Organisation of the Medical Emergency Team (MET)

This chapter is directly relevant to Section 2.1.1 of the CICM Second Part General Exam Syllabus (First Edition), which specifically lists “Rapid Response Systems / Critical Care Outreach” as something an intensive care specialist should have a detailed understanding of. Clearly this issue has importance, as it has been dedicated the very second chapter of Oh's Manual ("Outreach"). On page 13 of the 7th edition, Welch and Subbe discuss the issue of "setting up an outreach service", a heading which seems relevant to Question 4 from the second paper of 2016. This SAQ asked the candidates to describe how they would set up a rapid response team. The "key steps in planning an RRS" seems like an important point-form table to reproduce here, with appropriate copyright-defensive paraphrasing (see below). Other major sources for this answer come from the helpful references made in Chapter 2, specifically to the (mainly British) series of RRS guidelines. 

The following sequence was suggested in the discussion section of Question 4 from the second paper of 2016:

• • Appointment of  senior staff to develop the service
  • Managerial and clincal staff
  • Imperative to include ward staff
  • This forms the "working party"
• Planning and research by appointed committee members
  • Epidemiology of critical illness in the hospital
    • i.e. where is the service going to be required most: ED, recovery suite, in the wards
  • Epidemiology of unexpected deaths in the hospital
  • Source and timing of unplanned ICU admissions
  • "what is the pattern of adverse events where harm can be attributed to the process of care?"
  • Consider in this process the content of patient and family complaints, the results of root cause analysis and morbidity/mortality data
  • Use these to design a system of criteria for triggering an RRS response, and a system of clearly defined referral/escalation protocols.
• Needs analysis of
  • Patient mix
  • Ward staff skill levels
  • Proposed hours of service operation
  • Expected demand based on hospital size and specialty services
  • Availability of training facilities
  • Equipment needs
  • Funding
• Audit process planning
  • Identify data for prospective collection
  • "It is essential that robust data are collected", they said.
  • Assess key practices against "specific, measurable standards"
  • Have discrete goals for audit and evaluation:
    • to identify areas where training is required
    • to identify sources of systematic error
    • to identify the changes in critical care workload
  • Specific prospectively collected data may include:
    • numbers of referrals
    • Referral details (date, time, reason for referral)
    • Patient details
    • Significant problems identified
    • Interventions performed
    • Patient outcome
• Rapid Response Service design
  • "At a minimum, the team should be capable of assessment, diagnosis, initiation of resuscitation, and rapid triage of the critically ill patient"
  • The key word is "multiprofessional". You want a multiprofessional team.
  • Composition of the team and skills of the members should represent the niche need identified by the planning committe.
  • Some basic  airway and vascular access skills are probably the expected minimum skill level
• A "pragmatic, staged implementation":
  • Education of ward staff regarding the use of the trigger criteria
  • Education of RRS members to compete their skill set
  • System for update and recredentialling of RRS-relevant skills (eg. annual ALS course)
  • Incremental spread of RRS, increasing the number of clinical areas covered, the number of team members, and the responsibilities of the team
• Regular scheduled audit and evaluation
  • Nominate independent auditors
  • Organise multidisciplinary audit meetings
  • At a smaller level, organised regular RRS debrief sessions
  • "Successful systems are based upon multiprofessional working, and effective communication education, data collection/audit, learning from errors, and planned improvement of whole systems of care."