Nursing Grand RoundsNursing Grand RoundsApril 10, 2007April 10, 2007

Medical Emergency Teams at Medical Emergency Teams at MUHAMUHA

Review and UpdateReview and Update

Helena Walo, RN, BSNHelena Walo, RN, BSNInterim Manager, 8 EastInterim Manager, 8 East

Shelia Scarbrough, RN, MSNShelia Scarbrough, RN, MSNManager, Critical InterventionsManager, Critical Interventions

Cathleen Walters, RN, CCRNCathleen Walters, RN, CCRNClinical Nurse Leader, MICUClinical Nurse Leader, MICU

ObjectivesObjectives

• Understand the history and Understand the history and evolution of Medical Emergency evolution of Medical Emergency TeamsTeams

• Recognize opportunities for Recognize opportunities for collaboration and empowerment for collaboration and empowerment for nursing staff in utilizing METnursing staff in utilizing MET

• Discuss the nursing roles during a Discuss the nursing roles during a MET call at MUHAMET call at MUHA

Medical Emergency Medical Emergency TeamsTeams

Historical Perspective Historical Perspective

and and

EvolutionEvolution

Stagnate OutcomesStagnate Outcomes

• Studies from the 1970’s to present Studies from the 1970’s to present continue to demonstrate >50% continue to demonstrate >50% mortality from unexpected in-mortality from unexpected in-hospital cardiac arrests hospital cardiac arrests BMJBMJ. 2002;324:387-390. 2002;324:387-390

• From 1966 to 1999, the average ICU From 1966 to 1999, the average ICU readmission rate remained relatively readmission rate remained relatively unchanged at 7% unchanged at 7% Chest.Chest. 2000;118:492-502 2000;118:492-502

Fact:Fact:

Studies have shown that Studies have shown that patients often demonstrate patients often demonstrate signs and symptoms of signs and symptoms of physiological instability for physiological instability for several hours prior to a cardiac several hours prior to a cardiac arrestarrest

For example…For example…

• 70% of patients show evidence of respiratory 70% of patients show evidence of respiratory deterioration within 8 hours of arrestdeterioration within 8 hours of arrest

ChestChest. 1990;98:1388-1392. 1990;98:1388-1392

• 66% of patients show abnormal signs and symptoms 66% of patients show abnormal signs and symptoms within 6 hours of arrest and MD is notified in 25% of within 6 hours of arrest and MD is notified in 25% of cases cases

Crit Care MedCrit Care Med. 1994;22(2):244-247. 1994;22(2):244-247 • Abnormal clinical observations independently Abnormal clinical observations independently

associated with an increased high risk of mortality: associated with an increased high risk of mortality: decreased level of consciousness, loss of decreased level of consciousness, loss of consciousness, hypoxia, hypotension, and tachypnea. consciousness, hypoxia, hypotension, and tachypnea.

• Most common arrest-preceding events: hypoxia (51%) Most common arrest-preceding events: hypoxia (51%) and hypotension (17%).and hypotension (17%).

ResuscitationResuscitation. 2004;62(2):137-141. 2004;62(2):137-141

The Aussie Answer

““We can do better…”We can do better…”

• Austin Hospital in Heidelberg, Victoria, Austin Hospital in Heidelberg, Victoria, Australia Australia

• pioneered by Ken Hillmanpioneered by Ken Hillman• began by studying patients who had major began by studying patients who had major

surgery at the hospital and then suffered surgery at the hospital and then suffered significant complications such as significant complications such as reintubation, cardiac arrest or renal failure reintubation, cardiac arrest or renal failure

• complication rates = 16 to 17 percent, complication rates = 16 to 17 percent, consistent with research elsewhere consistent with research elsewhere

The Rapid Response Team is The Rapid Response Team is BornBorn

• Proponents of a Rapid Response Team spent Proponents of a Rapid Response Team spent months presenting their case to surgical and months presenting their case to surgical and medical units throughout the hospitalmedical units throughout the hospital

• Established straightforward criteria of Established straightforward criteria of clinical instability, beginning simply with the clinical instability, beginning simply with the staff member being worried about the staff member being worried about the patient and other indicators such as acute patient and other indicators such as acute changes in heart rate, blood pressure, or changes in heart rate, blood pressure, or level of consciousness level of consciousness

Results??? Results???

