Nurse Practitioner

led Rapid Response

Team perspective

Anna Green

Manager ICU Liaison service

Critical Care Nurse Practitioner

2013 ICU Liaison Team

• Gary Blackburn

– Lead Deteriorating Patient Rounding

• Grace Campbell

– Lead Sustainable ISBAR

• Nicola Donohoe

– Lead ICU Discharge and follow up guideline

• Michelle Kreusel

– Lead Join the Dots and RRT survey

• Greg Millsom

• Rom Binuya

Chameleon

• Highly specialised

• Colour changing abilities

• Three dimensional vision

• Specialised feet

• Long tongue

In the beginning....

• High demand for ICU beds

• Ward patients with complex care

• Admitted to ICU with preventable causes

• Delay in treating deteriorating patients

• High transfer rate over the weekend

Solution

• Case manage

patients post ICU

discharge

• To prevent

readmissions

Non Stop Small Challenges

• Complex care course

• Pager

• Grants – computer

• Office – store room

• Title change

• Reporting change

Non Stop Big Challengers: 3 months post commencement

• Ward referrals for deteriorating patients

• Ramp up calls – closed door culture

• Ordering diagnostic tests

• Prescribing medications

Nurse Practitioner journey started in 1998 through to endorsement in 2004

RAT

1. 1999 Leadership Development • All RRTs have calling criteria

• Usually based on deranged vital signs

– Difficulty breathing

– RR > 30

– SpO2 < 90% despite high flow oxygen

– HR > 120 bpm

– Systolic BP < 90 mmHg

– UO < 60mL over 2 hours

• Staff “worried” about the patient

2. Nurse Practitioner –phase 2 external evaluation: La Trobe University (MDS)

Patient Activities

• Health assessment

• Referral – future planning

• Intervention

• Diagnostic tests

• Prescribing

• Decision

Non Patient Activities

• Education of staff

• Consultation with health professionals

• Documenting visits

External evaluation continued

Consumer focus group • Role confusion • Education provided • Need 24hr service • Comparisons made with

junior doctors – Better understanding of

nursing care – Better rapport with nurses – In some cases more

knowledgeable than doctors

Stakeholder focus group • Anticipation of some

conflict of role definition • They would be more

credible with education qualifications

• Robust analysis of outcome data relating to implementation of the service

2012 Nurse Practitioners in Australia

128

12

179

185

27

94

18

67

Total = 714 (0.21%) nurse practitioners

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Improvement projects along the way

Patient at risk scoring tool

Colour alerts in medical records

ISBAR communication

Join the dots

Riskman rapid response entries

ICU Liaison Patient at Risk Scoring Tool

• RFD from ICU

• ICU follow up

• Repeat reviews

• Discharge from caseload

• Preventable readmissions

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ISBAR Communication

1. VMIA – lead agency

Sessions >42 Participants >350

2. Sustainability

Orientation (monthly) Incorporated into handover/clinical skills/medical

education sessions 3. ISBAR A3 Improvement Project

Audit / education Improved compliance of using ISBAR form

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Documentation Documentation

14:25 Nursing notes on the ward

15:30 Admitted to ICU with APO secondary to severe MR

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Issues:

1. Use of numbers vs joining dots

2. Incorrect recording in wrong space

3. Confusion where to put dot in square

4. Tds observations

5. Escalation protocol not followed

6. Reportable vital signs not recognised

7. Failure to recognise deterioration

18

And the story continues...

Simulation scenarios Colour alerts

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RRT entry

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Odd one out

Victorian Travelling Fellowship Program

Victorian

Travelling

Fellowship

Program

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Methodology

England (10)

Pre survey sent to hospitals in England

Site visits to the hospitals in England

Research reports returned for verification

Australia (10)

Preliminary survey sent to hospitals in Victoria

Hello is anyone else out there!

Comparison of Hospital demographics

England Victoria

Hospital bed size 772 315

ICU bed size 19 15

ICU admissions / year 1137 1243

Pts assessed / day 10 7

• 80% of the hospitals visited in England had designated high dependency beds on the general wards that are not managed by the ICU compared to 12% of the hospitals in Victoria.

• One hospital in Victoria had established an ICU LN service in a metropolitan hospital without an ICU.

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Key findings

All nurse led rapid response teams vs 1

65% used weighted score model

Average number of staff = 7 vs 1.8

90% worked 50% clinical & 50% non-clinical

65% covered 24hrs per day

100% ordered diagnostic tests

Majority had standing orders

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What has been the biggest impact

0

1

2

3

4

5

6

7

8

ACCCN SIG – ICU Liaison

• Support

• Communication

• Meetings

• Research

• Sharing information

• Position statement

Secondment to DoH

• 3 month secondment

• Sent to CEOs

• Every hospital with an ICU in Victoria has an ICU liaison role!

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Marked increase in ICU LN services from 2004

More than 120,000 patients were reviewed, most commonly after ICU

discharge

Little increase in the EFT for ICU LN services

Many hospitals revealed increased ICU LN workload with time.

Considerable differences in all measured variables between hospitals.

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Rounding Project

1. 2hrly rounding to each ward at both Western and Sunshine hospitals

2. Developed an audit tool

3. Education provided re clinical marker criteria. Inform NUMs of the

rounding project

4. Commenced rounding in the emergency departments

5. Energize and motivate ICU liaison nurse consultants

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Average 51 / 42 increase in referrals

APR MAY JUNE JULY AUG SEPT OCT NOV DEC JAN FEB MAR

Rounding 46 59 50 39 21 32

RRT calls 36 41 38 47 28 42 11 15 23 23 19 28

0

10

20

30

40

50

60

70A

xis

Titl

e

Sunshine RRT / Rounding referrals

Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar

Rounding 70 61 67 44 28 38

RRT calls 56 88 58 64 75 69 67 74 88 95 95 96

0

20

40

60

80

100

120

Axi

s Ti

tle

Western RRT / Rounding referrals

Decreased ICU ward

admissions

Decreased mortality from

unplanned ward admissions

Decreased code blue calls

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ICU Discharge Follow up Criteria

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ICU Liaison Nurse Role

1. Assess patients in the ICU prior to discharge and write a

comprehensive assessment using patient at risk score.

2. Provide follow up service for patients leaving ICU who meet ICU

follow up discharge criteria

3. Provide a nurse-led rapid response team review for

deteriorating patients

4. Minimum daily rounding to emergency departments and all

clinical areas at WH and SH

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2012 ICU Liaison service review

Follow up

Deteriorating Patient

Referrals

Extensions to practice Nurse

Practitioner

Travelling Fellowship

Patient Rounding

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What's left to do?

Position statement

National KPIs

National database

National reporting

Outpatient service

Nearly there!

24 Hour coverage business case