Medical Emergency Team - University of Alberta Hospital.pdf - Safer ...
Medical Emergency Team - University of Alberta Hospital.pdf - Safer ...
Medical Emergency Team - University of Alberta Hospital.pdf - Safer ...
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
<strong>Medical</strong> <strong>Emergency</strong> <strong>Team</strong><br />
<strong>University</strong> <strong>of</strong> <strong>Alberta</strong> <strong>Hospital</strong><br />
November 14, 2005<br />
Tracy Tarapaski<br />
Patient Care Manager GSICU
<strong>University</strong> <strong>of</strong> <strong>Alberta</strong> <strong>Hospital</strong><br />
• 677 bed tertiary academic referral center<br />
• Major referral center for<br />
– Cardiac sciences<br />
– Organ transplantation<br />
– Neurosciences<br />
– Trauma<br />
– Burns<br />
• Major teaching hospital for Faculty <strong>of</strong><br />
Medicine and Dentistry, <strong>University</strong> <strong>of</strong> <strong>Alberta</strong><br />
Page 2<br />
12/8/2005<br />
Healthier people in healthier communities.<br />
www.capitalhealth.ca
Why?<br />
• Higher proportion <strong>of</strong> older/sicker patients in hospital<br />
• Residents/physicians are <strong>of</strong>ten busy elsewhere and<br />
not immediately available<br />
• Residents/physicians and non-ICU RN’s have<br />
variable levels <strong>of</strong> clinical experience<br />
• Traditional medical education model has emphasized<br />
learning by trial and error<br />
• Inexpereinced RN’s sometimes document<br />
progressive deterioration without realizing need for<br />
intervention<br />
• Acute illness is <strong>of</strong>ten missed until too late to intervene<br />
in a meaningful way<br />
Page 3<br />
12/8/2005<br />
Healthier people in healthier communities.<br />
www.capitalhealth.ca
Objectives<br />
• Provide optimal care to at risk patients on hospitalwide<br />
basis<br />
• To reduce time between activation criteria and<br />
initiation <strong>of</strong> treatment<br />
• Reduce cardiac arrest calls by 30%<br />
• Facilitate timely ICU admission<br />
• Reduce ICU admissions and length <strong>of</strong> stay by 10-<br />
15%<br />
• Share critical care skills and expertise through<br />
educational partnership<br />
• Promote continuity <strong>of</strong> care<br />
• Thoroughly audit/evaluate these services<br />
Page 4<br />
12/8/2005<br />
Healthier people in healthier communities.<br />
www.capitalhealth.ca
The Logic <strong>of</strong> the <strong>Medical</strong> <strong>Emergency</strong><br />
<strong>Team</strong><br />
• Rescuscitating dead people is harder than<br />
resuscitating sick people!<br />
• Waiting for a cardiac arrest does not make<br />
sense!<br />
– Rinaldo Bellomo MD<br />
Page 5<br />
12/8/2005<br />
Healthier people in healthier communities.<br />
www.capitalhealth.ca
Getting Started<br />
• It was a collaborative process between Critical Care<br />
and referring services<br />
• We chose to initiate a 6 month pilot on a medical unit<br />
as part <strong>of</strong> the ICU Canadian Collaborative in<br />
September 2004<br />
• The pilot unit was chosen for the following reasons:<br />
– Complexity <strong>of</strong> the patients<br />
– Admissions/re-admissions to the ICU<br />
– Willingness <strong>of</strong> lead physician to participate<br />
Page 6<br />
12/8/2005<br />
Healthier people in healthier communities.<br />
www.capitalhealth.ca
Creating Our <strong>Team</strong><br />
• We developed roles and responsibilities for<br />
the following team members:<br />
– ICU RN<br />
– ICU Resident/Intensivist<br />
– Ward RT<br />
– Ward RN<br />
– Service Resident<br />
Page 7<br />
12/8/2005<br />
Healthier people in healthier communities.<br />
www.capitalhealth.ca
MET Triggers<br />
• Airway<br />
– Threatened -stridor<br />
• Breathing<br />
– Acute change in RR 36<br />
