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Type and Title of Submission


Title:

The Aintree Medical Emergency Team

Description:

If a deteriorating patient has a cardiac arrest then survival to discharge from hospital is less than 5%. The Medical Emergency Team (MET) was created following several clinical incidents to improve safety and quality of care for acutely ill/deteriorating patients and has resulted in a sharp and sustained reduction in cardiac arrests within the Trust.

Category:

Does the submission relate to the general implementation of all NICE guidance?

No

Does the submission relate to the implementation of a specific piece of NICE guidance?

Yes

Full title of NICE guidance:

CG50 - Acutely ill patients in hospital

Category(s) that most closely reflects the nature of the submission:

Is the submission industry-sponsored in any way?

No


Description of submission


Aim

Putting patient safety at the heart of emergency response is the key to the success of the Aintree Medical Emergency Team. Any hospital patient may become acutely ill and if recognition of deterioration is delayed and subsequent management inappropriate then this can result in late referral to critical care, avoidable cardiac arrests and unnecessary deaths. The overall aim of this initiative was to successfully operationalise a Medical Emergency Team (MET) to provide a 24 hour, 7 day a week appropriate emergency response to the clinical deterioration and acute illness of any patient in any location within the hospital.

Objectives

The key objective was to assure Trust compliance against NICE CG 50 - Acutely ill patients in hospital (2007) providing 24 hour, 7 day care for acutely ill patients at the point of need; regardless of their geographical location on the Hospital site. Key performance indicators for the MET initiative were established as: - in year 1 of MET operation a 30% reduction in cardiac arrest calls, with a trajectory of reduction for subsequent years. - in yr 1 of MET operation a 50% reduction in serious untoward incidents leading to patient harm, with zero incidents within 5 years.

Context

Following a series of clinical incidents relating to the failure to appropriately manage acute illness, a multi-professional group of clinical experts was established in February 2008 to review the provision for deteriorating patients, and to set in place improvements to the quality of care received. 'Theming' of the incidents revealed that although we had a system in place to track acute illness and physiological deterioration, (Modified Early Warning Scores); there was a systemic failure within the hospital when a patient's physiological condition merited review by a senior doctor. When patient deterioration occurred, the responder was often a junior doctor who failed to escalate to senior medics. It was also noted that few in-hospital cardiac arrests are sudden events, with most patients displaying signs of clinical deterioration on their observation/MEWS charts. Using a collaborative approach, the group decided to pursue the development of a Medical Emergency Team (MET) to provide an emergency response to clinical deterioration and acute illness. Prior to MET implementation, a comprehensive training and education programme was delivered to ensure that over 2,000 staff were aware of the MET Calling Criteria. Presentations were also made to Patient Groups and a full Equality and Diversity Impact Assessment was completed. The communication plan included the distribution of 2,000 MET referral criteria cards, MET awareness days and local media coverage ahead of the launch.

Methods

A co-ordinated approach to the care of the acutely ill patient needs multi-professional involvement. The Project Group included representation from ITU, Medicine, Surgery, Nursing, an AHP and an F1 Doctor. For information on the day-to-day operation and team composition of the MET please see the Powerpoint presentation attached. Buy-in from the Trust Board ensured high level leadership and Trust wide support. A small business case was funded to increase the establishment of the Outreach Team and to purchase two emergency trolleys which contain equipment and drugs for the care of the acutely ill patient. The logistics of bringing together a group of clinicians with different clinical priorities was the most challenging hurdle faced by the Project Group. Working Rosters and Job Plans were changed to ensure that the MET would have senior cover at all times. Another challenge was the belief that the critical care team should only review patients when called by a senior doctor; and not from MET calls made by nurses and junior doctors. Audit of the MET Calling Criteria ensured that the parameters are highly sensitive to the physiology of acute illness and that <2% of the calls made are inappropriate. There was also a consensus that immediate attendance at a MET call would prevent senior doctors from performing other duties. A sustained educational and training package to nearly 2,000 staff has driven home the message that 'There is no higher priority for a clinician than an acutely ill patient'. Speciality working within the Trust had let to the delivery of care in 'silos', meaning that there was no co-ordination of care for a deteriorating patient. The Project Group set out to drive away institutional inertia and convince others that different ways of working and the promotion of a team ethic was the safest way to provide acutely ill patients with the highest quality care.

Results and evaluation

The MET became operational on 24/11/09 and provides 24/7 care for the acutely ill patient at the point of need using bespoke MET Calling Criteria which are validated precursors to life threatening illness and cardiac arrest (see supporting info attached). MET audit is supported by a comprehensive clinical dashboard detailing MET activity, intervention and patient outcomes (see supporting info attached). In the first year of MET operation there has been a sustained 33% decrease in cardiac arrest calls with a 53% decrease for the last three months. Clinical incidents relating to failure to manage acute deterioration have also reduced by >50% in year 1 of MET operation. There has been an accelerated decrease in Aintree HSMR in the 12 months since MET operation (see supporting info attached). Other workstreams are developing as a result of MET audit: - one third of patients did not have oxygen in place on MET arrival, so an updated MEWS Policy was developed to include an algorithm for Nurse Led Response to Deterioration, which empowers nurses to deliver unprescribed oxygen to patients meeting the MET Calling criteria (see supporting info attached). - Around 20% of calls result in 'Do Not Attempt Resuscitation' decisions for those patients needing end of life care, so the Trust is reviewing its DNAR Policy to include 'Ceilings of Care' decisions on admission. The success of the MET has supported the Quality Strategy and work to create a safety culture within the Trust.

Key learning points

- A collaborative approach to the management of acute illness has increased clinical buy-in to the issue and delivered a more comprehensive solution. It also allows junior doctors to learn to care for the acutely ill patient in a supportive and educational environment. - The 'clinical dashboard' has proved essential in demonstrating outcomes in a credible and easily accessible manner with 'drillthrough' data available at a local level. - A full Training Needs Analysis and training and communication engagement plans with staff, patients and relatives are essential ahead of launch. - Board level support at an early stage was a major benefit to the Project - Celebrate success! We regularly communicate clearly how the MET is improving patient safety and we award certificates for MET Call of the Month and MET call of the Year. - Sharing our learning within the Cheshire and Mersey Network has led to the Aintree MET Model being taken up by several local acute Trusts. The MET is the only fully multi-disciplinary team of its kind in the Northwest and the first nationally to have 'surgical' team response. This pioneering status has helped support sharing of our learning. - Externally, the Trust is hosting a national safety conference to share learning with clinical teams from across the country, and we anticipate journal publication in 2011. The MET has been showcased to teams from other hospitals including the Johns Hopkins Hospital in Baltimore, with who we are jointly working on safety programmes. - Avoid taking criticism personally. Winning hearts and minds takes time.



This submission was shortlisted for the 2011 Shared Learning Award.

View the supporting material

Contact Details

Name:June Carr
Job Title:MET/Outreach Co-ordinator
Organisation:Aintree University Hospitals NHS Foundation Trust
Address:Lower Lane
Town:Liverpool
County:Merseyside
Postcode:L9 7AL
Phone:0151 529 2736
Email:june.carr@aintree.nhs.uk

 

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This page was last updated: 25 January 2011

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Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.