Robert Herkes makes the argument that ward staff should manage their own deteriorating patients. Presented at the ANZICS S&Q Conference 2014 on Rapid Response Teams.

1. Ward staff should manage their own
deteriorating patients
Robert Herkes
Director, Intensive Care Service, Royal Prince Alfred Hospital
Medical Director, NSW Organ and Tissue Donation Service.
on behalf of the RPA Clinical Emergency Steering Committee
Royal Prince Alfred Hospital in Sydney

2. APPROPRIATE STAFFING
the elephant in the room with RRT

3. RRT Design – using staff
appropriately.
•One design will not suit everywhere
•Need to consider –
• Governance
• Existing structures
• Size and staffing of hospital
• Hospital philosophy
• Evidence of current problems with deteriorating patients
• How much reform is needed?
Are there EXTRA Resources available?
Who is available to carry the RRT load?

4. RRTs at present

5. The modern hospital ward?
Has the medical community let the
wards degrade, when they need
re-engineering to cope with the
modern inpatient population?
(Sprinkler system from Quakers Hill Nursing Home)

6. Philosophical Decision
Patient deterioration on ward.
ICU issue because the ward can’t
triage properly – they can’t learn
OR
Same escalation everywhere –
call ICU….
Ward escalates – Only educate
ICU staff (but limited pool)
Small team of responders – ICU
doctors and nurses
Medical Emergency Team
Ward problem – Need redesign
ICU can help
Different escalation plans in
each ward and time of day
All staff educated to recognise
and respond to deterioration
Huge pool of responders
(35 teams at RPA)
Clinical Emergency Response System

7. Characteristics of traditional MET vs
modified CERS
MET CERS
Emphasis on response and resource provision Emphasis on education and prevention
The natural conclusion from increased activity is to
push for expansion on the MET – more ICU resources
The natural conclusion from increased system
activity is to push for extra ward education and re-
organise ward cover (day versus night)
Primary care teams have a perverse incentive not to
anticipate deterioration and to outsource response
work to the MET –> hypotensive – call MET
Primary care team has an incentive to anticipate and
prevent calls Should we change the ward model?
HDU everywhere….
May drive up the incidence of deterioration as
primary ward teams lose skill
Drives down the incidence of serious deterioration
via education and earlier intervention by the team
May improve skill base in wards
The ICU takes over more and more clinical
management in ward areas
The ICU is reserved as a safety net when the primary
response is inadequate
End of life management is initiated and conducted
by teams who are unfamiliar with patient
End of life management is initiated and conducted
by the primary care team
The responsibility and work of responding is
concentrated on a small number of clinical staff
The responsibility and work of responding is
distributed among a large number of clinical staff

8. How many calls for well functioning
RRT?
0.00
5.00
10.00
15.00
20.00
25.00
Sep-08
Nov-08
Jan-09
Mar-09
May-09
Jul-09
Sep-09
Nov-09
Jan-10
Mar-10
May-10
Jul-10
Sep-10
Nov-10
Jan-11
Mar-11
May-11
Jul-11
Sep-11
Nov-11
Jan-12
Mar-12
May-12
Jul-12
Sep-12
Nov-12
Jan-13
Mar-13
May-13
Jul-13
Sep-13
Nov-13
Jan-14
Mar-14
Total Number of Calls per Day
Average call duration 35 min.
Up to 4 simultaneously

9. Who is available to take the
deteriorating patient load?
• ICU staff - small numbers
• Excellent resuscitation and procedural skills
• Highly skilled in general medicine investigation and
diagnosis
• Significant home patient load i.e. in ICU
• Work as a tight team
• Ward Staff – large numbers
• Highly skilled in sub-specialty medicine e.g cardiology,
orthopaedics, haematology, respiratory
• Variable resuscitation skills
• Know their patients
• Round on their patients
• Work as a loose team

10. Who is available to take the
deteriorating patient load?
•ICU staff
• Out of usual comfort zone on ward
• No monitors, lines etc.
• Stores and equipment not easily available
• Don’t know staff
• Little sub-specialist knowledge - Oncology
• No previous knowledge of patient or their treatment
•Ward Staff
• Have seen patient and relatives over time
• In normal environment
• Know the lay-out of ward for stores and equipment
• Know the staff
• Can deliver sub-specialist treatments