• Overall adverse outcomes: relative risk reduction Overall adverse outcomes: relative risk reduction 57.8% 57.8%

• Respiratory failure: relative risk reduction 79.1% Respiratory failure: relative risk reduction 79.1% • Stroke: relative risk reduction 78.2% Stroke: relative risk reduction 78.2% • Severe sepsis: relative risk reduction 74.3% Severe sepsis: relative risk reduction 74.3% • Acute renal failure requiring renal replacement Acute renal failure requiring renal replacement

therapy: relative risk reduction 88.5%therapy: relative risk reduction 88.5%• Emergency intensive care unit admissions: relative Emergency intensive care unit admissions: relative

risk reduction 44.4% risk reduction 44.4% • Postoperative deaths: relative risk reduction 36.6% Postoperative deaths: relative risk reduction 36.6% • Duration of hospital stay after major surgery Duration of hospital stay after major surgery

decreased from a mean of 23.8 days to 19.8 daysdecreased from a mean of 23.8 days to 19.8 daysCritical Care Med. 2004 Apr;32(4):916-21Critical Care Med. 2004 Apr;32(4):916-21

Getting Started Kit:Getting Started Kit:Rapid Response Teams Rapid Response Teams How-to GuideHow-to GuideA national initiative led by IHI, the 5 Million Lives Campaign aims to A national initiative led by IHI, the 5 Million Lives Campaign aims to dramatically improve the quality of American health care by protecting dramatically improve the quality of American health care by protecting patients from five million incidents of medical harm between December patients from five million incidents of medical harm between December 2006 and December 2008. The How-to Guides associated with this 2006 and December 2008. The How-to Guides associated with this Campaign are designed to share best practice knowledge on areas of Campaign are designed to share best practice knowledge on areas of focus for participating organizations. focus for participating organizations. For more information and materials, go to For more information and materials, go to www.ihi.orgwww.ihi.org

/IHI/Programs/Campaign/IHI/Programs/Campaign

Differences MET can make:Differences MET can make:

• 50% reduction in non-ICU arrests 50% reduction in non-ICU arrests BMJ.BMJ. 2002;324:387-390 2002;324:387-390

• Reduced post-operative emergency ICU Reduced post-operative emergency ICU transfers (58%) and deaths (37%) transfers (58%) and deaths (37%)

Critical Care MedicineCritical Care Medicine. 2004;32:916-921. 2004;32:916-921

• Decrease from 30% to 4% of patient arrests Decrease from 30% to 4% of patient arrests prior to ICU transfer prior to ICU transfer

Anesthesia. Anesthesia. 1999;54(9):853-8601999;54(9):853-860

• 17% decrease in overall incidence of in-17% decrease in overall incidence of in-hospital cardiopulmonary arrests hospital cardiopulmonary arrests

Quality & Safety in health care. 2004;13(4):251-254Quality & Safety in health care. 2004;13(4):251-254

You are a nurse on a general medical/surgical unit.

One of your four patients is seriously ill and you are worried that her condition is slowly worsening.

You are appropriately implementing the chain of command on your patient’s behalf, but the process seems slow and you have other patient needs to attend.

Meds to be given, dressings to change, discharge paperwork to complete…

Imagine…Imagine…

Suddenly (or not…)Suddenly (or not…)

The entire course of your day is changed when a family member of the patient you were worried about cries down the hall that her mother has stopped breathing…

The Mayday team is called…

Statistically, at best, she has a 50/50 chance for recovery…

Failure to RescueFailure to Rescue

Three main causes: Three main causes:

• Failures in planning Failures in planning – (assessments, treatments, goals)(assessments, treatments, goals)

• Failure to communicate Failure to communicate – (patient to staff, staff to staff, staff to (patient to staff, staff to staff, staff to

physician, etc.)physician, etc.)

