Daryl Jones presents a talk on how RRTs are resourced throughout Australasia. Recorded at ANZICS S&Q 2014 - Rapid Response Reams

1. Resourcing / triggers for RRTs in
Australia and New Zealand
A/Prof Daryl Jones

2. Overview
• ANZICS-CORE MET survey
– Hours operation
– Additional funding
– Team composition / leader
– Calling criteria
• Calling criteria in New Zealand
• Implications for
– Registrar training
– Research / interpretation of outcomes
– Patient safety

3. ANZICS-CORE MET study
• Conducted 2010
• Details of
– Hours of operation
– Days per week
– Team members on MET
– Funding
– MET criteria

4. Resourcing and calling criteria
• Data from 39 hospitals
– Mostly Vic/NSW, public and tertiary
• All operated 24/7
• Funding
– None = 29/39 (74.3%)
– Partial = 8/39 (20.5%)
– Complete = 2/39 (5.2%)

5. Personnel Always involved Sometimes involved Total
Medical staff n(%)
ICU registrar 26 (66.7) 3 (7.7) 29 (74.4)
ICU resident 4 (10.3) 1 (2.6) 5 (12.8)
ICU consultant 1 (2.6) 4 (10.3) 5 (12.8)
Anaesthetic registrar 6 (15.4) 0 6 (15.4)
Emergency department registrar 2 (5.1) 2 (5.1) 4 (10.3)
Internal medical registrar 27 (69.2) 0 27 (69.2)
Medical resident 8 (20.5) 0 8 (20.5)
Parent unit doctors 5 (12.8) 1 (2.6) 6 (15.4)

6. Personnel Always involved Sometimes involved Total
Nursing staff n(%)
ICU nurse 28 (71.8) 2 (5.1) 30 (76.9)
Site manager 8 (20.5) 0 8 (20.5)
CCU nurse 8 (20.5) 0 8 (20.5)
ED nurse 3 (7.7) 2 (5.1) 5 (12.8)
ICU nurse consultant 4 (10.3) 0 4 (10.3)

7. Seniority / skill set
• 38/39 = physician led MET
• ICU consultant not often involved
– Also reported by Jacques etal (AIC 2008)
• In 7 sites (17.9%) most senior unable to intubate

8. Calling criteria: Adult Australian hospitals
• Marked variation in calling criteria
– ¾ had structured chart (ABCD)
– ¾ reference to threatened airway
» Variable wording
– 1
/3 included arrests in calling criteria
– Variable stipulations for FiO2 with hypoxia criteria
– Marked number of additional criteria
» Variable in nature
» Variable in wording

9. Calling criteria: thresholds for activation

11. Calling criteria in New Zealand
kia ora

12. • Reviewed in Oct 2011
• 20 district health boards

16. What’s that skip. You
disproved Einstein ?

17. Implications – “Quality and safety”
• Marked variation in
– Staff composition
– Calling criteria
– Available resource for review
• Undesirable practice variation
– Patients reviewed at different phase deterioration
– Variable skills responders
• Highly abnormal MET criteria “endorsing” unsafe practice
– “patient ok because don’t fulfil MET criteria”
– Normalisation of deviance (John Banja)

18. RR 30
MET call
ICU consultant
No MET call
HMO

19. Implications “Apples vs oranges”
• Implications  comparing hospitals
– ? RRT effective if wait too late
– Different outcomes despite same condition
– Difficult in comparing sites
– Difficulty in planning research / QI initiatives
• “unwise to assume the context in which the intervention [the
RRT] is applied is similar across all hospitals”
England and Bion CCF 2008

20. Implications – resourcing and training
• Only ¼ funded,
• 2009/2010 = 20,208 RRT calls, 15,207 patients (1/3 hospitals)
• Diversion of registrars from usual duties
– Training implications ICU – ↓ exposure to critical illness
– Safety implications for ICU patients
• Training implications MET – supervision/mentorship (No consultant)
• MET assessment not as thorough as could be
– Patient not getting “optimal dose” of MET for each MET

21. Resources for ICU

22. Resources for MET

23. • Need to develop business case
– ? Evidence of effectiveness
– ? Reducing overtime of parent team out of hours
– ? Nursing staff and JMO retention
– ? Reducing “inappropriate” ICU admissions
»EOLC MET calls triage patients unlikely to benefit from ICU

24. • Modern EOLC planning
– 1/3 METs have end of life care issues
– Referral: “Family want everything done”

25. Conclusions
• 35 sites report having MET 24/7
• ¼ dedicated funding
• Marked variation
– Team composition
– Calling criteria

26. • ? Quality and Safety issues
– Safety of some calling criteria thresholds
– Practice variation and comparing sites
• Recognition and resourcing for work