Early Rescue: Improving Transitions in Patient Care “Building Blocks in British Columbia” PANBC...
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Transcript of Early Rescue: Improving Transitions in Patient Care “Building Blocks in British Columbia” PANBC...
Early Rescue:Improving Transitions in Patient Care
“Building Blocks in British Columbia”PANBC
October 29th, 2011
Acknowledgements
• SHAIPE faculty– Surgical Healthcare Associated Infection Prevention Excellence
• Kim MacFarlane, CNS Critical Care• Lorna Jensen, CNE PACU, RCH• Jennifer Roy, UBC MSN student
Goals for today
• Failure to rescue literature• Early rescue movement
– Transitions in care
• Implications for nursing practice
So, what’s the problem ?
• Patients have been harmed or died as a result of failure to rescue
• Communication breakdown is responsible a lot of the time
• Transitions in care is a high risk time period for patients
Christian’s Story
Failure to Rescue
• In 2004, the IHI, along with the Joint Commission, identified FTR as the #1 contributor to hospital deaths
• Top 3 factors in Failure to Rescue– Failure to recognize early signs of deterioration – Failure to assess/plan– Failure to communicate
• High risk period: Transfer of Care
Guidelines for Practice
The Canadian Adverse Events Study – Drs G. Ross Baker, Peter G. Norton
• the first Canadian study (2004) to provide a national estimate of the incidence of AEs across a range of hospitals
• Findings on the incidence of adverse events among hospital patients:– almost 2.5 million annual hospital
admissions in Canada– 185 000 are associated with an AE and
close to 70 000 of– these are potentially preventable.
So How Do We Fix the Problem?
Early Rescue• Identifying risk and
recognizing early signs of deterioration
• Serial assessments, planning
• Taking action, escalating care – communicating the situation
Critical Thinking
Tools to Support Practice
• Decision-making support– Mews– Code blue review
• Clinical support tools– Algorithms
• Communication tools– SBAR
• Policies– MRP
Critical Care Reviews
PART 2: Comprehensive Code Blue Review Tool
For Quality Improvement Purposes
Only
PHN:____________________________________ Gender: Female Male
Age:______yrs Unit:_______ Event Date:_______________ Time:__________hr Review Date:______________ Time:__________hrs
A) REASON FOR REVIEW: See attached - PART 1: Initial Screening Tool for Code Blue Quality Review Additional Information: B) TYPE OF EMERGENT/ARREST SITUATION: i) Emergent Situation (explain): ii) Full Arrest (check presenting finding):
VF/pulseless VT PEA Asystole Bradycardia SVT VT with pulse Respiratory
Was this a witnessed arrest: Yes No C) INITIAL PATIENT OUTCOME: Immediately following the arrest: Survived Deceased If survived, post-arrest location and code status: Critical Care Unit Remains on Nursing Unit Other (state):____________________ Full Code DNR Other (state):____________________ D) CURRENT PATIENT OUTCOME: Remains in hospital Deceased (date/time): ________________________ E) FAMILY CONSIDERATIONS: Have family members requested follow-up information/meeting, or expressed concerns about care:
Yes (describe)
No
Unknown
Identifying High Risk Patients:Risk Factors/Predisposition
• Extremes of age- <1yr and >65yrs
• Surgical or invasive procedures
• Use of broad spectrum antibiotics
• Chronic Illness – DM, CRF, liver disease, heart disease
• Indwelling tubes (foley catheter) and lines (CVC)
• Genetic predisposition septic shock
• Compromised immune status – malnutrition, HIV, cytoxic/ immunosuppressive drugs, alcoholism, malignant neoplasms, solid-organ transplantation
• Primary infections (e.g. pneumonia, urinary tract, cholecystitis, peritonitis)
Kim MacFarlane, FH CNS, Critical Care, May 2011
Principles of Assessments & Planning
• Serial assessments are the foundation for recognition of change
• Trending is critical – connecting the dots• Continuous planning of next steps for patient care
Escalation of Care
Key Steps in the process….• Take action
1. “Takes action (taking action includes advocacy) to promote the provision of safe, appropriate and ethical care to clients (see Glossary for definition of the term “client”)”.
