Managing the Deteriorating Patient from a Nurse Practitioner led Rapid Response team perspective
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Transcript of Managing the Deteriorating Patient from a Nurse Practitioner led Rapid Response team perspective
Nurse Practitioner
led Rapid Response
Team perspective
Anna Green
Manager ICU Liaison service
Critical Care Nurse Practitioner
2013 ICU Liaison Team
• Gary Blackburn
– Lead Deteriorating Patient Rounding
• Grace Campbell
– Lead Sustainable ISBAR
• Nicola Donohoe
– Lead ICU Discharge and follow up guideline
• Michelle Kreusel
– Lead Join the Dots and RRT survey
• Greg Millsom
• Rom Binuya
Chameleon
• Highly specialised
• Colour changing abilities
• Three dimensional vision
• Specialised feet
• Long tongue
In the beginning....
• 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
Solution
• Case manage
patients post ICU
discharge
• To prevent
readmissions
Non Stop Small Challenges
• Complex care course
• Pager
• Grants – computer
• Office – store room
• Title change
• Reporting change
Non Stop Big Challengers: 3 months post commencement
• Ward referrals for deteriorating patients
• Ramp up calls – closed door culture
• Ordering diagnostic tests
• Prescribing medications
Nurse Practitioner journey started in 1998 through to endorsement in 2004
RAT
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
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
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
2012 Nurse Practitioners in Australia
128
12
179
185
27
94
18
67
Total = 714 (0.21%) nurse practitioners
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Improvement projects along the way
Patient at risk scoring tool
Colour alerts in medical records
ISBAR communication
Join the dots
Riskman rapid response entries
ICU Liaison Patient at Risk Scoring Tool
• RFD from ICU
• ICU follow up
• Repeat reviews
• Discharge from caseload
• Preventable readmissions
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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
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Documentation Documentation
14:25 Nursing notes on the ward
15:30 Admitted to ICU with APO secondary to severe MR
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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
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And the story continues...
Simulation scenarios Colour alerts
Footer Text 20
RRT entry
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Odd one out
Victorian Travelling Fellowship Program
Victorian
Travelling
Fellowship
Program
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Methodology
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
Hello is anyone else out there!
Comparison of Hospital demographics
England Victoria
Hospital bed size 772 315
ICU bed size 19 15
ICU admissions / year 1137 1243
Pts assessed / day 10 7
• 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.
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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
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What has been the biggest impact
0
1
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3
4
5
6
7
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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!
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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.
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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
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Average 51 / 42 increase in referrals
APR MAY JUNE JULY AUG SEPT OCT NOV DEC JAN FEB MAR
Rounding 46 59 50 39 21 32
RRT calls 36 41 38 47 28 42 11 15 23 23 19 28
0
10
20
30
40
50
60
70A
xis
Titl
e
Sunshine RRT / Rounding referrals
Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar
Rounding 70 61 67 44 28 38
RRT calls 56 88 58 64 75 69 67 74 88 95 95 96
0
20
40
60
80
100
120
Axi
s Ti
tle
Western RRT / Rounding referrals
Decreased ICU ward
admissions
Decreased mortality from
unplanned ward admissions
Decreased code blue calls
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ICU Discharge Follow up Criteria
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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
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2012 ICU Liaison service review
Follow up
Deteriorating Patient
Referrals
Extensions to practice Nurse
Practitioner
Travelling Fellowship
Patient Rounding
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What's left to do?
Position statement
National KPIs
National database
National reporting
Outpatient service
Nearly there!
24 Hour coverage business case