Ken Hillman presenting that ICU should triage & assess all deteriorating ward patients. Presented at the ANZICS S&Q Conference 2014 on Rapid Response Teams.

1. Intensive Care
Unit
THE ICU SHOULD TRIAGE AND
ASSESS ALL DETERIORATING WARD
PATIENTS
Ken Hillman
8th
International Conference on Safety, Quality, Audit and
Outcome Research in Intensive Care.
Melbourne. 7-9 July 2014

2. EVIDENCE THAT THERE
IS SOMETHING
WRONG IN ACUTE
HOSPITALS
9/0133

3. VITAL SIGN ANTECEDENTS
PRECEED
Cardiac arrests
Deaths
ICU admission
Schein et al Chest 1990;98:1388
Hillman et al Med J Aust 2000;173:236-40
Hillman et al Internal Med J 2001;31(6):343-48
1.2/0113

4. REASONS FOR SUBOPTIMAL CARE
PRIOR TO ICU ADMISSION
• Wrong people
• Too late
• No organisation
McQuillan et al BMJ 1998;316:1853
1.2/0007

5. SICK PATIENT
NURSE OBSERVES BUT CAN’T ACT
TRAINEE DOCTORS ACT BUT NOT
TRAINED
SPECIALIST – TRAINED BUT NOT IN ACUTE
MEDICINE
EVENTUALLY MULTIORGAN
FAILURE/CARDIAC ARREST AND ADMITTED
TO ICU
1.2/0073
Systems to
connect first
signs with
acute care
specialists

6. CHANGE
• Initially ridiculed
• Violently opposed
• Accepted as self evident
Schopenhauer
1/0556

7. THE POLITICS OF RAPID
RESPONSE SYSTEMS
Patients who have a rapid response are
as seriously ill with a similar mortality as
patients in ICU
Resuscitation 2004;62:137
Crit Care Resus 2007;9:151
45/0018

8. THE MANAGEMENT OF SERIOUSLY ILL PATIENTS IN:
ICUs
RRSs
FACED THE SAME CHALLENGES OF:
Hospital politics
The home team had always cared for their own
patients
We don’t need people trained in acute medicine
Funding
New boy on the block
1/0547

9. HOSPITAL MEDICINE
Diplomacy, politics and conformity with
the medical hierarchy usually trumps
patient care
24/0187

10. RAPID RESPONSE SYSTEMS
(RRS)
• Ignore location, concentrate on level of
illness and patient needs
• RRSs do not create the problem, they are
a response to it
45/0019

11. MATCHING LEVEL OF
ILLNESS WITH LEVEL OF
CARE
45/0023

12. MERIT STUDY
Only 5 of 2376 patients who had a MET
call did not have critical care interventions
Resuscitation 2010;81:25-30
1.4/0431

13. DO MET SYSTEMS WITH
SINGLE CRITERIA AND SINGLE
TIERED RESPONSE WORK?
1/0548

14. REDUCTION IN MORTALITY AND
CARDIAC ARREST RATES IN ADULT
AND PAEDIATRIC HOSPITALS
Arch Int Med 2010;170:18-26
CCM 2009;37:148
2/0253

15. MORE IMPORTANTLY
Early detection and management
of hypoxia and ischaemia is at
the core of Intensive Care
Medicine
37/0020

16. IN-HOSPITAL CARDIAC ARREST (IHCA)
AND MORTALITY RATES/1000 ADM
2002-2009 = 84 HOSPITALS IN NSW
2002 2009
IHCA 3.72 1.85 <0.001
IHCA Mortality 2.71 1.26 <0.001
Hospital
Mortality
17.63 14.36
2/0242
MJA 2014 – in press

17. IMPACT OF GRADUALLY INCREASING RRS
RATES IN 84 HOSPITALS OVER 9 YEARS
ICHA RELATED IMPROVEMENTS IN
MORTALITY
•5% due to CPR
•95% due to RRS prevention
THE END OF THE CPR ERA
MJA 2014 – in press
2/0246

18. THE RATES OF IHCA, IHCA-RELATED
MORTALITY AND HOSPITAL MORTALITY (per
1000 admissions) BETWEEN 2002-2009
Liverpool hospital
H2
H1
H3
Pre-RRS Post-RRS
10111213141516171819
Hospitalmortality(per1000admissions)
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Hospital mortality
LIverpool hospital
H1
H2
H3 Pre-RRS Post-RRS
1.02.03.04.05.06.07.0
IHCArate(per1000admissions)
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
IHCA rate
Liverpool hospital
H1
H2
H3
Pre-RRS Post-RRS
1.02.03.04.05.0
IHCArelatedmortality(per1000admissions)
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
IHCA related mortality
2.1/0004

19. IMPACT OF TWO-TIERED
SYSTEM
45/0038

20. HOSPITAL OF THE FUTURE
SERIOUSLY
ILL
PATIENTS
16/0015

21. FORWARD TO TEXTBOOK ON
RRS
Dedicated to:
‘the many patients who have suffered
and suffer because of an outdated
approach to acute hospital care’
Rinaldo Bellomo
1/0550