Download El sistema de respuesta rápida

Ventajas del Equipo de
Respuesta Rápida
7 de abril 2016
Dr. Julio Osorio
FCCP
1
Disclosures
Conflictos de interés- ninguno
Contenido
 Evolución de los sistemas de respuesta
rápida.
 Qué son los sistemas de respuesta rápida.
 Que evidencia apoya su uso.
 Cuáles son los diferentes equipos y que es
mejor.
 qué desencadenantes deben usarse para
activar.
 otras controversias.
Rapid Response System History
• In 1999 the Institute of
Medicine published a
report, To Err is Human:
Building a Safer System
– Report concluded 44,000 –
98,000 people die each
year as a result of
preventable medical errors
– Followed by the IM
Crossing the Quality
Chasm
Rapid Response System History
• The Institute of Healthcare Improvement
launched their “Saving 100,000 lives campaign”
which featured six “planks” in 2004
–
–
–
–
–
–
Medication Reconciliation
Prevention of surgical site infections
Prevention of ventilator associated pneumonia
Evidence-based care for acute myocardial infarctions
Prevention of central line infections
Rapid Response Teams
Rapid Response Systems
• A team of clinicians who respond to
patients hospitalized outside the ICU when
they meet a “clinical trigger” or other
predetermined mechanism
• Team provides rapid assessment and
triage
• Here to stay – JCAHO is requiring
hospitals to have “rapid response system”
in place
MEJORAR LA PRESTACIÓN
DE SERVICIOS
 El sistema de respuesta rápida (SRR) es el
sistema centrado en el paciente;
 Es para hacer hospitales más seguros.
 Los SRR son creados para prevenir
emergencias médicas en el hospital y
mejorar la calidad de la atención.
7
MEJORAR LA PRESTACIÓN
DE SERVICIOS
 Una emergencia médica en el hospital se produce
cuando un paciente hospitalizado se ha
deteriorado, fisiológicamente o psicológicamente,
hasta el punto donde existe un riesgo inminente
de un evento adverso o daño.
 El deterioro del paciente requieren con urgencia
recursos que son no siempre fácilmente
disponibles. Manejar la discrepancia entre
necesidades del paciente y recursos disponibles
es el sello de los RR.
8
MEJORAR LA PRESTACIÓN
DE SERVICIOS
 Aunque las habilidades individuales de los clínicos
pueden ser de una alta calidad y el
funcionamiento de departamentos distintivos
tales como UCI y urgencias, puede ser ejemplar,
los pacientes pueden caer entre las grietas en las
salas del hospital.
 Sus signos vitales no pueden registrarse con
precisión y pueden faltar los conocimientos
adecuados para atender con urgencia al paciente
en riesgo.
 Materiales y equipos en la sala pueden no ser
9
adecuadas.
MEJORAR LA PRESTACIÓN
DE SERVICIOS
 La paradoja es que los pacientes en el hospital
son cada vez mayores con múltiples
comorbilidades crónicas y vienen bajo el cuidado
de los médicos que se especializan cada vez más
alrededor de un solo Estado órgano o
enfermedad específico.
 Aunque han sido entrenados en cuidados
intensivos y reanimación en un momento en sus
carreras, estas habilidades son a menudo
perdidas sin continua práctica procesal en el
área.
10
MEJORAR LA PRESTACIÓN
DE SERVICIOS
 No todo el mundo está en una UCI; por lo tanto,
la UCI debe llegar a todos independientemente
de su ubicación.
11
MEJORAR LA PRESTACIÓN
DE SERVICIOS
 Tareas:
• Aumentar la colaboración entre servicios médicos o
quirúrgicos y especialistas en cuidado agudo y crítico.
• Eliminar las jerarquías rígidas dentro de hospitales, en el
que los médicos jóvenes están a menudo sin
supervisión; y el personal de enfermería registra signos
vitales pero no está facultado para actuar sobre ellas.
• Proporcionar criterios estandarizados para identificar
ptes. seriamente enfermos y deterioro de pacientes en
la sala.
• Los SRR reconocen a pacientes seriamente enfermos
antes que mueran o al final de la vida (EOL).
12
Why Simulation-Based Training?
