Early Rescue


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Deterioration of a patient can occur at any time in the patient’s journey and eventually they may need critical care intervention or worse. Hear about NHS Ayrshire & Arran’s rescue system and how their model for improvement was used to design, implement and sustain reliable care processes that facilitated a reduction in mortality rates.

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  • We needed immediate and radical change due to dire circumstances
  • Early Rescue

    1. 1. Early Rescue <ul><li>Diane Murray </li></ul><ul><li>Assistant Director Clinical Improvement </li></ul><ul><li>Susan Hannah </li></ul><ul><li>Clinical Improvement Lead </li></ul><ul><li>Eddie Docherty </li></ul><ul><li>Nurse Consultant </li></ul>
    2. 2. Session Aims <ul><li>To Describe; </li></ul><ul><li>Why we needed to improve </li></ul><ul><li>What we needed to do to improve </li></ul><ul><li>How we implemented changes for improvement </li></ul><ul><li>How much we improved </li></ul>
    3. 3. The Burning Platform
    4. 4. The “Burning Platform”
    5. 5. “ NHS hospital scandal which left 1,200 dead 400 of which could not be explained. This could happen again, warn campaigners ” Daily Mail 19 March 2009
    6. 6. Exploring HSMR <ul><li>3x2 Mortality Tool </li></ul><ul><li>50 Consecutive </li></ul><ul><li>Death Reviews </li></ul><ul><li>Exclude Patients </li></ul><ul><li>admitted to palliative </li></ul><ul><li>care facility </li></ul><ul><li>Apply GTT to </li></ul><ul><li>all box 4 </li></ul><ul><li>Validation by 2 external clinicians </li></ul><ul><li>Mediation Plan </li></ul><ul><li>QIS Involvement </li></ul><ul><li>Scottish Government reporting </li></ul>
    7. 7. What did we find? <ul><li>Failures </li></ul><ul><li>Identification of sick patients </li></ul><ul><li>Planning and execution of care and treatment </li></ul><ul><li>Rescue of deteriorating patients </li></ul>
    8. 8. Back to Basics An approach to improving care delivery to support the rescue of acutely unwell patients Susan Hannah Clinical Improvement Lead
    9. 9. 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
    10. 10. 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’
    11. 11. Improvement Methodology for All <ul><li>SPSP tools and methods to support implementation of improved practices </li></ul><ul><li>Plan-Do-Study–Act (PDSA) cycles to develop improvements in clinical practice </li></ul><ul><li>Engaging all staff to ensure ownership of new ways of working </li></ul>
    12. 12. Measurement for improvement - MEWS <ul><li>Developing an understanding of the value of measurement for improvement </li></ul><ul><li>Introducing new measures </li></ul><ul><li>Involving staff in measuring performance </li></ul><ul><li>Providing feedback and supporting improved practices </li></ul>
    13. 13. SBAR for all <ul><li>Communication for escalation of deteriorating patient </li></ul><ul><li>SBAR developed to support handovers and transfers </li></ul><ul><li>Implemented for all routine and emergency communications </li></ul><ul><li>Becoming the norm – ‘it’s just how we communicate now </li></ul>
    14. 14. Achieving Sustainability <ul><li>Monitoring and evaluating performance by: </li></ul><ul><li>Measuring compliance with MEWS weekly, improvement methodology to drive improvements </li></ul><ul><li>Evaluating quality of exchange using SBAR for escalation of patient concern and ward communication between staff at handover and transfer </li></ul><ul><li>Monitoring daily safety briefs to ensure effectiveness and compliance </li></ul>
    15. 15. Communicating Performance
    16. 16. Improving HSMR Improving ward MEWS and escalation of patient concern contributed to reduced numbers of unplanned admissions to HDU/ICU
    17. 17. Supporting the Emergency Response Team <ul><li>Back to Basics programme: </li></ul><ul><li>Improves staff capacity and capability to quickly identify deterioration </li></ul><ul><li>Ensures effective communication and escalation of findings and concerns </li></ul><ul><li>Improves record keeping and provides accurate documentation of patient observations and interventions </li></ul><ul><li>Increased awareness of safety issues for patients, staff and the environment </li></ul>
    18. 18. Eddie Docherty Nurse Consultant Managing the acutely unwell patient The development of an Emergency Response Team : a practical approach
    19. 19. Role <ul><li>Ward trawl and follow up of identified patients </li></ul><ul><li>Response to sick patients via MEWS or identified criteria only: </li></ul><ul><li>In the absence of the patient’s own team </li></ul><ul><li>or own team unable to respond within </li></ul><ul><li>30 minutes </li></ul><ul><li>All intervention will be fed back to own team </li></ul><ul><li>Rescue only! </li></ul>
    20. 20. Why do we need this team? <ul><li>Continuous clinical quality improvement </li></ul><ul><li>Changing face of ‘the front door’ </li></ul>
