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The Critical Care Outreach Service wasset up in 2001 to improve the earlyrecognition, management and treatmentof the deteriorating patient within theBorders General Hospital.
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The Critical Care Outreach Service was
set up in 2001 to improve the early
recognition, management and treatment
of the deteriorating patient within the
Borders General Hospital.
www.nhsborders.org.uk
Critical Care Outreach
2 3
Contents
Augmented Reality ................................................................................................2, 13
Welcome to the Scottish Borders .........................................................................3
Calum Campbell, Chief Executive ........................................................................4
Ronnie Dornan, Clinical Lead, Critical Care Outreach Team ................................5
Hazel Prentice, Clinical Nurse Specialist, Critical Care Outreach Team ...............6
Lisa Hume, Clinical Nurse Specialist, Critical Care Outreach Team .....................6
Jenny Morrison, Clinical Nurse Specialist, Critical Care Outreach Team .............7
Gill Palmer, Staff Nurse, Emergency Department .................................................7
Nigel Leary, Consultant Anaesthetist, Head of Service - Planned Care ...............8Simon Watkin, Consultant Physician, Head of Service – Medicine & Long Term Conditions ........................................9
Ed James, Consultant Microbiologist ...................................................................10
Jonathan Aldridge, Consultant - Intensive Care ....................................................10
Monitoring Chart ...................................................................................................11
Patient Testimonials ..............................................................................................12
Further Information / Credits ................................................................................16
Augmented Reality
To view additional explanations of the information contained in this booklet please download the free ‘Borders College App’ and scan the images marked with the AR symbol (above).
For full instructions on downloading and subscribing to the NHS Borders 2013 channel please see page 13.
3
Welcome to the Scottish Borders
Borders General Hospital (BGH) is situated on the outskirts of Melrose. The Borders covers a large and scenically beautiful area of the Southern Uplands of Scotland. Predominantly rural, it is historically a unique part of the country, the home of the Border Reivers, where annually each town in the region maintains its links with the past during the season of Common Ridings.
Seven-a-side rugby originated in Melrose and the Melrose event in particular draws large crowds each year. There are also facilities for fishing, golf, swimming, horse riding, mountain bike riding, cricket, football, hiking and many other activities in addition to cultural activities with music and art societies, drama and small theatres in Melrose and Selkirk.
The Scottish Borders offers all the benefits of rural life with easy access to the major cities of Edinburgh, Glasgow and Newcastle. All of this makes the Scottish Borders an enjoyable place to live and work.
With a population of around 113,000 the Borders is thriving. The local economy benefits from an active textiles industry and sustainable farming. At the heart of this community is the people and Borderers take great pride in not only their historical, but also more recent achievements such as Olympic, Grand National and World Rugby success. They also enjoy the many events and activities on offer across the region which covers a huge geographical area. It is this diverse rural community which NHS Borders is proud to serve.
4 5
Calum CampbellChief Executive
NHS Borders is an integrated Health Board in the South East of Scotland and covers a geographical area of approximately 18,002 miles, serving a population of just over 113,000 with around 4000 employees.
NHS Borders provides the full range of Primary Care services such as General Practitioners, Community Nurses and Dentists as well as Allied Health Professionals (Physiotherapists, Occupational Therapists etc) along with Secondary Care services such as Diagnostics, Medicine and Surgery as well as Inpatient and Community based Mental Health Services.
Scan the picture with the free ‘Borders College App’. Once the video starts to play ‘double tap’ the screen to get the full screen presentation.
5
Ronnie DornanClinical Lead, Critical Care Outreach Team
The Critical Care Outreach Service was set up in 2001 to improve the early recognition, management and treatment of the deteriorating patient within the Borders General Hospital. This required a change to the structures and processes within the current system.
An early warning trigger chart was developed, introduced and supported by an intensive ongoing education programme for clinical staff. Abnormal observations are highlighted in yellow boxes and two yellow boxes triggers a referral to the outreach team who attend, assess and examine the patient. Of all patients referred, 90% are managed on the ward by the Outreach Team and ward staff.