11. What are the calls for anyway?
Table. Frequency of single, multiple, and specific calling criteria, Jul 2009 - Jun 2012
Clinical Review
(Primary Care Team)
Rapid Response
Team (ICU)
TOTAL
Number of concurrent calling criteria [no. calls (% of call type)]
No criterion listed 3 (0.0) 0 3 (0.0)
Single criterion 8751 (77.9) 851 (52.1) 9602 (74.6)
Two concurrent criteria 2075 (18.5) 568 (34.8) 2643 (20.5)
Three or more concurrent criteria 408 (3.6) 214 (13.1) 622 (4.8)
Specific criteria [no. calls (% of call type)]
Systolic blood pressure <90mmHg 3061 (27.2) 191 (11.7) 3252 (25.3)
Respiratory rate >24/min 2376 (21.1) 123 (7.5) 2499 (19.4)
Respiratory rate >24/min AND pulse
oxygen saturation <90%
573 (5.1) 165 (10.1) 738 (5.7)
Systolic blood pressure >200mmHg 654 (5.1) 15 (0.9) 669 (5.2)
Decreased level of consciousness* 284 (2.5) 241 (14.8) 525 (4.1)
New seizure * 34 (0.3) 51 (3.1) 85 (0.7)
Other criteria 1848 (16.4) 552 (33.8) 2400 (18.6)
* Prominent among RRT callscompared to CRcalls

12. Don’t they all need to be seen by ICU?
Table. Immediate outcomes following CR and RRT calls, Jul 2009 - Jun 2012*
Clinical Review
(Primary Care Team)
Rapid Response
Team (ICU)
TOTAL
Outcome [no. of outcomes/no. of calls (% of call type)]
Stabilised on ward 8506/11237 (75.7) 679/1633 (41.6) 9185/12870 (71.4)
Transferred to
Intensive Care Unit
242/11237 (2.2) 592/1633 (36.3) 834/12870 (6.5)
Escalated to Rapid
Response Team
532/11237 (4.7) n/a 532/12870 (4.1)
Escalated to Cardiac
Arrest Team
50/11237 (0.4) 90/1633 (5.5) 140/12870 (1.1)
* Calls may have more than 1 outcome. n/a=not applicable

13. Where are these patients?
0
50
100
150
200
250
300
350
NumberofCalls
Specialty
Clinical Emergency ICU Assist Pre-Arrest Cardiac Arrest

14. If using ward staff set up CERS
committee
•Committee to oversee CERS represents whole of
Hospital
• ICU Doctor & Nurse *2
• Ward NUM *2
• Ward Nurse *2
• Allied Health representative
• Intern representative
• Resident representative
• Medical Registrar representative * 4
• Surgical Registrar representative
• Medical superintendent
• CERS Nurse
• Safety and Quality representative
• CEO of hospital

15. Educate, re-arrange, educate
• Educate nursing staff
• Vital signs, charting
• Recognising deterioration
• Escalation plans
• ‘Detect’ or similar education
• Educate registrar medical staff
• 2 day Clinical Emergency course for BPT and BST
• Rotate everyone through ICU
• Encourage residents to attend calls
• Audit system
• Review all calls
• Deal with problematic calls – talk to staff, discipline if needed
• Newsletter
• Engage Senior Clinicians
• Letters to VMOs if their registrars won’t co-operate

16. Does it work?

17. http://www.cec.health.nsw.gov.au/echartbook/cec-indicators-intro-chartbook/cec-indicators-btf
OUR ICU-team ‘DOSE’ is LOW compared to peer hospitals

18. http://www.cec.health.nsw.gov.au/echartbook/cec-indicators-intro-chartbook/cec-indicators-btf
Our arrest rate is at or below state average

19. RRT Design – using staff
appropriately.
•One design will not suit everywhere
• Ward physician based system can work well
• Uses all resources of hospital
• Escalates up to ICU when needed
• Limited adverse impact on ICU
• Positive impact on ward and ward staff
• Education and Audit vital
• Re-engineers whole hospital
• Continues patient focused care….
High dose ramp-up RRT
In the end we need to redesign ward care….