IMPLEMENTING RRTs and METsThe Journey – Liverpool Hospital

6th International Symposium on Rapid ResponseSystems and Medical Emergency Teams

Pittsburgh, USA, 11th-12th May 2010Ken Hillman

1982– CHARING CROSS

HOSPITAL, LONDON, UK

• 19 year old pillion passenger• Bled to death in the hospital

1/0194

1/0195

LIVERPOOL HOSPITAL - 1988

• Several cases of preventable deathson general wards

• Discussions with Intensive Care Unitcolleagues

• Name - Medical Emergency Team

MET CRITERIA

33 → 3 vital signs3 observationsWORRIED

LIVERPOOL HOSPITAL

SURGEONS - easyPAEDIATRICS and O & G - easyMEDICINE - ???

CRITICAL POINT– Departmental Meeting

CRITICAL POINT“Cause celebre”

MARKETING

1/0043

1/0282

LIVERPOOL HOSPITAL

• 300 beds• General, metropolitan hospital• Centre of huge population growth• Sleepy

ADMINISTRATION• General Manager• Medical Superintendent• No committees• No quality assurance committees• No business speak

TEACHING HOSPITAL STATUS- 1992

ACADEMICSINCREASE

CommitteesAdministrationStaff

CRITICAL POINTResearch and Publications

MET – FIRST PUBLICATIONS

DESCRIPTIVE• Lee A, Bishop G, Hillman KM. Daffurn K. The

medical emergency team. Anaesth Intensive Care1995;23(2):183-6

• Hourihan F, Bishop G, Hillman KM, Daffurn K, Lee A.The medical emergency team: A new strategy toidentify and intervene in high risk patients. ClinIntensive Care 1995;6(6):269-72

CRITICAL POINT

Health Minister announcesevery hospital in the State will

have the system

METRESISTANCE FROM WITHOUT

Spread around the world inverselyproportional to distance from

Liverpool Hospital

CRITICAL POINT (CHAMPIONS)

• Rinaldo Bellomo – Austin Hospital,Melbourne

• Julian Bion - Outreach Program - UK• Michael DeVita - Pittsburgh

OPPORTUNITIES FORWIDER IMPLEMENTATION

• Girl hit by golf ball - NSW• SARS epidemic - Ontario

VARIATIONS• Name of systems• Calling criteria• Response• Facilitators / blockers within

hospital

RESEARCH EVIDENCE

Often reinforces underlyingprejudices

MERIT STUDY

• Underpowered• Many reasons for not showing a

difference

Lancet 2005;365:2091-2097

META ANALYSIS• Reduction in cardiac arrests in paediatric hospitals

– 30%• Reduction in cardiac arrests in adult hospitals

– 30%• Reduction in deaths in paediatric hospitals

– 20%

“ We don’t believe there is yet enough evidence tosupport rapid response systems”

Arch Intern Med 2010;170:18-26

MERIT STUDYReduction in mortality in

Medical Emergency Teamhospitals

CCM 2010;38:700

Hospital SizeComplexity/“Standing”Infrastructure

Ease of Whole Hospital SystemImplementation

LIVERPOOL HOSPITALCULTURAL CONDITIONS

Transition to teaching hospital Limited bureaucracy Limitednumber of medical colleagues Reputation as iconoclastic

• Devolved ICU nursing responsibilities• ARC course• Day of surgery admission system

IT COULD PROBABLY NOT HAPPEN NOW