Early Rescue:Improving Transitions in Patient Care

“Building Blocks in British Columbia”PANBC

October 29th, 2011

Acknowledgements

• SHAIPE faculty– Surgical Healthcare Associated Infection Prevention Excellence

• Kim MacFarlane, CNS Critical Care• Lorna Jensen, CNE PACU, RCH• Jennifer Roy, UBC MSN student

Goals for today

• Failure to rescue literature• Early rescue movement

– Transitions in care

• Implications for nursing practice

So, what’s the problem ?

• Patients have been harmed or died as a result of failure to rescue

• Communication breakdown is responsible a lot of the time

• Transitions in care is a high risk time period for patients

Christian’s Story

Failure to Rescue

• In 2004, the IHI, along with the Joint Commission, identified FTR as the #1 contributor to hospital deaths

• Top 3 factors in Failure to Rescue– Failure to recognize early signs of deterioration – Failure to assess/plan– Failure to communicate

• High risk period: Transfer of Care

Guidelines for Practice

The Canadian Adverse Events Study – Drs G. Ross Baker, Peter G. Norton

• the first Canadian study (2004) to provide a national estimate of the incidence of AEs across a range of hospitals

• Findings on the incidence of adverse events among hospital patients:– almost 2.5 million annual hospital

admissions in Canada– 185 000 are associated with an AE and

close to 70 000 of– these are potentially preventable.

So How Do We Fix the Problem?

Early Rescue• Identifying risk and

recognizing early signs of deterioration

• Serial assessments, planning

• Taking action, escalating care – communicating the situation

Critical Thinking

Tools to Support Practice

• Decision-making support– Mews– Code blue review

• Clinical support tools– Algorithms

• Communication tools– SBAR

• Policies– MRP

Critical Care Reviews

PART 2: Comprehensive Code Blue Review Tool

For Quality Improvement Purposes

Only

PHN:____________________________________ Gender: Female Male

Age:______yrs Unit:_______ Event Date:_______________ Time:__________hr Review Date:______________ Time:__________hrs

A) REASON FOR REVIEW: See attached - PART 1: Initial Screening Tool for Code Blue Quality Review Additional Information: B) TYPE OF EMERGENT/ARREST SITUATION: i) Emergent Situation (explain): ii) Full Arrest (check presenting finding):

VF/pulseless VT PEA Asystole Bradycardia SVT VT with pulse Respiratory

Was this a witnessed arrest: Yes No C) INITIAL PATIENT OUTCOME: Immediately following the arrest: Survived Deceased If survived, post-arrest location and code status: Critical Care Unit Remains on Nursing Unit Other (state):____________________ Full Code DNR Other (state):____________________ D) CURRENT PATIENT OUTCOME: Remains in hospital Deceased (date/time): ________________________ E) FAMILY CONSIDERATIONS: Have family members requested follow-up information/meeting, or expressed concerns about care:

Yes (describe)

No

Unknown

Identifying High Risk Patients:Risk Factors/Predisposition

• Extremes of age- <1yr and >65yrs

• Surgical or invasive procedures

• Use of broad spectrum antibiotics

• Chronic Illness – DM, CRF, liver disease, heart disease

• Indwelling tubes (foley catheter) and lines (CVC)

• Genetic predisposition septic shock

• Compromised immune status – malnutrition, HIV, cytoxic/ immunosuppressive drugs, alcoholism, malignant neoplasms, solid-organ transplantation

• Primary infections (e.g. pneumonia, urinary tract, cholecystitis, peritonitis)

Kim MacFarlane, FH CNS, Critical Care, May 2011

Principles of Assessments & Planning

• Serial assessments are the foundation for recognition of change

• Trending is critical – connecting the dots• Continuous planning of next steps for patient care

Escalation of Care

Key Steps in the process….• Take action

1. “Takes action (taking action includes advocacy) to promote the provision of safe, appropriate and ethical care to clients (see Glossary for definition of the term “client”)”.

CRNBC Standards of Practice: Responsibility & Accountability

• Determine MRP• Communicate the findings• Document

Is this Patient in the Right Place to get the Right Care at the Right Time?

