cardiff and vale nhs trust ymddiriedolaeth gig caerdydd a’r fro the establishment of a rapid...

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


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”


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


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.


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


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)


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


Medical Rapid Response Team

Improving Patient Safety


Improving Patient Safety

• Observation Audit• PDSA cycles• Outcomes


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


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.


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


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


Methodology – Ward Staff

• Remedy non-compliant documentation

• Safety briefings• Named nurses• Feedback


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


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


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





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


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


The patient experience and process of

assessment


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


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.


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


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 ‘


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


Care InterventionsN= 1193

Jan 08 - July 09

Change in Medical Management plan Palliation plan DNAR

71%

10%6%


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


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


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%


Change In Culture

Real or Unreal?Hospital @ NightCritical CareAdult Medicine


Thank You

“In God we Trust, All others bring data”

“Quality begins with intent, which is fixed by management”

WE Deming

cardiff and vale nhs trust ymddiriedolaeth gig caerdydd a’r fro the establishment of a rapid...

Documents

hospital slide

critical care nurse

medical emergency team

rapid response team

timing of response

ill patients

response strategies

critical care consultant