Case study: a new Royal North

Shore Hospital RRT

Dr Liz Hickson, Dave Wastell, Sarah Webb

September 2013

Background to RRT

• Previously only a Code Blue RNSH ICU response in keeping with the MERIT study

• BTF initiative 2007 “track & trigger” system mandated – ICU only code blue responders

• ACSQHC 10 new Standards in 2012 – RRT core

• Concerns re RNSH SAC 1 & 2 events by executive

• NOT pushed by ICU

RNSH RRT Timeline

• Funding confirmed November 2012 for 1 year trial of 2 FTE Intensivists

• Start-up day in December 2012

• Commenced February 11, 2013

This is our story

Kotter’s 8 steps for leading change

• Act with urgency

• Develop a guiding coalition

• Develop a change vision

• Communicate the vision buy-in

• Empower broad-based action

• Generate short-term wins

• Don’t let up

• Make change stick

RNSH RRT Mission

• Our mission is to improve the quality of care of critically ill patients at RNSH.

RNSH RRT Vision

• Our vision is to work with the hospital inpatient teams as 'partners' in patient care, exceeding the standards for 'Recognising and Responding to the Deteriorating Patient', recommended by the Australian Commission on Safety and Quality in Health Care.

RNSH RRT Values

• Our values are teamwork, respect for others, support and innovative education and research.

Motto & Logo

RRT Composition – in-hours

• ICU Nurse

• ICU RRT Registrar

• RRT Intensivist

• Support CNC (Resuscitation Co-ordinator, BTF Co-ordinator)

RRT Composition – after-hours

• ICU Nurse

• ICU RRT Registrar

• ICU Advanced trainee reporting to the Admitting Intensivist

• Supported by ICU After Hours Nurse Manager

Post ICU Discharge/Follow-up ward round

• In-hours - RRT Intensivist & Support Nurse with primary responders if free to attend

• After-hours – RRT Registrar & RRT ICU nurse

Setting The Standard – A patient Journey at RNSH

• Educational package for staff by staff created by A/Prof Carole Foot

• Series of short films starring executive with clinical staff

• Used for orientation of staff in ICU & throughout the hospital

Topics needed

• National standards – Emphasis on Standard 9

• Implementation of the Between the Flags initiative

• New RRT operations & RRT red zone form

• Revised Code blue team responses

• End of life planning

• REACH trial

Chapters in the series • Chapter 1 – Introduction to the Standards • Chapter 2 – Clinical Handover • Chapter 3 – Use of Standard Observation Charts • Chapter 4 – Frequency of patient Observations • Chapter 5 - Recognising clinical deterioration • Chapter 6 – Ordering yellow zone review • Chapter 7 - Ordering red zone review • Chapter 8 – Rapid Response Team Review • Chapter 9 – Code blue response • Chapter 10 – Changing the call • Chapter 11 – End-of-Life planning • Chapter 12 – REACH initiative • Chapter 13 – Red zone EMR form for the Rapid Response Team • Chapter 14 – Conclusion and credits

Between The Flags

• Based on the SAGO chart

• Yellow & red zones

BTF Escalation processes

• Yellow zone clinical reviews performed by ward staff

• Red zone rapid responses by RRT & ward staff together

• Code blue responses based on zones around the hospital

Education plan

• Weekly RRT/BTF teaching session (Thursday 1430-1530) open to all ICU & ward staff – Simulations – Case discussions – Presentations on key topics

• RNSH RRT pages on ICU Wiki • RRT Cards for common problems • Ongoing education sessions for medical & nursing

orientation of new staff • Mock code blue ward program

Post ICU Discharge initiative

• ACHS Intensive Care Clinical Indicators 2011

• Aim was to see if a process could reduce unplanned ICU readmissions within 72 hours

• A screening tool was devised based on papers that used a multivariate analysis to identify risk factors associated with readmission

• A standard review form used as a checklist for up to 3 days of review

RRT – early outcome data

February - July 2013

Principal reasons for RRT activation

535, 38%

167, 12%

153, 11%

130, 9%

36, 3%

33, 2%

10, 1% 345, 24%

Low SBP

High HR

High SBP

Low SpO2

Serious concerns by staff

Sudden drop GCS

Seizures

Other

Results to date

• RRT primary & secondary outcomes

• Post-ICU discharge service outcomes

RRT Primary outcomes

• RRT calls/1000

• Unplanned ICU admissions

• Unplanned cardiopulmonary arrest rate/1000 (CPA/1000)

