Welcome to the AAMI Foundation’s Patient Safety Seminar with Brad Winters, MD Sue Verrillo, MSN, RN, CRRN Johns Hopkins Hospital Friday, May 20, 2016 1
What system, structural, and technological changes are necessary to capture real-time, critical data of early deterioration in adult postoperative inpatients, to prevent failure to rescue?
AAMI Foundation • Vision: To drive the safe adoption and use of healthcare technology • National Coalition to Promote Continuous Monitoring of Patients on Opioids • NEW Opioid Safety & Patient Monitoring Compendium • National Coalition for Alarm Management Safety • NEW AAMI Foundation Alarm Compendium • Consider making a donation! • Contact Marilyn Flack at mflack@aami.org.
A Special Thanks 4
Thank You to Our Premier Industry Partners Without their financial support, we would not be able to undertake the various initiatives under the National Coalition to Promote Continuous Monitoring of Patients on Opioids. The AAMI Foundation and its co-convening organizations appreciate their generosity. The AAMI Foundation is managing all costs for the series. The seminar does not contain commercial content. Diamond Platinum Gold
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Nursing Continuing Education Disclosure Statement • This seminar is jointly provided today with our co-provider, the National Association of Clinical Nurse Specialists (NACNS). • 1.0 contact hour will be awarded for this seminar. This seminar may be accessed online at the AAMI Foundation website for nursing CE up to two years from today’s date. • This continuing nursing education activity was approved by the Alabama State Nurses Association, an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation (ANCC). • Criteria for successful completion includes attendance at the session and submission of a completed evaluation form. You can submit the fee for the CE credit by going to the AAMI store at http://my.aami.org/store/detail.aspx?id=PSSOPIOID16-1. . A link to the evaluation form will be sent to you for completion and a certificate sent to you upon completion of the evaluation. • The planning committee members have declared no conflict of interest along with our faculty for today’s session. • Contributions to the AAMI Foundation have been received from the identified sponsors to support program initiatives and projects. However, the program content for today’s seminar has been planned independently by AAMI staff with the seminar presenters. • Approval of the continuing education activity does not imply endorsement by the provider, ANCC or the Alabama State Nurses Association. 7
Polling Questions 8
Speaker Introductions • Bradford D. Winters, Ph.D., M.D., FCCM Associate Professor Anesthesiology and Critical Care Medicine and Surgery / Core Faculty Armstrong Institute for Patient Safety and Quality johns Hopkins University and Johns Hopkins Hospital • Sue Carol Verrillo, MSN, RN, CRRN Nurse Manager Zayed 11 East Johns Hopkins Hospital
Awareness of Problem Statement HealthGrades 2013 has reported that 1 out of every 10 postoperative Medicare patients currently dies after developing either: • Pulmonary embolism/ Deep Vein thrombosis • Pneumonia/Sepsis • Shock/ Cardiac Arrest • Gastrointestinal Bleeding 10
The Sequence of Failure to Rescue • Patient found “dead in bed” • Code Blue called • Everyone runs • ACLS performed • Chaos ensues • If ROSC patient goes to ICU • If not patients goes to morgue • Everyone goes back to what they were doing.
Galvanizing the Initiative • Until the mid 1990’s few ever asked: ** Why did this patient arrest? AND… ** Could we have prevented it? 12
Turn of the Millennium • Appreciation that most in-hospital cardio-respiratory arrests have a clear “ prodrome ” began to emerge. • Schein et al. 1990 • Hillman et al., 1991 • Silber et al., 1992 • Smith and Wood, 1998 • McQuillan et al., 1998 • Buist et al., 1999 • Goldhill et al., 1999 • Hillman et al., 2001 • Kause et al., 2004 • Patients don’t suddenly become critically ill, they are just suddenly recognized as such
The Medical Emergency Team • Developed in response to the understanding that arrests don’t suddenly happen and that we should be able to intervene • The MET is not just a team, it is a patient safety system • Consists of: • The Afferent Limb (recognition) • The Efferent Limb (response) • Administrative System to collect and analyze data • Education system to train staff • Other versions include: Rapid Response Team, Patient at Risk Team, Critical Care Out Reach Team, etc.
