Imogen Mitchell talks on how do we know if the call has been successful. Presented at the ANZICS S&Q Conference 2014 on Rapid Response Teams.

1. How do we know the call has been successful?
ANZICS Safety and Quality Conference
Melbourne, July 2014
Prof Imogen Mitchell
Director, Intensive Care, The Canberra Hospital
Deputy Dean, ANU Medical School
Member, National Advisory Committee, Recognising and Responding to Clinical Deterioration

2. Outline
• Purpose of Rapid Response Teams
• Determination of success:
patient and family experience
patient management
patient outcome
• Achievable?

3. vital signs
performed
interpreted by
nurse
communicate
interpreted by
doctor
timely &
appropriate
review
timely &
appropriate
management
• Timely and appropriate management of
deteriorating patient complex process
• Many opportunities for delays/poor
communication
• Delays increase likelihood of critical
illness and death

4. Role of Rapid Response Teams
• Deteriorating patients at risk of critical illness and death
• Rapid response teams provide timely and appropriate care
• Provide expert care of the deteriorating patient
• Averting multiple organ failure or cardiac arrest

5. SUCCESS OF RRT REVIEW

6. RRT reviews per month

7. PATIENT AND FAMILY EXPERIENCE

8. Cutting for Stone: Abraham Verghese
Professor for the Theory and Practice of Medicine at Stanford University Medical School
Dr Stone, Professor Of Surgery:
“My son’s terrible death is not something I will ever get over, but perhaps in time it will be less painful. But I cannot get over one image, a last
image that could have been different. Before I was asked to leave the room in a very rough manner, I must tell you that I saw my son was terrified
and there was no one who addressed his fear. The only person who tried was a nurse. She held my son’s hand and said, ‘Don’t worry, it will be all
right.’ Everyone else ignored him. Sure, the doctors were busy with his body. It would have been merciful if he had been unconscious. They had
important things to do. They cared only about his chest and belly. Not about the little boy who was in fear….I saw no sign of the slightest bit of
human kindness. My son and I were irritants. Your team would have preferred for me to be gone and for him to be quiet. Eventually they got their
wish. Dr. Stone, as head of surgery, perhaps as a parent yourself, do you not feel some obligation to have your staff comfort the patient? Would
the patient not be better off with less anxiety, less fright? My son’s last conscious memory will be of people ignoring him. My last memory of him
will be of my little boy, watching in terror as his mother is escorted out of the room. It is the graven image I will carry to my own deathbed. The fact
that people were attentive to his body does not compensate for their ignoring his being”

9. Patient and Family Experience
• Pre-eminent measure for success of RRT review
• Daunting experience
huge numbers of unknown people at a time of uncertainty/fear
little communication and pastoral support
family members often sent out of the room

10. Patient and Family Experience
• Measure patient and family experience
questionnaires
• Reflect:
include families in the experience 1
reassure the patient and explain what is happening
assign staff member to explain to families what is going on
revisit the patient and family afterwards to follow up for clinical and ongoing support
1 Jabre et al N Engl J Med 2013; 368:1008-1018

11. PATIENT MANAGEMENT

12. Patient Management
• Timeliness
Duration: time triggering RRT criteria to RRT Review
delays associated with worse outcome 1
• Decision making
Repeat RRT review: number of RRT reviews on same patient
multiple reviews associated with worse outcome2
Delayed ICU admission: admitted within 24 hours original RRT review
ongoing triggers at stand down of RRT review
1 Calzavacca PE et al. Resuscitation 2010 81: 31-35
2 Calzavacca PE et al Resuscitation 2010 81: 1509-1515

13. Patient Management
• Decision making
Ward Staff
Timely RRT call out: no delay in RRT being called
RRT
Appropriate stand down of RRT: patient trajectory appropriate
Appropriate ICU admission: patient will benefit from ICU
Appropriate end of life care: definitive plan in place, patient comfortable
• Communication
Appropriate communication: patient and family aware of plans
RRT aware and understand management plan
home team aware and understand plans
1 Calzavacca PE et al. Resuscitation 2010 81: 31-35
2 Calzavacca PE et al Resuscitation 2010 81: 1509-1515

14. Patient Management Measures
• Retrospective audit of all RRT reviews
i. Ward Staff
Time from RRT trigger to RRT Call out: Delay, extent of delay (? association with EOL)
ii. RRT
ICU admission: Delay ie after 4 hours of RRT review (bed/decision)
Presence of RRT triggers at stand down And need for repeat RRT review/ICU admission
Repeat RRT call out
Appropriate treatment limitation DNR plan at end of RRT review/died with EOL plan

15. Positive and Negative RRT Outcomes 1
Positive Negative
Admission to ICU Timely Delayed
Alive on ward No trigger Still triggering
Died With terminal care plan Cardiac arrest
Other Alive with DNR plan Lost to follow up
Trigger from new dx
Chronic condition trigger
Discharge from hospital
1 Subbe et al Critical Care and Resuscitation 2013; 15: 33-39

16. Summary of outcomes 24 hours after initial RRT trigger
% positive outcomes for all patients 1
1 Subbe et al Critical Care and Resuscitation 2013; 15: 33-39

17. PATIENT OUTCOME

18. Patient Outcome
• Important to remember that patients only die once…so can only count patient death once
• Can review:
Initial RRT outcome (1st RRT, Multiple RRTs)
RRT Post 24 hours
RRT Post ICU Admission
RRT hospital discharge
• Ideally quality of life after RRT review

19. Canberra Melbourne 1
Initial RRT % %
Number 2464 6139
Remain on Ward 1509 61.2 3583 58.3
Transfer to ICU 381 15.5 650 10.5
Died at RRT 57 2.3
Died before leaving hospital 280 11.4 1794* 29.2
Patients Remaining on Ward at 24 hours
Number 1509 3583
Number stay on same ward 1092 72.4 3183 88.8
Transfer to ICU 60 4 378 10.5
Repeat RRT 302 20 454 12.7
1 Schneider et al Resuscitation 2013; 84: 477-482, * Treatment limitation only

20. Conclusion
• Need to gather patient and family feedback
• Measure the process of RRTs
need strict data dictionary
measure over time
measure team (ward and RRT) satisfaction
• Measure patient outcome
remember patients can only die once
• Feedback to team and ward staff