Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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Christopher S Parshuram MBChB DPhil. staff physician Critical Care Program scientist and head outcomes research and healthcare delivery pillar of Child Health Evaluative Sciences Program. Hospital for Sick Children. director Centre for Safety Research. career scientist Ontario Ministry of Health and Long Term Care. associate professor Interdepartmental Division of Critical Care Medicine & Departments of Paediatrics & Health Policy, Man-agement and Evaluation. director of paediatric research Patient Safety Centre, Faculty of Medicine, Univeristy of Toronto, Canada.

MET MET MET MET MET MET RRTMET MET RRTMET RRTRRTRRTRRTMET RRTMET MET RRTMET MET RRTMET MET RRTMET MET RRTMET MET RRTMET MET RRTMET MET RRTMET MET RRTMET RRTRRTRRTMET RRTMET MET RRTMET RRTRRTMET RRTMET MET RRTMET RRTRRTMET RRTMET MET RRTMET MET RRTMET RRTMET RRTMET MET RRTMET RRTRRTRRT2009-10in review

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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named inventor Bedside PEWS patent pending (worldwide)owned by Hospital for Sick Children

2008-9 Member : Committee on Optimizing Graduate Medical Trainee (Resident)Hours to Improve Patient Safety

disclosures

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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section index1 lessons from MERIT2 new horizons & outcomes3 new horizons & outcome4 first take the plank from..5 education & deskilling6 mimicry

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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lessons from MERIT

Chen, J., K. Hillman, et al. (2009). “The impact of introducing medical emergency team system on the documentations of vital signs.” Resuscitation 80(1): 35-43.

Flabouris, A., J. Chen, et al. (2010). “Timing and interventions of emergency teams during the MERIT study.” Resuscitation 81(1): 25-30.

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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‘record of SBP, RR, HR 15-min before an event was absent in 3657 (62%) cases, incomplete in 1122 (19%) cases, & complete in 1120 (19%)’ Hilman 2005 Lancet

...........do MET-RRTeams alter documentation?

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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designcenters

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Chen 2009

MET + calling criteria 2m | 4m implement | 6m study any | all missing SBP HR RR < 15 min | >15min & <24 hr

secondary analysis of RCT data23 Australian hospitals calls MET/CAT, unexp ICU/death

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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results Chen 2009Control MET p

N events 1101 2291missing last 15 minutes

RR all events 89% 70% 0.003RR emerg call 94% 70% 0.008

>1 missing all events 91% 74% 0.002missing >15m < 24 hoursAll 3 missing emerg call 7% 5% <0.0001

SBP all events 8% 5% 0.005

after MET (the 6m study period)

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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50 p-values reported p<0.01 (p<0.001)for emergency teams calls only SBP @baseline better in controls (p<0.0001) SBP@implement worse in controls (p<0.0001) SBP@studyperiod worse in controls (p<0.0001)

the message from Lancet remains documentation can be improved

comments Chen 2009

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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what were the interventions provided by emergency team calls in MET and control hospitals ?

Flabouris

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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designcenters

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MET + criteria 6 months (‘study’ period)critical care interventions event outcome (CA, death, UICU )

secondary analysis of RCT data23 Australian hospitals2407 emergency team calls

Flabouris 2010

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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2376 calls / events 512 (21.5%) from control hospitals 1864 (78.5%) MET hospitals similar demographics & MET time at scene median IQR 22 (14-36) min longest for CA admitted to ICU 44.5 (30-54) min

5 had no ‘critical care intervention’

results

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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interventions % events CAT METward interventions 81% 73% 83%

airway 21.5% 41% 16% *breathing 99% 99% 99%

circulation 12% 23% 9% *CC drugs 26% 40% 21% *

transfer to ICU 19% 24% 18%

most calls 06-12, best CPA outcomes 12-24 * p <0.001

results

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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comment Flabouris 20107.4% events missing from analysis - duplicates (0.5%) / not mached to main database (4.9%) - inconsistent definitions in database (1.3%) ?5-7% EM calls missing VS

critical care interventions: included transfusion, sedatives, & ICU transfer

results reflect differences : CAT vs MET but high proportion of CCI in both - was MET too late ?

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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Vazquez (2009). Journal of Hospital Medicine 4(7): 449-452.

Kaplan (2009). J Trauma-Injury Infection & Critical Care 67(1): 173-8

Cabrini (2009). Intensive Care Medicine 35(2): 339-343.

Snyder (2009). American Surgeon 75(9): 834-838.

