RAPID RESPONSE SYSTEM: A/Prof. Michael Buist Dadeog Hospital & Moash Uiversity, Melboure, Australia. mbuist@patietrack.com A Commo Theme. The Efferet arm is Effective The Afferet arm is NOT Effective The Afferet arm Failed i MERIT The more sophisticated Afferet arm RRS: The Afferet Arm Case Detectio Efferet Arm Trigger PATIENT EVENT ( mismatch to reasoably available resource) ADMINISTRATIVE ARM (admi, audit, educatio, feedback, data RRT, MET, OUTREACH, HOSPITALIST AFFERENT ARM: CASE DETECTION AIM PREVENT CARDIAC ARREST PREVENT OR FACILITATE ICU/HDU UTILIZATION PREVENTABLE DEATHS DNR IMPLEMENTATION CLINICAL SERVICE MINIMAL FALSE +VE RATE CASE DETECTION MEDICAL EMERGENCY TEAM OBJECTIVE CRITERIA BEDSIDE OBSERVATIONS (Resps, Heart rate, BP, Sats, Urie output, Neuro obs, temp, stridor) Simple cut poit obs vs Scorig System Subjective criteria Worried www.metcoferece.com 1
MET CRITERIA Modified Early Warig System 3 2 1 0 1 2 3 SBP <70 71-80 81-100 101-199 >200 HR <40 41-50 51-100 101-110 111-129 >130 RR <9 9-14 15-20 21-29 >30 Temp <35 35-38.4 >38.5 AVPU A V P U MEWS > 5 = icreased risk of death & critical care admissio Case Detectio: Issues Deaths amogst patiets with blood pressure <90 mm Hg versus duratio of blood pressure <90 mm Hg Validatio of Criteria Sesitivity vs Specificity of criteria Cut poit vs score Objective vs Subjective Face Validity Patiet populatio Reliability of observatios take Are the observatios take INCIDENCE OF ABNORMAL OBSERVATIONS ( =1471) (Buist et al Resus 2004) EVENT OUTCOME AT THE TIME OF EVENT ( = 1471) (Buist et al Resus 2004) www.metcoferece.com 2
INDEPENDENT PREDICTORS OF MORTALITY AT HOSPITAL DISCHARGE (Buist et al, Resus 2004) Prevalece of MET-criteria i a Swedish Uiversity Hospital Bell, Korad et al, i press OBSERVATION/EVENT RR < 6/mi RR > 30/mi LOC LOC SaO2 < 90% BP < 90 mmhg ODDS RATIO ( 95% CI) 12.3 (2.2-69.6 6.5 (3.6-11.8) 6.6 (3.1-13.9) 6.2 (2.5-14.8) 2.6 (1.7-3.9) 2.5 (4.6-7.4) Amog 895 patiets i a sigle hospital o two differet days 4.5% met MET criteria! Mortality icreased Figure 2. Kapla-Meier curve stratified by patiet category CASE DETECTION: Future Directios Dr M Cretikos Dr B Cuthbertso Real time modelig of bediside data captured electroically TRIGGER ISSUES: Trigger of Care vs Cotiuum of Care Who pulls the trigger What is the trigger Cogitio/ Telephoe/ Actio Iefficiet 16 PACE- Pre Arrest Criteria for Escalatio study. 3 tier respose to abormal bedside obs Paret registrar, ICU (seior fellow) & cardiac arrest 170 evets (ICU admit, o DNR deaths & cardiac arrests) over 3 moths (16/01/05) Sigificat delays Nurses ot requestig assistace Medical delays i gettig higher order care. Piza M & Mudaliar Y, upublished 2005 www.metcoferece.com 3
122 critical evets 66 ICU admissios 56 cardiac arrests CRITICAL EVENTS AND ALL HOSPITAL ADMISSIONS 29 < 1 Hour istability 93 > 1hour istability 19 Died 47 Died 5 ICU 0 Died 24 arrests 19 Died 61 ICU 23 Died 32 arrests 24 Died FREQUENCY OF MEDICAL OFFICER REVIEWS CLINICAL FUTILE CYCLES PATIENT BEDSIDE NURSE BEDSIDE NURSE INTERN/JMO INTERN/JMO PATIENT REVIEW PATIENT MANAGEMENT/ CONSULT REGISTRAR REGISTRAR REVIEW (ED,OT,OP) PATIENT MANAGEMENT TREATMENT INVESTIGATION ( DOUGHNUT OF DEATH ) INFORM CONSULTANT REVIEW PATIENT PROGRESS CLINICAL FUTILE CYCLES CLINICAL FUTILE CYCLES SPECIALIST CONSULTANT REVIEW SUBSPECIALITY REFERRAL AT REGISTRAR LEVEL FURTHER PATIENT REVIEW TREATMENT INVESTIGATION DISCUSSION WTH CONSULTANT DIFFERENT TEAMS OF ONCALL DOCTORS HEIRARCHICAL REFERRAL MODEL TIME CONSUMPTION (6.5 hours, rage 0-432) DIAGNOSIS ORIENTATED MANAGEMENT RELIANT ON: TIMELY RESPONSE OF ALL STAFF IN A WELL COORDINATED SEQUENCE CORRECT DIAGNOSIS CORRECT ASSESSMENT OF SEVERITY COMMUNICATED APPROPRIATE ACTIONS TAKEN www.metcoferece.com 4
Acute Symptoms to Iitial Call for Help by Nurse (=55) 17% of episodes where urses did ot call for help (=11) Setiel = PACE evet threshold Setiel = PACE evet threshold surgery/sca surgery/sca Iitial help to call for higher order help (=67) Call for Highest Order Care to Arrival (=81) Setiel = PACE evet threshold (3 days) Setiel = PACE evet threshold surgery/sca surgery/sca FINDINGS 1. 26% of episodes were ot reviewed by the withi 1 hour of the acute observatio 2. Nursig staff did ot activate PACE call optios i 17% episodes 3. Vital sigs ot moitored with sufficiet frequecy 4. Delays i performig essetial surgery / other complex itervetios eg dialysis / chest draiage WHY WOULDN T YOU CALL THE MET? Nurses Survey of 351 ward urses, Austi hospital, Melb Likert scale 17 questios about MET 91% - MET preveted cardiac arrests 97% - MET helped maage uwell patiets However 72% whe preseted with a patiet who fulfilled MET criteria would still call the paret cliical first. Joes D et al, upublished 2005 www.metcoferece.com 5
Nurses & MET calls AFFERENT ARM Poor sesitivity ad specificity of curret case detectio tools The Trigger is depedet o a huma pullig it. Joes D et al, upublished 2005 www.metcoferece.com 6