Early Rescue:
Improving Transitions in Patient Care
“Building Blocks in British Columbia”
PANBC
October 29th, 2011
Acknowledgements
• SHAIPE faculty
– Surgical Healthcare Associated Infection Prevention Excellence
• Kim MacFarlane, CNS Critical Care
• Lorna Jensen, CNE PACU, RCH
• Jennifer Roy, UBC MSN student
Goals for today
• Failure to rescue literature
• Early rescue movement
– Transitions in care
• Implications for nursing practice
So, what’s the problem ?
• Patients have been harmed or died as a result of
failure to rescue
• Communication breakdown is responsible a lot of
the time
• Transitions in care is a high risk time period for
patients
Christian’s Story
Failure to Rescue
• In 2004, the IHI, along with the Joint
Commission, identified FTR as the #1
contributor to hospital deaths
• Top 3 factors in Failure to Rescue
– Failure to recognize early signs of deterioration
– Failure to assess/plan
– Failure to communicate
• High risk period: Transfer of Care
Guidelines for Practice
The Canadian Adverse Events Study –
Drs G. Ross Baker, Peter G. Norton
• the first Canadian study (2004) to provide
a national estimate of the incidence of AEs
across a range of hospitals
• Findings on the incidence of adverse
events among hospital patients:
– almost 2.5 million annual hospital
admissions in Canada
– 185 000 are associated with an AE and
close to 70 000 of
– these are potentially preventable.
So How Do We Fix the Problem?
Early Rescue
• Identifying risk and
recognizing early signs
of deterioration
• Serial assessments,
planning
• Taking action, escalating
care – communicating the
situation
Critical Thinking
Tools to Support Practice
• Decision-making support
– Mews
– Code blue review
• Clinical support tools
– Algorithms
• Communication tools
– SBAR
• Policies
– MRP
Critical Care Reviews
PHN:____________________________________
Gender:  Female
Age:______yrs
PART 2: Comprehensive Code
Blue Review Tool
For Quality Improvement Purposes
Only
 Male
Unit:_______
Event Date:_______________ Time:__________hr
Review Date:______________ Time:__________hrs
A) REASON FOR REVIEW:
 See attached - PART 1: Initial Screening Tool for Code Blue Quality Review
Additional Information:
B) TYPE OF EMERGENT/ARREST SITUATION:
i) Emergent Situation (explain):
ii) Full Arrest (check presenting finding):
 VF/pulseless VT
 Bradycardia
 Respiratory
 PEA
 SVT
 Yes
Was this a witnessed arrest:
 Asystole
 VT with pulse
 No
C) INITIAL PATIENT OUTCOME:
Immediately following the arrest:
 Survived
If survived, post-arrest location and code status:
 Critical Care Unit
 Remains on Nursing Unit
 Full Code
 DNR
 Deceased
 Other (state):____________________
 Other (state):____________________
D) CURRENT PATIENT OUTCOME:
 Remains in hospital
 Deceased (date/time): ________________________
E) FAMILY CONSIDERATIONS:
Have family members requested follow-up information/meeting, or
expressed concerns about care:
 Yes (describe)
 Unknown
 No
Identifying High Risk Patients:
Risk Factors/Predisposition
• Extremes of age- <1yr and • Compromised immune
>65yrs
status – malnutrition, HIV,
• Surgical or invasive
cytoxic/
procedures
immunosuppressive
• Use of broad spectrum
drugs, alcoholism,
antibiotics
malignant neoplasms,
• Chronic Illness – DM, CRF,
solid-organ
liver disease, heart disease
transplantation
• Indwelling tubes (foley
catheter) and lines (CVC)
• Primary infections (e.g.
• Genetic predisposition
pneumonia, urinary tract,
septic shock
cholecystitis, peritonitis)
Kim MacFarlane, FH CNS, Critical Care, May 2011
Principles of Assessments & Planning
• Serial assessments are the foundation for
recognition of change
• Trending is critical – connecting the dots
• Continuous planning of next steps for patient care
Escalation of Care
Key Steps in the process….
•
Take action
1. “Takes action (taking action includes advocacy) to promote
the provision of safe, appropriate and ethical care to
clients (see Glossary for definition of the term “client”)”.
