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