Cardiac Monitoring Unit (CMU)
Hull Royal Infirmary
♥THE
JOURNEY SO FAR..
Diane Rothwell, Project Manager
North & East Yorkshire & Northern
Lincolnshire CHD Collaborative
diane.rothwell@herhis.nhs.uk
REGION & BASE
CMU MICROSYSTEM
Doctors
Nurses
Domestics and caterers
Ward Clerk
Diabetic nurse
PATIENTS
Physio and
Physio Assistants
Pharmacist
Social Worker
Cardiac
Rehab. Nurse
Smoking cessation
officer
Dietician
Paramedics
Scarborough
Bridlington
Grimsby
Ward 80
AAU
Ward 8
Ward 8
HDU
ICU
Ward 6 (CHH)
Ward 80
Ward 7 (CHH)
Combined pr
ICU (CHH)
Chest P Clinic
CMU
MICROSYSTEM
Combined Pr
ECG Dept (o/p
Home
Scunthorpe
Par/Ambulance
Louth
ICU (HRI)
York
Combined Procedures
Private Sector
HDU
Other Hospital
ICU
HDU
Aca. Cardiology
GP/Home
Information Flow
Patient Flow
ENGAGAING PERSONNEL
WITHIN THE MICROSYSTEM
2 WAY COMMUNICATION BOARD
CHALLENGE OF THE MONTH
The CMU Team work
together to Provide
Quality Care That
Reaches the Heart of the
Problem
“Your Heart in Our Hands”
‘P’ATIENTS
Aim: To find out what our patients think about the care and
services we provide.
To carry out Discovery
Interviews
with
Patients’ and their
carers.
PDSA in
Progress
♥ OTHER
PDSA’S PLANNED
♥ Patient Information
♥ Suggestion Box
♥ Patient Questionnaire
Interviews
being
scheduled
DISCOVERY INTERVIEW PDSA
‘P’ERSONNEL
♥ Staff
Survey
♥ Assessment Tool
♥ Online Workforce Survey
‘P’ERSONNEL
I
I would recommend CMU as a great
place to work
would recommend CMU as a great place to
work
12
11
12
11
10
9
8
7
6
5
4
3
2
1
0
10
9
8
7
6
5
4
3
2
1
0
Strongly Agree
Agree
Disagree
Strongly Disagree
Strongly Agree
How easy is it to ask anyone a question about the
w ay w e care for patients?
12
11
10
9
8
7
6
5
4
3
2
1
0
Very Easy
Easy
Difficult
Very Difficult
Agree
Disagree
Strongly Disagree
‘P’ROCESSES
Paramedics
Patient in
ambulanceHRI
Bottle neck - In
rural areas 4045 minute
journey to HRI
5 minutes
VALUE
ADDED
Paramedic
gives asprin
if
appropriate
AAU NurseDiamorphine
given
House
officer
orders
analgesia
Paramedic
gives
VENFLON
Some Junior
doctors
don't use
AMI
pathway and
take full
History
5 minutes
ECG given
to House
officer
(staff grade
doctor)
Bottle neck - In
rural areas lack
of ambulance
can delay time
Ambulance
arrives -Hull
Royal Infirmary
A&E
AAU Nurse
takes ECG
to doctor
Result available on
computer in AAU
(Not CMU)
AAU Nurse
establishes if
asprin
administered
3 minutes
Ambulance arrives
Patient
removed
from
ambulance
into A&E
ambulance
entrance
Onset of chest
pain in patien t
AAU Nurse
Monitors
patient
AAU Nurse
does ECG
Triage nurse
to triage
point
CMU Nurse
set up
monitor and
baseline obs
Consent for
strep gained
- explanation
of issues
for
treatment,
side effects
etc.