Scan the picture with the free ‘Borders College App’. Once the video starts to play ‘double tap’ the screen to get the full screen presentation.
6 7
Hazel Prentice Clinical Nurse Specialist, Critical Care Outreach Team
A nurse would take the observations and then enter these at the top of the early warning chart as is standard practice. The recordings are then transposed into the grid further down the chart and if 2 yellow boxes are hit, the nurse would contact the Critical Care Outreach Team. If there is a suspicion of infection, the sepsis 6 is triggered and there is a prompt at the bottom of the chart.
Scan the picture with the free ‘Borders College App’. Once the video starts to play ‘double tap’ the screen to get the full screen presentation.
Lisa HumeClinical Nurse Specialist, Critical Care Outreach Team
Monitoring ChartSee page 11
TEMP200 40190 38180 36170 34160150140130120110100908070605040
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01:00 03:00 04:00 05:00 06:00 07:00 08:00 09:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 22:00 23:00 24:00
FiO2
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WCC <3 or>123-12
HR >10060-100<60
RR >209-20<9
Temp.>38 or<36
BP Sys >100<100
Peripheral +Hypoperfusion –Urine >40
<40Sweating +
–Confusion +
–SIRS Score
Total
Total
Balance
MONITORINGCHART
If any 2 scores cross into shaded area – inform Outreach Team– check Arterial SaO2Base Excess urgently– inform Medical Staff
NAME OR ADDRESSOGRAPH
DATE:DATE OF ADMISSION:CONSULTANT:
HT
WT
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SPECIMENS
RSOU
MSU
BLOOD CULTURESSPUTUM CULTURES
PREV DAY INPUTOUTPUTBALANCECUMULATIVE
B1095
INPUT
OUTPUT
SIRS SUSPECTED INFECTION = SEPSIS
SEPSIS 61 Start on high flow oxygen
Take Blood Cultures
Give Antibiotics
Give Fluid Bolus
Check Lactate (consider ABG)Measure Hourly urine
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ALL WITHIN ONE HOUR
7
Scan the pictures with the free ‘Borders College App’. Once the video starts to play ‘double tap’ the screen to get the full screen presentation.
Jenny Morrison Clinical Nurse Specialist, Critical Care Outreach Team
The Critical Care Outreach Team have developed a high dependency skills course which is run throughout the hospital. This is open for all staff to attend. It is multidisciplinary taught and multidisciplinary attended. This helps us to achieve hospital wide awareness of the importance of early recognition.
Gill PalmerStaff Nurse, Emergency Department
The Critical Care Outreach Team come down to the Emergency Department to assist with the care of our critically ill patient. We see many patients who are critically unwell and the role of the Emergency Department is to recognise the sick and deteriorating patient and to highlight them to the Critical Care Outreach Team as soon as possible. The team provide their expertise in a timely fashion and this ensures that timely treatment is given where appropriate. It gives good continuity of care for patients and their families when patients are transferred from the Emergency Department to the ward.
8 9
Nigel LearyConsultant Anaesthetist, Head of Service - Planned Care
Since 2001, annual audit has shown an increase in referrals of Critical Care Outreach patients by the Outreach Team to Critical Care Services but 90% of referrals can be managed by the Outreach Team on the wards. This is a result of the lead time enabled through the early warning trigger system. Of the patients that are admitted to Intensive Care, it has been shown that they are admitted with far less organ system derangement so that only 1 system is in jeopardy rather than 2 or 3 and this has resulted in a lower level of intervention being required, and for patients this means a lower length of stay in Intensive Care and outcomes are much improved. The latest Scottish mortality ratios have indicated that over 50% of the patients who are predicted to die survive to be discharged from hospital.Scan the picture with the free ‘Borders College
App’. Once the video starts to play ‘double tap’ the screen to get the full screen presentation.
