Improve Critical Care - 1000livesplus.wales.nhs.uk … · Web viewThe evidence base behind the implementation of Sepsis Care Bundles/Pathway: Early recognition of severe sepsis

The ‘How to Guide’ forImproving Critical

Care

Rapid Responseto Acute Illness

Main contacts for Rapid Response to Acute IllnessCampaign Director leading on the content area: Alan WillsonFaculty member for this content area: Dave Hope and Mark SmithiesPoint person for the content area: Chris Hancock

IA/Senior IA: Mike DavidgeOther (as determined by Director):

Intranet: http://nww.1000livescampaign.wales.nhs.ukWebsite: www.1000livescampaign.wales.nhs.uk

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http://www.1000livescampaign.wales.nhs.uk/

http://nww.1000livescampaign.wales.nhs.uk/

Improving Critical Care


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Content Area

Drivers Interventions

Improve Critical Care

Reduce complications from: Ventilators Central lines Severe Sepsis HCAIs

Provide patient and family driven care

Create an environment of collaboration and culture of safety

Involve Leadership in safety

Reliable processes of care: Ventilator management Central line management Identification and treatment of

sepsis Hand hygiene

Processes Inclusion of patient/ public

representation on local critical care improvement team

Integrate patient/family into improvement work

Promote open communication among team and family

Processes Multi disciplinary rounds and daily

goal setting Ensure staff have knowledge and

expertise in improvement work Ensure communication and

collaboration within a multi disciplinary team

Appropriate infrastructure:

Integrate leadership into improvement efforts

Rapid response to acutely ill patients (Shared with medical/surgical improvement, surgical complications and

Reliable processes are contained in the NICE guidance (50) on identification and treatment of acute illness and include

Establishment of and training for a whole hospital early warning system

Development of and training in graded risk based response to acute illness

Audit process and outcomes Inclusion of Trust board

management, referring medical teams and ward staff in audit



Table of Contents

Rapid response to Acute Illness Getting Started List..........................4Goal: To reduce mortality and prevent harm to the hospital population through improving the recognition and response to acute illness..................................................................................................5Summary of NICE guidance (50).........................................................7

Prevent harm from lack of recognition and treatment of the acutely ill......................................................................................................8

Processes......................................................................................8Implement NICE guidance (50) on recognition and treatment of the acutely ill including these interventions: -..............................8

Goal: Reduce complications and mortality from severe sepsis......10Surviving Sepsis Campaign.........................................................11

Goal: Reduce complications and mortality from severe sepsis......14Getting Started..............................................................................16

Engage Senior Leadership Support.............................................16Leadership and Organisational Culture.......................................16Using the Model for Improvement..............................................17Forming a Team..........................................................................18Setting Aims...............................................................................19First Test of Change....................................................................19Barriers That May Be Encountered.............................................19Establish Feedback Mechanisms.................................................20Track Measures over Time..........................................................20

Tips and Tricks...............................................................................21


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Rapid response to Acute Illness Getting Started List

Prior to testing and implementation of system for rapid response to acute Illness organisations may wish to consider the following:

Engage senior leadership support

Appoint a cross Trust multi-disciplinary implementation team to: -

o Steer and co-ordinate the interventiono Review process and outcome data o Perform qualitative review of circumstances surrounding

sudden deterioration in patient’s condition.o Link with critical incident reporting

Appoint individual or team as ‘process owner’. This ‘rapid response co-ordinator’ will have extensive experience of both critical and acute care but should not be funded from critical care resources.