CMU SHO
informed
Triage nurse
phones AAU
(dedicated
phone)
Patient transferred
to AAU trolley
3-5 minutes
AAU agree
to take
Paramedics
handover
Digami
Regime
started on
appropriate
patient in
AAU after
30 minute
delay
AAU Nurse Strep tends
to be
finished in
AAU
IF
appropriate
a Cardiology
registrar
may be
called
AAU Doctor
Rings CMU
2 minutes
G P gives
Diamorphine
& Cycizine
Ambulance
crew take
patient to
AAU
2 minutes
AAU nurse
greets
patient
Patient
transferred
to CMU
with:
AAU Nurse
AAU Doctor
AAU Porter
CMU staff
nurse
accepts
patient if
bed
available
This is variable
CMU Staff/
ECG
Technician
ECG
Review at
90 minutes
Bottleneck- Can
take 5 minutes to
12 hours to find
notes that have
not been
received by the
ward
History
taken by
SHO CMU
If fails 90
minutes
ECG
consider
REACT trial
Ring porter
in Theatre
lift
If no bed
CMU staff
decant
patient to
ward 8/80
Bed in CMU
becomes
available
Call bed Coordinator
(Bleep 203)
if no Bed
Physio and/
or CMU
nurses start
Physio 1b
exercises
Rethrombolysed
if needed
CMU
Nursing
staff
introduce
patient to
initial rehab
booklet
If Lysis
successful
CMU staff
nurse
proceeds
with bedrest
and
monitoring
Record 2
hour ECG
by CMU
nurse/ECG
technician
Record each
treatment &
inform
nursing/
medical
staff if any
problems
DailyPhysio finds
out patients
with a
definite MI
and finds
out their
condition
(Mon-Fri)
Porter breaks and
After 10pm general
porter used
Day time -10pm
porter has key.
After 10pm kept in
Cupboard on AAU
Nurse in
charge
reviews
ward
occupancy
(ward 8)
Find
patients who
have moved
wards and
follow to
continue
treatment
Nurse
transfers
patient from
CMU to
Ward 8
Patient may
stay in AAU
Bottle neck O ften beds not
available
Start
inpatient
cardiac
rehab
programme
from
appropriate
stage until
completion
(daily)
Nurse/
Physio
G ive all
relevant
information
required to
aid recovery
Nurse
continues
health
education
Rehab
stages
reiterated by
nurse
Take home
medication
sorted by
SHO and
Pharmacy
Day/Stage 2
Bottleneck - Bed
blocking. If no
beds in CMU
decant other
patients if
required.
(Involve Reg)
Contact Bleep
holder and ward
Nurse/
dietitian/
Physio all
carry out
health
education
Nurse
Identifies
patient
worries and
concerns
Nurse
discusses
discharge
with patients
Nurse
reiterates
stages to
patient
Nurses
involve the
family as
appropriate
Communication
Day/stage 4
Nurse/
Facilitator
gives heart
manual for
patient to
read
Nurse
Checks
CK's
Nurse
checks
patient's
cholesterol
Can refer to
dietitian
Nurse fills in
care
pathway
(not AAU
one)
Dietitian
receives
referral from
from nursing
staff (ward
8 or CMU)
Dietitian sees
patient on
ward for
assessment
and advice
Referral to
social
services
Follow-up
arrangements
made by ward
clerk
Nurse/Physio
continue with
Physiotherapy
Pharmacist
check drug
cards and
gives
patient
education
Nurse carries
out social
assessment
SHO review
Bottle neck
Nurse
explore
patient's risk
factors
Referred to
physiotherapy
Nurse
reiterates
stages to
patient
SHO
Review
Nurse
requests
transport for
discharge
Tests
requested
for postdischarge
Nurse
discusses
medication
with patient
Physiotherapy
Nurse
completes
discharge
letter
Patient
given chest
pain leaflet
by nurse
Nurse
completes
discharge
ECG
Bottleneck
Nurse checks
discharge
arrangements
Nurses gets
date for
R.N.U
Nurse
allocates
bed
Bottle neck- Time
consuming
Meet patient and
explain the role
of
Physiotherapist
Ward clerk
Daily filing
of
casenotes
Nurse
completes
ECG
Nurse in
charge/
named
nurse
Informs
ward clerk &
SHO 's of
transfer
details
SHO
Review
More
physiotherapy
Day/stage 5
O ften
problem in
getting hold
of notes
Nurse in
charge
negotiates
appropriate
inter-ward
transfers to
create bed
space
Nurse or
ECG
technician
carries out
ECG
Inform rehab co-ordinator of
confirmed MI's relaying all patient
admission information from board
and nurse C/P files
Nurse
explains
rehabilitation
Referred to
Cardiac rehab
programme
administrator
Daily Physio
checks
medical
notes and
writes
Patient
O rientated
Medical
Record
(Mon-Fri)
Ward 8
nurse in
charge
discusses
patient
transfer
details with
CMU
Nurse in
charge
