Early Rescue

Diane MurrayAssistant Director Clinical Improvement

Susan Hannah Clinical Improvement Lead

Eddie Docherty Nurse Consultant

Session Aims

To Describe;

Why we needed to improve

What we needed to do to improve

How we implemented changes for improvement

How much we improved

The Burning Platform

The “Burning Platform”

AC

AB

AA

Z

Y

X

WV

UT

S

N

R

Q

OP

MLK

J

I

H

GF

E

C

B

D

A

0

1

2

3

4

5

6

0 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000 45,000

Number of Patients

Rat

e(%

)

“NHS hospital scandal which left 1,200 dead 400 of which could not be explained. This could happen again, warn campaigners”

Daily Mail19 March 2009

Exploring HSMR•3x2 Mortality Tool50 Consecutive Death Reviews •Exclude Patientsadmitted to palliativecare facility

•Apply GTT to all box 4

•Validation by 2 external clinicians

•Mediation Plan

•QIS Involvement •Scottish Government reporting

What did we find?

Failures

•Identification of sick patients

•Planning and execution of care and treatment

•Rescue of deteriorating patients

Back to Basics

An approach to improving care delivery to support the rescue of acutely unwell patients

Susan HannahClinical Improvement Lead

What We Needed to Improve

Early recognition of deteriorating patient

Regularity of observations according to clinical concern

Complete and accurate MEWS and action plan recording

Nursing staff escalation where expected

Appropriate response of medical staff to MEWS

Consistent approach to documentation of decision making

Clinical Improvement in Acute Ward Settings

Delivering education at the point of care

Accurate patient observation and MEWS; identifying and responding to patient deterioration

Escalation of patients effectively through SBAR communication at all times

Awareness of patient safety issues through Safety Brief ‘huddles’

Improvement Methodology for All

SPSP tools and methods to support implementation of improved practices

Plan-Do-Study–Act (PDSA) cycles to develop improvements in clinical practice

Engaging all staff to ensure ownership of new ways of working

Measurement for improvement - MEWS

Developing an understanding of the value of measurement for improvement

Introducing new measures

Involving staff in measuring performance

Providing feedback and supporting improved practices

Back to Basics - Improving the Quality of MEWS

Detailed MEWS measurement tool introduced w eekly

Bac

k to

Bas

ics

com

men

ces

staf

f aw

aren

ess

and

trai

ning

Measuring performance of MEWS

w ith short audit tool

50%

60%

70%

80%

90%

100%

3/1

/09

4/1

/09

5/1

/09

6/1

/09

7/1

/09

8/1

/09

9/1

/09

10

/1/0

9

11

/1/0

9

12

/1/0

9

1/1

/10

2/1

/10

3/1

/10

4/1

/10

5/1

/10

6/1

/10

7/1

/10

8/1

/10

9/1

/10

10

/1/1

0

11

/1/1

0

11

/1/1

0

12

/1/1

0

1/1

/11

2/1

/11

3/1

/11

4/1

/11

5/1

/11

Date

SBAR for all

Communication for escalation of deteriorating patient

SBAR developed to support handovers and transfers

Implemented for all routine and emergency communications

Becoming the norm – ‘it’s just how we communicate now

Back to Basics - SBAR Exchanges of High Quality

Reinforce SBAR quality w ith staff

1:1 staff education to improve quality of SBAR exchanges

Intr

oduc

tion

of B

ack

to B

asic

s in

crea

sed

min

torin

g an

d ed

ucat

ion

in th

e w

ard

50%

60%

70%

80%

90%

100%

3/1/

09

4/1/

09

5/1/

09

6/1/

09

7/1/

09

8/1/

09

9/1/

09

10/1

/09

11/1

/09

12/1

/09

1/1/

10

2/1/

10

3/1/

10

4/1/

10

5/1/

10

6/1/

10

7/1/

10

8/1/

10

9/1/

10

10/1

/10

11/1

/10

11/1

/10

12/1

/10

1/1/

11

2/1/

11

3/1/

11

4/1/

11

5/1/

11

Date

Achieving Sustainability

Monitoring and evaluating performance by:

• Measuring compliance with MEWS weekly, improvement methodology to drive improvements

• Evaluating quality of exchange using SBAR for escalation of patient concern and ward communication between staff at handover and transfer

• Monitoring daily safety briefs to ensure effectiveness and compliance

Communicating Performance

Improving HSMR

Jun 08, Jun 09 & Jun 10 HSMR Reviews Top 5 Trigger Comparisons

0

2

4

6

8

10

12

14

16

18

20

M8 - Antiemetics G4 -Readmission to

hospital within 30days

G5 - Shock orcardiac arrest

G2 - Any patientfall

G3 - PressureUlcer

L13 - Nosocomialpneumonia

L11 - HospitalAcquired Infection

G1 - Lack of earlywarning score or

early warningscore requiring

response

I2 - Unplannedtransfer to ICU or

HDU

Trigger

To

tal

Jun 2008

Jun 2009

Jun 2010

Improving ward MEWS and escalation of patient concern contributed to reduced numbers of unplanned admissions to HDU/ICU

Supporting the Emergency Response Team

Back to Basics programme:

• Improves staff capacity and capability to quickly identify deterioration

• Ensures effective communication and escalation of findings and concerns

• Improves record keeping and provides accurate documentation of patient observations and interventions

• Increased awareness of safety issues for patients, staff and the environment

Eddie Docherty Nurse Consultant

Managing the acutely unwell patient The development of an Emergency Response Team :

a practical approach

Role

• Ward trawl and follow up of identified patients• Response to sick patients via MEWS or

identified criteria only:

In the absence of the patient’s own team

or own team unable to respond within

30 minutes• All intervention will be fed back to own team

• Rescue only!

Why do we need this team?

• Continuous clinical quality improvement

• Changing face of ‘the front door’

The Evidence So far

A number of observational studies from Australia and the United States of America have shown

beneficial effects in reducing cardiac arrests after the introduction of a MET/RRS

• Buist MD, Moore GE, Bernard SA, et al. (2002) Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study. BMJ. 324(7334): 387-390.

• Bellomo R, Goldsmith D, Uchino S, et al. (2003) A prospective before-and-after trial of a medical emergency team. Med J Aust. 179(6): 283-287.

• DeVita MA, Braithwaite RS, Mahidhara R, et al. (2004) Use of medical emergency team responses to reduce hospital cardiopulmonary arrests. Qual Saf Health Care. 13(4): 251-254.

• Offner PJ, Heit J, Roberts R. (2007) Implementation of a rapid response team decreases cardiac arrest outside of the intensive care unit. J Trauma. 62(5): 1223-1227; discussion 1227-1228.

• Hillman K, Chen J, Cretikos M, et al. (2005) Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet. 365(9477): 2091-2097.

Evidence (2)

– A large cluster randomized control trial (MERIT) failing to show reduction in cardiac arrests by MET.

– The study was highly under-powered to detect such an effect???

• Hillman K, Chen J, Cretikos M, et al. (2005) Introduction of the medical emergency team (MET) system: a cluster- randomised controlled trial. Lancet. 365(9477): 2091-2097.

• Are we asking the right questions?

• HSMR figures

• Advanced metrics

Call-out criteria

• General Ward

• High care area

• Emergency Response call-out criteria – • High Dependency

• Airway– Any airway compromise

• Breathing– Marked respiratory distress / progressive dyspnoea

• Marked change in respiratory pattern unrelieved by nursing interventions

• Marked de-saturation unrelieved by nursing interventions

• Circulation– Impending circulatory collapse

• Marked haemodynamic compromise despite nursing intervention

• Sustained symptomatic dysrythmia

• Disability– Acute change in mental state

• Decreased responsiveness (new, persistent)• Seizure activity (new, persistent)

• Exposure– Uncontrolled pain despite treatment– Staff concern – Uncontrolled bleeding

• Emergency Response Team call-out criteria – General Ward Area

• Airway– Any airway compromise

• Breathing– Respiratory distress/ progressive dyspnoea

• Respirations less than 8/min or greater than 30 min (new, persistent)

• Sa02 less than 88 per cent on oxygen (new, persistent)

• Increase in oxygen requirements to 50%

• Circulation– HR >130 or HR< 40

• Blood pressure less than 90mmHg (new, persistent)• Symptomatic dysrythmia

• Disability– Acute change in mental state

• Decreased responsiveness (new, persistent)• Seizure activity

• Exposure– Uncontrolled pain despite treatment

• Staff concern, for example sustained chest pain despite nursing intervention

• Uncontrolled bleeding

Patient in Cardiac Arrest?