Establish single track and trigger system for the Trust

Determine the optimum structure for response based upon level of risk and clear lines of responsibility

Provide education and training

Establish quantitative and qualitative feedback mechanisms

Measure effectiveness


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Goal: To reduce mortality and prevent harm to the hospital population through improving the recognition and response to acute illness.The recently published literature from NICE and NPSA have highlighted that a significant risk to patient safety exists from the lack of recognition and treatment of acutely ill adults in Hospital. Studies into this specific problem identify that about 40% of ITU admissions are preceded by error and that the mortality rate is much higher in the patients that experience error. Several other studies, including the National Confidential Enquiry into Peri-Operative Deaths have come to similar conclusions and these findings are entirely consistent with the experience of clinicians in the field. In Wales as annual level 3 admissions number about 8000 and the 40% of admissions that receive poor care show a mortality increase of about 20% (35% vs. 56%) then the death toll is approximately 640 per year. This is a conservative estimate and does not include those patients who deteriorate and die prior to ICU admission.This potentially avoidable mortality is due to systemic failures in all hospital areas and will be resolved only by adoption of the problem and co-ordination of the response at a Trust board level. Although hospital Critical Care departments are an enormous resource in the treatment of the acutely ill they are not funded to respond in isolation on behalf of the whole hospital.This is why in evaluating the evidence supporting the interventions for the Saving 1000 Lives campaign the NPHS found little support for the effectiveness in isolation of Rapid Response Teams, Medical Emergency Teams or Critical Care Outreach.Trusts will only respond effectively to this problem when medical, surgical and critical care areas collaborate in improving systems of care. An effective system must

Operate hospital-wide Work 24 hours a day Facilitate rapid treatment Facilitate escalation of care Feedback to referring teams on process and outcome

In Welsh hospitals where this problem is being addressed the model for implementation depends upon an individual or group who co-ordinate activity, training and data collection. This individual or group must


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have experience in acute and critical care but can only work when independently funded.It is the aim of the Saving 1000 Lives campaign to support Trusts in implementing the NICE guidance (50) on acutely ill patients in hospital and to therefore reduce harm for the entire hospital population. This ‘How to guide’ has been adapted from the Safer Patient Initiative guidance on Rapid Response Teams and details service improvement methodology as well as tips and techniques learnt from the Safer Patients Initiative, Saving 100,000 Lives Campaign and Welsh Critical Care Improvement Programme.

ReferencesP McQuillan et al. Confidential inquiry into quality of care before admission to intensive care. BMJ 1998;316:1853–1858An acute problem? National Confidential Enquiry into Patient Outcome and Death 2005. http://www.ncepod.org/2005report/summary.pdf


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http://www.ncepod.org/2005report/summary.pdf

Summary of NICE guidance (50)Adult patients in acute hospital settings, including patients in the emergency department for whom a clinical decision to admit has been made, should have:

physiological observations recorded at the time of their admission or initial assessment

a clear written monitoring plan that specifies which physiological observations should be recorded and how often.

Physiological observations should be recorded and acted upon by staff who have been trained to undertake these procedures and understand their clinical relevance.Physiological track and trigger systems should be used to monitor all adult patients in acute hospital settings.Physiological observations should be monitored at least every 12 hours, unless a decision has been made at a senior level to increase or decrease this frequency for an individual patient.Staff caring for patients in acute hospital settings should have competencies in monitoring, measurement, interpretation and prompt response to the acutely ill patient appropriate to the level of care they are providing. Education and training should be provided to ensure staff have these competencies, and they should be assessed to ensure they can demonstrate them.A graded response strategy for patients identified as being at risk of clinical deterioration should be agreed and delivered locally. It should consist of the following three levels.– Low-score group:– Medium-score group:– High-score group:If the team caring for the patient considers that admission to a critical care area is clinically indicated, then the decision to admit should involve both the consultant caring for the patient on the ward and the consultant in critical care.


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Prevent harm from lack of recognition and treatment of the acutely ill

ProcessesUnder Trust Board leadership Critical Care departments to link with medical and surgical directorates in directing this work

Engage senior leadership support Appoint a cross Trust multi-disciplinary implementation

team to: -o Steer and co-ordinate the interventiono Review process and outcome data o Perform qualitative review of circumstances surrounding

sudden deterioration in patient’s condition.o Link with critical incident reporting

Appoint individual or team as ‘process owner’. This ‘rapid response co-ordinator’ will have extensive experience of both critical and acute care but should not be funded from critical care resources.

