Nurse Practitioner
led Rapid Response
Team perspective
Anna Green
Manager ICU Liaison service
Critical Care Nurse Practiti...
2013 ICU Liaison Team
• Gary Blackburn
– Lead Deteriorating
Patient Rounding

• Grace Campbell

• Michelle Kreusel
– Lead ...
Chameleon
•
•
•
•
•

Highly specialised
Colour changing abilities
Three dimensional vision
Specialised feet
Long tongue
In the beginning....

Solution
• Case manage
patients post ICU
discharge
• To prevent
readmissions

• High demand for ICU
...
Non Stop Small Challenges
•
•
•
•
•
•

Complex care course
Pager
Grants – computer
Office – store room
Title change
Report...
Non Stop Big Challengers:
3 months post commencement
• Ward referrals for
deteriorating patients

RAT

• Ramp up calls – c...
1. 1999 Leadership Development
• All RRTs have calling criteria

• Usually based on deranged
vital signs
– Difficulty brea...
2. Nurse Practitioner –phase 2 external
evaluation: La Trobe University (MDS)
•
•
•
•
•
•

Patient Activities
Health asses...
External evaluation continued
•
•
•
•

Consumer focus group
Role confusion
Education provided
Need 24hr service
Comparison...
2012 Nurse Practitioners in Australia

12
179
128

185

67

27
94
18
Total = 714 (0.21%) nurse practitioners
Improvement projects along the way
Patient at risk scoring tool
Colour alerts in medical records

ISBAR communication
Join...
ICU Liaison Patient at Risk Scoring Tool
•
•
•
•

RFD from ICU
ICU follow up
Repeat reviews
Discharge from
caseload
• Prev...
ISBAR Communication
1. VMIA – lead agency

Sessions >42
Participants >350
2. Sustainability

Orientation (monthly)
Incorpo...
Documentation
Documentation
14:25 Nursing notes on the ward

15:30 Admitted to ICU with APO secondary to severe MR

Footer...
Issues:
1. Use of numbers vs joining dots

2. Incorrect recording in wrong space
3. Confusion where to put dot in square
4...
18
And the story continues...
Simulation scenarios

Colour alerts
RRT entry

Footer Text

20
Odd one out

Footer Text

21
Victorian Travelling Fellowship
Program
Victorian
Travelling
Fellowship
Program
Methodology

Hello is anyone
else out there!

England (10)

Pre survey sent to hospitals in England
Site visits to the hos...
Comparison of Hospital
demographics
England

Victoria

Hospital bed size

772

315

ICU bed size
ICU admissions / year
...
Key findings
All nurse led rapid response teams vs 1
65% used weighted score model

Average number of staff = 7 vs 1.8
90%...
What has been the biggest impact
8

7
6
5
4
3
2
1
0

Footer Text

26
ACCCN SIG – ICU Liaison
•
•
•
•
•
•

Support
Communication
Meetings
Research
Sharing information
Position statement
Secondment to DoH
• 3 month secondment
• Sent to CEOs

• Every hospital with an
ICU in Victoria has an
ICU liaison role!
Marked increase in ICU LN services from 2004
More than 120,000 patients were reviewed, most commonly after ICU
discharge
L...
Rounding Project
1.

2hrly rounding to each ward at both Western and Sunshine hospitals

2.

Developed an audit tool

3.

...
Western RRT / Rounding referrals

Average 51 / 42 increase in referrals

120

80
60
40
20
0

Apr May Jun

Jul

Aug Sept Oc...
ICU Discharge Follow up Criteria

Footer Text

32
ICU Liaison Nurse Role
1. Assess patients in the ICU prior to discharge and write a
comprehensive assessment using patient...
2012 ICU Liaison service review
Follow up

Patient
Rounding

Travelling
Fellowship

Footer Text

Deteriorating
Patient
Ref...
What's left to do?
Position statement
National KPIs

National database
National reporting
Outpatient service

Footer Text
...
Nearly there!

