To decrease the number of cardiac arrests by 60 percent within the medical health system by the end of a six-month trial (November 30, 2005).

• Codes per 1,000 inpatient discharges

Goal: Decrease the rate of codes by 60 percent in hospital codes for all medical inpatient units (excluding stillbirths and deaths in the emergency room)

• Medical Emergency Team utilization
• Track number of calls and relate to code frequency

Other indicators being measured:

• Number of cardiac arrests
• Number of patients who died from cardiac arrests
• Number of in-hospital deaths (hospital mortality)
• Number of ICU bed-days occupied by survivors of cardiac arrests
• Number of hospital bed-days occupied by survivors of cardiac arrests

The Medical Emergency Team (MET) [also known as a Rapid Response Team] was piloted as a trial within four inpatient medical units (GI, Respiratory, Oncology and General Internal Medicine). The team consists of an ICU RN and a Respiratory Therapist (RT) and is designed to facilitate enhanced assessment of patients at risk by highlighting and responding to clinical triggers such as change in level of consciousness, increased oxygen needs, etc. The MET RN and RT collaborate with the ward nurse, assess the patient, and assist with calling the physician, implementing orders, and transferring as necessary.

• Developed a medical directive to allow ICU RNs on the team to order basic blood work, ECG, chest x-ray, and to allow Respiratory Therapists to perform an ABG, prior to contacting the physician
• Implemented a hotline to activate the Medical Emergency Team
• Provided in-services on all wards involved in the pilot to provide education on the MET
• Identified clinical triggers that should warrant a MET call
• How to activate MET via locating
• What the MET Nurse is able to do (enhanced assessment and prioritizing of treatment) and emphasized that MET does not take the place of a physician call (to encourage staff to call even when it may seem trivial)
• Provided laminated badges with the clinical triggers, and the MET hotline number, to all front-line staff
• Posted the same information in washrooms, staff lounges, and on all telephones in the nursing stations
• Conducted pre-roll out surveys to assess nurses' comfort level around caring for critical or deteriorating patients
• Conducted post MET call surveys to assess the effectiveness of the service and how to improve it
• Developed teaching cases with the ward educators based on MET calls, which were used to teach enhanced assessment skills to the ward staff
• Linked with the Sepsis team to promote education and awareness of sepsis among the ward staff

Although the data so far is very preliminary, we believe that using a Rapid Response or Medical Emergency Team (MET) will result in earlier identification of patients at risk of deteriorating. Timely intervention should result in a decreased incidence of cardiac arrest.

Lessons Learned:

• Involve all stakeholders as early as possible. The roll out requires feedback and support from many different areas, and it is important that they all understand what it is that you are trying to achieve (e.g., directors, managers, educators, physicians, and health records).
• Initially focus on obvious clinical changes. As uptake improves work with the ward staff to identify more subtle changes, emphasize earlier activation.
• Start small-trial the project in a manageable area first, and then expand slowly. The uptake of info is very slow. The message must be repeated many times, different ways and reinforced often.
• Do daily walking rounds on the wards and ask very pointed questions of the staff: “Do you have any patients that you are concerned about?”  This will result in a surprising increase in the number of MET calls.
• Follow up all cases to ensure that there are no gaps in communication between shifts.
• Use post call surveys to trend what is working well in terms of activation and utilization by the ward staff.
• Work with ward educators to build teaching cases from actual calls to enhance the ward staff’s knowledge and assessment skills.

Mike Cass, Medical Emergency Team RN Coordinator
Trillium Health Centre
mcass@nt.thc.on.ca

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