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![Page 1: Just-in-time Training: Building an Interprofessional Learning System at the Bedside of Our Sickest Patients City-Wide Grand Rounds 5 th Annual Excellence.](https://reader035.fdocuments.us/reader035/viewer/2022062717/56649e245503460f94b12c6a/html5/thumbnails/1.jpg)
Just-in-time Training: Building an Interprofessional Learning System at the Bedside of Our Sickest Patients
City-Wide Grand Rounds5th Annual Excellence in Clinical TeachingGrand Rapids Medical Education Partners
September 22nd, 2011Patrick Brady, MD, MSc
General and Community Pediatrics and Hospital Medicine andJames M. Anderson Center for Health Systems Excellence
Cincinnati Children’s Hospital Medical Center
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Disclosures
• The author has no relevant financial relationships to disclose or conflicts of interest to resolve
• This presentation will not involve discussion of unapproved or off-label, experimental or investigational use of commercial products or devices
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Objectives
• Describe using “situation awareness” to recognize patient deterioration
• Discuss an interprofessional model for identifying and mitigating patient risk
• Investigate opportunities and challenges in role-modeling and teaching this learning system
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Just-in-time learning
• Just-in-time learning occurs at moment when needed
• Contrasted with just-in-case learning that often features topics (like how to run a code) that learners are unlikely to need on any given shift or day
• Just-in-time learning has advantages of highly motivated learners
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Clinical Case
5 year old patient is hospitalized with gastroenteritis:
• After initial improvement bedside nurse notes he has worsening diarrhea, an elevated HR and his parents note he is “not acting right”
• First two calls to intern are not returned• On third call intern notes that he “was just
down there” and “the kid was fine”
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• Night shift begins– Shift change is interrupted several times– Family concerns come up briefly but is noted can
“wait until rounds” in morning
• Parents note he is “much worse” than in ED– But patient care tech forgets to convey this to
nurse
• Heart rate begins to rise again– New nurse notes this was same value from earlier
when kid was “just fine”
Clinical Case, continued
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Rounds the next day
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Or… CODE occurs
• Mortality of outside ICU code in pediatrics is 50-66%
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High Reliability Organizations (HROs)
• Deal with constant risk yet have exemplary safety records
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Core Characteristics of HROs
• Preoccupation with Failure
- Encourage reporting of small errors and convene to address
• Reluctance to Simplify Interpretations
- Encourage diversity in experience, perspective, opinion
• Commitment to Resilience
- “errors don’t disable”
• Deference to Expertise
- Decision making deferred to workers with the most
knowledge and expertise not the highest rank
• Sensitivity to Operations
- Find loopholes in system’s defenses, barriers and
safeguards on the frontline. Maintain Situation Awareness
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Failure to Rescue
• Failure to rescue from a complication of an underlying illness or a complication of medical care
• Reflects– the quality of monitoring and/or – the effectiveness of actions taken once early
complications are recognized
• Rapid response systems and early warning scores are most common interventions
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Failure to Rescue
• Outcomes after arrest or code outside of Intensive Care Unit are dismal– 50-67% mortality in pediatrics– 70-90% mortality among adults– Substantial neurologic morbidity among survivors
• Evidence that vital sign abnormalities occur before arrests in majority of cases but are:– Not fully recognized and/or– Not sufficiently acted on
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• Multicenter, risk-adjusted study using data from >80,000 patients in ACS National Quality Improvement Program
• Included patients that had undergone inpatient general or vascular surgery
• Stratified into low-mortality and high-mortality hospitals
• Looked at rates of complications in each
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Results
p=NS
p=NS
P<0.001
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Mortality rate Cardiac arrest rate
AdultsNo significant reduction
Children21% reduction, significant
Pooled
Arch Intern Med. 2010;170(1):18-26
better worse better worse
Pooled
Adults34% reduction
Children38% reduction
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Mortality rate Cardiac arrest rate
AdultsNo significant reduction
Children21% reduction, significant
Pooled
Arch Intern Med. 2010;170(1):18-26
better worse better worse
Pooled
Adults34% reduction
Children38% reduction
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CPR
Medical Emergency
Team
Early Warning
Score
Systematic identification & Mitigation
Time
Clinicalstatus
Effort needed to return to recovery
Admission Assessment
Anticipated Recovery
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What is Situation Awareness?
