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Nursing Grand Rounds April 10, 2007

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  • 1. Nursing Grand Rounds April 10, 2007 Medical Emergency Teams at MUHA Review and Update Helena Walo, RN, BSN Interim Manager, 8 East Shelia Scarbrough, RN, MSN Manager, Critical Interventions Cathleen Walters, RN, CCRN Clinical Nurse Leader, MICU
  • 2. Objectives
    • Understand the history and evolution of Medical Emergency Teams
    • Recognize opportunities for collaboration and empowerment for nursing staff in utilizing MET
    • Discuss the nursing roles during a MET call at MUHA
  • 3. Medical Emergency Teams Historical Perspective and Evolution
  • 4. Stagnate Outcomes
    • Studies from the 1970’s to present continue to demonstrate >50% mortality from unexpected in-hospital cardiac arrests BMJ . 2002;324:387-390
    • From 1966 to 1999, the average ICU readmission rate remained relatively unchanged at 7% Chest. 2000;118:492-502
  • 5.  
  • 6. Fact: Studies have shown that patients often demonstrate signs and symptoms of physiological instability for several hours prior to a cardiac arrest
  • 7. For example…
    • 70% of patients show evidence of respiratory deterioration within 8 hours of arrest
    • Chest . 1990;98:1388-1392
    • 66% of patients show abnormal signs and symptoms within 6 hours of arrest and MD is notified in 25% of cases
    • Crit Care Med . 1994;22(2):244-247
    • Abnormal clinical observations independently associated with an increased high risk of mortality: decreased level of consciousness, loss of consciousness, hypoxia, hypotension, and tachypnea.
    • Most common arrest-preceding events: hypoxia (51%) and hypotension (17%).
    • Resuscitation . 2004;62(2):137-141
  • 8. The Aussie Answer
  • 9. “We can do better…”
    • Austin Hospital in Heidelberg, Victoria, Australia
    • pioneered by Ken Hillman
    • began by studying patients who had major surgery at the hospital and then suffered significant complications such as reintubation, cardiac arrest or renal failure
    • complication rates = 16 to 17 percent, consistent with research elsewhere
  • 10. The Rapid Response Team is Born
    • Proponents of a Rapid Response Team spent months presenting their case to surgical and medical units throughout the hospital
    • Established straightforward criteria of clinical instability, beginning simply with the staff member being worried about the patient and other indicators such as acute changes in heart rate, blood pressure, or level of consciousness
  • 11. Results???
    • Overall adverse outcomes: relative risk reduction 57.8%
    • Respiratory failure: relative risk reduction 79.1%
    • Stroke: relative risk reduction 78.2%
    • Severe sepsis: relative risk reduction 74.3%
    • Acute renal failure requiring renal replacement therapy: relative risk reduction 88.5%
    • Emergency intensive care unit admissions: relative risk reduction 44.4%
    • Postoperative deaths: relative risk reduction 36.6%
    • Duration of hospital stay after major surgery decreased from a mean of 23.8 days to 19.8 days
    • Critical Care Med. 2004 Apr;32(4):916-21
  • 12. Getting Started Kit: Rapid Response Teams How-to Guide A national initiative led by IHI, the 5 Million Lives Campaign aims to dramatically improve the quality of American health care by protecting patients from five million incidents of medical harm between December 2006 and December 2008. The How-to Guides associated with this Campaign are designed to share best practice knowledge on areas of focus for participating organizations. For more information and materials, go to www.ihi.org /IHI/Programs/Campaign
  • 13. Differences MET can make:
    • 50% reduction in non-ICU arrests
    • BMJ. 2002;324:387-390
    • Reduced post-operative emergency ICU transfers (58%) and deaths (37%)
    • Critical Care Medicine . 2004;32:916-921
    • Decrease from 30% to 4% of patient arrests prior to ICU transfer
    • Anesthesia. 1999;54(9):853-860
    • 17% decrease in overall incidence of in-hospital cardiopulmonary arrests
    • Quality & Safety in health care. 2004;13(4):251-254
  • 14. Imagine… 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…
  • 15. 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…
  • 16. Failure to Rescue
    • Three main causes:
    • Failures in planning
      • (assessments, treatments, goals)
    • Failure to communicate
      • (patient to staff, staff to staff, staff to physician, etc.)
    • Failure to recognize deteriorating patient condition
  • 17. MET Evolution at MUSC It’s a process…
  • 18. MUSC’s MET history
    • Began as a small task force with interest in the “idea”
    • Sheila Scarbrough, RN, MSN began role as Critical Interventions Manager in July 2006
    • Policy development, networking, collaborating with interdisciplinary teams
    • Education component developed with the Simulation Center in October 2006.
    • MET training for ICU nurses, MDs, pharmD’s, RT’s (i.e. code team members) in December 2006
    • Trail of MET responses began January 3, 2007 on 6E, 7E, and 8E
    • Expanded to 8W in March and 10W in April
    • Also in Children’s hospital
    • Future plans: Careful planning and implementation is crucial to success!!!
  • 19. Nurses Make the Difference
    • Majority of MET initiation is nurse driven – nurses recognize the s/s, nurses make the call for the MET team
    • At MUSC, a critical care nurse from the MICU will answer the MET pager and is an integral part of the MET
  • 20. SBAR
    • Addresses all 3 causes of Failure to Rescue
    • A crucial tool to improve communication between caregivers and improve patient outcomes
    • Gives MET a concise and complete picture of the patient’s condition
    • Information given allows team to intervene quickly and appropriately
  • 21. Role Delineation for Nurses
    • General floor:
    • utilizes assessment skills to follow algorithm for intervention,
    • works with patient’s primary team,
    • makes the call to the MET if the patient meets criteria,
    • remains with patient
    • prepares for MET arrival,
      • have chart available,
      • significant PMH, allergies
      • most recent VS, labs, recent medications, procedures
      • SBAR
  • 22. Role Delineation for Nurses
    • ICU
    • Arrives with advanced monitoring equipment – brings ICU to the patient
    • Receives information from primary care nurse
    • Completes initial assessment to include pertinent VS and lab work
    • Continues to provide critical care as appropriate
    • Documents accurately on MET form
  • 23. FYI
    • Physicians collaborate to determine further intervention and patient disposition
    • MET is NOT the BAT
      • You can call BOTH at the same time!
    • MET is NOT the Mayday team
      • If patient is in a life threatening situation, a Mayday will be called.
      • Goal is to intervene BEFORE the patient reaches this point.