benita a scott - the bays hospital - “getting the right fit“– a nurse-led rapid response...
DESCRIPTION
Benita A Scott presented this at the 2014 Managing the Deteriorating Patient Conference. The conference discussed the latest strategies to recognise and respond to the acute patient in clinical deterioration. You can find out more about next year's conference at http://bit.ly/1sjQubiTRANSCRIPT
“GETTING THE RIGHT FIT” A Nurse-Led Rapid Response System
Benita Scott – NUM High Dependency Unit
2nd Annual Managing the Deteriorating Patient Conference ,
22- 23 Sep 2014, Novotel Melbourne on Collins.
Overview of a Nurse-led RRS
• The context to the project.
• The challenges and barriers to creating “the right-fit”.
• How it was sold to key stakeholders.
• The outcomes achieved so far.
• What we have yet to achieve.
• Lessons learned.
www.thebays.com.au
2 KEY Messages
1. Tailored to fit, an effective system is a strong protective strategy against failure to rescue.
2. It can improve service delivery in both our approach & management of potential deterioration; and can benefit the human experience for patients & clinicians – as 2 key stakeholder groups.
www.thebays.com.au
THE CONTEXT – BACKGROUND TO THE RRS PROJECT
“Getting the Right Fit”
www.thebays.com.au
• The Bays Hospital Group Inc.
• Not-for-profit community-owned organisation
• The Mornington Peninsula
• Private sector + donations
• Encompassing Aged Care & Dialysis - Hastings
Mornington campus -
acute medical/surgical site
The Bays Hospital – The Facility
Historical Significance
Victorian Bush Nursing Association
King George 5th Memorial Bush Nursing Hospital, 1937 – 8 beds; nursery & labour room, & OT
• The Bays Hospital – as it looks today.
Today
106 beds, Medical/Surgical - multiple specialties; including obstetrics, HDU, 5 operating theatres. In a rapidly expanding community, we service an aging population, with complex health needs.
• Evolution of the project…
The Bays Hospital Rapid Response System (RRS).
In response to -
Increasingly complex patients & attention to
adverse events within the health care sector:
• Peri-Operative Care Working Party, 2011
- Focus: Improving patient outcomes.
• Quality project: Leadership Course
• Analysis of how nurses could incorporate the Working Party recommendations into practice – generalized to all patients.
Impetus For The RRS Project
When talking about how to improve clinical outcomes, we are talking about how to minimise risk & avoid potentially preventable adverse events.
A literature review revealed that – Barriers to recognising & responding to clinical
deterioration are universal.
• Sub-optimal communication & team-work; time-delays; & missed triggers have been highlighted as central to the issue of failure to rescue.
Universal significance
Coinciding with the development of Standard 9. • Accentuated the need for a formalised
approach. Standard 9… advocates having formal systems to facilitate
recognizing early indicators of deterioration, & rapid reporting systems based on escalation protocols.
Remember,
• Up to 84% of patients show signs of clinical deterioration 6-8 hrs preceding Cardiac arrest…
(Buist, Jarmolowski, Burton et al, 1999; Jones, DeVita Bellomo, 2011;
Revisiting Statistics…
Failure to rescue issues can be remedied by the
implementation of an effective RRS tailored specifically to organisational needs & resources.
Winters et al, 2013
Hypothesis
• Goal – improve service to prevent ‘failure to rescue’
• Enlist the necessary supports and investments to create the right fit between needs & resources.
• Utilise Standard 9 to sell it to Organisational stakeholders & drive the process.
• Achieve compliance with Standard 9. • Grow the RRS in response to lessons learned from
outcomes studied.
Identifying the Goals
Creating The Right Fit – Organisation-specific Needs & Resources
“Getting the Right Fit”: a nurse-led rapid response system.
www.thebays.com.au
‣ No resident Medical Officer on-site.
‣ Limited financial resources
Smaller outer-metropolitan, community-owned facility
‣ Limited time due to competing interests
RRT Leaders have an active patient assignment.
‣ The types of patients - older, complex needs, vulnerable to deterioration.
Specific Considerations
• Patient assessment skills must be impeccable.
• Strong reliance on clinical judgment.
• We needed to design processes & guidelines that were robust, & efficient.
• Attractive to nurses
• Positive impacts for nurses.
• User-friendly
• Workable
Implications For Nurses
• Nurse-led RRS - 1 clear choice
Aspirations
• To incorporate some of the principles of Critical Care outreach – – The HDU RN (Critical Care) already fulfilling an informal
role of consultation & review.
– Keen to attribute some acknowledgment of that role.
• And overall a more systematic and co-ordinated approach to managing the at-risk patient.
