Emergency team improves outcomes

A Medical Emergency Team (MET) at Thunder Bay Regional Health Sciences Centre is being credited with having a significant impact on patient outcomes. One of 31 critical care response teams funded by the Ministry of Health and Long-Term Care, the Thunder Bay initiative has contributed to a decrease in hospital mortalities and cardiac arrests, claimed Dr. Adrian Robertson, the team's physician lead.

The conventional protocol for responding to hospital patients showing signs of deterioration was for ward staff to contact their primary physician.

"But if a physician was in OR, interviewing a patient or in the middle of a family meeting, he probably wouldn't answer his page," said Robertson. "Because we're based in Intensive Care, we're always answering our pagers."

In the past, added Robertson, ward staff may not even have called the primary physician if they knew he wasn't available or would only be returning at the end of the day.
"Now, because they know we're available, they'll call us."

Often, the primary physician doesn't have the required expertise to respond to a rapidly deteriorating patient and has to call other physicians for assistance, once again losing valuable time.

24/7

One nurse and one physician on shift in ICU are assigned to provide the service 24 hours a day, seven days a week.

They help out in ICU, but can be freed up if they're paged, explained Carolyn Freitag, who shares RN lead duties with colleague Diane Olsen.

Any nurse or health care professional in the hospital can summon the team if there is a change in a patient's breathing or vital signs, or if there's a just a gut feeling that something's not right.

"We have 15 minutes to respond, but we're usually there in five minutes," said Olsen.
The physician and registered nurse on duty arrive at the patient's bedside with a cart equipped to serve as an ICU on wheels with a monitor measuring heart rate, blood pressure and oxygen saturation, a defibrillator, emergency drugs, airway equipment and IVs. Equipment for electrocardiograms and X-rays can be sent for if necessary and lab tests can be ordered.

The best scenario, said Robertson, is if the patient's primary physician and the ward nurse are also on hand to assess the patient.

Follow-up

"The primary physician knows the patient's past history and the ward nurse has been looking after the patient. It's a more responsive, more collaborative model."

The team will often monitor a patient through the night and return the next day. Team members also follows up on patients transferred out of ICU to the wards for 48 hours, said Olsen.

"We'll go and visit these patients, review their charts, assess them and report back to the MET physician."

The few days immediately following a patient's transfer out of ICU is a high-risk time, said Robertson.

"By following up, we can look for the very first signs of deterioration and bring them back to ICU if we need to. We can nudge patients back in the right direction because of the timeliness of the care and response. There are at least one or two dramatic cases each week that make us feel good about the work we do."

The team has also received training for end-of-life counselling.

Not everyone wants aggressive therapy, but many doctors and nurses don't feel comfortable raising the issue, or aren't trained for the delicate task, said Freitag
"We add value by bringing it to the forefront. By not addressing it, we do a disservice to our patients."

According to Robertson, a graduate of the University of Manitoba Medical School and a specialist in emergency medicine and critical care, the concept of the critical care response teams originated in Australia 10 years ago and is only now being introduced to Canada.

"Ontario is on the cutting edge of this. The whole idea is brand new," he remarked.

The teams across Ontario gauge their effectiveness by tracking cardiac and respiratory arrests, hospital mortality and length of stay in the ICU. Thunder Bay Regional Health Sciences Centre claims a significant decrease in hospital mortality and an improvement in the incidence of cardiac arrests since the team has been in place.

Team-building

"An opportunity to take on a project like this is great for team-building and morale," said Robertson. "It has given all of us an opportunity to get to know each other a lot better. It's also been great to see the nurses take on the challenge of expanding their knowledge base and scope of practice. It has been a fantastic project to participate in."

Sudbury Regional is currently the only other hospital in Northern Ontario with an intensivist-led critical care response team, but an alternative model is under review for smaller community hospitals.

According to Ministry spokesperson Andrew Morrison, preliminary results from some hospitals show improvements of 20 to 40 per cent for such metrics as cardiac and respiratory arrests. In the U.S., the U.K and Australia, critical care response teams report rates of improvements as high as 60 per cent.

No other jurisdiction has rolled out so many critical care response teams in such a short period of time, said Morrison.

The Thunder Bay team responded to in excess of 500 calls in its first year of operation.