Transcript CCR Teams Ontario Presentation

Critical Care Response Teams in
Ontario:
Rationale, Research and Results
Stuart F. Reynolds, M.D.
Disclosures
Physician Lead, Ministry of Health and Long Term
Care, Critical Care Response Team Project
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Outline
Overview of a Rapid Response System
Rationale
Reviewing the evidence
Snapshot of the Ontario experience
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Rapid Response System
Framework
Afferent Limb
Efferent Limb
Administrative Limb
Afferent Limb
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Event Detection – Identifying the patient at risk
 Bedside Clinician
 Empowerment
 Education
• Calling Criteria
• Recognition of the critically ill
Efferent Limb
Structure varies with jurisdiction
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U.K. – Outreach
Australia – MET
U.S.A. – MET, Hospitalists, RRT’s
Canada – CCRT’s
• MET during day
• Outreach at night with Intensivist backup
Patient Assessment & Treatment
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Administrative Limb
Leadership
Implementation & Planning
Data Collection & Analysis & Feedback
 Design feedback mechanisms to the team and to the
teams response areas
 Track data to improve utilization of the team
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Why bother??
A code does not occur out of the “Blue”
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 Cardiac arrests over 4 months
• 84% had documented clinical deterioration within 8
hours pre-arrest
Recognizing clinical instability in hospital patients before
cardiac arrest or unplanned admission to intensive care. A
pilot study in a tertiary-care hospital.
Buist MD, Jarmolowski E, Burton PR, Bernard SA, Waxman BP, Anderson J.
Retrospective review, over one year of all:
 cardiac arrests
 unplanned ICU admission
Median duration of instability 6.5 hours prior to
Critical Event
Med J Aust. 1999 Jul 5;171(1):22-5
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Prospective confidential inquiry
Reviewed 100 consecutive patients admitted to
ICU
Revealed that up to 41% of ICU admissions could
possibly be avoided.
Related to:
failure to appreciate alterations in the ABC’s and delay
in ICU Consultation
J R Coll Physicians Lond. 1999 May-Jun;33(3):255-9
Unexpected deaths and referrals to intensive care of patients on
general wards. Are some cases potentially avoidable?
McGloin H, Adam SK, Singer M.
6 months review of all hospital deaths, unplanned
ICU admissions
4% of deaths were potentially avoidable, early
warning signs not appreciated.
ICU Admissions
 32% of which clinical deterioration was not appreciated
 ICU mortality higher 52% vs 35%
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Et Tu?
Is Early Death Following ICU
Admission Preventable?
Anika Minnes, John T Granton, Wilfrid
Demajo, Anne Marie Sweeney, Stuart F.
Reynolds, Thomas E. Stewart, and Niall
D. Ferguson
University Health Network
University of Toronto
Vitals within 6 hours of ICU admission
All
Early Death
No Early Death
Number
120
21
99
Resp Rate
50%
38%
53%
Saturation
76%
71%
77%
Systolic BP
75%
71%
76%
Heart Rate
73%
62%
75%
8%
0
10%
20%
14%
21%
Urine Output
Drop in LOC
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Rationale
There is time for intervention
 The evolution of physiological deterioration is relatively slow.
There are warning signs
 Clinical deterioration can be detected utilizing common vital signs
There are effective treatments
 Early Goal Directed Therapy
 ACS therapy
 Oxygen, NIV for COPD, CHF
Many critical interventions are time dependant.
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Trauma
Severe Sepsis
ACS
CVA
Expertise exists and can be deployed
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Critical Care Response Teams in Ontario are:
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A systematic approach to the early identification
and facilitation of resuscitation of in-patients at
risk of deterioration.
A way to provide Comprehensive Critical Care
Services
 Prophylactic interventions
• Follow-up of patients recently discharged from the ICU to prevent
readmission
• Rounds on high-dependency units
continued …
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A way to provide critical care education
 Teaching nursing unit personnel
 Signs and symptoms of an at risk patient
 Utilization of calling criteria
 Teaching medical students and residents how to recognize and
resuscitate the acutely ill patient
A way to Support and Coordinate the care
of patients
 Assistance with end-of-life decision discussion
 Improving communication between the ICU and other units
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Hospital Mortality
Observational
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Cardiac Arrest
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Lancet, June 2005
MERIT at a glance
 23 Hospitals
 Variable Hospital Size and Type
 Variable Team Structure
 Implementation timeline
 2 month baseline
 4 month implementation phase
 6 month evaluation phase
 Outcomes
 Primary – composite
 Secondary
- No Difference
- No Difference
• Cardiac Arrests
• Unexpected ICU admissions
• Unexpected deaths
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Critical Care 2005, 9:R808-R815
Vol 9 No 6 Research
Long term effect of a medical emergency team on cardiac arrests
in a teaching hospital
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Daryl Jones, Rinaldo Bellomo, Samantha Bates, Stephen Warrillow, Donna Goldsmith, Graeme
Hart, Helen Opdam and Geoffrey Gutteridge
Dose Response Curve
17 MET calls per 1000 inpatient
admissions is associated with
reduction in cardiac arrest rate
of 1 per 1000 admissions
How does this compare to MERIT?
