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![Page 1: 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.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649dca5503460f94ac0cb8/html5/thumbnails/1.jpg)
Run, Don’t Walk: Improving Outcomes in Pediatrics Using a
Rapid Response Team
Wednesday, June 4, 20085:00 – 6:00 p.m. EDT
© American Academy of Pediatrics 2008
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Moderator: Paul Sharek, MD, MPH, FAAPAssistant Professor of Pediatrics, Stanford School of MedicineMedical Director of Quality ManagementChief Clinical Patient Safety OfficerLucile Packard Children’s HospitalPalo Alto, California
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This activity was funded through an educational grant from the Physicians’
Foundation for Health Systems Excellence.
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Visit our website:http://www.aap.org/saferhealthcare
Resources: Useful strategies, valuable information links, and expert advice on reducing or eliminating medical errors affecting children.
Webinars: Register for an upcoming, live Webinar, and earn a maximum of 1.0 AMA PRA Category 1 Credit™. Or, access a full archive, including audio, from one of the past Webinar offerings. Or, download just the
Podcast or slide set from an archive.
Latest News: Links to recent articles relating to pediatric patient safety.
Email List: An e-community dedicated to pediatric patient safety issues and information exchange with other clinicians.
Parents’ Corner: Resources to help parents understand what they can do to help ensure their optimal safety in the health care that their child
receives.
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DISCLOSURES
None of the individuals involved in this webinar (Speakers, Moderator, Project Advisory Committee members, or
Staff) has disclosed any relevant financial relationships or any financial relationships with the manufacturer(s)
of any commercial product(s) and/or provider of commercial services discussed in CME activities.
None of the individuals (Speakers, Moderators, Project Advisory Committee members, or Staff) has disclosed
that they intend to discuss or demonstrate pharmaceuticals and/or medical devices that are not
approved.
Refer to full AAP Disclosure Policy & Grid available below for download.
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CME CREDITLive Webinar Only
The American Academy of Pediatrics (AAP) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The AAP designates this educational activity for a
maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
This activity is acceptable for up to 1.0 AAP credits. These
credits can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Fellows of the American Academy of Pediatrics.
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OTHER CREDITLive Webinar Only
This program is approved for 1.0 NAPNAP contact hours of which 0 contain pharmacology (Rx) content per the National Association of Pediatric Nurse Practitioners Continuing Education Guidelines.
The American Academy of Physician Assistants accepts
AMA PRA Category 1 Credit(s)TM from organizations accredited by the ACCME.
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Speaker: Annie Moulden, MBBS, FRACPClinical Leader, Patient Safety and RiskRoyal Children’s HospitalMelbourne, Victoria, Australia
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Speaker: Jim Tibballs, MBBSPhysician Intensive Care Unit and Resuscitation OfficerRoyal Children’s HospitalMelbourne, Victoria, Australia
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Speaker: Sharon Kinney, RN, MNRoyal Children’s HospitalMelbourne, Victoria, Australia
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Run, don’t walk: Improving outcomes in pediatrics using a rapid response team
The Melbourne experience
Dr Annie MouldenAssoc Prof Jim TibballsMs Sharon Kinney
Royal Children’s HospitalMelbourne, Australia
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Why did we introduce the MET?
Annie Moulden
Clinical Leader, Patient Safety & Risk
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Dr Jim Tibballs
Intensive Care Physician & Resuscitation OfficerRoyal Children’s Hospital, Melbourne, Australia
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RAPID RESPONSE TEAMS
Medical Emergency Team (MET)
Rapid Response Team (RRT)
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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
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‘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
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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
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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
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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
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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
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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)
ANY one or more of the following:
MET calling criteria
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MET calling criteria
4. Severe respiratory distress, apnoea or cyanosis
Age Respiratory Rate
Term-3 months >60
4-12 months >50
1-4 years >40
5-12 years >30
12 years+ >30
5. Tachypnoea
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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
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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
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8. Acute change in neurological status or convulsion
9. Cardiac or respiratory arrest
MET calling criteria
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Does MET make any difference to cardiac arrest and mortality?
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PREDICTABLE (PREVENTABLE) CARDIAC ARREST & DEATH
(per 1000 admissions)
BEFORE MET
AFTER MET
1 YEAR
AFTER MET
4 YEARS
CARDIAC ARREST
0.16 0.00(p=0.02)
0.07(p=0.04)
DEATH 0.11 0.00(p=0.04)
0.01(p=0.001)
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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)
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Sharon Kinney
MET Coordinator,
Royal Children’s Hospital, Melbourne
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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 staffSupportive & positive attitude to callers of MET
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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)
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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
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Time of day for MET calls (4 year period, n = 809)
0
10
20
30
40
50
60
Time of day (hours)
Nu
mb
er o
f M
ET
cal
ls
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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