Cardiac Monitoring Unit Cardiac Monitoring Unit (CMU) (CMU) Hull Royal Infirmary Hull Royal Infirmary Diane Rothwell, Project Diane Rothwell, Project Manager Manager North & East Yorkshire & North & East Yorkshire & Northern Lincolnshire CHD Northern Lincolnshire CHD Collaborative Collaborative diane diane [email protected] [email protected] ♥ THE JOURNEY SO THE JOURNEY SO FAR.. FAR..
Cardiac Monitoring Unit (CMU) Hull Royal Infirmary Cardiac Monitoring Unit (CMU) Hull Royal Infirmary Diane Rothwell, Project Manager North & East Yorkshire.
Mar 27, 2015
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Cardiac Monitoring Unit (CMU)Cardiac Monitoring Unit (CMU)
Hull Royal InfirmaryHull Royal Infirmary
Diane Rothwell, Project Diane Rothwell, Project ManagerManager
North & East Yorkshire & North & East Yorkshire & Northern Lincolnshire CHD Northern Lincolnshire CHD CollaborativeCollaborativedianediane.rothwell@[email protected]
♥THE JOURNEY SO THE JOURNEY SO FAR..FAR..
REGION & BASEREGION & BASE
CMU MICROSYSTEMCMU MICROSYSTEM
Nurses
DoctorsDomestics and caterers
Diabetic nurse
Pharmacist
Dietician Smoking cessation
officerCardiac
Rehab. NurseSocial Worker
Physio and Physio Assistants
Ward Clerk
PATIENTS
CMU MICROSYSTEM
Grimsby
AAU
Ward 8
Ward 80
Combined pr
Chest P Clinic
ECG Dept (o/p
Scunthorpe
Louth
York
Private Sector
ICU
HDU
Scarborough
Aca. Cardiology
Bridlington
GP/Home
Paramedics
Ward 80
Ward 8
Ward 6 (CHH)
Ward 7 (CHH)
ICU (CHH)
Combined Pr
Home
Par/Ambulance
ICU (HRI)
HDU
Other Hospital
HDU ICU
Combined Procedures
Information Flow
Patient Flow
2 WAY COMMUNICATION BOARD
ENGAGAING PERSONNEL ENGAGAING PERSONNEL WITHIN THE WITHIN THE
MICROSYSTEMMICROSYSTEM
CHALLENGE OF THE CHALLENGE OF THE MONTHMONTH
The CMU Team work together to Provide Quality Care That
Reaches the Heart of the Problem
“Your Heart in Our Hands”
‘‘P’P’ATIENTSATIENTS
To carry out Discovery Interviews
with Patients’ and their carers.
Interviews being
scheduled
PDSA in Progress
Aim: To find out what our patients think about the care and services we provide.
♥ OTHER PDSA’S PLANNED
♥ Patient Information
♥ Suggestion Box
♥ Patient Questionnaire
DISCOVERY INTERVIEW PDSA
‘‘P’P’ERSONNELERSONNEL
♥ Staff SurveyStaff Survey♥ Assessment ToolAssessment Tool♥ Online Workforce Online Workforce
SurveySurvey
‘‘P’P’ERSONNELERSONNELI would recommend CMU as a great
place to work
0123456789
101112
Strongly Agree Agree Disagree Strongly Disagree
I would recommend CMU as a great place to work
0
1
2
3
4
5
6
7
8
9
10
11
12
Strongly Agree Agree Disagree Strongly Disagree
How easy is it to ask anyone a question about the way we care for patients?
0
1
2
3
4
5
6
7
8
9
10
11
12
Very Easy Easy Difficult Very Difficult
‘‘P’P’ROCESSESROCESSES
3 minutes
3 minutes
1 minute
3-5 minutes
2 minutes
2 minutes
2 minutes
3 minutes
2 minutes
3 minutes
5 minutes
10 minutes
70 minutes
5 minutes
This is variable
Imediately on arrival
Day/Stage 2
Day/stage 3
Day/stage 4
Day/stage 5
Onset of chest pain in patien t
Patient calls 999
Patient Calls GP
GP calls 999 and goes to
patient
Ambulance arrives -Hull
Royal Infirmary A&E
Ambulance arrives
Patient transferred to AAU trolley
Bottle neck - In rural areas 40-
45 minute journey to HRI
GP takes History
GP examines
patient
GP gives asprin if
appropriate
GP Inserts cannulae
GP gives Diamorphine & Cycizine
Paramedics Patient in
ambulance- HRI
Bottle neck - In rural areas lack of ambulance can delay time
Paramedic gives asprin
if appropriate
VALUE ADDED
VALUE ADDED
Paramedic gives
VENFLON
Paramedic gives
Oxygen
VALUE ADDED
Patient removed
from ambulance into A&E
ambulance entrance
Paramedic rings bell
Triage nurse to triage
point
Triage nurse phones AAU (dedicated
phone)
AAU agree to take
Ambulance crew take patient to
AAU
AAU nurse greets patient
Paramedics handover
AAU Nurse does ECG
AAU Nurse complete
Observations
AAU Nurse Monitors patient
AAU Nurse establishes if
asprin administered
AAU Nurse takes ECG to doctor
ECG given to House officer
(staff grade doctor)
Problem for oxygen
saturation
House officer
assesses
House officer orders
analgesia
AAU walks to controlled
drugs cupboard
AAU nurse gets
controlled drugs
Strep in same drugs cupboard as controlled
drugs
AAU Nurse-Diamorphine
given
Asprin given if not
already
AAU Makes up S trep in treatment
room
AAU Nurse give strep
AAU Nurse - S trep tends
to be finished in
AAU
Some Junior doctors
don't use AMI
pathway and take full History
Doctor takes
history
Consent for strep gained - explanation
of issues for
treatment, side effects
etc.
