MRS JAMILA CHELLAN QI SUMMIT PRESENTATION

16/10/2014

MRS JAMILA CHELLAN QI SUMMIT PRESENTATION

16/10/2014

INTRODUCTION

I • Good Afternoon . Mrs. Jamila Chellan. Nurse Manager at JMH.

S • Clinical handover communication is posing a patient safety issue

in healthcare institutions

B •  Inadequate or ineffective communication has been noted by JCI

as the root cause of nearly 70% of all reported sentinel events.

A •  Inadequate or ineffective communication can lead to tragic errors

and even death

R • Use a structured communication technique .This is important as

we all have different styles of communication varying by culture, profession and gender

City Hospital – 031 314 3000 Citi Med - 0800 333 911 Isipingo Hospital – 031 913 7000 Gandhi Mandela Nursing Academy - 031 309 3094 Durdoc Hospital – 031 314 3000 Behavioural Health Centre - 031 309 1353 Ascot Park Hospital – 031 374 8000

SBAR COMMUNICATION

S-Situation

B-Background

A-Assessment

R-Recommendation

*  Allows for clinical handover to be done in a formal and structured way with a great deal of information communicated in a succinct and brief manner.

City Hospital – 031 314 3000 Citi Med - 0800 333 911 Isipingo Hospital – 031 913 7000 Gandhi Mandela Nursing Academy - 031 309 3094 Durdoc Hospital – 031 314 3000 Behavioural Health Centre - 031 309 1353 Ascot Park Hospital – 031 374 8000

http://www.jointcommission.org/PatientSafety/National PatientSafetyGoals/07_hap_cah_npsgs.htm

CLINICAL HANDOVER USING SBAR

" Clinical handover is a critical component of health-care quality and safety.

" During their journey throughout the hospital, patients are exposed to several transfers across different areas of diagnosis and levels of care.

" At each stage of the process, information about their health needs is communicated among hospital staff at change of shift and within shifts.

" “SBAR”, is one of the most widely used communication tools in patient safety when clear and concise communication is critical.

City Hospital – 031 314 3000 Citi Med - 0800 333 911 Isipingo Hospital – 031 913 7000 Gandhi Mandela Nursing Academy - 031 309 3094 Durdoc Hospital – 031 314 3000 Behavioural Health Centre - 031 309 1353 Ascot Park Hospital – 031 374 8000

BACKGROUND

"   The significance for the development of a structured hands-off process has been found in multiple studies. "   The IOM Report, 1999, in the U.S.A ,”To Err is Human” building a safer healthcare system and “An organisation with a memory "in 2000,in the U.K are landmark reports that laid the foundations for patient safety throughout the world.

"   SBAR communication has been recommended as one of the many tools to improve the transfer of information and reduce communication breakdowns.

"   70% of sentinel events reported to The Joint Commission are related to communication errors

City Hospital – 031 314 3000 Citi Med - 0800 333 911 Isipingo Hospital – 031 913 7000 Gandhi Mandela Nursing Academy - 031 309 3094 Durdoc Hospital – 031 314 3000 Behavioural Health Centre - 031 309 1353 Ascot Park Hospital – 031 374 8000

SBAR: a shared mental model for improving communication between clinicians. 2006, 32(3):167-175. http://www.jcipatientsafety.org/docViewer.asp

COMMUNICATION AS ROOT CAUSE OF SENTINEL EVENTS

Available Collation of sentinel event-related data reported to The Joint Commission (1995-2005). Available http://www.jointcommission.org/SentinelEvents/Statistics

THE EFFECTS OF POOR COMMUNICATION

City Hospital – 031 314 3000 Citi Med - 0800 333 911 Isipingo Hospital – 031 913 7000 Gandhi Mandela Nursing Academy - 031 309 3094 Durdoc Hospital – 031 314 3000 Behavioural Health Centre - 031 309 1353 Ascot Park Hospital – 031 374 8000

Evidence-based reports note that:

Ineffective handovers can lead to:

" Wrong treatment, delay in Rx , severe adverse events, patient complaints

" Increase health care costs, Increase length of stay (and more)

Australian Council for Safety and Quality in Health Care. Clinical hand-over and Patient Safety Literature Review Report; March 2005. Available http://www.safetyandquality.org/clinhovrlitrev.pdf

