Centro de Transportes Aduana de Burgos y Puerto Seco

This chapter shows how institutionalisation progressed from preceding work achieved in the initiation and implementation stages. For change to become permanent it must be embedded into the organisational psyche. A nurse-led CCOT achieved recognition as a permanent service in the DHB during 2007-2009. Integral to permanence is policy, and so policies were created to guide, audits to evaluate and processes provided to escalate care for the physiologically unstable patient on the ward. Nurses benefited from development of nursing assessment, decision

making and intervention skills. Fewer patients deteriorated. Junior doctors benefited from educational input, practical support and the increased safety of the clinical environment. Critical Care Outreach Team composition and skill level continued to sustain Outreach as an important service of the DHB.

Becoming permanent

The theme, becoming permanent, is demonstrated through policy, education, trust and co- operation. The process of the nurse-led CCOT reaching permanence was achieved from 2007 to 2009. Permanence ensured continuity of CCOT for the DHB hospital service and consumers. The service and EWS policies were integrated into DHB official policy. Support for Outreach from senior medical, nursing and management groups continued with dynamic leadership from the ICU CNS and Outreach nurses.

Policy

Specific policy was needed to set the standards for guiding behaviour in the hospital to ensure patient safety. Three policies were introduced: the CCOT Service Policy, the Early Warning System policy, and the Patient Observation Frequency policy. The CCOT Service policy and the

82 Early Warning System policy provide comprehensive overviews of the service and the

following policy excerpts demonstrate how the operation of the CCOT is defined:

CCOT Service Policy: The CCOT Service policy aims to give a clear concise overview

of the purpose, functions, roles, management, staffing, referral process and audit activity related to this service (p.1).

The primary role of the CCOT Service includes:

a) Clinical support for the ward based patient requiring critical care assessment and/or interventions

b) Education and support of all staff managing such patients c) Supporting the ICU/HDU by monitoring patients following their discharge from intensive and high dependency care (p.6).

Introduction of the CCOT Early Warning Score System policy supported change in practice by holding staff accountable for following the prescribed response times, minimum vital sign observations and escalation algorithm (Appendix 9) for care of the physiologically unstable patient on the ward. The policy is specific and applies to all staff:

Policy, Early Warning System:

Principles of the Early Warning System (EWS)

x All staff within EWS active departments must ensure that patient observations and EWS scores are recorded as per the EWS chart

x The EWS algorithm should be adhered to at all times (appendix C) unless

signed off by the patient’s own consultant

x All staff responsible for patient care working in EWS active departments must receive training and updates in the use of this tool. This applies to permanent and temporary staff (p.4).

Early recognition of the physiologically unstable patient is dependent on observations recorded at intervals appropriate to the individual patient. As discussed previously, frequency of vital sign observations had been at the discretion of the registered nurse. The Patient Observation Frequency policy prescribes the frequency for assessing patient vital signs during the in-patient journey.

83 Prior to the introduction of the EWS the decision whether to report alterations in patient

physiological status had been optional. Response time by doctors had not been mandatory. The senior CNS reflected on the need for policy:

Clinical Nurse Specialist: The policy holds the whole thing [Outreach] together. I think the first thing to say is the EWS had to be policy driven. The policies are clear but the more important thing is that they give guidelines for the people who are working with them (p.5)

When a patient scores three or more, the EWS escalation algorithm requires ward nurses to contact the junior doctor of the patient’s team and to page the CCOT nurse. The Outreach pager is carried by the Outreach nurse during the day and the co-ordinator of ICU at night. The information sent by the ward nurse is the latest EWS score and the observations made of blood pressure, heart rate, oxygen saturation, respiratory rate, urine output (if available), and level of consciousness. From this information the CCOT nurse assesses the urgency of the situation and decides whether to respond immediately or within the thirty minute timeframe dictated by the EWS policy. Likewise the junior doctor paged must assess the patient within the thirty minute interval. Outreach nurses regularly escalate care needs to specialty consultants and ICU consultants after they have assessed a patient. After hours the ICU coordinator responds to the EWS trigger by phone. Referrals that require further investigation are communicated to the night ICU registrar to follow-up. Response to a EWS of three or more is mandatory for junior doctors. The Clinical Nurse specialist explained why the policy is important:

Clinical Nurse Specialist: The nurses can insist that “I'm really sorry, I have to

call you [doctor] because it [EWS]says...” and particularly for junior doctors it [policy]says “this is not negotiable”. You can't decide not to come. So I think that the policy is really important (p.6).

The success of policy is dependent on staff adhering to the directives within the policy. Policy is then audited for compliance. The EWS Policy outlines the commitment CCOT has to

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Early Warning System Policy:

x Each EWS active department will be internally audited to monitor early warning score compliance. The audit programme is co-ordinated by the

Clinical Nurse Specialist (Critical Care)

x Audit results and recommendations will support Nurse Educators/ Clinical Coaches in determining the training needs of EWS active clinical areas. Meetings with department Clinical Nurse Educators and Clinical Coaches will be facilitated to ensure these audits support and inform the training needs of individual departments (p.7).

The introduction of these policies together with the continued efforts of the Outreach team and staff acceptance of the total package endorsed Outreach integration into the organization. Incorporation of EWS by ward staff into practice is reflected in the sustained increase in numbers of referrals made annually. The following graph illustrates the continual growth since Outreach started:

Figure 8. ICU referrals by year. Source (CCOT Database)

Hospital patient throughput has increased from a total of 51,000 patients discharged in 2005, to a total of 61,308 patients in 2010. Despite the increase in patient throughput, the number of deaths from cardiac arrests in the hospital has declined per 1000 patients. However, emergency calls to the 777 number, the hospital’s cardiac and medical emergency number, have increased

974 1187 1589 2014 2112 0 500 1000 1500 2000 2500 2006 2007 2008 2009 2010 Numb er of patients Year