Model Selection
Afferent Limb - • Single parameter trigger - abnormal observation / concern • 3 tiered escalation protocol Efferent Limb - 2 categories of response Clinical Review – Snr RN, HDU RN &/or MO Emergency Call - RRT
• Defined governance structure • Delineation of responsibility • Defined communication processes • Underpinning educational program
Model Structure
‣ HDU CCRN - ALS Team Leader ‣ NUM/Snr RN In-charge wards x 2 ‣ Hospital Supervisor ‣ 2 x RN’s from each ward - of these 1 x RN providing cover for HDU ‣ Direct-care nurse
When able, during theatre operating/day time hrs – ‣ RN PACU/OT ‣ MO – Anaesthetist/VMO: decisions of care.
Rapid Response Team structure
The RRS functions as an extension of the health care team…
With continuous feedback to clinicians,
On-going direct patient engagement
- respectful of patients’ express wishes.
Patient, family, carer
Health care
Team
RRS
It Is Paramount
• Targeted strategies to various stakeholders groups to acquire their investment & support.
Selling it to the stakeholders
• Governance
• MO’s - MAC
• Education
• Clinical leaders
• Clinical workforce
• Allied health
• Patients = patients/family/carers
• Visitors
Stakeholder groups
• Tools – Policies, charts, forms etc
• Techniques – procedure, processes, The Trial, data collection, reporting, feedback
• Education –
• MO awareness,
• Intensive graded clinical education program
• Non-clinical staff - awareness
• Information to patients/family/carers
3 Key Facets of Project Delivery
Greatest resource
- Our People
The beating heart
of the Organisation
Specific Features
Maximise our existing resources
• Visiting Medical Officers (VMO) – Private Hospital Consultants.
• Valued customers.
- Experts; years of established practice; with broad across-campus responsibilities; large case-loads.
- Time constraints.
- Not present on site: unique challenge to acquire their united support.
Knowing the Stakeholder Groups
The Steering Committee engaged
• 2 x Consultant VMO – Physician, Anaesthetist
• To represent medical stakeholders
• Providing advice & feedback on core features –
• Parameters of Calling Criteria, MO response times & responsibilities
• Advocating to the greater medical fraternity
• -> Endorsement via Medical Advisory Committee
Medical Officer Engagement
• Overarching Policy – “RRS & Escalation of Care”.
Defining - Governance arrangements
- Roles/responsibilities
- Backup strategies – flow chart
- Delineation of MO responsibility : for when multiple MO are involved in care
- Evaluation & improvements systems
• “Observations & Patient Assessment Policy”
• Organisation- specific observations chart
• Escalation Protocol
• Clinical Review Form / SBAR tool
• Critical Incident Debrief Form
Specific features - Tools
• Strong clinical input – leaders from all areas.
• RRS Steering Committee Oct 2012.
• Enabling team decisions on tool design, &
• Implementation plan.
• The greatest challenge -
• Finding the time (competeing interests).
• Together, we worked to overcome the barriers
& resistance,
to sell the project to the greater
clinical workforce.
Clinical workforce investment
• A Organisation-specific Observations Chart was designed - derived from the ADDS Chart.
• Escalation protocol’s calling criteria & actions were tailored to meet needs & resources. – Sedation score instead of AVPU
– Added GCS
– Prescriptive triggers & actions.
• Dedicated Clinical Review Form
• Challenges – Efforts had to be targeted to overcome change-barriers.
– The defining & endorsement of MO Response times was strongly debated – settled on “MO will repond as practicable”.
Chart development - features
Adult Trigger & Response Chart
Adult Trigger & Response Chart
The Algorithm
Process, procedures, implementation plan
‣ The Clinical Trial commenced Aug 2013 – 31st Dec 2013 ‣ Acceptance of the changes required the hard sell around promoting a positive safety culture. ‣ Up-skilling & team-work. ‣ Standing agenda item at meetings – The RRS & The
National Standards. ‣ Quality management system-eQstats ‣ Recording of HDU R/v in Clinical Review Book. ‣ Engage the HDU staff to ‘believe’ in the system.
Techniques
• Awareness education • Deteriorating patient education • Based on the DETECT program – adapted. • Two tiered Program
• Snr Staff Education – Clinical responders • Ward staff – pathophysiology, recognition, concern, &
notifications • Total 44 sessions, in 5 body-systems modules • 102 staff attendees over a 10 wk period.
• ALS Education/training • ALS Level 11 – Assistants training.
Targeted Education Program
Educational Achievements
Current ALS provider No’s: ‣ 21 ALS providers. 88% compliant with annual Ax ‣ ALS Level 11 – 30 staff have attended & 6 with current competency. Further 6 new Level 11.
