run, don’t walk: improving outcomes in pediatrics using a rapid response team wednesday, june 4,...

Run, Don’t Walk: Improving Outcomes in Pediatrics Using a

Rapid Response Team

Wednesday, June 4, 20085:00 – 6:00 p.m. EDT

© American Academy of Pediatrics 2008

Moderator: Paul Sharek, MD, MPH, FAAPAssistant Professor of Pediatrics, Stanford School of MedicineMedical Director of Quality ManagementChief Clinical Patient Safety OfficerLucile Packard Children’s HospitalPalo Alto, California

This activity was funded through an educational grant from the Physicians’

Foundation for Health Systems Excellence.

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Speaker: Annie Moulden, MBBS, FRACPClinical Leader, Patient Safety and RiskRoyal Children’s HospitalMelbourne, Victoria, Australia

Speaker: Jim Tibballs, MBBSPhysician Intensive Care Unit and Resuscitation OfficerRoyal Children’s HospitalMelbourne, Victoria, Australia

Speaker: Sharon Kinney, RN, MNRoyal Children’s HospitalMelbourne, Victoria, Australia

Run, don’t walk: Improving outcomes in pediatrics using a rapid response team

The Melbourne experience

Dr Annie MouldenAssoc Prof Jim TibballsMs Sharon Kinney

Royal Children’s HospitalMelbourne, Australia

Why did we introduce the MET?

Annie Moulden

Clinical Leader, Patient Safety & Risk

Dr Jim Tibballs

Intensive Care Physician & Resuscitation OfficerRoyal Children’s Hospital, Melbourne, Australia

james.tibballs@rch.org.au

RAPID RESPONSE TEAMS

Medical Emergency Team (MET)

Rapid Response Team (RRT)

WHY DO SOME CHILDREN DIE UNEXPECTEDLY IN HOSPITAL?

SOMETIMES CARDIAC ARREST IS NOT PREDICTABLE

SOMETIMES CARDIAC ARREST IS PREDICTABLE, BUT …

Severity of illness is not recognized Help is not requested until cardiac arrest No assistance is available Assistance is available but delayed

‘RATIONALE’ of MET/RRT

… prevent predictable cardiac arrest

Outcome from cardiac arrest is poor Some cardiac arrests are ‘unexpected’

… but which are predictable (‘foreseeable’) on basis of symptoms and signs

… and which might be prevented if child treated intensely early

MET or RRT is …

ORGANIZATIONAL CHANGE

ANY staff, no matter how junior or senior, may call MET/RRT … Without discussion with seniors Without discussion with colleagues Without permission of seniors Without discussion with doctors

MET at Royal Children’s Hospital Melbourne, Australia

SYSTEMS SOLUTION … One–tier system Team of doctors (3) and nurse (1) from

intensive care/emergency dept Respond immediately to call for assistance

on wards/departments- Can manage medical/surgical emergencies- Treat patient on ward to stabilize, transfer etc

What does MET do?

Assess and treat the patient as required

Discuss management of the patient with the members of the treating (attending) unit

Admit the child to ICU or continue to help manage on ward as required

Elements of MET/RRT

Educate staff to recognize serious illness Establish MET calling criteria Call for assistance Provide immediate assistance Collect data, feedback to staff, educate

1. Nurse or doctor WORRIED about clinical state

2. Airway threat

3. Hypoxaemia:SpO2 <90% in any amount of oxygen

SpO2 <60% in any amount of oxygen

(cyanotic heart disease)

ANY one or more of the following:

MET calling criteria

MET calling criteria

4. Severe respiratory distress, apnoea or cyanosis

Age Respiratory Rate

Term-3 months >60

4-12 months >50

1-4 years >40

5-12 years >30

12 years+ >30

5. Tachypnoea

MET calling criteria

6. Tachycardia or bradycardia

Age Bradycardia Tachycardia

Term- 3 months <100 >180

4-12 months <100 >180

1- 4 years <90 >160

5-12 years <80 >140

12 years+ <60 >130

MET Calling Criteria

7. Hypotension

Age BP (systolic)

Term- 3 months <50

4-12 months <60

1- 4 years <70

5-12 years <80

12 years+ <90

8. Acute change in neurological status or convulsion

9. Cardiac or respiratory arrest

MET calling criteria

Does MET make any difference to cardiac arrest and mortality?

PREDICTABLE (PREVENTABLE) CARDIAC ARREST & DEATH

(per 1000 admissions)

BEFORE MET

AFTER MET

1 YEAR

AFTER MET

4 YEARS

CARDIAC ARREST

0.16 0.00(p=0.02)

0.07(p=0.04)

DEATH 0.11 0.00(p=0.04)

0.01(p=0.001)

TOTAL UNEXPECTED CARDIAC ARREST & DEATH (UNPREDICTABLE + PREDICTABLE)

(per 1000 admissions)

BEFORE MET

(1999-2002)

AFTER 1 YEAR MET

AFTER 4 YEARS MET

CARDIAC ARREST

0.19 0.11 0.17

DEATH 0.12 0.06 0.04

(p=0.03)

Sharon Kinney

MET Coordinator,

Royal Children’s Hospital, Melbourne

Implementing MET (initial)

Support from the executive

Introduction letter to all medical staff and heads of department

Educational sessions +++Emphasis on empowering nursing & medical staff

MET posters

MET staffSupportive & positive attitude to callers of MET

Implementing MET (ongoing)

Other education Sick child workshops number of places for staff on PLS/APLS courses

Regular clinical practice meetings reviewing MET data & selected cases

MET coordinator role within the Clinical Quality & Safety Unit

Ongoing review of critical events (identify & follow up problems with the MET system and/or other hospital processes of care)

Possible concerns

De-skilling ward staff

There will be too many unnecessary (trivial) calls

Taking resources away from ICU (or elsewhere) especially at night time

Time of day for MET calls (4 year period, n = 809)

0

10

20

30

40

50

60

Time of day (hours)

Nu

mb

er o

f M

ET

cal

ls

Take away points Do you have potentially preventable cardiac arrests/deaths?

What resources are available/needed to support a 24 hour service that can promptly respond to a MET call?

Enlist support from the hospital leadership team

Educate and empower ward staff to request MET

Ensure MET staff adopt a supportive attitude to ward staff initiating the MET call irrespective of perceived appropriateness

Collect data – ongoing evaluation & feedback to staff