ANZICS S&Q 2014 - RRT: Chris Nickson on the ICU registrars perspective
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Chris Nickson gives a talk on the ICU registrars perspective on RRTs. Recorded at the ANZICS S&Q Conference 2014: Rapid Response Teams.
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ANZICS S&Q 2014 - RRT: Chris Nickson on the ICU registrars perspective
- 1. RAPID RESPONSE TEAMS The Registrars’ Perspective Chris Nickson ICU Fellow, The Alfred
- 3. Photo by mic wernej, Flickr
- 4. Photo by Ksayer1, from Flickr
- 5. ANZICS-CORE MET dose Investigators, Jones D, Drennan K, Hart GK, Bellomo R, Webb SA. Rapid Response Team composition, resourcing and calling criteria in Australia. Resuscitation. 2012 May;83(5):563-7. doi: 10.1016/j.resuscitation.2011.10.023. Epub 2011 Nov 6. PubMed PMID: 22067975.
- 6. 74%
- 8. Photo by Tim Williams, Flickr
- 11. What do other ICU Registrars think?
- 12. Jacques T, Harrison GA, McLaws ML. Attitudes towards and evaluation of medical emergency teams: a survey of trainees in intensive care medicine. Anaesth Intensive Care. 2008 Jan;36(1):90-5. PubMed PMID: 18326139.
- 13. Self-administered questionnaire sent to all 356 JFICM trainees in May 2006 136 responses 84% = >300 bed hospitals
- 14. 8 years ago! 38% response rate Anonymous Not reliability tested
- 15. SUPER GOOD FUN MET SURVEY
- 16. 78% involved in METs 39% on MET duty >50% 56% had 0-2 calls/12h Call length: 74% >20 min, 28% >30 min
- 17. MET calls are the largest non-ICU component of ICU trainees workload Workload is the same, day or night (staffing isn’t!)
- 18. What are the first three words that spring to mind when you hear the words ‘MET call’?
- 19. Chaos, clueless, resuscitation boring, again?, action need I go? Not another one bugger me, again? please not again better be real painful, AF, good cause end of life annoying frustrating repetitive probably nothing serious just another faint walk don’t run
- 20. My heart fills with joy when a MET call is announced
- 21. I would rather be a Medical Registrar than attend MET calls
- 22. What are the implications for registrar training?
- 23. 66% “MET enhanced the quality of their training”
- 24. “Rapid synthesis & decision making” “Diagnosis & resuscitation” “Leadership, negotiation and non-technical skills” “Outreach work is the future”
- 25. 61% “they were well trained” 77% “ICU experience sufficient training” 77% “not supervised”
- 26. A lack of supervision and training in RRT response… … however trainees think they have the skills
- 27. Photo by Shawn Carpenter, Flickr
- 28. Slide courtesy of Cliff Reid
- 29. Should ICU be in the MET team? Photo by Stefan, Flickr
- 30. 81% felt they were a “general fix it” 55% “doing the work of an RMO or resident” 43% vs 41% thought admitting team vs MET were in best position
- 31. 71% “every hospital with an ICU should have a MET team” 68% “MET leader should be from ICU”
- 33. What is good about RRT? Photo by Kristian Niemi, Flickr
- 34. 70% thought MET team “improved ward care” 71% “MET accelerated EOL discussions”
- 35. “experience at rapid assessment” “essential part of training”
- 36. “get out and about” “makes a difference” “makes everyone happy” “breaks down barriers” “able to teach and support” “the uncertainty!”
- 37. What is bad about RRT? Photo by JD Hancock, Flickr
- 38. “deskills other staff” “teams have no responsibility” “MET picks up the mess” “time and resources taken away from ICU”
- 39. “everyone disappears… too many standing around” “justifying that MET does not mean coming to ICU” “Often not an ICU issue” “Too many! Inappropriate! Not specific enough!” “The uncertainty!”
- 41. If registrars thought METs had a positive impact on… 1. managing patients in the wards (x4.7) 1. the ICU (x2.8)
- 42. Where does this leave us?
