Implementing Rapid Response Teams (RRT) National Call September 13, 2007
Purpose By the end of this call, participants will have: Heard successes and learnings from Improvement Teams Updated information on the SHN Campaign, Getting Started Kits and reporting worksheets Answers to your team s questions about intervention-specific changes and measurement An understanding of benefits and expectations of enrolling in the Canadian ICU Collaborative September 13, 2007 2
CCHSA Campaign Support SHN National Steering Committee Secretariat - CPSI Clinical Support CIHI Campaign Structure Canadian ICU Collaborative Peer Support Network Western Node Teams CAPHC Measurement Working Group & CMT Patients Operations Quebec Campaign Ontario Node ISMP Canada Education & Resource Working Group Atlantic Node Communication Working Group Other Canadian Faculty Partner Network IHI September 13, 2007 3
Teams Continue to Enroll 800 700 600 500 400 Updated August 21, 2007 Safer Healthcare Now! Overview Total # Enrolled Teams September 2005 to August 2007 403 443 491 546 557 579 602 628 669 695 718 734 300 296 200 100 118 0 Total # of Enrolled Teams Sep-05 Nov-05 Mar-06 Jun-06 Aug-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 May-07 Jun-07 Jul-07 Aug-07 September 13, 2007 4
Safer Healthcare Now! Enrollment by Intervention Improve Care for Acute Myocardial Infarction Prevent Adverse Drug Events through Medication Reconciliation Prevent Central Line-Associated Bloodstream Infection Prevent Surgical Site Infection Prevent Ventilator-Associated Pneumonia Total Intervention Deploy Rapid Response Teams Number of Teams 52 111 282 66 129 94 734 As at August 21, 2007 September 13, 2007 5
Safer Healthcare Now! Enrollment by Province & Territory Province/Territory New Brunswick Newfoundland & Labrador Nova Scotia Prince Edward Island Quebec Ontario Alberta British Columbia Manitoba Northwest Territories Saskatchewan Yukon Total Number of Teams 24 16 56 11 22 278 63 118 55 1 22 1 669 September 13, 2007 6 As at May, 2007
Enrollment Update West Ontario Atlantic Quebec Total Healthcare Delivery Organizations [includes hospitals, agencies, services and regions (with one or more hospitals participating)] 53 115 25 17 210* *Total at August 21, 2007 September 13, 2007 7
16 14 12 10 8 6 4 2 0 Codes per 1,000 Discharges INTERVENTION - RRT MEASURE: 1.0 Codes per 1000 Discharges Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jan-06 Month Local Team National Goal September 13, 2007 8 Dec-05 Nov-05 Number
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Percent of Codes outside ICU INTERVENTION - RRT MEASURE: 2.0 Percent of Codes Outside ICU Jun-08 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Month Local Team National Goal September 13, 2007 9 Jan-06 Dec-05 Percent Nov-05
50 45 40 35 30 25 20 15 10 5 0 Number of RRT Calls INTERVENTION - RRT MEASURE: 3.0 Utilization of Rapid Response Team May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Apr-06 Month Local Team National Goal September 13, 2007 10 Mar-06 Feb-06 Jan-06 Dec-05 Nov-05 Number of Calls
Rapid Response Teams: The Ontario Experience Dr. Stuart Reynolds
Trillium s Medical Emergency Team Mike Cass
Background At Trillium Health Centre (Mississauga, Ontario) we have reduced cardiac arrests, ICU admissions and mortality by responding to signs of early clinical deterioration. Our team is comprised of critical care nurses and respiratory therapists, supported by Intensivists, with a mandate of bringing critical care to the patient. Medical directives are used to facilitate expedited assessment September 13, 2007 13