Recent Systematic Review: Adult Non- ICU CA
Adult Total Mortality
What does this tell us? • These numbers have changed little since the first systematic review (there are now at least 7) • Point estimates have shift slightly • CA incidence reduced by ≈40% • Mortality reduced by≈ 15% • Confidence intervals have tightened • Our current model seems to have hit a limit; • But Why??? 9/25/2013 17
Evidence of Afferent Limb Failure Author Year Salient Point Salient Point Salient Point 1 2 3 Buist et al 1999 Median time between Range 0-432 hrs Median # physician visits = 2 documented instability and without any action cardiac arrest = 6.5 hrs Calzavacca et al 2008 Early recognition is most robust component ↑ delay with physician activators Boniatti et al 2013 Calls delayed 21.4% 61.8% mortality with delayed calls Simmes et al 2012 16% activations delayed 1-2 days Vetro et al 2011 20% had objective warning signs, but no MET call Shearer et al 2012 4.04% of adult population were Of those patients, 42% did NOT Despite 69.2% of the staff medically unstable have RRT called recognizing they met criteria Bucknall et al 2013 Most patients meeting MET Increases hospital mortality at criteria never have call made 30 and 60 days Oglesby et al 2011 71% ICU admissions delayed from floors Adelstein et al 2011 Despite process improvements- 26% of episodes of Associated with delays in care deterioration Frydshou and Gillesberg 2013 Only ½ ICU admits went through an RRT Guinane et al 2013 14% of sample met MET criteria Those meeting criteria had 2 – 4% activation rate X’s LOS 18
Underlying Causes? • Certainly some is due to hierarchy / Concept of patient “ownership” • More likely poor quality of patient monitoring on general wards • Intermittent nature • Poor fidelity • Inaccuracy • Delayed communication
Since 2009 TJC Patient Safety Goal #16……… • Despite the wide implementation of RRSs this has not gotten much better. “Should we call for help?” • We can provide a response team (better management and treatment) but we can’t seem to eliminate the failure to recognize the need to activate that team 20
Response to this Afferent Failure: Risk Scoring Systems Author Year Finding Finding Subbe et al 2001 MEWS “SOCCER” 2006 Extended criteria catch earlier signs Bell et al 2006 Extended Restricted criteria → low criteria → sensitivity & ↑ missed workload opportunities to intervene ↑specificity for ↓ sensitivity and Cretikos et al 2007 combo vs PPV 15.7% Maurice & 2007 Intermittent vs Simpson unable to id at risk patients Gao et al 2007 Systematic No scoring review 36 system studies adequate 21
Response to this Afferent Failure: Safety Culture Improvement • Teamwork Tools • Adaptive Approaches • Emphasizing Wisdom of Frontline Staff • Staff Safety Assessments • Comprehensive Unit Safety Programs • TEAMSTEPPs training • Learning from Defects 22
In response to this Afferent Failure: "In Pursuit of High Reliability ” Sensitivity to operations: Preserving constant awareness by leaders and staff of the state of the systems and processes that affect patient care. This awareness is key to noting risks and preventing them. • Changing historic vital sign collection process • Total patient situational awareness vs. “snapshot in time” • Recognizes the dynamic nature of patient condition • Providing caregivers with essential data to intervene sooner • Longitudinal data trending • Identify vital sign patterns predictive of patient deterioration • Analyze “inter - relationships” between independent parameters • Integrate alarm management with current nurse call equipment • Development of meaningful alarm notification algorithms
A new call to arms
Can we do better? • The RRS Afferent Limb Consensus Conference concluded that, at present and for the foreseeable future, identifying and stratifying who is at risk for clinical deterioration on general wards is difficult and likely to be imperfect despite much research. • Patients are dying and being harmed and we can’t wait • They issued a call to industry to partner with clinicians to develop and implement continuous high fidelity monitoring systems that were acceptable to patients, had minimal false alarms, could improve nurse workflow and workload and prevent unrecognized deterioration.
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