Early Rescue: Improving Transitions in Patient Care

1. Early Rescue:Improving Transitions in Patient Care “Building Blocks in British Columbia” PANBC October 29th, 2011

2. Acknowledgements • SHAIPE faculty • Surgical Healthcare Associated Infection Prevention Excellence • Kim MacFarlane, CNS Critical Care • Lorna Jensen, CNE PACU, RCH • Jennifer Roy, UBC MSN student

3. Goals for today • Failure to rescue literature • Early rescue movement • Transitions in care • Implications for nursing practice

4. So, what’s the problem ? • Patients have been harmed or died as a result of failure to rescue • Communication breakdown is responsible a lot of the time • Transitions in care is a high risk time period for patients

5. Christian’s Story

6. Failure to Rescue • In 2004, the IHI, along with the Joint Commission, identified FTR as the #1 contributor to hospital deaths • Top 3 factors in Failure to Rescue • Failure to recognize early signs of deterioration • Failure to assess/plan • Failure to communicate • High risk period: Transfer of Care

7. Guidelines for Practice

8. The Canadian Adverse Events Study – Drs G. Ross Baker, Peter G. Norton • the first Canadian study (2004) to provide a national estimate of the incidence of AEs across a range of hospitals • Findings on the incidence of adverse events among hospital patients: • almost 2.5 million annual hospital admissions in Canada • 185 000 are associated with an AE and close to 70 000 of • these are potentially preventable.

9. So How Do We Fix the Problem? Early Rescue • Identifying risk and recognizing early signs of deterioration • Serial assessments, planning • Taking action, escalating care – communicating the situation Critical Thinking

10. Tools to Support Practice • Decision-making support • Mews • Code blue review • Clinical support tools • Algorithms • Communication tools • SBAR • Policies • MRP

11. Critical Care Reviews

12. Extremes of age- <1yr and >65yrs Surgical or invasive procedures Use of broad spectrum antibiotics Chronic Illness – DM, CRF, liver disease, heart disease Indwelling tubes (foley catheter) and lines (CVC) Genetic predisposition septic shock Compromised immune status – malnutrition, HIV, cytoxic/ immunosuppressive drugs, alcoholism, malignant neoplasms, solid-organ transplantation Primary infections (e.g. pneumonia, urinary tract, cholecystitis, peritonitis) Identifying High Risk Patients:Risk Factors/Predisposition Kim MacFarlane, FH CNS, Critical Care, May 2011

13. Principles of Assessments & Planning • Serial assessments are the foundation for recognition of change • Trending is critical – connecting the dots • Continuous planning of next steps for patient care

15. Escalation of Care Key Steps in the process…. • Take action • “Takes action (taking action includes advocacy) to promote the provision of safe, appropriate and ethical care to clients (see Glossary for definition of the term “client”)”. CRNBC Standards of Practice: Responsibility & Accountability • Determine MRP • Communicate the findings • Document

18. Communication tools…. • Huddles • SBAR • Handover

19. Handover • A fundamental element of safe patient care • Development of standard procedures is 1 of the top 5 priorities of the World Health Organization's • High risk period of time (Roughton & Severs, 1996)

20. Joint Commission - 2006

21. Clinical Handover – Key Facts Clinical handover is a high risk scenario for patient safety. Dangers include discontinuity of care, adverse events and legal claims of malpractice (Wong et al, 2008) Survey of Australian doctors revealed that 95% believed that there were no formal or set procedures for handover (Bomba and Praska, 2005) An Australian study of emergency department handover found that in 15.4% of cases, not all required information was transferred, resulting in adverse events (Ye et al, 2007) Survey of junior doctors in the UK discovered that 83% believe that handover processes were poor. Written handover was rarely received, accounting for only 6% of all handovers (Roughton and Severs, 1996) A detailed analysis of nursing handover revealed that some handovers promote confusion and did not assist in patient care (Sexton et al, 2004) Handover is among the most common cause of malpractice claims in the USA, especially among trainees, accounting for 20% of cases (Singh et al, 2007) A survey among trainees in the USA suggested that 15% of adverse events, errors or near misses involved handover (Jagsi et al, 2005)

