WebEx Quick Reference - IHI · WebEx Quick Reference ... and into the paper documentation ......
Transcript of WebEx Quick Reference - IHI · WebEx Quick Reference ... and into the paper documentation ......
4/20/2011
1
Kathy Duncan, RN, Director
Christine McMullan, MPA, Faculty
April 2011
These presenters have nothing to disclose
2
WebEx Quick Reference
• Welcome to today’s session!
• Please use Chat to “All
Participants” for questions
• For technology issues only,
please Chat to “Host”
• WebEx Technical Support:
866-569-3239
• Dial-in Info: Communicate /
Join Teleconference (in menu)
Raise your hand
Select Chat recipient
Enter Text
4/20/2011
2
When Chatting…
Please send your message to
All Participants
3
Early Warning Scoring Systems
Kathy Duncan, RN, Director
Christine McMullan, MPA, Faculty
April 2011
These presenters have nothing to disclose
4/20/2011
3
Abbott Northwestern Hospital Minneapolis, MN
• Outcome of chart review: ─ 20 patients reviewed that had Code Blue without a RRT call within 24 hrs prior to
code:
─ Based on retrospective and concurrent chart reviews, difficult to say if medical intervention would have prevented the code or transfer to higher level of care.
─ Concurrent chart reviews of patients on pilot unit found that 39/50 (78%) of patients were in the “green zone” , 10/50 (20%) were in the “yellow” zone and 1 patient in the “orange” zone
─ Two patients that were in the “green zone” had RRT called during the shift
• Physiological Conditions that “flag” at risk patients: ─ Biggest indicators of EWSS increasing were respiratory rate and heart rate
─ UO rarely documented but when it was, it attributed to higher EWSS
EWSS Score 12 hrs 8 hrs 4 hours Time of code
0-1 7/18 pts (39%) 3/17 pts (18%) 5/18 pts (28%) 19/20 (95%)
2-3 7/18 pts (39%) 6/17 pts (35%) 4/18 pts (22%)
4-5 2/18 (11%) 5/17 (29%) 4/18 pts (22%) 1/20 (5%)
> 6 2/18 (11%) 3/17 pts (18%) 5/18 pts (28%)
Southeast Georgia Health System
• Outcome of chart review: ─ Did patients exhibit signs of medical decline prior to code
blue/transfer to higher level of care? Only 4/10 (40%)
─ Would scoring system have identified patients at risk 4hrs, 8hrs or 12 hrs prior to code blue/transfer to higher level of care? Yes. 3/10 (30%) at 4 hrs and 1/10 (10%) at 12 hrs.
─ Could medical intervention have possibly prevented the code blue/transfer to higher level of care? Yes in 3/10 (30%)
• Identify trends of physiologic conditions that appeared to flag “at risk” patients ─ The only one that seemed to impact was respiratory rate.
─ None with a difference in LOC
─ Urine output data was almost non-existence with only 2/10 (20%) with adequate information to score
4/20/2011
4
Middlesex Hospital
Middletown, CT.
• Outcome of chart review: ─ Did patients exhibit signs of medical decline prior to code
blue/transfer to higher level of care? 100% of the patients had at least a score of “1” on the MEW scale
─ Would scoring system have identified patients at risk 4hrs, 8hrs or 12 hrs prior to code blue/transfer to higher level of care? Depending on what MEW score is used as a trigger, If scale was
>1 90% of the patients would have met the trigger.
─ Could medical intervention have possibly prevented the code blue/transfer to higher level of care? With the exception of one patient perhaps.
• Identify trends of physiologic conditions that appeared to flag “at risk” patients
The most common trigger at the hours before the code was the RR breaths/min.
Early Warning Systems: The Next Level of Rapid Response Expedition
Carmen Ferrell, RN, MSN, CCRN Nancy Christiansen, RN, MSN, CCRN Soudi Bogert, RN, BSN, CCRN
4/20/2011
5
St. Joseph Hospital of Orange
525 bed, not for profit
Acute care with BHS unit
Opened 1929
Sisters of St. Joseph of Orange
Shared services to CHOC
Admits: 31,784
ALOS - Acute 3.47 days
ED: 110,200 visits
OR: 33,100 surgeries
OB: 5935 deliveries
Payer Mix
HMO 27%
Medicare 19%
PPO 19%
Capitated 18%
Medical/caid 11%
Other 6%
Early Warning System
• Early Warning System (EWS) is part of the Rapid Response System at Saint Joseph Hospital Orange (SJO)
– EWS are symptoms that identify a patient at risk for clinical deterioration
– EWS are the trigger to activate Rapid Response Team (RRT)
– The RRT at SJO is called the Medical Emergency Team (MET) which begun in May 2004
4/20/2011
6
Initial MET (Reactive) Outcomes
SJO- Code Blue by area and MET, Qtr 1 06-Qtr 1 08
30
19 2316
30
18 1422 21
21
22
28
19
1329
115
16
4
5
6
7
66
47
6
58
44
58
44
52
78
84
97 99
0
20
40
60
80
100
120
Qtr 1 CY 06 Qtr 2 CY 06 Qtr 3 CY 06 Qtr 4 CY 06 Qtr 1 CY 07 Qtr 2 CY 07 Qtr 3 CY 07 Qtr 4 CY 07 Qtr 1 CY 08
# o
f E
ven
ts
OTHER
Med / Surg
Critical Care
MET
Rapid Response Team Evolution
