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You are here: Home / 03. Intensive Care / Rapid Response Teams (MERT, RRT)

Rapid Response Teams (MERT, RRT)

July 14, 2011 by CrashMaster

Med Emerg Response Teams

 

crit care 2006;10:121 and R30

 

Table 1:  Calling Criteria for Medical Emergency Teams

 

  • Staff member is worried about the patient
  • Airway
    • Noisy breathing / stridor
  • Breathing
    • Acute change in respiratory rate to < 8 or > 30 breaths / min
    • Acute change in pulse oximetry saturation to < 90% despite oxygen administration
  • Circulation
    • Acute change in heart rate to < 40 or > 130 beats / min
    • Ischemic chest pain ¶
    • Acute change in systolic blood pressure to < 90 mmHg
    • Acute change in urinary output to < 50 mL in 4 hrs.
  • Conscious state
    • Acute change in conscious state
    • Multiple seizures¶

 

 

¶ Indicates criteria specific for The Northern Hospital
Table 2:  Common reasons for MET calls at The Austin Hospital

 

 

Cause of the MET call

Number of calls

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

218

66

52

16

11

11

12

30

 

20

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

Altered conscious state

Sepsis

Stroke / Transient ischemic attach or Intracranial bleed

Seizure

Hypovolemia

Cardiogenic shock / acute coronary syndrome

Drug related

CO2 narcosis

Vasovagal, arrhythmia, cardiac arrest, encephalopathy, uremia, meningitis

No cause documented

93

13

13

11

8

6

5

5

21

 

12

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

Oliguria

Sepsis

Cardiogenic shock

Hypovolemia

Urinary tract obstruction

Drug related, hepatorenal syndrome, stroke

No cause documented

31

7

7

4

2

5

3

 


Table 3:  Proposed minimum criteria for managing a MET call

 

  • Determine the etiology of the deterioration
  • Document the events surrounding the MET call

(A pre-formatted fluorescent yellow sticker is used at The Austin Hospital)

  • Organize a management plan and appropriate medical follow-up
  • Automatic medical referral for surgical patient subject to a MET call for a medical reason in cases where the patient remains on the ward¶
  • Communicating with the parent unit (or their cover) that the MET has occurred
  • Compulsory review of the patient by an Intensivist for a patient requiring two MET reviews in a seven day period ¶
  • Communicating with the intensivist if the following criteria are fulfilled:
    • The patient remains unstable following initial resuscitation
    • The patient requires ICU or HDU admission
    • The patient may require ICU or HDU admission in the future
    • The patient has been admitted to ICU or HDU during this hospital admission
    • The members of the MET are unsure how to manage the patient (i.e. the members of the MET are worried about the patient).

 

 

 

¶ Criteria specific for Austin Hospital.

 

MET, Medical Emergency Team; ICU, Intensive Care Unit; HDU, High Dependency Unit.

 
Table 4: An approach to managing a MET call

 

Ask and Assess

Ask the staff how you can help themAsk about the reason for the MET call

Assess for the etiology of the deterioration

 

Begin basic investigations and resuscitation therapy

 

Call for help / call consultant if needed

 

Discuss, Decide, and Document

Discuss MET with parent unit / consultant

Discuss advanced care planning if appropriated

Decide where the patient needs to be managed

Document the MET and subsequent frequency of observations

 

Explain: the cause of the MET, the investigations required and subsequent management plan

 

Follow-up: which doctor to follow-up the patient?  What are the criteria for doctor re-notification?

 

Graciously thank the staff at the MET

 
Table 5:  Management of the “Hypoxic – tachypneic MET call”

 

Assess for etiology

  • Pulmonary edema / Cardiac failure (Past history of heart disease.  Current evidence of myocardial ischemia, raised JVP, oedema, bilateral crepitations, cardiomegaly)
  • Dependent atelectasis/collapse (Patient immobile, basal chest signs, recent surgery)
  • Asthma / COAD (Wheeze, prolonged expiration, hyper-inflated chest)
  • Sepsis anywhere.   eg lung, kidney, wound, intra-abdominal.
  • Pulmonary embolism – immobile, recent surgery, history of thrombo-embolism, tachycardia, ECG changes of right ventricular strain

 

Begin basic investigations and resuscitation

  • Administer oxygen and obtain portable CXR
  • ECG, Cardiac enzymes, electrolytes
  • Sepsis screen: FBE, CRP, blood, urine, sputum, wound.
  • Consider ABG +/- lactate
  • Pulmonary edema – Loop diuretic, morphine, nitrates, oxygen, posture, consider CPAP
  • Dependent atelectasis/collapse – chest physiotherapy, humidified oxygen
  • Asthma / COAD – bronchodilators, steroids, antibiotics ?BiPAP.
  • Pulmonary embolism – V/Q scan or CTPA.  Consider anti-coagulation.

 

Call for help

  • SaO2 < 90% despite 10L inspired oxygen
  • RR > 40, elevated PaCO2, altered conscious state

 

Discuss & Decide

  • Is the patient stable or unstable?
  • What is the management plan?
  • Does the patient need ICU/HDU/surgery?
  • Communicate with patient/Next of kin/parent unit/Intensivist
  • What is the subsequent follow up plan?

 

Explain

  • Cause of the hypoxia and subsequent management plan.
  • Subsequent observations required.

 

Follow-up

  • Who will follow-up the patient?

 

 

JVP = jugular venous pressure, COAD = chronic obstructive airways disease, WCC = white cell count, ECG = electrocardiogram, CXR = chest X-ray, ABG = arterial blood gas, FBE = full blood examination, CRP = C-reactive protein, V/Q = ventilation perfusion, CTPA = CT pulmonary angiogram, SaO2 = saturation oxygen, RR = respiratory rate, PaCO2­ = partial pressure of carbon dioxide, ICU = Intensive Care Unit, HDU = High dependency Unit.

 

 

crit care 2006;10:R30

 

Full annotated bibliography (Crit Care Med 2006;34:2463)

 

 

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Filed Under: 03. Intensive Care


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