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6.3 – 1.2 = 5.1 MET calls/1000
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Predicted impact on
Cardiac Arrests of 5 MET
calls
= 0.3/1000
Critical Care Response Team
Expansion Project
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USE IT or LOSE IT!!!
Implementation Principles
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Local leadership, Central Coordination
Strong Local Leadership:
 MD lead, co lead nurse leader or RRT leader,
Administrative Support
 Navigation of the Cultural, Sociologic, Political Mine Fields
Central Coordination
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Support Local Leadership!!!
Coordinating Communication between sites
Identify Hospitals
Define Team Structure
Defining Roles and Responsibilities
Identification of Accountabilities
Data Analysis & Feedback
Timeline for CCRT Project
Phase I – Preparation and team development,
training and marketing. May 2006 – Oct 2006
 six months
 284 RN’s and RRT’s trained – wonderful
collaboration between local and central leadership
 Development of a CRI CCRT Course
Phase II – Preceptorship. Nov 2006 – Jan 2007
 8 hour day – limited service
 consolidation of training, marketing
 twelve weeks
III – 24/7 service began January 29, 2007
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Evaluation Plan
Managing Success – Managing Improvement
 Outcome Measures
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Code Blue
Cardiac Arrests
Respiratory Arrests
Hospital Mortality
Readmission Rate
Length of Stay
 Improving Implementation
 Audit
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Criteria
Location of Patient
Code Blue
Unanticipated ICU admissions
CCRT Consults
 Call Volume
•
Service
 Qualitative assessments
 Accountability Measures
 Return on Investment
• Why people use service
• Why people don’t use service
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Some Early Results
First Month of 24 hour service
MERIT
34 CCRT
activations per
1000 inpatient
admissions
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90
5%
Outcomes of
1739 Consults
64
4%
Phase II
415
24%
Stay on Unit
Transferred to ICU*
Transferred to Step down Unit**
Other
1170
67%
Going Forward
Will the outcomes follow the implementation?
Return on investment
Refining the processes
Testing Alternative Models
• Hospitalist
• Education interventions
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Dr. Adrian Robertson
Carolyn Freitag
Diane Olsen
Dr. Markus Kargel
Marilyn Lee
Dr. Neil Antman
Mike Cass
Cindy Hawkswell
Dr. Lorenzo del Sorbo
Karen Meredith
Dr. Eli Malus
Mary Cunningham
Dr. Doug Austgarden
Sharon Foster
Dr. Craig W. Reid
Maureen Taylor-Greenly
Dr. Hy Dwosh
Judy Froud
Dr. Michael S. Miletin
Anna Maria Magdic
Dr. Natalie Needham-Nethercott
Rebecca Jesso
Dr. Steven Lapinsky
Patricia Hynes
Dr. Donna McRitchie
Jasmine Tse
Dr. Joanne Meyer
Geeta Juta
Dr. Roman Jaescke
Lily Waugh
Dr. Chris Hayes
Gail Wilson
Dr. Don Burke
Janet Riehl
Dr. Martin Chapman
Karen Smith
Dr. Janos Pataki
Gail Lang
Lynn Varga
Dr. Jonathen Hooper
Joselyn Mugford
Dr. Stewart Aitken
Carol Shelton
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Dr. Laurence Chau
Nancy Merrill
Eileen MacDonald-Karcz
Dr. Craig Reid
Sue Bubb
Dr. Alan Baxter
Janet Moore-Holmes
Wendy Fortier
Dr. Stuart Reynolds
Ingrid Daley
Denise Morris
Dr. Peter Kraus
Karen Cziraki
Dr. Dan Howes
Rana Fowler
Dr. Frank Rutledge
Jasna Gole
Jackie Walker
Dr. Wael Haddara
Dr. Ron Butler
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Thanks
To our CCRT Leadership and Teams!!!!
[email protected]