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Similaire à Newly Qualified Nurses Teaching
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Plus de Dr Shibu Chacko MBE
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Newly Qualified Nurses Teaching
- 1. Newly Qualified Nurses Teaching Shibu Chacko
- 2. Introduction •Critical Care Outreach Team – Who we are? •Working Hours •Bleep Number: 725 •Method of referral: SBAR
- 3. Aims of the session • To develop skills to assess an acutely unwell patient • To learn to identify the deviations from normal • To identify why the patient in the scenario deteriorated • To identify different teams of professionals that are available to help • To be able to identify and make an SBAR call . • To be able to identify the appropriate course of treatment for this patient
- 4. Clinical Situation •81 year old Mrs. Jessop admitted to hospital following a fall at home and she sustained a fracture of the neck of femur following fall. •She had several falls at home recently •She believes the falls at home could be because she is ‘feeling dizzy’ at times. •Patient underwent surgery and is back in the ward
- 5. Past History •Insulin Dependent Diabetic •Episodes of falls at home •Very frail looking •Lives alone
- 6. Now – 2 days post op •Not eaten or drunk much since the surgery •Feeling very weak and lethargic •Reported couple of episodes of loose stools overnight •Now sitting up in bed, but not communicating much / Refused to eat breakfast. •Handover form night nurse – Very limited
- 7. Hand over from Night Nurse •Nurse informed that patient is not progressing ‘very well’. •Had episodes of loose stools and now weak and lethargic. •The nurse thought the patient might need a blood transfusion. •Observations: Pulse 101 / min, Resp 18/min, BP 100/60 mm of Hg, Temp 35.5ºC and blood sugar 5.5mmols. NEWS 3
- 8. How would you assess this patient?
- 9. Steps •Reassess the patient using ABCDE approach
- 10. Scenario continued • Patients observations gradually deteriorated • Patient tells the nurse she feels weak and does not want anything to eat • She states she cannot get out of bed today as she is lethargic.
- 11. What to do next? •Escalate your concerns – CCOT or Doctors or Both •Use SBAR •But no help available
- 12. Scenario Continued Mrs Jessop is still complaining feeling vey weak and is communicating less, appearing unresponsive. Observations are stable at HR 104, Sats 94%, BP 98/60, Temp 35.5 Blood pressure has dropped a little
- 13. Expected outcomes •Management of the unresponsive patient •Emergency call •2222 call •Act appropriately until help arrives
- 14. ABCDE Assessment ( Smith et al, 2002) Criteria Assessment Findings Initial Interventions A – Airway Patent B - Breathing Tachypnoec (Respiratory rate 28 / min), Increased work of breathing, Sweaty and clammy, Oxygen saturation 90% on room air Commenced on High flow oxygen 15 lpm via non rebreathe mask, ABG specimen collected C – Circulation Tachycardic (Heart rate 152 bpm), ECG showed arrhythmia, BP 92 / 60mm of hg (MAP52) Temperature 35.2 degree Celsius, ABG showed K+ level of 1.7mmol/l ECG done – Flat T waves, Colloids- 500mls of Gelaspan given, Urgent Bloods sent to lab D – Disability AVPU – V (Response to Voice) BM – 6.2mmols/l E – Exposure Abdomen soft, but tender
- 15. Initial Management •ABCDE Assessment •Investigations – ECG, Arterial blood gas analysis, Biochemistry •Multidisciplinary management – Medical Team, Anaesthetic team, Outreach, ICU Registrar •Central line insertion – Femoral vein •Concentrated KCL (40mmol in 100mls)administration via Central Line •Moved to ITU for further management
- 16. Why patient deteriorated? Patient Ownership of the Patient Cannula tissued, Fluid stopped Communicatio n from Lab to ward Failure to report to Nurse by CSW Timing of Report Location of the Patient – Side room
- 17. Management of Evidence 1 •Early identification of deterioration 2 •Escalation of care 3 •Multidisciplinary Communication 4 •Use of SBAR 5 •Documentation – NEWS 6 •Use of resources like Outreach
- 18. Use of SBAR as a communication tool •SBAR is a communication tool that standardizes information to be given and lessons on communication variability, making report concise, objective, and relevant (Benson et al, 2007). •Effective communication with the use of SBAR helps to decrease adverse events and promote patient safety (Laws, 2010).
