Presentation on theme: "Mortality Reduction in Medical/Surgical Care – Rapid Response Teams and SBAR Strategies September 24, 2004."— Presentation transcript:
1 Mortality Reduction in Medical/Surgical Care – Rapid Response Teams and SBAR Strategies September 24, 2004
2 Presenter BioRobert Brush, MD, has practiced as a Pulmonary and Critical Care Specialist at Borgess Medical Center since 1977.For the past two years, Dr. Brush has been the Chief Quality Officer at Borgess.
3 Rapid Response Teams“A Rapid Response Team (RRT, MET) is a group of healthcare professionals who respond quickly to threatened clinical deterioration. They should be seen as a “pre-code” team that brings critical care skills to the patient’s bedside. The IHI considers the RRT as potentially the most important mortality reduction initiative.”
4 Attending asks medical resident to see patient. How It Usually Goes:A 65 y/o male with history of sleep apnea, post-op cholecystectomy complains of dyspnea. RR=30, SpO2 dropped to 87% on 4L O2/NC.Nurse calls attending who gives additional morphine and increases O2 to 6L.Patient “calms down” and RR=24, but SpO2 falls to 85% so nurse calls attending back.Attending asks medical resident to see patient.
5 How It Usually Goes (continued): Resident (HO-1) talks to the nurse on the phone and orders ABG, CXR, ECG, CBC and electrolytes. He says he’ll see the patient after he finishes with a new patient in ER.Resident reviews the lab work 90 minutes later and asks the senior resident to see the patient with him.As the residents enter the room, patient stops breathing. A “Code” is called. Patient survives but spends the next two weeks in ICU on a ventilator.
6 How It Should Go:A 65 y/o male with history of sleep apnea, post-op cholecystectomy complains of dyspnea. RR=30, SpO2 dropped to 87% on 4L O2/NC.Nurse feels the patient is “slipping” quickly and calls the Rapid Response Team.Within five minutes, the patient is assessed, lab work and CXR is ordered and BiPAP is begun.CXR and I&O review shows the patient is fluid overloaded.
7 How It Should Go (continued): The patient is given IV Lasix.The patient is transferred to a step down unit.The diuretic is effective.The patient returns to the Med/Surg Unit the following day and is discharged from the hospital two days later.
8 Rapid Response Team – What Is It? Team with critical care skills that “brings critical care to the patient’s bedside”Assist/augment floor nurse’s evaluationProvides early intervention to slow or prevent clinical deterioration
9 RRT – Rationale (When Do You Open the Parachute?) 6 – 8 hour window pre-code when deterioration may be turned around“Failure to Rescue” – failure to recognize (nurse or therapist) versus failure to respond (physician)
10 RRT – Structure Team composition may vary: Physician – Intensivist versus ResidentPhysician Assistant/Nurse PractitionerCritical Care Trained NurseRespiratory Therapist
11 RRT – Functions Responds within minutes Attending MD called after RRT is calledAssess patient with the floor nurseIntervene with or without attending MDTransport to higher level of care when neededSummon Code Team if needed
12 RRT – When to Call Respiratory Rate > 24 or < 8 Falling SpO2 Δ level of consciousnessΔ BP and/or HR by 20% from baselineDecreasing urine outputSTAFF IS WORRIED ABOUT PATIENT!
13 RRT – Possible Interventions Acute change in Respiratory Status:Oximetry/ABG’sOxygenCXRNeb TXBiPAPIntubation
14 RRT – Possible Interventions (continued) Acute change in HP/BP:12 Lead ECGABGOxygenAtropineAmiodaroneExternal PacemakerDopamine InfusionOther
15 RRT – Possible Interventions (continued) Acute Change in LOC:ABG’s, OxygenElectrolytes, Glucose LevelNaloxone, FlumazenilCT Brain, MRI
16 RRT – Outcomes ↓ Incidence of cardiac arrests ↓ Arrests on floor as ↑ # of RRT calls↓ ICU transfers↓ Overall mortalityImprove “critical thinking”
17 Before and After Trial of a Medical Emergency Team Pre-METPost-METCardiac Arrests6322Deaths from Cardiac Arrest3716ICU Bed Days16333Hospital Bed Days1353159Total Hospital Deaths302222University of Melbourne (MJA 2003; 179(6): 283)
18 RRT – Metrics Number of RRT calls/number of discharges per month Number of non-ICU codes/number of discharges per monthNumber of deaths/number of discharges per month
19 Reduction in “Code Zeros” RRT Trial BeganBorgess Medical Center
20 RRT – Building the Team Choosing and teaching the team Communicating with the nursesCommunicating with the physiciansEncourage collegial relationships among nursesDiscourage intimidationTeach “critical thinking” to all
21 RRT – Barriers PHYSICIANS – Threatened Autonomy NURSES – Feel intimidated by critical care nurse/respiratory therapists
22 SBAR DefinedSBAR is a situational briefing tool that logically organizes information so that it can be transferred to others in an accurate and efficient manner.
