Transcript Run, Don’t Walk: Improving Outcomes in Pediatrics Using a Rapid Response Team Wednesday, June 4, 2008 5:00 – 6:00 p.m.

Run, Don’t Walk: Improving Outcomes in
Pediatrics Using a Rapid Response Team
Wednesday, June 4, 2008
5:00 – 6:00 p.m. EDT
© American Academy of Pediatrics 2008
Moderator:
Paul Sharek, MD, MPH, FAAP
Assistant Professor of Pediatrics, Stanford School of Medicine
Medical Director of Quality Management
Chief Clinical Patient Safety Officer
Lucile Packard Children’s Hospital
Palo Alto, California
This activity was funded through an
educational grant from the Physicians’
Foundation for Health Systems Excellence.
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Speaker:
Annie Moulden, MBBS, FRACP
Clinical Leader, Patient Safety and Risk
Royal Children’s Hospital
Melbourne, Victoria, Australia
Speaker:
Jim Tibballs, MBBS
Physician Intensive Care Unit and Resuscitation Officer
Royal Children’s Hospital
Melbourne, Victoria, Australia
Speaker:
Sharon Kinney, RN, MN
Royal Children’s Hospital
Melbourne, Victoria, Australia
Run, don’t walk: Improving
outcomes in pediatrics using a
rapid response team
The Melbourne experience
Dr Annie Moulden
Assoc Prof Jim Tibballs
Ms Sharon Kinney
Royal Children’s Hospital
Melbourne, Australia
Why did we introduce the
MET?
Annie Moulden
Clinical Leader, Patient Safety & Risk
Dr Jim Tibballs
Intensive Care Physician & Resuscitation Officer
Royal Children’s Hospital, Melbourne, Australia
[email protected]
RAPID RESPONSE TEAMS
Medical Emergency Team (MET)
Rapid Response Team (RRT)
WHY DO SOME CHILDREN DIE
UNEXPECTEDLY IN HOSPITAL?

SOMETIMES CARDIAC ARREST IS NOT PREDICTABLE

SOMETIMES CARDIAC ARREST IS PREDICTABLE, BUT …




Severity of illness is not recognized
Help is not requested until cardiac arrest
No assistance is available
Assistance is available but delayed
‘RATIONALE’ of MET/RRT
… prevent predictable cardiac arrest


Outcome from cardiac arrest is poor
Some cardiac arrests are ‘unexpected’
… but which are predictable (‘foreseeable’) on
basis of symptoms and signs
… and which might be prevented if child treated
intensely early
MET or RRT is …

ORGANIZATIONAL CHANGE

ANY staff, no matter how junior or senior, may
call MET/RRT …




Without discussion with seniors
Without discussion with colleagues
Without permission of seniors
Without discussion with doctors
MET at Royal Children’s Hospital
Melbourne, Australia
SYSTEMS SOLUTION …



-
One–tier system
Team of doctors (3) and nurse (1) from
intensive care/emergency dept
Respond immediately to call for assistance
on wards/departments
Can manage medical/surgical emergencies
Treat patient on ward to stabilize, transfer etc
What does MET do?

Assess and treat the patient as required

Discuss management of the patient with the
members of the treating (attending) unit

Admit the child to ICU or continue to help
manage on ward as required
Elements of MET/RRT





Educate staff to recognize serious illness
Establish MET calling criteria
Call for assistance
Provide immediate assistance
Collect data, feedback to staff, educate
MET calling criteria
ANY one or more of the following:
1. Nurse or doctor WORRIED about clinical state
2. Airway threat
3. Hypoxaemia:
SpO2 <90% in any amount of oxygen
SpO2 <60% in any amount of oxygen
(cyanotic heart disease)
MET calling criteria
4. Severe respiratory distress, apnoea or cyanosis
5. Tachypnoea
Age
Respiratory Rate
Term-3 months
>60
4-12 months
>50
1-4 years
>40
5-12 years
>30
12 years+
>30
MET calling criteria
6. Tachycardia or bradycardia
Age
Bradycardia
Tachycardia
Term- 3 months
<100
>180
4-12 months
<100
>180
1- 4 years
<90
>160
5-12 years
<80
>140
12 years+
<60
>130
MET Calling Criteria
7. Hypotension
Age
BP (systolic)
Term- 3 months
<50
4-12 months
<60
1- 4 years
<70
5-12 years
<80
12 years+
<90
MET calling criteria
8. Acute change in neurological status or convulsion
9. Cardiac or respiratory arrest
Does MET make any difference to
cardiac arrest and mortality?
PREDICTABLE (PREVENTABLE) CARDIAC ARREST & DEATH
(per 1000 admissions)
BEFORE
MET
AFTER MET
1 YEAR
AFTER MET
4 YEARS
CARDIAC
ARREST
0.16
0.00
0.07
(p=0.02)
(p=0.04)
DEATH
0.11
0.00
0.01
(p=0.04)
(p=0.001)
TOTAL UNEXPECTED CARDIAC ARREST & DEATH
(UNPREDICTABLE + PREDICTABLE)
(per 1000 admissions)
BEFORE MET
(1999-2002)
AFTER 1
YEAR MET
AFTER 4
YEARS MET
CARDIAC
ARREST
0.19
0.11
0.17
DEATH
0.12
0.06
0.04
(p=0.03)
Sharon Kinney
MET Coordinator,
Royal Children’s Hospital, Melbourne
Implementing MET (initial)

Support from the executive

Introduction letter to all medical
staff and heads of department

Educational sessions +++
Emphasis on empowering nursing &
medical staff

MET posters

MET staff
Supportive & positive attitude to
callers of MET
Implementing MET (ongoing)

Other education


Sick child workshops
 number of places for staff on PLS/APLS courses

Regular clinical practice meetings reviewing
MET data & selected cases

MET coordinator role within the Clinical Quality &
Safety Unit

Ongoing review of critical events (identify &
follow up problems with the MET system and/or
other hospital processes of care)
Possible concerns

De-skilling ward staff

There will be too many unnecessary
(trivial) calls

Taking resources away from ICU (or
elsewhere) especially at night time
Number of MET calls
Time of day for MET calls
(4 year period, n = 809)
60
50
40
30
20
10
0
23
21
19
17
15
13
11
09
07
05
03
01
00
00
00
00
00
00
00
00
00
00
00
00
Time of day (hours)
Take away points

Do you have potentially preventable cardiac
arrests/deaths?

What resources are available/needed to support a 24 hour
service that can promptly respond to a MET call?

Enlist support from the hospital leadership team

Educate and empower ward staff to request MET

Ensure MET staff adopt a supportive attitude to ward staff
initiating the MET call irrespective of perceived
appropriateness

Collect data – ongoing evaluation & feedback to staff