DEVELOPMENT OF A PROTOCOL LED DISCHARGE IN HIGH DEPENDENCY

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DEVELOPMENT OF A PROTOCOL LED DISCHARGE IN HIGH
DEPENDENCY

• SR FIONA GROOGAN
• SR JANET MILLS
• March 2008

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INTRODUCTION

• 900 ADULT CASES, 70 PAEDIATRIC
• 13 BEDS IN CARDIAC ICU
• 8 BEDS IN HIGH DEPENDENCY
• STAFFED FOR 10 ICU/6 HDU- ROTATION
• MEDICAL COVER- NO DESIGNATED HDU COVER
• GEOGRAPHICAL LOCATION OF GENERAL WARD

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GOALS

• AIM OF INTRODUCING PROTOCOL LED DISCHARGE (PLD)
  WAS TO REDUCE DELAYS IN DISCHARGING PATIENTS DUE
  TO REDUCED MEDICAL AVAILABILITY (EWTD)
• TO PROVIDE OPTIMAL UTILIZATION OF CRITICAL CARE
  BEDS

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• TO EMPOWER EXPERIENCED NURSES TO DISCHARGE PTS
  FROM HDU TO WARD
• PROVIDE PATIENT CENTERED CARE
• ENHANCE PRACTICE DEVELOPMENT WITHIN THE UNIT
• TO COMPLEMENT AND SUPPORT MEDICAL STAFF NOT
  REPLACE THEM

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DEVELOPMENT

• SNAPSHOT AUDIT (NOV 05) N20
• CLINICALLY ASSESSED BY NURSES AT 9AM 95 FIT
  FOR DISCHARGE
• WHEREAS MEDICAL ASSESSMENT TIMES
• 15 ASSESSED 8AM-9AM
• 40 ASSESSED 9AM-10AM
• 40 ASSESSED 10AM-11AM
• 5 ASSESSED 11AM-12MD
• 65 OF PTS DISCHARGED BETWEEN 11-12MD
• 20 BEFORE 10AM

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PROCESS

• RESEARCHED AND BENCHMARKED
• DRAFTED A PROPOSAL
• SISTER IN HDU CONSULTED
• SURGEONS, ANAESTHETISTS, NURSING STAFF CONSULTED
  
• 
  
• STANDARDISED DISCHARGE PROTOCOL CREATED WITH
  GUIDELINES
• ALL CONSULTANT SURGEONS AGREED TO PROTOCOL

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• EDUCATIONAL SESSIONS HELD WITH NURSING STAFF
• OUR AIM AT THIS STAGE WAS TO ASSESS FEASIBILITY
  OF THE PROTOCOL BY STAFF COMPLETING THE FORM AS
  AN AUDIT TOOL, IF NOT USING IT TO DISCHARGE
  PATIENTS
• TO COMMENCE FEBRUARY 06

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FIRST AUDIT

• FROM 15/06/06 UNTIL 30/10/06
• 183 PATIENTS WENT THROUGH HDU
• 141 PLD FORMS WERE FILLED IN EQUATES TO 77 OF
  THROUGHPUT
• 80 OF THESE PTS MET PLD CRITERIA

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INCORRECT USE OF PROTOCOL

• 13 OF FORMS WERE NOT SIGNED
• 18 WERE NOT PROPERLY COMPLETED
• BOXES WERE NOT TICKED OR VARIANCES WERE NOT
  FILLED IN PROPERLY OR AT ALL.
• EXAMPLES
• Hb lt8.0. BUT NO VARIANCE WRITTEN
• NOT ABLE TO CLEAR SECRETIONS. AGAIN NO VARIANCE
  WRITTEN (DO THEY REQUIRE SUCTIONING?)
• ABDOMINAL X-RAY DOCUMENTED IN BOX WITH NO
  EXPLANATION OR RESULT

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CORRECT USE OF PROTOCOL

• EXAMPLES Hb LOW, REG INFORMED, RECHECK Hb IN
  AM/PT COMMENCED ON GALFER
• WCC ABNORMAL - COMMENCED ON CIPROXIN/REG INFORMED
• CATHETER NOT REMOVED - PT HAD BENIGN PROSTATE
  PROBLEMS PRE-OP/MOBILITY POOR
• PT IN CONTROLLED AF- DIGOXIN GIVEN/REG INFORMED

