CRITICAL RESPONSE
Frank Corcoran - Titusville, USA
When I came to PMC, the Institute of Healthcare Improvement (IHI) had put out initiatives and directives stating it was possible to save 100,000 lives if we did some basic things in our hospitals. One of them was to implement a rapid response team.
The principle is that nurses taking care of patients on the clinical floors don't typically have critical care experience. So when they see that something has changed acutely in the patient, it may be better to have a critical care nurse assess the patient. That's the principle — get to the patients on the Med-Surg floors before they code.
At Parrish Medical Center, we developed a protocol for the rapid response team that gives the critical care nurses basic interventions to implement that all the physicians agree to. These are basic interventions at which ICU nurses are skilled and do all the time.
Our rapid response team is called the CAT, for Critical Assessment Team. Its purpose is to quickly get to a patient who is having acute changes and help rescue them if needed.
Here's how it works. If the nurse on the floor sees an acute change in his or her patient, or simply has a bad feeling about the patient's condition, they can call the CAT number on the ICU dedicated “hot phone.” The ICU nurse picks up and the floor nurse tells them what's happening. Then CAT members go to the floor with our protocol, assess the patient, call the physician, do some basic interventions and, with consensus of those involved in the patient's care, decide if the patient should go to the ICU for higher level care or can be stabilized on the floor. All the nurses in the hospital carry a SpectraLink phone, so they can call us quickly if there is a problem. When we first started, we averaged 5 to 10 calls a month from the floor nurses.
Once we implemented the CAT, we noticed our mortality rate decreased by 10 percent. The number of Code Blues outside the ICU, which is one of the big-picture measures I look at, decreased by 10 to 15 percent. We then increased our CAT goal to 20 calls a month.
After a year and a half of using the CAT, the number of Code Blues outside the ICU began to increase despite having 20 CAT responses a month. We were still meeting our goals, but we were getting called on the wrong patients.
So we did a Six Sigma Green Belt project that looked at the CAT process. Because we were having increased Code Blues outside the ICU, our mortality rate had remained flat from the 10 percent drop we had seen initially. It wasn't really moving, yet we were still doing all these CAT responses.
Then, Kathy Aries, our nursing IT clinical specialist, introduced me to CareFocus™ from Thomson Reuters. She explained how it worked and that she could develop a current list of patients that we could screen for CAT responses as often as once every two minutes if we wanted.
I gave her the CAT criteria — acute changes in heart rate, blood pressure, oxygen saturation, respiratory rate, urine output, and neurological changes — and she developed the profile. We run the profile every two hours and also decided to review it at our Bed Board meetings. We do the Bed Meetings four times a day; they include all the Med-Surg charge nurses, the ICU charge nurse, and house supervisor. The purpose of the meeting is to look at staffing: How many patients do we have on the floors? Do we need to move a nurse from one floor to another? What kind of help do you (the charge nurses) need? That became the perfect setting to review the CAT screening list.
We pull up the list on a large TV monitor that everyone at the Bed Board Meeting can see. We screen every patient, and assess the clinical changes that have triggered that particular patient to show up on the list: What vital sign was off that made them show up on the list? After 24 hours, if the patient doesn't have any vital signs outside that parameter, they come off the list. So we're looking at current information in the last 24 hours, and we're looking at information that is out of the range of the normal vital signs, which we define from the CAT criteria.
As we assess these patients, we can also see the trend of them getting better. Sometimes we see them going down. At that point we would send the CAT members out — the ICU nurse and a respiratory therapist. We go to that patient and bring in their floor nurse; then we all work together to assess the patient from head to toe. We look at the labs and medications, what's going on with the patient, and then utilize our protocol. That helps us determine if the patient needs IV fluids, medications, or additional tests. We all work together as a team and decide if the patient goes to the ICU or if we simply stabilize them.
After implementing Care Focus CAT Screening, from September 2009 to January 2010, our mortality rate dropped by 30 percent, and Code Blues outside the ICU dropped by 76 percent. I could hardly believe the data it when I analyzed it; it was simply amazing.
We also looked at the number of actual mortalities we had in the prior year and how many we'd have this year if we kept the current trend — 63 lives would be saved this year based on those trends. The mortalities have decreased even more since then. They're 33 percent less than the prior five months, and Code Blues outside the ICU are down 74 percent. We've sustained these results over the past seven months compared to the prior year.
Our care partners are starting to get the feel for it, the knack for it, and are looking into it. We've given all the ICU nurses access to CareFocus. What's great is that it has the critical lab work or the critical labs highlighted, so it's a bold point and they can easily compare it and the new results. We find our care partners are starting to use it for other things as well.
Our charge nurses look at that list four times a day, but it goes back to having the tools to do our job right; having and using the right technology. You put that together with the right nursing care, the right mindset to sit and evaluate patients, and with all those things together, we've made a difference. At Parrish Medical Center we all work together, which helps us help our patients.
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Parrish Medical Center, Titusville FL Using CareFocus Since 2009 |
Frank Corcoran, RN, BSN, Director of ICU / RT / Hemodialysis / Infection Control, Parrish Medical CenterCORCORAN'S PROFILE
We have been using Care Focus Clinical Navigator since September 2009 for our CAT, or Critical Assessment Team. Before that we had used Care Focus for other areas.