Long Term Mechanical Ventilation Transitioning Patients from CrCU to an Enhanced Care Unit to...
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Long Term Mechanical Ventilation Transitioning Patients from CrCU to an Enhanced Care Unit to Improve Patient Flow CACCN Evolutions in Critical Care 2014
Long Term Mechanical Ventilation Transitioning Patients from
CrCU to an Enhanced Care Unit to Improve Patient Flow CACCN
Evolutions in Critical Care 2014
Slide 2
Darlene Baldaro, BSc, RRT, PPL/Clinical Respiratory Educator,
Respiratory Therapy and Professional Practice Tina Chopra BScN, RN,
Clinical Nurse Educator, Neuro-Stroke Medicine Unit Danielle
Ferreira, RN, BScN, BHSc, Clinical and Special Projects
Coordinator/Critical Care Response Team Co-Lead, Critical Care
Department
Slide 3
Background 2004/05: Ministry launched Critical Care
Transformation Strategy Purpose: improve quality of care and system
performance in adult critical care services 1 Findings: Critical
care bed capacity increasingly limited across province 1
Contributing factor to shortage - use of ICU beds for medically
stable chronically ventilated patients 1 No ad equate alternative
setting appropriate for these patients 1 1.Chronic Ventilation
Strategy Task Force Final Report, June 30, 2006
Slide 4
Long Term Mechanical Ventilation Patients Those patients
suffering from a severe respiratory impairment who require
ventilatory support for more than 6 hours per day for more than 21
days, but who do not require additional services provided by a
CrCU. 1 LTMV Chronic Ventilation Strategy Task Force Final Report,
June 30, 2006; page 11.
Slide 5
Patient 19 year old male with Duchenne muscular dystrophy PMHx:
wheelchair bound, cardiomyopathy Suffered a left MCA stroke
complicated by aspiration pneumonia Admitted to KGH then
transferred to NYGH Intubation Trach Failed TM trials, PAV trials
considered ventilator-dependent Liaised with WPH: Discussions home
or complex care centre Patient and family resistance due to fear of
transition out of ICU
Slide 6
Background Demand for ICU beds for this patient population
projected to increase by 92 - 120% over the next 25 years 1
Historically, these patients remain in ICU until an alternative
care setting is secured in either the community or a chronic
ventilator unit. 1 The wait time for a LTMV bed can be several
months to years. 2 Recognition that we needed to change and invest
in how we manage LTMV patients. 1 1.Chronic Ventilation Strategy
Task Force Final Report, June 30, 2006 2.Long-term Ventilation
Service Inventory Program. Final Report. July 31, 2008.
Slide 7
Background The Ontario Chronic Ventilation Strategy Task Group
was established to address Access to Services and Wait Time
Strategy. 1 Mandate: a.Identify strategies to facilitate the
transfer of medically stable, LTMV patients out of ICUs and into a
more appropriate care settings. 1 b.Prepare a care strategy and
related resource allocation recommendations to address their needs.
1 1.Chronic Ventilation Strategy Task Force Final Report, June 30,
2006
Slide 8
Care Setting 2.Long-term Ventilation Service Inventory Program.
Final Report. July 31, 2008. 2 2 CCC Inpatient medical ward
Slide 9
Interprofessional LTMV Transition Planning Group To improve
patient flow and increase critical care capacity, these patients,
at times, are transferred to an inpatient medical unit. However,
acute care hospitals were surveyed through PPNO and the majority
response indicated this was not common. Our Innovative Solution:
Transition care of LTMV patients from our CrCU to the wards
Slide 10
Enhanced Care Unit (ECU) 3 bed intermediate care unit (not a
step-down) Located on a regular inpatient medical unit (Neurology
& Stroke) Utilized for patients ready for transfer out of the
ICU but have ongoing complex care needs e.g. tracheostomy patients
with frequent suctioning Staffed with ward nurses1 nurse: 2
patients 2 nurses: 3 patients (today) Intermittent monitoring
Slide 11
Transitioning Patients from CrCU to ECU Purpose: To enhance
patient quality of life Improve patient flow with improved bed
turns Improve access to CrCU Increase critical care capacity Better
utilization of resources Interprofessional collaboration
Professional development Maximize scope of practice
Slide 12
Interprofessional LTMV Transition Planning Group
Interprofession al LTMV Planning Group Needs Assessment
Communication Plan IPE Collaborative IP Mentorship & Support
Chronic Ventilator Motorized wheelchair Mobility devices for
ambulation Social media devices CrCU, RRT, Inpatient Unit
interprofessional HCP Coordinated coverage between GIM and CrCU MDs
Patient & Family LTMV Patient Care Plan Teaching package
Interactive education sessions Pre and post confidence survey
Transfer of Care Mentorship eDocumentation Pt Concern Algorithm
Contingency Plan Patient and Family
Slide 13
Project Timeline January 2013 February 2013 March 2013April
2013Future Monthly Transition Planning Meetings Developed Patient
Concern Algorithm Chronic ventilator trial IS documentation
Communication Plan to CrCU and RRT staff Communication re:
physician coverage Developed IP Patient Care Plan Developed
Education Plan Communication to ECU staff IPE provided Allied
Health Team Meeting Communication to Patient/family Transition Go
Live! CrCU Nursing mentorship RRT mentorship Mobility training (PT,
CrCU Team Attendant with Unit RN/PT/PTA Build capacity
Slide 14
Training and Support Interactive workshop 22 participants
Performance skills stations and simulation scenarios Performance
evaluation competency assessment Post evaluation survey
Slide 15
Slide 16
CrCU Interprofessional PFCC Team Patient Family Centred Care
(PFCC)
Slide 17
Mentorship Interprofessional: CrCU Team ECU Team (e.g. RRT RN)
Intraprofessional: CrCU nurses ECU nurses CrCU Allied Health ECU
Allied Health
Slide 18
Inpatient Unit Nursing Response to Mentorship 87.5% responded
to the survey; 100% of respondents were positive It increased my
self-confidence and understanding how to look after patient on
ventilator. They were able to encourage and mentor really well.