– Acute change in SpO2
MET Activation Process<br />
Staff Member identifies MET Trigger and notifies Charge Nurse/CSR<br />
Charge Nurse/CSR calls 33# to activate MET and notify Service Resident on Call.<br />
<strong>Hospital</strong> locating activates MET pager<br />
Overhead page “<strong>Medical</strong> <strong>Emergency</strong> <strong>Team</strong> to……..”<br />
<strong>Medical</strong> <strong>Emergency</strong> <strong>Team</strong> and Junior Resident arrive,<br />
assess patient and initiate treatment<br />
Patient stabilized and remains on Unit<br />
Patient stabilized and transferred to GSICU<br />
End-<strong>of</strong>-life discussions<br />
Page 9<br />
12/8/2005<br />
Healthier people in healthier communities.<br />
www.capitalhealth.ca
MET Equipment<br />
• Transport monitor with following capabilities<br />
– ECG monitoring<br />
– Sp02 monitoring<br />
– NIBP<br />
– Pressure monitoring module<br />
• Resuscitation bag<br />
• Drugs<br />
Page 10<br />
12/8/2005<br />
Healthier people in healthier communities.<br />
www.capitalhealth.ca
Supplies<br />
• Needles and syringes<br />
• Triple lumen catheter<br />
• MAC central line<br />
• Minor suture bundle<br />
• Sutures<br />
• Scalpel blades<br />
• Stethoscope<br />
• D5W 100cc minibag<br />
• 250cc D5W bag<br />
• IV catheters<br />
• Goggles<br />
• End tidal C02 monitor<br />
• 500cc pentespan<br />
• Pressure monitoring tubing, bag and cable<br />
• ECG leads<br />
Page 11<br />
12/8/2005<br />
Healthier people in healthier communities.<br />
www.capitalhealth.ca
Drugs<br />
• Paralytic agent rocuronium<br />
• Versed<br />
• Levophed<br />
• NaHC03<br />
• Epinephrine<br />
• Amiodarone<br />
• Neostigmine<br />
• Atropine<br />
• Ephedrine<br />
• Calcium chloride<br />
• MgS04<br />
• D50W<br />
• Premixed KCL<br />
• Lasix<br />
• Ventolin and atrovent<br />
Page 12<br />
12/8/2005<br />
Healthier people in healthier communities.<br />
www.capitalhealth.ca
Data Collection Tools<br />
• Data collection is paper based<br />
• Developed data collection tool to be filled out by ICU<br />
RN<br />
• Developed MET evaluation tool to be filled out by unit<br />
RN<br />
• Developed database<br />
• Provide monthly summary reports to participating<br />
units<br />
• Provide 6 month summary report comparing units<br />
Page 13<br />
12/8/2005<br />
Healthier people in healthier communities.<br />
www.capitalhealth.ca
Process<br />
• <strong>Team</strong> enrolled in Canadian ICU Collaborative<br />
• Education provided to ICU and Unit Staff participating<br />
in MET<br />
• Each call reviewed<br />
• Monthly debriefing sessions<br />
• Issues addressed and changes implemented<br />
• MET spread to second medical unit in November<br />
2004<br />
• MET expanded to third medicine unit in April 2005<br />
• 6 month formal review<br />
Page 14<br />
12/8/2005<br />
Healthier people in healthier communities.<br />
www.capitalhealth.ca
MET roll-out @ UAH<br />
Med Subspec 3<br />
Med Subspec 2<br />
Med Subspec 1<br />
Planning<br />
Monitoring-PDSA cycles<br />
M A M J J A S O N D J F M A M J J A S<br />
Page 15<br />
12/8/2005<br />
2004 2005<br />
Healthier people in healthier communities.<br />
www.capitalhealth.ca
Impact <strong>of</strong> MET 1 Year Later<br />
MSS 1 MSS 2 MSS 3<br />
Date <strong>of</strong> initiation Sep 1, 2004 Nov 1, 2004 Apr 1, 2005<br />
MET Calls 36 20 6<br />
Cardiac arrests 4 11 0<br />
Cardiac arrests/100<br />
separations<br />
1.4 2.1 0<br />
% Change 48.9% 285.8% 100%<br />
% ICU admissions with<br />
MET activation<br />
60% 38.7% 41.7%<br />
ICU ALOS (days) 6.1 5.9 6.5<br />
% Change 39.7% 2.5% 27.2%<br />
Page 16<br />
12/8/2005<br />
Healthier people in healthier communities.<br />
www.capitalhealth.ca
Patient disposition following MET call<br />
Admitted to<br />
ICU<br />
Remained<br />
on unit<br />
Change in<br />
