Dusk to Dawn Rapid Response: UK 911

1. Dusk to DawnRapid Response: UK 911 Patricia Burkhart, Cletus Carvalho, Rachel Copeland, Dan Goulson, Kathy Isaacs, Paula Sandford

3. Project Charge Optimize coverage after normal hours within UK HealthCare

4. “We must demonstrate outstanding outcomes. This will require a committed multi-disciplinary team approach that focuses aggressively on quality and efficiency. Standardization, coordination, and integration will be our core operating principals moving forward.” Michael Karpf, MD September 8, 2010

5. Background • Poor performance in regards to mortality, quality and safety • Night coverage has been identified as a system weakness • There have been some bad outcomes

6. Issues • Personnel attending to deteriorating patients may not have the appropriate skills to intervene • Sometimes there is delayed activation of a rapid response to a deterioration

7. The right skills to help the patient at the right time

8. Research

9. Night Coverage Task Force • An internal team sponsored by Dr. Lofgren • Led by Colleen Swartz and Paul DePriest • Membership consists of high level medical, nursing, and administrative leaders

10. Night Coverage Task Force • Made a preliminary report this past summer

11. Literature Review

12. Hospitalists would help to solve many night coverage issues, but are expensive. Cost would run about 67-77,000 for a PA and 53-98,000 for NP. Weinstein, 2002

13. System improvements included RRT and technological advances such as remote monitoring. Schulkin, 2008

14. Suggested 24/7 coverage by in-house Intensivists to help provide continuity of care Arabi, 2008

15. 84% of patients had identifiable deterioration long before they had their arrest. These included changes in breathing pattern, pulse rate, and level of consciousness Schien,

16. Estimate that 51 cardiac arrests were prevented over 2 years by utilizing a rapid response system, with a trend toward lower mortality Lighthall, 2010

17. Current State at Night • No services have attending in-house • Exceptions are ED, OB, and Anes • Much cross-covering exists among house staff • Nursing staff is relatively junior

18. External Survey • Sent questions to top 7 performers in UHC • Asked about their models of care

19. Highlights of findings • Clarian – Methodist • For deterioration, RRT is called first, then attending • RRT activated through a specific phone # • University Hospitals – Case • There is 24/7 medical hospitalist coverage both with and without NPs

20. Highlights of findings • Ohio State • RRT includes hospitalist and acute care NP 24/7 • No response from Kansas, Arizona, Rush, or Wisconsin

21. Interventions

22. Model Scenario Table

24. Recommendations

25. Three Prong Model • Hospitalist for night coverage, 11p – 7a • Increase skill set at bedside and in RRT • Rapid Response Team, 24/7

26. Hospitalist • Must have interventional skills • Would provide attending supervision for admissions • Support RRT • Available at night

27. Increase skills • Bedside nurses will recognize deteriorations • Nurse practitioners on RRT can intervene • Hospitalist has high-level skills

28. Rapid Response Team • Available constantly • Includes NPs • One consistent method of activation

29. One number One call Every time

30. Financial Aspects

31. Revenue • Billings for procedures • Billing for nighttime admission H&Ps

32. Cost Avoidance • Reduce ICU admissions through early intervention

33. Expenses • Wages • Training costs

35. Summary of Recommendations • RRT as a first responder model • Consistent activation – think 911 • Skilled nocturnist for RRT support • Measurement of outcomes

36. Conclusions

37. “… the most sophisticated intensive care often becomes unnecessarily expensive terminal care when the pre-ICU system fails.” Peter Safar, MD

38. Failure to rescue … … is not an option

39. References • Chen, J., Bellomo, R., Flabouris, A., Hillman, K., & Finfer, S. (2009). The relationship between early emergency team calls and serious adverse events. Critical Care Medicine, 37, 148-153. • Fletcher, K. E., Saint, S., & Mangrulkar, R. S. (2005). Balancing continuity of care with residents’ limited work hours: defining the implications. Academic Medicine, 80(1), 39-43. • Hillman, K., Parr, M., Flabouris, A., Bishop, G., & Stewart, A. (2001). Redefining in-hospital resuscitation: the concept of the medical emergency team. Resuscitation, 48, 105-110. • Hunt, E. A., Walker, A. R., Shaffner, D. H., Miller, M. R., & Pronovost, P. J. (2008). Simulation of in-hospital pediatric medical emergencies and cardiopulmonary arrest: highlighting the importance of the first 5 minutes. Pediatrics, 121, e34-e43. • Moldenhauer, K., Sabel, A., Chu, E. S., & Mehler, P. S. (2009). Clinical triggers: An alternative to a rapid response team. The Joint Commission Journal on Quality and Patient Safety, 35, 164-174. • Sharek, P. J., Parast, L. M., Leong, K., Coombs, J., Earnest, K., & Sullivan, J. et al. (2007). Effect of a rapid response team on hospital-wide mortality and code rates outside the ICU in a children’s hospital. JAMA, 298, 2267-2274. • Thomas, K., Force, M. V., Rasmussen, D., Dodd, D., & Whildin, S. (2007). Rapid response team: Challenges, solutions, benefits. Critical Care Nurse, 27(1), 20-27.