A strong achievement for Education!
What We Know So Far – Statistics & Human Factors Benefits
“Getting the Right Fit”: a nurse-led rapid response system.
www.thebays.com.au
• Results of an Observations Chart audit
• Some clinical performance indicator numbers – No of clinical reviews – HDU
– No of int up-transfers
– No of ext up- transfers - emergency
– No of Code Blue & Cardiac/respiratory Arrest Calls
– Mortality without DNR after arrest since inception
• Anecdotal evidence about staff
perceptions
What We Know So Far
Observations Charts Audits
• Of the 23% of the sample with abnormal observations documented, only
• 41% had care escalated as per Protocol.
• 57% had observations monitored at the frequency specified in monitoring plan.
• 73% had observations at the minimum frequency of 8 hourly in the previous 24 hrs.
• 87% had core observations documented as instructed.
• “Repeated education & feedback to the workforce can increase RRS dose rates & increase positive impact” Winters, Weaver et al, 2013.
Education - An Ongoing Need
Month
HDU R/V
Pt days
Sep 13 10 2147
Oct 13 5 2181
Nov 13 9 2067
Dec 13 10 1799
Jan 14 6 1680
Feb 14 1 1902
Mar 14 4 2008
Apr 14 3 1875
May 14 3 1910
June 14 9 1893
July 14 2 1796
Aug 14 6 2055
Total 68 23,313
No of HDU Reviews
HDU RV - Average of 40 mins per call. Av 5.6 calls/m Av 2.9/1000 bed days c/f Cabrini 400+ bed+ICU 1.74 MET/1000 bed days. (Bucknell 2010, Monash Uni, + ICU) HDU RV is the earliest intervention for potentially serious adverse event
• Pharmacy plan precludes standing orders.
• ALS providers can initiate 1st line drugs.
• Advise Pathology + electrolyte replacement
• ECG & rhythm interpretation
• IV access & fluid management
• Oxygen therapy & respiratory support - HFT, BiPAP/CPAP
• Haemodynamic monitoring
• ABG analysis
• Recommend medication orders
Nurse-initiated Interventions
HDU Initiated Strategies
Authority to recommend->
• Cardiac monitoring – telemetry or hardwire
• Internal Up-transfer
• Emergency Ext Up-transfer to tertiary facility
Vast majority of cases
• Stabilisation in patient room
• Stabilisation in HDU -> RTW within 1– 2 days.
At times
• Encourages decisions about resuscitation status.
Outcomes from HDU Review / RRT Calls
Code Blue Int up t/f Ext Upt/f RIP NoDNR
Bed Days
6 m Pre RRS Jan-July 2013
2 32 23 2 10,047
Trial Aug-Dec 13
6 (x3 Nov)
42 18 2 + 1 (x1 pall Post CA)
12,282
Jan 2014 RRS Fully Operational
6 m PostRRS Jan-July 2014
4 30 10 1+ 1 (x1 pall Post CA)
13,064
totals 12 104 51 5 35,393
No RRT Code Blue Em Calls Pre & Post RRS
Clinical Indicator Numbers
Dose rate of Code Blue RRT Calls
• 0.19/1000 bed days 6 m pre RRS
• 0.48/1000 bed days during RRS Trial
• 0.30/1000 bed days 6 m post RRS implementation
Unexpected deaths, No DNR
• 4 successful resuscitations post CA – survival to discharge = 2: Trial Stage
• 3 successful resuscitations post CA – survival to discharge =2: Post RRT inception
• Clinical indicators – are of controversial usefulness
The Bays data –
• Statistically low significance, small sample
• Lower-acuity facility – limited comparability
• changing pt demographic
• Infancy of implementation.
∎EARLY DAYS
- Mitchell & colleagues 2014, report that it may be many years before statistical benefits are evident
What We Know So Far
↓ cardiac arrests ↓ unexpected deaths ↓ un-planned HDU/ICU admissions & LOS ↓ un-planned returns to OT ↓ LOS
↓ healthcare costs
Importantly,
Secondary benefits are of noteworthy validity in terms of overall patient safety
& stakeholder benefits.
Statistics vs Collateral Benefits
– Effective tools
– Education & up-skilling
– Clinical workforce engagement
– Co-ordinated team response
– Clinical reviews
– Patient Assessment
– Nurse-driven interventions
– Communication & team-work
– Management of Em calls/Arrest
– Code Deconstruction & Debrief
What We Are Doing Well
Strengthened medical/nursing relationship.
• Greater understanding of roles. • Greater confidence in the clinical workforce. • Mutual respect. • Improved communication. • Removes some of the burden of calls by averting
deterioration & utilising the role of Clinical Review.
