Rapid Response Systems

Transcription

1 Rapid Response Systems Where are we now? Professor Gary B Smith Centre of Postgraduate Medical Research & Education School of Health and Social Care Bournemouth University

2 Declaration of potential conflicts q q q q Professor Smith s wife is a minority shareholder in The Learning Clinic Ltd., which is the developer of VitalPAC, a clinical software system for identifying patient deterioration and escalating care. Professor Smith is an unpaid research advisor to TLC and has received reimbursement of travel expenses from TLC for attending symposia in the UK. Past/present member of: o Development group for related reports / documents by NICE, NPSA, DH and Royal College of Physicians of London o Executive Committee of the Resuscitation Council (UK) o RC (UK) s Immediate Life Support (ILS) course working group o National Cardiac Arrest Audit steering committee Co-developer of the ALERT course President-elect of International Society for Rapid Response Systems

3 Journal publications re: Rapid Response Systems Medical Emergency Team Rapid Response System Critical Care Outreach Team Early warning Score Track & Trigger Total Source: PubMed

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5 MERIT study Even in the MET hospitals that knew they were part of a clinical trial, monitoring, documentakon, and response to changes in vital signs were not adequate

6 Chain of prevention Smith GB. Resuscitation 2010; 81:

7 Impact of ILS course training on calls % staff trained Spearpoint et al. Resuscitation 2009; 80:

8 63.8% of mortality values above mean 13.5% 63.8% of mortality values above mean 13.5% 77.2% 7.4% Schmidt et al. BMJ Qual Saf 2014;0:1 11

9 Early warning scores vs MET criteria Royal College of Physicians of London Courtesy of K Hillman

10 Early warning scores vs MET criteria EWSs outperform MET criteria for a series of adverse patient outcomes Tirkkonen et al. Acta Anaesth Scand 2014;58: Churpek et al. Chest 2013;143:

11 Timing of RRT activations n = 652 Emergency Team End-of-Life Care investigators Crit Care Resusc 2013; 15: 15 20

12 Vital signs Hands et al. BMJ Qual Saf 2013; 22: Galhotra et al. Crit Care Med 2006; 34: MET Calls The Medical Emergency Team End-of-Life Care investigators Crit Care Resusc 2013; 15: MET Calls

13 Effect of late RRT calling on outcome Timely MET Call Delayed MET Call Acute change in conscious level or arrhythmia Respiratory distress or hypotension Downey et al. CCM 2008; 36: Quach et al. J Crit Care 2008; 23:

14 Mortality 70.00% 60.00% Effect of multiple RRT calling on outcome Single RRT call N = 1664 Multiple RRT calls 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% All DNACPR For CPR Admitted to ICU Not admitted to ICU Calzavacca et al. Resuscitation 2010;81:

15 Re-deterioration within 48 h of stabilisation 410 patients Fall of sbp to < 90 mm Hg or symptomakc drop of > 30 mm Hg from baseline Khalid et al. J Crit Care 2014; 29:54 59

16 9,221,138 admission 82 acute hospitals January 2002 December 2009 Chen et al. MJA 2014;201:

17 RRTs and end-of-life care q Systematic review q Frequency of MET interventions & EoL care assessed in 16 studies q Limitation of medical therapy in 1.7% % q Patients with pre-existing DNACPR decisions ranged from 6% - 34% q None of them reported initiation of palliative care treatment after limitation Tan et al. Crit Care Resusc 2014; 16: 62 68

18 Mean costs per patient day Simmes et al. J Eval Clin Pract 2014;20:

19 International Society for Rapid Response Systems hup://

20 Summary q Rapid response is about a system not a team q Education appears to improve prevention of cardiac arrest and immediate survival following cardiac arrest q Improved vital sign monitoring of patients appears to reduce hospital mortality q EWS perform better than MET calling criteria q Vital signs monitoring and the calling of RRTs overnight needs further attention q Delayed calling, repeated calling and re-deterioration risk poorer outcomes q RRSs appear to reduce hospital mortality, IHCA rate and IHCArelated mortality q DNACPR discussions & end-of-life care is an important part of RRSs