    21. 21. The Evidence So far <ul><li>A number of observational studies from Australia and the United States of America have shown </li></ul><ul><li>beneficial effects in reducing cardiac arrests after the introduction of a MET/RRS </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul>
    22. 22. Evidence (2) <ul><ul><li>A large cluster randomized control trial (MERIT) failing to show reduction in cardiac arrests by MET. </li></ul></ul><ul><ul><li>The study was highly under-powered to detect such an effect??? </li></ul></ul><ul><li>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. </li></ul>
    23. 23. <ul><li>Are we asking the right questions? </li></ul><ul><li>HSMR figures </li></ul><ul><li>Advanced metrics </li></ul>
    24. 24. Call-out criteria <ul><li>General Ward </li></ul><ul><li>High care area </li></ul>
    25. 25. <ul><li>Emergency Response call-out criteria – </li></ul><ul><li>High Dependency </li></ul><ul><li>Airway </li></ul><ul><ul><li>Any airway compromise </li></ul></ul><ul><li>Breathing </li></ul><ul><ul><li>Marked respiratory distress / progressive dyspnoea </li></ul></ul><ul><li>Marked change in respiratory pattern unrelieved by nursing interventions </li></ul><ul><li>Marked de-saturation unrelieved by nursing interventions </li></ul><ul><li>Circulation </li></ul><ul><ul><li>Impending circulatory collapse </li></ul></ul><ul><li>Marked haemodynamic compromise despite nursing intervention </li></ul><ul><li>Sustained symptomatic dysrythmia </li></ul><ul><li>Disability </li></ul><ul><ul><li>Acute change in mental state </li></ul></ul><ul><li>Decreased responsiveness (new, persistent) </li></ul><ul><li>Seizure activity (new, persistent) </li></ul><ul><li>Exposure </li></ul><ul><ul><li>Uncontrolled pain despite treatment </li></ul></ul><ul><ul><li>Staff concern </li></ul></ul><ul><ul><li>Uncontrolled bleeding </li></ul></ul><ul><li>Emergency Response Team call-out criteria – General Ward Area </li></ul><ul><li>Airway </li></ul><ul><ul><li>Any airway compromise </li></ul></ul><ul><li>Breathing </li></ul><ul><ul><li>Respiratory distress/ progressive dyspnoea </li></ul></ul><ul><li>Respirations less than 8/min or greater than 30 min (new, persistent) </li></ul><ul><li>Sa02 less than 88 per cent on oxygen (new, persistent) </li></ul><ul><li>Increase in oxygen requirements to 50% </li></ul><ul><li>Circulation </li></ul><ul><ul><li>HR >130 or HR< 40 </li></ul></ul><ul><li>Blood pressure less than 90mmHg (new, persistent) </li></ul><ul><li>Symptomatic dysrythmia </li></ul><ul><li>Disability </li></ul><ul><ul><li>Acute change in mental state </li></ul></ul><ul><li>Decreased responsiveness (new, persistent) </li></ul><ul><li>Seizure activity </li></ul><ul><li>Exposure </li></ul><ul><ul><li>Uncontrolled pain despite treatment </li></ul></ul><ul><li>Staff concern, for example sustained chest pain despite nursing intervention </li></ul><ul><li>Uncontrolled bleeding </li></ul>
    26. 26. 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 <ul><li>Emergency Response Team callout Criteria </li></ul><ul><li>General Ward Area </li></ul><ul><li>Airway </li></ul><ul><ul><li>Any airway compromise </li></ul></ul><ul><li>Breathing </li></ul><ul><ul><li>Respiratory Distress/ progressive dyspnoea </li></ul></ul><ul><ul><li>Respirations less than 8/min or greater than 30 min(new, persistent) </li></ul></ul><ul><ul><li>Sa02 less than 88% on oxygen(new, persistent) </li></ul></ul><ul><ul><li>Increase in oxygen requirements to 50% </li></ul></ul><ul><li>Circulation </li></ul><ul><ul><li>HR >130 or HR< 40 </li></ul></ul><ul><ul><li>Blood pressure less than 90mmHg (new, persistent) </li></ul></ul><ul><ul><li>Symptomatic dysrythmia </li></ul></ul><ul><li>Disability </li></ul><ul><ul><li>Acute change in mental state </li></ul></ul><ul><ul><li>Decreased responsiveness (new, persistent) </li></ul></ul><ul><ul><li>Seizure activity </li></ul></ul><ul><li>Exposure </li></ul><ul><ul><li>Uncontrolled pain despite treatment </li></ul></ul><ul><ul><li>Staff concern e.g. sustained chest pain despite nursing intervention </li></ul></ul><ul><ul><li>Uncontrolled bleeding </li></ul></ul>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
    27. 27. Why ANP’s?
    28. 28. Competence Framework
    29. 29. Log Book and Case note review
    30. 30. <ul><li>Simulator work </li></ul><ul><li>Systems and staff ‘testing’ </li></ul>
    31. 31. <ul><li>It worked in Crosshouse </li></ul><ul><li>SO LETS TAKE IT TO AYR HOSPITAL? </li></ul><ul><li>Same principle- but different players </li></ul><ul><li>So……………… </li></ul>
    32. 32. Engagement <ul><li>Associate director of medicine and nurse consultant ‘road show’ </li></ul><ul><li>Clinical director level / ward manager/ critical care ‘champions’- influencing the key influencers </li></ul><ul><li>Taking it to the wards- not waiting for them to come to us. </li></ul><ul><li>Making sure its safe- </li></ul><ul><ul><ul><ul><ul><li>AND PROVING IT </li></ul></ul></ul></ul></ul><ul><li>one patient & one nurse- one area- one week </li></ul>
    33. 36. <ul><li>Any Questions? </li></ul>