Rapid Response Teams

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Rapid Response Teams

• Why, who, what?
• Noel Gibney MB FRCP(C)
• Critical Care Program
• Capital Health
• Division of Critical Care Medicine
• University of Alberta
• Edmonton, AB

2
UAH Medical Emergency Team

• Acknowledge
• The work and commitment of the team
• Cindy Scouten RN
• The Canadian ICU Collaborative
• Dr. Ann Kirby
• Dr. Rinaldo Bellomo

3
Critical Care is not a location-it is a level of
care and expertise that seriously ill patients
require
4
Referral Area
Capital Health 1.0 M population 1.6 M referral
area (Alberta 3.2 M)
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University of Alberta Hospital

• 677 bed tertiary academic referral centre
• Major referral centre for
• Cardiac sciences
• Organ transplantation
• Neurosciences
• Trauma
• Burns
• Major teaching hospital for Faculty of Medicine
  and Dentistry, University of Alberta

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UAH GSICU

• 30 beds (29 funded)
• 92 occupancy
• 1,400 patients/yr
• 11 elective surgical cases
• 33 admitted 0700-1700
• 64 admitted 1700-0700
• Mean APACHE II 21
• Mortality 14
• 3 intensivist teams
• 13 intensivists
• 1 chief resident
• 6 junior residents

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Outcomes following cardiac arrest at UAH

• Unwitnessed cardiac arrest mortality
• 82-90
• Patients admitted to ICU from ward
• 40 - 60 mortality
• Overall ICU mortality
• 13-15

Brindley PG et al. CMAJ 2002167343-8
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The Logic of the Medical Emergency Team

• Resuscitating dead people is harder than
  resuscitating sick people!
• Waiting for a cardiac arrest does not make sense!

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Traditional system
Unstable patient
Patient arrests admitted to ICU
RN identifies problem
No ICU beds
Junior resident notified
Senior ICU resident discusses with intensivist
Junior resident assesses patient
Senior ICU resident assesses patient
Junior notifies senior
Senior assesses patient
Junior ICU resident notifies ICU senior
Senior notifies attending
Junior ICU resident assesses patient
Attending wants ICU consult
Junior resident consults ICU resident
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Cardiac arrest team

• UAH adult cardiac arrest team response from CCU
• 2007 with opening of Mazankowski Heart Institute,
  CCU will be closer to Tim Hortons than Med/Surg
  Units at UAH!
• UAH GSICU will take over cardiac arrest response
• Transitional planning

X
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What is a Medical Emergency Team?

• A team of clinicians who bring critical care
  expertise to the patient bedside (or wherever it
  is needed).
• The goal To prevent deaths in patients who are
  failing outside intensive care settings.

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Difference Between MET and Cardiac Arrest Calls

• Cardiac arrest no time
• Cardiac arrest intervene first and ask questions
  later
• Cardiac arrest pandemonium
• MET call there is time
• MET call ask questions first
• MET thoughtful, planned approach

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Code team CCU
MET Team GSICU
Combined MET/Code team GSICU
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Why?

• We have had problems providing timely quality
  care to critically ill patients on med/surg units
• We have high proportion of ICU patients admitted
  from med/surg units
• We believe that rapid response teams can improve
  patient care

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Italy 1494
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Planning options

• Implementation
• Big bang
• Staged
• Team
• Separate RRT and Code
• Merged RRT and Code
• Team members
• RN, MD, RT
• RN, RT
• RN

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MET _at_ UAH

• Collaborative process between Critical Care and
  referring services
• Team
• ICU RN
• ICU Resident/Intensivist
• Ward RT
• Ward RN
• Service resident
• Equipment
• Transport monitor
• Airway, central lines, drugs
• Data collection-paper based
• Database

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Objectives

• Provide optimal care to at risk patients on
  hospital-wide basis
• To reduce time between activation criteria and
  initiation of treatment
• Reduce cardiac arrest calls by 30
• Facilitate timely ICU admission
• Reduce ICU admissions and length of stay
• Share critical care skills and expertise through
  educational partnership
• Promote continuity of care
• Thoroughly audit/evaluate these services

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Roles and Responsibilities

• Physicians
• Attend every MET call within 5 15 min.
• Assess the patient then ensure coordinate all
  diagnostic therapeutic measures for optimal
  patient care communicate to the patients
  attending team.
• RTs RNs
• Assess, diagnose guide the patients health
  care team to carry out treatment as per
  physicians orders
• Work collaboratively with the patients care
  team, ensuring clear communication and sharing of
  knowledge.
• Support the ward staff in assessment management
  of the patient.