- 43. The Worst Things about MET Calls Photo by JD Hancock, Flickr
- 44. Registrars’ perspectives are important RRT impacts on training RRT systems can be improved
- 45. Photo by JD Hancock, Flickr Patients are more important!
Editor's Notes
- I am… Thanks…
- Discloures
- Any registrars here? How many people here have worked as a registrar as part of a MET or RRT team?
- Objectives To convince you that the registrar’s persepcitve is improtant and show you why Give some insights into the registrar’s perspective, and what this means for RRTs and for the registrar’s themselves
- Why care about the registrar’s perspective? Because, in most settings in Australasia, ICU registrars are an integral part of RRTs. For the RRT to work the ICU Registrar has to play their part effectively. As this this shows: 39 of 108 Australasian hospitals responded giving a 36.1% response rate respondents were typically Victorian, publisc tertiary hospitals All were 24h/day 7 days a week services
- An ICU trainee (resident, registrar or Fellow) was always involved 77% of the time, and sometimes involved a further 4% of the time This illustrates the core role played by ICU registrars in RRTs – at least in tertiary hospitals
- Photo from http://www.blp.com.au/projects/the-alfred-hospital-intensive-care-unit-/ I now work at The Alfred which has the most sophisticated RRT system I have encountered. There are mandatory MET calls for well defined criteria. There is an external ICU registrar who takes referrals and attends MET call, does an ICU follow up round and works closely with the ICU Liaison Nurse who remains the real hero of the RRT system. Overnight the ICU influence on the eards extends even further, as we a ‘Nicght Clinical Leader’ from the ICU SR ranks who oversees all the other medical staff on the wards. You will here about these different aspects in other talks at this meeting by Kyle Brooks, Amy Krepska and Owen Roodenberg
- Photo by Tim Williams, Flickr But over the years I have had training positions in 7 hospitals in 3 States and Territories of Australia as well as New Zealand. I have seen ward based emergencies dealt with in different ways, by different people, using different systems of care My experiences certainly colour my own perception of the RRT, and I am sure it is the same for other registrars as well
- So, what do I think…
- First, I’d like to reflect on the experience that really casts a shadow of how I perceive MET calls. When was in my second year as a doctor I was working in a small hospital in NZ. One particular night I was covering the paediatrics and Ob/Gyn wards. At handover I told about a patient I didn’t to worry about (famous last words) because she was admitted under the medical team. She was an 18 year-old woman pregnant with her second child who had been admitted with ankle edema and mild shortness of breath. She had known rheumatic heart disease. The dates were uncertain, but the CTG was good and there was a plan to do an ultrasound the next day. I figured I’d go up to have a look once I got on top of a few pressing jobs. Only an hour or two later a ‘Paeds/ Ob-Gyn only arrest’ call went out. That meant I was the only doctor on site who was required to attend. I got to the ward to find a young barely responsive hypoxic woman lying flat on the bed in respiratory distress with crackles through her chest, a weak pulse and a difficult to measure blood pressure. Then she arrested, and I commenced CPR and called for help. Before senior staff arrived, I had intubated her after a gush of gastric contents and been told that she collapsed on the toilet after delivering her baby… I had no idea where the baby was, what gestation it was or if anyone one was looking after it. When senior staff arrived chaos ensued – there was no critical care-trained specialist in attendance – and it was all to no avail. The patient died from acute pulmonary in the setting mitral stenosis, presumably due to the auto-transfusion of blood from the uterus following delivery/ miscarriage. Autopsy suggested that he baby was not viable. I expect everyone in critical care has stories like this. It motivated me to want to be the type of doctor that can deal with a situation like that, to be able to give patients like her the best chance possible to survive It may be that even the best intensivist in the world would not have made a difference in that particular case, but at some point if senior help had been called earlier, it is hard to believe that things couldn’t have been improved – and if if the patint could not be helped, it is clear the staff involved needed assistance and support Indeed, after this case the hospital restructured their emergency response system So, it is fair to say that I’m a big supporter of any attempt at reversing the This was an example of the ‘inverse care law’ – the most critically ill patients with the greatest needs are often seen by the staff least equipped to help to help them, and RRTs – in some shape of form – seem to me to be necessary to achieve this.