Implement NICE guidance (50) on recognition and treatment of the acutely ill including these interventions: -

Establish single track and trigger system for the Trust Establish level of competence for training Measure training uptake Determine the optimum structure for response based upon level

of risk and clear lines of responsibility Establish criteria for initiating response Establish a simple process for initiating the response Provide education and training for responders Use standardised tools Establish qualitative feedback mechanisms


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Measures:

Measure Name Operational Definition Data Collection SourceNumber of cardiac arrest calls

Monthly calls for cardiac arrest team

Rapid response co-ordinator or hospital switchboard.

Number of calls for rapid response to medium and high risk acute illness

Monthly number of calls for a response to patients who have been assessed as being of medium or high risk illness.

Rapid response co-ordinator

Qualitative review and feedback on outcomes of cardiac arrest and rapid response calls.

Multidisciplinary evaluation of the processes and actions prior to the call being made and the outcome following the response.Should be linked with critical incidence reporting and feedback mechanism in place to report to all stakeholders.


Number of do not attempt resuscitation (DNAR) orders

Monthly number of DNAR orders made.



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Goal: Reduce complications and mortality from severe sepsis Intervention level: All level 0, 1, 2, 3 and 3T units.The term sepsis covers a number of infectious diseases that result in a common picture of multiple organ failure. It is a condition with high prevalence – about 2.3% of hospital patients and about 27% of intensive care patients 1, 2. Mortality rates are very high – around 30 – 50%. In Wales this equates to the deaths of between 700-1100 people in ICU annually. Globally, sepsis kills about half a million people a year: as many as myocardial infarction.Until recently sepsis has had a low public profile. Reporting of cause of death on death certificates often omits the term sepsis so its prevalence has been under-reported. Effective treatments have been hard to come by. Times are changing though and there is a growing international consensus both on the scale of the challenge and the practical ways to bring down mortality rates 3.The good news is that the most effective treatments are simple interventions such as giving oxygen, large volumes of intravenous fluids and antibiotics 4. The main challenge is that these treatments must be given early in the disease process to be effective. The main focus then has to be on the early identification of patients with sepsis and in delivery of a package of treatments within a few hours of the onset of the disease. These simple targets are hard to achieve and require us to redesign how patients are monitored and treated throughout the hospital.

1. Angus DC et al. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome and associated costs of care. Critical Care Medicine 2001; 29; 1303-102. Padkin AM et al. Epidemiology of severe sepsis occurring in the first 24 hours in intensive care units in England, Wales and Northern Ireland. Critical Care Medicine 2003: 31; 2332–83. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock 2008. Crit Care Med. 2008; 36(1): 296-3274. Rivers E et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345: 1368-1377


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Surviving Sepsis CampaignThe Surviving Sepsis Campaign is an International campaign to reduce mortality and morbidity from sepsis by 25% over a 5 year period through the introduction of Sepsis Care Bundles. These bundles consist of interventions that have solid evidence in improving mortality. These consist of 2 elements; the first 6 hours from the diagnosis of Severe Sepsis or Septic Shock (time zero) known as the Resuscitation Bundle and the first 24 hours from diagnosis known as the Management Bundle.Early experience with the bundles at The University Hospital of Wales (UHW) and Nevill Hall Hospital (NHH) highlighted the following difficulties:

Inconsistency in the early diagnosis of severe sepsis and septic shock

Frequent inadequate volume resuscitation Late or inadequate use of antibiotics Frequent failure to support the cardiac output when depressed Frequent failure to control hyperglycemia adequately Frequent failure to use low tidal volumes and pressures in acute

lung injury Frequent failure to treat adrenal inadequacy in refractory shock

To overcome these difficulties the SSC care bundles have, in some areas, been operationalised into a care pathway with achievement of the so called ‘sepsis six’ within 1 hour of diagnosis as the primary intervention. As the characteristics of these ‘sepsis six’ are similar to the initial response to acute illness, it is recommended that sepsis bundles are incorporated into the recognition and response to acute illness system.