CRNBC Standards of Practice: Responsibility & Accountability
• Determine MRP• Communicate the findings• Document
Is this Patient in the Right Place to get the Right Care at the Right Time?
Do RN Assessments
& Interventions
No response within 10 minutes, repeat page
ANDCall RN in Charge from
another unit for input
Unable to Reach GP
or Specialist
No response within 10 minutes
of 2nd page to MRP
Instability Progressing
Critical Illness
Beginning?
No Improvement
or Worsening
Slight Instability
Monitor closely(q 1 – 2 hours)
Repeat MEWS/Monitoring vital signs
at appropriate intervals
Vital Signs
No improvement or worsening at any timeContact MD or Call a Code if required
Escalation of Care
Get Help Now!
NOTIFYPrepareSBAR
Get Care Level from DNR sheet
Do RN Assessments
& Interventions
LPNs – Inform RN now
MRP Responds within 10 minutesSees pt. within 30
minutes
Right PlaceWith PCCIdentified,
Implemented Documented
Care Plan
Right Care
Call Family to advise
Is Higher Level of Care Needed?
∙ Increased Monitoring?∙ Specialized Equipment?∙ Specialized Meds/Tx?
Who can help problem solve?
∙ PCC, Shift Coordinator∙ RN in Charge, Buddy Unit∙ Consider ICU or ER staff
- Admin on Call
Notify PCC/Charge RN/Site Leader/
Shift Coordinator
Is Code Blue required?
Is RT required?
(Information re Medical –
On- Call to be inserted here)
If no Shift Coordinator, call 898994 Identify your Site, Ask them to Page Administrator on Call
Provide your name and ward’s direct phone number
Cal
l Fam
ily w
ith
Pla
n o
f C
are
Still worried about your
patient?
PCC/Charge RN/Site Leader/Shift Coordinator
Determine if/when to call MRP
Is Code Blue required?
Is RT required?
Are appropriate monitoring
and interventions
available?
Notify MRP
What am I seeing?
What don’t I like?
Patient does not seem
to be doing well
How can I get an MD?
ME
WS
S
core
: 1-
2M
EW
S
Sco
re:
3M
EW
S S
co
re:
≥4 o
r in
cre
ases
b
y 2
in A
NY
Cat
eg
ory
Is Code Blue required?
Is RT required?
Arr
ange
tran
sfer
to
anot
her
unit
or h
ighe
r le
vel o
f car
e pr
n
DRAFT MEWS/Escalation of Care Algorithm v 4.5 October 2010
A
B
C
D
E
F
Communication tools….
• Huddles• SBAR• Handover
Handover
• A fundamental element of safe
patient care
• Development of standard procedures is 1 of the top 5 priorities of the World Health Organization's
• High risk period of time (Roughton & Severs, 1996)
Joint Commission - 2006
PrecautionsExplain what’s expected to be
different or unusual about
the pt
ProblemsExplain what’s
different or unusual about
this pt
PurposeProvide a
rationale for the care plan
PlanDiagnosis,
treatment plan, next steps
PatientName, sex,
age, identifiers,location
The Five P’s
Clinical Handover – Key FactsClinical handover is a high risk scenario for patient safety. Dangers include
discontinuity of care, adverse events and legal claims of malpractice (Wong et al, 2008)
Survey of Australian doctors revealed that 95% believed that there were no formal or set procedures for handover (Bomba and Praska, 2005)
An Australian study of emergency department handover found that in 15.4% of cases, not all required information was transferred, resulting in adverse events (Ye et al, 2007)
Survey of junior doctors in the UK discovered that 83% believe that handover processes were poor. Written handover was rarely received, accounting for only 6% of all handovers (Roughton and Severs, 1996)
A detailed analysis of nursing handover revealed that some handovers promote confusion and did not assist in patient care (Sexton et al, 2004)
Handover is among the most common cause of malpractice claims in the USA, especially among trainees, accounting for 20% of cases (Singh et al, 2007)
A survey among trainees in the USA suggested that 15% of adverse events, errors or near misses involved handover (Jagsi et al, 2005)
Handover
• Joint Commission identified communication was a key factor in 70% of all sentinel events 1
• 94% of nurses identified different nurses give handover in different ways 2
• 82% of nurses agreed a standardized handover was needed
• 85% felt there was need for improvement in the way nurses communicate
1 . The Joint Commission on Accreditation of Health care organizations. Sentinel event statistics (2004). http://www.jointcommission.org/Sentinel !Events/Statistics