Evidence Based Research

City Hospital – 031 314 3000 Citi Med - 0800 333 911 Isipingo Hospital – 031 913 7000 Gandhi Mandela Nursing Academy - 031 309 3094 Durdoc Hospital – 031 314 3000 Behavioural Health Centre - 031 309 1353 Ascot Park Hospital – 031 374 8000

12 Simulated Patients 5 consecutive handover cycles – 3 different styles

" Verbal handover resulted in loss of all data

" Note taking style resulted in loss of 31%

" Form with verbal handover resulted in

minimal loss

Pothier, D, Monteiro, P, Mooktiar, M, Shaw, A “Pilot study to show the loss of important data in nursing handover”. British Journal of Nursing, 2005, vol14, No. 20.

WHERE DO WE LEARN THIS FROM ?

High Reliability Organizations "   Nuclear Power

"   NASA and Mission Control

"   Aviation: Crew Resource Management

"   Air traffic control

HIGH RELIABILITY ORGANISATIONS HAVE HIGH POTENTIAL FOR RISK

Developed, studied, and formalized effective methods for safe transitions in operations. Healthcare organizations are now integrating successful lessons from these high-reliability institutions to design safer systems for patients.

INTERNATIONAL PATIENT SAFETY GOALS

EFFECTIVE COMMUNICATION

JCI - PSG 2# " The Joint Commission on

Accreditation of Hospitals has added standardized communication to the Patient Safety Goals and formally recommends SBAR as the industry best practice.

I-SBAR

City Hospital – 031 314 3000 Citi Med - 0800 333 911 Isipingo Hospital – 031 913 7000 Gandhi Mandela Nursing Academy - 031 309 3094 Durdoc Hospital – 031 314 3000 Behavioural Health Centre - 031 309 1353 Ascot Park Hospital – 031 374 8000

TRADITIONAL CLINICAL HANDOVER

" Clinical handover took place between team leaders only.

" It excluded the other team members.

" Clinical handover was therefore fragmented.

" When clinical situations arose there was the blame shame approach to the situation, “I told her”, and “she told me” type of communication

" Some staff came in late as handover was not important to them.

" Staff worked independently of each other, were only interested in the information of their assigned patients.

City Hospital – 031 314 3000 Citi Med - 0800 333 911 Isipingo Hospital – 031 913 7000 Gandhi Mandela Nursing Academy - 031 309 3094 Durdoc Hospital – 031 314 3000 Behavioural Health Centre - 031 309 1353 Ascot Park Hospital – 031 374 8000

PDCA

QUALITY IMPROVEMENT PROJECT

BENEFITS

Transformations (anecdotal evidence)

"   Punctuality has improved tremendously- supported by Kronos audits "   More staff are present at 07h00 SBAR handovers. "   Staff are more confident/teamwork has improved. "   The SBAR templates prompts critical thinking.(templates used) "   Communication is more effective and is continuous. "   Hospital managers receive complete reports following weekends, public holidays –go into

meetings fully informed. "   The written format allows for catching up on information following staff days off/

returning from leave. "   Decreases likelihood of lost communication as handover is structured and in a written

format. "   Staff share and take an equal responsibility in being well informed about the unit. "   Increases the accuracy and safety of hands-off communication "   SBAR ensures that nurses relay effective communication at change of shift by passing the

baton until the next teams arrives. "   The ultimate BENEFIT is that the patients are in safe hands 24/7 through effective

communication.

City Hospital – 031 314 3000 Citi Med - 0800 333 911 Isipingo Hospital – 031 913 7000 Gandhi Mandela Nursing Academy - 031 309 3094 Durdoc Hospital – 031 314 3000 Behavioural Health Centre - 031 309 1353 Ascot Park Hospital – 031 374 8000

WHERE TO FROM HERE !

" Nurse-to-Nurse at patient transfers.

" Nurse - to –Physician during telephone conversations.

" Debriefings on internal issues.

" Administrative Team meetings and even e-mail communication

" With Leadership support and clinician champions.

" Conduct staff surveys on the SBAR Tool.

