Critical Care Response Teams in Ontario:

Rationale, Research and Results

Stuart F. Reynolds, M.D.

2

Disclosures

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

3Outline

Overview of a Rapid Response System

Rationale

Reviewing the evidence

Snapshot of the Ontario experience

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Efferent Limb

Administrative Limb

Afferent Limb

Rapid Response System Framework

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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, RRT’s Canada – CCRT’s

• MET during day• Outreach at night with Intensivist backup

Patient Assessment & Treatment

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Administrative Limb

LeadershipImplementation & PlanningData Collection & Analysis & Feedback

Design feedback mechanisms to the team and to the teams response areas

Track data to improve utilization of the team

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

10Recognizing 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 5;171(1):22-5

Prospective confidential inquiryReviewed 100 consecutive patients admitted to ICU

Revealed that up to 41% of ICU admissions could possibly be avoided.

Related to:failure to appreciate alterations in the ABC’s 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?

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%

J R Coll Physicians Lond. 1999 May-Jun;33(3):255-9

McGloin H, Adam SK, Singer M.

Et Tu?

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 NetworkUniversity 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 Output8% 0 10%

Drop in LOC20% 14% 21%

16Rationale

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 educationTeaching 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 HospitalsVariable Hospital Size and TypeVariable 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

Vol 9 No 6 ResearchLong term effect of a medical emergency team on cardiac arrestsin a teaching hospitalDaryl Jones, Rinaldo Bellomo, Samantha Bates, Stephen Warrillow, Donna Goldsmith, Graeme Hart, Helen Opdam and Geoffrey Gutteridge

Critical Care 2005, 9:R808-R815

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

Critical Care Response Team Expansion Project

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USE IT or LOSE IT!!!

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Implementation PrinciplesLocal leadership, Central CoordinationStrong Local Leadership:

MD lead, co lead nurse leader or RRT leader, Administrative Support

Navigation of the Cultural, Sociologic, Political Mine FieldsCentral 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 RN’s and RRT’s 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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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 don’t use service

Evaluation PlanManaging Success – Managing Improvement

32Some Early ResultsFirst Month of 24 hour service

34 CCRT activations per 1000 inpatient

admissions

MERIT

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117067%

41524%

905%

644%

Stay on Unit

Transferred to ICU*

Transferred to Step down Unit**

Other

Outcomes of 1739 Consults

Phase II

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Going Forward

Will the outcomes follow the implementation?Return on investmentRefining the processesTesting Alternative Models

• Hospitalist• Education interventions

35Dr. Laurence ChauNancy MerrillEileen MacDonald-KarczDr. Craig ReidSue BubbDr. Alan BaxterJanet Moore-HolmesWendy FortierDr. Stuart ReynoldsIngrid DaleyDenise MorrisDr. Peter KrausKaren CzirakiDr. Dan HowesRana FowlerDr. Frank RutledgeJasna GoleJackie WalkerDr. Wael HaddaraDr. Ron Butler

Dr. Steven LapinskyPatricia HynesDr. Donna McRitchieJasmine TseDr. Joanne MeyerGeeta JutaDr. Roman JaesckeLily WaughDr. Chris HayesGail WilsonDr. Don BurkeJanet RiehlDr. Martin ChapmanKaren SmithDr. Janos PatakiGail LangLynn VargaDr. Jonathen HooperJoselyn MugfordDr. Stewart AitkenCarol Shelton

Dr. Adrian RobertsonCarolyn FreitagDiane OlsenDr. Markus KargelMarilyn LeeDr. Neil AntmanMike CassCindy HawkswellDr. Lorenzo del SorboKaren MeredithDr. Eli MalusMary CunninghamDr. Doug AustgardenSharon FosterDr. Craig W. ReidMaureen Taylor-GreenlyDr. Hy DwoshJudy FroudDr. Michael S. MiletinAnna Maria MagdicDr. Natalie Needham-NethercottRebecca Jesso

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Thanks

To our CCRT Leadership and Teams!!!!

Stuart.Reynolds@uhn.on.ca