In the United States:
• Average 1.2 million healthcare related incidents per
year
• $29 billion a year associated with medical errors
• 66% of those errors are associated with
communication issues
According to the 1999 Institute of Medicine
Report ‘To Err Is Human’, approximately
100,000 Americans die each year from
‘preventable’ hospital errors. The annual
toll exceeds the combined number of
deaths and injuries from motor vehicle
and airline crashes, suicides, falls,
poisonings and drownings.
WHY Rapid Response Team
Training?
• The Joint Commission
– 2008 National Patient Safety Goals
• Goal 16: Improve recognition and response to changes
in a patient’s condition.
o 16A: The organization selects a suitable method
that enables health care staff members to directly
request additional assistance from a specially
trained individual(s) when the patient’s condition
appears to be worsening
WHY Rapid Response Team
Training?
• IHI: Institute for Healthcare Improvement
100,000 Lives Campaign
– Introduces proven best practices to extend or save as
many as 100,000 lives by reducing morbidity and mortality
– Activating a Rapid Response Team is one of six strategies to
prevent avoidable deaths
• Deploy Rapid Response Teams…at the first sign of
patient decline
Research Findings
Majority of patients who arrest in the hospital
have signs of deterioration for 6-8 hours
Saves Lives
Reduces LOS
Calls for RRT’s doubles after the 1st year
implementation
30 % decrease in cardiopulmonary arrests in
one documented study.
Approximately 40 % of patients survive to
discharge following RRT activation
El sistema de respuesta
rápida - SRR
 El Sistema de respuesta rápida (SRR)
describe el complejo siguiente estructura
(Figura 1):
•
•
•
•
la
la
la
la
extremidad aferente (brazo),
extremidad eferente,
extremidad evaluativa
rama administrativa.
18
Rapid Response Systems
• Components
– Afferent Limb
• How RRS is activated
– Efferent Limb
• How the RRS responds
– Evaluative Process
• Data collection on RRS effectiveness
– Administrative or Governance Structure
• Hiring/ firing etc
What are rapid response systems?
Rapid Response System
Afferent Arm
(identification)
Prediction
of deterioration
risk over time
Prognostication
tools
Efferent Arm
(response)
Detection
of active
deterioration
Standardized
calling criteria
Early warning
scores
Code blue
team
Medical
emergency
team
Tools to supplement the clinical skills of
nurses and physicians at the bedside
WHY Initial Responder training?
Critical Incidents:
• High percentage outside critical care areas
• Survival highly dependent on Initial or First Responders
• Multiple factors influencing outcomes include:
– Patient co-morbidities and initial cardiac rhythm
– Duration of incident and time to defibrillation
• Need for rapid and effective BLS and ACLS
La importancia de la dosis en
el SRR
 En muchas terapias en la enfermedad crítica
existe una relación entre la dosis de la terapia
dada y la respuesta.
 La dosis es citada a menudo como el número de
llamadas MET / 1000 admisiones, aunque
también ha sido citado como llamadas MET /
1000 días de cama.
 La gran mayoría de estudios informe una
reducción después de la introducción de un RRS
SAEs sólo si representa la dosis > 20
llamadas/1000 admisiones.
22
Quién responde a ¿qué?
METs (equipos dirigidos por
prescripción de los médicos) o
CCOs RRTs (equipos dirigidos por los
personal que no pueden prescribir
terapias como las enfermeras).
23
What are the different teams and
which is best?
• Medical Emergency Teams (MET)
– Physician-lead
– RN & RT support
– Ramp down model
• Rapid Response Teams (RRT)
– RN & RT lead w/ dedicated on call physician
– Ramp up model
• Critical Care Outreach (CCO)
– RRT/ MET with prospective / proactive component
Which team is best?
MET- MD lead
• Pros:
– Immediate definitive
treatment
– Advanced airway
management and
central venous access
• Cons
– Expensive
– Intimidating to bedside
staff to activate
RRT - RN/RT lead
• Pros
– Less expensive
– Less intimidating to
beside staff to activate
• Cons
– Less efficient;
– Delay to definitive
treatment
Which team is best?
• MET vs RRT Response Teams:
• No mortality difference in observational
studies
¿Educación y formación:
cursos o a la cabecera?
Depende
• Miembros de 4 ramas.
27
El Equipo
capacidad de prescribir terapia;
habilidades avanzadas de la vía
aérea;
capacidad para establecer líneas
vasculares centrales;
capacidad para comenzar a un nivel
de ICU de atención en la cabecera.
