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Advocacy Tool Kit on Medical Emergency Teams

Key information to help respiratory therapists make the case for the full inclusion of their profession on all Medical Emergency Teams

Information designed to:

• Raise awareness about the potential enhancement of the current level of inclusion and participation of respiratory therapists in Medical Emergency Teams.
• Support respiratory therapists in defending and promoting their profession’s consistent participation and full inclusion on Medical Emergency Teams.

Objectives

Alert hospital-based respiratory therapists to the possibility that their respective hospital may be establishing a Medical Emergency Team without any respiratory therapists' input or participation.

Provide respiratory therapists with resources and information to help them advocate for the participation of respiratory therapists in all aspects of Medical Emergency Teams.

Background

Medical Emergency Teams (MET), also known under various titles such as Rapid Response Teams (RRT), Critical Care Response Teams (CCRT) and Rapid Assessment of Critical Events (RACE) teams - are interdisciplinary teams of healthcare practitioners that have expertise in the delivery of care to critically ill patients in pre-cardiac arrest situation. For the purpose of this document, the Canadian Society of Respiratory Therapists (CSRT) has chosen to refer to all such teams as Medical Emergency Teams (MET).

Numerous studies have been conducted to identify the in-hospital pre-cardiac arrest deterioration of patients. The US-based Institute for Healthcare Improvement (IHI) and the Canadian Safer Healthcare Now! Campaign (SHN) reviewed many of these studies in the development of their Rapid Response Team (RRT) Intervention Strategy (further information on these studies can be found at www.saferhealthcarenow.ca and at www.ihi.org). According to information gathered by the SHN and the IHI, the implementation of METs can result in a reduction of mortality associated with cardiac arrest and ICU admissions in hospitals.

The CSRT views the implementation of METs as a positive development in Canadian healthcare for its members, the respiratory therapist community in general and the general public. The Society therefore supports the implementation of METs. However, the CSRT is aware that many provinces are allocating funding to hospitals to establish METs yet not all hospitals are structuring their teams according to the guidelines provided by the SHN and the IHI. Some of the alternative team structures do not include respiratory therapists.

Relevant Facts

• Studies designed to identify key factors associated with pre-cardiac arrest patient consistently pinpoint some type of respiratory deterioration as a key identifier. One study identified respiratory deterioration as the best discriminator in identifying high-risk patient groups.
  
  
• 70% (45/64) of patients show evidence of respiratory deterioration within 8 hours of arrest.
  
  
• Respiratory therapists are trained in assessing, monitoring and treating patients they suspect may be demonstrating respiratory compromise.
  
  
• Respiratory therapists receive specific training related to the treatment of respiratory insufficiency using a number of modalities that can be applied to stabilize patients in critical decline outside of the ICU. These modalities include patient positioning, appropriate O2 therapy, CPAP/BiPAP, etc.
  
  
• Respiratory therapists in many hospitals are the first responders to evaluate critical, pre-arrest patients. This role has given respiratory therapists the opportunity to gain significant experience in applying critical care knowledge outside of the ICU setting.
  
  
• The SHN presents four team structure models. These all include respiratory therapists:
  • ICU RN and Respiratory Therapist (RT)
  • ICU RN, RT, Intensivist, Resident
  • ICU RN, RT, Intensivist or Hospitalist
  • ICU RN, RT, Physician Assistant
    
    
• The SHN and the IHI identified that training of the team in critical care skills, communication and professionalism are critical to successful implementation of a MET.

Factors to be considered

Respiratory therapists’ critical care expertise

Critical care is the focal point of most respiratory therapists' practice in Canada. The vast majority of Canadian ICUs require the respiratory therapist's skills in airway management, ventilation, blood gas analysis, etc.

Currently, respiratory therapists in many hospitals perform the role of first responder to patients that are identified on the ward as being in a potential critical decline. The respiratory therapist is called upon to assess the patient, provide an appropriate treatment plan (such as oxygen therapy), perform blood gas procurement and analysis, and communicate this information to the appropriate healthcare provider. The respiratory therapist then typically provides follow up treatment such as adjusting oxygen therapy, assisting the patient and nursing staff with properly positioning the patient to optimize breathing, applying CPAP/noninvasive ventilation (if in an appropriate non-ICU setting), performing pulmonary hygiene techniques, and providing a range of more aggressive interventions should the patient require intubation and resuscitation.

One of the great benefits reaped from respiratory therapists applying their extensive critical care expertise outside of the ICU is that further valuable experience is gained in understanding what techniques can safely be applied in a ward setting without immediate access to the full gamut of typical ICU medical equipment and pharmaceuticals nor the assistance of staff with critical care expertise who would normally be available within the ICU setting.