Bottle neck - NO written consent
FBC, U&E, B loodsugar, LKT, CK.
Lipids
Result available on computer in AAU
(Not CMU)
Digami Regime
started on appropriate patient in AAU after 30 minute
delay
AAU Doctor Rings CMU
AAU Nurse Rings CMU
IF appropriate
a Cardiology registrar may be called
CMU staff nurse
accepts patient if
bed available
Call bed Co-ordinator
(B leep 203) if no Bed
Bottle neck - Often beds not
available
Patient may stay in AAU
If no bed CMU staff
decant patient to ward 8/80
Bed in CMU becomes available
Ring porter in Theatre
lift
Get AAU Porter who has key to
lift
Day time -10pm porter has key.
A fter 10pm kept in Cupboard on AAU
Patient transferred
to CMU with:
AAU NurseAAU DoctorAAU Porter
Porter breaks and After 10pm general
porter used
Arive on CMU and
transferred to bed
CMU SHO informed
History taken by
SHO CMU
There is often a problem
getting old note for
comparison of ECG pre
Lysis
CMU Nurse set up
monitor and baseline obs
History taken by
CMU Nurse
Relative cared for by CMU nurse
Digami started if
not completed in
AAU
Access blood results by phoning
AAU
Bottle neck - Problem in phoning for
results
CMU nurses complete 30 minute post-Lysis ECG
CMU Staff/ECG
TechnicianECG
Review at 90 minutes
Re-thrombolysed
if needed
If Lysis successful CMU staff
nurse proceeds
with bedrest and
monitoring
If fails 90 minutes
ECG consider
REACT trial
If entered in to Trial CMU nurses and
doctors follow
REACT guidelines
Name nurse introduces
themselves
Check glucose and if >11mmPx
then IV dextrose
and insulin
Education started by Dietitian if
going onS/C insulin
CMU nursing & medical staff
complete admission
documentation (written &
clerking in)Ward clerk
books patient and requests
notes
Often case notes are not where the tracing states they were. Left in rooms which
are not easily
accessible
Bottleneck- Can take 5 minutes to 12 hours to find notes that have
not been received by the
ward
CMU Nurse establish when Post Lysis -ECG's need doing and
order (9-5) out of hours
nursing staff do
Record 2 hour ECG by CMU
nurse/ECG technician
Physio S tage 1a exercises by Physio or CMU nurse
Daily- Physio finds out patients
with a definite MI and finds out their condition (Mon-Fri)
Daily - Physio checks medical
notes and writes Patient
Orientated Medical Record
(Mon-Fri)
Meet patient and explain the role
of Physiotherapist
S tart inpatient cardiac rehab
programme from
appropriate stage until completion
(daily) Nurse/Physio
Give all relevant
information required to
aid recovery
Find patients who have moved wards and follow to continue
treatment
Bottle neck- Time consuming
Record each treatment &
inform nursing/medical
staff if any problems
Facilitate Heart
Manual (Daily)
Referred to Cardiac rehab programme
administrator
CMU Nursing
staff introduce patient to
initial rehab booklet
Physio and/or CMU
nurses start Physio 1b exercises
CMU nursing
staff inform patient and relatives what is going to happen whist in
hospital -Ongoing
throughout the stay
Ward 8 nurse in charge
discusses patient transfer
details with CMU
Nurse in charge reviews
ward occupancy
(ward 8)
Nurse in charge
negotiates appropriate inter-ward
transfers to create bed
space
Nurse in charge
allocates ward bed for CMU-ward transfer
Nurse in charge/named nurse
Informs ward clerk &
SHO's of transfer details
Bottleneck - Bed blocking. If no beds in CMU decant other patients if required.