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MET RN Assignment

• MET assignments will be indicated in the hour
  book
• The MET RN will have a light patient assignment
  and must not be doubled
• The charge nurse/UM/CNE will assume the MET role
  if operationally necessary
• MET nurse will function as the second Code RN
• If the second MET RN does not do Code, the code
  pager will be assigned to a Code RN

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MET RN Assignment

• At the start of the shift, must ensure that the
  RN beside you is prepared to take over care of
  your patient by giving a brief report
• If it is anticipated being on a MET call for an
  extended period of time, call the Charge nurse
  to ensure appropriate coverage of your patient
• The expectation is the covering RN will provide
  all patient care in MET RNs absence

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MET RN Responsibilities

• Carry the MET pager and hand off at shift change
  to the oncoming MET RN
• Sign in on sheet in List Binder
• Check MET equipment at start of day shift to
  ensure all contents are present and was checked
  on night shift
• Night RN must check contents of bag/cart with
  checklist, check medications for expiry dates and
  sign off in binder
• Restock equipment after each MET call
• Take MET equipment to the unit and return
  equipment to ICU after each MET call

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MET RN Responsibilities

• Perform a head to toe assessment of patient to
  determine severity of situation and intervene
  appropriately and chart on ICU nursing assessment
  sheet
• Receive report from unit RN
• Assists/performs diagnostic or therapeutic
  treatment
• Assist in education and support of Unit staff in
  regards to follow up care or treatment

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Unit RN Role

• Activate MET according to established criteria
• Provide MET with the necessary patient
  information
• Explain MET to patients family
• Have chart and MAR in patients room
• Ensure suction, O2, emergency drugs and
  resuscitation basket are in room
• Assist in care of MET patient
• Assist with documentation
• Monitor the patient at the end of MET call

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Unit Resident Responsibilities

• The Resident for the Unit needs to be notified
  when the MET team is called
• The Resident calls the patients attending
  Physician to notify that the patients status has
  changed and the MET team has been called
• The Resident collaborates with the MET team

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MET Physician Responsibilities

• Clinical bedside assessment with written
  documentation in patients clinical record
• Coordination of appropriate diagnostic
  procedures/interventions
• Coordination of appropriate level of care
  discussions when indicated and associated
  documentation in patients clinical record
• Communicate all diagnostic and therapeutic
  measures to the patients attending team
• Each MET assessment will be discussed with the
  Intensivist and patients attending team prior to
  METs departure

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MET Physician

• The MET physician may be unable to stay with the
  patient for the entire MET call
• It is acceptable for the physician to leave the
  MET RN with the patient to carry out
  interventions as ordered
• The physician must be available to the MET RN by
  phone for further instructions or for issues that
  may arise

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MET RT Responsibilities

• Ongoing ventilation/oxygenation assessment and
  management
• Assist with intubations
• ABG sampling, analysis and interpretation
• Stat 12 lead ECG (1600-0700 hours)
• Accompany patients with unstable airways or
  critically ill within hospital
• Completes written documentation of therapies,
  interventions and patient response

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MET RT Responsibilities

• Follows patient as recommended by MET
• Communicates patient status to other team members
  
• Provides expertise and assistance to unit staff
  caring for patient
• Includes patient at RT shift change report

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MET Medications

• NMB Rocuronium Date when removed from fridge
  (good for 30 days out of Fridge)
• Versed 5mg vials X 3 (restock from Pyxis, MET
  patient)
• Levophed 4mg X 4 vials
• NaHCO3 X 2 amps
• Epinephrine 11000 preloaded X 2amps
• Amiodarone 300mg to be mixed in 100cc minibag of
  D5W
• Atropine X 2 vials

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MET Medications

• Ephedrine X 2 vials
• Calcium chloride X 1 amp
• MgSO4 X 1 amp
• D50W X 1 amp
• Premixed minibag KCL 1 X 20 mEq, 1 X 10 mEq
• Lasix X 2 vials
• Ventolin and Atrovent side stream X 1
• Check medications for expiry dates
• Fentanyl is available on the units for intubation

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MET Equipment

• Stethoscope
• D5W 1 X 100cc minibag, 1 X 250cc bag
• Pentaspan 1X 500cc bag
• ECG leads
• 14 gauge quick catheter X 4
• 16 gauge quick catheter X 1
• Goggles
• End tidal CO2 detector
• Monitor Printer with paper inserted and NIBP
  module with cuff

• Needles and filter needles
• Syringes
• 10cc syringe NS X 2
• Triple lumen
• Pressure monitoring tubing
• Pressure bag
• Minor suture bundle
• Suture (3-0 Prolene) X 2
• Scalpel blades X 2