• Failure to recognize deteriorating Failure to recognize deteriorating patient conditionpatient condition

MET Evolution at MUSCMET Evolution at MUSC

It’s a process…It’s a process…

MUSC’s MET historyMUSC’s MET history

• Began as a small task force with interest in the “idea”Began as a small task force with interest in the “idea”• Sheila Scarbrough, RN, MSN began role as Critical Sheila Scarbrough, RN, MSN began role as Critical

Interventions Manager in July 2006Interventions Manager in July 2006• Policy development, networking, collaborating with Policy development, networking, collaborating with

interdisciplinary teams interdisciplinary teams • Education component developed with the Simulation Center Education component developed with the Simulation Center

in October 2006.in October 2006.• MET training for ICU nurses, MDs, pharmD’s, RT’s (i.e. code MET training for ICU nurses, MDs, pharmD’s, RT’s (i.e. code

team members) in December 2006team members) in December 2006• Trail of MET responses began January 3, 2007 on 6E, 7E, and Trail of MET responses began January 3, 2007 on 6E, 7E, and

8E8E• Expanded to 8W in March and 10W in AprilExpanded to 8W in March and 10W in April• Also in Children’s hospital Also in Children’s hospital • Future plans: Careful planning and implementation is crucial Future plans: Careful planning and implementation is crucial

to success!!!to success!!!

Nurses Make the DifferenceNurses Make the Difference

• Majority of MET initiation is nurse Majority of MET initiation is nurse driven – nurses recognize the s/s, driven – nurses recognize the s/s, nurses make the call for the MET nurses make the call for the MET teamteam

• At MUSC, a critical care nurse from At MUSC, a critical care nurse from the MICU will answer the MET pager the MICU will answer the MET pager and is an integral part of the MET and is an integral part of the MET

SBARSBAR

• Addresses all 3 causes of Failure to Addresses all 3 causes of Failure to RescueRescue

• A crucial tool to improve A crucial tool to improve communication between caregivers communication between caregivers and improve patient outcomesand improve patient outcomes

• Gives MET a concise and complete Gives MET a concise and complete picture of the patient’s conditionpicture of the patient’s condition

• Information given allows team to Information given allows team to intervene quickly and appropriatelyintervene quickly and appropriately

Role Delineation for NursesRole Delineation for Nurses

General floor: General floor: • utilizes assessment skills to follow utilizes assessment skills to follow

algorithm for intervention, algorithm for intervention, • works with patient’s primary team,works with patient’s primary team,• makes the call to the MET if the patient makes the call to the MET if the patient

meets criteria, meets criteria, • remains with patientremains with patient• prepares for MET arrival, prepares for MET arrival,

– have chart available, have chart available, – significant PMH, allergiessignificant PMH, allergies– most recent VS, labs, recent medications, most recent VS, labs, recent medications,

proceduresprocedures– SBARSBAR

Role Delineation for Nurses Role Delineation for Nurses

• ICUICU

• Arrives with advanced monitoring Arrives with advanced monitoring equipment – brings ICU to the patientequipment – brings ICU to the patient

• Receives information from primary care Receives information from primary care nurse nurse

• Completes initial assessment to include Completes initial assessment to include pertinent VS and lab workpertinent VS and lab work

• Continues to provide critical care as Continues to provide critical care as appropriateappropriate

• Documents accurately on MET formDocuments accurately on MET form

FYIFYI

• Physicians collaborate to determine Physicians collaborate to determine further intervention and patient dispositionfurther intervention and patient disposition

• MET is NOT the BATMET is NOT the BAT– You can call BOTH at the same time!You can call BOTH at the same time!

• MET is NOT the Mayday teamMET is NOT the Mayday team– If patient is in a life threatening situation, a If patient is in a life threatening situation, a

Mayday will be called.Mayday will be called.– Goal is to intervene BEFORE the patient Goal is to intervene BEFORE the patient

reaches this point.reaches this point.