- 19. Interprofessional Working Inter- professional working Communication Ownership Use of resources- 24/7 CCOT Team work Continuity of care Shared responsibility
- 20. Reflection •Confusion of whom to contact with the results •Better management from admission •Communication from lab to medical team •Early Escalation of concern – Interprofessional working •Seeking help from seniors regarding management •Involving CCOT early – communication •Risk of Central line insertion in ward – Infection control risks
- 21. Reflection •Confusion of whom to contact with the results •Better management from admission •Communication from lab to medical team •Early Escalation of concern – Interprofessional working •Seeking help from seniors regarding management •Involving CCOT early – communication •Risk of Central line insertion in ward – Infection control risks
- 22. Conclusion •Introduction of SBAR as a communication tool •Introduction of Trust wide blood results flow chart •Introduction of medical handover sheets •Implementation of teaching programmes for the target groups – HDU / ALERT / BEACH Courses •Mandatory to have bleep number on the form •Only Trained members of staff are allowed to receive blood results over the phone.
Notes de l'éditeur
- The mnemonic “ABCDE” stands for Airway, Breathing, Circulation, Disability, and Exposure. The Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach is a systematic approach to the immediate assessment and treatment of critically ill or injured patients. The approach is applicable in all clinical emergencies (Thim et al 2012).
- ECG Changes: There are usually no ECG changes in patients with mild hypokalaemia, but these may become evident in moderate to severe hypokalaemia including the presence of U waves, T wave flattening, or ST segment changes (Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 2000). ABG : It involves collecting a sample of arterial blood through a puncture at the radial / brachial / femoral artery and analysing through a ABG analyser machine. This test is very quick and will give information on the respiratory and metabolic status of the body. This will also provide information on the elements like sodium, potassium, chloride, haemoglobin etc. as well. Multidisciplinary management and inter-professional working: As the patient is very unwell and in periarrest state, there need to be a decision from the multidisciplinary team. KCL administration via central line: Large potassium administration of concentrated KCL is the efficient way of repleting K+ in patients in severe hypokalaemia and is best carried through central venous lines as it carries a risk of phlebitis and severe pain around the site of infusion (David et al 2010).The maximum recommended intravenous dose of potassium is 20 mmol/h, but more rapid administration (initial infusion of 2 mmol/min for 10 min, followed by 10 mmol over 5—10 min) is indicated for unstable arrhythmias when cardiac arrest is imminent. Rapid bolus injection of potassium should be avoided in all circumstances as this may precipitate cardiac arrest (Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care, 2000).
- Communication from the Lab: As there was no bleep number on the form, lab didn’t know whom to report the abnormal results. The blood specimen was sent in the morning and the results were delayed until18.00hrs. Responsibility of the parent team: The doctor who ordered the blood test did not check the results before they finished the shifts or handedover to the on-call team for follow up. Time of the call: The ward staff received the call at 18.000 hours, which is a busy time for the ward with evening meal, drug rounds, IV antibiotics, visitors etc. The parent team finished their shift and only the on-call team was available. Assumptions of peoples Knowledge: The CSW who took the message did not have any formal training before to understand the results nor the Lab highlighted it as an abnormal value.