Aim Decrease the number of cardiac arrests Decrease the number of ICU patient days Decrease the number of ICU readmissions Improve nursing staff satisfaction and ability to cope with critically ill/ deteriorating patient September 13, 2007 14
Team members Respiratory Therapy ICU Nurses Intensivists Director of Medicine ICU Manager Educators Health Records Analysts Sepsis team lead September 13, 2007 15
25 20 15 10 5 0 Results 1.0 Codes per 1000 Discharges Nov 2006 Dec 2006 Jan 2007 Feb 2007 Mar 2007 Apr 2007 May 2007 Jun 2007 Jul 2007 Aug 2007 Sep 2007 Oct 2007 Nov 2007 Dec 2007 Jan 2008 Feb 2008 Mar 2008 Apr 2008 May 2008 Jun 2008 April 2006 - MET expanded to surgery thus surgery and med units are included Month Actual Goal September 13, 2007 16 Apr 2006 May 2006 Jun 2006 Jul 2006 Aug 2006 Sep 2006 Oct 2006 Feb 2006 Mar 2006 Dec 2005 Jan 2006 Nov 2005 Codes per 1000 dischargesr
160 140 120 100 80 60 40 20 0 Results 3.0 Utilization of Rapid Response Team Oct 2006 Nov 2006 Dec 2006 Jan 2007 Feb 2007 Mar 2007 Apr 2007 May 2007 Jun 2007 Jul 2007 Aug 2007 Sep 2007 Oct 2007 Nov 2007 Dec 2007 Jan 2008 Feb 2008 Mar 2008 Apr 2008 May 2008 Jun 2008 Sep 2006 Month Actual Goal September 13, 2007 17 Aug 2006 Jun 2006 Jul 2006 Apr 2006 May 2006 Mar 2006 Feb 2006 Dec 2005 Jan 2006 Nov 2005 Number of calls
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Results 2.0 Percent of Codes Outside ICU Oct 2006 Nov 2006 Dec 2006 Jan 2007 Feb 2007 Mar 2007 Apr 2007 May 2007 Jun 2007 Jul 2007 Aug 2007 Sep 2007 Oct 2007 Nov 2007 Dec 2007 Jan 2008 Feb 2008 Mar 2008 Apr 2008 May 2008 Jun 2008 Month Actual Goal September 13, 2007 18 Aug 2006 Sep 2006 Jul 2006 Jun 2006 May 2006 Mar 2006 Apr 2006 Feb 2006 Dec 2005 Jan 2006 Nov 2005 Percentage
16 14 Results THC - MED - Most Responsible Diagnosis or Comorbid Condition: Cardiac Arrest (I46.* ICD-10CA) or Respiratory Arrest (R09.2 ICD-10CA) # of Cases Discharge Period: Apr 2003 to Oct 2006 Disch Nursing Units: M-MED or M-ICU Cardiac Arrest and Respiratory Arrests UCL (12.7/mth) Average (6.4/mth) LCL (0/mth) Average, UCL (Upper Control Limit), LCL (Lower Control Limit) are calculated using Apr/03 to May/05 data (24 months Jun/03 SARS excl) 14 12 10 10 9 9 9 10 MET started at end of May/05 10 9 8 Number 8 6 5 5 7 5 6 6 5 6 7 5 6 7 6 6 5 5 5 7 5 4 2 0-2 2 0 Annual Summary: FY03/04-78 FY04/05-73 FY05/06-54 Count is based on 1 Arrest per Discharge 4 2 4 4 0 4 2 3 4 1 4 4 4 Jun/05-Oct/06 w MET there was a 29% or 32 cases reduction in Cardiac/Respiratory Arrests on the Medical Units (incl ICU), compared to 17 months prior to MET (Dec/03-Apr/05) Apr-03 Jun-03 Aug-03 Oct-03 Dec-03 Feb-04 Apr-04 Jun-04 Aug-04 Oct-04 Dec-04 Feb-05 Apr-05 Jun-05 Aug-05 Oct-05 Dec-05 Feb-06 Apr-06 Jun-06 Aug-06 Oct-06 Discharge Month Control Limits: useful for showing unexpected variations; further investigation is warranted when one point falls outside upper or lower control limit or eight successive points fall on one side of mean indicating change in process; Six successive points increasing or decreasing is a trend. September 13, 2007 19
All ICU Visits Indicator Dec/03- Apr/05 Jun/05- Oct/06 Change ICU Visits 2,571 2,457-4% ICU Average LOS (days) per visit 4.8 5.0 0.2 ICU Readmission Rate 6.1% 5.9% less by 0.2% September 13, 2007 20
