case study: a new rapid response team model- icu consultant led rapid response multidisciplinary...
TRANSCRIPT
Case study: a new Royal North
Shore Hospital RRT
Dr Liz Hickson, Dave Wastell, Sarah Webb
September 2013
Background to RRT
• Previously only a Code Blue RNSH ICU response in keeping with the MERIT study
• BTF initiative 2007 “track & trigger” system mandated – ICU only code blue responders
• ACSQHC 10 new Standards in 2012 – RRT core
• Concerns re RNSH SAC 1 & 2 events by executive
• NOT pushed by ICU
RNSH RRT Timeline
• Funding confirmed November 2012 for 1 year trial of 2 FTE Intensivists
• Start-up day in December 2012
• Commenced February 11, 2013
This is our story
Kotter’s 8 steps for leading change
• Act with urgency
• Develop a guiding coalition
• Develop a change vision
• Communicate the vision buy-in
• Empower broad-based action
• Generate short-term wins
• Don’t let up
• Make change stick
RNSH RRT Mission
• Our mission is to improve the quality of care of critically ill patients at RNSH.
RNSH RRT Vision
• Our vision is to work with the hospital inpatient teams as 'partners' in patient care, exceeding the standards for 'Recognising and Responding to the Deteriorating Patient', recommended by the Australian Commission on Safety and Quality in Health Care.
RNSH RRT Values
• Our values are teamwork, respect for others, support and innovative education and research.
Motto & Logo
RRT Composition – in-hours
• ICU Nurse
• ICU RRT Registrar
• RRT Intensivist
• Support CNC (Resuscitation Co-ordinator, BTF Co-ordinator)
RRT Composition – after-hours
• ICU Nurse
• ICU RRT Registrar
• ICU Advanced trainee reporting to the Admitting Intensivist
• Supported by ICU After Hours Nurse Manager
Post ICU Discharge/Follow-up ward round
• In-hours - RRT Intensivist & Support Nurse with primary responders if free to attend
• After-hours – RRT Registrar & RRT ICU nurse
Setting The Standard – A patient Journey at RNSH
• Educational package for staff by staff created by A/Prof Carole Foot
• Series of short films starring executive with clinical staff
• Used for orientation of staff in ICU & throughout the hospital
Topics needed
• National standards – Emphasis on Standard 9
• Implementation of the Between the Flags initiative
• New RRT operations & RRT red zone form
• Revised Code blue team responses
• End of life planning
• REACH trial
Chapters in the series • Chapter 1 – Introduction to the Standards • Chapter 2 – Clinical Handover • Chapter 3 – Use of Standard Observation Charts • Chapter 4 – Frequency of patient Observations • Chapter 5 - Recognising clinical deterioration • Chapter 6 – Ordering yellow zone review • Chapter 7 - Ordering red zone review • Chapter 8 – Rapid Response Team Review • Chapter 9 – Code blue response • Chapter 10 – Changing the call • Chapter 11 – End-of-Life planning • Chapter 12 – REACH initiative • Chapter 13 – Red zone EMR form for the Rapid Response Team • Chapter 14 – Conclusion and credits
Between The Flags
• Based on the SAGO chart
• Yellow & red zones
BTF Escalation processes
• Yellow zone clinical reviews performed by ward staff
• Red zone rapid responses by RRT & ward staff together
• Code blue responses based on zones around the hospital
Education plan
• Weekly RRT/BTF teaching session (Thursday 1430-1530) open to all ICU & ward staff – Simulations – Case discussions – Presentations on key topics
• RNSH RRT pages on ICU Wiki • RRT Cards for common problems • Ongoing education sessions for medical & nursing
orientation of new staff • Mock code blue ward program
Post ICU Discharge initiative
• ACHS Intensive Care Clinical Indicators 2011
• Aim was to see if a process could reduce unplanned ICU readmissions within 72 hours
