Download MET: Essential Qualities of the Efferent Limb Efferent arm of MET

Rinaldo Bellomo, MD - June28,2006
MET: Essential Qualities of the Efferent Limb
Efferent arm of MET
MET: Essential Qualities of the
Efferent Limb
Rinaldo Bellomo
Austin Hospital
Melbourne
Australia
The Team must have the right
people
ICU Fellow
ICU Nurse
Medical Fellow
ICU Specialist available
Must deliver the intervention
The intervention must be timely
The intervention must be appropriate
The intervention must be safe
The intervention must be collegial
The intervention must show compassion
The intervention must involve communication
The Team must be competent
ICU nurse/fellow know each other
Can work well together
Can easily summon ICU support if needed
Have airway skills and other advanced care skills
Have monitor, transducers, BiPAP, drugs,
catheters etc.
It must have credibility!
Interventions by MET
Other: IV fluids, CPAP, BiPAP, O2, bag and mask ventilation,
suctioning, naloxone, airway, GTN, Lasix, glucose,
vasoactive drugs, antiepileptic agents, blood, transport etc.
www.metconference.com
Minimum standards of
competence:intervention
Procedures: airway, tracheostomy care/change,
IV access, arterial/central line insertion, CPAP,
BiPAP, bag and mask ventilation, ogyen delivery
systems, LAM
Ability to monitor
Ability to transport
Medications: IV fluids, furosemide, drugs for
intubation, inotropes, vasopressors
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Rinaldo Bellomo, MD - June28,2006
MET: Essential Qualities of the Efferent Limb
Minimum standards of competence:
diagnostic skills
Physical examination skills
Interpretation of EKG
Interpretation of CXR
Interpretation of biochemical tests
Interpretation of hematological tests
Hypoxia / Increased respiratory rate
Pulmonary oedema / fluid overload
Pneumonia / aspiration
Exacerbation chronic obstructive airways
disease
Sepsis
Pulmonary embolism
Arrhythmia
Sputum plug, narcotized, acidemia,
pleural effusion, tracheostomy blocked,
atelectasis, intracranial event
No cause documented
Altered conscious state
Sepsis
Stroke / Transient ischemic attack
or Intracranial bleed
Seizure
Hypovolemia
Cardiogenic shock / acute coronary
syndrome
Drug related
CO2 narcosis
Vasovagal, arrhythmia, cardiac
arrest, encephalopathy, uremia,
meningitis
No cause documented
www.metconference.com
The MET syndromes
Respiratory distress/hypoxia
Tachycardia
Hypotension
Change in conscious state
Oliguria
End of life care
218
66
52
16
11
11
12
30
Hypotension
Sepsis
Bleeding / hypovolemia
Acute pulmonary oedema / myocardial
ischemia
Arrhythmia
Cardiac arrest
Epidural related, Pulmonary embolism,
anaphylaxis, vasovagal, Narcosis
No cause documented
112
30
28
15
10
4
13
15
20
93
13
13
11
8
6
5
5
21
Tachcyardia
Arrhythmia
Sepsis
Acute pulmonary oedema /
myocardial ischemia
Drug related
Hypovolemia
Respiratory distress
Pulmonary embolism, Epidural
related, stroke
No cause documented
77
29
13
10
4
3
3
3
11
12
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Rinaldo Bellomo, MD - June28,2006
MET: Essential Qualities of the Efferent Limb
End of life care: >20% of MET calls!
Oliguria
Sepsis
Cardiogenic shock
Hypovolemia
Urinary tract obstruction
Drug related, hepatorenal
syndrome, stroke
No cause documented
31
7
7
4
2
5
3
Efferent arm: needs to be able to treat the
syndromes and diseases behind them
Sepsis is the big one
Acute pulmonary edema is big
Fluid management is big
Bleeding
AMI
Rhythm disturbances
End of life care
Anthropological rule set No 1
The ward staff must see that something special
has arrived
They must perceive that the team can handle
what is happening
They must feel grateful that the team has arrived
They must feel they have done the right thing for
their patient
The Team must have the right equipment
The MET pack
Must contain all that allows a mini-ICU to be
created anywhere in the hospital
Must allow ICU care for up to one hour to be
delivered
The ward staff must think: these guys have
thought of everything!
www.metconference.com
3
Rinaldo Bellomo, MD - June28,2006
Collegiality
Never ask “what is wrong?”
Always ask “how can we help you?”
Greet ward staff and introduce yourselves
Say hello to patient if possible and explain why
you are there
Involve staff in the process of patient care
Compassion
Show concern for the well-being of the patient
Show concern about how the ward staff might
feel (sense of failure? sense of ignorance?)
Show concern about how the family might feel
(frightened? confused?)
Focus on “cure”......but also comfort
Competence is difficult to judge
Compassion and humanity will be remembered
and more calls will be made
Competence in critical care cannot be judged by
patients. But they will remember kindness
Competence in critical care cannot be judged by
families. But they will remember explanations,
compassion and courtesy
www.metconference.com
MET: Essential Qualities of the Efferent Limb
Communication
Explain what your initial assessment suggests
Communicate this to patient, staff and if
appropriate later on, speak with family
Communicate with primary unit about
assessment and care plan
Communicate a care plan for the next 24 hours if
patient is not admitted to ICU
Culture
Australia is a multicultural society
Must be aware of different cultural needs
Cultural needs and values of patients
Cultural needs and values of staff
Cultural needs and values of family
Education
MET calls provide unique real-life settings for
nursing and medical education
If possible explain what you are doing and why
Show abnormalities on CXR or EKG or in
laboratory findings or physical examination
For many young doctors and nurses this is a
tremendous learning opportunity
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Rinaldo Bellomo, MD - June28,2006
Example
Ward staff are watching you
Patients are watching you
Families may be watching you
Trainees are watching you
Show the highest level of professionalism
Conclusions
Nobody can do this right unless they are trained
At Austin Hospital both doctors and nurses are
being trained in mock situations
Simulation is vital
Insight into the most common syndromes likely
to be seen is vital
Knowing the most common diseases is also vital
www.metconference.com
MET: Essential Qualities of the Efferent Limb
Conclusions
Being in the efferent limb of the MET system is
extremely challenging
The skills required for optimal patient care are
many
The knowledge required is substantial
The social and human skills equally important
Conclusions
The efferent limb of the MET system is “what
people see”
Working in the efferent limb is exciting
Many ICU nurses at Austin want to rotate into
the role
Formal training is necessary
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