24 Hour coverage business case
Managing the Deteriorating Patient from a Nurse Practitioner led Rapid Response team perspective
Managing the Deteriorating Patient from a Nurse Practitioner led Rapid Response team perspective
Managing the Deteriorating Patient from a Nurse Practitioner led Rapid Response team perspective
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Managing the Deteriorating Patient from a Nurse Practitioner led Rapid Response team perspective

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Anna Green, Manager – ICU Liaison Team, Western Health delivered this presentation at the 2013 Managing the Deteriorating Patient conference. The management of patients in clinical deterioration has become a chief concern for Australian hospitals, with a patient’s potential for deterioration existing in every hospital ward and health service across the country. This annual event focusses on improving education for staff caring for these patients, and improving the policies and protocols in place to maintain patient safety. For more information, please visit the event website: www.healthcareconferences.com.au/deterioratingpatients

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Managing the Deteriorating Patient from a Nurse Practitioner led Rapid Response team perspective

  1. 1. Nurse Practitioner led Rapid Response Team perspective Anna Green Manager ICU Liaison service Critical Care Nurse Practitioner
  2. 2. 2013 ICU Liaison Team • Gary Blackburn – Lead Deteriorating Patient Rounding • Grace Campbell • Michelle Kreusel – Lead Join the Dots and RRT survey • Greg Millsom – Lead Sustainable ISBAR • Rom Binuya • Nicola Donohoe – Lead ICU Discharge and follow up guideline
  3. 3. Chameleon • • • • • Highly specialised Colour changing abilities Three dimensional vision Specialised feet Long tongue
  4. 4. In the beginning.... Solution • Case manage patients post ICU discharge • To prevent readmissions • High demand for ICU beds • Ward patients with complex care • Admitted to ICU with preventable causes • Delay in treating deteriorating patients • High transfer rate over the weekend
  5. 5. Non Stop Small Challenges • • • • • • Complex care course Pager Grants – computer Office – store room Title change Reporting change
  6. 6. Non Stop Big Challengers: 3 months post commencement • Ward referrals for deteriorating patients RAT • Ramp up calls – closed door culture • Ordering diagnostic tests • Prescribing medications Nurse Practitioner journey started in 1998 through to endorsement in 2004
  7. 7. 1. 1999 Leadership Development • All RRTs have calling criteria • Usually based on deranged vital signs – Difficulty breathing – RR > 30 – SpO2 < 90% despite high flow oxygen – HR > 120 bpm – Systolic BP < 90 mmHg – UO < 60mL over 2 hours • Staff “worried” about the patient
  8. 8. 2. Nurse Practitioner –phase 2 external evaluation: La Trobe University (MDS) • • • • • • Patient Activities Health assessment Referral – future planning Intervention Diagnostic tests Prescribing Decision Non Patient Activities • Education of staff • Consultation with health professionals • Documenting visits
  9. 9. External evaluation continued • • • • Consumer focus group Role confusion Education provided Need 24hr service Comparisons made with junior doctors – Better understanding of nursing care – Better rapport with nurses – In some cases more knowledgeable than doctors Stakeholder focus group • Anticipation of some conflict of role definition • They would be more credible with education qualifications • Robust analysis of outcome data relating to implementation of the service
  10. 10. 2012 Nurse Practitioners in Australia 12 179 128 185 67 27 94 18 Total = 714 (0.21%) nurse practitioners
  11. 11. Improvement projects along the way Patient at risk scoring tool Colour alerts in medical records ISBAR communication Join the dots Riskman rapid response entries Footer Text 11
  12. 12. ICU Liaison Patient at Risk Scoring Tool • • • • RFD from ICU ICU follow up Repeat reviews Discharge from caseload • Preventable readmissions