allocates
ward bed for
CMU-ward
transfer
Physio
Stage 1a
exercises
by Physio
or CMU
nurse
Facilitate
Heart
Manual
(Daily)
G et AAU
Porter who
has key to
lift
AAU Nurse
Rings CMU
2 minutes
G P Inserts
cannulae
There is
often a
problem
getting old
note for
comparison
of ECG pre
Lysis
Arive on
CMU and
transferred
to bed
10 minutes
AAU Nurse
give strep
Bottle neck Problem in
phoning for
results
Digami
started if
not
completed in
AAU
CMU nurses
complete 30
minute postLysis ECG
O ften case
notes are
not where
the tracing
states they
were. Left in
rooms which
are not
easily
accessible
CMU
nursing
staff inform
patient and
relatives
what is
going to
happen
whist in
hospital O ngoing
throughout
the stay
If entered in
to Trial CMU
nurses and
doctors
follow
REACT
guidelines
Name nurse
introduces
themselves
AAU Makes
up Strep in
treatment
room
VALUE
ADDED
Education
started by
Dietitian if
going onS/C
insulin
Relative
cared for by
CMU nurse
CMU Nurse
establish when
Post Lysis ECG 's need
doing and
order (9-5) out
of hours
nursing staff
do
Ward clerk
books patient
and requests
notes
Imediately on arrival
Strep in
same drugs
cupboard as
controlled
drugs
70 minutes
G P takes
History
VALUE
ADDED
Problem for
oxygen
saturation
3 minutes
1 minute
GP
examines
patient
History
taken by
CMU Nurse
Bottle neck NO written
consent
AAU Nurse
complete
O bservations
Paramedic
rings bell
G P calls 999
and goes to
patient
Access
blood results
by phoning
AAU
2 minutes
3 minutes
Patient Calls
GP
Doctor
takes
history
FBC, U&E,
Bloodsugar,
LKT, CK.
Lipids
3 minutes
Patient calls
999
Check
glucose and
if >11mmPx
then IV
dextrose
and insulin
Asprin given
if not
already
House
officer
assesses
Paramedic
gives
O xygen
G P gives
asprin if
appropriate
CMU nursing &
medical staff
complete
admission
documentation
(written &
clerking in)
AAU nurse
gets
controlled
drugs
AAU walks
to controlled
drugs
cupboard
Nurse reads
medical
notes
CMU and
Ward 8
named
nurse
accept
patient onto
ward and
handover
information
SHO review
Nurse
checks
medication
Bottleneck - ???
Why When how?
Discontinue
monitoring if
appropriate
Day/stage 3
Nurse sets
up cardiac
monitoring
(if telemetry
liaise with
CMU)
CMU Microsystem process for AMI
Consultant/
registrar
review
Nurse
Reiterates
stages
Technician
performs
ECG
Nurse
facilitates
heart
manual
Physiotherapy
Patient discharged
‘P’ROCESSES
Smoking cessation
officer
‘P’ATTERNS
Patients Admited, Transfered In and Out, and Discharged to/from CMU by Hour
3 Month Period
60
50
Deaths
Discharges
Transfers Out
Transfers In
Admits
40
30
20
23
22
21
20
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
0
10
‘P’ATTERNS
TRANSFERS FROM OTHER
HOSPTIALS
400
350
300
250
200
150
100
50
0
20
18
16
14
12
10
33% AMI
6
4
2
INCREASE – WHY?
Statistical Process
Control
Jan-2004
Dec-2003
Nov-2003
Oct-2003
Sep-2003
Aug-2003
0
Jul-2003
c
8
Jun-2003
in
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May-2003
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Apr-2003
N
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Mar-2003
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Feb-2003
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Number of Patients
TOP TEN
The 5 P’s!
Processes
Patterns
Patients
Personnel
Purpose
ASPIRATIONS




Patient Experience
Improve the ‘interface’ with other
Microsystems
Integration ‘service improvement is not
a separate activity’
Ensure that CMU is a place that people
feel happy about coming to work.
Microsystems
has given me
a much
needed boost
of enthusiasm
I feel
privileged to
have had the
experiences
I’ve had
We are
creating a
culture that
supports
service
improvement
I was full of
ideas of how
we could use
the concept in
CMU
I must admit
my initial
thoughts were
somewhat
sceptical
Reflections of
Clinical Microsystems
I feel better
equipped to
suggest ways
in which we
could change
Microsystems
has helped us
explore ways
of improving
communication
Staff feel
empowered to
make small
changes from
within our
microsystem
I contracted
‘microsytemiti
s
Being
involved with
‘Microsystems
’ has made a
difference to
staff morale