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Mobile Intensive Care: Team Approach to Continuous Quality Improvement
presented by
Brent Hobbs RN, BSN, CNCC(c) Regional Director, Patient Transportation Services
March 1, 2013
BC Patient Safety & Quality Council
Objectives
• About Interior Health
• Summary of Challenges
• Mobile ICU Model (High Acuity Response Team)
• Continuous Quality Improvement (CQI)
• Lessons Learned
Interior Health
• Publicly administered • Comprehensive services • 742,000 residents • Size of Oregon • Spans 8 mountain ranges • 16 community hospitals • 4 service area hospitals • 2 tertiary referral
hospitals • To Calgary & Vancouver
for quaternary care
Golden Regional Hospital
Interior Health
Challenge for High Acuity Patients
1. Long Distances to Definitive Care
2. Provincial Ambulance • Basic Life Support Paramedic (Ground Ambulance) Challenge: Clinical gap bridged by rural RN / MD
• Critical Care Paramedic (Air Ambulance) Challenge: Mountains and weather
Impact: Availability of rural medical services
Impact: Quality of care
It doesn’t take much...
… to overwhelm a Rural Hospital
1 Family MD 1 RN Limited Lab Limited DI
Mobile Intensive Care
Regional Hospital
High Acuity Response Team (HART)
HART Overview: ICU “Without Walls”
• Critical Care RN • RRT as required
• Support & stabilize patient at rural hospital
• ICU-level care in transit
• Goals: • Optimal patient care • Keep rural RN/MD in
community
HART Bases
Approach to Continuous Quality Improvement
• Engage the caregiver
• Consult the customer
• Focus on the patient
• Evidence-informed
• Inter-professional
• Accountable
Laying the Foundation for HART
CQI processes don’t need to stick because they are embedded in the program’s design.
Patient
Electronic Registry
Customer
CQI Model
Audit
Care Providers
A Case Study from some beautiful remote location within IHA
High speed MVC-1pt. (unconscious, head, chest, leg injuries)
How did HART perform in this example?
CQI in Action: Clinical/Operational Audit
Quality Assurance Form Mission Review
Form(s)
Patient Care Record
Patient Care Record
CQI in Action: Staff Inform Process
Quality Assurance Form
CQI in Action: Analyze, Action Plan
CQI: Collect Data
• Respiratory Rate • Sp02 • Temperature • Blood Pressure • Heart Rate
Intervention Details from HART PCR Time 0: Pt. unstable on arrival Time 1-2: Low BP, Tachycardia, Tachypnea, Hypoxemia, Combative
• IV sedation, spinal immobilization, intubation, insert chest tube, start fluid bolus Time 5: SaO2 94%; BP low, CVP 8—initiate Voluven bolus Time 9: SaO2 98%; BP 116/78; sedated Time 15: SaO2 98%; CVP 12, BP 126/84 Time 19: Transfer of care from ambulance to receiving facility stretcher
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Time of Vital Signs During Transport
Abnormal Physiology
Normal Physiology
Monitoring Clinical Efficacy
CQI in Action: Communicate, Close Loop
CQI in Action: Accountability & Reporting
In over 1000 transfers to date, HART is meeting the performance benchmark for patient packaging 88% of the time
1. Underestimated workload requirements Manual data entry - Recommend Electronic Patient Care Record (ePCR)
2. Too much emphasis on Operational Benchmarks Recommend Clinical QA Oversight Committee
- Develop & trend clinical benchmarks (e.g. successful intubations)
3. Increase communication with customer Recommend more outreach to enhance rural partnership with HART
- Clinical rounds & education
Brent. Hobbs2@interiorhealth.ca Office: 250-870-5758
Lessons Learned
Brent. Hobbs2@interiorhealth.ca Office: 250-870-5758
• Demmons L.L., James S.E. 2010. ASTNA Standards for Critical Care & Specialty
Ground Transport, 2nd Ed. Greenwood Village: Air & Surface Transport Nurses Association.
• Duncan K.D., McMullan C., Mills B.M. 2012. Early warning systems. Nursing, 42(2), 38-45.
• Jansen J., Cuthbertson B.H. 2010. Detecting critical illness outside the ICU: the role of track and trigger systems. Current Opinion in Critical Care, 16, 184-190.
• Johnson K. 2012. Ground critical care transport. A lifesaving intervention. Critical Care Nurse, 26(1), 80-81.
• Singh J.M., MacDonald R.D., Bronskill S.E., Schull M.J. 2009. Incidence and predictors of critical events during urgent air-medical transport. Canadian Medical Association Journal, 181(9), 579-584.
Brent. Hobbs2@interiorhealth.ca Office: 250-870-5758
References
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