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Situation Awareness
3. Anticipate“Projection”
Decide
2. Recognize &Understand
“Comprehension”
Act
1. Gather Information“Perception”
↑HR, ↑diarrhea,parent concern
Recognize dehydration
Progress toshock if untreated
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Situation Awareness in Other Industries
• Situation awareness failures have been studied in other high-risk, complex organizations:– Including military, aviation, and nuclear power
• 88% of commercial aviation accidents found to be due to poor situation awareness
• Poor SA found to be leading contributor to human error in review of military aviation mishaps (Hartel, Smith, Prince, 1991)
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Situation Awareness in Medicine
• In trauma and rescucitation simulations, increased SA associated with:– Level of experience– Achievement of objectives– For individuals and teams
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Situation Awareness
3. Anticipate“Projection”
Decide
1. Gather Information“Perception”
2. Recognize &Understand
“Comprehension”
Act
Miss ImportantInformation
Miss Context asInfo Not Integrated
WrongPrediction
WrongDecision!
Threats to SA
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Situation Awareness
3. Anticipate“Projection”
Decide
1. Gather Information“Perception”
2. Recognize &Understand
“Comprehension”
Act
Miss ImportantInformation
Systematically Identify High Risk Patients
Miss Context asInfo Not Integrated
Communicate EachRisk to Watchstander
WrongPrediction
Predict/Mitigate/Escalate as Team
WrongDecision!
RightDecision!
Potential Solutions
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Eliminate:•Serious Safety Events (SSEs) related to SA failures
– SSEs defined as serious harm or death associated with deviation from standard of care
•Codes outside the ICU related to SA failures•UNSAFE transfers (UNrecognized Situation Awareness Failure Events)
– Patient transferred from unit to ICU and within 1 hour is:• Intubated• Placed on inotropes OR• Given 3 or more fluid boluses
Our Aims:
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Why Target UNSAFE transfers?
• Adult and pediatric studies show these patients are at increased risk for mortality– Children admitted from hospital floor vs. ER or OR 65%
more likely to die
• ~1 patient per day is transferred from unit to ICU• On average, every 5 days a child is transferred that
met criteria for UNSAFE transfer
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UNSAFE Transfers and Mortality
• Preliminary analysis at CCHMC has shown a 16% mortality for UNSAFE transfers
• ~8-fold higher than 2.1% all-PICU mortality over the same time period
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Eliminate SSEson inpatients related to SA.
codes outside ofICU related to SA, and UNSAFE transfers
No unrecognizedclinical
deterioration
ImprovedSituation
Awareness
Escalate riskthat is not
fully addressed
Identify patients at risk
Predict courseof most at
risk patients
Mitigate risk on unit
Systematically & Reliably
Learn from eachevent
Key Driver Diagram
Aim
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Family concerns
High risk therapies
Watcher
Early Warning Score ≥5
Communication concern
Concerns identified from chart reviewFamily concern about patient safety
High risk or unfamiliar therapies (insulin on surgery floor)
Elevated Pediatric Early Warning Score (PEWS)
Clinician gut feeling patient at risk (e.g., patient is less interactive)
Communication concern judged to impact patient safety (often involving multiple medical teams)
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Bedside nurse
Intern
Family concerns
High risk therapies
Watcher
Early Warning Score ≥5
Communication concern
Bedside Team
Identify
Tested on 1 general pediatric unit using Model for Improvement and Plan-Do-Study-Act (PDSA) cycles
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Teaching Identification
• Once identified, each risk is tied to specific and standardized actions– Support is built in to system
• No news is not good news• Opportunity to identify learners in need of
assistance• “Trusting your gut” does not come naturally
– What is different?