The Survive Sepsis Resuscitation Pathway can be obtained from:http://www.survivesepsis.org/Further information can be obtained from the following links:www.ihi.orgwww.aboutsepsis.comhttp://www.survivesepsis.org/


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http://www.survivesepsis.org/

http://www.aboutsepsis.com/

http://www.ihi.org/

http://www.survivesepsis.org/

http://www.survivingsepsis.org/http://www.sepsisforum.org/

The evidence base behind the implementation of Sepsis Care Bundles/Pathway:

Early recognition of severe sepsis and septic shock, with early aggressive resuscitation aimed at meeting defined goals [Rivers E, et al. Early recognition of severe sepsis and septic shock, with early aggressive resuscitation aimed at meeting defined goals. New England Journal of Medicine. 2001;345(19):1368-1377.]

Early use of appropriate antibiotics [Iregui M, et al. Clinical importance of delays in the initiation of appropriate antibiotic treatment for ventilator-associated pneumonia. Chest. 2002;122(1): 262-268.]

Tight control of blood glucose [van den Berghe G, et al. Intensive insulin therapy in critically ill patients. New England Journal of Medicine. 2001;345(19):1359-1367.]

Low volume and low pressure ventilation for acute lung injury patients [The NIH-ARDS Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. New England Journal of Medicine. 2000;342(18):1301-1308.]

Use of activated protein C for severe sepsis [Bernard GR, et al. Efficacy and safety of recombinant human activated protein C for severe sepsis. New England Journal of Medicine. 2001;344(10): 699-709.]

Use of low-dose steroids in refractory septic shock [Annane D, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. Journal of the American Medical Association. 2002;288(7):862-887.]


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http://www.ihi.org/IHI/Topics/CriticalCare/Sepsis/Literature/Effectoftreatmentwithlowdosesofhydrocortisoneandfludrocortisoneonmortalityinpatientswithsepticshock.htm

http://www.ihi.org/IHI/Topics/CriticalCare/Sepsis/Literature/EfficacyandsafetyofrecombinanthumanactivatedproteinCforseveresepsis.htm

http://www.ihi.org/IHI/Topics/CriticalCare/Sepsis/Literature/VentilationwithlowertidalvolumesforacutelunginjuryandARDS.htm

http://www.ihi.org/IHI/Topics/CriticalCare/Sepsis/Literature/Intensiveinsulintherapyinthecriticallyillpatients.htm

http://www.ihi.org/IHI/Topics/CriticalCare/Sepsis/Literature/Clinicalimportanceofdelaysintheinitiationofappropriateantibiotictreatmentforventilatorassociatedpneu.htm

http://www.ihi.org/IHI/Topics/CriticalCare/Sepsis/Literature/Earlygoaldirectedtherapyinthetreatmentofseveresepsisandsepticshock.htm

http://www.ihi.org/IHI/Topics/CriticalCare/Sepsis/Literature/Earlygoaldirectedtherapyinthetreatmentofseveresepsisandsepticshock.htm

http://www.sepsisforum.org/

http://www.survivingsepsis.org/


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Goal: Reduce complications and mortality from severe sepsis Intervention level: All level 0, 1, 2, 3 and 3T units.Processes:Elements of the Surviving Sepsis Campaign Resuscitation Bundle

Serum lactate measured Blood cultures obtained prior to antibiotic administration From the time of presentation, broad-spectrum antibiotics to be

given within 3 hours for ED admissions and 1 hour for non-ED ICU admissions

In the event of hypotension and/or lactate >4mmol/L (36mg/dL): Deliver an initial minimum of 20 ml/kg of crystalloid (or colloid

equivalent) Give vasopressors for hypotension not responding to initial fluid

resuscitation to maintain mean arterial pressure (MAP) > 65 mm Hg.

