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“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