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MET pilot roll-out _at_ UAH
GI
Nephrology
Hematology
Planning
Monitoring-PDSA cycles
M
A
M
J
J
A
S
O
N
D
J
M
J
J
A
S
F
M
A
2005
2004
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Planning process
RRT Steering Group
Culture change
Team to team
Senior admin
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Medical Emergency Team Process
Staff Member identifies MET Trigger
Calls 33 to activate MET and notify Service
Resident on Call.
Hospital locating activates MET pager Overhead
page Medical Emergency Team to..
Medical Emergency Team and Junior Resident
arrive, assess patient and initiate treatment
Patient stabilized and remains on Unit Patient
stabilized and transferred to GSICU End-of-life
discussions
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Time of MET calls
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MET called by
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Why was MET called?
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Actions taken by MET
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MET Calls Aug 04-Jan 06
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Cardiac arrests/100 admissions
Hematology
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Cardiac arrests/100 admissions
Nephrology
Late calls Brittle patients Minimal physiological
reserve Calls filtered through residents Variable
attending support
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Cardiac arrests/100 admissions
Gastroenterology
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UAH Cardiac Arrests
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MET call duration

• Range 25 mins 1 hr 45 mins
• One outlier 7 hrs!!
• Mean 49 mins

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Patient disposition following MET call
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Issues

• Late activation
• Filtering of calls
• ICU consult instead of MET activation
• Role definition
• New switchboard staff
• Lack of ICU beds
• Data management
• Attitude issues
• End-of-life

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Diagnosing Dying

• Recognizing and correctly diagnosing medical
  emergencies is vital
• Providing prompt and competent treatment for such
  emergencies is vital
• The MET is an important approach to both
• However....the MET rapidly faces a new
  differential diagnosis life-threatening
  emergency or dying?

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Protection from cardiac arrest teams!
Frances Polack 84 y.o. nurse
This is what you have to do if there is no MET
system!!
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• No significant decrease in cardiac arrests or
  mortality
• MET called only 1/3 of time triggers met in
  intervention cluster hospitals
• Strong suggestion of outreach implementation in
  control cluster

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Attitude 1 ego/aggression
Testosterone
Testosterone
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Attitude 2 the goalie
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Attitude 3 - Not my problem!
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Attitude 4 Silverback
The largest of the apes, the Mountain Gorilla is
a highly intelligent and gentle creature. Despite
a ferocious reputation, the gorilla rarely makes
use of his incredible strength. When it comes to
defending the family or breeding rights, however,
it's full-force fury, gorilla-style.
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Attitude 5 Academic Health Centre Silos
Departmental ego is more important to than
patient care
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MET
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Resolution

• Education, multiple meetings with attending
  physicians.
• Educational sessions, one-on-one discussions with
  residents involved in late MET calls
• Education, discussions with UAH Medical Council.
• Education, discussions with new Chair, Dept. of
  Medicine.
• Dinner, education, discussions with service
  chiefs, Chair of Medicine.

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Resolution

• Education, multiple meetings with attending
  physicians.
• Educational sessions, one-on-one discussions with
  residents involved in late MET calls
• Education, discussions with UAH Medical Council.
• Education, discussions with new Chair, Dept. of
  Medicine.
• Dinner, education, discussions with service
  chiefs, Chair of Medicine.

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Attitude 6 Thank you!!!

• Guest appearances
• requests for MET on services prior to formal
  implementation
• Interest
• in learning more about management of critically
  ill
• Improvement in team relations
• With referring units/depts.
• ? Improved RN recruitment from referring
  units/depts.

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What we have learned

• Must have strong ICU leadership MD/RN
• Dont wait until you have full funding
• Start a pilot
• Take small bites
• Measure bite by bite
• Share ideas freely
• Steal new ideas shamelessly
• Give frequent feedback to referring services

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MET-what we have learned

• Deal with problems in real time as they arise
• Request formal review of problems resulting in
  poor outcomes
• One-on-one huddles are critical
• Invite residents to office to discuss patient
  care issues
• Communication and education are critical
• Political pressure may be required in large
  academic health centres
• High level administrative support is vital in
  large academic health centre
• Be patient, be very, very, very, very patient
• Dont wait until hospital culture is right-start
  changing the culture with MET

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UAH MET Roll-out
Neuro
Surg
Med/Psych
G.I.
Nephro
Hem
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Issues to be resolved

• Price of success
• Increasing calls
• End-of-life
• Educational feedback to referring services
• Need for more staffing
• MD - ?intensivists, ?hospitalists
• RN
• Data management
• Spread
• Pilot project at Grey Nuns Community Hospital
• Discussions re implementation at Glenrose Rehab
  Hospital
• Extend outreach at UAH
• Follow-up team
• Patient clinic

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• How many psychiatrists does it take to change a
  lightbulb?

• Only one, but the lightbulb must want to be
  changed!

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Change

• He who rejects change is the architect of decay. 
  The only human institution which rejects progress
  is the cemetery.  Harold Wilson
• If you're in a bad situation, don't worry it'll
  change.  If you're in a good situation, don't
  worry it'll change.  John A. Simone, Sr.
• Change is the law of life. And those who look
  only to the past or present are certain to miss
  the future. John F. Kennedy
• Progress is a nice word. But change is its
  motivator and change has its enemies. Robert F.
  Kennedy
• It is not necessary to change. Survival is not
  mandatory W. Edwards Deming

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• Thank you for your attention