Medical Emergency Team - University of Alberta Hospital.pdf - Safer ...

Medical Emergency Team
University of Alberta Hospital
November 14, 2005
Tracy Tarapaski
Patient Care Manager GSICU

University of Alberta Hospital
• 677 bed tertiary academic referral center
• Major referral center for
– Cardiac sciences
– Organ transplantation
– Neurosciences
– Trauma
– Burns
• Major teaching hospital for Faculty of
Medicine and Dentistry, University of Alberta
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Why?
• Higher proportion of older/sicker patients in hospital
• Residents/physicians are often busy elsewhere and
not immediately available
• Residents/physicians and non-ICU RN’s have
variable levels of clinical experience
• Traditional medical education model has emphasized
learning by trial and error
• Inexpereinced RN’s sometimes document
progressive deterioration without realizing need for
intervention
• Acute illness is often missed until too late to intervene
in a meaningful way
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Objectives
• Provide optimal care to at risk patients on hospitalwide
basis
• To reduce time between activation criteria and
initiation of treatment
• Reduce cardiac arrest calls by 30%
• Facilitate timely ICU admission
• Reduce ICU admissions and length of stay by 10-
15%
• Share critical care skills and expertise through
educational partnership
• Promote continuity of care
• Thoroughly audit/evaluate these services
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The Logic of the Medical Emergency
Team
• Rescuscitating dead people is harder than
resuscitating sick people!
• Waiting for a cardiac arrest does not make
sense!
– Rinaldo Bellomo MD
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Getting Started
• It was a collaborative process between Critical Care
and referring services
• We chose to initiate a 6 month pilot on a medical unit
as part of the ICU Canadian Collaborative in
September 2004
• The pilot unit was chosen for the following reasons:
– Complexity of the patients
– Admissions/re-admissions to the ICU
– Willingness of lead physician to participate
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Creating Our Team
• We developed roles and responsibilities for
the following team members:
– ICU RN
– ICU Resident/Intensivist
– Ward RT
– Ward RN
– Service Resident
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MET Triggers
• Airway
– Threatened -stridor
• Breathing
– Acute change in RR 36
– Acute change in SpO2

MET Activation Process
Staff Member identifies MET Trigger and notifies Charge Nurse/CSR
Charge Nurse/CSR calls 33# to activate MET and notify Service Resident on Call.
Hospital locating activates MET pager
Overhead page “Medical Emergency Team to……..”
Medical Emergency Team and Junior Resident arrive,
assess patient and initiate treatment
Patient stabilized and remains on Unit
Patient stabilized and transferred to GSICU
End-of-life discussions
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MET Equipment
• Transport monitor with following capabilities
– ECG monitoring
– Sp02 monitoring
– NIBP
– Pressure monitoring module
• Resuscitation bag
• Drugs
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Supplies
• Needles and syringes
• Triple lumen catheter
• MAC central line
• Minor suture bundle
• Sutures
• Scalpel blades
• Stethoscope
• D5W 100cc minibag
• 250cc D5W bag
• IV catheters
• Goggles
• End tidal C02 monitor
• 500cc pentespan
• Pressure monitoring tubing, bag and cable
• ECG leads
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Drugs
• Paralytic agent rocuronium
• Versed
• Levophed
• NaHC03
• Epinephrine
• Amiodarone
• Neostigmine
• Atropine
• Ephedrine
• Calcium chloride
• MgS04
• D50W
• Premixed KCL
• Lasix
• Ventolin and atrovent
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Data Collection Tools
• Data collection is paper based
• Developed data collection tool to be filled out by ICU
RN
• Developed MET evaluation tool to be filled out by unit
RN
• Developed database
• Provide monthly summary reports to participating
units
• Provide 6 month summary report comparing units
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Process
• Team enrolled in Canadian ICU Collaborative
• Education provided to ICU and Unit Staff participating
in MET
• Each call reviewed
• Monthly debriefing sessions
• Issues addressed and changes implemented
• MET spread to second medical unit in November
2004
• MET expanded to third medicine unit in April 2005
• 6 month formal review
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MET roll-out @ UAH
Med Subspec 3
Med Subspec 2
Med Subspec 1
Planning
Monitoring-PDSA cycles
M A M J J A S O N D J F M A M J J A S
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Impact of MET 1 Year Later
MSS 1 MSS 2 MSS 3
Date of initiation Sep 1, 2004 Nov 1, 2004 Apr 1, 2005
MET Calls 36 20 6
Cardiac arrests 4 11 0
Cardiac arrests/100
separations
1.4 2.1 0
% Change 48.9% 285.8% 100%
% ICU admissions with
MET activation
60% 38.7% 41.7%
ICU ALOS (days) 6.1 5.9 6.5
% Change 39.7% 2.5% 27.2%
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Patient disposition following MET call
Admitted to
ICU
Remained
on unit
Change in
code status
Total
50% 50% 0% 100%
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Met called by
13%
4%
13%
RN
MD
RT
Other
70%
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Time of MET calls
33%
07:00-19:00
19:00-07:00
67%
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MET call duration
• Range 25 mins – 1 hr 45 mins
• Mean 49 mins
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Most common triggers
• A review of admissions to the ICU has demonstrated
that many patients have 2 to 3 triggers present at
time of MET call
Triggers
Total
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Airway 13
HR 1
BP 6
Multiple triggers 12
O2 Sat 13
RR 5
Worried about patinet 13
Unknown 8
Grand Total 71
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Issues
• Originally planned to implement in 3 other medical units
• Service chiefs for these areas refused to have MET response
– Interference with traditional model of resident “education”
• Hospital/regional support in principle
– Not prepared to ensure service wide acceptance
• Problems with recurrent delayed MET calls in second medicine
unit
– Late calls with codes called soon after MET arrival
– Due to rotating internal medicine residents attitudes to MET
– RN’s disempowered by residents
– Variable acceptance by attending physicians
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Resolution
• Education, multiple meetings with attending
physicians and admininstration
• Educational sessions, one-on-one
discussions with residents involved in late
MET calls
• Education, discussions with UAH Medical
Council
• Education, discussions with new Chair
Department of Medicine
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Lessons
• Universal triggers required
• Education required for ICU and inpatient unit staff and
physicians
• Support from medical and operational leaders essential
• Project champions vital for implementation
• Increase project visibility via trigger pocket cards and posters
• Regular debriefing meetings to problem solve and maintain
communication flow
• Support of the ICU Canadian Collaborative is fundamental to
success
• Use of PDSA cycles (plan,do,study,act) to implement change
and maintain momentum
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Pocket Trigger Cards
MET
33# ask for MET
Airway Threatened - stridor
Breathing
* Acute change in RR 36
* Acute change in SpO2

Next Steps
• Permanent funding received
• Planning in process for extension of program
to all services at University of Alberta Hospital
• November 2005 spread to remaining medical
units, family medicine and psychiatry
• February 2006 spread to surgery
• June 2006 spread to neurosciences
• Combine MET and Code Team by 2007
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