 City Hospital – 031 314 3000 Citi Med - 0800 333 911 Isipingo Hospital – 031 913 7000 Gandhi Mandela Nursing Academy - 031 309 3094 Durdoc Hospital – 031 314 3000 Behavioural Health Centre - 031 309 1353 Ascot Park Hospital – 031 374 8000

CONCLUSION

" Transitions in health care occur millions of times every day across the world, but they tend to be unstructured and incomplete.

" In Root Cause Analyses, these hands-off transitions have been identified as the source of significant medical error and tragic patient outcomes.

" Sentinel event data now creates an urgency for change.

" Strategies developed in high reliability organizations can be applied to health care industry.

" The Joint Commission’s International Patient Safety Goals have now accelerated the pace of change in applying human factor science to patient care handoff transitions.

City Hospital – 031 314 3000 Citi Med - 0800 333 911 Isipingo Hospital – 031 913 7000 Gandhi Mandela Nursing Academy - 031 309 3094 Durdoc Hospital – 031 314 3000 Behavioural Health Centre - 031 309 1353 Ascot Park Hospital – 031 374 8000

Situation

S Total no of patients: 20 Empty beds: 5

Daily Ward round done: yes Number of staff required for tonight   1 RN 1 SN number of staff required for the morning:  1SN

Background

B admissions  5 discharges  5 transfers in  nil transfers out  2 unstable patients  1 Mr. G narcotic control check  correct

Assessment

A critical results awaited  1 expecting new patients  5 patients not seen by physician  1 No.surgery cases pending/next day  1 pm 5 booked for mane possible discharges  3 outstanding tasks  critical asset register

Recommendations

R staffing issues  night and morning cover req. sickness  3 staff pharmacy requests/challenges  nil supplies request/challenges  nil equipment check and repairs  1 suction sent for repairs Any other: in-service done on patient falls

QMS: NUR GEN FR 00_27/2

CLINICAL HANDOVER SBAR TOOL FOR CHANGE OF SHIFT DAILY SBAR REPORT

HOSPITAL UNIT MANAGERS- 14h30 REPORT Date: 16-10-2014 Ward: Surgical Signature Unit Manager/Team leader

S

Situation

I am calling about________________Mr Smith____________________________________________________________ The patient’s status is _______________critically ill rapidly deteriorating____________________________________________________________ The problem I am calling about is__________Respiration_________________________________________________________ I have just assessed the patient personally: Vital signs are BP____80/40____ Pulse_____140____ Resp rate______40/50_____ Temperature_______38.5___ I am concerned about the following because : BP: □ over 200 □√ less than 100 □ 30 mmHg below usual, Pulse: √□ less than 40 and symptomatic

Respiration : □√ over 30 or □ less than 8, Temperature □ over 38 or □ less than 36 Urine output : □ less than 200 mls / hr □√ 25 mls / hr , SPO2 : √□ less than 88% on 6 litres via nasal cannula

B

Background

The patient’s mental status is: □ Alert and oriented to person, place and time √□ Confused and co-operative or non co-operative □ Agitated or combative □ √Lethargic but conversant and able to swallow

□ Comatose □ √Eyes closed □ Not responding to stimuli. The skin is: □ Warm and dry Pale □ √Mottled □ √Diaphoretic □ √Extremities are cold □ Extremities are warm The patient is: □ √on oxygen □ not on oxygen The patient has been on______6__(l/min) or (%) oxygen for _____ minutes(hours), The oximeter is reading__70__________%, The oximeter does not detect a good pulse and is giving erratic readings.

A

Assessment

This is what I think the problem is:______________________________________________________________________ The problem seems to be: □ cardiac □√ infection □ neurologic □ √respiratory I am not sure what the problem is but the patient is deteriorating. The patient seems to be unstable and may get worse, we need to do something.

R Recommendation

From Physician:__________Name of Physician_________________________________________________________________________ □ √Transfer the patient to HDU □√ Come to see the patient at this time □ Talk to the patient or family about status. □ Ask a consultant to see the patient now Are any tests needed : Do you need any tests like □ √Chest x-Ray □ √ABG □ √ECG □ √ FBC /UE Others:______ __PCT___ ___PRO BNP_____________________________________________________________________________ If a change in treatment is ordered then ask: How often do you want vital signs?, How long do you expect this problem will last?, If a patient does not get better when would you want us to call again?

