Benita A Scott - The Bays Hospital - “Getting the Right Fit“– A Nurse-Led Rapid Response System (RRS) Without an On-Site Medical Officer

“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