In the event of persistent arterial hypotension despite volume resuscitation (septic shock) and/or initial lactate >4 mmol/L (36 mg/dl): Achieve central venous pressure (CVP) of >8 mm HgAchieve central venous oxygen saturation (ScvO2) >70%

Elements of the Sepsis Six Give 100% oxygen via non-rebreathe bag Take blood cultures Give IV antibiotics Start IV fluid resuscitation with Hartmann’s or equivalent Check haemoglobin and lactate Place and monitor urinary catheter unless fully mobile (monitor

UO)


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Measures

Measure Operational Definition Data Collection SourcePercentage compliance with sepsis resuscitation bundle

1. Determine the numerator: the number of patients fully compliant within 6 hours with the sepsis resuscitation bundle in one month.2. Determine the denominator: all patients identified as having severe sepsis requiring a response in one month.3.Calculate the care bundle compliance as a percentage by dividing the numerator by the denominator and multiplying the result by 100

A report on this measure is currently generated by the WCCIP database.

Percentage compliance with ‘sepsis six’

1. Determine the numerator: the number of patients fully compliant within 1 hour with the ‘sepsis six’ in one month.2. Determine the denominator: all patients identified as having sepsis requiring a response in one month.3.Calculate the care bundle compliance as a percentage by dividing the numerator by the denominator and multiplying the result by 100

A report on this measure is currently generated by the WCCIP database.

Severe sepsis mortality


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Getting StartedHospitals will not successfully implement these interventions overnight. If you do, chances are that you are doing something sub-optimally. A successful program involves careful planning, testing to determine if the process is successful, making modifications as needed, re-testing, and careful implementation.

Engage Leadership Support Select the team and the venue. Assess where you stand presently. Is there a process in place? If

so, work with staff to begin preparing for changes. Organize an educational program. Teaching the core principles

to staff will open many people’s minds to the process of change. Introduce the interventions to the staff.

Engage Senior Leadership Support Engage senior leadership (executive and physician) support and

buy-in, i.e., “We are going to do this; this is important and the right thing to do for our patients.”

Make an explicit organizational commitment to establishing the Rapid Response system.

Craft a very clear and widely disseminated communication message from senior leadership.

Leadership and Organisational CultureChanging practice requires a change in organizational culture and attitudes about what is acceptable. The organisational culture within an individual organisation, or even at the local level of a department or patient care unit, develops based on overt and subtle messages employees receive. Leadership actions strongly influence employee beliefs as to what leaders consider important, even more so than what is actually said. This includes not only what leaders do, but also what they do not do. Teamwork is essential in health care today, and communication within the team is indicative of the organisational culture. Everyone must be considered as an equally important member of the team, regardless of their role, and not only encouraged to speak up, but required to do so. If non-clinical or non-professional (i.e., non-licensed or certified) staff


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are not treated as equal members of the team, they will be less likely to point out an unsafe condition or take action. What changes can we make that will result in improvement?Understanding how organizational culture develops is important to changing it, and practical tools are available to effect change:

Implement Leadership WalkroundsTM, a structured approach for senior leaders to talk directly with front-line staff about patient safety.

Train staff in the use of SBAR, a structured format for communication which stands for Situation-Background-Assessment-Recommendation and establishes a clear layout of information in a manner that is non-threatening and allows for appropriate assertion.

Conduct briefings on units to increase staff awareness by bringing them together for 5 to 10 minutes as part of the daily routine.

Involve patients and families in processes, such as rounds.

