Presentation on theme: "Implementation of the NICE Guidance (50) in Wales Chris Subbe, Wrecsam."— Presentation transcript:
Implementation of the NICE Guidance (50) in Wales Chris Subbe, Wrecsam
Changing clinical practice To ensure early identification of the acutely ill patient and prevent deterioration of clinical condition. To reduce patient mortality, morbidity and length of stay. To reduce ICU admissions and re-admission.
Sick patients & Cardiac arrests Near all arrests in patients known to be unstable. –Patients with dyspnea are at increased risk. Sax FL, Medical patients at high risk for catastrophic deterioration, Critical Care Medicine, % of cardiac arrests are proceeded by deterioration of respiratory and mental function. Schein RMH, Clinical Antecedents to in-Hospital Cardiopulmonary Arrest, Chest, % of cardiac arrests have documented deterioration 6 hours pre-arrest. Franklin C, Developing strategies to prevent inhospital cardiac arrest, Critical Care Medicine, 1994
Abnormalities up to 72 hours pre-ICU
100,000 Lives Campaign Rapid Response Team Acute Myocardial Infarction Adverse Drug Events (ADEs) Central Line Infections Surgical Site Infections Ventilator-Associated Pneumonia
Adult patients in acute hospital settings, including patients in the emergency department for whom a clinical decision to admit has been made, should have: physiological observations recorded a clear written monitoring plan Physiological observations should be recorded and acted upon by staff who have been trained and are competent. Assessment and monitoring
Assessment and monitoring: physiological observations Initial assessment should include at least: heart rate respiratory rate systolic blood pressure level of consciousness oxygen saturation temperature.
EWS - H ow to find the sick ? Score = =7
Sick patients & MET Medical Emergency Team replaces Arrest Team (1990) Criteria for Call out Anybody can call Hourihan F, The medical emergency team: a strategy to identify and intervene in high risk patients, Clin Intensive Care, 1995 Reduction in Cardiac Arrest Parr MJA, The Medical Emergency Team: 12 month analysis of reasons for activation, immediate outcome and not-for resuscitation orders, Resuscitation, 2001 Criteria for MET alert AirwayThreatened BreathingRespiratory arrest –RR 36 CirculationCardiac arrest –PR 140 –BP < 90 mmHg NeurologySudden LOC –GCS >2 –Repeat. or prolonged seizure OtherAny U R seriously worried about
Can we identify sick medical patients? Prospective study Medical admissions MEWS > 4: risk of –HDU –ICU –Death Scores HDUICUDeath
NEW score “We recommend that the physiological assessment of all patients should be standardised across the NHS with the recording of a minimum clinical data set result in an NHS early warning (NEW) score.” To …”be used at all stages in the acute care pathway, including pre-hospital assessment, eg by the GP, ambulance service or other healthcare professionals.“
Graded response strategy Low-score group Increase frequency of observations and alert the nurse in charge Medium-score group Urgent call to team with primary medical responsibility for the patient Simultaneous call to personnel with core competencies for acute illness High-score group Emergency call to team with critical care competencies and diagnostic skills
Priestley et al. Intensive Care Med 2004; 30: Critical Care Outreach Ward-randomized trial of phased introduction in a general hospital –York, 800 bedded, 16 wards, 32 wks –Gradual introduction, paired wards –7450 patients, 2903 eligible –Pre/Post vs Control/Intervention Hospital mortality 0.52 ( )
Hillman K, ICS State of the Art meeting 2004 MET & mortality V RCT of 23 hospitals events, patients Outcomes [Control vs MET] Cardiac arrests 2.6 vs1.6/1000 admissions ICU admissions (unplanned) 4.9 vs 4.2 Death 1.2 vs 1.1 No significant difference ….. But –Very poor compliance with call-out criteria [50% of patients with adverse events]
MERIT - Methods 23 Australian hospitals Cluster randomization Cardiac arrests vs MET –2 month baselines, 4 months education, 6 months collection Improvement in all hospitals re-CPR & unexpected admissions to ICU Hillman et al, Lancet, 365:
MET informed if 15 min abnormal? Control (no MET) Intervention (MET) Cardiac arrests96%95% Unplanned ICU9%30% Unexpected death 25%8%
Bellomo, MET conference 2006
Size of team?
Models METOutreach led Outreach supported ResearchTrialRCT? IdentificationMET criteriaScore InterventionIntensivist team Intensive care skills Practitioners Own team Quality control METOutreach?
Model The job …
Vital elements Reliable identification –System that is credible –Sensitivity/specificity? Trained staff –MET –Outreach –ALERT –Ward staff (?) Reliable response
Staff need to be competent in using the locally agreed 'track and trigger' system. Use baseline assessment to check use of track and trigger systems. Use existing team and network meetings to communicate agreed response strategy. Use Department of Health competencies and training matrix to implement training plan for staff. Training and competencies
Who is who?
Conclusion No comparative data, but … –Simple scores more reproducible –Pros beat amateurs most times