ANZICS S&Q 2014 - Abstract Presentation: Singh on After-hours vs in-hours MET calls

Manoj Y Singh MD, IDCC, FNB, EDIC, FCICM
Department of Intensive Care Lecturer,
The Canberra Hospital, Australia The Australian National University
Email: Manoj.Singh@act.gov.au
Twitter: @Drmanoj_s
Scott L, Mitchel I, Rai S, TCH Outreach Team
Are after-hours Medical
emergency systems any
different to work-hours METs

No competing interest!!
Are after-hours Medical
emergency systems any
different to work-hours METs

Introduction
• Post inception of the RRS
AreAfter-hoursMETsanydifferenttoWork-hoursone?
• 2002–2008 period, RRS
hospital
• >50% lower IHCA
rate,
• 40% lower IHCA-
related mortality,
• 6% lower overall
hospital mortality.
Chen J et al Resuscitation June 2014Crit Care Med 2010; 38:445–450

IHCA rate/mortality plateaued?
Impact of RRS in Australia
Chen J et al Resuscitation June 2014
22%22%
11%
No difference in outcomes & 1-year post-discharge mortality

Reasons?
• Burden!!!
– In 2009, RRT
• 18800 calls
• At any hour 2/27 hosp ls/hour
– This rate is on the
rise
• >700% rise !!!
• Non preventable
events/factors
Crit Care Resusc 2013; 15: 273–278

IHCA mortality
• Modifiable factors
– Science of resuscitation & after-care
– Early recognition of deteriorating pts
• Missed MET opportunities
– Better EOL planning
– Fewer multiple METs/ review calls
– Improved skill mix of hospital staff
– Better after-hours care in the hospital

After-hour METs
Is it a KPI for
after-hours
care in the
hospital?

The issue with After-hours!
• Staff numbers and skill mix
• Lack of supervision
– Run mainly by JMOs
• Lack of care coordination
• Poor multidisciplinary communication
The hospital sleeps but the diseases don’t !!!

Study Aim
• Whether after-hours MET calls any
different to the work-hours MET calls?
– Primary outcome
• Compare all-cause in-hospital mortality
– Secondary outcomes
• Hourly variations in number of METs
• Hourly variations in in-hospital mortality
depending on the time of their first MET
• Hourly variations in MET triggers

Methodology
• Retrospective study
– Inclusion criteria
• All adult pts who had MET calls recorded at the
Canberra hospital (TCH) between 1st January
2012 to 31st June 2013
• Used MET database to get the data
– TCH a 600 bedded tertiary referral & trauma
center & university teaching hospital
• 22 bedded ICU unit
• 69,000 separations in 2012 & 73,821 in 2013

Methodology
• Ethics approval was obtained from the
TCH HREC

Methodology
• After-hours MET definition
– No standard definition proposed in literature
– We aimed to compare the two cohorts with an
after-hour definition of
(A) 18:00-05:59 hours (based on ANZICS
after-
hour discharge from ICU)
&
(B)18:00-07:59 hours (based on our hospital
working hours)

Methodology
• Exclusion criteria
–All METs in people
• Age<16 years,
• Not in-patients (staff, visitors etc),
• METs in Mental health unit

Methodology
• Statistics
– To calculate all cause in-hospital mortality
• We assigned patients into the two cohorts
depending on their time of their first MET
call
• Expressed as Odds Ratio (OR) with 95%
CI (fisher exact test)
• A p value <0.05 was considered statistically
significant

Results
• 2487 MET episodes were recorded during
study period
• 539 were excluded
• 1948 MET call episodes included in study
– 1573 patients (55.1% males) accounted for
the above
• Majority (82.13%) were attended by a
dedicated Outreach team

Results
• 284 (18.01%) pts had multiple MET calls
during their hospital stay
• 115 (7.31%) pts had multiple METs within
24 hours period
• 77(4.8%) patients were made NFR during
their first MET
• 167(10.6%) patients had preexisting NFR
prior to MET

Results
• After-hour MET calls
– Definition A (17:59-05:59 hrs): 836 (42.91%)
– Definition B (17:59-07:59 hrs): 996 (51.12%)

Results
• After-hour METs: 996 (51.12%) (B)
0
20
40
60
80
100
120
140
60
51
63
45
39
56
78
82
85
103
119
108
88 90
112
79 79
89
117
121
108
68
62
46

Results
• Weekday distribution of MET calls (n)
0
20
40
60
80
100
120
140
160
180
200
Monday Tueday Wedday Thursday Friday Saturday Sunday
147
178
174
186
146
139 142
107
138
128 127
110
125
101
Total Work-hours
Total After-hours

Results
• Weekday distribution of MET calls(n)
0
20
40
60
80
100
120
140
160
180
200
147
178
174
186
146
139 142
107
138
128 127
110
125
101
47
81
64
59
47
64
52
32 31
37
31 34
27 2728 26 27
37
29
34
22
Total Work-hours
Total After-hours
18:00-21:5923:59
22:00-01:59
02:00-06:00