Using the Model for ImprovementIn order to move this work forward, the campaign team recommends using the Model for Improvement. Developed by Associates in Process Improvement, the Model for Improvement is a simple yet powerful tool for accelerating improvement that has been used successfully by hundreds of health care organizations to improve many different health care processes and outcomes. The model has two parts:

Three fundamental questions that guide improvement teams to 1) set clear aims, 2) establish measures that will tell if changes are leading to improvement, and 3) identify changes that are likely to lead to improvement.

The Plan-Do-Study-Act (PDSA) cycle to conduct small-scale tests of change in real work settings — by planning a test, trying it, observing the results, and acting on what is learned. This is the scientific method, used for action-oriented learning.

Implementation: After testing a change on a small scale, learning from each test, and refining the change through several PDSA cycles, the team can implement the change on a broader scale — for example, for an entire pilot population or on an entire unit.


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http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/Safety+Briefings+(IHI+Tool).htm

http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.htm

http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/Patient+Safety+Leadership+WalkRounds%E2%84%A2+(IHI+Tool).htm

Spread: After successful implementation of a change or package of changes for a pilot population or an entire unit, the team can spread the changes to other parts of the organization or to other organizations.You can learn more about the Model for Improvement on www.IHI.orgForming a TeamNo single person can create system-level improvements alone. First, it is crucial to have the active support of leadership in this work. The leadership must make patient safety and quality of care strategic priorities in order for any infection reduction improvement team to be successful. Once leadership has publicly given recognition and support (financial resource, person-time) to the programme each hospital will have its own methods for selecting a core team. The team should use the Model for Improvement to conduct small-scale, rapid tests of the ideas for improvement over various conditions in a pilot population. The team should also track performance on a set of measures designed to help them see if the changes they are making are leading to improvement, and regularly report these measures back to leadership. The Campaign Team recommends a multidisciplinary team approach. Teams should be heterogeneous in make-up, but homogeneous in mindset. The value of bringing diverse personnel together is that all members of the care team are given a stake in the outcome and work to achieve the same goal. All the stakeholders in the process must be included, in order to gain the buy-in and cooperation of all parties. For example, teams without nurses are bound to fail. Teams led by nurses and therapists may be successful, but often lack leverage; physicians must also be part of the team. Some suggestions to attract and retain excellent team members include using data to define and solve the problem; finding champions within the hospital who are of sufficiently high profile and visibility to lend the effort immediate credibility; and working with those who want to work on the project rather than trying to convince those that do not.The team needs encouragement and commitment from an authority in acute and critical medicine. Identifying a champion increases a team’s motivation to succeed. When measures are not improving fast enough, the champion re-addresses the problems with staff and helps to keep everybody on track toward the aims and goals.Eventually, the changes that are introduced become established. At some point, however, changes in the field will require revisiting the processes that have been developed. Identifying a “process owner,” a


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http://www.ihi.org/

figure who is responsible for the functioning of the process now and in the future, helps to maintain the long-term integrity of the effort.

Setting AimsImprovement requires setting aims. An organization will not improve without a clear and firm intention to do so. The aim should be time-specific and measurable; it should also define the specific population of patients that will be affected. Agreeing on the aim is crucial; so is allocating the people and resources necessary to accomplish the aim.Teams are more successful when they have unambiguous, focused aims. Setting numerical goals clarifies the aim, helps to create tension for change, directs measurement, and focuses initial changes. Once the aim has been set, the team needs to be careful not to back away from it deliberately or "drift" away from it unconsciously.

First Test of ChangeOnce a team has prepared the way for change by studying the current process and educated the affected parties, the next step is to begin testing the intervention.

Begin using the intervention with one patient. Work with each nurse who cares for the patient to be sure they

are able to follow the bundle and implement the checklist and daily goals sheet.

Make sure that the approach can be carried over from shift to shift to eliminate gaps in teaching and utilization.

Process feedback and incorporate suggestions for improvement. Once the intervention has been applied to one patient and

subsequent shifts, increase utilization to the remainder of the ward/unit.