Do RN Assessments

& Interventions

No response within 10 minutes, repeat page

ANDCall RN in Charge from

another unit for input

Unable to Reach GP

or Specialist

No response within 10 minutes

of 2nd page to MRP

Instability Progressing

Critical Illness

Beginning?

No Improvement

or Worsening

Slight Instability

Monitor closely(q 1 – 2 hours)

Repeat MEWS/Monitoring vital signs

at appropriate intervals

Vital Signs

No improvement or worsening at any timeContact MD or Call a Code if required

Escalation of Care

Get Help Now!

NOTIFYPrepareSBAR

Get Care Level from DNR sheet

Do RN Assessments

& Interventions

LPNs – Inform RN now

MRP Responds within 10 minutesSees pt. within 30

minutes

Right PlaceWith PCCIdentified,

Implemented Documented

Care Plan

Right Care

Call Family to advise

Is Higher Level of Care Needed?

∙ Increased Monitoring?∙ Specialized Equipment?∙ Specialized Meds/Tx?

Who can help problem solve?

∙ PCC, Shift Coordinator∙ RN in Charge, Buddy Unit∙ Consider ICU or ER staff

- Admin on Call

Notify PCC/Charge RN/Site Leader/

Shift Coordinator

Is Code Blue required?

Is RT required?

(Information re Medical –

On- Call to be inserted here)

If no Shift Coordinator, call 898994 Identify your Site, Ask them to Page Administrator on Call

Provide your name and ward’s direct phone number

Cal

l Fam

ily w

ith

Pla

n o

f C

are

Still worried about your

patient?

PCC/Charge RN/Site Leader/Shift Coordinator

Determine if/when to call MRP

Is Code Blue required?

Is RT required?

Are appropriate monitoring

and interventions

available?

Notify MRP

What am I seeing?

What don’t I like?

Patient does not seem

to be doing well

How can I get an MD?

ME

WS

S

core

: 1-

2M

EW

S

Sco

re:

3M

EW

S S

co

re:

≥4 o

r in

cre

ases

b

y 2

in A

NY

Cat

eg

ory

Is Code Blue required?

Is RT required?

Arr

ange

tran

sfer

to

anot

her

unit

or h

ighe

r le

vel o

f car

e pr

n

DRAFT MEWS/Escalation of Care Algorithm v 4.5 October 2010

A

B

C

D

E

F

Communication tools….

• Huddles• SBAR• Handover

Handover

• A fundamental element of safe

patient care

• Development of standard procedures is 1 of the top 5 priorities of the World Health Organization's

• High risk period of time (Roughton & Severs, 1996)

Joint Commission - 2006

PrecautionsExplain what’s expected to be

different or unusual about

the pt

ProblemsExplain what’s

different or unusual about

this pt

PurposeProvide a

rationale for the care plan

PlanDiagnosis,

treatment plan, next steps

PatientName, sex,

age, identifiers,location

The Five P’s

Clinical Handover – Key FactsClinical handover is a high risk scenario for patient safety. Dangers include

discontinuity of care, adverse events and legal claims of malpractice (Wong et al, 2008)

Survey of Australian doctors revealed that 95% believed that there were no formal or set procedures for handover (Bomba and Praska, 2005)

An Australian study of emergency department handover found that in 15.4% of cases, not all required information was transferred, resulting in adverse events (Ye et al, 2007)

Survey of junior doctors in the UK discovered that 83% believe that handover processes were poor. Written handover was rarely received, accounting for only 6% of all handovers (Roughton and Severs, 1996)

A detailed analysis of nursing handover revealed that some handovers promote confusion and did not assist in patient care (Sexton et al, 2004)

Handover is among the most common cause of malpractice claims in the USA, especially among trainees, accounting for 20% of cases (Singh et al, 2007)

A survey among trainees in the USA suggested that 15% of adverse events, errors or near misses involved handover (Jagsi et al, 2005)

Handover

• Joint Commission identified communication was a key factor in 70% of all sentinel events 1

