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1 Deteriorating patients: Are we reaching them? A/Prof Daryl Jones Overview The past Serious adverse events / cardiac arrests and their antecedents The present The MET and national standard 9 What s wrong with current paradigm? The future = Moving things upstream What to audit

2 The past: Wilson study; MJA ,000 admissions to 28 hospitals in NSW & SA 16.6% of admissions associated with "adverse event which resulted in disability (13.7% permanent disability, 4.9% resulted in death) longer hospital stay for the patient Caused by health care management 51% of adverse events considered preventable. We were not alone Country admissions AEs disability death. Aus 14, % 13.7% 4.9% UK % 15% 10% % 33% disability or death NZ ,4 12.9% 15% disability or death Can % Den. 1, % 28.9% disability or death 10% AE 1 / 4 die or disabled 1. Sari etal Qual Saf Health Care Vincent etal BMJ ,4 Davis etal NZ Med J Baker etal Schiøler T etal Ugeskr Laeger. 2002

3 Outcomes of in-hospital cardiac arrests Systematic review: Fennessy etal IMJ (in press) 2052 arrests in 10 studies reporting initial rhythm 31.4% had VT/VF (? Late detection) Where outcome data were available Mortality = 74.6% [2477/3319] Highly desirable to prevent these There are warning signs Serious adverse events are preceded by signs of instability in up to 80% Schein etal Chest 1990 USA Buist etal MJA 1999 Aus Hodgets etal Resuscitation 2002 UK Nurmi etal Act Anaes Scan 2005 Fin Bell etal Resuscitation 2006 Swe

4 Warning signs manifest as: Changes in the patients status Need for increased therapy (esp O 2 ) Derangement in the patients vital signs These may be present for 6-8 hrs Recognising deterioration in the past Junior ward doctors and nurses may not have developed skill set to identify and treat critically ill patients on ward McQuillan etal BMJ 1998 UK Buist etal MJA 1999 Aus Bell etal Resus 2006 Swe

5 Rationale Medical Emergency Team 1. Adverse events are common 2. They have warning signs 3. Deterioration often occurs slowly (there is time to intervene) 4. Early intervention improves outcome 5. Ward doctors lack experience with very sick patients 6. Skilled staff exist in the ICU Imbalance between 1» Patient needs» Resources available 1. DeVita CCM 2006 Australia was an early adopter of METs 75% implemented MET by May 2002 Jones et al Crit Care 2008 Effectiveness of the MET

6 The old paradigm Hospital inpatient Abnormal vital signs MET call Cardiac arrest Mort 2% Mort 75% Effectiveness of MET Takes time to embed in hospital culture Three meta-analyses show reduction in cardiac arrests One meta-analysis shows decreased all-cause hospital mortality Suggests we may be reaching deteriorating patients 1. Winters BD, etal Ann Intern Med Hillman K etal Arch Intern Med Maharaj R Crit Care. 2015

7 MET = the current paradigm Increasing number with time High risk population Very high mortality» Overall 25% 1,2 Approx 1/3 have issues around end of life care 1,3 Between 1/10 1/5 admitted to ICU 1,3 Better outcomes than cardiac arrest...however Jones D AIC 2015 Jones D etal CCR 2013 Jones D etal Current opinion critical care 2013? Risk 80% of 1.5/ % of 20/1000 Code Blue MET Too big for one team

8 International society for Rapid Response Systems Need to develop preventative strategies Hospital inpatient Abnormal vital signs MET call Cardiac arrest Mort 2% Mort 25% Mort 75% Future paradigm Current paradigm Old paradigm

9 The future? Role of continuous patient monitoring apple watch is better than hospital monitoring Problems with false alarms Real time prognostication & decision support Jones D etal Resuscitation 2013 Clinical audit are we reaching them Standardised clinical indicators ACSQHC ACHS Cardiac arrest Were there warning signs in prior 12-24hr (MET criteria / increasing oxygen / staff concern) Were these acted on Should that patient have received CPR

10 MET calls Did the patient have criteria that fulfilled pre-met activation i.e. urgent clinical review (UCR) Were these acted on» Call initiated» Timely response» Appropriate therapy Were there issues with sub-optimal» Triage during transitions of care (ED, ICU or OR ward)» End of life care planning Who should do the audit? Combination Central (quality safety risk / governance) Spot or aggregate audits Show patterns / trends and areas of need Parent unit (e.g. as part of M+M) Some audit of own emergency calls Look at own management Develop local strategies to improve care Research

11 Conclusions 1990s: 2000s: 2010s CA and SAE had antecedents METs introduced reduced cardiac arrests Some deteriorating patients reached Strategies to reduce MET calls Audit of CAs / MET calls to look at 1. contributing factors 2. potential preventability

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