meet the professor – how i run my met team · meet the professor – how i run my met team ken...
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Intensive CareUnit
MEET THE PROFESSOR – HOW I RUN MY MET TEAM
Ken Hillman Critical Care Canada Forum. 13th-16th November 2011
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PATIENTS SUDDENLY DIE IN GENERAL HOSPITAL WARDS NOT IN ICU/OT/
ED ENVIRONMENTS
2/0032
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• Up to 80% of patients with in-hospital cardiac arrest have changes in vital signs within eight hours before arrest [Schein RMH. Chest 1990; 98:1388-1392]
• Up to 41% of admissions to ICUs are potentially avoidable [McQuillan P. BMJ 1998;316:1853-1858]
• Patients admitted from general wards have higher mortality than those from the OR, ED or Recovery
1.2/0002
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HOSPITALS ARE A 19TH
CENTURY CONSTRUCT
• Strong vertical components based on individuals
• Almost no horizontal silos
1.2/0005
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SILOS• Individual doctor/patient relationship at the centre of
training and practice• Different tribes
– Doctors– Nurses– Allied Health– Managers– Government
• Strong silos– Wards– Specialised care units– Emergency Department– Operating Rooms
1.5/0051
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HOSPITALS ARE A 19TH
CENTURY CONSTRUCT
• Comprehensive monitoring and specialised staff – ER, ICU, OT, recovery, CCU
• General wards – low staff ratios, manual monitoring in random, inaccurate and non-standardised way
1.2/0097
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HOSPITAL POPULATION• Older• Multiple co-morbidities• Complex drugs and interventions• Societal expectations of medicine• Reluctance of medicine to discuss its
own limitations
1.5/0090
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OTHER FACTORS• Medical specialisation• Committee medicine• Poor undergraduate training in acute
medicine• Disempowerment of nursing staff• Medical hierarchies and politeness
trumping patient care
1.5/0091
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SICK PATIENT
NURSE OBSERVES BUT CAN’T ACT
TRAINEE DOCTORS ACT BUT NOT TRAINED
SPECIALIST – TRAINED BUT NOT IN ACUTE MEDICINE
EVENTUALLY MULTIORGAN FAILURE/CARDIAC ARREST AND ADMITTED TO ICU
Systems to connect first signs with acute care specialists
1.2/0073
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Well
Patient
Sick
Pre-arrest
Cardiac Arrest
Time
DEAD2/0024
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2/0026
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EMERGENCY TEAM CALLSMean time <30 min/callEqually distributed across days of weekDiurnal pattern – 0601 – 1200 h more common
Resuscitation 2010;81:25
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VARIATIONS IN RAPID RESPONSE SYSTEMS (RRS)
• Single criteria for calling• Score criteria• Single tier response• Double tier response• Outreach team
1.13/0009
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ICUs and RRSs• Both novel and challenged existing hospital
structure• Both took time to be accepted• Both required special skills, experience and
knowledge• Both require funding and staffing• Neither have been unequivocally shown to
have benefit• Both systems built around the needs of
seriously ill patients
1.13/0010
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LEVEL OF ILLNESS AND OUTCOME FOR RRS AND ICU
PATIENTS THE SAME
Crit Care Resus 2008;10:24Resus 2004;62:137
1.13/0011
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INTERVENTIONSEmergency Team Calls
(ie non-cardiorespiratory arrest)
512 control hospitals1864 MET hospitals Only 5 of these were not critical care interventions Only 1 had an assessment/examination
Resuscitation 2010;81:25
1.4/0359
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BORDERS BETWEEN ICUs and RRSs
• Variations in ICU admission and discharge criteria
• Variation in case mix in hospitals• Variation in staffing numbers and skill
levels in general wards
OFTEN RANDOM CHANCE ABOUT WHERE SERIOUSLY ILL ARE IN THE HOSPITAL
1.13/0012
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BORDERS BETWEEN ICUs and RRSs
• Designed around seriously ill patients• Our hospital colleagues had little insight into
how inappropriate their skills were for caring for the seriously ill
• Initial resistance to both ICUs and RRSs - now legitimate
• Concept closed / open ICUs / RRSs
1.13/0013
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BORDERS BETWEEN ICUs and RRSs
Austin Hospital, Melbourne – mature system; 50 calls/1000 patient admissions
• 2000 1700 ICU adm 250 MET calls• 2008 2000 ICU adm 1600 MET calls
1.13/0014
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EXTENSION OF METCONCEPT
• MET becomes surrogate dying team• Intensivists make diagnosis of dying • Parallel urgent Palliative Care response system
1.14/0001
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MET AND END-OF-LIFE CARE
• Multicentre international study• About one-third of all calls were to make end-
of-life decisions• Many calls were made after hours• Large workload for MET teams and huge
problem in dealing with end-of-life in acute hospitals.
CCM 2011: in press
1.14/0002
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DOES A MET/RRS WORK?
2/0017
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SINGLE CENTRE STUDIES ALL SHOW A REDUCTION
IN CARDIAC ARRESTS AND DEATHS
• System implementation is different from drug and procedural implementation
• A large Hawthorn effect is essential
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BEFORE/AFTER MET
50% reduction in CARDIAC ARRESTS after casemix adjustment odds ratio
0.5: 95% CI 0.35-0.73
BMJ 2002;324:387
2/0039
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MERIT STUDY
The MET system reduces mortality
Crit Care Med 2009;37:148-153
1.4/0360
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META ANALYSIS30% reduction in paediatric
mortality and cardiac arrest rates30% reduction in adult cardiac
arrest ratesNOT ACHIEVED BY ANY OTHER
INTERVENTION
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REDEFINING RESUSCITATION
Is about system implementationas well as individual clinical skills
2/0017
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EFFECTIVE IMPLEMENTATION OF RAPID RESPONSE SYSTEMS
1. Triggering criteria 2. Response – 24/7 of at least one person with advanced
resuscitation skills3. Ownership and administration within a hospital4. Education
• Awareness – EVERYONE• Basic resuscitation – NURSES AND ON-SITE MEDICAL STAFF• Advanced resuscitation – MINIMUM 1 PERSON 24/7
5. Key performance Indicators (KPIs)• Measure problem• Track implementation and maintenance• Measure effectiveness
ALL IMPLEMENTED SIMULTANEOUSLY
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THE FUTURE – Changing Hospital Population
• LOS• Older, sicker, more complex procedures• Multiple co-morbidities• Changing role of general ward
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THE FUTURE• Universal non-invasive signal
generation monitoring• Use algorithms from signals to
triage patients
2/0178
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NEED TO CARE FOR CRITICALLY ILL PATIENTS
NOT CRITICAL CARE UNITS
1.5/0092