Glossary
SE - Structural Empowerment

Exemplary Exemplar
SE1EO: Describe and Demonstrate Two Improvements in Different Practice Settings because of Nurse Involvement in Organizational Decision-Making Groups such as Committees, Councils, and Task Forces

Increase in Rapid Response Calls and development of EWSS

Background and Purpose:
Jersey City Medical Center’s Rapid Response Team has been in existence for several years in support of the 5 million lives campaign, www.ihi.org.  The goal of the Rapid Response Team is to prevent patients, outside of the Critical Care and Emergency Department, from deteriorating. The Institute for Healthcare Improvement (IHI) recommends 25 calls per 1000 patient discharges. A review of the number of RRT Calls in 2010 revealed a need to increase the use of the rapid response team and ensure a reliable process for assessment and management of patients who are identified at risk for deterioration. The interdisciplinary Rapid Response Code Blue taskforce was established in 2010. Through the years this taskforce has successfully changed the culture of JCMC to one that supports nursing staff in the early recognition of deteriorating patients and increasing the activation of RRT calls (See attached sample of meeting minutes).   

Goals:

The RRT/ Code Blue Task force established the following goals:

  • Increase RRT calls to exceed an average 25 call per 1000 patient discharges per month
  • Decrease non critical care code blue calls to an average rate of 3.8 (5% decrease from baseline) or less per month

Participants:

Composition of Rapid Response Code Blue Task Force

Name

Title

Mabel LaForgia MSN, RN, CNL

Critical Care Clinical Nurse Leader (2010-2012), Internal Consultant , Nursing Director (2013)

Claudia Garzon-Rivera MSN, RN, CNL (Chair of Committee 2011-2012)

Critical Care Clinical Nurse Leader (2010-2012), Internal Consultant , Nursing Director (2013)

Erin Salmond BSN, RN  (Chair of committee 2013)

Critical Care Nurse Manager

Selena Bray BSN, RN,

Nursing Director 5W

Dokun Dairo MD

Chief Resident (2011-2012)

Dr. Douglas Ratner

Chief Medical Director

Nicole Sardinas MSN, RN,

Critical Care Educator (2010-2012), Director of Education (2013)

Mario Pozzo

EMS Director

Amber Cioffo RN

RRT Nurse Responder

Joanie Knuth BSN, RN

RRT Nurse Responder

 

Methods and Approach:

During the last four years increasing rapid response calls was a main strategic focus for JCMC. The taskforce implemented many initiatives in efforts to achieve the goal of increasing RRT calls to greater than 25 calls per 1000 discharges. The implementation of the Early Warning Scoring System (EWSS) and the restructuring of the Rapid Response Team was the key to achieving this goal.

A review of the literature by the Rapid Response/Code Blue Task Force revealed that failures to rescue often result from delays in identifying early signs and symptoms of deterioration, breakdown in communication between providers, and preventable delays in care. Therefore, the RRT code blue task force placed emphasis on implementation of an Early Warning Scoring System (EWSS) and team building strategies.  Using criteria available in the literature and adopting a user friendly approach, Mabel LaForgia RN, MSN, CNL and Claudia Garzon-Rivera MSN, RN, CNL developed a EWSS tool to meet the needs of the patients and nurses at JCMC. The EWSS is a color scoring graph that encompasses a range of normal vital signs to abnormal findings that alert the end user to reassess the patient or call for an RRT intervention.  The premise of the EWSS is to detect early deterioration before the patient decompensates. The tool was color coded using the stop light approach to provide visual cues for the nursing staff. Symptoms for sepsis were also incorporated into the tool to assist with identification of patients at risk for severe sepsis and septic shock outside of the critical care units (please see attached Early Warning Scoring System).

In 2011, the RRT nursing structure was revised. Previously, the responding RRT nurse was a critical care RN who was assigned this task in addition to his or her critical care patient assignment. The idea of a RRT/Charge nurse role (who does not have a patient assignment) was presented to the taskforce. This new role would allow the charge nurse respond to rapid response calls,  manage the patient flow, maintain a safe nurse-patient ratio in critical care during RRT calls, and increase the availability of the charge nurse to educate nursing staff on when to call an RRT. Once Administrative approval was obtained for the new role, applicants were interviewed and in mid 2011 a new team comprised of nurses who were interested in achieving JCMC’s goals of preventing deaths through early intervention was established.

