Transitioning Patients To and From the BC Cancer Agency and Vancouver General Hospital

Transitioning Patients Between

BC Cancer Agency & Vancouver – Acute

Quality Forum

February 27, 2014

Sue Fuller Blamey Darren Kopetsky

Case for Change

Patient Safety Event with a patient transferred from Vancouver General Hospital (VGH) to BC Cancer Agency for an out-patient Radiation Therapy appointment

Collaboration between BC Cancer Agency and Vancouver General Hospital

•Met with leaders, educators, physicians & front-line staff from both Hospitals •Reviewed transfer process between organizations

Transfer of patients from other facilities to Radiation Therapy at BCCA

Radia

tion

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Patie

nt 1. Patient transfers

to BCCA for evaluation for

Radiation Therapy

2. Patient returns to sending facility due to agitation

and disorientation

4. Patient transfers to BCCA escorted

by sending hospital nurse

3. Patient transfer plan created at

sending hospital

5. Patient arrives in Radiation

Therapy Dept at BCCA agitated

and in pain

6. Resident assesses patient and obtains medication from in-

patient unit

7. Nurse draws up medication in

syringe and brings down to RT

8. Resident assesses that

patient has settled but asks nurse to leave medication

with him

9. Patient is transferred to

treatment unit in RT and now requires pain medication

10. Resident gives verbal order to the

sending facility nurse for

medication

11. Sending facility nurse gives medication

14. Patient assessed as

breathing normally with no decreased

RR

16. Resident checks patient

status throughout evening with VGH

nursing staff

12. Staff physician assesses patient

to be stable

15. Patient is transferred back to

VGH

13. RT gives patient Radiation

Therapy

Presenter

Presentation Notes

Vancouver – Acute Services = Vancouver General Hospital, UBC Hospital, GF Strong

Review of Transition Processes

• Realized that the process was really complex with many possible ways for the process to fail •Conducted a Failure Modes Effects Analysis (FMEA) to identify defective process steps and mistake-proof the process •Listed the top 12 ways that the process could fail

Transfer of patients from another facility to Radiation Therapy at BCCA

Radia

tion

Thera

pis

tB

CC

A N

urs

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CC

A S

taff

phys

icia

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BC

CA

phys

icia

n -

re

sident

Nurs

e –

se

ndin

g faci

lity

Patie

nt 1. Patient transfers

to BCCA for evaluation for

Radiation Therapy

2. Patient returns to sending facility due to agitation

and disorientation

4. Patient transfers to BCCA escorted

by sending hospital nurse

3. Patient transfer plan created at

sending hospital

5. Patient arrives in Radiation

Therapy Dept at BCCA agitated

and in pain

6. Resident assesses patient and obtains medication from in-

patient unit

7. Nurse draws up medication in

syringe and brings down to RT

8. Resident assesses that

patient has settled but asks nurse to leave medication

with him

9. Patient is transferred to

treatment unit in RT and now requires pain medication

10. Resident gives verbal order to the

sending facility nurse for

medication

11. Sending facility nurse gives medication

14. Patient assessed as

breathing normally with no decreased

RR

16. Resident checks patient

status throughout evening with VGH

nursing staff

12. Staff physician assesses patient

to be stable

15. Patient is transferred back to

VGH

13. RT gives patient Radiation

Therapy

Failure Modes:1. Nurse not aware

of care plan or Nursing summary2. Does not bring

pain meds3. Care plan lacks pain management

4. Lack of communication

about patient needsFailure Modes:

1. Unclear physician’s order2. Floor nurse not sticking to 7 rights3. No after-hours

transfer policy4. No procedure

for retrieving medications after-

hours

Failure Modes:1. Nurse

uneducated on BCCA protocol

2. Unclear policy on who can give

pain meds in BCCA

3. VGH staff unaware of RT

procedureFailure Modes:

1. No RN communication back to sending

agency2. No MD follow-

up3. Interagency

communication for planning next trip

Transfer Failure Modes

Prior to transfer

• Lack of communication about patient needs • Nurse unaware of patient care plan • Lack of pain management plan prior to transfer • No medication with patient for transfer

During clinic

• Unclear physician orders • No 7 rights of medication administration • No after-hours policy for retrieving medication at BCCA • Nurse uneducated about BCCA RT protocol

Post clinic

• No policy for VCH nurse to give medications • No communication back to sending hospital from BCCA • No written physician follow-up post procedure

