Question 30

College answer

Syllabus topic/section:

2.1.1    Structure and Process - Rapid Response Systems / Critical Care Outreach: L1

Discussion: 

Some candidates had difficulty in providing a definition of a rapid response system, instead providing a list of team members or else a discussion on how to finance and implement a system, which was not what the question asked for. Similarly, other candidates listed equipment used which was also not asked for. It was clear to the examiners that many candidates had been members of or taken part in a rapid response system but had not thought critically about the role/function of a rapid response system. A review of the CICM IC-26 policy, Minimum Standards for Intensive Care Unit-Based Rapid Response Systems, would aid in answering this question. Candidates are reminded CICM professional documents are examinable.

Candidates who achieved more marks understood the systems nature of a rapid response system and the principles underlying both generation of a call and the nature of the response, including potential systems issues.

The marking rubric is included to aid the candidate’s future study.

Discussion

Definition:

"A Rapid Response System (RRS) describes a hospital wide structure providing a safety net for patients potentially becoming critically ill who have a mismatch between their clinical needs and the local resources to manage them within the patient’s current location"

- Joint CICM and ANZICS Position Statement

Key principles:

• Detection of early signs of deterioration:
  • Deterioration of patient is usually heralded by steretypic changes in physiological parameters
  • If this deterioration is detected and averted, the patient is less likely to require ICU admission
  • MET systems aim to increase the rate of early detection, and focus critical care services to the aid of deteriorating patients
  • MET service are coordinated by a system of call criteria based on physiological parameters which - with even minor deviations from normal values - can be sensitive in detecting a patient at risk of ICU admission or death.
• Mandated time critical escalation of the response:
  • Breached criteria actiuvate the response, removing the hindrance of human factors
  • MET services then deploy an ICU-level skill set in the ward, which should improve the quality of care for critically ill patients
  • Prevention of ICU admission should be a cost-effective measure, working on the premise that ICU admission is more costly than MET team maintenance.
  • End-of-life care quality should improve with the involvement of ICU staff
• Increased and timely access to care resources
  • Critically ill patients will be identified early and appropriate care will be implemented earlier, including deescalation and palliative management
  • Bedside education of ward staff in the management of critically ill patients should improve 
  • Expansion of the role and importance of the ICU within the hospital should help developa supportive collaborative relationship with ward staff and hospital medical/surgical teams

Assessment:

• History
  • Duration of bypass
  • Medication, eg., ACE-I
  • Pre-op infections
  • Residual antiplatelet effects 
  • Massive diuresis  from bypass
  • TTE/TIE results (eg. LVOT obstruction?)
• Examination
  • Temperature
  • Drain output
  • Peripheral perfusion
  • PPV, SVV, cardiac indices
  • Air entry (pneumothorax? Haemothorax?)
• Investigations
  • ABG (lactate, Hb)
  • CXR (haemothorax, mediastinal widening)
  • ECG (arrhythmia, ST changes)
  • TOE to assess contractility, valve failure (mitral / tricuspid)

Cardiac arrest:

• Notify surgeons
• Assemble team - two to begin to scrub, the rest to perform ALS
• Defer chest compressions; assess rhythm
  • Three "stacked shocks" for VF
    • If you can't control a shockable rhythm with three stacked shocks, you give amiodarone immediately 
  • Pacing (rate of 90, DDD) in asystole
  • If they are already paced and in PEA, turn off the pacing to "unmask" VF.
• Do not use full dose adrenaline (rather, give smaller doses)
• After five minutes of unsuccessful resuscitation the chest should be re-opened.