24 SBAR - Rationale Fosters “critical thinking” skills Nothing “lost in translation”Saves timeHelps RNs/RTs be the patient advocate
25 Assertive BehaviorIndividuals speaking up and stating their information with appropriate persistence until there is resolution, all done in the interest of better patient care.
26 Assertiveness - Obstacles Hierarchy/Power distanceLack of common mental model“Don’t want to look stupid”“Not sure I’m right”“I’ve been burned before”
27 SBAR - Situation “I am (name and unit).” “I am calling about (patient’s name androom number).”“The problem I am calling about is (state the problem).”
28 Situation - Example“I am Mary, a nurse on 3 North, calling about your patient Mrs. Brown in room 345 bed 2. The problem I am calling about is her new complaint of dyspnea and her increasing respiratory rate.”
29 SBAR - Background State admission diagnosis and date of admission. Give brief synopsis of hospital course and treatment to date.Give vital signs including SpO2 and physical assessment pertinent to the problem.
30 Background - Example“Mrs. Brown was admitted 3 days ago with pneumonia. She’s been on Levaquin and improving each day, no more fever and less cough and sputum.Now her vital signs are RR=32 P=86, BP= 90/60, T=100.1 and SpO2= 88% on 2L.Her breathing looks labored and she has new crackles in the right lower lobe.”
31 SBAR - AssessmentGive your impression of the present situation. A diagnosis is not necessary.If the situation is unclear, at least try to indicate what body system is involved.State how severe the problem seems to be.If appropriate, state that the problem could be life threatening.
32 Assessment - Example“I think Mrs. Brown could be developing worsening pneumonia in the right lower lobe.”
33 SBAR - RecommendationGive the physician your recommendations for the thing(s) that you think should be done, based on your assessment.
34 Recommendation - Examples “I have called the Rapid Response Team.”“I think you should come to see the patient now.”“I think you need to talk to the family about code status.”“I think the patient needs a portable CXR and blood cultures.”
35 Before You Call Have patient’s chart and MAR Have today’s labs Review most recent Progress NoteReview nursing notes for past shiftKnow the “code status”
36 SBAR - Obstacles Nursing acceptance – “but this is what I always do when I call the doctor.” Yes,but is this the way you always document?Physician acceptance – Doctors are notaccustomed to nurses or therapists givingthem unsolicited recommendations.
37 Before SBAR Nurse: “Dr. Green, room 345’s potassium was 3.1 today.” Doctor: “Who’s potassium was 3.1?”Nurse: “Mrs. Brown in 345 bed 1, your partner’s patient.”Doctor: “What was her last potassium?”Nurse: “I don’t know; let me go find the chart.”3 min. later – “It was 3.5 two days ago.”Doctor: “Is she on any diuretics?”Nurse: “I don’t know. Let me go find the MAR.”2 min. later: - “Yes, she’s on Lasix.”Doctor: “Has she had any complaints tonight?”Nurse: “I don’t know, her nurse is at lunch.”….etc.etc.
38 After SBARNurse: “Hello, Dr. Green, this is Nancy the nurse taking care of your partner’s patient, Mr. Brown, in room 345, bed 1. I’m calling you because her potassium just returned and is 3.1.He is a 46 y/o man admitted 2 days ago for CHF. He’s been on Lasix since admission but no potassium supplement. His V/S are P=80; BP 110/84; RR=14 and T= He is asymptomatic, no complaints of weakness and feels well.I think he is hypokalemic from his Lasix and needs some potassium supplement.”
39 Rapid Response Teams and SBAR Contact InformationBorgess Medical Center Project ManagerRobert Brush, MDChief Quality OfficerBorgess Medical Center – Kalamazoo, MISystem Office LiaisonJohn GarboDirector, Clinical Excellence