CRNBC Standards of Practice: Responsibility & Accountability
•
•
•
Determine MRP
Communicate the findings
Document
Is this Patient in the Right Place
to get the Right Care at the Right Time?
Vital Signs
Do RN
Assessments
& Interventions
Repeat MEWS/
Monitoring vital signs
at appropriate intervals
Monitor closely
(q 1 – 2 hours)
B
What am
I seeing?
What don’t
I like?
Progressing
Critical
Illness
Beginning?
Do RN
Assessments
& Interventions
Is RT required?
Prepare
SBAR
Get Care Level
from DNR sheet
Is Code Blue
required?
LPNs –
Inform RN now
C
MRP Responds
within 10 minutes
Sees pt. within 30
minutes
With PCC
Identified,
Implemented
Documented
Call Family
to advise
Right Place
Right Care
No
or
Worsening
Determine if/
when to call MRP
Care Plan
Notify MRP
Improvement
PCC/Charge
NOTIFY RN/
Site Leader/Shift Coordinator
D
Are appropriate
monitoring
and
interventions
available?
Is Higher Level of
Care Needed?
∙ Increased Monitoring?
∙ Specialized Equipment?
∙ Specialized Meds/Tx?
Notify PCC/
Charge RN/
Site Leader/
Shift
Coordinator
Is RT required?
Who can help
problem solve?
Is Code Blue
required?
∙ PCC, Shift Coordinator
∙ RN in Charge, Buddy Unit
∙ Consider ICU or ER staff
- Admin on Call
E
How can I get
an MD?
Escalation
of Care
Get Help Now!
F
Still worried
about your
patient?
No response within 10
minutes, repeat page
AND
Call RN in Charge from
another unit for input
Is RT required?
Is Code Blue
required?
No response
within 10 minutes
of 2nd page to
MRP
Unable to
Reach GP
or
Specialist
If no Shift Coordinator, call 898994
Identify your Site, Ask them to Page Administrator on Call
Provide your name and ward’s direct phone number
(Information
re Medical –
On- Call to be
inserted here)
Call Family with Plan of Care
MEWS
Score: 3
Patient does
not seem
to be doing
well
Slight
Instability
Instability
MEWS Score: ≥4 or increases
by 2 in ANY Category
DRAFT MEWS/Escalation of Care Algorithm
v 4.5 October 2010
A
Arrange transfer to
another unit or higher
level of care prn
MEWS
Score: 1- 2
No improvement or worsening at any time
Contact MD or Call a Code if required
Communication tools….
• Huddles
• SBAR
• Handover
Handover
• A fundamental element of safe
patient care
• Development of standard procedures is 1 of the
top 5 priorities of the World Health
Organization's
• High risk period of time (Roughton & Severs,
1996)
Joint Commission - 2006
Patient
Name, sex,
age, identifiers,
location
Precautions
Explain what’s
expected to be
different or
unusual about
the pt
Plan
Diagnosis,
treatment plan,
next steps
The Five P’s
Problems
Explain what’s
different or
unusual about
this pt
Purpose
Provide a
rationale for the
care plan
Clinical Handover – Key Facts
Clinical handover is a high risk scenario for patient safety. Dangers include
discontinuity of care, adverse events and legal claims of malpractice
(Wong et al, 2008)
Survey of Australian doctors revealed that 95% believed that there were no
formal or set procedures for handover (Bomba and Praska, 2005)
An Australian study of emergency department handover found that in 15.4%
of cases, not all required information was transferred, resulting in
adverse events (Ye et al, 2007)
Survey of junior doctors in the UK discovered that 83% believe that
handover processes were poor. Written handover was rarely received,
accounting for only 6% of all handovers (Roughton and Severs, 1996)
A detailed analysis of nursing handover revealed that some handovers
promote confusion and did not assist in patient care (Sexton et al, 2004)
Handover is among the most common cause of malpractice claims in the
USA, especially among trainees, accounting for 20% of cases (Singh et
al, 2007)
A survey among trainees in the USA suggested that 15% of adverse events,
errors or near misses involved handover (Jagsi et al, 2005)
Handover
• Joint Commission identified communication was a
key factor in 70% of all sentinel events
• 94% of nurses identified different nurses give
handover in different ways
• 82% of nurses agreed a standardized handover
was needed
• 85% felt there was need for improvement in the
way nurses communicate
1
2
. The Joint Commission on Accreditation of Health care organizations. Sentinel event statistics (2004). http://www.jointcommission.org/Sentinel