07/21/11

Reasons for Failure Modes

Unclear procedures for

transferring patients to and from VCH and

BCCA and retrieving

medications after-hours

Staff at VGH thought BCCA

was part of VGH Minimal

planning prior to transfer

Is the patient too sick to travel

Communication issues between care providers Verbal orders Lack of staff

education

Failure Modes Analysis Worksheet

Analysis of Failure Modes

List Root

Causes Score severity

and probability of recurrence of

each root cause

Identify solutions to mistake-proof each root

cause and failure

Recommendations/Solutions

1. Staff at VGH and BCCA need to communicate verbally and in writing prior to patient transfer

2. VGH staff to contact physician prior to transfer if patient condition changes

3. VGH staff education re: RadiationTherapy procedure

4. Discussion at BCCA MAC re: appropriate use of verbal orders

5. Patient requires pain management plan prior to transfer

Presenter

Presentation Notes

One of the first things that we realized was that there was a lack of verbal and written communication between staff in the two organizations. Both organizations created a checklist. BCCA created a checklist for nurses to learn more about the patient and to identify if the patient is too ill to transfer over. VGH completes their checklist to prepare the patient for transport and identify if the patient is too ill to travel or requires an accompaniment of a nurse. Staff in BCCA and VGH need to contact a physician prior to transfer if the patient is acutely ill to ascertain if the patient should be re-booked for the out-patient appointment at another time or if the BCCA physician can come over to VGH to complete the consultation. VGH staff were not aware that BC Cancer Agency was not part of VGH and was several blocks or 20 minutes away. VGH required education about radiation therapy, including the process, patient requirements to move on and off a CT scan table and the longer duration of some treatments (4 hours at times). BCCA physicians needed to review when to use verbal orders and change practice. Staff needed to be aware that pain management needed to be provided to patients prior to transport as well as other medications. BC Cancer Agency has many chemotherapy medications but not many others so if a patient requires insulin or other medication, the patient would have to come back to VGH.


6. Create intra-facility policy on ability for VGH nurses to give medications at BCCA & after-hours medication procurement at BCCA

7. Education re: 7 rights of medication administration

8. Protocols for giving medication after-hours at BCCA

Presenter

Presentation Notes

6. BC Cancer Agency physicians have privileges at VGH so they are able to document in the VGH chart and write orders for VGH staff to follow. If the VGH nurse is comfortable giving a particular medication that is within his/her scope of practice, then CRNBC and legal council support VGH nurses administering medications at BCCA during transfer. 7. The 7 rights of medication administration education was reviewed as part of the roll out of the new process. 8. BC Cancer Agency created a procedure and process for obtaining after-hours medications. At this time, there was none.

Created Checklists for BCCA and Vancouver – Acute Hospitals

Presenter

Presentation Notes

This is the BC Cancer Agency Transfer checklist. BCCA nurses call over 24 – 48 hours in advance of the in-patient coming to VGH to obtain patient information, and ascertain if the patient is too acutely ill to travel. The patient may be re-booked at a later date, the oncologist may be asked if he/she can travel to VGH for the consult or the patient may be stable enough for transport or require urgent radiation therapy for pain relief.

Created Checklists for BCCA and Vancouver – Acute Hospitals

Presenter

Presentation Notes

This is the VGH transfer checklist. There are a number of important prompts on the checklist including: Is the patient too acutely ill to travel, the number of the BCCA Vancouver Centre to call to speak with a nurse about the patient, pain medication, advance care plan, isolation status, and relevant conditions that staff at BCCA should be aware of. Patients that are certified under the Mental Health Act should be accompanied by a nurse.

Clinical Practice Document Vancouver – Acute

07/21/11

Presenter

Presentation Notes

This shows the VGH guidelines that were implemented in VGH with education to staff.


9. BCCA Communication back to sending facilities 10. PHSA Handovers Framework 11. Patients too ill to transfer should be re-booked

Presenter

Presentation Notes

9. The team found that there was verbal communication about the event at the time, but that BCCA staff cannot document in the VGH patient record, there was no documentation or transfer note back to VGH. BCCA created a simple “Communication Handover form” that would be sent back to VGH if the patient had an adverse event or received medication. 10. This event triggered the PHSA Quality and Safety Department to conduct a best practice literature search and create a Transitions Framework for all of PHSA of the components that ensure a safe transition of care. The PHSA Board also identified Transitions and Handovers as a Board Quality and Safety Goal for the past 3 years in PHSA. 11. One of the main ideas that has come out of the process is that most of these patients have out-patient clinic or treatment appointments booked as out-patients. They then become more acutely ill and get admitted to a hospital. The first question that now comes up as part of the transition checklist discussion involves “is the patient too ill to transfer or can the appointment be re-booked or can the BCCA oncologist see the patient in that hospital (if attached to the Cancer centre). The BCCA is an out-patient clinic with minimal medications, the code team in most centres comes from 911 or the host hospital, and the clinics are not generally set up to care for patients on stretchers.