 Physician’s SBAR A 30-60 Second Report

Before Calling The Physician 1. Assess the patient. 2. Read most recent notes. 3. Have the chart in-hand. 4. Identify yourself

PATIENTS NAME: WARD:   CASE NO:  

SAMPLE NURSE TO PHYSICIAN – ISBAR TOOL

SBAR Report Obstetric Patients

S Situation

•  Identify yourself and where you are calling from •  Patient’s name and reason for report : Mrs Smith •  Patient was admitted for:___Imminent Eclampsia__________ •  I am concerned about:

o  FHR : 140-160 o  Contraction Pattern-nil o  Blood Pressure (give examples) 160/100 o  Vaginal Bleeding, nil etc. presenting with headaches, blurred

vision,epigastric pain, albuminuria,oedema

B Background

•  Gravida__1_ Para__0_ @__34_ weeks gestation •  Obstetrician attending __Dr SM______________ •  Significant medical and obstetrical history includes: Primigravida -unbooked •  Problems with current pregnancy are raised blood pressure. •  Relate the complaints by the patient and the pain level : cannot see properly,

nausea and vommiting ,headaches and grade 4 pain level

A Assessment

•  Maternal Vital Signs : 160/100 Pulse 96 Oedema Grade 4 •  FH=Variability, Baseline, Accelerations, Decelerations, Contraction Pattern •  Significant Lab Values : bloods taken for U/E, FBC, urates,LFT •  Intrauterine Resuscitative Measures : IV fluids •  Give your conclusions about the present situation. Words like “might be” or “could

be” are helpful. Presenting as imminent eclampsia

R Recommendation

•  What I need from you is______commence on MgS04 Regimen_________ •  Be specific about a time frame within 15 min •  Suggestions for tests/treatments: NPO

o  Liver Function Studies, syntocinon, syntometrine, Magnesium Level ,Coagulation Profile, Antibiotics, etc.

o  Clarify orders, vital sign frequency, under what circumstances to call back.

SAMPLE NURSE TO OBSTETRICIAN - ISBAR TOOL Perinatal SBAR A 30-60 Second Report  

Before Calling The Obstetrician 1. Assess the patient. 2. Read most recent notes. 3. Have the chart in-hand.

PATIENTS NAME: WARD;   CASE NO:  

THANK YOU

REFERENCES

" Australian Council for Safety and Quality in Health Care. Clinical Handover and Patient Safety: http://www.safetyandquality.org/internet/safety/publishing: Accessed October 3rd,2014

" Department of health, 2000.”An organization with a Memory’, Report of an expert Advisory Group on Learning from adverse events in the NHS, London, United Kingdom

"   Haig, Sutton, Whittington, “SBAR: A Shared Mental Model for Improving Communications between Clinicians”, Journal on Quality and Patient Safety, March 2006, 32(3), 167-175

"   Helmreich R.L., Merritt A.C.: Culture at Work in Aviation and Medicine: National, Organizational and Professional Influences.Aldershot, U.K.: Ashgate, 2001.

" Joint Commission International 2007.’Meeting the International Patient Safety Goals’, Oakbrook Terrace, Illinois 60523 USA

" Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. A report of the Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academy Press 2000

" Pothier, D, Monteiro, P, Mooktiar, M, Shaw, A “Pilot study to show the loss of important data in nursing handover”. British Journal of Nursing, 2005, vol14, No. 20

▪  . City Hospital – 031 314 3000 Citi Med - 0800 333 911 Isipingo Hospital – 031 913 7000 Gandhi Mandela Nursing Academy - 031 309 3094 Durdoc Hospital – 031 314 3000 Behavioural Health Centre - 031 309 1353 Ascot Park Hospital – 031 374 8000

For Cost Effective Quality Health Care

City Hospital – 031 314 3000 Citi Med - 0800 333 911 Isipingo Hospital – 031 913 7000 Gandhi Mandela Nursing Academy - 031 309 3094 Durdoc Hospital – 031 314 3000 Behavioural Health Centre - 031 309 1353 Ascot Park Hospital – 031 374 8000 WEBSITE: www.jmh.co.za