Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Concepts, Processes and Tools - Australian Commission on Safety
Transcript
WA Country Health Service & Royal Perth Hospital A joint venture in improving clinical handover developing standardised clinical handover Concepts, Processes and Tools Identify Situation Observation Background Agree a Plan Read Back Project Deliverables 1. Analyse the patient safety risks associated with clinical handover with inter hospital patient transfers. 2. Develop minimum data set for our selected cohort (deteriorating IHPT) both Written & Verbal 3. Develop Toolkit to support implementation Identify Situation Observation Extent of the problem • 350,000 ED presentations • 110,000 separations • 380,000 in patient bed days • 10,000 patient transfers to another acute care facility within Western Australia (WA). • Over 7,000 of these Via RFDS / St Johns Ambulance/ Fire Emergency services • Complex processes Referral Arranging patient transport Background Rely too heavily on multiple players having local knowledge of the WA health system and the differing service delineations both within the Perth metropolitan area health services WACHS is moving towards a model of central clinical coordination of all inter hospital patient transfers and part of this project involves the development of clinical handover systems Emerging picture of serious adverse outcomes from absent incomplte handovers Agree a Plan Read Back Identify Tracing & remedying failures Situation CH transport provider logistics Referring Doctor CH CH CH transfer nurse / volunter ambo CH Observation CH CH Referring nurse CH Background transit hospital CH receiving hospital Agree a Plan Read Back transit medical/ nursing team CH CH CH Ambulance paramedic/ nurse escort Transfer of professional responsibility and accountability across multiple systems and providers / agencies/ professional and volunteer groups Identify Analysis of adverse events and incident Situation Observation • Clarity of message • Hierarchy of power influences Background • Transfer of accountability Agree a Plan Read Back • Team and cross team work Collaborative effort Identify Situation Observation Background Agree a Plan Read Back Setting the scene… Identify Situation Observation Background Agree a Plan Read Back Royal Perth Hospital Identify Situation Observation Background Agree a Plan Read Back Identify Situation Observation Background Agree a Plan Read Back Identify Situation Observation Background Agree a Plan Read Back Identify Situation Observation Background Agree a Plan Read Back WA Country Health Service Identify Situation Observation Background Agree a Plan Read Back Identify Situation Observation Background Agree a Plan Read Back Identify Situation Observation Background Agree a Plan Read Back Identify Situation Observation Background Agree a Plan Read Back Identify Situation Observation Background Agree a Plan Read Back Identify Situation Observation Background Agree a Plan Read Back Carnarvon Identify Same, same but different Situation Observation Background Agree a Plan Perth Read Back Lake Grace Identify Situation Observation Background Agree a Plan Read Back RPH Trauma teams Identify Situation Observation Background Agree a Plan Read Back Burns teams Identify Situation Observation Background Agree a Plan Read Back Emergency teams Identify Situation Observation Background Agree a Plan Read Back Psychiatric Emergency team Identify Situation Observation Background Agree a Plan Read Back Neonatal resus teams Identify Situation Multiple transport providers Observation Background Agree a Plan Read Back Project Team Identify Situation Observation Background Agree a Plan Madeleine Connolly and Jill Porteous absent Read Back Identify Situation Observation Background Agree a Plan Read Back Handover is just words…iSoBAR is an answer The Why, the What & ‘How will you know when you get there’? WA Country Health Service & Royal Perth Hospital Identify Situation 4 Ps of Marketing • Product Observation • Price Background • Place (distribution) Agree a Plan Read Back • Promotion 350,000 ED presentations 7,000 transfers via 3 transport providers Product Identify Tracing & remedying failures Situation CH transport provider logistics Referring Doctor CH CH CH transfer nurse / volunter ambo CH Observation CH CH Referring nurse CH Background transit hospital CH receiving hospital Agree a Plan Read Back transit medical/ nursing team CH CH CH Ambulance paramedic/ nurse escort Transfer of professional responsibility and accountability across multiple systems and providers / agencies/ professional and volunteer groups Product Cyclone George Product Product Product a contour line of constant pressure • I – Identify • S – Situation • O – Observation • B – Background • A – Agree a plan • R – Read back Product Product SBAR • Situation • Background • Assessment • Recommendation Missing – Identify – Read back Product Product Price- cost to the patient Place Identify Situation Observation Background Agree a Plan Read Back Place Identify Situation Observation Background Agree a Plan View from 3 sides of Wyndham hospital Read Back Place Identify Situation Observation Background Agree a Plan Kununurra Read Back Place Identify Situation Observation Background Agree a Plan Read Back Mud football , Derby Cable Beach Broome Identify Situation