Learning Session 7

1. Learning Session 7

2. Executive Leadership supporting the improvement of Safety and Quality Outcomes Patient Safety: (number one corporate objective) We will ensure patients confidence in our services by always putting patient safety first Processes & Structures: We will develop services and structures that deliver the right thing, first time, every time Leadership engagement: All Executive Directors are linked to all 5 work-streams, actively participate in the work-streams and the Patient Safety walk-rounds NHS Borders

3. NHS Borders Outreach Service Ronnie Dornan Clinical Nurse Specialist - Critical Care Outreach Dr Nigel Leary Consultant in Anaesthesia and Critical Care NHS Borders

4. Critical Care Outreach ServiceBorders General Hospital Ronnie Dornan B.Sc RN Clinical Nurse Specialist - Critical Care Outreach

5. Critical Care Outreach Team Clinical Nurse Specialist 3 Outreach Sisters 7 day service 0900 – 2130

6. Problems and Principles • Failure to recognise the deteriorating patient • Failure to communicate • Failure to rescue • Adverse events often preceded by abnormal vital signs • Lack of response is associated with poor outcomes

7. National Outreach Objectives • To avert admissions to ITU • To ensure timely admission to ITU and discharge back to ward • To share skills and expertise through educational partnership • To promote continuity of care • Audit and evaluation of outreach Guidelines for the introduction of Outreach Service Standards and Guidelines The Intensive Care Society 2002

8. Local Objectives • To improve and maintain patient safety in the Borders General Hospital • Early delivery of Sepsis Bundles • Early intervention to prevent multi-organ failure • The right care in the right place at the right time by the right people • Develop a hospital wide approach to the early identification of the at-risk patient

9. Outreach Service Timeline 2001 Outreach began 2005 Outreach enhanced to 25% / 24hr 2006 Outreach enhanced to 33% / 24hr 2007 Outreach enhanced to 50% / 24hr

10. Culture • Non judgemental, non punitive response to all referrals • Proactive approach to the identification of the at risk patient • Review all patients on SIRS/Shock chart • Follow up of all patients discharged from ITU (Discharge Summary) • Technical Support ( Non-Invasive Ventilation, Central Venous Lines, Intercostal Chest Drains, Tracheostomy care)

11. Education • FY1 / Medical and Nursing Student rotation to ITU • Formal and Informal education • Hospital wide education programme on the “at risk” early warning scoring system for nurses, doctors and students • High Dependency Nursing Skills Course for ward nurses and midwives

12. High Dependency Nursing Skills Course • Early recognition of the “at risk” patient • Tracheostomy Care / Suction / Humidification • Airway Management / Oxygen Delivery • Neurological Assessment • Non-Invasive Ventilation / CPAP • Respiratory Assessment • Management of ICD • Management of Acute GI Bleed

13. High Dependency Nursing Skills Course • Management of DKA • ABG analysis • Chest X-Ray Interpretation • Sepsis • Management of Central Venous Lines • Pancreatitis • Management of Acute Pain

14. Outreach in Action • Interaction with base speciality staff • Ward nurse • FY1 / FY2 / SpR • Consultant • Anaesthetic support provided 24/7 • DNAR

15. Support ITU consultant involvement 10% total workload

16. Source of referral • Nurses • Doctors • Anaesthetists • Hospital At Night Team • Physiotherapist • Acute Pain Service • Critical Care Outreach • Patients / Relatives

17. SIRS / Sepsis / Shock SIRS WCC <4 or >12 Temp < 36oC or >38oC HR > 100 Resps >20 Sepsis Infection Confirmed or Suspected Severe Sepsis Blood Pressure <100mmHg Peripheral Hypoperfusion Urine < 40mls/hr Sweating Confusion SBAR Cards Critical Care Outreach Referral 9am-9pm Bleep 6321 9pm-9am Call ITU 26296

18. SIRS / Shock chart

19. Referral source

20. Condition

21. Impact

22. Impact

23. Summary • Needs to be a hospital wide approach to critical illness • Rolling programme of education and reinforcement • 90% of Outreach referrals managed on wards • Reduction in cardiac arrest calls • Reduction in Out of Hours admissions to ITU • ITU Outcomes

25. Features of Outreach • Nurse-lead service (Critical Care background) • Uses an Early Warning System (SIRS) • Proactive • Ward based Education • NOT just the CAVALRY • Different to a MET (Medical EmergencyTeam)

26. Value of Outreach Is it worth investing in Outreach services? • Quality of care • Cost • Outcomes

27. Quality of Care • Decrease in Cardiac Arrest calls (85%) • Increase in DNAR decisions • Decrease in OOH admissions to ITU • Decrease in Invasive Ventilation • Decrease in Renal Haemofiltration

31. Cost • 90% of sepsis managed on wards • Decrease in levels of organ support • Decrease ITU length of stay • Release of ITU beds • Reduction in ITU drug budget (rAPC)

32. Outreach Activity - %

33. ITU Activity – organ support

35. ITU Activity – rAPC

36. Outcomes • Decrease in Cardiac Arrest rate • Decrease in ITU mortality • Decrease in ITU SMR

37. ITU Activity - mortality

39. Summary • Strong association between presence of Outreach and better quality of patient care • Enables more cost-effective care • SAVES LIVES

40. Suggestion Quality improvement measures in ITU • MDT ward rounds • Weekly M&M meetings • Incident reporting • Data to SPSP • Care bundles • HAI surveillance • Outreach services

42. Mortality

43. Questions? • Why does it work? • Would I close an ITU bed to resource an Outreach service?