The RRS and Resident Education Dr Daryl Jones
Overview Patients in crisis The traditional approach RRT criteria objectify crisis Outcomes of MET patients Education phase Austin hospital Improving RRT patient management Identifying causes Simulation training Nurses attitudes to the MET Austin and Alberta
Patients in crisis Serious adverse events common in hospitalized patients Australia 1 New Zealand 2 USA 3 Canada 4 Incidence adverse events = 3.7% to 16.6% = 37 166 / 1000 admissions 1. Wilson etal MJA 1992 2. Davis etal NZ Med J 1998 3. Brennan / Leape 1984 4. Baker etal 2000
Serious adverse events are preceded by signs of instability in up to 80% Schein etal Chest 1990 USA Buist etal MJA 1999 Aus Hodgets etal Resuscitation 2002 UK Nurmi etal Act Anaes Scan 2005 Fin Bell etal Resuscitation 2006 Swe
Traditional approach 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 Bell etal Resus 2006 Swe
Patient fulfils criteria MET activated
Concerns Junior staff have difficulty detecting crisis Once crisis is detected the approach is variable All of the benefits of the RRS approach relate involvement of the RRT The RRT has now de-skilled these staff even further
However... RRT criteria objectify a patient in crisis
Criteria can be tailored by hospital Tells Junior doctors What is important (BP,HR,UO,GCS,RR,SpO 2 ) What values suggest deterioration
MET patients are at increased risk Mortality hospital inpatients < 4% TNH Australia: 195 calls over 9 months 1 31.8% overall 10.3% if no limitation medical treatment Dandenong Australia 32.2% overall and 21.8% if not NFR Seven hospital study (5 Aus, 1 Can, 1 Swe) 518 patients, 652 MET calls over one month Mortality 12.3% if no limitation medical therapy 1. Casamento CCR 2007 2. Buist MJA 1999
Education points If a patient has deranged vital signs that fulfil MET criteria then the patient is at increased risk Such patients need increased frequency of observation and follow-up
Education phase of the MET Austin hospital mortality surgical patients
Bellomo et al Austin MJA 2003 Reduced CAs 63 22 Reduced CA deaths 37 16 (21) 302 deaths in hospital 222 (saved 80 deaths) 99 MET calls triggered» Almost every call saved a life Now know, many patients have criteria and get no call Some of benefits likely due to education of ward staff
Some of benefit from RRS approach seen before introduction of RRT Not all of benefit can be ascribed to RRT Ward staff education likely to be contributing factor
Improving RRT patient management Identifying causes 400 MET calls Austin hospital Separated out according to calling criteria Then looked at clinical cause for call as recorded by the registrar 50% of all calls» Sepsis (especially chest)» APO / heart failure» Arrhythmias
Simulation training DeVita etal (Qual Saf Health Care 2005) Simulation training 138 people (69 ICU RNs, 48 Dr, 21 Resp ther.)»e-learning»didactic session on day»3 scenarios»debriefing Improved self grading of performance
Simulated survival improved from 0 to 89% Initial team completion rate 10-45% This improved to 80-95% in third session
Austin approach to MET management 1 1. Jones etal CCF 2006
Nurses attitudes to the MET Austin Hospital 1 Approached ½ of all nurses 100% response rate 17 questions (items) Likert agreement type scale MET calls reduce my skills when managing sick patients»53% strongly disagree _ 96.6%»43.6% disagree 1. Jones etal Qual Saf Health Care 2006
Using the MET increases my workload when caring for a sick patient 39.9% Strongly disagree _ 84.3% 44.4% disagree MET calls teach me how to better manage sick patients in my ward 53.7 agree _ 70.8% 17.1% strongly agree
Alberta, Canada 1 293 nurses, 93.9% response rate MET calls reduce my skills when managing sick patients 46.2% strongly disagree _ 91.3% 45.1% disagree 1. Bagshaw etal Am J Crit Care. 2010
Using the MET increases my workload when caring for a sick patient 35.6% Strongly disagree _ 81.3% 45.7% disagree MET calls teach me how to better manage sick patients in my ward 32.6 agree _ 42.8% 10.2% strongly agree
Two hospitals 644 nurses More than 90% deny de-skilling 43% to 70% think it improves their skills
Conclusions In past junior doctors had difficulty recognising patient in crisis RRT criteria objectify sick patients at increased risk Audit of RRT calls allows focus of education and QI Some of benefit from RRS due to education alone Simulation training improves performance / competence? Effect on patient outcome Nurses surveyed > 90% deny that RRT deskills them Approx 50% think it improves their skills