22. Handover • Joint Commission identified communication was a key factor in 70% of all sentinel events 1 • 94% of nurses identified different nurses give handover in different ways 2 • 82% of nurses agreed a standardized handover was needed • 85% felt there was need for improvement in the way nurses communicate 1 . The Joint Commission on Accreditation of Health care organizations. Sentinel event statistics (2004). http://www.jointcommission.org/Sentinel !Events/Statistics 2. Clarke et al (2009). The PACT Project: Improving communication at handover. The Medical Journal of Australia, 190 (11), S125-127

23. Handover • Physicians identified1 : • The need for more detailed information • The need for nurses to specifically identify the issue/problem • The importance of nurses having the information at hand when reporting • The need to know whether standard procedures and protocols were carried out 1. Clarke et al (2009).The PACT Project: Improving communication at handover. The Medical Journal of Australia, 190 (11), S125-127

24. Types of Handover • Nurse shift change • Physician transferring responsibility to another practitioner • Physician on-call responsibility • Temporary relief coverage i.e. coverage of breaks • Anaesthesiologist report to recovery room nurse • Nursing & physician handover from ER to unit • Handover from in-patient to host hospital, community, GP

25. Nurse Handover • Unique to each unit • Written, paper • Verbal: nurse to nurse, audio report, group reports • Hybrids • At the bedside • Paper and verbal report • time overlap The most effective handovers include an opportunity for questions

27. Barriers to Handover • Lack of education • Resistance of Change • Lack of devoted time to handover • Problems with the physical setting i.e. confidentiality, noise, disruption • Language barriers between clinicians • Failures in modes of communication i.e. fax machines, lost notes • Lack of research on best-practices for handover • Lack of financial resources for implementation of standardized practices

28. Tips for Effective Communication • Allow for face-to-face communication whenever possible • Ensure 2 way communication • Allow as much time as possible • Use both verbal and written communication • Conduct handoffs at the patient’s bedside whenever possible • Involve staff in the development of handoff standards • Use communication techniques i.e. SBAR • Clearly outline the the transfer of responsibility • Use technology to streamline templates & processes • Monitor, evaluate, gain feedback from the staff

29. Peri-Operative Guidelines for Transfer of Patient Care • The receiving care provider will be notified of the impending transfer • The receiving care provider will be given a complete report before or at the time of transfer • Opportunity is provided for questioning between the giver and receiver of patient ASPAN 2010-12 pg 89

30. Fraser Health Surgical Program PeriAnesthesia Discharge/Transfer of Care • Discharge Summary documented on PACU record • All reports are verbal and written/documented • Telephone or in person • Receiver has an opportunity to ask questions • Communication tool developed for the receiving units • Assist RN with communication when receiving phone reports • Can be used a worksheet • Notepad; quick & placed by the phones for ease of use

33. Teamwork Makes it all Work! • Communication • Mentorship • Drawing upon resources • Unit, site leaders • Experienced nurses • Clinical experts • Collegiality

34. Questions to Ponder • What tools or processes would support your unit in identifying early signs of deterioration of patients? • What guidelines would support your team when responding to a deteriorating patient? • What are process/tools are in place in your environment for patient handover? • What tools would improve communication processes for patients coming into your care or transferring to another unit?

35. So what are the Implications for Nursing Practice? • Nurses are well positioned to prevent adverse events, failure to rescue • Standardizing nursing assessment, planning, and communication process & tools improves patient care and patient outcomes • The decisions and actions of nurses save lives

36. Resources & References Patient safety Institute: http://www.patientsafetyinstitute.ca/English/Pages/default.aspx National Institutes of Health: http://www.iom.edu/ Canadian Adverse Events Study: http://www.cmaj.ca/cgi/content/abstract/170/11/1678 You Tube Huddles: Family Medicine (6:62 mins) http://www.youtube.com/watch?v=5YC7NxK9vlY Planned Care Huddles (3:26 mins) http://www.youtube.com/watch?v=Wttxm7jAnb4 Plastic Surgery Daily huddles (4:16 min) http://www.youtube.com/watch?v=dfAnpGgsQbA