1. Nurse Practitioners aren’t built in a day.
Anna Green
Nurse Practitioner – ICU Liaison
Nurse Practitioner Project Officer
Western Health, Australia

2. Map of Australia Melbourne
If you are planning on coming to Australia then your visit would not be complete without a stay in Melbourne.
We pride ourselves on our sporting venues which includes the formula 1 Grand Prix, the Melbounre Cup HorseRace, and our own brand of football known as Aust. Fooltball League.
Melbourne is also renown for its arts and culture centres and not to mention exquisite dining venues.
Melbourne

3. Leadership core competencies
Visionary
Idea
Commitment
Energising
When researching up on leadership skills The common theme was these core leadership competencies were repeated again and again and can be best summarized by Jodie McLeod in her article in Human Capital Issue as:
creating a vision around where you need to go
Energising people to ensure that they’re empowered to come on board with you and follow you
Building commitment to the vision…
Given what I have said about leadership how does this differ to what I do normally.
Empowerment
McLeod J. Leaders aren’t built in a day. Human Capital Issue 3.1: 24-27

4. ICU Liaison Nurse Role Case-Manage patients post ICU discharge
Accept referrals for unstable patients
Rapid Response System - respond to clinical marker referrals
Initially established to only case manage pts post ICU discharge
Within 3 months of commencing in this role we started receiving referrals from nursing and allied health staff for other patients on the wards who were clinically deteriorating.
It wasn’t long after this that referrals from medical staff started to occur and has continued to increase each year of operation. It is not uncommon to be asked by the ICU medical staff or ward medical staff to review clinically unstable patients on the ward, to assess if ICU admission is required.
Whilst we receive a large proportion of referrals for unstable patients in the ward there are still others who are admitted to ICU from the ward where we have had no involvement with and have shown significant signs of clinical instability for several hours and in some cases days.
It was these patients we were not referred to us that led us to come up with the clinical marker referral system. This system is based on the MET. The MET in some hospitals in Australia, has replaced the traditional resuscitation team and respond to emergency calls for all pts showing signs of pre-determine vital sign abnormality. Our clinical markers that are based on the MET criteria have been modified following a 3 month review of all unplanned admissions unto ICU to identify earlier signs of deterioration than pre arrest criteria.

5. ICU Liaison hours worked
Two full time EFT
7 day a week cover
8am to 6pm
One day a week allocated to non clinical work
Research
Leadership
Education
Meetings/Committee
Working towards 24 hour service
Expanding service throughout the network

6. Leadership development
Internal
External
1996
1998
Obtaining an office and equipment
Changes to the reporting structure of the role
Meeting organisational demands that were separate to individual demands
Complex care course
Process improvement team
Policy and procedure manual
Rewarded with leadership development course
Extending hours to full time
Self
Leadership skills

7. Goal achievement Australia's First Critical Care NURSE PRACTITIONER
2004
My application to the NBV was back in May 2002 and it was 2 1/2 years later that I was finally endorsed. Waiting that length of time was frustrating however, it was more important to get the process right. All of us who have gone through the endorsement process in Victoria have an immense sense of achievement and are very proud of the commitment of not only ourselves but also the NBV and the DHS Victoria.
So in essence my training in becoming a NP whilst working in an advanced practice role took 6 years which does not take in account 10 years previously of working in my specialty area of critical care.

8. Three Fundamental Problems
Failure in planning
Failure to
Rescue
Failure to communicate
In the 100,000 Lives Campaign they report on three main systemic issues contributing to the problem of failure to rescue.
The first is failure in planning which includes assessments, treatments and goals
The second is failure to communicate including patient to staff, staff to staff, and staff to physician etc)
The last is a failure to recognise the deteriorating patient
And all of these contribute to fail to rescue
Hence the rapid proliferation of MET, Outreach Teams and the ICU Liaison Teams.
Failure to recognise
deteriorating patient condition

9. What is a Rapid Response System?
Medical Emergency
Team
Outreach
Team
ICU Liaison Team
A rapid response system (RRS) involves the utilisation of a variety of hospital resources, for the detection and treatment of patients in crisis, to prevent deterioration, morbidity or death.
MET – Liverpool Hospital 1990
ICU Liaison – Western Hospital 1996
Outreach Team – UK Late 1990’s early 2000
MET & Liaison –
The aim of implementing a RRS is to reduce the number of unexpected in-patient deaths.
MET & ICU Liaison Service

10. What are these warning signs?
Altered CNS
Fall in GCS of >2 points
Heart Rate >120 per minute
Systolic blood pressure <90mm Hg
Respiratory Rate >30 breaths per minute
Sa02 >90% on oxygen
Difficulty in breathing
UO <60mls for 2 hours
“Worried Staff”
(Green & Williams 2006)
These criteria are the MET criteria for Liverpool Hospital
These reportable ranges vary depending on the individual hospital.
In the UK the criteria used are based on Franklins article that identified warning signs 6hrs of arrest.
Differences include
Lowering the upper range of heart rate to 125
Lowering the upper range of respiratory rate to 30 breaths/minute

11. Changes to criteria ranges
New criteria
Omitted criteria

12. What difference Can a NP led Rapid Response Team Make?
Fast Track Patients to the ICU
Decreased cardiac arrest calls
Increased medical emergency calls
Improved survival for medical emergencies
+/- reduction in readmissions (Ball et al., 2003; Pittard, 2003)
+/- reduction in ICU patient mortality (Ball et al., 2003; Garcea et al., 2004; Priestly et al., 2004)
+/- decrease ICU LofS
(Green & Williams, 2006)

13. Survey Responses Clear Guidelines Prompt Support ‘Back-up’
(Green & Williams, 2006)

14. Survey Response Disagreement with parameters Overstepping boundaries
Increased workload for ICU MO
Poor response from MO when called
Further education
(Green & Williams, 2006)

15. What extended practices do I need
Referral to ICU consultants
Ordering of diagnostic tests
Ordering of radiological tests
Limited prescribing rights
Admission / Discharge

16. ICU Liaison – extensions to practice
Limited
Prescribing
Counselling
Clinical
Practice
Initiate
Diagnostics
Admit /
Discharge
Management
Policy
Research
Direct referral to
Medical
Specialists
Education
Conference

17. Reflecting on my achievements
Pioneered the ICU Liaison Role
Implemented Nurse-led Rapid Response Team
Australia’s 1st Critical Care NP
Published 5 Papers
National / International Guest Speaker
Founding Member of the Victorian NP Group

18. Future Endeavour's Expansion Succession Planning Victorian NP Group
Australian Network

19. Concluding remarks: leadership tips for the Nurse Practitioner
Reenergize via successful results
Leave your comfort zone
Do not avoid conflict
Benefit the organisation
Recognise when change needs to occur and acting upon it