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PATIENTS READMITTED

• DURING THIS TIME PERIOD TEN PATIENTS WERE
  READMITTED TO ICU FROM GENERAL WARD
• ONLY FOUR OF THESE PATIENTS HAD PLD FORMS FILLED
  OUT FOR US TO AUDIT
• REASONS FOR READMISSION WERE SEPSIS ? 2 AND
  PROBLEMS WITH STERNUM ? 2
• OF THE FOUR TWO WERE CLEARLY MDL,TWO PLD BUT ONE
  DID NOT FIT THE CRITERIA

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PLD READMISSIONS

• PATIENT 1 WHO WAS READMITTED DUE TO STERNOTOMY
  PROBLEMS MET THE CRITERIA
• PATIENT 2 READMITTED DUE TO SEPSIS HAD VARIANCES
  (ACCORDING TO THE DOCUMENTATION) NOT ACTED UPON
  e.g. WCC 14.6, Hb 7.2 AND PAIN SCORE NOT FILLED
  IN

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FEEDBACK FROM HDU STAFF

• STAFF WORRIED ABOUT THEIR ACCOUNTABILITY AND
  SUPPORT FROM MEDICAL STAFF
• WANTED ADJUSTMENTS MADE TO FORM
• ANXIETY STILL FELT BY EXPERIENCED STAFF

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RECOMMENDATIONS

• CHANGE PROTOCOL DOCUMENTATION
• MORE TRAINING SESSIONS ON IMPLEMENTING PROTOCOL
• ONLY THE NURSE IN CHARGE OR THEIR DEPUTY TO SIGN
  THE FORM
• ENSURE DOCUMENTATION COMPLETE BEFORE PATIENT
  DISCHARGED

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2ND AUDIT

• FROM 1ST MARCH 2007 31ST AUGUST 2007 386 PTS
  WERE TREATED IN HDU
• 207 PLD FORMS WERE COMPLETED IN THIS TIME PERIOD
• RESPONSE RATE OF 54

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OF THESE-

• 97 OUT OF 207 WERE PLD
• 90 PTS DID NOT FIT CRITERIA
• THE REMAINING 20 FORMS WERE NOT ALL COMPLETED
  PROPERLY, DIFFICULT TO ASSESS WHETHER IT WAS
  CLINICAL OR DOCUMENTATION ISSUES

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TIME OF DISCHARGE

• ON THE MLD THE AVERAGE DIFFERENCE BETWEEN
  ASSESSMENT AND ACTUAL DISCHARGE WAS 2 HRS 20 MINS
• ON THE PLD FORMS THE AVERAGE TIME BETWEEN
  ASSESSMENT AND ACTUAL DISCHARGE WAS 5 HRS

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RATIONALE

• EXAMPLES OF REASONS FOR DELAYS IN PLD
• - General Cardiac Ward (5A) BEDS BLOCKED WITH
  PATIENTS FROM OTHER WARDS
• -EITHER NO MALE OR NO FEMALE BAY IN WARD 5A
• -TWO DELAYS WERE FOR 3 DAYS AND 11 HRS DUE TO
  BEDS NOT AVAILABLE

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PTS READMITTED TO ICU

• BETWEEN MARCH AND AUGUST 07, 4 PATIENTS WERE
  READMITTED FROM 5A TO ICU
• NONE OF WHICH WERE PROTOCOL LED DISCHARGED
• THEY DID NOT FIT THE CRITERIA
• THREE WITH RESPIRATORY PROBLEMS AND ONE WITH
  RHYTHM PROBLEMS

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FEEDBACK FROM STAFF

• WANT GUARANTEE FROM CONSULTANTS RE PROTOCOL
• WANT FORM ADJUSTED SLIGHTLY AGAIN
• WANT CLARIFICATION ON WHEN TO CARRY OUT CXR
• ANXIETY - THREE PATIENTS COLLAPSING IN GENERAL
  WARD 07- 2 CHEST OPEN

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LIMITATIONS

• FOCUSED EDUCATION AND TRAINING ON HDU
• THE ICU SISTERS WERE NOT INVESTED IN THE PROCESS,
  LACKED OWNERSHIP
• LACK OF WARD CLERKS LED TO PROBLEM PHOTOCOPING
  FORMS

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SUMMARY

• GEOGRAPHICAL
• ACCOUNTABILITY ONGOING ISSUE
• INCREASING COMORBIDITY OF PTS
• PLD IS IN PLACE WHEN MEDICAL STAFF NOT AVAILABLE
• HDU NOW OPEN 7 DAYS A WEEK
• A WORK IN PROGRESS