Increased confidence. It gives me confidence that somebody is
available in case I needed help. ICU nurses very helpful.
Parameters and when to ask for help with the CCRT and RT was
helpful.
Slide 19
Enhanced Care Unit PFCC Team
Slide 20
Results
Slide 21
Patient Update Transferred to chronic ventilator Family
participation in care Daily outings on hospital grounds; occasional
external outings Visited complex continuing care chronic ventilator
unit Improved quality of life with patient directing their
care
Slide 22
Increased Capacity/Bed Turn in the CrCU Chronic Vent Business
Case Analysis Increase capacity is based on average LOS for our
CrCU patients of 5.1 days applied to the extra bed days made
available by relieving chronic vent pressures Based on the
initiative to move chronic vents out of the CrCU there could be an
increase in annual fiscal capacity/bed turns of: Source: Critical
Care Information System (CCIS)
Slide 23
Conclusion The IP project group identified barriers,
implemented resources and effective strategies to facilitate the
transfer of care of a LTMV patient from the CrCU to an inpatient
medical unit. A vast amount of coordination and collaboration of
education, mentorship and care was completed. The IP, collaborative
PFCC effort between the CrCU, RRT and ECU Teams enabled a
successful transition.
Slide 24
Where We Are Today ECU policy and standard of care Continued
family involvement and training Increased census of patients in the
ECU Model of care is continually evolving; Increase skill mix to
include RPNs Continue to liaise with Alternative Care Settings for
disposition and best practices in LTMV management Need to monitor
efficiencies and effectiveness, i.e. bed turns, surge in CrCU Need
to monitor calculated days for ECU blocked beds
Slide 25
Questions
Slide 26
Special Thanks To: Interprofessional LTMV Planning Group Susan
Woollard, RN, Project Manager Dr. Donna McRitchie, MD Dr. Phil
Shin, MD Millie Paupst, MD Wendy Cheung, RN Marina Bitton, RN
Elizabeth Villar-Guerrero, RN Sandra Ramdeyall, RN Tanya Chinner,
RRT Jo-Ann Fernando, RN Kathy Tossis, PT Tova Milnes, Taheera
Habib, SW Debbie Conway-Chung, RN
Slide 27
References 1.The Chronic Vent Strategy Task Group. Chronic
ventilation strategy task force: final report [Internet]. Toronto:
The Ministry of Health and Long-Term Care; 2006 Jun 30. [cited 2013
Jan]. Available from:
http://www.health.gov.on.ca/english/providers/program/critical_care/docs/report_cvtg.pdf
2.National Long Term Mechanical Ventilation Steering Committee.
Long-term ventilation service inventory program: final summary
report [Internet]. The Ministry of Health and Long-Term Care:
Toronto; 2008 Jul 31. [cited 2013 Jan]. Available from:
http://www.rtso.ca/themes/acquia_marina/pdfs/LTV%20SIP%20Summary%20Report-FINAL.pdf
3.College of Respiratory Therapists of Ontario. Optimizing
respiratory therapy services: a continuum of care from hospital to
home [Internet]. Toronto: The College; 2010 Jun. [cited 2013 Jan].
Available from:
http://www.crto.on.ca/pdf/ProfPractice/HFO_Final_Report.pdf
http://www.crto.on.ca/pdf/ProfPractice/HFO_Final_Report.pdf
4.Improving the experience of patients requiring or at risk of
long-term mechanical ventilation final report. July 2010. 5.McKim
DA, Road J, Avendano M, Abdool S, Ct F, Duguid N, et al. Home
mechanical ventilation: A Canadian Thoracic Society clinical
practice guideline. Can Respir J [Internet]. 2011 [cited 2013
Jan];18(4):197-215. Available from:
http://www.respiratoryguidelines.ca/sites/all/files/2011_CTS_HMV_Executive_Summary.pdf