Iyengar (2009). Critical Care (London, England) 13(4): R126.

new horizons & outcomes

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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before & after study no mortality benefits‘significant improvements in EoL care’showing a concurrent control group is useful

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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Vazquez 2009

MET with CC8 months ending May 2006 & May 2007

comfort care orders | patient distressopiod administration | chaplain

retrospective before - after single 425 bed hospital end-of-life care initiated in ward

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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before RRT after RRT pN patients 197 197

comfort care orders 90 (47%) 133 (68%) 0.0001

pain score (0-10) 3.7 3.0 0.045

opiods given 84 (43%) 134 (68%) 0.0001

chaplain present 119 (60%) 142 (72%) 0.02

similar CA, UICU, hospital mortality

results Vazquez 2009

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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results Vasquez 2009RRT involved in 61 patients end-of-life care

before RRT No RRT EoL

p

N patients 197 136

comfort care orders 90 (46%) 87 (64%) 0.0001

pain score (0-10) 3.7 3.0 0.06

opiods given 84 (43%) 92 (67%) 0.0001

chaplain present 119 (60%) 74 (54.4%) 0.2

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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Table 2a RRT looked goodTable 2c benefits not direct RRT effect >> good use of concurrent control grouppotential indirect benefit of MET-RRT

perhaps as in many before and after studies things may get better with time

comment Vasquez 2009

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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System errorsduty hour effects shift-work / handover report from a formalized MET review process

kaplan

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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RRT with explicit criteria 15 months from Oct 2006appropriateness (vs. criteria)

preventability | time of call

prospective data retro. clinical review single hospital98 surgical RRT activations

Kaplan 2009

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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98 activations82 (84%) analysed 76 (93%) overnight 21-06:00 76 (93%) 48-72 hours post-operative 78 (95%) transferred to ICU / SSDU ..... only 46% required intubation

results Kaplan 2009

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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22 (27%) preventable ‘error’ physician 4 (5%) preventable ‘error’ registered nurse 35 (43%) judgement error 32 (39%) error of omission

46 (56%) potentially preventable

results Kaplan 2009

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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16% missing ‘incomplete’ data opaque and problematic classificationtiming of calls does not mean covering is bad all ‘appropriate’ | deterioration over hours | ? better recognition actually the same residents

was there a hidden agenda vs. duty hours ? new mechanism MET call M+M

comment Kaplan 2009

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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describing MET supervised acute NIV on hospital wards

heading one

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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ward-based NIV (2-24 hr > intermittent)

6 months (2005-2006)

intubation | death | complication

prospective case seriessingle, 1100 bed hospital 129 studied (25% of MET activity)

Cabrini 2009

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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129 patients 45 (34%) acute pulmonary oedema 34 (26%) COPD 30 (23%) pneumonia NIV for 4.7 days 3.1 MET visits for 24 hours CPAP most commonly 0.76 visits / day thereafter

results Cabrini 2009

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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10% (13) intubated (where?)

7 immediate failure (5 intubated)

12% (14) died (all with DNR)

5% nasal ulceration 2% excessive leak 2% malfunction

results Cabrini 2009

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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‘MET’ since 1980 - single anaesthetisttransient NIV for ~ 5 daysadvantages : ICU shortagesdisadvantages: complications urgent intubation ~10% relevance: ICU outside ICU. are outcomes good enough? (no)

comments Cabrini 2009

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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prospective adult surgical adminstrative data American College of Surgeons National Quality Improvement Program dataset

Snyder

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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24/7 MET(2RN +CC physician | calling criteria)

2 years (2006 April | 2007 June | 2008 June)

unplanned intubation | 30 d mortality

before & after MET single, 908 bed adult hospital2426 vascular or general surgery

Snyder 2009

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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pre-MET post-MET ptotal patients 1815 611

unplanned intubation 45 (2.5%) 19 (3.1%) 0.40

30 day mortality 43 (2.4%) 19 (3.1%) 0.32

of 61 intubated 26 (43%) diedsevere COPD in 19% of patients Relative Risk intubation 10

results Snyder 2009

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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1 negative before & after system level study 2 most unplanned intubations in the ICU 3 used prospective administrative data4 severe COPD single biggest risk5 simple analysis only (not MV / no risk adjustment) 6 potential prototype for future studies

comments

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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traditionally CA & unplanned ICU used as adverse event trigger in modern era how is the MET-RRT call?

Iyengar

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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none4 weeks in 2007adverse events | preventable AE

Iyengar 2009near prospectivesingle center, 487 bed hospital65 new MET calls

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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Adverse events (3 physician agreement) 23 (35%) had an adverse event 16 (24%) preventable adverse events 14 had therapeutic errors 3 immediately life threatening

Iyengar 2009

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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efficient process : very high conversion ratevs. CAES ~20% of screen positive had AE

if 35% of 40 MET calls / 1000 admit = pAE then 14 preventable AE /1000 admit

‘new’ reporting tool for quality improvements

comment Iyengar 2009

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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Cooper, S., R. Cant, et al. (2010).“Rating medical emergency teamwork performance: Development of the Team Emergency Assessment Measure (TEAM).” Resuscitation 81(4): 446-452.

first take the plank from..