Engage in additional PDSA cycles to refine the process and make it more reliable.

Barriers That May Be Encountered Fear of change


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All change is difficult. The antidote to fear is knowledge about the deficiencies of the present process and optimism about the potential benefits of a new process. Communication breakdownOrganizations have not been successful when they failed to communicate with staff about the importance of the interventions, as well as when they failed to provide ongoing teaching as new staff become involved in the process. Physician and staff “partial buy-in” (i.e., “Is this just

another flavor of the week?”)In order to enlist support and engage staff, it is important to share baseline data and to share the results of improvement efforts. If the run charts suggest a large improvement compared to baseline, issues surrounding “buy-in” tend to fade.

Establish Feedback MechanismsOrganizations should examine Rapid Response data for lessons learned and patterns and trends, for example, respiratory events related to narcotics. The information gained from the Rapid Response calls can also be used to identify opportunities to address system failures, such as recognition, planning and communication failures.

Feedback information on rapid response process and patient outcome to:

o Trust board as part of the ‘quality dashboard’o Staff on acute wardso Rapid response steering and co-ordinating groups

Look for lessons learned hospital-wide and link to critical incident reporting system.

Use data to drive educational programs. Share the success stories.

It is important to create feedback mechanisms to the staff to foster understanding of the rapid response system and its benefits. Particularly during the initial stages of establishing the team, organizations find it useful to tell the stories of patients who were rescued by the team. These stories are useful in garnering support for the team as well as sustaining the process.

Track Measures over TimeImprovement takes place over time. Determining if improvement has really occurred and if it is a lasting effect requires observing patterns


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over time. Run charts are graphs of data over time and are one of the single most important tools in performance improvement. Using run charts has a variety of benefits:

They help improvement teams formulate aims by depicting how well (or poorly) a process is performing.

They help in determining when changes are truly improvements by displaying a pattern of data that you can observe as you make changes.

They give direction as you work on improvement and information about the value of particular changes.

Tips and TricksMore than 3,000 hospitals across the US have been working hard to implement the Campaign interventions. Here are some of the "tips and tricks" for successful testing and implementing of each intervention that we have gathered from our site visits to Campaign hospitals, our Campaign calls, and our Discussion Groups on IHI.org.

Be tolerant of “false alarms.” Staff should be praised for calling even if, after assessment, the patient condition did not appear to warrant calling the Rapid Response Team.

Get the word out – initially and continuously. Communicate, communicate, communicate! You cannot do enough of this. Particularly in the beginning, get the word out often. Be systematic and relentless with your communication. The power of sharing the Rapid Response Team stories with medical and nursing staff cannot be underestimated.

Pilot the process on one hospital unit. This will allow you to test the notification process, documentation tools, and follow-up mechanisms.

Utilize mock Rapid Response calls during the pilot. This provides the opportunity to test operational processes as well as discuss staffing contingency plans and assignments before full implementation.

Allow the RR staff to test and edit the documentation tool. The staff completing the document will design a form that flows well and is simple to complete, which will increase compliance with completion of the document.

Design and encourage the development of opportunities for the Rapid Response staff to “connect” to additional staff within the


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hospital—for or example, follow-up visits to patients who remain on the med-surg floor, debriefing opportunities after a call, etc.

Encourage the Rapid Response Team staff to design a mechanism to ensure that the documentation tools, protocols, and resources are present at every call. For example, some teams use a bright-colored “zippered notebook” that contains the documentation tools, logs, protocols, and resources such as physician chain-of-command flow sheet, ACLS guidelines, frequently-used phone numbers, etc.

LinksExtensive evidence supports the care recommendations in this Guide. Selected references as well as practical tools are available on the Campaign intranet and websites.


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Improve Critical Care - 1000livesplus.wales.nhs.uk … · Web viewThe evidence base behind the implementation of Sepsis Care Bundles/Pathway: Early recognition of severe sepsis

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