Indicator Cardiac/Respir atory Arrest Diagnosis and ICU Visit Dec/03-Apr/05 Jun/05-Oct/06 Change ICU Visits 104 69-34% ICU Average LOS (days) per visit 6.7 7.1 0.4 ICU Readmission Rate 16% 14% less by 2% September 13, 2007 21
Changes Tested MET rounds to educate staff case studies from real MET Calls SBAR for all communication b/w RN and MD September 13, 2007 22
Lessons Learned Communication-gaps exist at all levels of communication therefore clinically significant findings aren t being addressed Knowledge-clinical education hasn t evolved with patient population. Clinically significant findings get missed Workload-staff feel too busy to investigate/assess/monitor patients who aren t behaving as expected September 13, 2007 23
Next Steps Increase education aspect re sepsis, respiratory failure, shock etc Partner with cardiac system to deliver PPCI in house within 30 minutes of chest pain for appropriate patients Continue to support sepsis education hospital wide September 13, 2007 24
Questions
Updates to RRT GSK Minimal changes in May 2007 Canadian Example : Calgary Health Region More results added with graphs of MET call frequency and cardiac arrest rates Note graph mislabeled on pg 11 Appendix A detailed history of the testing and implementation of the Calgary program 1 st Intl Consensus Conference June 2005 CCM 2006; 34:2463-2478 September 13, 2007 26
Updates to Measurement Worksheets Three worksheets for each measure: chart, data entry and submitted by Compliance to individual bundle components Instructions for new section September 13, 2007 27
Resources RRT Getting Started Kit & Worksheets http://www.saferhealthcarenow.ca/default.aspx?fold erid=82&contentid=186 Communities of Practice http://www.saferhealthcarenow.ca/default.aspx?fold erid=124 Canadian ICU Collaborative Improvement Guide Available when enrolled in the Collaborative September 13, 2007 28
About the Canadian ICU Collaborative
Benefits of Participating Faster learning and quicker gains September 13, 2007 30
Benefits of Participating (continued) Face-to-face Learning Sessions Evidence-based changes, ready to test and implement Coaching from experienced Faculty on application of changes Education and training on tools for improvement and measurement Advice on targeted strategies to overcome resistance and address barriers Monthly feedback on progress from the Collaborative Faculty Monthly conference calls specific to challenges your team is facing A List-Serve that provides real-time sharing of information, direct to your email Inbox A website for storing and sharing your documents with others A comprehensive Improvement Guide with examples, checklists, tools No cost to join! September 13, 2007 31
Expectations for Participating Teams Commitment of a team sponsor Full participation of a multidisciplinary team Development of measures Regular reporting of progress to the Faculty Willingness and commitment to implement rapid and widespread changes Desire to innovate Regular access to email and Internet September 13, 2007 32
Collaborative Resources To Enroll http://www.saferhealthcarenow.ca/default.aspx?fold erid=104&contentid=420 About the ICU Collaborative http://www.improvementassociates.com/dnn/default.aspx?tabid=190 About Breakthrough Series Collaboratives (general) http://www.ihi.org/ihi/results/whitepapers/thebrea kthroughseriesihiscollaborativemodelforachieving %20BreakthroughImprovement.htm September 13, 2007 33
Questions
Contacts Bruce Harries, Collaborative Director bharries@telus.net September 13, 2007 35