Does the Patient meet the ERT call out criteria or are they triggering a MEWS >4

NO

Activate the Cardiac Arrest team via 2222

YES

Emergency Response Team callout Criteria General Ward Area

AirwayAny airway compromise

BreathingRespiratory Distress/ progressive dyspnoeaRespirations less than 8/min or greater than 30 min(new, persistent)Sa02 less than 88% on oxygen(new, persistent)Increase in oxygen requirements to 50%

CirculationHR >130 or HR< 40Blood pressure less than 90mmHg (new, persistent)Symptomatic dysrythmia

DisabilityAcute change in mental stateDecreased responsiveness (new, persistent)Seizure activity

ExposureUncontrolled pain despite treatmentStaff concern e.g. sustained chest pain despite nursing interventionUncontrolled bleeding

Contact Patients own team, develop a continuing plan of care

Patients own team unavailable or unable to attend in 30 mins or request ERT activation

Activate the

Emergency

Response team*

ERT team Assess and initiate appropriate intervention

Contact Patients own team and develop a continuing plan of care

Documentation by ERT, follow up protocol activated

ERT Activation and feedback Pathway

* Dial 0 Switchboard and ask them to fast page the Emergency Response Team

Why ANP’s?

Competence Framework

Log Book and Case note review

• Simulator work

• Systems and staff ‘testing’

It worked in Crosshouse

SO LETS TAKE IT TO AYR HOSPITAL?

Same principle- but different players

So………………

Engagement

• Associate director of medicine and nurse consultant ‘road show’

• Clinical director level / ward manager/ critical care ‘champions’- influencing the key influencers

• Taking it to the wards- not waiting for them to come to us.

• Making sure its safe- AND PROVING IT

one patient & one nurse- one area- one week

Crosshouse Hospital (excluding maternity and paediatrics)ERT Activity per 1000 OBD

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00

18.00

20.00

22.00

24.00

26.00

Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11

Month

ER

T A

ctivity p

er

10

00

OB

D

ITU Outreach per 1000 OBD ERT Calls per 1000 OBD P.A.R. Assessments per 1000 OBD

NHS Ayrshire & Arran: Crosshouse Hospital. Unadjusted Inpatient Mortality

to April 2011.

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Oct

-06

Nov

-06

Dec

-06

Jan-

07Fe

b-07

Mar

-07

Apr

-07

May

-07

Jun-

07

Jul-0

7A

ug-0

7S

ep-0

7O

ct-0

7N

ov-0

7D

ec-0

7Ja

n-08

Feb-

08M

ar-0

8A

pr-0

8M

ay-0

8Ju

n-08

Jul-0

8A

ug-0

8S

ep-0

8O

ct-0

8N

ov-0

8D

ec-0

8

Jan-

09Fe

b-09

Mar

-09

Apr

-09

May

-09

Jun-

09Ju

l-09

Aug

-09

Sep

-09

Oct

-09

Nov

-09

Dec

-09

Jan-

10Fe

b-10

Mar

-10

Apr

-10

May

-10

Jun-

10Ju

l-10

Aug

-10

Sep

-10

Oct

-10

Nov

-10

Dec

-10

Jan-

11Fe

b-11

Mar

-11

Apr

-11

Month

%

Baseline Period

Baseline Mean = 3%Oct 06 - Dec 07

National Target 15% ____

Local Target 30% _ _ _

Awareness Training Back to Basics. ERT

& Coding Improvements Implemented

Median lines change in relation to shifts in run chart

Increased service pressures

Any Questions?