Introduction of the SIRS (SystemicInflammatory Response Syndrome) early warning chart to all clinical areas
Ronnie Dornan appointed asClinical Nurse Specialist to set up Nurse Lead CriticalCare Outreach Service(Monday - Friday 0900 - 1700)Introduction of a hospital wideeducation programme on the useof SIRS early warning chart to
expedite the early indentification,management and treatment of
sepsis.Introduction of a follow-up servicefor all patients discharged fromCritical Care.
19962001
Technical support to wards onCentral Lines, Tracheostomy care,
Intercostal Chest Drains, Non-InvasiveVentilation.Introduction of multidisciplinary High
Dependency nursing skills course.Introduction of a rotational staffprogramme between Critical Care and ward areas.
2005
Appointment of Specialist NurseHazel Prentice to Outreach Team.(Service expansion to 7 day cover0900 - 1700)
2007 Appointment of Specialist NursesLisa Hume and Jenny Morrison to Outreach Service.
(Service expansion to 7 day cover0900 - 2130)
2008
Scottish Patient Safety Programme(SPSP) SBAR / Safety Brief / GlobalTrigger Tool
2010
Critical Care Outreach presentationat the Royal College of Physicians,London - Ronnie Dornan & Dr Nigel Leary
2009SPSP Learning session - OutreachPresentation - Ronnie Dornan
2012 Chart redesign to incorporate
SEPSIS 6
SPSP Learning session - OutreachPresentation - Ronnie Dornan, Dr Nigel Leary
Critical Care Outreach Timeline
1640outreachreferrals
567ITU discharge
follow up
CCO Annual Workload 2012
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CCO ObjectivesAvert admissions to ITUEnsure timely admission to ITU and
discharge back to wardShare skills and expertise through educational partnershipPromote continuity of careAudit and Evaluation
CCO Team
Critical Care OutreachTeam (l-r)Jenny MorrisonRonnie DornanHazel Prentice
Lisa Hume
Critical Care Outreach Timeline Illustration of poster issued separately.
9
Simon WatkinConsultant Physician, Head of Service – Medicine & Long Term Conditions
Critical Outreach means that if any of my patients are showing significant signs of deterioration, through using the early warning system there is a reliable way of being identified, assessed and treated by the expert team of Nurses within the Outreach Team. Following a contact being made, an Outreach Nurse will arrive promptly and will be able to make an expert assessment of the patient. By doing that, they may be able to prevent further deterioration of the patient and this will also probably reduce the chance of them needing to be admitted to Intensive Care. For those that need Intensive Care the Nurses will be able to arrange for transfer quickly.
It is also likely that the patient’s length of stay will be shorter, their chance of dying will be reduced and risk of further complications will also be reduced by keeping a patient on a general ward whenever possible.
Critical Care Outreach is a way of putting into practice all the recommendations that have come from studying unnecessary mortality and morbidity in hospital patients, the ability to rapidly assess people who are deteriorating and the ability to stabilise them as quickly as possible and if necessary transfer them to an intensive care setting. If I was a patient I would be very pleased to see the Critical Care Outreach Team coming to see me if I knew that my condition was getting worse. For me, it’s about the right person being in the right place at the right time.
Scan the picture with the free ‘Borders College App’. Once the video starts to play ‘double tap’ the screen to get the full screen presentation.
10 11
Ed JamesConsultant Microbiologist
Sepsis 6 is a series of 6 actions which should be performed within 1 hour of a patient developing sepsis. In this context, sepsis is defined as a patient with 2 or more markers of systemic inflammatory response and a clinical suspicion that infection is driving the process.
The 6 actions are:
• administer high flow oxygen• administer intravenous fluids• take a sample for blood culture• administer appropriate intravenous anti-
biotics• take a sample for blood lactate• commence urine output measurement.
In NHS Borders ensuring these actions are completed within the hour is facilitated through the Critical Care Outreach Team.
Scan the picture with the free ‘Borders College App’. Once the video starts to play ‘double tap’ the screen to get the full screen presentation.
Jonathan AldridgeConsultant - Intensive Care
To hear additional information regarding the poster (issued separately) scan the picture of Jonathan Aldridge.