- Nature of the deficiencies in the recognition and response to patient deterioration These often include infrequent, late or incomplete vital signs assessments; lack of knowledge of normal vital signs values; poor design of vital signs charts; poor sensitivity and specificity of ‘track and trigger’ systems; failure of staff to increase monitoring or escalate care, and staff workload (Fuhrmann et al 2008). The patient was nursed in an isolation because of the diarrhoea, which resulted poor monitoring of his deterioration. 2. Education in acute care Staff education is an essential part of implementing a system to prevent cardiac arrest (Campello et al 2009). Studies shows that medical and nursing staff lack knowledge and skills in acute care, e.g., oxygen therapy, fluid and electrolyte balance, pulse oximetry and drug doses (Derham 2007). Medical school training provides poor preparation for doctors’ early careers, and fails to teach them the essential aspects of applied physiology and acute care (Goldacre et al 2003). 3. Multidisciplinary Communication Acute hospitals now use early warning scores (EWS) or calling criteria to identify the need to escalate monitoring, treatment, or to call for expert help (Hillman et al, 2005). 4. Use of SBAR Nursing staff and junior doctors often find it difficult to ask for help or escalate treatment as they feel their clinical judgement may be criticised. Hospitals should ensure all staff are empowered to call for help and also trained to use structured communication tools such as SBAR (Situation-Background-Assessment-Recommendation) tools to ensure effective inter-professional communication (Marshall et al, 2009). 5. Staffing levels Hospital staffing tends to be at its lowest during the night and at weekends. This may influence patient monitoring, treatment and outcomes. Admission to a general medical ward after 17.00 h or to hospital at weekends is associated with increased mortality (Bell & Redelmeier, 2001). 6. Appropriate placement of patients (Admission to ICU) Ideally, the sickest patients should be admitted to an area that can provide the greatest supervision and the highest level of organ support and nursing care. International organisations have offered definitions of levels of care and produced admission and discharge criteria for high dependency units (HDUs) and ICUs (Haupt et al, 2006).
- Interprofessional teamwork is regarded as essential to tackling poor service delivery, to improve patient safety, to improve patient outcomes and to increase patient satisfaction with care (Haynes et al., 2009) Communication Issues – Doctor to Laboratory , laboratory to ward, Nursing staff to Outreach, CSW to Staff Nurse, Doctor to On call team Politics – Ownership of the patient Inadequate utilization of resources- Use of 24 hour Outreach Team work / Team effectiveness / Team structure Continuity of care – failure to hand over to on call team Roles and responsibilities – shared responsibility
- Confusion of whom to contact with abnormal blood results Lab should have asked the designation of ward staff before giving out the results or should have asked to speak to the nurse who is looking after the patient. Patient was hypokalaemic at the time of admission, so a better plan should have been made to manage this patient with regular monitoring, twice daily blood tests, ensure fluids are running and chase the blood results etc. Use SBAR to communicate critical information between various professionals. When the cannula was tissued, the nurse should have escalated the concern and care to next level like CCOT / site team to get the patient cannulated and recommenced the IVI with KCL.
- Confusion of whom to contact with abnormal blood results Lab should have asked the designation of ward staff before giving out the results or should have asked to speak to the nurse who is looking after the patient. Patient was hypokalaemic at the time of admission, so a better plan should have been made to manage this patient with regular monitoring, twice daily blood tests, ensure fluids are running and chase the blood results etc. Use SBAR to communicate critical information between various professionals. When the cannula was tissued, the nurse should have escalated the concern and care to next level like CCOT / site team to get the patient cannulated and recommenced the IVI with KCL.
- SBAR – new communication tool introduced to facilitate the communication between individuals and teams. Now it is mandatory to report any abnormal blood results to the ward or to the treating physician by an SBAR call. Blood results flow chart - Flow charts were introduced to monitor the trends in the blood results. It also contains the normal values, so it immediately gives the nurses / doctor an opportunity to cross check a value whether it is normal or not. The chart is normally attached to the front cover of the patients notes. The parent team will use the Medical hand over sheets to hand over the patients they are concerned to the on-call team. It will contain the patients details and any outstanding care required like chasing bloods, x-rays, scan etc. Teaching programmes made widely available for the nursing staff. In addition we introduced a course called BEACH ( Bedside Emergency Assessment Course for Health Care Assistants) which is a nationally recognised course designed by the University Hospitals Portsmouth NHS Trust. Also made it mandatory to have a bleep number of the person ordering bloods on the form and only trained members of the team is allowed to take telephone calls from the lab. With the introduction of the new blood tracking system, it is easy to identify / track who collected the specimen as it tracks the users id number on the label.