Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
The Establishment of a Rapid Response Team to Identify Acutely Ill Adult Patients
Gemma EllisConsultant Nurse, Adult Critical Care
Cardiff
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Project Outline• Management Board Sept 2007 – SPI II Initiative (Trigger tools
and Rapid Response Teams) 100,000 Lives Campaign hospitals should initiate RRT as 1 of 6 strategies to reduce preventable in-hospital deaths
• BackgroundThere is a significant body of research that suggests that the recognition of acute illness in adults in hospital is often delayed and its subsequent management may be inappropriate. This leads to the possibility of late and avoidable admissions to critical care and unnecessary patient deaths
• NICE 50 guidelines were issued for consultation on “Acutely ill patients in hospital: Recognition of and response to acute illness in adults in hospital”
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
NICE CG 50 GuidelinesNICE CG 50 - “Acutely ill patients in hospital: Recognition of and response to acute
illness in adults in hospital” The guidelines cover the care of all acutely ill adult patients in hospital, including
patients in emergency departments. It addresses three key areas: 1. Identification of patients who are either at risk of clinical deterioration or
whose clinical condition is deteriorating. This includes assessment of: scoring tools that record physiological parameters and neurological state; the level of monitoring needed; and the recording and interpretation of the data obtained.
2. Response strategies, including the timing of response and patient management, and the communication of monitoring results to relevant healthcare professionals, including the interface between critical care and acute specialities.
3. Discharge of patients from critical care areas back to ward-based care. This includes monitoring requirements on the ward and the timing of transfer
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Why Rapid Response Teams?
Rapid Response Team Results:Measure: Before: After: Rel Risk Reduction:
No. cardiacarrests 63 22 65% (p=.001)
Deaths fromcardiac arrest 37 16 56% (p=.005)
No. days inICU post arrest 163 33 80% (p=.001)
No. days in hospital post arrest 1363 159 88% (p=.001)
Inpatient Deaths 302 222 25% (p=.004)
*Table adapted from Bellomo R, Goldsmith D, Uchino S, et al. A prospective before-and-after trial of a medical emergency team. Medical Journal of Australia. 2003;179(6):283-287.
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Historical Background • Previous Pilot 2002/2003 – Medical Emergency Team
– A critical care consultant– A critical care nurse– A registrar from the relevant specialty– This would require the following staffing resources:– Consultant x 1.67– F Grade nurse x 6 at UHW– A & C Grade 4 x 0.5
• Other Issues – Emergency Role of Medicine Nurse Practitioner – Confusion over process from different disciplines.– Clinical lead required– Professional educational strategy – Inconsistent team response to emergency algorithm– Team approach needed
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Other Considerations
• Composition of RRT’s is not standardized• Optimal Triggers• Cost effectiveness is not established• Need to establish efficacy – published
datais limited
• Benefit to improve end of life care (? Optimal approach to improving end of life care)
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Initial Pilot Project Outline•Funding for two extra Nurse Practitioners
•SPI II Project
•12 Month Project
•Daily (Mon-Fri) presence of nurse practitioner with acute/critical care training to provide immediate support (08-00 to 18-00 hrs)
•Commenced Jan 2008 with roll-out across wards
•Extended to three General Medical Wards, A7, B7, C6
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Medical Rapid Response Team
Improving Patient Safety
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Improving Patient Safety
• Observation Audit• PDSA cycles• Outcomes
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Observation PDSA cycles
• Documenting recommended frequency on EWS chart
• Documenting recommendations of frequency in hours
• Documenting changes of frequency in MDT notes
• Implementing recommended frequency of observations
• Documenting any abnormal physiology within the MDT
notes
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Worksheet for Testing Change – A7
Aim: Primary: To reduce mortality and adverse effects Secondary: To ensure that there are implemented recommendations of frequency of observations @ 95% reliable within 2 weeks from start date (29th Feb 2008)
Every goal will require multiple smaller tests of change
Describe your first (or next) test of change Person Responsible
When to be done
Where to be done
Are the recommended frequencies of observations implemented? Jane Morris Yvonne Welburn
3rd March – 4th March
Cubicles1 & 2 A7S
Plan List the tasks needed to set up this test of change Person
Responsible When to be done
Where to be done
1. Andrew Brown, Nurse in-charge and Emma English awareness of eligibility of all patients to have documented recommendations of frequency of observations implemented on EWS chart.
2. Nurse caring for patients in bed 1 & 2 on A7 S needs to be aware of
need to ensure observations are recorded as frequently as documented on top of EWS chart.
3. Ensure health care support workers on A7S are aware of need for
observations to be recorded as documented at top of EWS chart.
4. Qualified nurse / health care support worker to implement the recommended frequency of observation recording.
5. Ensure effective communication of process at handover.
6. Non compliance to be remedied.
7. posters displayed outside cubicles to promote awareness
Jane Morris Yvonne Welburn
3rd March – 4th March
Cubicles 1& 2 A7S
Predict what will happen when the test is carried out Measures to determine if prediction succeeds
All patients who have been identified as eligible for observation recording will have observations recorded as frequently as recommended on top of the EWS chart.
All patients will have recommended frequency of observations implemented.
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Do Describe what actually happened when you ran the test Cubicle 1 had 8 hourly observations documented on top of the EWS chart and 8 hourly observations recorded. Cubicle 2 had 8 hourly observations documented on top of the EWS chart and 8 hourly observations recorded.