  13. 13. ISBAR Communication 1. VMIA – lead agency Sessions >42 Participants >350 2. Sustainability Orientation (monthly) Incorporated into handover/clinical skills/medical education sessions 3. ISBAR A3 Improvement Project Audit / education Improved compliance of using ISBAR form Footer Text 14
  14. 14. Documentation Documentation 14:25 Nursing notes on the ward 15:30 Admitted to ICU with APO secondary to severe MR Footer Text 15
  15. 15. Issues: 1. Use of numbers vs joining dots 2. Incorrect recording in wrong space 3. Confusion where to put dot in square 4. Tds observations 5. Escalation protocol not followed 6. Reportable vital signs not recognised 7. Failure to recognise deterioration Footer Text 17
  16. 16. 18
  17. 17. And the story continues... Simulation scenarios Colour alerts
  18. 18. RRT entry Footer Text 20
  19. 19. Odd one out Footer Text 21
  20. 20. Victorian Travelling Fellowship Program Victorian Travelling Fellowship Program
  21. 21. Methodology Hello is anyone else out there! England (10) Pre survey sent to hospitals in England Site visits to the hospitals in England Research reports returned for verification Australia (10) Preliminary survey sent to hospitals in Victoria Footer Text 23
  22. 22. Comparison of Hospital demographics England Victoria Hospital bed size 772 315 ICU bed size ICU admissions / year 19 1137 15 1243 10 7 Pts assessed / day • 80% of the hospitals visited in England had designated high dependency beds on the general wards that are not managed by the ICU compared to 12% of the hospitals in Victoria. • One hospital in Victoria had established an ICU LN service in a metropolitan hospital without an ICU.
  23. 23. Key findings All nurse led rapid response teams vs 1 65% used weighted score model Average number of staff = 7 vs 1.8 90% worked 50% clinical & 50% non-clinical 65% covered 24hrs per day 100% ordered diagnostic tests Majority had standing orders Footer Text 25
  24. 24. What has been the biggest impact 8 7 6 5 4 3 2 1 0 Footer Text 26
  25. 25. ACCCN SIG – ICU Liaison • • • • • • Support Communication Meetings Research Sharing information Position statement
  26. 26. Secondment to DoH • 3 month secondment • Sent to CEOs • Every hospital with an ICU in Victoria has an ICU liaison role!
  27. 27. Marked increase in ICU LN services from 2004 More than 120,000 patients were reviewed, most commonly after ICU discharge Little increase in the EFT for ICU LN services Many hospitals revealed increased ICU LN workload with time. Considerable differences in all measured variables between hospitals. Footer Text 29
  28. 28. Rounding Project 1. 2hrly rounding to each ward at both Western and Sunshine hospitals 2. Developed an audit tool 3. Education provided re clinical marker criteria. Inform NUMs of the rounding project 4. Commenced rounding in the emergency departments 5. Energize and motivate ICU liaison nurse consultants Footer Text 30
  29. 29. Western RRT / Rounding referrals Average 51 / 42 increase in referrals 120 80 60 40 20 0 Apr May Jun Jul Aug Sept Oct RRT calls 56 88 58 64 75 69 Jan Feb Mar 70 Rounding Nov Dec 61 67 44 28 38 67 74 88 95 95 96 Sunshine RRT / Rounding referrals Decreased ICU ward admissions Decreased mortality from unplanned ward admissions Decreased code blue calls 70 60 50 Axis Title Axis Title 100 40 30 20 10 0 APR MAY JUNE JULY AUG SEPT OCT NOV DEC JAN FEB MAR Rounding Footer Text RRT calls 46 36 41 38 47 28 42 59 50 39 21 32 11 15 23 23 19 28 31
  30. 30. ICU Discharge Follow up Criteria Footer Text 32
  31. 31. ICU Liaison Nurse Role 1. Assess patients in the ICU prior to discharge and write a comprehensive assessment using patient at risk score. 2. Provide follow up service for patients leaving ICU who meet ICU follow up discharge criteria 3. Provide a nurse-led rapid response team review for deteriorating patients 4. Minimum daily rounding to emergency departments and all clinical areas at WH and SH 33 Footer Text 33
  32. 32. 2012 ICU Liaison service review Follow up Patient Rounding Travelling Fellowship Footer Text Deteriorating Patient Referrals Extensions to practice Nurse Practitioner 34
  33. 33. What's left to do? Position statement National KPIs National database National reporting Outpatient service Footer Text 35
  34. 34. Nearly there! 24 Hour coverage business case

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