2. Clarke et al (2009). The PACT Project: Improving communication at handover. The Medical Journal of Australia, 190 (11), S125-127
Handover
• Physicians identified1 :– The need for more detailed information– The need for nurses to specifically identify the
issue/problem– The importance of nurses having the information at hand
when reporting– The need to know whether standard procedures and
protocols were carried out
1. Clarke et al (2009). The PACT Project: Improving communication at handover. The Medical Journal of Australia, 190 (11), S125-127
Types of Handover
• Nurse shift change• Physician transferring responsibility to another
practitioner• Physician on-call responsibility• Temporary relief coverage i.e. coverage of breaks• Anaesthesiologist report to recovery room nurse• Nursing & physician handover from ER to unit• Handover from in-patient to host hospital,
community, GP
Nurse Handover
• Unique to each unit
• Written, paper
• Verbal: nurse to nurse, audio report, group reports
• Hybrids– At the bedside– Paper and verbal report– time overlap
The most effective handovers include an opportunity for questions
Barriers to Handover
• Lack of education• Resistance of Change• Lack of devoted time to handover• Problems with the physical setting i.e.
confidentiality, noise, disruption• Language barriers between clinicians• Failures in modes of communication i.e. fax
machines, lost notes• Lack of research on best-practices for handover• Lack of financial resources for implementation of
standardized practices
Tips for Effective Communication
• Allow for face-to-face communication whenever possible• Ensure 2 way communication• Allow as much time as possible• Use both verbal and written communication• Conduct handoffs at the patient’s bedside whenever
possible• Involve staff in the development of handoff standards• Use communication techniques i.e. SBAR• Clearly outline the the transfer of responsibility• Use technology to streamline templates & processes• Monitor, evaluate, gain feedback from the staff
Peri-Operative Guidelines for Transfer of Patient Care
• The receiving care provider will be notified of the impending transfer
• The receiving care provider will be given a complete report before or at the time of transfer
• Opportunity is provided for questioning between the giver and receiver of patient
ASPAN 2010-12 pg 89
Fraser Health Surgical Program PeriAnesthesia Discharge/Transfer of Care
• Discharge Summary documented on PACU record
• All reports are verbal and written/documented– Telephone or in person– Receiver has an opportunity to ask questions
• Communication tool developed for the receiving units– Assist RN with communication when receiving phone reports– Can be used a worksheet – Notepad; quick & placed by the phones for ease of use
Teamwork Makes it all Work!
• Communication
• Mentorship
• Drawing upon resources– Unit, site leaders– Experienced nurses– Clinical experts
• Collegiality
Questions to Ponder
• What tools or processes would support your unit in identifying early signs of deterioration of patients?
• What guidelines would support your team when responding to a deteriorating patient?
• What are process/tools are in place in your environment for patient handover?
• What tools would improve communication processes for patients coming into your care or transferring to another unit?
So what are the Implications for Nursing Practice?
• Nurses are well positioned to prevent adverse events, failure to rescue
• Standardizing nursing assessment, planning, and communication process & tools improves patient care and patient outcomes
• The decisions and actions of nurses save lives
Resources & References
Patient safety Institute: http://www.patientsafetyinstitute.ca/English/Pages/default.aspx
National Institutes of Health: http://www.iom.edu/
Canadian Adverse Events Study: http://www.cmaj.ca/cgi/content/abstract/170/11/1678
You Tube Huddles:
• Family Medicine (6:62 mins)
• http://www.youtube.com/watch?v=5YC7NxK9vlY
• Planned Care Huddles (3:26 mins)
• http://www.youtube.com/watch?v=Wttxm7jAnb4
• Plastic Surgery Daily huddles (4:16 min)
• http://www.youtube.com/watch?v=dfAnpGgsQbA