Further Work on Handovers & Transitions in Both Organizations

Vancouver – Acute •Clinical Practice Document on Transfer of Patients for Tests/Procedures: Patient Accompaniment

• expands use of checklist beyond BCCA • identifies when accompaniment is required, and what to consider when using clinical judgment to establish requirements in other scenarios.

Presenter

Presentation Notes

Vancouver Acute has used this checklist for all transfers to other organizations. It has been very helpful for all staff learn the steps to prepare patients for transport either within VGH or to another organization. Both organizations have gained an appreciation of the work that occurs in both organizations that enables a better working relationship.

Further Work on Handovers & Transitions in Both Organizations

PHSA: Handovers and Transitions Framework Addresses three types of hand-offs (Internal, External, Intra-agency). Each PHSA agency or service must include in their processes and procedures the following core elements: a)Standard mechanism of transfer b)Patient/Caregiver involvement c)Interactive communication d)Comprehensive information e)Review of previous history f)Documentation g)Ensure minimal interruptions

Presenter

Presentation Notes

PHSA to PHSA: Handoffs within the same unit person A to person B (i.e. Break coverage) person A to person C (i.e. Shift to shift) Transitions between units/professionals/locations within the same agency Transition between PHSA agencies or services 2. Between PHSA and Community/providers/external: Transitions from PHSA agency or service to the patient’s home (discharge) Transitions from the PHSA agency or service to community care services / providers /external agency Transitions to PHSA agency or service from the patient’s home (admissions)* Transitions to the PHSA agency or service from community care services / providers /external agency* 3. Between PHSA and different Health Authorities

Reporting, Measuring & Evaluation

Series1, 4

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Number of BCCA Transitioning Events

Next Steps – Roll out to other Health Authorities

•Transfer Checklist rolled out to Fraser Health – Abbotsford & Surrey and now the rest of Fraser Health in progress •Preliminary meetings with Interior Health and Northern Health to implement program •Meetings arranged with Island Health to discuss potential implementation

Key Learnings

• Need to collaborate with key stakeholders to get to the bottom of all root causes of the failures

Partnerships

• Need to understand each other’s process in order to make adjustments to prevent errors

Learning about other

organizations

• Regularly communication after implementation • Re-implementation of staff education and

procedures Communication

Thank you to Original Participants in this Process

Original Team Dr. James Morris

Lise Belanger

Dr. Peter Lim

Dr. Ryan Carlson

Brendan Tomkins

Frankie Goodwin

Janice Dirksen

Karen Janes

Lorraine Blackburn

Darren Kopetsky

Sue Fuller Blamey

VGH & Vancouver Cancer Centre Prab Gill, Jennifer Tabamo, Iryna Clark, Susan HarrisonSalt, Rita Mah, Sarah Hawley, Priscilla Messier, Katherine Garaghan, Lynn Paddon, Jacqueline Rocheleau, Elizabeth Beddard-Huber, Kylie Perrins , Jennifer Rosychuk, Nancy Runzer, Sharon Manship, Mary Flaherty, Sue Fuller Blamey, Tracy Lust ,Jean Carr

Nancy Edge

Original Team – BCCA & VGH

07/21/11

Thank-you to all other BCCA Leaders & Health Authorities

Fraser Health & Fraser Valley Cancer Centre

Sue Gill, Patti Devion, Teresa O’Callaghan, Cherie Taylor, Sharon Brar, Shannon deBruychere, Chantele Pamplin, Lorna Roe, Tammy Currie, Tracy Lust, Savik Sidhu, Joy Sue, FB, Stephanie Aldridge,

Northern Health – Cancer Centre for the North

Ladonna Fehr, Pam Tobin, Della Webb, Andrea Wolowski, Sue Fuller Blamey, Tracy Lust

Interior Health & Sindi Ahulwalia Hawkins Centre for

the Southern Interior Lynda Foley, Heather Cook, June Bianchini, Allison Filewich, John Larmet ,Joyce Pocha, Sandi Broughton Sue Fuller Blamey, Tracy Lust

Island Health & Vancouver Island Centre Kelly Nystedt, Caroline Ehmann, Brenda La Prairie, Kathleen Yue,

Tracy Lust, Sue Fuller Blamey

Keeping Cancer

Patients Safer

Questions?

Health & Medicine

Transitioning Patients To and From the BC Cancer Agency and Vancouver General Hospital