Raising staff awareness of patient deterioration, shock
Hospital system drops preventable codes by 70%
It's when they looked back at what they had accomplished that they realized they really had been organized. For every performance improvement project, minute details and myriad elements make it almost impossible to go from A to B to C. But in retrospect, and with stops and starts and rework, the team at Children's Healthcare of Atlanta did a good job.
Their focus was early detection of patient deterioration. Amber Cocks, MSHCM, senior quality and process improvement consultant, and Christiane Levine, RN, quality and patient safety program manager, both at the health care system, led the team. "The first thing we absolutely wanted to do was to rescue the patients from harm. We had found several points of failure within our own processes and abilities to protect patients, and so we started by addressing those failure points," Levine says.
Handoff communication
The two started by evaluating and strengthening handoff communication between providers. They standardized transfer of care using the SBAR (Situation-Background-Assessment-Recommendation) technique.
They started by asking: What's often missing in this transition? Clinicians were pulled together to discuss this from their point of view, something Cocks and Levine say is essential — getting input from those handling the transfer process day in and day out. The two assembled "transfer of care champions" in each area and identified the nurse-to-nurse, shift-to-shift transfer as the greatest area for evaluation.
The team worked to identify trends in missing areas of information, and Cocks and Levine sought to isolate the "minimum set of information, the most important things they felt needed to be communicated about their patients during transfer of care."
The list they created could be modified by any department as needed. When it was first used, many departments laminated the list and put it where personnel could see. Now that most staff are familiar with the elements, there is no form needed but the hospital system also has the ability in its electronic health system to populate the information in real-time on the computer screen.
"It was really neat because the way it was organized is we started with general care nurses and then, once we got them to agree on the information they felt they wanted, then we brought in different groups of nurses. The ICU nurses then came in with general care and talked about what information they all needed to get together — what the OR needed from general care, from critical care.... And so it sort of spiderwebbed out so that everybody knew what to expect when they were giving or receiving reports from one of the other areas," says Levine.
Educating staff with simulation
The recognition of shock was a different campaign. "What we ended up doing," Levine says, "we really sort of shifted our whole philosophy on educating staff. And instead of sending out a bulletin to say, 'Everybody review shock. Don't forget to watch for tachycardia,' we completely shifted our model for the way we teach staff into simulator-based and scenario-based teaching."
It's important, she says, "to bring in at the beginning of the discussion of any kind of program or improvement process your clinical learning team, the people that create learning for your organization... I think that's probably a really underutilized resource, and our patient quality and safety team is partnering very closely with our learning services."
Levine and Cocks took true case study scenarios as teaching opportunities with high-fidelity simulators. Those scenarios were programmed into computers so the on-screen patient would act like an actual one. Staff walked through the scenarios and made decisions or recommendations based on what they saw. They could actually see missed opportunities; for instance, a staff member could replay a scenario and see when the patient's heart rate went up.
Let's say the staff member says, "OK, I'm going to give an IV fluid bolus now. Now what's my heart rate?" And if the on-screen patient doesn't respond, then the staff member knows he or she has missed something else. Now the nurse might say, "I'm going to call the rapid response team." As part of the yearly review of nurse competencies, every single staff member has to go through the simulation training.
Moving toward quicker recognition of patient shock, the team used both root-cause analysis and common cause analysis. One thing it found was there often was a lack of IV access. Oftentimes, staff didn't know when the IV team was in-house, Cocks says, or they didn't have a list of where or who to go to if an IV was needed. The team wanted a 24/7 IV team, which it does not yet have, so Cocks recognized experts in the critical care and emergency department settings that should be called on if an IV was needed.
Don't be afraid to speak up
Along with staff education, Levine and Cocks say it was necessary to make it clear that they wanted staff to speak up if a patient was in danger and that staff should never fear speaking up — and most importantly, that hospital administration would always stand behind them if they did.
Levine says that before, a lot of staff were too intimidated to speak up. For instance, if one staff member says to a nurse, "I think this patient is going into shock," the nurse might respond, "Who are you to tell me she's tachycardic?" With the "Speak Up" campaign, they sought to make it safe for anyone to call a rapid response team or to ask for proper help if a patient was deteriorating.
"We also offered scripting to them, and the No. 1 thing people said was, 'I'm not going to call the rapid response team because I'm not going to have someone chew my head out for calling them.' And so what we did was we scripted [the communication]."
She notes the RRT at Children's is "driven by the staff and owned by the staff." The team comprises one nurse and one respiratory therapist, and the hospital tries not to assign them so they are free to fulfill the RRT duties.
The team, which is part of the mentor program of the Institute for Healthcare Improvement, is expected to respond within five minutes of a call. "I think one of the reasons we've been really successful is because we looked at our failure points and built a team based on our failure points, not based on a structure other hospitals used," Levine says.
PEWS used for early intervention
The pediatric early warning score system, also known as PEWS, was developed by a UK hospital. Children's Healthcare got it from Cincinnati Children's Hospital Medical Center. Levine says "it's a series of assessments, and you score a patient on those assessments every four hours or more frequently as needed. And it can help paint a clinical picture of deterioration six to eight hours before an adverse event would occur."
As soon as a patient is admitted at the system, a PEWS score is taken, and that score and every subsequent assessment is placed in the patient's chart. An algorithm goes along with the scoring system. The entire assessment, Levine says, takes less than 30 seconds to complete.
Since the nurses were the ones using the system, Levine says physicians were just taught, "This is what it is. This is how it's scored, and please just be aware if a nurse calls you and says, 'I don't know... My gut is telling me something is wrong and the PEWS score has gone up,' then please be aware that the evidence has shown that it's a good predictor of an impending cardiac or respiratory arrest."
Preventable code rates decreased
It was after evaluating and defining the elements of handoff communication and after educating staff to recognize early signs of deterioration, that Children's Healthcare began to roll out the rapid response team.
Levine says years ago she spoke with the lead author of a seminal study at Lucile Packard Children's Hospital in Stanford, CA, which showed that rapid response teams decreased pediatric death rates. At the time, Children's Healthcare had only seen a 10% drop in code rates a year after implementing its RRT.
"She said, 'You will not see a drop until at least two years.' And you know what? At two years, we bottomed off. So there's something about that two-year mark, and I think it just takes that long to really change your hospital's culture," Levine says.
Now, the system has decreased its preventable code rate by 70%. When she looks back at the entire process — beginning with transfer communications, staff education, and introducing the PEWS system — Levine says, "we realized [our success] was because by doing all of these things, we turned our ship around when we speak about culture. Because all of a sudden, we created a culture where it was safe to speak up. It was safe for nurses to critically think about IV access because now they had a tool that told them, 'You can think through this. It's OK. Here it is.' And standardizing transfer of care, making sure that they understood when it doesn't go right, it goes wrong for everybody — the patient and the nurse."
(For more information, contact:
Amber Cocks, MSHCM, senior quality and process improvement consultant, Children's Healthcare of Atlanta. E-mail: [email protected];
Christiane Levine, RN, quality and patient safety program manager, Children's Healthcare of Atlanta. E-mail: [email protected].)
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