ANZICS S&Q 2014 - RRT: Alex Psirides on Managing the MET call
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Alex Psirides on Managing the MET call. Presented at the ANZICS S&Q Conference 2014 on Rapid Response Teams.
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ANZICS S&Q 2014 - RRT: Alex Psirides on Managing the MET call
- 1. MANAGING THE MET CALLTEACHING ADVANCED MEDICAL TRAINEES ALEX PSIRIDES INTENSIVE CARE SPECIALIST WELLINGTONICU.COM @PSIRIDES July 2014
- 2. THREE QUESTIONS • What do ICU trainees see during MET calls? • What skills do they need to manage them? • How can we teach them?
- 3. THE SINATRA FALLACY “If they can make it there, they’ll make it anywhere.” F.Sinatra 1980
- 4. A BRIEF OUTLINE OF THE PROBLEM
- 7. THE ICU TRAINING MODEL • Closed, controlled environment with equipment immediately to hand • Senior medical advice immediately available • Senior nursing staff on-site 24/7 • Low patient : nurse ratio • Patient deterioration detected immediately & usually follows predictable trajectory • Trainees heavily supervised
- 8. THE MET ‘TRAINING’ MODEL • Open, uncontrolled environment with equipment randomly distributed if available at all • Senior medical & nursing staff solar-powered • High patient : nurse ratio • Patient deterioration may have been ongoing for some time & follow unpredictable trajectory • Trainees unsupervised • Trainees expected to manage a heterogenous team of equally unsupervised people they’ve usually never met before
- 11. WHAT’S SO SPECIAL ABOUT THE MET CALL?
- 12. WHAT’S SO SPECIALABOUT THE MET CALL? The Pathology: • 6% MET calls due to ‘staff worried’ • Severe physiological derangement: • Of 1 system in 62% of patients • Of 2 systems in 26% of patients • Of 3 systems in 6% of patients • 15% patients had no documented provisional diagnosis • 90% of calls due to hypoxia, hypotension or altered conscious state MET syndromes & an approach to their management. Jones, Duke et al, Critical Care 2006, 10
- 13. WHAT’S SO SPECIALABOUT THE MET CALL? Acute Death: • One third of MET calls involve acute end-of-life care • A MET call doubles the rate of Limitation of Medical Therapy or Not For Resuscitation documentation Effect of MET on documentation of advance care directives. Knott, Psirides & et al, CCR 2011
- 14. Care for all at the end of life. Murray BMJ 2008, 336
- 15. The Location & The Staff: • Remote environment • Multiple people of varying skill sets likely to attend • Panic, guilt & miscommunication • Team leadership may not be apparent & difficult to establish in a crisis • Politics & team hierarchy • ‘My patient’ WHAT’S SO SPECIALABOUT THE MET CALL?
- 16. Communication: • Working with distressed ward staff • Establishing a history when no-one knows the patient • Intra-team dynamics • Communication with patient & family (who may all be present) • …whilst simultaneously diagnosing & resuscitating a critically ill patient WHAT’S SO SPECIALABOUT THE MET CALL?
- 17. • Working with uncertainty • The patient has deteriorated despite treatment for their admitting condition because • The treatment is wrong • There is a side effect of their treatment • They have something new wrong with them WHAT’S SO SPECIALABOUT THE MET CALL?
- 18. THE MET SKILLSET Knowledge • The need for a MET system • Conditions that cause MET calls & their differentials Practical ability • Technical skills (intubation, NIV, CV access etc) Leadership skills • Lead – don’t do, prioritise, co-ordinate, manage resources Communication skills • Obtain & give handover to non-critical care trained staff, communicate with patient, family, MET members
- 19. TEAM THEORY “A team is not a bunch of people with job titles, but a congregation of individuals, each of whom has a role which is understood by other members. Members of a team seek out certain roles and they perform most effectively in the ones that are most natural to them.” Dr. R
- 20. Anaesthetist’s non-technical skills. Flin, Patey et al. BJA 105,1 A N T S
- 21. Q: WHY DO DOCTORS IGNORE WARNING SIGNS BUT PILOTS DON’T? A: THE PILOT IS ALSO ON THE PLANE
- 22. THE A TO F OF BAD TRAINEES Arrive shouting Blame Criticise Declare Dead Exit, Exaggerate, Email all your colleagues Write about it on Facebook A B C D E
- 23. THE A TO G OF GOOD TRAINEES Ask & Assess Begin Basic investigations Communicate, Call for help if needed Discuss, Decide & Document Explain aetiology & management Follow-up Graciously thank staff MET syndromes & an approach to their management. Jones, Duke et al, Critical Care 2006, 10 A B C D E F G
Editor's Notes
- AKA ‘leaving the silo’ Apologies to nursing colleagues as this is medically focussed
- Distribution of patients in a hospital Some patient have junior medical & nursing staff actively attempting to push the patient to the right
- Rinaldo Bellomo talks about how patients have changed – they are older & more co-morbid Paradigm shift in patient management Medical education has not changed to reflect this Created a new breed of undead patients
- Not just treatment equipment but also monitoring equipment
- The current MET training model
- ‘Leaving the ICU silo’ Credit to Victoria Brasil Whenever the ICU doctor leaves the ICU silo, most doctors they meet are either an idiot or obstructive. At worse, they are an obstructive idiot
- Review of 400 MET calls at the Austin Infections, cardiogenic shock or pulmonary oedema & arrhythmias responsible for 53% of all triggers for MET calls
- Trainees may be forced into making palliative decision on patients they have never met before without the presence of the parent team or the patient’s family ICU registrars from other specialties (especially anaesthesia) may be particularly uncomfortable with this
- Rinaldo Bellomo has talked about ‘My patient’ & how a system designed in the 18th century no longer applies to modern medicine, that of the named physician
- Intra-team dynamics – always a house surgeon performing a blood gas
- Most patients who deteriorate do so after being admitted for 24 hours Treatment is wrong – wrong antibiotic, wrong diagnosis etc Patients are increasingly more co-morbid; the sort of patients who were previously managed in-hospital 30-40 years ago are now managed at home. The sort of patients who would have died 30 years ago are now managed in the ward.
- Practical ability includes teaching trainees how to cope when you don’t have your anaesthetic technician or an ultrasound machine Communication – cricoid in the drug cupboard anecdote
- Practical ability includes teaching trainees how to cope when you don’t have your anaesthetic technician or an ultrasound machine Communication – cricoid in the drug cupboard anecdote
- Adapted from the UCEM guidelines Credit to Dr.Nickson
- A – ask the staff how you can help them, ask about the reason for the MET call, assess for the aetiology of the deterioration C – call the Consultant D – discuss MET with the parent unit/Consultant, discuss advanced care planning if needed, decide where the patient is best managed, document the MET & subsequent frequency of observations as well as a plan F – which doctor will follow the patient up? What are the criteria for doctor re-notificaiton