- 77%
- Best attempt…
- Self-administered questionairre sent all 356 JFICM trainees in May 2006 50% in ICU at the time 38% response rate (136 trainees) only ANZ residents and only if experienced of METs questions developed from pilot focus groups, trainee interviews and previoustrainee satisfaction survey they used a combination of Likert scales and open ended questions, responses to which were used verbatim They assessed for internal consistency and performed appropriate statistical analyses They used multiple logistic regression to create a model to identify significant predictors of favourable perception of MET activities on ICU training
- Response rate 38%, but 76% of 178 engaged in ICU currently Anonymous so couldn’t follow up Questionnaire not reliability tested
- I sent out a the ‘Super Good Fun MET Call survery’ to 30 ICU trainees around the country – again with a Victorian bias – and got 23 responses (77% response rate) No pilot studies were performed No statistical analyses No tests of reliability
- 78% had been involved in METs, rarely with an ICU consultant involved (3%) 39% on MET duty >50% 56% had 0-2 calls/12h Call length: 74% >20 min, 28% >30 min
- MET calls are the largest non-ICU component of ICU trainees work Workload is the same, day or night (staffing isn’t!) Given this, Ithought it might worth finding out out what ICU registrars gut reactions say
- 77%
- Some actually do get joy! But most don’t… But does this mean they dislike METs or they’re just neutral or ambivalent
- Using a fairly concrete comparison it is clear that ICU Registrar’s aren’t THAT despondent – none would rather be a med reg than attend a EMT call
- Despite this ambivalence 66% “MET enhanced the quality of their training” 74% in my survey
- Develop ablility to quickly synthesise info and make decisions Involvement in EOL discussions and decisions are initiated Recognition of the critically ill, rather than being seved up to you Experience at liasing and negotiating with other teams Diagnositc ,resuscitation and leadership and non-technical skills Outreach work is likely to be core ICU business in the future
- What do ICU trainees think about their training? 77% reported not being supervised when performing METs
- 77%
- For me this is a red flag – for although I accept many skills are transferable – it is hard to believe true expertise in conducting RRTs can be developed without training in the specific MET-related issues nor without feedback on performance
- Slide courtesy of Cliff Reid It also doesn’t work in the other worst case scenario, what my friend Cliff Reid, calls ‘the chicken bomb’ situation – when external muppet factors have taken over and everyone is running around like a headless chicken -
- 77%
- 77%
- 77%
- 77%
- 77%
- 77%
- 77%
- 77%
- Everyone else disappears.. lack of responsibiliy Justifying that MET does not = coming to ICU The uncertainty! Too many people standing around Often not an ICU issue Inappropriate MET call criteria DNRs not done Too many! Mandatory MET calls aren’t specific enough Always happen when you go to the toilet
- multiple logistic regression to create a model to identify predictors
- Perceptions about the impact of METs on managing patients on the wards (4.7 times more likely, 95% CI 1.9 to 11.6) And impact on MET on ICU (2.8 times more likely, 95% CI 1.1 to 7.2)
- A few one liners summing up MET calls for registrars: A mechanism for displacement of REM sleep from the intensive care team to the treating physician A shitty job but someone’s got to do it Trips to see the worried well You can live with them, someone might not live without them
- The ICU Registrars perspective is important because the way RRT systems operate currently in Australasia has them playing a key role in the way they run. MET calls account for a significant portion of the ICU Registrar’s workload There may well be a need for more MET-specific training, though ICU Registrars don’t seem to think they need it Registrars experiences suggest that the RRT systems currently employed may be improved – lack of specificity, ensure admitting teams maintain responsibility, further refine criteria or intensity of response Although ICU Registrars are important, patients are more important, and ICU Registrars agree!
- Photo by JD Hancock, Flicker So establishing and conveying the benefits of MET calls to patients – both on the wards and in the ICU – may be the best way of building interest and enthusiasm for RRTs… apart from the fact that expanding our roles outside of the ICU may be critical for ensuring trainees have jobs in the future!