Results
• Distribution of MET triggers (%)
0
5
10
15
20
25
30
Airway RR<5 Respiratory
arrest
HR< 40 Seizures Cardiac
Arrest
HR>140 RR>36 Dec GCS Worried BP<90
1.7
0.26 0.26
1.52
3.68 3.68
12.14
11.69
23.74
15.82
25.44
1.55
0.11 0.23
1.55
3.11
5.5
12.67 13.15
17.1
19.97
25
Work-hours
After-hours

Results
• All cause in-hospital mortality (A)
– 21.81% (142/651) for “after-hours”
– 18.16% (160/881) “work-hours”
• OR 1.25, CI 0.97-1.61, p value 0.07
• All cause in-hospital mortality (B)
– 22.69% (175/771) for “after-hours”
– 18.26% (139/761) “work-hours”
• OR 1.31, CI 1.02-1.68, p value 0.031

Results
• Mortality during at their first MET call
– 2.25% (15/666) for “after-hours”
– 2.87% (26/907) for “work-hours”
• OR 0.78, CI 0.41-1.48, p value 0.45

Results
• In-hospital mortality as per time of their
first MET (A)
23.1
26.2
20
38.5
22.5
27.8
31.5
24.3
26.5
15.5
22.2
10.3
14.6
18.3
15.3
20
15.2 14.5
15.8 15
22
18.2
32
17.6
0
5
10
15
20
25
30
35
40
45
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Results
• In-hospital mortality as per time of their
first MET (B) p value 0.031
23.1
26.2
20
38.5
22.5
27.8
31.5
24.3
26.5
15.5
22.2
10.3
14.6
18.3
15.3
20
15.2 14.5
15.8 15
22
18.2
32
17.6
0
5
10
15
20
25
30
35
40
45
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Results
• Cardiac arrest rates (n)
23.1
26.2
20
38.5
22.5
27.8
31.5
24.3
26.5
15.5
22.2
10.3
14.6
18.3
15.3
20
15.2 14.5
15.8 15
22
18.2
32
17.6
0
5
10
15
20
25
30
35
40
45
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
0
2
4
6
8
10
12
Cardiac Arrest

Discussion
• Worried calls (n)
23.1
26.2
20
38.5
22.5
27.8
31.5
24.3
26.5
15.5
22.2
10.3
14.6
18.3
15.3
20
15.2 14.5
15.8 15
22
18.2
32
17.6
0
5
10
15
20
25
30
35
40
45
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 230
5
10
15
20
25
30
35 Worried

MET Trigger
• More from surgical wards(n)
0
5
10
15
20
25
Worried SBP<90 HR>140 HR<40 RR>36 RA RR<5 CA Airway Dec GCS Rpt
Seizures
19.08 19.08
13.73
1.05
10.07
0.13 0.13
1.7 1.57
17.39
3.01
16.24
21.95
12.5
2.07
15.65
0.3 0.3
4.53
1.77
20.87
3.84
Surgical ward
Medical ward

Discussion
• CVS parameters: SBP<90 mmHg
23.1
26.2
20
38.5
22.5
27.8
31.5
24.3
26.5
15.5
22.2
10.3
14.6
18.3
15.3
20
15.2 14.5
15.8 15
22
18.2
32
17.6
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
0
5
10
15
20
25
30
35
40
45
SBP <90
SBP <90

Discussion
• Respiratory parameter: RR>36/min(n)
23.1
26.2
20
38.5
22.5
27.8
31.5
24.3
26.5
15.5
22.2
10.3
14.6
18.3
15.3
20
15.2 14.5
15.8 15
22
18.2
32
17.6
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
0
2
4
6
8
10
12
14
16
18
20
RR>36
RR>36

Discussion
• Neurological parameter: Dec GCS(n)
23.1
26.2
20
38.5
22.5
27.8
31.5
24.3
26.5
15.5
22.2
10.3
14.6
18.3
15.3
20
15.2 14.5
15.8 15
22
18.2
32
17.6
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
0
5
10
15
20
25
30
35 Dec GCS

Study limitations
• Retrospective cohort study
• Impact of staffing ratios & skill mix in the
two cohorts
• Effect of many other co-variates
• Effect on multiple METs on outcome
• Cross over effects of subsequent METs

Study limitations
• Effect of limitation of medical treatment on
the overall in-hospital mortality
– LOMT set prior/at/after METs
• We are looking into this in our extended
review
– LOMT revoked = ?delay in treatment
Acta Anaesthesiol Scand 2013; 57: 1268–1274

Study Strengths
• Only few studies have looked at the hourly
variations of METs
– compared hourly variation of in-hospital
mortality depending on the time of MET
– Most studies- cardiac arrest variations
• It may give some insight to
– Variations in MET trigger patterns each hour
– Possible areas of improvement
– Possible using after-hour METs as KPI
• Generated further research questions

Conclusions
• After-hours MET calls had increased in-
hospital mortality risk
• There is a difference in the way MET is
triggered in after-hours than work-hours
• There may be a potential to decrease in-
hospital deterioration related mortality
further

Questions
Thank You
Neurologicalprognosispostcardiacarrest:Wherewestand?

