1. Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro The Establishment of a Rapid Response Team to Identify Acutely Ill Adult Patients Gemma Ellis Consultant Nurse, Adult Critical Care Cardiff

2. Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro Project Outline Management Board Sept 2007 – SPI II Initiative (Trigger tools and Rapid Response Teams) 100,000 Lives Campaign hospitals should initiate RRT as 1 of 6 strategies to reduce preventable in-hospital deaths Background There is a significant body of research that suggests that the recognition of acute illness in adults in hospital is often delayed and its subsequent management may be inappropriate. This leads to the possibility of late and avoidable admissions to critical care and unnecessary patient deaths NICE 50 guidelines were issued for consultation on “Acutely ill patients in hospital: Recognition of and response to acute illness in adults in hospital”

3. Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro NICE CG 50 Guidelines NICE CG 50 - “Acutely ill patients in hospital: Recognition of and response to acute illness in adults in hospital” The guidelines cover the care of all acutely ill adult patients in hospital, including patients in emergency departments. It addresses three key areas: 1.Identification of patients who are either at risk of clinical deterioration or whose clinical condition is deteriorating. This includes assessment of: scoring tools that record physiological parameters and neurological state; the level of monitoring needed; and the recording and interpretation of the data obtained. 2.Response strategies, including the timing of response and patient management, and the communication of monitoring results to relevant healthcare professionals, including the interface between critical care and acute specialities. 3.Discharge of patients from critical care areas back to ward-based care. This includes monitoring requirements on the ward and the timing of transfer

4. Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro Why Rapid Response Teams? Rapid Response Team Results: Measure: Before: After: Rel Risk Reduction: No. cardiac arrests 63 22 65% (p=.001) Deaths from cardiac arrest 37 16 56% (p=.005) No. days in ICU post arrest 163 33 80% (p=.001) No. days in hospital post arrest 1363 159 88% (p=.001) Inpatient Deaths 302 222 25% (p=.004) *Table adapted from Bellomo R, Goldsmith D, Uchino S, et al. A prospective before-and- after trial of a medical emergency team. Medical Journal of Australia. 2003;179(6):283-287.A prospective before-and- after trial of a medical emergency team

5. Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro Historical Background Previous Pilot 2002/2003 – Medical Emergency Team –A critical care consultant –A critical care nurse –A registrar from the relevant specialty – This would require the following staffing resources: –Consultantx1.67 –F Grade nursex6 at UHW –A & C Grade 4x0.5 Other Issues – Emergency Role of Medicine Nurse Practitioner –Confusion over process from different disciplines. –Clinical lead required –Professional educational strategy –Inconsistent team response to emergency algorithm –Team approach needed

6. Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro Other Considerations Composition of RRT’s is not standardized Optimal Triggers Cost effectiveness is not established Need to establish efficacy – published data is limited Benefit to improve end of life care (? Optimal approach to improving end of life care)

7. Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro Initial Pilot Project Outline Funding for two extra Nurse Practitioners SPI II Project 12 Month Project Daily (Mon-Fri) presence of nurse practitioner with acute/critical care training to provide immediate support (08-00 to 18-00 hrs) Commenced Jan 2008 with roll-out across wards Extended to three General Medical Wards, A7, B7, C6

8. Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro Medical Rapid Response Team Improving Patient Safety

9. Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro Improving Patient Safety Observation Audit PDSA cycles Outcomes

10. Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro Observation PDSA cycles Documenting recommended frequency on EWS chart Documenting recommendations of frequency in hours Documenting changes of frequency in MDT notes Implementing recommended frequency of observations Documenting any abnormal physiology within the MDT notes

11. Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro

13. Methodology - MRRT Full involvement of the MRRT 24hr cycle >95% compliance Identical bed space rollout Displayed ‘up and coming’ PDSA cycles Clearly displayed daily results

14. Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro Methodology – Ward Staff Remedy non-compliant documentation Safety briefings Named nurses Feedback

15. Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro

16. Audit - EWS Chart Use N = 64N = 106

17. Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro Audit Results - Observations Taken No reliability Reliable / sustainable system

18. Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro Audit Results - Abnormal Physiology Documentation Multiple PDSA cycles

19. Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro Audit Results – Observation Frequency Never documented 95% Reliability and sustainability Never documented

20. Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro

21. Audit Results – Early Warning Score Earlier alert to deterioration Less severity of illness

22. Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro The patient experience and process of assessment

23. Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro What is SBAR? SBAR (Situation-Background-Assessment Recommendation) Framework for communication between members of the health care team about a patient's condition SBAR is an easy-to-remember, concrete mechanism useful for framing any conversation, especially critical ones, requiring a clinician’s immediate attention and action SBAR was introduced by the MRRT as a uniform method of communication throughout the medical wards

24. Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro

25. Ward Staff Handover Situation –EWS 4 - Temp 33.8, Heart Rate 47bpm, AVPU Background –Admitted with falls and UTI and a history of Dementia Assessment –HR 47bpm, BP 119/63, RR 18, 02 Sats 92%, AVPU temp 33.8, BM 5.4mmols Recommendation –Warm patient, check manual observations, immediate review.

26. Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro SBAR Results

27. Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro MRRT Assessment S Patient scoring 4 on EWS chart, temperature 33.8C, heart rate 47bpm- sinus bradycardia. Alert only to voice B Patient has a picture of dementia (very agitated, constantly undressing herself) falls, presented with facial bruising and a UTI A A -Patent B – RR 18 bpm, oxygen saturations 92%, bilaterally laboured breathing, no audible wheeze C – HR 47, sinus bradycardia on ECG, BP 119/63, patient cold to touch, output not being measured, not eating or drinking as too drowsy, patient pulls out cannula when awake, U & E showed slightly raised urea and creatinine D– A V P U patient responding by eye opening only to voice temperature hypothermic at 33.8°c, blood sugar within normal range E - Widespread bruising, offensive urine, incontinent, having TDS Haloperidol, Temazepam nocté, patient looks ‘drugged ‘

28. Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro R –  Warm patient up with blankets  Monitor input and output on fluid chart  IVI  Encourage diet and fluids when awake  Avoid sedative medication, clear sedation limits  Check routine bloods  Consultant to document resuscitation status and ceiling point of treatment

29. Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro Care Interventions N= 1193 71% 10% 6%

30. Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro The Future Continued Data Collection for quality assurance – sustainability and reliability Expansion of Team to Cover All Areas –Seven wards – 187 beds plus a MEAU Expansion of hours Secured Funding Future Trust-wide Use

31. Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro Change in Cardiac Arrest Calls WardPeriod of Pre – RRTPost- InterventionRRT A3L - Sept ’07 to March ’08 3 Sept ’08 to March ’09 2 B6 - Dec ’07 to March ’08 7 Dec ’08 to March ’09 3 C7 - Jan ’07 to March ’08 28 Jan ’08 to March ’09 8

32. Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro Continuing Audit SBAR – July 2008 to July 2009 1193 calls Issues, new staff, new wards Medical Interventions - to date 1193 calls 3/day DNAR issues 11/155 = 10% Drugs 334/1193 = 28% Fluids 293/1193 = 25% Oxygen 297/1193 = 25%

33. Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro Change In Culture Real or Unreal? Hospital @ Night Critical Care Adult Medicine

34. Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro Thank You “In God we Trust, All others bring data” “Quality begins with intent, which is fixed by management” WE Deming