28
la simulación
La simulación es un método
educativo que puede utilizarse para
transferir conocimientos teóricos y
habilidades prácticas en práctica.
29
Criteria cont’d
Acute Change in:
Heart Rate <40 or > 130
SBP < 90 mm Hg
RR <8 or >30
O2Sat <90
Mental Status (LOC)
UO < 50 ml/hr
Escalas
National Early Warning Score (NEWS)*
PHYSIOLOGICAL
PARAMETERS
3
Respiration Rate
≤8
Oxygen
Saturations
≤91
Any Supplemental
Oxygen
2
92 - 93
1
0
9 - 11
12 - 20
94 - 95
≥96
Yes
Temperature
≤35.0
Systolic BP
≤90
Heart Rate
≤40
Level of
Consciousness
91 - 100
1
2
3
21 - 24
≥25
No
35.1 - 36.0
36.1 - 38.0
101 - 110
111 - 219
41 - 50
51 - 90
38.1 - 39.0
≥39.1
≥220
91 - 110
111 - 130
A
≥131
V, P, or U
*The NEWS initiative flowed from the Royal College of Physicians’ NEWS Development and Implementation Group (NEWSDIG) report, and was jointly developed and funded in collaboration with the
Royal College of Physicians, Royal College of Nursing, National Outreach Forum and NHS Training for Innovation
Please see next page for explanatory text about this chart.
© Royal College of Physicians 2012
31
What triggers should be used?
• A wide variety of activation criteria exists
• There is little evidence to support their
validity
Winters et al. Rapid response sytems: A systematic review. Crit Care.
2007; 35(5) 1238-1243.
Types of Triggering Systems
• Aggregate Scoring Systems
– Scores combining several physiologic parameters
• Modified Early Warning System (MEWS)
• Patient At Risk Team (PART) calling criteria
• Single Parameter criteria
– Routine observations of vital signs
• Harborview RRT calling criteria
• Combination scoring system
– Incorporates aggregate scoring system
– Team is activated if any single parameter scores “at
Highest”
Aggregate Scoring Methods
• Modified Early Warning System (MEWS)
– RRS is activated when score >4 or 5
Gardner-Thorpe et al. The value of modified early warning score (MEWS) in a
surgical in-patients: a prospective observational study Ann R Coll Surg Engl.
2006; 88:571-5
Aggregate Scoring Methods
• Patient At Risk Team (PART) criteria
– RRS activated when patient meets 3 or more
criteria or absolute criteria
Goldhill et al. The patient-at-risk team: identifying and managing seriously ill
ward patients. Anaesthesia. 1999; 54: 853-860
Single parameter trigger criteria
 Intuitive sense that something is wrong with patient
 Acute change in mental status
 New onset of agitation or restlessness
 Acute change in respiratory status:
 Stridor – noisy airway
 Respiratory rate  < 12  > 32
 Increased WOB
 SaO2 < 92% with increased FiO2
 ABG requested for respiratory concern
 Acute change in CV status
 HR  < 55  > 120
 SBP  <90  > 170
 New onset of chest pain
 Acute change in temp.  < 35  > 39.5
Triggering Systems
Scoring System
• Pros
– Less False alarms
– Higher scores are able
to predict poor
outcomes
• Cons
– More complex for
bedside staff
– Some do not include
subjective criteria
Clinical triggers
• Pros
– Easy for bedside staff
to use
• Cons
– More false alarms
Triggering Systems
• What does the evidence say?
– At present no studies have compared different
activation criteria
– No single activation criteria has been
adequately validated
– A systematic review by Gao et al was unable
adequately compare data due to heterogenity
Triggering Systems
• Subjective “worry” criteria versus Objective
criteria
• Family members activating RRS?
Factores humanos y su impacto
en pacientes, familias y
personal.
 Atención al paciente segura y confiable es una
prioridad internacional.
 Del Instituto de medicina estima que 100
pacientes mueren cada día en los Estados Unidos
de causas yatrogénicas.
 A pesar de niveles sin precedentes de los gastos,
errores médicos prevenibles continúan siendo
abundantes;
 La incoordinación continúa frustrando a
pacientes, familiares y proveedores;
 y los costos de salud continúan aumentando.
40
¿Auditoría y evaluación: los
datos que se recogen?
 Los Datos son importantes para definir la
necesidad de una RR, gestionar su
implementación y afinar su impacto.
 herramienta para reducir
• El paro cardio-pulmonar,
• muertes y
• retraso de admisiones a la unidad de cuidados
intensivos.