Lessons learnt
• Study raises further questions on the
impact of after-hours hospital care on in-
hospital mortality
• Stimulus for further research
– Patients with limitation of care excluded
– Influence of disease, chronic illness, age etc
on mortality
– Experience of the skill-mix of staff at MET
outcome

Study limitations

Results
• Cardiac arrest rates (n)
23.1
26.2
20
38.5
22.5
27.8
31.5
24.3
26.5
15.5
22.2
10.3
14.6
18.3
15.3
20
15.2 14.5 15.8 15
22
18.2
32
17.6
0
10
20
30
40
50
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
0
2
4
6
8
10
12
Cardiac Arrest

Discussion
• CVS parameters for MET(n)
23.1
26.2
20
38.5
22.5
27.8
31.5
24.3
26.5
15.5
22.2
10.3
14.6
18.3
15.3
20
15.2 14.5
15.8 15
22
18.2
32
17.6
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
0
5
10
15
20
25
30
35
40
45
HR<40
HR>140
SBP <90

Discussion
• Respiratory parameters for MET(n)
23.1
26.2
20
38.5
22.5
27.8
31.5
24.3
26.5
15.5
22.2
10.3
14.6
18.3
15.3
20
15.2 14.5
15.8 15
22
18.2
32
17.6
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
0
2
4
6
8
10
12
14
16
18
20 Resp Arrest
RR<5
RR>36

Discussion
• Neurological parameters for MET(n)
23.1
26.2
20
38.5
22.5
27.8
31.5
24.3
26.5
15.5
22.2
10.3
14.6
18.3
15.3
20
15.2 14.5
15.8 15
22
18.2
32
17.6
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
0
5
10
15
20
25
30
35
Seizures
Dec GCS
Airway

Discussion

Discussion
• Is there a pattern?
0
20
40
60
80
100
120
140
60
51
63
45
39
56
78 82 85
103
119
108
88 90
112
79 79
89
117 121
108
68
62
46

Discussion

Discussion
• Weekday distribution of MET calls (n)
0
20
40
60
80
100
120
140
160
180
200
147
178 174
186
146
139 142
107
138
128 127
110
125
101
Total Work-hours
Total After-hours

Discussion
• Is there a pattern?
0
20
40
60
80
100
120
140
60
51
63
45
39
56
78
82
85
103
119
108
88 90
112
79 79
89
117
121
108
68
62
46

Discussion
• In-hospital mortality as per time of MET
23.1
26.2
20
38.5
22.5
27.8
31.5
24.3
26.5
15.5
22.2
10.3
14.6
18.3
15.3
20
15.2 14.5
15.8 15
22
18.2
32
17.6
0
5
10
15
20
25
30
35
40
45
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Discussion
Incidence: 2 per1000 cases
N= 181 episodes

Discussion
Incidence: 2 per1000 cases
• Intra-op use of phenylephrine
infusion
• OR, 3.05; 95% CI, 1.08-8.66;
• P=.04
• Greater intraop fluid administration
(per 500-mL fluid bolus,
• OR, 1.06; 95% CI, 1.01-1.12;
• P=.03.

Methodology
• RRS/MET team
• First responders Second responders
• Outreach registrar
• Outreach nurse
• Outreach SRMO Forth responders
• +/- ICU SR
• +/- ICU consultant
Third responders
• ICU registrar/SR
• Outreach nurse
• ICU registrar
• ICU access nurse
• ED registrar +/- ED consultant
• ED nurse / Outreach nurse

Results
• Median duration of MET call during after-
hours was not significantly different to
work-hours MET calls
– Median 60 vs. 58 minutes

Introduction
• The Pre-RRS era
CODE BLUE

Lessons learnt
• In-hospital mortality post MET can be
further decreased but requires early
recognition of a deteriorating patient
• We can staff the RRT resources
depending on the MET patterns at your
hospital
– ?More staff in the evening

Results
• After-hour METs: 836 (42.91%) (A)
0
20
40
60
80
100
120
140
60
51
63
45
39
56
78
82
85
103
119
108
88 90
112
79 79
89
117
121
108
68
62
46

Study limitations
• Effect of limitation of medical treatment
– LOMT set prior/at/after METs
– LOMT revoked = ?delay in treatment

Discussion
• Meaningful association with mortality ???
23.1
26.2
20
38.5
22.5
27.8
31.5
24.3
26.5
15.5
22.2
10.3
14.6
18.3
15.3
20
15.2 14.5
15.8 15
22
18.2
32
17.6
0
5
10
15
20
25
30
35
40
45
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
0
5
10
15
20
25
30
35
Worried
Cardiac Arrest

ANZICS S&Q 2014 - Abstract Presentation: Singh on After-hours vs in-hours MET calls

Recommended

Recommended

More Related Content

Similar to ANZICS S&Q 2014 - Abstract Presentation: Singh on After-hours vs in-hours MET calls

Similar to ANZICS S&Q 2014 - Abstract Presentation: Singh on After-hours vs in-hours MET calls (20)

More from ANZICS

More from ANZICS (20)

Recently uploaded

Recently uploaded (20)

ANZICS S&Q 2014 - Abstract Presentation: Singh on After-hours vs in-hours MET calls

Editor's Notes