Secondary benefits of RRS
A patient who witnessed a recent RRT call to a CA in HDU wrote to DON:
praised the “responsiveness, team-work, professionalism & sensitivity of the Team.
An Anaesthetist who recently co-led a RRT resuscitation praised the team:
“it was the best run code [she].. had ever attended”.
Anecdotal Evidence
• Code Blue Call • Post Hernia Repair • -> VF Arrest • -> DCR X 5 • ROSC -> FH by MICA • Coronary stenting • Returned to The Bays 1 wk later to thank the staff
& praise the team efforts & interactivity.
• Incident Non-conformance Report
Effective RRS in action
RRS Satisfaction survey
Majority of respondents
Agree or strongly agree
That the RRS:
• “Provides an effective support system for nurses”
• “Enhances a positive safety culture”
• “Improves team work”
• “Empowers nurses in recognition & response”
• “Provides an opportunity for teaching & up-skilling”; &
• “When effective, provides ↑job satisfaction”.
One respondent to the statement
• “I have total confidence in the RRT responders”
Wrote next to her √ in an undecided …
“who are they???”
The web-based education system – 2013
Enables clinical staff to access all of the RRS education, theoretical ALS/BLS, scenario-based case studies 24/7. Mandatory education.
How do we continue to reach all of the target audience?
• Escalation due to patient, family, carer or other staff member concern is yet to be fully realised.
• Independent method for escalation for patient/family/carers.
• Seeking consumer representation into the patient/family/carer escalation initiative.
• Further developments in Policy & Procedures related to advance care-directives, treatment-limiting decisions & end-of-life decision-making.
Still Required – Developmental Actions
Vigilant & careful, on-going surveillance is
• A fundamental requirement; central to the success of the system.
• A significant challenge.
Coupled with
• Staying on top of the culture in the workplace by maintaining the quality/safety focus – requiring on-going investment from all levels of the Organisation.
On-going Surveillance
• Long term impacts on Cardiopulmonary arrest numbers.
• Survival to discharge.
- improved data collection methods needed.
• Impact on Mortality/CA of deteriorating signs – retrospective auditing.
- Newly established Code Blue Committee,
(1st meeting Sep 14) will review all Code Blue calls, collect data, linking it to the monthly mortality report.
Still Yet To Learn
• 26 June, 2014 ISO Accreditation measured against all 10 National Standards –
• All 18 Core actions were satisfactorily met
• 5 developmental actions were sited as having significant work underway.
• Congratulated by the surveyor, particularly for the work achieved for Standard 9.
In Summation
Recapping
• A nurse-led RRS, when well-fitted to meet the specific needs & resources of an organisation, is a valuable protective strategy against failure to rescue.
• An effective RRS has revealed other meaningful gains for
clinicians - such as up-skilling, improved team-work & communication and improved early intervention, & may ultimately improve the quality and safety experience for both patients and clinical stakeholders.
Thank you
www.thebays.com.au
• Australian Commission on Safety and Quality in Health Care, National Consensus Statement: Essential elements for recognsing and responding to clinical deterioration, Sydney, ASQHSC, 2010.
• Buist M, Jarmoloski E, Burton R, Bernard S, Waxman B, Anderson J. Recognising clinical instability in hospital patients before cardiac arrest or unplanned admission to intensive care. Med J Aust. 1999; 171: 22-25.
• Enhancing Perioperative Care in the Private Hospitals on the Mornington Peninsula, Vic, A Working Party Document, 2011.
• Gerdik C, Vallish RO, Miles SA, Wludyka PS, & Panni MK. Successful implementation of a family & patient rapid response team in an adult level 1 trauma centre. Resuscitation 2010; 81 (12); 1676 – 1681.
• Jones D, DeVita M, Belloma R. Rapid response teams, N Engl J Med 2011; 365: 139-146.
• Kohn LT, Corrigan JM, Donaldson MS. To Err is Human: Building a Safer Health System. Committee on Quality of Health Care in America, Institute of Medicine, Washington, DC: National Academy Press; 2000.
• MERIT study investigators, Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. The Lancet 2005; 365 (9477); 2091- 2097.
• Mitchell A, Schatz, M & Francis H. Designing a critical care nurse-led rapid response team using only available resources: 6 years later. Critical Care Nurse June 2014; 34 (3); 41-56.
• Winters B, Weaver S, Pfoh E, Yang T, Pham J, Dy S. Rapid response systems as a patient safety strategy: a systematic review. Ann Intern Medicine 2013 Mar; 158 (5 Pt 2); 417 – 25..
References