• Survival from in-hospital cardiac arrest/1000

• Hospital mortality/1000 (HSMR in the future)

Yellow & Red zone calls

115 133 153 156 147 170 208 263 286 229 203 227 310 249 254 296 295 341

354 345 449

357 390 427

497

575

722

648 609

655

737

648 791

832 1001

1012

0

200

400

600

800

1000

1200

1400

Jan

-12

Feb

-12

Mar

-12

Ap

r-1

2

May

-12

Jun

-12

Jul-

12

Au

g-1

2

Sep

-12

Oct

-12

No

v-1

2

Dec

-12

Jan

-13

Feb

-13

Mar

-13

Ap

r-1

3

May

-13

Jun

-13

Clinical Reviews

Rapid Response

RRT Red zone responses

249 254 296 295

341

0255075

100125150175200225250275300325350

Feb-13 Mar-13 Apr-13 May-13 Jun-13

RRT calls

Red zone RRT reviews

• Mean RRT calls/1000

– 6 months Pre RRT = 56.8

– Post RRT – June 30 = 57.5

BUT

– Effect likely greater as duplicate calls now uncommon

RRT response times

• 99.4% of calls attended within 15 min

ICU unplanned admissions

2.9 2.3

4 4.5 5.9

5 4.2

5.4

3.2 2.6 2.6 4

2.6

6.3 6.9 7.5

5.8

7.9 6.8 7.1

8.1

11.5

13.4 14.3

11.1

16.2

9.2 9.2

11.5 10.3

13.7

11.8 11.3

13.5 14.7

16 16.9

15.1

18.8

0

2

4

6

8

10

12

14

16

18

20

Jun

-12

Jul-

12

Au

g-1

2

Sep

-12

Oct

-12

No

v-1

2

Dec

-12

Jan

-13

Feb

-13

Mar

-13

Ap

r-1

3

May

-13

Jun

-13

Code blue %

RRT/ICU review %

Total % of ICUadmissions

Unplanned admissions

• Jan-June 2013

– 91% discharged to ward alive; 9% died in ICU

– Approx. 60% Surgical vs 40% Medical

– 67% out of hours (1800-0800)

– Mean ICU length of stay 4.1 days

– Overall mean APACHEII scores of total ICU admissions remains at 14 over 3.5 years

Post ICU discharge service

0

50

100

150

200

250

300

2011 2012 2013 Feb-Jun

Mean monthly ICUadmissions

Mean monthly ICU livedischarges

Unplanned readmssions<72h

Constant 93% survival

Constant 2%

Revised post-ICU discharge review criteria

• Long stay patients (>10 days)

• Patients with traches

• Patients discharged after 6pm

• Consultant discretion

CPA/1000

• Mean rate July 2012 – Jan 2013 = 0.97 for 34666 total separations

• Mean rate Feb 2013 - July 2013 = 0.6 for 25006 total separations

• RR CPA/1000 = 0.9

(95% CI 0.5-1.6 p=0.7)

Hospital deaths/1000

• Mean rate July 2012 – Jan 2013 = 14.1 for 34666 total separations

• Mean rate Feb 2013 - July 2013 = 9.8 for 25006 total separations

• RR Death/1000 = 0.97

(95% CI 0.84-1.12 p=0.7)

RRT Secondary outcomes

• Outcomes from cardiopulmonary arrest

• Critical incident event rate

• Qualitative Feedback – ward staff & RRT

CPA outcomes

60 58

24

33

8

0 0 4

8 4

0

10

20

30

40

50

60

70

2012 2013

Death %

D/C home %

Transfer to anotherhospital %

D/C own risk %

Other %

Cardiopulmonary arrest form

Critical incidents • 2011 & 2012 – 5 SAC 1 & 6 SAC 2 associated

with failure to detect & escalate deterioration

• Since RRT commenced – 0 SAC 1 or SAC 2 events

Qualitative feedback about the RRT

• Surveys of Ward nurses, Ward JMOs & SMOs

• Surveys of RRT staff

• Ongoing analysis but generally positive feedback

Going forwards…

• Ongoing negotiation regarding ICU resources in general, as well as RRT for 2014

• Red zone call database analysis

• Development of in hospital CPA database

SUSTAINING A SERVICE

Questions?