41
Rapid response systems: mixed results
Mortality rate
better
Cardiac arrest rate
worse
better
Adults
No significant
reduction
worse
Adults
34% reduction
Children
Children
21% reduction
38% reduction
Pooled
Pooled
Chan PS, Jain R, Nallmothu BK, Berg RA, Sasson C. Rapid Response Teams: A Systematic Review and Meta-analysis. Arch Intern Med. Jan 11 2010;170(1):18-26.
RRS
Does it Work?
Before
After
No. of cardiac arrests
63
22
Deaths from cardiac arrest
37
16
No. of days in ICU post arrest
163
33
No. of days in hospital after arrest
1363
159
Inpatient deaths
302
222
Bellomo R, Goldsmith D, Uchino S, et al. A prospective before-and-after trial of a
medical emergency team. Medical Journal of Australia. 2003;179(6):283-287.
Mod 143
Page
05.2 Page 43
TEAMSTEPPS 05.2
RRS
Does the RRS Work?
 50% reduction in non-ICU arrests
Buist MD, Moore GE, Bernard SA, Waxman BP, Anderson JN, Nguyen TV. Effects of a medical
emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital:
preliminary study. BMJ. 2002;324:387-390.
 Reduced post-operative emergency ICU transfers (58%)
and deaths (37%)
Bellomo R, Goldsmith D, Uchino S, et al. Prospective controlled trial of effect of medical emergency team
on postoperative morbidity and mortality rates. Crit Care Med. 2004;32:916-921.
 Reduction in arrest prior to ICU transfer (4% vs. 30%)
Goldhill DR, Worthington L, Mulcahy A, Tarling M, Sumner A. The patient-at-risk team: identifying and
managing seriously ill ward patients. Anesthesia. 1999;54(9):853-860.
 17% decrease in the incidence of cardiopulmonary arrests
(6.5 vs. 5.4 per 1000 admissions)
DeVita MA, Braithwaite RS, Mahidhara R, Stuart S, Foraida M, Simmons RL. Use of medical emergency
team responses to reduce hospital cardiopulmonary arrests. Qual Saf Health Care. 2004;13(4):251-254.
Mod 144
Page
05.2 Page 44
TEAMSTEPPS 05.2
Top 5 Interventions for RRT Calls
Oxygen therapy
Non-invasive positive pressure
ventilation by mask or ventilator
Nebulizer treatments
IV fluid bolus required
Lasix administered
Potential Economic Benefit
Conservatively ICU care costs $2,000$3,000/day
If 10% of admissions avoided and 10% of
those patients admitted to ICU have
shortened LOS’ we would save 5,500 ICU
days. Results in $11,000,000 savings
Opens up additional ICU beds for patients
requiring admission.
Facilitates more timely admissions from the
Floor, ED, PACU and outside transfers
MICU Experience cont’d
Top 3 Primary events for calls made:
Respiratory Distress
Hypotension
Change in LOC
Time Investment:
10-60 minutes per call
What does the evidence say?
• Winter’s et al conducted a literature review
– Searched medical literature database
– From 10228 possible articles, 8 were
determined to be applicable
Winters et al. Rapid response sytems: A systematic review. Crit Care. 2007; 35(5):
1238-1243
Evidence to Support RRS
Winters et al. Rapid response sytems: A systematic review. Crit Care.
2007; 35(5) 1238-1243.
Evidence to Support RRS
Winters et al. Rapid response sytems: A systematic review. Crit Care. 2007; 35(5)
1238-1243
Winters et al Conclusions:
– “weak to moderate” level of evidence to
support RRS in reducing hospital mortality
and cardiac arrest rates
– Large randomized trials are needed to prove
that RRS are effective
– Observational studies may have been
influenced by “Hawthorne” effect
Merit Study
• Large cluster-randomized trial
• Showed no effect
• Criticism of Merit Study include:
– Increase in “RRS-like” activities in control hospitals
– Sudden decrease in end-points in control
– Study was underpowered
Barriers
Late Calls…near arrest
Units initially hesitant to call for help
Concern about floor physician/ICU physician conflict
Floor nurses concerned about “going over someone’s
head”
Limitation of resources…using stressed resources
Documentation of event
No documentation from requesting units
Inconsistent documentation from responders
56
57
58