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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T 20 S

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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