Critical Care in the Borders General Hospital
Mean length of stay in ICU and Combined Units (2011)
We have the lowest length of stay in Scotland. We believe that early recognition and rescue of critically ill patients allows a rapid reversal of organ dysfunction
UICU Combined ICU/HDU
Borders General
Hospital
Specialist ICU
Out of hours admissions toICU and Combined Units (2011)
We have a significantly low rate of admission to critical care out of hours. This is in part due tothe early recognition of patients.
UICU Combined ICU/HDU
Borders General
Hospital
Specialist ICU
Our unit is a mixed medical and surgical elective and emergency combined high
dependency and intensive care unit. The graphs below present statistics which
illustrate some of the sucesses that we have had in critical care in the Borders.Some of these successes can be attributed to the input from the critical care
outreach team and its systems as well as the excellent work from the team in
intensive care.
Who We Are
Scottish Standardised Mortality Ratiosin ICU and combined units (2002 - 2011)
The Borders General Hospital is part of a thriving critical care community in Scotland with excellent results.
Standardised Mortality Ratios in ICUand Combined Units (2011)
Mortality in critical care in the Borders continues tobe one of the lowest in Scotland.
UICU Combined ICU/HDU
Borders General
Hospital
Specialist ICU
Dr Jonathan AldridgeCritical Care Consultant
Hospital Outcomes - Track chart for Case Mix Adjusted Hospital Mortality (January 2013)
Summary
Doing well but continual improvement.Multiple factors in our success:• Care bundles • Scottish Safety Patient Programme• Early recognition facilitated by outreach
Part of an excellent multidisciplinary team.
CHARTS
1 & 2
CHARTS
3 & 4
CHART
5
Prepared for Premier IHI visit May 2013. Data from Scottish Intensive Care Society Audit Group 2012. Produced by Borders College.
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Monitoring ChartTE
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12 13
Patient Testimonials
“Throughout the critical stages of my illness they answered questions and put me at ease”
“With the advice I was given by the Critical Care Team I felt confident to go home to recover and to prepare myself for my operation seven weeks later”
“The term Critical Care Outreach was unfamiliar to me but the reality of the care we received at BGH Melrose made a huge difference to our overall experience”“Although our son did not need to be
transferred to ITU we knew that he was being monitored very closely”“
”
“My pain level was managed effectively and every member of staff I encountered treated me with real empathy and respect”
“We may not have been aware of what the Critical Care Outreach programme involved, but the impact of this innovative programme was absolutely vital to us. It is the little things that can make all the difference to patients and close family which is why the structured approach to CCO works so well”
13 ”
Augmented Reality To view additional explanations of the information contained in the booklet or associated poster please download the free ‘Borders College App’ and scan the images marked with the AR symbol (above).
The free app is available from Google Play or iTunes. Search for Borders College.
Getting the Augmented Reality to Work
Open up the ‘App’ on your smartphone or tablet.
To subscribe to the NHS Borders 2013 channel please follow these instructions:
1- Click on the Aerial image on the top left of the screen.
2- Click the arrow image, bottom right, to scroll along to the search function. Click on search.
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Point the camera at the picture to be scanned.
Scan the picture with the free ‘Borders College App’. Once the video starts to play ‘double tap’ the screen to get the full screen presentation. Double tap the screen, when the video is playing, to stop the video.
If you have problems playing the video, close the App and then re open it before trying again.
On rare occasions, if you have problems, you may need to delete the App and then re download it.
1514
Notes
15
Further InformationRonnie DornanClinical Lead, Critical Care Outreach TeamNHS BordersBorders General HospitalMelroseTD6 [email protected]
Jonathon AldridgeConsultant AnaesthetistNHS BordersBorders General HospitalMelroseTD6 [email protected]
CreditsThe production of this publication and the accompanying posters, videos, images and Augmented Reality have been produced in partnership with Borders College E-Learning Team and Publications & Marketing Section. • Project Manager - Suzanne Scott • Videos / Photos - Jason Baxter • Infographic Posters - Niall White • Augmented Reality & Booklet - Cameron Reith • Technical Support - Wullie Mair.
