1. Critical Care Response Teams in Ontario: Rationale, Research and Results Stuart F. Reynolds, M.D.

2. 2 Disclosures Physician Lead, Ministry of Health and Long Term Care, Critical Care Response Team Project

3. 3 Outline Overview of a Rapid Response System Rationale Reviewing the evidence Snapshot of the Ontario experience

4. 4 Efferent Limb Administrative Limb Afferent Limb Rapid Response System Framework

5. 5 Afferent Limb Event Detection – Identifying the patient at risk Bedside Clinician Empowerment Education Calling Criteria Recognition of the critically ill

6. 6 Efferent Limb Structure varies with jurisdiction U.K. – Outreach Australia – MET U.S.A. – MET, Hospitalists, RRTs Canada – CCRTs MET during day Outreach at night with Intensivist backup Patient Assessment & Treatment

7. 7 Administrative Limb Leadership Implementation & Planning Data Collection & Analysis & Feedback Design feedback mechanisms to the team and to the teams response areas Track data to improve utilization of the team

8. Why bother?? A code does not occur out of the Blue

9. 9 Cardiac arrests over 4 months 84% had documented clinical deterioration within 8 hours pre-arrest

10. 10 Recognizing clinical instability in hospital patients before cardiac arrest or unplanned admission to intensive care. A pilot study in a tertiary-care hospital. Buist MD, Jarmolowski E, Burton PR, Bernard SA, Waxman BP, Anderson J. Buist MDJarmolowski EBurton PRBernard SAWaxman BPAnderson J Retrospective review, over one year of all: cardiac arrests unplanned ICU admission Median duration of instability 6.5 hours prior to Critical Event Med J Aust. 1999 Jul 5;171(1):22-5

11. Prospective confidential inquiry Reviewed 100 consecutive patients admitted to ICU Revealed that up to 41% of ICU admissions could possibly be avoided. Related to: failure to appreciate alterations in the ABCs and delay in ICU Consultation

12. 12 Unexpected deaths and referrals to intensive care of patients on general wards. Are some cases potentially avoidable? 6 months review of all hospital deaths, unplanned ICU admissions 4% of deaths were potentially avoidable, early warning signs not appreciated. ICU Admissions 32% of which clinical deterioration was not appreciated ICU mortality higher 52% vs 35% J R Coll Physicians Lond. 1999 May-Jun;33(3):255-9 McGloin HMcGloin H, Adam SK, Singer M.Adam SKSinger M

13. Et Tu?

14. Is Early Death Following ICU Admission Preventable? Anika Minnes, John T Granton, Wilfrid Demajo, Anne Marie Sweeney, Stuart F. Reynolds, Thomas E. Stewart, and Niall D. Ferguson University Health Network University of Toronto

15. 15 Vitals within 6 hours of ICU admission AllEarly DeathNo Early Death Number 1202199 Resp Rate 50%38%53% Saturation 76%71%77% Systolic BP 75%71%76% Heart Rate 73%62%75% Urine Output 8%010% Drop in LOC 20%14%21%

16. 16 Rationale There is time for intervention The evolution of physiological deterioration is relatively slow. There are warning signs Clinical deterioration can be detected utilizing common vital signs There are effective treatments Early Goal Directed Therapy ACS therapy Oxygen, NIV for COPD, CHF Many critical interventions are time dependant. Trauma Severe Sepsis ACS CVA Expertise exists and can be deployed

17. 17 Critical Care Response Teams in Ontario are: A systematic approach to the early identification and facilitation of resuscitation of in-patients at risk of deterioration. A way to provide Comprehensive Critical Care Services Prophylactic interventions Follow-up of patients recently discharged from the ICU to prevent readmission Rounds on high-dependency units

18. 18 continued … A way to provide critical care education Teaching nursing unit personnel Signs and symptoms of an at risk patient Utilization of calling criteria Teaching medical students and residents how to recognize and resuscitate the acutely ill patient A way to Support and Coordinate the care of patients Assistance with end-of-life decision discussion Improving communication between the ICU and other units

19. 19

20. 20 Hospital Mortality Observational

21. 21 Cardiac Arrest

22. 22 Lancet, June 2005

23. 23 MERIT at a glance 23 Hospitals Variable Hospital Size and Type Variable Team Structure Implementation timeline 2 month baseline 4 month implementation phase 6 month evaluation phase Outcomes Primary – composite- No Difference Secondary- No Difference Cardiac Arrests Unexpected ICU admissions Unexpected deaths

24. 24 Dose Response Curve Vol 9 No 6 Research Long term effect of a medical emergency team on cardiac arrests in a teaching hospital Daryl Jones, Rinaldo Bellomo, Samantha Bates, Stephen Warrillow, Donna Goldsmith, Graeme Hart, Helen Opdam and Geoffrey Gutteridge Critical Care 2005, 9:R808-R815 17 MET calls per 1000 inpatient admissions is associated with reduction in cardiac arrest rate of 1 per 1000 admissions

25. 25 How does this compare to MERIT? 6.3 – 1.2 = 5.1 MET calls/1000

26. 26 Predicted impact on Cardiac Arrests of 5 MET calls = 0.3/1000

27. Critical Care Response Team Expansion Project

28. 28 USE IT or LOSE IT!!!

29. 29 Implementation Principles Local leadership, Central Coordination Strong Local Leadership: MD lead, co lead nurse leader or RRT leader, Administrative Support Navigation of the Cultural, Sociologic, Political Mine Fields Central Coordination Support Local Leadership!!! Coordinating Communication between sites Identify Hospitals Define Team Structure Defining Roles and Responsibilities Identification of Accountabilities Data Analysis & Feedback

30. 30 Timeline for CCRT Project Phase I – Preparation and team development, training and marketing. May 2006 – Oct 2006 six months 284 RNs and RRTs trained – wonderful collaboration between local and central leadership Development of a CRI CCRT Course Phase II – Preceptorship. Nov 2006 – Jan 2007 8 hour day – limited service consolidation of training, marketing twelve weeks III – 24/7 service began January 29, 2007

31. 31 Outcome Measures Code Blue Cardiac Arrests Respiratory Arrests Hospital Mortality Readmission Rate Length of Stay Accountability Measures Return on Investment Improving Implementation Audit Criteria Location of Patient Code Blue Unanticipated ICU admissions CCRT Consults Call Volume Service Qualitative assessments Why people use service Why people dont use service Evaluation Plan Managing Success – Managing Improvement

32. 32 Some Early Results First Month of 24 hour service 34 CCRT activations per 1000 inpatient admissions MERIT

33. 33 Outcomes of 1739 Consults Phase II

34. 34 Going Forward Will the outcomes follow the implementation? Return on investment Refining the processes Testing Alternative Models Hospitalist Education interventions

35. 35

36. 36 Thanks To our CCRT Leadership and Teams!!!! Stuart.Reynolds@uhn.on.ca