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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 1 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 2 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 4 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 5