code status<br />
Total<br />
50% 50% 0% 100%<br />
Page 17<br />
12/8/2005<br />
Healthier people in healthier communities.<br />
www.capitalhealth.ca
Met called by<br />
13%<br />
4%<br />
13%<br />
RN<br />
MD<br />
RT<br />
Other<br />
70%<br />
Page 18<br />
12/8/2005<br />
Healthier people in healthier communities.<br />
www.capitalhealth.ca
Time <strong>of</strong> MET calls<br />
33%<br />
07:00-19:00<br />
19:00-07:00<br />
67%<br />
Page 19<br />
12/8/2005<br />
Healthier people in healthier communities.<br />
www.capitalhealth.ca
MET call duration<br />
• Range 25 mins – 1 hr 45 mins<br />
• Mean 49 mins<br />
Page 20<br />
12/8/2005<br />
Healthier people in healthier communities.<br />
www.capitalhealth.ca
Most common triggers<br />
• A review <strong>of</strong> admissions to the ICU has demonstrated<br />
that many patients have 2 to 3 triggers present at<br />
time <strong>of</strong> MET call<br />
Triggers<br />
Total<br />
Page 21<br />
12/8/2005<br />
Airway 13<br />
HR 1<br />
BP 6<br />
Multiple triggers 12<br />
O2 Sat 13<br />
RR 5<br />
Worried about patinet 13<br />
Unknown 8<br />
Grand Total 71<br />
Healthier people in healthier communities.<br />
www.capitalhealth.ca
Issues<br />
• Originally planned to implement in 3 other medical units<br />
• Service chiefs for these areas refused to have MET response<br />
– Interference with traditional model <strong>of</strong> resident “education”<br />
• <strong>Hospital</strong>/regional support in principle<br />
– Not prepared to ensure service wide acceptance<br />
• Problems with recurrent delayed MET calls in second medicine<br />
unit<br />
– Late calls with codes called soon after MET arrival<br />
– Due to rotating internal medicine residents attitudes to MET<br />
– RN’s disempowered by residents<br />
– Variable acceptance by attending physicians<br />
Page 22<br />
12/8/2005<br />
Healthier people in healthier communities.<br />
www.capitalhealth.ca
Resolution<br />
• Education, multiple meetings with attending<br />
physicians and admininstration<br />
• Educational sessions, one-on-one<br />
discussions with residents involved in late<br />
MET calls<br />
• Education, discussions with UAH <strong>Medical</strong><br />
Council<br />
• Education, discussions with new Chair<br />
Department <strong>of</strong> Medicine<br />
Page 23<br />
12/8/2005<br />
Healthier people in healthier communities.<br />
www.capitalhealth.ca
Lessons<br />
• Universal triggers required<br />
• Education required for ICU and inpatient unit staff and<br />
physicians<br />
• Support from medical and operational leaders essential<br />
• Project champions vital for implementation<br />
• Increase project visibility via trigger pocket cards and posters<br />
• Regular debriefing meetings to problem solve and maintain<br />
communication flow<br />
• Support <strong>of</strong> the ICU Canadian Collaborative is fundamental to<br />
success<br />
• Use <strong>of</strong> PDSA cycles (plan,do,study,act) to implement change<br />
and maintain momentum<br />
Page 24<br />
12/8/2005<br />
Healthier people in healthier communities.<br />
www.capitalhealth.ca
Pocket Trigger Cards<br />
MET<br />
33# ask for MET<br />
Airway Threatened - stridor<br />
Breathing<br />
* Acute change in RR 36<br />
* Acute change in SpO2
Next Steps<br />
• Permanent funding received<br />
• Planning in process for extension <strong>of</strong> program<br />
to all services at <strong>University</strong> <strong>of</strong> <strong>Alberta</strong> <strong>Hospital</strong><br />
• November 2005 spread to remaining medical<br />
units, family medicine and psychiatry<br />
• February 2006 spread to surgery<br />
• June 2006 spread to neurosciences<br />
• Combine MET and Code <strong>Team</strong> by 2007<br />
Page 26<br />
12/8/2005<br />
Healthier people in healthier communities.<br />
www.capitalhealth.ca