• A screening tool was devised based on papers that used a multivariate analysis to identify risk factors associated with readmission
• A standard review form used as a checklist for up to 3 days of review
RRT – early outcome data
February - July 2013
Principal reasons for RRT activation
535, 38%
167, 12%
153, 11%
130, 9%
36, 3%
33, 2%
10, 1% 345, 24%
Low SBP
High HR
High SBP
Low SpO2
Serious concerns by staff
Sudden drop GCS
Seizures
Other
Results to date
• RRT primary & secondary outcomes
• Post-ICU discharge service outcomes
RRT Primary outcomes
• RRT calls/1000
• Unplanned ICU admissions
• Unplanned cardiopulmonary arrest rate/1000 (CPA/1000)
• Survival from in-hospital cardiac arrest/1000
• Hospital mortality/1000 (HSMR in the future)
Yellow & Red zone calls
115 133 153 156 147 170 208 263 286 229 203 227 310 249 254 296 295 341
354 345 449
357 390 427
497
575
722
648 609
655
737
648 791
832 1001
1012
0
200
400
600
800
1000
1200
1400
Jan
-12
Feb
-12
Mar
-12
Ap
r-1
2
May
-12
Jun
-12
Jul-
12
Au
g-1
2
Sep
-12
Oct
-12
No
v-1
2
Dec
-12
Jan
-13
Feb
-13
Mar
-13
Ap
r-1
3
May
-13
Jun
-13
Clinical Reviews
Rapid Response
RRT Red zone responses
249 254 296 295
341
0255075
100125150175200225250275300325350
Feb-13 Mar-13 Apr-13 May-13 Jun-13
RRT calls
Red zone RRT reviews
• Mean RRT calls/1000
– 6 months Pre RRT = 56.8
– Post RRT – June 30 = 57.5
BUT
– Effect likely greater as duplicate calls now uncommon
RRT response times
• 99.4% of calls attended within 15 min
ICU unplanned admissions
2.9 2.3
4 4.5 5.9
5 4.2
5.4
3.2 2.6 2.6 4
2.6
6.3 6.9 7.5
5.8
7.9 6.8 7.1
8.1
11.5
13.4 14.3
11.1
16.2
9.2 9.2
11.5 10.3
13.7
11.8 11.3
13.5 14.7
16 16.9
15.1
18.8
0
2
4
6
8
10
12
14
16
18
20
Jun
-12
Jul-
12
Au
g-1
2
Sep
-12
Oct
-12
No
v-1
2
Dec
-12
Jan
-13
Feb
-13
Mar
-13
Ap
r-1
3
May
-13
Jun
-13
Code blue %
RRT/ICU review %
Total % of ICUadmissions
Unplanned admissions
• Jan-June 2013
– 91% discharged to ward alive; 9% died in ICU
– Approx. 60% Surgical vs 40% Medical
– 67% out of hours (1800-0800)
– Mean ICU length of stay 4.1 days
– Overall mean APACHEII scores of total ICU admissions remains at 14 over 3.5 years
Post ICU discharge service
0
50
100
150
200
250
300
2011 2012 2013 Feb-Jun
Mean monthly ICUadmissions
Mean monthly ICU livedischarges
Unplanned readmssions<72h
Constant 93% survival
Constant 2%
Revised post-ICU discharge review criteria
• Long stay patients (>10 days)
• Patients with traches
• Patients discharged after 6pm
• Consultant discretion
CPA/1000
• Mean rate July 2012 – Jan 2013 = 0.97 for 34666 total separations
• Mean rate Feb 2013 - July 2013 = 0.6 for 25006 total separations
• RR CPA/1000 = 0.9
(95% CI 0.5-1.6 p=0.7)
Hospital deaths/1000
• Mean rate July 2012 – Jan 2013 = 14.1 for 34666 total separations
• Mean rate Feb 2013 - July 2013 = 9.8 for 25006 total separations
• RR Death/1000 = 0.97
(95% CI 0.84-1.12 p=0.7)
RRT Secondary outcomes
• Outcomes from cardiopulmonary arrest
• Critical incident event rate
• Qualitative Feedback – ward staff & RRT
CPA outcomes
60 58
24
33
8
0 0 4
8 4
0
10
20
30
40
50
60
70
2012 2013
Death %
D/C home %
Transfer to anotherhospital %
D/C own risk %
Other %
Cardiopulmonary arrest form
Critical incidents • 2011 & 2012 – 5 SAC 1 & 6 SAC 2 associated
with failure to detect & escalate deterioration
• Since RRT commenced – 0 SAC 1 or SAC 2 events
Qualitative feedback about the RRT
• Surveys of Ward nurses, Ward JMOs & SMOs
• Surveys of RRT staff
• Ongoing analysis but generally positive feedback
Going forwards…
• Ongoing negotiation regarding ICU resources in general, as well as RRT for 2014
• Red zone call database analysis
• Development of in hospital CPA database
SUSTAINING A SERVICE
Questions?