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Bedside nurse
InternWatchstander
Senior Resident
WatchstanderCharge Nurse
Family concerns
High risk therapies
Watcher
Early Warning Score ≥5
Communication concern Attending
Bedside Team
Unit Team
Identify Mitigate
Tested on 4 nursing units with learning and adaptations
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Teaching Mitigation Plans
• Learners (intern and new bedside nurses) communicate using SBAR– Situation
– Background
– Assessment
– Recommendation/Plan
• Mitigation occurs with interprofessional team bedside
• Made explicit if each member believes plan “fully addresses” patient risk
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Bedside nurse
InternWatchstander
Senior Resident
WatchstanderCharge Nurse
Safety Team(Nurse Manager
and Safety Officer)
Family concerns
High risk therapies
Watcher
Early Warning Score ≥5
Communication concern
Medical Response
Team (MRT)
Attending
Bedside Team
Unit Team
OrganizationTeam
Identify Mitigate Escalate
Tested on 4 nursing units then spread on 3/22/10
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Proactive Safety Team
• Three times daily discussion of any concerns not fully addressed and any predicted calls of Medical ResponseTeam
• Includes:– Charge nurse from
each unit– Nurse manager– Senior attending
Safety Officer
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Teaching Escalation
• Opportunity to model best practices• Accountable to peers/leaders
– “I don’t know” who is sickest patient went from common answer to embarrassing one
• Culture of independence to culture of interdependence
• Escalation is “how we do things here”• Celebrate successes
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Median: 5 days
Desired direction of change
Pilot testing
Phase 2 begins
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SA testing begins
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SA testing begins
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Identifying is only the start
• First year of journey moved from relying on individual clinicians to a system that identified >90% of patients who had UNSAFE transfers– BUT in many cases risk was not successfully
mitigated/reversed – AND risk was not escalated even when patient
was not improving
• Watching the “watchers”
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SMART Aim
• S - Specific• M - Measurable• A – Actionable• R – Relevant• T – Time bound
• “Some is not a number. Soon is not a time.”– Don Berwick
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• Identifying the problem or concern
• Making responsible parties aware
• Forming a plan• Predicting an expected
outcome within a fixed amount of time
• Deciding on an escalation plan if outcome is not met in time
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Robust plan PDSAs began
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Shared Mental Model
• “The perception of, understanding of, or knowledge about a situation or process that is shared among team members through communication”– AHRQ
• Also called Shared SA
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High-Risk Patients Throughout Hospital
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High Reliability Teams
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High Reliability Teams in Healthcare
Doc Right Doc Left
Airway
Nurse Right Nurse Left
Team Leader
Recorder
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Thank you
• Mentors– Patrick Conway– Tom DeWitt– Gerry Fairbrother– Uma Kotagal– Steve Muething– Derek Wheeler
• Grant support: NRSA T32
• QI Team– Marshall Ashby– Victoria DeCastro– Regan Gallagher– Maria Geiser– Marty Goodfriend– Dawn Hall– Jason Olivea– Christy White
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• Reference slides follow
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Total Number of Times each Safety Element Failed(FY07 – Jan. 2010)
Failure Type % of times this failure occurred
Situation Awareness 45%
Coordination of Care 45%
Reliable Escalation 24%
Family Engagement 21%
Any of the 4 above 62%
Serious Safety Event Root Causes
Background
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Time Setting Attendees Topics
8:00 Conference room
Safety officer, nurse manager, charge nurse on each unit
Any SA concerns not fully addressed, predicted MRTs
16:00 Rounds on unit → conf. room Any SA concerns not
fully addressed, follow-up1:00 Rounds on
unitNurse manager, charge nurse on each unit
Methods
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SMART AIM
KEY DRIVERSINTERVENTIONS
For identified watchers on TCC, wewill increase
to 100% those thathave a robust
mitigation/escalation plan* in place by
7/1/2011
Reliable tools to support robust planning
Charge RN, MPS, and SOD coaching
System to supportrapid learning on unit
KeyDotted box = Placeholder for future additionsGreen shaded = Current or Past Work
Revision Date: 6-2-2011
GLOBAL AIM
Root Cause1). There was ineffective identification, mitigation and escalation on TCC
Clarity of what is alwaysescalated
Knowledgeable and engagedstaff
Comfort and confidence to escalate
*robust plan includes: new change in management, prediction, contingency plan, and clear criteria to escalate
Eliminate SSEs and MRT-preventable codes and reduce by half UNSAFE transfers across inpatient
Proper identification of watchers patients
Robust Plan Form (LOR 2)
Team huddle form changed to include all members
contact info (LOR 2)
Standardized Vocabulary
Unit Wide Training Blitz – June 2011
Charge RN Focused Training – July 2011
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Data System
• Tools and database designed to assess both the reliability of the identify and mitigate/escalate process as well as UNSAFE transfers
• Apparent Cause Analysis form completed on each floor to ICU transfer
• Data distributed (with patient-level story) each week to Microsystem leaders in weekly report
• Control Plan designed with Mesosystem leaders to identify special cause and target interventions
Methods
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Safety Attitudes(AHRQ Safety Culture Survey)
Safety Behaviors(Identify, Mitigate, and Escalate)
Near Misses
UNSAFE Transfers(UNrecognized Situation
Awareness Failure Events)
Arrest
Methods: Measure
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What about breakdowns in steps of process?
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Barriers to problem detection in teams
• Production pressure discourages vigilance• High cost of conveying information• Team member may think team already knows• Inexperienced members may miss early signs• Team may not realize common understanding
is lost
-Klein. Cogn Tech Work 2006