Study Describe the measured results and how they compared to the predictions
100% compliance
Act Describe what modifications to the plan will be made for the next cycle from what you learned Extend the cycle to Beds 1 & 2 on A7 North Inform nurse looking after Beds 1 & 2 on A7N Inform HCSW looking after Beds 1 & 2 on A7N Promote the implementation of recommended frequency Advertise compliance Ask nurse in charge to handover to night PDSA No 2
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Methodology - MRRT
• Full involvement of the MRRT• 24hr cycle• >95% compliance • Identical bed space rollout• Displayed ‘up and coming’ PDSA
cycles• Clearly displayed daily results
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Methodology – Ward Staff
• Remedy non-compliant documentation
• Safety briefings• Named nurses• Feedback
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Audit - EWS Chart UseEWS Chart pre and post introduction of MRRT
0
10
20
30
40
50
60
70
80
90
100
2008 2009
% C
om
pli
an
ce
EWS Chart
N = 64 N = 106
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Audit Results - Observations Taken
Patient observation and MEWS pre and post introduction of MRRT
0
10
20
30
40
50
60
70
80
90
100
Heart Rate RespiratoryRate
blood Pressure OxygenSaturations
AVPU Temperature
Observation
Co
mp
lian
ce %
Jan-08 Jul-09
No reliability
No reliability
Reliable / sustainable
system
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Audit Results - Abnormal Physiology DocumentationAbnormal physiology and qualified Nurse review pre and post MRRT
introduction
0
10
20
30
40
50
60
70
80
90
100
Abnormal PhysiologyDetected
Abnormal Physiologydocumented
Qualified Nurse reviewDocumented
% C
om
pli
an
ce
Jan-08 Jul-09
Multiple PDSA cycles
Multiple PDSA cycles
Multiple PDSA cycles
Multiple PDSA cycles
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Audit Results – Observation Frequency
Recommended frequency of observations pre and post MRRT
0
10
20
30
40
50
60
70
80
90
100
Documented RecommendedFrequency
Frequency recommendationsImplemented
Observations taken 12 hourly(minimum) unless
documented otherwise
% C
om
pli
an
ce
Jan-08 Jul-09
Never documented
95% Reliability and
sustainability
Never documented
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Audit Results – Early Warning Score
EWS Pre and Post introduction of MRRT
0
10
20
30
40
50
60
70
80
90
100
Less than 3 3 or 4 5 or more
Jan-08 Jul-09
Earlier alert to deterioration
Less severity of illness
Less severity of illness
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
The patient experience and process of
assessment
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
What is SBAR?• SBAR (Situation-Background-Assessment
Recommendation)
• Framework for communication between members of the health care team about a patient's condition
• SBAR is an easy-to-remember, concrete mechanism useful for framing any conversation, especially critical ones, requiring a clinician’s immediate attention and action
• SBAR was introduced by the MRRT as a uniform method of communication throughout the medical wards
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Ward Staff HandoverSituation
– EWS 4 - Temp 33.8, Heart Rate 47bpm, AVPUBackground
– Admitted with falls and UTI and a history of Dementia
Assessment– HR 47bpm, BP 119/63, RR 18, 02 Sats 92%,
AVPU temp 33.8, BM 5.4mmolsRecommendation
– Warm patient, check manual observations, immediate review.
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
SBAR ResultsSBAR July 08 - July 09
0
10
20
30
40
50
60
70
80
90
100
Situation Background Assessment Recommendation
% C
om
pli
ance
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
MRRT AssessmentS Patient scoring 4 on EWS chart, temperature 33.8C, heart rate
47bpm- sinus bradycardia. Alert only to voice
B Patient has a picture of dementia (very agitated, constantly undressing herself) falls, presented with facial bruising and a UTI
A A - PatentB – RR 18 bpm, oxygen saturations 92%, bilaterally laboured breathing, no audible wheezeC – HR 47, sinus bradycardia on ECG, BP 119/63, patient cold to touch, output not being measured, not eating or drinking as too drowsy, patient pulls out cannula when awake, U & E showed slightly raised urea and creatinineD– A V P U patient responding by eye opening only to voice
temperature hypothermic at 33.8°c, blood sugar within normal rangeE - Widespread bruising, offensive urine, incontinent, having TDS Haloperidol, Temazepam nocté, patient looks ‘drugged ‘
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
R –
Warm patient up with blankets
Monitor input and output on fluid chart
IVI
Encourage diet and fluids when awake
Avoid sedative medication, clear sedation limits
Check routine bloods
Consultant to document resuscitation status and ceiling point of treatment
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Care InterventionsN= 1193
Jan 08 - July 09
Change in Medical Management plan Palliation plan DNAR
71%
10%6%
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
The Future• Continued Data Collection for quality
assurance – sustainability and reliability
• Expansion of Team to Cover All Areas– Seven wards – 187 beds plus a MEAU
• Expansion of hours• Secured Funding• Future Trust-wide Use
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Change in Cardiac Arrest Calls
Ward Period of Pre – RRT Post-Intervention RRT
A3L - Sept ’07 to March ’08 3 Sept ’08 to March ’09 2 B6 - Dec ’07 to March ’08 7 Dec ’08 to March ’09 3 C7 - Jan ’07 to March ’08 28 Jan ’08 to March ’09 8
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Continuing AuditSBAR – July 2008 to July 2009 1193 callsIssues, new staff, new wards
Medical Interventions - to date 1193 calls 3/day
DNAR issues 11/155 = 10%
Drugs 334/1193 = 28%
Fluids 293/1193 = 25%
Oxygen 297/1193 = 25%
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Change In Culture
Real or Unreal?Hospital @ NightCritical CareAdult Medicine
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Thank You
“In God we Trust, All others bring data”
“Quality begins with intent, which is fixed by management”
WE Deming