-life decision discussion
• Improving communication between the ICU and other
  units

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Hospital Mortality Observational
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Cardiac Arrest
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Lancet, June 2005
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MERIT at a glance

• 23 Hospitals
• Variable Hospital Size and Type
• Variable Team Structure
• Implementation timeline
• 2 month baseline
• 4 month implementation phase
• 6 month evaluation phase
• Outcomes
• Primary composite - No Difference
• Secondary - No Difference
• Cardiac Arrests
• Unexpected ICU admissions
• Unexpected deaths

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Dose Response Curve
Critical Care 2005, 9R808-R815
Vol 9 No 6 Research Long term effect of a medical
emergency team on cardiac arrests in a teaching
hospital Daryl Jones, Rinaldo Bellomo, Samantha
Bates, Stephen Warrillow, Donna Goldsmith, Graeme
Hart, Helen Opdam and Geoffrey Gutteridge
17 MET calls per 1000 inpatient admissions is
associated with reduction in cardiac arrest rate
of 1 per 1000 admissions
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How does this compare to MERIT?
6.3 1.2 5.1 MET calls/1000
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• Predicted impact on Cardiac Arrests of 5 MET
  calls
• 0.3/1000

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Critical Care Response Team Expansion Project
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• USE IT or LOSE IT!!!

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Implementation Principles

• Local leadership, Central Coordination
• Strong Local Leadership
• MD lead, co lead nurse leader or RRT leader,
  Administrative Support
• Navigation of the Cultural, Sociologic, Political
  Mine Fields
• Central Coordination
• Support Local Leadership!!!
• Coordinating Communication between sites
• Identify Hospitals
• Define Team Structure
• Defining Roles and Responsibilities
• Identification of Accountabilities
• Data Analysis Feedback

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Timeline for CCRT Project

• Phase I Preparation and team development,
  training and marketing. May 2006 Oct 2006
• six months
• 284 RNs and RRTs trained wonderful
  collaboration between local and central
  leadership
• Development of a CRI CCRT Course
• Phase II Preceptorship. Nov 2006 Jan 2007
• 8 hour day limited service
• consolidation of training, marketing
• twelve weeks
• III 24/7 service began January 29, 2007

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Evaluation PlanManaging Success Managing
Improvement

• Outcome Measures
• Code Blue
• Cardiac Arrests
• Respiratory Arrests
• Hospital Mortality
• Readmission Rate
• Length of Stay
• Accountability Measures
• Return on Investment

• Improving Implementation
• Audit
• Criteria
• Location of Patient
• Code Blue
• Unanticipated ICU admissions
• CCRT Consults
• Call Volume
• Service
• Qualitative assessments
• Why people use service
• Why people dont use service

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Some Early ResultsFirst Month of 24 hour service
MERIT
34 CCRT activations per 1000 inpatient admissions
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• Outcomes of 1739 Consults
• Phase II

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Going Forward

• Will the outcomes follow the implementation?
• Return on investment
• Refining the processes
• Testing Alternative Models
• Hospitalist
• Education interventions

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Thanks

• To our CCRT Leadership and Teams!!!!
• Stuart.Reynolds_at_uhn.on.ca