The MET reduces cardiac arrests. Dr Daryl Jones
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1 The MET reduces cardiac arrests Dr Daryl Jones
2 Overview Epidemiology of in-hospital arrests Failings of traditional model of care Principles of the MET Evidence from single centre studies Meta-analysis of RRTs and cardiac arrests Biological mechanism and plausibility Conclusions
3 Epidemiology of in-hospital arrests Incidence varies substantially Buist etal / 1000 admissions (Post MET) 1 Chan etal / 1000 admissions (Pre RRT) 2 Differ substantially to out of hospital cardiac arrests Are rarely sudden or unexpected 1. Buist etal BMJ Chan etal JAMA 2008
4 Epidemiology of in-hospital arrests Many follow iatrogenic complications 1 Up to 84% have deterioration prior to event (Resp > multiple > cardiac > neurological) 1-4 Median duration instability 6.5 hours 3 Many receive sub-optimal care 4 1. Bedell etal JAMA Schein etal Chest Buist etal MJA Hodgets etal Resusc. 2002
5 Failings of traditional model of care Unwell patient Deranged vitals Vitals measured Doctor called Timely & definitive Rx Manual and intermittent vitals Frequency up to 8 hrly Incomplete vitals (esp RR) Discretion to call doctor Doctor availability Escalation of problems up hierarchical chain Dr intervention varies
6 Principles of the MET MET = Specialized team Similar to cardiac arrest team Called when patient has»hr = zero»bp = zero»rr = zero»level of consciousness = zero
7
8 Principles of the MET... Cont... Deterioration has warning signs Deterioration occurs slowly Junior ward staff may not recognize deterioration or adequately escalate care ICU staff exist in the same building Early intervention improves outcome
9 Principles of the MET... Cont... take critical care expertise to the patient before, rather than after, multiple organ failure or cardiac arrest occurs England and Bion 2008
10 Evidence from single centre studies Dandenong before and after study Unexpected cardiac arrest»3.77 / 1000 in 1996 (before intervention)»2.05 / 1000 in 1999 (after intervention)»after adjustment for case mix MET associated with a cardiac arrest (OR 0.50, 95% CI 0.35 to 0.73) 1. Buist BMJ, 2001
11 Staff fail to call the MET To improve use of MET» orientation programme for first year doctors,» professional development course for medical registrars,» evolving role of liaison ICU nurses. Between 2000 and 2005 cardiac arrests 24% per year (2.4/1000 to 0.66/1000) Buist etal BMJ Nov 2007
12 Austin Hospital Cardiac arrests and hospital mortality» CAs (65%)» deaths due to CA (56%) Bellomo etal MJA 2003
13 Long term 500% increased use of the MET
14 With MET calls there are arrests Jones etal CCF 2005
15 Pittsburgh retrospective analysis over 6.8 yr»3269 MET responses»1220 cardiopulmonary arrests MET responses» 13.7 to 25.8/1000; p< »17% arrests (6.5 to 5.4/1000 p = 0.016).
16 Royal Children's Hospital Before (41 mo.) and after (12mo.) study CA 0.19/1000 to 0.11/1000 (NS) CA deaths 0.12/1000 to 0.06/1000 (NS) In CAs with antecedent MET criteria» CAs 17 to 0 (risk difference 0.16/1000, p = )» CA deaths from 12 to 0 (risk diff 0.11/1000, p = )
17 Results of meta-analysis 34% cardiac arrests Chan etal Arch.Int.Med 2010
18 Biological mechanism and plausibility Up to 84% of CAs are preceded by signs of instability MET decreases CAs by 12-65% Biologically plausible
19 For every 17 MET calls, might prevent one cardiac arrest 1 Mechanism of effect Stopping deterioration Advanced care planning 1. Jones etal CCF 2005
20 Stopping deterioration MET performs ICU-type interventions to stabilize and prevent arrest MERIT study 1» Immature RRS high proportion (>90%) of critical care type interventions (airway, ventilation, inotropes) Study at Austin 2» 38/99 (38.4%) needed such interventions 1. Flabouris etal Resusccitation Bellomo etal MJA 2003
21 MET assists with EOLC planning Liverpool 713 (3.8%) METs over 12 mo 1»27/ 713 (3.8%) made NFR during MET 1 Study of 900 patients at Austin Hospital 2»7.3% new designation of NFR after 1. Parr etal Resus Calzavacca etal ICM 2008
22 Dandenong = 152METs in 124 patients 1»13 (10.4% )NFR during MET TNH = 195 calls over 12 months 2»8.2% had new LOMT after MET review Hence 1/26 (3.8%) to 1/10 (10.4%) of MET calls might new LOMT Similar in magnitude of 1/17 1. Buist BMJ Casamento CCR 2008
23 Conclusions In-hospital cardiac arrests preceded by warning signs Intervention by MET during this period reduces cardiac arrests Likely to be a combination of two mechanisms Stabilisation and prevention of further deterioration Improved EOLC planning and NFR designation
24 Future research Optimizing use of MET for those most likely to benefit from it Whether CAs in MET-equipped hospitals still have antecedents? Missed METs
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