Medical Emergency Teams

Their role in reducing adverse

events

A/Prof Daryl Jones

Overview

• What are adverse events / preventable ?

• Problems with these definitions

• The MET and adverse events

– Rationale

– Evidence of effectiveness / reducing AEs

– Uptake in Australia

• Moving things upstream

– Linking with quality safety and risk

– Pre-emptive and pro-active care

What are adverse events ?

• Quality in Australian Health Care Study 1995

– 14,000 admissions in 28 hospitals

– 16.6% showing adverse events

»51% deemed preventable

»4.9% causing death

»13.7% permanent disability.

• Unintended injury or complication that resulted in

disability, death of prolonged hospital stay and was

caused by the health care management rather than

by the underlying disease process

Wilson etal. MJA 1995

Admissions AEs disability death .

UK 1006 1 8.7% 15% 10%

1014 2 10.8% 33% disability or death

NZ 6579 3,4 12.9% 15% disability or death

Can. 3745 5 7.5%

Den. 1,0976 9.0% 28.9% disability or death

1. Sari etal Qual Saf Health Care. 2007

2. Vincent etal BMJ 2001

3,4 Davis etal NZ Med J 1998

5. Baker etal 2000

6. Schiøler T etal Ugeskr Laeger. 2002

10% AE 1/4 die or disabled

Problems with definition

• Retrospective analysis

– ? Do you have all the information

– What else was going on at the time?

• “Arm chair expert”

• Preventability subjective 1

• Focus on iatrogenesis - ? System / disease / clinical

factors

• Does not help clinicians identify “at-risk” patient

prospectively

1. Hayward RA, Hofer TP. JAMA. 2001; 286: 415-20.

Are there objective warning signs

• Audits cardiac arrest and unplanned ICU

admission 1990s

• Often signs of deterioration

– Chest pain

– Change in vital signs

– Need for increased oxygen

– Abnormal blood tests

– Expressed concern by doctor or nurse

Cardiac arrests have warning signs

• Up to 84% preceded by abnormal vital signs or

development of new problems

– Schein etal Chest 1990 USA

– Buist etal MJA 1999 Aus

– Hodgets etal Resus. 2002 UK

– Nurmi etal Act Anaes Scan 2005 Fin

– Bell etal Resus. 2006 Swe

• RR = Best predictors of mortality

• RR = WORST measured vital sign

More objective……..however

Studies Real Life

Event

? Warning signs

Warning signs

? Event

Medical Emergency Team (MET)

• Invented by Ken Hillman

• Rationale

1. Adverse events are common

2. They have warning signs

3. Deterioration often occurs slowly (there is time to intervene)

4. Early intervention improves outcome

5. Ward staff may lack experience with very sick patients

6. Skilled staff exist in the ICU

MET – moves things upstream

Hospital

inpatientAbnormal

vital signs

MET

call

Cardiac

arrest

Mort 2% Mort 80%

• Respond Blue

– HR = 0

– BP = 0

– Pulse = 0

– Consciousness = 0

Objective criteria

Decision support

Point of care

Expected response

• detector

• responder

MET in Australia

• Now in > 70% Australian hospitals with ICUs

• A major mechanism for identification and review of

deteriorating patients

• “Mandatory need” – ACSQHC – National standard 9

• In many hospitals

– 3-8% of all hospital admissions > 24hr reviewed

by the MET

– In-hospital mortality MET patients ≈ 20%

– One year mortality heart attack ≈ 10%

Uptake in Australia and New Zealand

75%

implemented

MET by May

2002

Effectiveness of the METJones et al Crit Care 2008

Increased use with time

Evidence for reducing adverse events

• Most convincing evidence = Cardiac arrests

1. Dandenong Buist etal BMJ 2002 Aus

2. Austin Bellomo etal MJA 2003 Aus

Jones etal CCF 2006

4. Pittsburgh DeVita QSHC 2004 USA

5. RCH Tibbals etal Arc Dis Child Aus

6. Nijmegan Simmes etal Ann Int Care Neth

7. Karolinska Konrad etal ICM 2008 Swe

8. St V’s (Melb) Satamaria CCM 2010 Aus

9. California Lighthall Ana Anal 2010 USA

10. Boston Beitler CCF 2011 USA

• In-hospital mortality reduction

1. Karolinska Konrad etal ICM 2008 Swe

2. Austin Jones etal Resus 2007 Aus

3. Boston Beitler CCF 2011 USA

4. Karolinska Konrad etal ICM 2008 Swe

5. Phili Sarani etal Resus 2011 USA

So arrests + surgical deaths

However ....................