Observation Background Agree a Plan Place Read Back Promotion Handover is just words…iSoBAR is an answer Putting it into practice-Role Play WA Country Health Service & Royal Perth Hospital Pitfalls Identify Situation Observation Background Agree a Plan Read Back Surname URN Given Names DOB Government of Western Australia WA Country Health Service Address Postcode Gender SITUATION Date Time Medicare No. Ambulance fund number DVA colour and number AB TSI ABTSI Primary language spoken Interpreter required Yes No Contact person/NOK Contact No. NFR status documented Yes No Relationship Aware of transfer Yes No known Unknown Organ donor Contact number Referring hospital contact person: Name Usual GP/Contact No. Signature Designation Principle diagnosis/problem Other diagnoses/problems Identify Situation Reason for transfer AIRWAY BREATHING COLOUR CIRCULATION SKIN PULSE BEHAVIOURAL patent compromised unremarkable shallow unremarkable pale unremarkable warm / hot unremarkable regular Harm to self Harm to others ventilated deep rapid flushed mottled cool / cold dry irregular slow Requires physical restraint slow cyanotic moist / clammy rapid laboured Glascow Coma Score strong OBSERVATIONS Usual conscious state (if known) asymmetrical C-SPINE weak audible wheeze immobilised not palpable Observation Airway management plan Yes (Time) Airway compromise relayed to transport provider Pulse Resp rate B.P. Vital signs Temp. No Outcome; SpO2 Intravenous (IV) access Second IV access No access required Fasted from Food (gauge, site, insertion time/date) Intercostal catheter Failed IV access Pain Score O2 rate/device time: IV fluids charted Fluid balance Chart Arterial line Fluids Nasogastric tube Central venous line Time last voided Other Continent Incontinent Indwelling catheter BACKGROUND Current episode medications (refer to Medication Chart for time last given) Effect ALERTS Mental Health Act Voluntary Involuntary Investigations(results if available) Risk assessment Yes Results attached No Drug Allergy (state drug/reaction) Relevant Social issues AGREED PLAN Dietary needs Receiving hospital Receiving doctor Bed arranged with: Transfer form faxed to receiving hospital Mobility Forensic Unit Contact number Confirmed bed Bariatric Client Microbiological Pressure area risk Other: Yes Yes No No ATTACH ALERGY STICKER Past relevant medical history WACHS MEDICAL RECORD TRIAL INTER HOSPITAL TRANSFER IDENTIFY Hospital Inter Hospital Patient Transfer ADULT/CHILD HANDOVER Background Agree a Plan Read Back Handover is just words…iSoBAR is an answer ‘How will you know when you get there’? WA Country Health Service & Royal Perth Hospital Identify Situation Observation Background Agree a Plan Read back Identify Roll out “ready or not” • Change ready environment Situation • Staff encouraged to implement in their context • The tools and educational support Observation • Examples - Bed side, patient transfer, allied health referrals……….. Background • Evaluation of innovation spread • Variable results Agree a Plan Read Back Identify After the trial The good Situation Observation Background • There is less waffle in the communication, and its more succinct • It prompts us to ask the right questions • It helps us cope with the high turn over of staff • We used to have bits of paperwork often go missing, so the isobar form has ensured that a comprehensive summary is passed on • It has helped to change the culture and increase staff awareness of safety issues associated with verbal handover • The tools are great The bad Agree a Plan Read Back • Focused on the form • Seen as a medical responsibility especially the A and R • Looking for a mandate Identify Lessons learnt What worked Situation Observation • Focusing on a problem that was real and recognized by clinicians • Clinician lead - not top down • On the ground engagement and listening Background • Marketing expertise • Diffusion of innovation Agree a Plan Read Back • KISS Identify Situation Lessons learnt What didn’t • Form can become the focus rather than the concept Observation • Delays in implementation of enabling initiatives (care coordination, RFDS funding arrangements etc) Background • Engagement with and of transport providers • Under scoped we were n’t equipped for the extent of Agree a Plan Read Back implementation that a change ready environment demanded Identify Situation Observation Making it stick –A good proposal for change? • Based on best evidence • Well presented and attractive • Concrete messages Background Agree a Plan Read Back • Clear targets • Different format for different audiences Questions? Diffusion of innovation Identify Getting ready to change iSoBAR toolkit developed Situation Understand/diagnose YOUR issues in YOUR context Observation Background Plan your SPECIFIC change Conduct a SMALL test STUDY results and Act on them in next small test keep testing & expanding target Agree a Plan SOURCE Easy Guide to CPI NSW health Read Back iSoBAR - Getting ready to change Identify • Context Situation Observation Background Agree a Plan Read Back • Define issues / problem to be resolved - do you need to collect data? • Describe what you are trying to achieve with whom - Be specific NOT just ‘improve” handover How will you know the change is an improvement? • Plan and conduct a SMALL test, how will you STUDY the results before moving on to second test?