(Involve Reg) Contact B leep
holder and ward
Nurse transfers
patient from CMU to Ward 8
Nurse allocates
bed
CMU and Ward 8 named nurse
accept patient onto
ward and handover
information
Nurse sets up cardiac monitoring
(if telemetry liaise with
CMU)
Nurse reads medical notes
Nurse checks
medication
Nurse fills in care
pathway (not AAU
one)
Nurse explains
rehabilitation
Nurse checks patient's
cholesterol Can refer to
dietitian
Dietitian receives
referral from from nursing staff (ward 8 or CMU)
Dietitian sees patient on ward for
assessment and advice
Nurse Checks
CK 's
Nurse completes
ECG
Referred to physiotherapy
Nurse Identifies patient
worries and concerns
Ward clerkDaily filing
of casenotes
Often problem in
getting hold of notes
Inform rehab co-ordinator of confirmed MI's relaying all patient admission information from board
and nurse C/P files
Nurse or ECG
technician carries out
ECG
Rehab stages
reiterated by nurse
Nurse/dietitian/
Physio all carry out
health education
Nurse explore
patient's risk factors
Nurses involve the family as
appropriateCommunication
Nurse/Facilitator
gives heart manual for patient to
read
Nurse/Physio continue with
Physiotherapy
Pharmacist check drug cards and
gives patient
education
Nurse carries out social
assessment
Referral to social
services
Bottleneck - ??? Why When how?
SHO review
Discontinue monitoring if appropriate
Consultant/registrar review
Nurse Reiterates
stages
Physiotherapy
Nurse facilitates
heart manual
Technician performs
ECG
Nurses gets date for R.N.U
Nurse checks discharge
arrangements
Nurse requests
transport for discharge
SHO Review
Bottleneck
Follow-up arrangements made by ward
clerk
Nurse reiterates stages to patient
Nurse discusses discharge
with patients
Take home medication sorted by SHO and Pharmacy
Nurse continues
health education
More physiotherapy
SHO Review
Bottle neck
Nurse reiterates stages to patient
SHO review
Tests requested for post-discharge
Nurse discusses medication with patient
Physiotherapy
Nurse completes discharge
letter
Patient given chest pain leaflet by nurse
Nurse completes discharge
ECG
Patient discharged
AMI PROCESS MAP
LV CHD COLLABORATIVE
CMU Microsystem process for AMI
‘‘P’P’ROCESSESROCESSES
Smoking cessation officer
Patients Admited, Transfered In and Out, and Discharged to/from CMU by Hour 3 Month Period
0
10
20
30
40
50
60
0 1 2 3 4 5 6 7 8 9
10 11 12 13 14 15 16 17 18 19 20 21 22 23
DeathsDischargesTransfers OutTransfers InAdmits
‘‘P’P’ATTERNSATTERNS
‘‘P’P’ATTERNSATTERNSTOP TEN
050
100150200250300350400
Num
ber o
f Pat
ient
s
TRANSFERS FROM OTHER HOSPTIALS
0
2
4
6
8
10
12
14
16
18
20
Jan
-2003
Feb
-2003
Mar-
2003
Apr
-200
3
May-
200
3
Jun
-2003
Jul
-2003
Aug
-2003
Sep
-2003
Oct-
2003
Nov-
200
3
Dec-
200
3
Jan
-2004
INCREASE – WHY?33% AMI
OCCUPIED BEDS
0
1
2
3
4
5
6
7
8
9
10
11:00 17:00 24:00
Statistical Process
Control
The 5 P’s!The 5 P’s!
PPatternsatterns
PPersonnelersonnel
PProcesserocessess
PPatientsatients
PurposePurposeASPIRATIONSASPIRATIONS
Patient ExperiencePatient Experience Improve the ‘interface’ with other Improve the ‘interface’ with other
MicrosystemsMicrosystems Integration ‘service improvement is Integration ‘service improvement is
not a separate activity’not a separate activity’ Ensure that CMU is a place that Ensure that CMU is a place that
people feel happy about coming to people feel happy about coming to work.work.
Reflections ofReflections of
Clinical MicrosystemsClinical Microsystems
I must admit my initial
thoughts were somewhat sceptical
I contracted ‘microsytemiti
s
Microsystems has given me a much
needed boost of
enthusiasm
I feel privileged to have had the experiences
I’ve had
I was full of ideas of how we could use the concept
in CMU
I feel better equipped to
suggest ways in which we
could change
Being involved with
‘Microsystems’ has made a difference to staff morale
We are creating a
culture that supports service
improvement
Staff feel empowered
to make small
changes from within our
microsystem
Microsystems has helped us explore ways of improving
communication
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