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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usual ‘process problem’ is frontline identifica-tion of patient at risk to MET...what about the ME-Team performance?a new scale is developed

cooper

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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nanascale validity | internal consistencyinter-rater reliability

lit./expert develop | sim tested6 or 7 ‘independent’ expertssimulated resusc. 56 video + 15 live

Cooper 2010

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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17 scales identified 14 included57 items ‘collapsed’ 27 reviewed12 items all rated 0-4 2 leadership | 7 teamwork | 2 task management | 1 global

results Cooper 2010

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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items correlated with global rho 0.81 - 0.94

multiple raters mean ICC 0.60 for the items

test then re-test 6 months later kappa 0.53

15 realtime simulations (med students) scores clustered middle no reliability reported

12 items Cooper 2010

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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development too definative? items removed after ‘clinical’ evaluationimperfect reliability between raters & over timegood internal consistency the performance of MET is assumed if MET is to become more effective MET assessment tools are required

comment Cooper 2010

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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Sarani, B., S. Sonnad, et al. (2009). “Resident and RN perceptions of the impact of a medical emergency team on education and patient safety in an academic medical center.” Critical Care Medicine 37(12): 3091-3096.

Fuhrmann, L., A. Perner, et al. (2009). “The effect of multi-professional education on the recognition and outcome of patients at risk on general wards.” Resuscitation 80(12): 1357-1360.

education & deskilling

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

heading one

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is MET taking over and diluting education? Single center survey all felt MET improved pateint safety more involvment more positive response

........... but what about education and skills?

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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MET for 1 year 516 activations

2 months - weekly remindersresusc. educ | resusc. skillfreq. MET user | quality feedback

web-based survey single, academic hospitaleligible =154 residents | 497 RN

Sarani 2009

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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79% Resp. rate (67% residents 83% RN)

1 ‘resuscitation skill reduced’ residents neutral | RN moderate disagree (p<0.01)

2 ‘resuscitation education reduced’ moderate disagreement all | RN disagree more (p<0.01)

3 ‘MET lead feedback is useful’ neutral (surgical residents disagree moderately) RN mod. agree (p<0.01)

results Sarani 2009

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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1 reasonable response rate2 educational impact ‘neutral’3 advise ‘neutral / moderately un-useful’4 limitationsself-report of perceptions | single center | new MET

MET could & should have a positive effect > MET-Ed needs to be improved

comments Sarani 2009

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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‘sim-education’ is the solution to identification does a comprehensive course improve recognition?

Fuhrman

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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1 day multi-prof Hi-Fi Sim courseJune-July 2006 | 2007 Nov-Dec abnormal vital signs | staff aware of risk mortality 30 day & 180 day | Hosp. LOS

prospective before -aftersingle, 4 general wards 3 medical, 1 surgical

1583 pateints 690-pre | 873 post

Fuhrmann 2009

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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criteria Resp Rate <6 or >30 bpm Saturation <90% (any oxygen) Heart Rate <50 or >130 bpm Systolic BP <90 or >200 mmHg

~50 pateints measured ‘in the evening’ if abnornal .... then ‘aware / not aware’

abnormal Fuhrmann 2009

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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intervention applied less than intended 50% of medical staff | 70% of nursing staff vs. intended >75% of staff

abnormal signs in ~ 19%

results Fuhrmann 2009

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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results Fuhrmann 2009before Ed after-Ed p

N patients 690 873

N abnormal vital signs 129 (19%) 155 (18%) 0.64

N analysed 115 140

nurse aware 47 (41%) 54 (39%) 0.8

Mortality 30 day 14 (11%) 17 (11%) 1.0

Mortality 180 day 29 (23%) 28 (22%) 1.0

Hospital LOS 15 13 0.11

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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1 medical students measured vital signs is 2 hour training enough ? | inter-rater reliability? | gold standard

2 no action on abnormal signs ethical approval | meaning of abnormal?

3 ‘abnormal’ was common ~20% what happened next ?

4 what about sim-Ed is not real enough ? do not assume education helps

comment Fuhrmann 2009

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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Hookman, P. and J. S. Barkin (2009). “Clostridium difficile associated infection, diarrhea and colitis.” World Journal of Gastroenterology 15(13): 1554-1580.

The creation of a Rapid Response Team for in-hospital containment of C. difficile colitis.

........ is the highest form of respect

mimicry...

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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Ms. Elizabeth Ulreryk Academic Librarian Hospital for Sick Children

acknowledgement

Christopher S Parshuram Scientist Child Health Evaluative Sciences The Research Institute. Staff Physician Department of Critical Care Medicine Hospital for Sick Children Toronto. Faculty of Medicine Univerisity of Toronto Ontario Canada

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thank you

chris@sickkids.ca