Need to move things further upstream

Hospital

inpatientAbnormal

vital signs

MET

call

Cardiac

arrest

Mort 2% Mort 20% Mort 80%

How ?

Old paradigmCurrent

paradigmFuture

paradigm

ACQSHC consensus statement – deteriorating patients

• A. Clinical processes

– Measurement and recording of observations

– Escalation protocols

– Rapid response systems

– Communication processes

• B. Organizational pre-requisites

– Organizational supports

– Education

– Evaluation and monitoring

– Use of new technology

Coupling clinicians with administration

• Deteriorating patient committee

– Expert advisory committee – meets monthly (BHH)

– Sub-committees = working committees

• Modification of VHIMS (RiskMan)

– Fiona Webster, Fiolmena Ciavarella, Eileesh Diviney

– Electronic data entry calls

– Automatically e-mailed to parent unit / quality coordinators

– Parent units start to audit their own calls

• MET forum / EOLC forum strategic planning

• ORC and urgent clinical review

Observation and Response Chart (ORC)

Escalation policy

Moving upstream - Epidemiology of MET patients

• In 1990s studied “antecedents to CAs”

– From these observations MET

• Now need to study MET call patients (sickest patients in

hospital) preventative strategies.

– Timing in relation to hospital admission

– Timing – over 24 hr period

– Common causes of MET calls

» AF, APO, sepsis

– Location of MET calls

» Approx 40% calls occur on 3 surgical wards

– End of life call issues = approx 35% calls

Dr start Dr end

RN

handover

RN

handoverRN

handover

Timing of 2568 MET calls

“MET syndromes” based on theme

• End-of-life care MET call

– Limitations of medical therapy / palliative care needed

• Expertise / Escalation

– Critical care input essential

– Often start ICU-level care at the bed side

– Often admitted to ICU / HDU

• Expeditious / Educational

– Largely active ward level care

– MET respond rapidly and provide definitive plan

So what ?

• End of life MET calls

– Train staff how to “have the talk”

– Better advanced care planning and palliative care

• Expertise / Escalation

– Teach staff principles of CRM / NTS

– MET may become a crisis for the team escalate to consultant

– Implications for triage ICU patients / ICU access

• Expeditious / Education

– Many of these calls might be managed by ward staff

– ? Effect on introduction of urgent clinical review

– Opportunity for teaching of junior ward staff / practice team leading

1/3

1/7 - 1/10

1/2

In the future = “pre-emptive and pro-active”

Risk stratification

Jones, Dunbar, Bellomo MJA 2012

Two patients: SBP 85mmHg HR 140 bpm

• 17 yo fit female with

moderate N+V

• No delay MET call

• Call 930 am Wed

• ICU consultant team

leader MET

• Admitted under

Internal Med

• On medical ward

• ICU bed free if needed

• 85 yo male with IHD, CRF, DM

• Day 3 post laparotomy bowel

Cancer

• Cellulitic wound

• Surgical admission

• Boarder on thoracic ward

• MET 3am Sat, 6hr delayed

• No dedicated MET registrar

• ICU full

Patient 1 Patient 2

Summary

• Concept of “adverse events”

– Useful from perspective of patient “harm” and

medical defence – usually retrospective

– Less useful for clinicians to prospectively “risk

stratify a patient”

– ?? Better concept = clinical deterioration

• Deterioration hospital inpatients common

– Approx 3-8% patients staying > 24hr get a MET

• METs probably reduce CAs + surgical deaths

• BUT.. ≈20% MET patients die in hospital

• “Moving forward” = “Moving upstream”

– Better end of life care planning some areas

– Need to audit MET calls = antecedents

– Pre-emptive and pro-active management in others

»Risk profiling of patients – including before they get into

hospital

»Medical co-management high risk surgical patients