• From our initial results it was evident that a great deal of education on identification of early warning signs of deterioration were needed
• The EWS triggers were hardwired through education and into the paper documentation system
• RRT caused a decrease in Code events in the first 18 months but our trending down leveled off
• After review, we found EWS triggers on the flow sheet were not consistently assessed / used by the nurses
4/20/2011
7
Dedicated MET Development
• 24 Hour coverage September, 2008
• Aim to improve EWS process & compliance
• MET RN:
– Responds to “Emergent” Overheard Calls
– Available for “Consult Requests”
– Performs daily “Proactive Rounding” on pts identified as High Risk
Dedicated MET RN EWS Process
• Requested Charge RN on each floor to assist Staff RN in identifying highest acuity pts for EWS scoring
• EWS scoring education provided to med/surg areas & flyers posted
• EWS tool faxed to the MET RN each shift
• MET RN prioritized rounding based on EWS scores
• Finding: non-compliance & inconsistent reporting
• Lack of computer documentation played a part
4/20/2011
8
High Alert Report
• Created to serve as an early warning tool
• Generated from computer
• Pt list with diagnosis, and high alert labs
– Hemoglobin
– K+
– Mg+
– Troponin
– BNP
• MET RN rounds pro-actively on pts identified via report
4/20/2011
9
Outcomes- Post Dedicated Team
SJO- Code Blue by area and MET, Q3 '08- Q4 '10
17 23 28 2721 19 25
17 22 17
17 7
13 9 1711
12
8
14
4
00
14 0
0
1
2
1
0
102
66
99 100
8174
64 64
48
38
0
20
40
60
80
100
120
Qtr 3
CY 08
Qtr 4
CY 08
Qtr 1
CY 09
Qtr 2
CY 09
Qtr 3
CY 09
Qtr 4
CY 09
Qtr 1
CY 10
Qtr 2
CY 10
Qtr 3
CY 10
Qtr 4
CY 10
# o
f E
ven
ts
OTHER
Med / Surg
Critical Care
MET
Lessons Learned
• Difficult to extract early warning criteria with paper documentation
• Anticipating electronic documentation implementation August, 2011
– Built in alerts for HR, RR, BP, Temp, Urine output
– Report to be built that will pull current patient data and be available to the MET RN
4/20/2011
10
Next Steps
• We are in the process of making all the forms electronic and incorporating EWS into electronic alerts
• Pilot the EWS scoring to ensure appropriate data is being formatted into computerized documentation
• Continue to re-educate
Questions
4/20/2011
11
Repeated Use of the PDSA Cycle
Hunches
Theories
Ideas
Changes That
Result in
Improvement
A P
S D
A P
S D
Very Small
Scale Test
Follow-up
Tests
Wide-Scale Tests
of Change
Implementation of
Change
Sequential building of knowledge under a wide range of conditions Spread
Aim: Implement Rapid Response Team on non-
ICU unit
Improved
Communication
A P
S D
A P
S D
Cycle 1: ICU nurse responds to rapid response team calls on one unit,
one shift for one day
Cycle 2: Repeat cycle 1 for three days
Cycle 3: Have Respiratory Therapist attend
rapid response calls with ICU Nurse
Cycle 4: Expand coverage of RRT on unit
to one unit for one shift for five days
Cycle 5: Have Nurse Practitioner
respond to calls in addition to RT and
RN
Cycle 6: Expand rounds to
one unit for one shift seven
days a week
4/20/2011
12
Checking Results
• Compliance with tool
─Accuracy: Are staff accessing correctly?
─Frequency: Are staff accessing at
desired frequency?
• What actions are required as a result
of the score?
• Does the tool adequately reflect the
patient’s medical status?
4/20/2011
15
29
3 2 1 0 Score
*
Behavior
• Lethargic,
Confused,
• or Reduced
Pain Response
• Irritable or Agitated
and Not Consolable
• Sleeping,
• Irritable and
Consolable
• Playing
• Appropriate for pt.
Cardiovascular • Grey or
• CRT ≥5 or
• Tachycardia 30
above OR
• Bradycardia for
age
• CRT 4 seconds or
• Tachycardia of 20
above normal
parameters
• Pale or
• CRT 3 Seconds
• Pink, CRT 1-2
Seconds
Respiratory
• 5 Below normal
with retractions
and/or
• ≥50% FiO2
• >20 above normal,
• using accessory
muscles or
• 40-49% FiO2 or
• ≥ 3 LPM
• >10 above normal
• Using accessory
muscles or
• 24-40% FiO2 or ≤2
LPM
• Any initiation of O2
• WNL for Age
• No Retractions
TOTAL ** Parental concern should be an automatic call to the Rapid Response Team
Pediatric Early Warning Score – PEWS
Most Critical Stable
* Add 2 points for frequent interventions (suction, positioning, O2 changes) or multiple IV attempts.
Score ≥ 7 Assmt. q 30 mins. Score 6 Assmt. every 1 hour. Score 5 Assmt. every 1-2 hours. Score 0-4 Assmt. q 4 hours
4/20/2011
16
Homework • Using MEWS
─ Utilize one of the above tools and test tool on one patient, with one
nurse and “unofficially” record results
─ Obtain feedback from nurse
* was the tool easy to use?
* how long did it take to assess the patient?
* was score an accurate reflection of patient’s medical condition?
* what medical intervention did the patient require?