To decrease the number of code blue events by 50 percent.

• Code blue events (Jun-Aug 2004)
• Code blue events (Jun-Aug 2005)

Using formats for Medical Emergency Teams (METs) from many other hospitals we developed our own MET at one of our three hospitals.

• Bring the organizing team together a month before starting.
• Identify who will be on the team and if it is mandatory or voluntary. Select the right people and good ambassadors of the ICU.
• Develop several different models to determine whether case load will be lighter or resource nurses/charge nurses will participate.
• Agree on what areas in the hospital you will respond to. (We added Radiology early on and have not added our Rehab Hospital.)
• Clarify exactly what the MET can do without a physician’s order during a call.
• Determine how documentation of the MET call will appear in the patient record. Our floor nurses document the assessment, recommendations, and physician call in their nursing notes.
• Develop a data collection tool and change it as needed.
• Decide who will keep the collection tool and track the data.
• Develop an evaluation form and determine how the evaluation form will get back to the ICU.
• Obtain a box and fill it with supplies that your team feels you need.
• Educate supervisors with a PowerPoint presentation about the program and then walk to each floor, each shift, and provide the numbers and several bullet points about the program.
• Go back to the floors on different days or weekends and talk about the program over and over.
• Make name tags or ribbons that identify you as a MET member.
• Provide education sessions, mock METs, with several different shifts and play out possible scenarios of common diseases, i.e., CHF, PE, A Fib, Altered Mental status with your Intensivists.
• Determine a system for notification: Beepers, zone phones, and operators. Then figure out a back-up plan when that doesn’t work and give that to the floors as well.
• Speak with your Operators and their supervisor to verify you have a back-up several times a month when you initiate the program.
• Develop a storyboard for the physician lounge and stay there for several days during specific times to provide more information.
• Adopt a specific communication tool. We use SBAR (Situation- Background-Assessment-Recommendation).
• Allow a learning period for the ICU nurse to communicate directly with physicians and teach the floor nurses SBAR communication tool during every MET.
• Educate the nurses and respiratory therapists on specific language tools that will not insult their peers and help them to become mentors.
• Provide an Intensivist back-up by phone in case a physician will not respond and the patient is unsafe in their current setting.
• Review the MET calls monthly and see if a specific diagnosis is repetitive and provide education.

There is a significant reduction in the number of code blues in our hospital over a three-month period compared to the previous year (June-August 2004 vs. June-August 2005).

Lessons Learned:

• Avoid certain language to prevent resistance from physicians and physician extenders. Start the conversation by identifying yourself and saying, "Doctor, there has been a change in status in your patient__________."
• Do not allow the MET to become a barrier to admission to the ICU. (Admissions to the ICU were questioned even if a physician ordered it and they were asked, "Why wasn’t a MET called?")
• Consider adding your Nursing Supervisor (bed monitor) to your team in case patients need to be transferred.
• Determine who will respond if the MET nurse is off the floor with a patient and his/her buddy is too busy. Some simple rules early on will prevent missing MET calls.
• Speak to physicians who have refused the recommendations of the MET that the Intensivist felt were appropriate and explain the purpose of the team and potential benefits.
• Verify who on the MET has the final say about the patient. On our team, the nurse who carries the box has the final say despite input from the whole team.
• Include families in the MET and explain who you are and why you are there.
• Verify your team will check every test that they order and provide that info to physicians.
• Have your team recheck the patient an hour later after the MET if the patient is not transferred.
• Provide recognition for the MET members in your hospital system.

Marilyn Kole, MD, FCCP, Corporate Medical Director, Intensive Care Services
Lee Memorial Health System
Marilyn.Kole@Leememorial.org

[Storyboard presentation at IHI's National Forum, December 2005]