Barriers to triggering

the RRS

A/Prof Daryl Jones

Conflict of interest

• ACSQHC - $AU $77k – research grant

• Eastern Health - $ AU 5k – consultancy fees

• Academic bias RRT

Overview

• What happened in the era pre-MET ?

• Is there any evidence of barriers ?

• An approach to considering barriers

• Barriers to detection

• Barriers to recognition

• Barriers to escalation

• What can we do to fix the problem?

Further reading

• ACSQHC - http://www.safetyandquality.gov.au

• Buist M. CCM 2008: 634

• Marshall et al. Implementation Science 2011, 6:39

• Surveys

– Jones et al. Nurses’ Attitudes to a Medical Emergency Team Service in a

Teaching Hospital. Qual Saf Health Care 2006: 427

– Bagshaw SM, et al. A Survey of Nurses' Beliefs About the Medical

Emergency Team System in a Canadian Tertiary Hospital. Am J Crit Care.

2010;19: 74-83

• DeVita etal ―Identifying the hospitalised patient in crisis‖—A consensus

conference on the afferent limb of Rapid Response Systems.

Resuscitation; 2010: 375–382

• Jones L, etal A literature review: factors that impact on nurses’ effective

use of the MET. JCN; 2009: 3379.

Surveys

• Nurses attitudes to the MET

• 17-item questionnaire; Likert agreement scale

• Alberta Canada

– 614 nurses

– 293 (47.7%) were approached

– 275 completed the survey (RR, 93.9%).

• Melbourne Australia

– 689 nurses

– 351 (50.9%) approached and RR 100%

> 600 nurses

> 95% RR

Before the MET

• Junior ward doctors and nurses may not

have sufficient skill set to identify and treat

critically ill patients on ward

–McQuillan etal BMJ 1998 UK

–Buist etal MJA 1999 Aus

• RRT called when patients fulfil objective calling criteria

• Often also have a ―worried‖ criterion

Airway Obstructed airway

Noisy breathing / stridor

Problems with a tracheostomy tube

Breathing Difficulty breathing

RR < 8 or RR > 25 breaths/min

SpO2 < 90% despite high flow oxygen

Circulation HR < 40 or HR > 120 bpm

Systolic BP < 90 mmHg

UO < 50mL over 4 hours

Other Acute change in conscious state

You are worried for any other reason

Evidence of barriers

• MERIT study

– Cluster RCT 23 Australian hospitals

– No difference in composite outcome

– Substantial proportion of patients had MET criteria > 15min

before event BUT no MET called

»

Hillman etal Lancet 2005

? Evidence barriers …..contin..

• Melbourne Victoria

• Cardiac arrests

– 28 % of 162 cardiac arrests followed an initial MET call 1

– 84% of these < 5min after MET activation

– Delayed MET activation cardiac arrest

• Delayed MET activation common (>30 min delay) 1,2

» GCS 35% (16hr)

» Arrhythmia 24% (13hr)

» Resp distress 50% (12hr)

» Hypotension 39% (5hr)

1. Jones etal ICM 2006 3. Quach etal JCC 2008

2. Downey etal CCM 2008

24-50% calls delayed

median 5 – 16hr delay

Quach etal JCC 2008

Delayed MET activation

increases death

? Evidence barriers …..contin..

• Victoria – RESCUE study Prof Tracey Bucknall

– 10 hospitals with mature RRSs

– Retrospective chart review prior 24 hr period

– 2199 in-patients, 1587 patients in hospital for at least 24

hours prior to data collection

– 5.67% (n=90) had MET criteria.

– only 5(5.5%) received a MET call within 24 hours

• South Australia

– 6 months, 443 patients

– 575 events

»6.1% cardiac arrests

»68.7% MET calls

»25.2% unplanned ICU admission

– 22.8% had MET criteria but no call in prior 24 hr

– Afferent limb failure had increased:

»Unplanned ICU admission

»NFR documentation

» In-hospital mortality

1. Trinkle Resuscitation 2011

Summary – evidence of barriers

• Afferent limb failure is common

–Absolute = not called at all

–Relative = delayed calling

• Associated with increased mortality

–? How much of this relates to end of life care

Approach to considering barriers

Marshall et al. Implementation Science 2011

• Theoretical

triangulation

• Cognitive engineering

model of situational

awareness

• Sociologically informed

models of inter-

professional practice

Steps in afferent limb

Measure

vital signs

Fulfil RRT

criteria

Activate

RRT

Detection Recognition Escalation

Failure of detection

• MERIT study 1

– In adverse events »60% no BP, HR, RR within 15 minutes of event

• Post op major surgery 2

– 211 patient files, 5 large hospitals

– first 3 post-op days, »Only 17% complete documentation of vitals and

medical and nursing review.

– first 7 postoperative ward days, »nursing review not documented 5.6% shifts

»medical review not documented 14.9% days.