House wide educational sessions were offered to nurses from different specialties, medical residents, respiratory therapists, patient care technician, and unit clerks. This was done in efforts to increase awareness regarding the need to increase RRT calls and to provide nurses the support and tools necessary. The RRT training was conducted over a couple of days using the Agency for Healthcare Research and Quality’s “TeamSTEPPS Rapid Response Systems Module,” by Nicole Sardinas MSN, RN, CCRN, Critical Care Nurse Educator and Claudia Garzon-Rivera MSN, RN, CNL, CCRN, Critical Care Clinical Nurse Leader and Mabel LaForgia MSN, RN, CNL, CCRN, Critical Care Clinical Nurse Leader. 

The support and guidance of the Rapid Response taskforce has empowered nursing staff to increase the number of RRT calls per month.  Yearly accomplishments and improvements such as those described in the table below have assisted in JCMC’s commitment to reaching the establish goals.

Year

Focus

Accomplishment

2010

Established RRT code Blue task force

 

Enhance teamwork by providing education to Rapid response team members using TeamSTEPPS methodology

Added increase in RRT calls as a tactic in JCMC strategic plan

 

Implement a culture of safety promoting “There is never a wrong reason to call the Rapid Response Team”

Task force developed with established goals

Rapid Response Team building sessions provided rapid response team members and responding RNs (see attached flyer)

RRT and code blue calls added to liberty health strategic plan score card

Educations sessions provided to medical residents reinforcing “there is never a wrong reason for calling RRT”

2011

Decrease failures to rescue and unplanned transfers to critical care by utilizing patient risk scores and alerts to develop an algorithm for response to deteriorating patients

 

 

Educate RRT members, Nursing Staff, Physicians, and Respiratory Therapists using Team STEPPS approach

 

Redesign  current RRT Nursing structure

 

Established process for debriefing after code blue

Early Warning Scoring System developed and implemented

 

EWSS policy developed and approved by Professional Practice and Quality and Safety Nursing Council

 

Education provided to all nursing staff using TeamSTEPPS methodology. Booklet developed and distributed to RN and PCT staff (See attached)

Critical Care Charge RN’s new role as the RRT Responding RN

2012

Develop  and distribute resources for nursing staff

 

 

 

 

Increase awareness of RRT calls to include non clinical departments

 

 

Utilize EWSS in the emergency department to ensure transfer to appropriate level of care

Flyer developed for RNs describing RRT process (see attached)

RRT Medication inventory revised to include additional medication as recommended by RRT code blue taskforce

RRT TeamSTEPPS booklet revised

EWSS scoring tool discussed during RN orientation

Guidelines for Calling RRT added to employee orientation program (see attached)

Process implemented in the ED

2013

Updated EWSS and rapid response criteria to include updated best practices

Establish process in EMR

 

 

 

 

Charge RN role transition to Patient Care Coordinator Role

 

Reinforced use of SBAR communication

Unit based CNLs transitioned to internal consultants

EWSS policy updated to include Screening prior to transfer

Worked with informatics RN to establish EWSS template for EMR

Successfully obtained approval from medical records for electronic documentation of EWSS

PCC provide education regarding RRT calls during Registered nurse orientation

Reinforced RRT criteria during unit based debriefings/huddles
Mabel LaForgia MSN, RN, CNL and Claudia Garzon-Rivera MSN, RN, CNL provide guidance and support to RRT committee

 

Outcomes:
The chair of the Rapid Response Committee collects monthly data on the number of RRT calls and code blues outside of the Critical Care & Emergency Departments.  A year to date rate is established and monitored to ensure sustained results over time.  Since the development of the task force in 2010, Rapid Response Team, calls have steadily increased demonstrating an established culture of safety. This increase in RRT calls has led to early detection of patients prior to deterioration. This is evident JCMC’s ability to sustain a rate of less than 3.8 code blue calls per month. 

Surviving Sepsis Campaign

Background and Purpose

In 2010, the need to reduce mortality and improve quality of care through the early diagnosis and treatment of patient in severe sepsis and septic shock was recognized. The PI steering committee identified “the Surviving Sepsis Campaign” as a key element in reducing overall mortality.
Using the Six Sigma methodology a quality and safety harm event prevention charter was created (See attached Charter). Mabel LaForgia MSN, RN, CNL, and Claudia Garzon-Rivera MSN, RN, CNL were appointed to lead the initiative.  A multidisciplinary task force was established (See attached sample of meeting minutes) to review data and implement evidence based strategies to reduce mortality.  Claudia Garzon-Rivera MSN, RN, CNL and Mabel LaForgia MSN, RN, CNL, reviewed mortality data from all patients discharged between January 2008 through June of 2009 with ICD codes of Severe Sepsis and Septic shock. The Baseline data collected revealed an overall mortality rate of 46%. This data was presented to the task force and the following goal below was established.