!Events/Statistics
2. Clarke et al (2009). The PACT Project: Improving communication at handover. The Medical Journal of Australia, 190 (11), S125-127
1
Handover
• Physicians identified :
1
– The need for more detailed information
– The need for nurses to specifically identify the
issue/problem
– The importance of nurses having the information at hand
when reporting
– The need to know whether standard procedures and
protocols were carried out
1. Clarke et al (2009). The PACT Project: Improving communication at handover. The Medical Journal of Australia, 190 (11), S125-127
Types of Handover
• Nurse shift change
• Physician transferring responsibility to another
practitioner
• Physician on-call responsibility
• Temporary relief coverage i.e. coverage of breaks
• Anaesthesiologist report to recovery room nurse
• Nursing & physician handover from ER to unit
• Handover from in-patient to host hospital,
community, GP
Nurse Handover
• Unique to each unit
• Written, paper
• Verbal: nurse to nurse, audio report, group reports
• Hybrids
– At the bedside
– Paper and verbal report
– time overlap
The most effective handovers
include an opportunity for questions
Barriers to Handover
•
•
•
•
•
•
•
•
Lack of education
Resistance of Change
Lack of devoted time to handover
Problems with the physical setting i.e.
confidentiality, noise, disruption
Language barriers between clinicians
Failures in modes of communication i.e. fax
machines, lost notes
Lack of research on best-practices for handover
Lack of financial resources for implementation of
standardized practices
Tips for Effective Communication
•
•
•
•
•
•
•
•
•
•
Allow for face-to-face communication whenever possible
Ensure 2 way communication
Allow as much time as possible
Use both verbal and written communication
Conduct handoffs at the patient’s bedside whenever
possible
Involve staff in the development of handoff standards
Use communication techniques i.e. SBAR
Clearly outline the the transfer of responsibility
Use technology to streamline templates & processes
Monitor, evaluate, gain feedback from the staff
Peri-Operative Guidelines for Transfer of Patient Care
• The receiving care provider will be notified of the impending
transfer
• The receiving care provider will be given a complete report
before or at the time of transfer
• Opportunity is provided for questioning between the giver
and receiver of patient
ASPAN 2010-12 pg 89
Fraser Health Surgical Program PeriAnesthesia
Discharge/Transfer of Care
• Discharge Summary documented on PACU record
• All reports are verbal and written/documented
– Telephone or in person
– Receiver has an opportunity to ask questions
• Communication tool developed for the receiving units
– Assist RN with communication when receiving phone reports
– Can be used a worksheet
– Notepad; quick & placed by the phones for ease of use
Teamwork Makes it all Work!
• Communication
• Mentorship
• Drawing upon resources
– Unit, site leaders
– Experienced nurses
– Clinical experts
• Collegiality
Questions to Ponder
• What tools or processes would support your unit
in identifying early signs of deterioration of
patients?
• What guidelines would support your team when
responding to a deteriorating patient?
• What are process/tools are in place in your
environment for patient handover?
• What tools would improve communication
processes for patients coming into your care or
transferring to another unit?
So what are the Implications for Nursing Practice?
• Nurses are well positioned to prevent adverse
events, failure to rescue
• Standardizing nursing assessment, planning, and
communication process & tools improves patient
care and patient outcomes
• The decisions and actions of nurses save lives
Resources & References
Patient safety Institute: http://www.patientsafetyinstitute.ca/English/Pages/default.aspx
National Institutes of Health: http://www.iom.edu/
Canadian Adverse Events Study: http://www.cmaj.ca/cgi/content/abstract/170/11/1678
You Tube Huddles:
• Family Medicine (6:62 mins)
• http://www.youtube.com/watch?v=5YC7NxK9vlY
• Planned Care Huddles (3:26 mins)
• http://www.youtube.com/watch?v=Wttxm7jAnb4
• Plastic Surgery Daily huddles (4:16 min)
• http://www.youtube.com/watch?v=dfAnpGgsQbA