1. Hillman etal Lancet 2005

2. McGain etal MJA 2008

• Cretikos et.al. (MJA 2008)

– Respiratory rate; the neglected vital sign

• Leuvan CH, Mitchell I. (CCR 2008)

– Missed opportunities

•RR most poorly recorded vital sign

• Diurnal variation of MET calls - few calls overnight 1

• The more givers visit a patient, the more likely they are

to detect patient deteriorations 2

1. Jones et al CCF 2005

2. DeVita 2005

Failure of recognition

• Part time / agency staff not familiar with criteria

• Staff work at multiple hospitals with different criteria

• Use of discretion (survey responses)

Strongly

Disagree

Disagree Uncertain Agree Strongly

agree

If my patient fulfils listed MET criteria

but does not look unwell I would not

make a MET call 22.1 39.5 22.6 13.8 2.0

27.9 44.2 21.1 3.8 3.0

• In some wards (burns / trauma)

– MET criteria very often breached (―normal‖)

– May not suggest worsening outcome

• May need to change MET criteria to increase use 1

Strongly

Disagree

Disagree Uncertain Agree Strongly

agree

I would call a MET on a patient I

am worried about even if their

vitals signs are normal 1.1 19.4 23.6 41.9 14.0

5.6 19.6 26.7 36.8 11.3

1. Jones etal AIC 2006

Failure of escalation

1. Perception that the MET does not work

2. Allegiance to parent unit

3. Fear of criticism

– Management of patient

– Making the call

4. Perceptions of increased work load

5. Perception that the MET is overused

• Perception that the MET does not work

Strongly

Disagree

Disagree Uncertain Agree Strongly

agree

The MET prevents unwell

patients from having an arrest 0.6 4.6 3.7 38.0 53.1

2.6 4.2 9.1 43.8 40.4

Strongly

Disagree

Disagree Uncertain Agree Strongly

agree

The MET can be used to prevent

a minor problem from becoming a

major problem

1.4 2.6 3.2 37.5 55.3

3.4 4.5 7.9 36.8 47.4

• Jones L etal JCN

– Education / in-service on MET associated with increased use

of MET

» Drives uptake and increased use with time

» Reduces delays in activation

– Expertise of nurse may affect rates of activation

» How senior

» Prior positive experience with MET

– Local culture / educational efforts on certain wards

1. Jones L JCN 2009

• Allegiance to the parent unit

Strongly

Disagree

Disagree Uncertain Agree Strongly

agree

When one of my patients is sick, I

call the covering doctor before

calling a MET.

1.7 9.0 17.2 58.0 14.0

1.2 12.6 10.3 59.0 16.9

Strongly

Disagree

Disagree Uncertain Agree Strongly

agree

If I cannot contact the covering

doctor about my sick patient, I

activate a MET call.

1.7 6.4 10.7 47.8 33.3

1.2 8.9 15.1 46.5 28.3

• Fear of criticism

Strongly

Disagree

Disagree Uncertain Agree Strongly

agree

I don’t like calling MET because

I will be criticised for not looking

after my patient well enough

51.4 44.0 3.1 0.9 0.6

47.0 45.2 4.9 1.9 1.1

Strongly

Disagree

Disagree Uncertain Agree Strongly

agree

I am reluctant to call a MET on

my patients because I will be

criticised if they're not that unwell

35.4 46.3 8.3 8.0 2.0

31.1 44.2 9.4 13.1 2.3

• Belittling comments and accusations that the MET call was

made too early 1

• MET taking control / not communicating with ward staff –

disempowered

• Size of team too large

1. Jones L JCN 2009

• Perception that MET calls increase workload

Strongly

Disagree

Disagree Uncertain Agree Strongly

agree

Using the MET system increases

my work load when caring for a

sick patient

39.9 44.4 6.6 8.3 0.9

35.6 45.7 4.1 2.6 1.9

• Perception that the MET is overused

Strongly

Disagree

Disagree Uncertain Agree Strongly

agree

I think that the MET is overused

in the management of hospital

patients

43.4 42.9 9.7 2.9 1.1

What can we do about this?

• Improve detection

– Electronic monitoring of vital signs – particularly overnight

– Tailored plan about monitoring of vital signs

– (ACSQHC – National consensus statement)

– Graphical representation of vital signs

– Cultural shift to emphasize importance of vital signs (―vitals‖)

• Improved recognition

– Education / posters

– Tools to assist decision support

» Algorithms and electronic alerts

» Colour coded vital sign charts

• Audit and feedback afferent limb failure

• If repeat offenders governance

• Acknowledge allegiance to parent unit

– ? Realistic to manage all deteriorations (5-10% admissions)

– Education of ward staff about deteriorating patients

– Emphasis on repeated review

» Is abnormal becoming normal

» If not escalate

Conclusions

• Afferent limb failure is common

• Probably increases mortality (? EOLC/NFR)

• Barriers

– Detection / Recognition / Escalation

– Cognitive / socio-cultural

• Actions

– Cultural shift to importance of monitoring / vitals

– Education / decision support at point of care

– Never criticise ward staff / realistic workload for RRT patient

remaining on the ward

Questions