• 94% of nurses identified different nurses give handover in different ways 2

• 82% of nurses agreed a standardized handover was needed

• 85% felt there was need for improvement in the way nurses communicate

1 . The Joint Commission on Accreditation of Health care organizations. Sentinel event statistics (2004). http://www.jointcommission.org/Sentinel !Events/Statistics

2. Clarke et al (2009). The PACT Project: Improving communication at handover. The Medical Journal of Australia, 190 (11), S125-127

Handover

• Physicians identified1 :– The need for more detailed information– The need for nurses to specifically identify the

issue/problem– The importance of nurses having the information at hand

when reporting– The need to know whether standard procedures and

protocols were carried out

1. Clarke et al (2009). The PACT Project: Improving communication at handover. The Medical Journal of Australia, 190 (11), S125-127

Types of Handover

• Nurse shift change• Physician transferring responsibility to another

practitioner• Physician on-call responsibility• Temporary relief coverage i.e. coverage of breaks• Anaesthesiologist report to recovery room nurse• Nursing & physician handover from ER to unit• Handover from in-patient to host hospital,

community, GP

Nurse Handover

• Unique to each unit

• Written, paper

• Verbal: nurse to nurse, audio report, group reports

• Hybrids– At the bedside– Paper and verbal report– time overlap

The most effective handovers include an opportunity for questions

Barriers to Handover

• Lack of education• Resistance of Change• Lack of devoted time to handover• Problems with the physical setting i.e.

confidentiality, noise, disruption• Language barriers between clinicians• Failures in modes of communication i.e. fax

machines, lost notes• Lack of research on best-practices for handover• Lack of financial resources for implementation of

standardized practices

Tips for Effective Communication

• Allow for face-to-face communication whenever possible• Ensure 2 way communication• Allow as much time as possible• Use both verbal and written communication• Conduct handoffs at the patient’s bedside whenever

possible• Involve staff in the development of handoff standards• Use communication techniques i.e. SBAR• Clearly outline the the transfer of responsibility• Use technology to streamline templates & processes• Monitor, evaluate, gain feedback from the staff

Peri-Operative Guidelines for Transfer of Patient Care

• The receiving care provider will be notified of the impending transfer

• The receiving care provider will be given a complete report before or at the time of transfer

• Opportunity is provided for questioning between the giver and receiver of patient

ASPAN 2010-12 pg 89

Fraser Health Surgical Program PeriAnesthesia Discharge/Transfer of Care

• Discharge Summary documented on PACU record

• All reports are verbal and written/documented– Telephone or in person– Receiver has an opportunity to ask questions

• Communication tool developed for the receiving units– Assist RN with communication when receiving phone reports– Can be used a worksheet – Notepad; quick & placed by the phones for ease of use

Teamwork Makes it all Work!

• Communication

• Mentorship

• Drawing upon resources– Unit, site leaders– Experienced nurses– Clinical experts

• Collegiality

Questions to Ponder

• What tools or processes would support your unit in identifying early signs of deterioration of patients?

• What guidelines would support your team when responding to a deteriorating patient?

• What are process/tools are in place in your environment for patient handover?

• What tools would improve communication processes for patients coming into your care or transferring to another unit?

So what are the Implications for Nursing Practice?

• Nurses are well positioned to prevent adverse events, failure to rescue

• Standardizing nursing assessment, planning, and communication process & tools improves patient care and patient outcomes

• The decisions and actions of nurses save lives

Resources & References

Patient safety Institute: http://www.patientsafetyinstitute.ca/English/Pages/default.aspx

National Institutes of Health: http://www.iom.edu/

Canadian Adverse Events Study: http://www.cmaj.ca/cgi/content/abstract/170/11/1678

You Tube Huddles:

• Family Medicine (6:62 mins)

• http://www.youtube.com/watch?v=5YC7NxK9vlY

• Planned Care Huddles (3:26 mins)

• http://www.youtube.com/watch?v=Wttxm7jAnb4

• Plastic Surgery Daily huddles (4:16 min)

• http://www.youtube.com/watch?v=dfAnpGgsQbA