situational awareness - ubc alumni...
TRANSCRIPT
Situational Awareness
The role of the physician in a team
approach to recognition and support for patients at risk of
deterioration 2013
Facts about deteriorating children at BCCH & SHHC
• Some children get sicker • Most are identified and their risks mitigated • But… sometimes we don’t and as a result we
have had episodes of patient harm related to one or more system failures resulting in: –Delayed recognition of deteriorating patient status –Failure to notify most appropriate healthcare team member(s) –Delay in response by most appropriate healthcare team member
Contributing factors to patient harm with deteriorating children
• A review of our existing processes indicated we had unclear processes for:
• Recognition of the subtleties of clinical deterioration
• Inconsistent use of standardized language for communicating patient concerns (SBAR)
• No standard process (across BCCH) for notification of healthcare team members
• Created a recognition and notification process in 2009 • Great results based on a 60% reduction in critical events • 2011 had an increase in critical events and… • Through a 2012 review found out:
• It wasn’t being followed by nurses as it was extra steps in documentation
• It held little value to RNs for their patients • Most surgeons, surgical trainees and sub specialty pediatricians didn’t
know what it was
… AND we were still having recognition, notification and response issues for deteriorating children
Improving our processes
Situational Awareness of At Risk Patient
Our hope is to identify patients sooner rather than later in their illness trajectory.
Improving our process for patients at risk of deterioration
Redesigned process to include expectations for the following 3 steps:
1. Identification of patients at risk of deterioration 2. Mitigation of the risk 3. Escalation to a higher level of care if mitigation
unsuccessful
Identify – Mitigate- Escalate
STEP 1: Identification of patients at “immediate” risk
Enhanced identification of at risk patient through: • Adoption of Cincinnati Children’s situational awareness
model: • 5 categories to identify at risk children (See next slide)
• Streamlined age specific patient flowsheets with: • Pediatric Early Warning Score (PEWS) with coloured out of
norm sections • Neuro-VS flowsheet incorporated
• Standardized check-in processes between charge nurse and RNs
• Visual cue for care providers of patients deemed at risk (Room number on white board colored in red)
Situational awareness
What nurses are basing their “at risk” assessment on…
PEWS
• PEWS is an international process for identifying patients who are at risk of deterioration
• Most focus on CVS and Respiratory with basic neurological assessment
• BCCH adopted the National Health Services (UK) PEWS score
• The PEWS score is a maximum of 6 points All patients are given 1 point for each of the following:
• Patient/family/healthcare provider concern • Severe/moderate respiratory distress • On oxygen • Decreased level of consciousness • Respiratory rate above or below age parameters • Heart rate above or below age parameters
Physicians & PEWS
GOAL: To understand the PEWS scoring process and its implications for your patient
Look for # of check marks and VS trend lines of ticks in shaded areas. Is this normal for this patient? What could be contributing to this presentation? How does this compare to the past few hours?
STEP 2: Mitigation of risk factors
• RN reports to charge nurse at risk patients • Charge nurse explores actions for mitigation with RN
and/or deems necessity to inform medical or surgical physician of patient status • Depending on status of patient charge nurse may escalate
care for immediate intervention • Physician/surgeon or trainee delegate is notified of the
situation, background, assessment and request (SBAR) for care for at risk patient
• *Physician reviews patient in a timely manner (see next slide for PEWS recommendations); determines treatment/diagnostics and evaluates patient responses
* Note: Not all patient concerns require a visual assessment but if a nurse requests your physical presence it usually means she/he is worried and something is changing for your patient.
PEWS Score Actions
0-1
2
3
4
5-6
Proposed PEWS Score Responses
Nurse in Charge & Resident/Fellow MUST come to assess patient & NOTIFY
attending Nurse in Charge & Attending Physician
MUST assess patient within 1 hour
Nurse in Charge & Resident/Fellow MUST Review
Nurse in Charge MUST Review
RN continues monitoring
STEP 2: Mitigation of risk factors
What happens if I can’t get to my patient because I… …am in the OR/clinic?… am at home?...am at offsite clinical?
• Know your program’s back-up service plan for patient coverage during “business hours” (Mon to Fri from approximately 0700-1800 hrs).
• After hours for CTU patients: • Call CTU senior if unable to get there and request a consult and management until
you arrive. Their availability is dependent on their own patient loads and acuity at that time.
• After hours for non-CTU patients: • Mon to Fri (non-stats), there is a First Responder program where sub-specialty
medical fellows are available to support care until you are able to get to your patient. They are a bridge in care and not replacements for your care!
• Weekends & Stats. You can call the CTU senior and request they assess your patient until you can get there. Their availability is dependent on their own patient loads and acuity at that time.
STEP 3: Escalation of care for patients at risk
Care should be escalated to the next level of care provider (e.g., resident trainee to fellow to attending) or care service (e.g., CTU to PICU Consult) if : • the patient does not improve with treatment • the patient continues to deteriorate • you are unfamiliar with patient’s condition &/or treatment
required • do not have the resources available (human or equipment)
to support the patient’s needs
CODE BLUE At BCCH a Code Blue is called by dialing 33.
State “Code Blue, Children’s Hospital, Unit & Room number” The code team has 2 Peds Residents, PICU resident, RT, & 2 PICU nurses.