Important facts related to respiratory therapists' knowledge of critical care:

• Respiratory therapists have expertise in:
  • Patient assessment (respiratory, cardiac, renal);
  • Oxygen therapy;
  • Respiratory medications and the delivery of aerosolized medications;
  • Blood gas procurement and analysis;
  • Airway management (both invasive and non-invasive);
  • Ventilation (both invasive and non-invasive);
  • Pulmonary hygiene; and
  • Anatomy, physiology and pathophysiology, with an emphasis on (but not limited to) the respiratory system.
• More than 50% of respiratory therapists are certified in ACLS
• Many respiratory therapists provide first response to patients that are experiencing a pre or post cardiac arrest medical emergency.
• Respiratory therapists have significant experience in applying critical care knowledge outside of the ICU setting.

Interdisciplinary Team Concepts

Many reports in the last few years have identified the implementation of interdisciplinary teams as an important strategy for improving the delivery of healthcare. The Health Council of Canada included this as a key recommendation in their first and second reports on the status of the Canadian health care system.

The interdisciplinary team involves interdependent goal setting, sharing of responsibilities and respect and collaboration in both performing and evaluating the outcome of the MET intervention. Critically ill patients often have extremely complex histories and pathologies. Successful treatment of these patients requires a multi-disciplinary approach.

The value of an interdisciplinary team is often not realized if the team does not receive adequate training to function cohesively. Information published by the SHN indicates that successful METs require appropriate training for all team members. Training is not limited to updating critical care knowledge. For example, training a MET could start with ensuring team members have advanced critical care training, including training in Advanced Cardiac Life Support.

However the MET's training should also include becoming knowledgeable in:

• Team building and team concepts;
• Identifying the expertise, skills, experience and scope of practice of the team members;
• Establishing proper communication among team members (in both critical and non critical situations);
• Establishing proper communication and demonstrating professionalism when responding to nursing staff that are calling upon the services of the team;
• Providing non-judgmental, non-punitive feedback to the individuals that call the team; and
• Marketing the value of the team to colleagues inside and outside of the ICU.

Funding

Many hospitals receive funding from their provincial governments to establish METs. Most provinces that are providing funding to hospitals for METs are not prescriptive in how the funding is to be utilized. For example, the funding agreement often will not specify the structure, operation or training of the team.

A key funding-related issue arising from the implementation of METs is the perception that there is no need to allocate funding for respiratory therapy resources participating on METs since respiratory therapists are already performing the role of first respondent to patients in critical decline.

However, according to the experience of some institutions that have successfully implemented a MET, an effectively marketed team should see an increase in the number of calls that the team receives as staff throughout the hospital become aware of its value. According to the SHN 66% of cardiac arrest patients showed abnormal signs and symptoms within 6 hours of their arrest. Only 25% of these patients are reported to a physician.vi When a MET is properly implemented and well marketed, more pre-cardiac arrest patients are identified and the team must subsequently respond to a much greater volume of calls. This situation results in a workload for that team that is higher than that which would previously have been handled by a respiratory therapist performing his or her role as first responder. As a result, any funding decisions must take into account the fact that the number of patients identified as requiring a MET intervention and the number of calls to the team will increase If your hospital is implementing a MET, the CSRT encourages you to provide administrators with the following recommendations:

• It is essential that effective internal communication and marketing strategies surrounding the implementation of the team be applied to raise awareness of the MET in order to maximize its potential.
• Respiratory therapists should be considered for a leadership position on the MET and should be involved in the education and training of the team as they have significant experience in the role of first responder to patients in critical decline. over time. Respiratory therapy resources should therefore be funded accordingly.

Each institution must individually assess and address funding needs to allow various members to fully participate on the MET. The historical role of a respiratory therapist is to respond to medical emergencies. In institutions where this role is to be reassigned to a MET, there may already be adequate respiratory therapy resources to implement a well structured team.

In institutions where the implementation of a MET will result in an excessively increased workload for its respiratory therapists, additional staff should be hired to ensure a qualified and trained respiratory therapist is available to respond to all MET calls. Funding for this additional staffing must be allocated based on the situation at the particular institution.

Recommendations

Respiratory therapists clearly posses the critical care knowledge and experience required to respond to medical emergencies. They have extensive experience in dealing with medical emergencies on the wards, outside of the ICU and ER settings. This makes respiratory therapists the ideal profession to participate in the education and training of team members. Extensive experience with medical emergencies on the wards also contributes to making respiratory therapists the ideal healthcare professionals to assume a leadership role on the team.

In order to maximize METs effectiveness, all teams should fully incorporate a respiratory therapist. Also, MET members should be trained to function as a team in order to apply current critical care skills, to communicate effectively and to act professionally.

The CSRT also recommends ensuring that your department gets involved early – both in the planning and the operation of the team.