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.
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
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!”
45. Photo by JD Hancock, Flickr
Patients are more
important!
Notes de l'éditeur
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!