Goal:

Decrease sepsis mortality rates to 36% or less (a 25% decrease from baseline) and sustain results over five years.

Participants:

A Collaborative team consisting of representation from the Department of Medicine, Critical Care, Quality Management, Nursing Leadership, Infection control, Pharmacy, Laboratory, Respiratory Therapy, and Emergency Department was formed.

Sepsis Collaborative Taskforce

Interdisciplinary Team Members

Title

Claudia Garzon-Rivera MSN, RN, CNL, CCRN

Clinical Nurse Leader

Mabel LaForgia MSN, RN, CNL, CCRN

Clinical Nurse Leader

Ribhia Abdelhady

Corporate Director of Laboratory Services

Michael Bessette MD

Director of Emergency Services

Mike Curci Pharm D

Corporate Director of Pharmacy

Vicki DeChirico MSN, RN, CIC

Infection Control Nurse

David Flores MD

Critical Care Physician Intensivist

Kenneth Garay MD

SVP and Chief Medical Officer

Adriana Grigoriu MD

Infectious Disease Director

Wren Lester MS, CPHQ

Corporate Director of Performance Improvement

Omayra Sanabria

Supervisor, Respiratory Therapist

 Nicole Sardinas MSN, RN, CCRN

Clinical Educator, Critical Care

 Chris Amato BSN, RN, CEN

Clinical Educator, Emergency Department

 Christina Simeone BSN, RN

Nurse Director Critical Care

 Jessica Walsh MSN, APN

Assistant Director of Nursing

Nan Rao Pharm D

Clinical Pharmacist

Erin Salmond BSN, RN

Critical Care Manager

Cheryl Jaron BSN, RN

Critical Care PCC

*Members from Critical Care Committee provided input as well

 

 

Methods and Approach:

The Clinical Nurse Leaders for critical care reviewed best practices protocols regarding the identification and treatment of patients with severe sepsis and septic shock. The surviving sepsis campaign was an instrumental evidence base resource used by Mabel LaForgia CNL and Claudia-Garzon Rivera CNL to evaluate the gaps that existed in practice. In depth chart reviews of thirty random charts were completed to explore the current treatment plan and identify opportunities for improvement. Evidence based strategies were proposed and implemented by the taskforce.  Nurses and Nursing leaders were instrumental in the implementation of strategies to reduce mortality.

Year

Major Accomplishments

2010

Sepsis multidisciplinary team monthly meeting held

Evidence based resources developed for nursing and medical team (See attached resources)

Reinforce use of the evidence based clinical pathways and resuscitation algorithms with physicians and nursing staff

Initiated Activate Team Sepsis to facilitate transfer to the ICU within 90 minutes

Implemented Severe sepsis/ septic shock screenings for all RRTs

RRT/code sepsis activated for inpatients screening positive

Continuing Education provided for Critical care and day and night shift

Increased awareness by implementing an advertising campaign and presenting to the board of trustees and medical staff

Trending of Mortality rates

Sepsis introduction during RNO for all new hires

2011

Critical Care initiative  learning sessions provided to critical care staff

Monthly Mortality rates presented at critical care committee

Code Sepsis policy developed and implemented

Mortality rates added to strategic planning score card

Severe Sepsis and Septic shock criteria added to RN yearly competency

RRT Forms updated to include sepsis criteria

Sepsis order-sets revised to reflect updated criteria

2012

Ongoing education provided to staff nurses and critical Care

Education provided to staff nurses on medical surgical floors

Medical surgical RNs encourage to call RRT for patient exhibiting signs and symptoms of septic shock

Nursing pathway updated

Severe Sepsis and Septic Shock criteria added to nursing plan of care/handoff tool

Established process for severe sepsis septic shock screening in ED

Severe Sepsis Septic Shock Screening added to physician H&P

 

Measurements & Outcomes:

Analysis of Data

The adoption of the Surviving Sepsis Campaign Guidelines and the ongoing commitment of the medical and nursing staff, led to significant reductions in mortality rates of patients meeting criteria for severe sepsis and septic shock. Since the development of the task force in 2010, JCMC RNs and physicians have collaborated to sustained mortality rates below the established goal of a 25 % reduction from baseline.