Just-in-time Training: Building an Interprofessional Learning System at the Bedside of Our Sickest Patients

City-Wide Grand Rounds5th Annual Excellence in Clinical TeachingGrand Rapids Medical Education Partners

September 22nd, 2011Patrick Brady, MD, MSc

General and Community Pediatrics and Hospital Medicine andJames M. Anderson Center for Health Systems Excellence

Cincinnati Children’s Hospital Medical Center

Disclosures

• The author has no relevant financial relationships to disclose or conflicts of interest to resolve

• This presentation will not involve discussion of unapproved or off-label, experimental or investigational use of commercial products or devices

Objectives

• Describe using “situation awareness” to recognize patient deterioration

• Discuss an interprofessional model for identifying and mitigating patient risk    

• Investigate opportunities and challenges in role-modeling and teaching this learning system

Just-in-time learning

• Just-in-time learning occurs at moment when needed

• Contrasted with just-in-case learning that often features topics (like how to run a code) that learners are unlikely to need on any given shift or day

• Just-in-time learning has advantages of highly motivated learners

Clinical Case

5 year old patient is hospitalized with gastroenteritis:

• After initial improvement bedside nurse notes he has worsening diarrhea, an elevated HR and his parents note he is “not acting right”

• First two calls to intern are not returned• On third call intern notes that he “was just

down there” and “the kid was fine”

• Night shift begins– Shift change is interrupted several times– Family concerns come up briefly but is noted can

“wait until rounds” in morning

• Parents note he is “much worse” than in ED– But patient care tech forgets to convey this to

nurse

• Heart rate begins to rise again– New nurse notes this was same value from earlier

when kid was “just fine”

Clinical Case, continued

Rounds the next day

Or… CODE occurs

• Mortality of outside ICU code in pediatrics is 50-66%

High Reliability Organizations (HROs)

• Deal with constant risk yet have exemplary safety records

Core Characteristics of HROs

• Preoccupation with Failure

- Encourage reporting of small errors and convene to address

• Reluctance to Simplify Interpretations

- Encourage diversity in experience, perspective, opinion

• Commitment to Resilience

- “errors don’t disable”

• Deference to Expertise

- Decision making deferred to workers with the most

knowledge and expertise not the highest rank

• Sensitivity to Operations

- Find loopholes in system’s defenses, barriers and

safeguards on the frontline. Maintain Situation Awareness

Failure to Rescue

• Failure to rescue from a complication of an underlying illness or a complication of medical care

• Reflects– the quality of monitoring and/or – the effectiveness of actions taken once early

complications are recognized

• Rapid response systems and early warning scores are most common interventions

Failure to Rescue

• Outcomes after arrest or code outside of Intensive Care Unit are dismal– 50-67% mortality in pediatrics– 70-90% mortality among adults– Substantial neurologic morbidity among survivors

• Evidence that vital sign abnormalities occur before arrests in majority of cases but are:– Not fully recognized and/or– Not sufficiently acted on

• Multicenter, risk-adjusted study using data from >80,000 patients in ACS National Quality Improvement Program

• Included patients that had undergone inpatient general or vascular surgery

• Stratified into low-mortality and high-mortality hospitals

• Looked at rates of complications in each

Results

p=NS

p=NS

P<0.001

Mortality rate Cardiac arrest rate

AdultsNo significant reduction

Children21% reduction, significant

Pooled

Arch Intern Med. 2010;170(1):18-26

better worse better worse

Pooled

Adults34% reduction

Children38% reduction

Mortality rate Cardiac arrest rate

AdultsNo significant reduction

Children21% reduction, significant

Pooled

Arch Intern Med. 2010;170(1):18-26

better worse better worse

Pooled

Adults34% reduction

Children38% reduction

CPR

Medical Emergency

Team

Early Warning

Score

Systematic identification & Mitigation

Time

Clinicalstatus

Effort needed to return to recovery

Admission Assessment

Anticipated Recovery

What is Situation Awareness?

Situation Awareness

3. Anticipate“Projection”

Decide

2. Recognize &Understand

“Comprehension”

Act

1. Gather Information“Perception”

↑HR, ↑diarrhea,parent concern

Recognize dehydration

Progress toshock if untreated

Situation Awareness in Other Industries

• Situation awareness failures have been studied in other high-risk, complex organizations:– Including military, aviation, and nuclear power

• 88% of commercial aviation accidents found to be due to poor situation awareness

• Poor SA found to be leading contributor to human error in review of military aviation mishaps (Hartel, Smith, Prince, 1991)

Situation Awareness in Medicine

• In trauma and rescucitation simulations, increased SA associated with:– Level of experience– Achievement of objectives– For individuals and teams

Situation Awareness

3. Anticipate“Projection”

Decide

1. Gather Information“Perception”

2. Recognize &Understand

“Comprehension”

Act

Miss ImportantInformation

Miss Context asInfo Not Integrated

WrongPrediction

WrongDecision!

Threats to SA

Situation Awareness

3. Anticipate“Projection”

Decide

1. Gather Information“Perception”

2. Recognize &Understand

“Comprehension”

Act

Miss ImportantInformation

Systematically Identify High Risk Patients

Miss Context asInfo Not Integrated

Communicate EachRisk to Watchstander

WrongPrediction

Predict/Mitigate/Escalate as Team

WrongDecision!

RightDecision!

Potential Solutions

Eliminate:•Serious Safety Events (SSEs) related to SA failures

– SSEs defined as serious harm or death associated with deviation from standard of care

•Codes outside the ICU related to SA failures•UNSAFE transfers (UNrecognized Situation Awareness Failure Events)

– Patient transferred from unit to ICU and within 1 hour is:• Intubated• Placed on inotropes OR• Given 3 or more fluid boluses

Our Aims:

Why Target UNSAFE transfers?

• Adult and pediatric studies show these patients are at increased risk for mortality– Children admitted from hospital floor vs. ER or OR 65%

more likely to die

• ~1 patient per day is transferred from unit to ICU• On average, every 5 days a child is transferred that

met criteria for UNSAFE transfer

UNSAFE Transfers and Mortality

• Preliminary analysis at CCHMC has shown a 16% mortality for UNSAFE transfers

• ~8-fold higher than 2.1% all-PICU mortality over the same time period

Eliminate SSEson inpatients related to SA.

codes outside ofICU related to SA, and UNSAFE transfers

No unrecognizedclinical

deterioration

ImprovedSituation

Awareness

Escalate riskthat is not

fully addressed

Identify patients at risk

Predict courseof most at

risk patients

Mitigate risk on unit

Systematically & Reliably

Learn from eachevent

Key Driver Diagram

Aim

Family concerns

High risk therapies

Watcher

Early Warning Score ≥5

Communication concern

Concerns identified from chart reviewFamily concern about patient safety

High risk or unfamiliar therapies (insulin on surgery floor)

Elevated Pediatric Early Warning Score (PEWS)

Clinician gut feeling patient at risk (e.g., patient is less interactive)

Communication concern judged to impact patient safety (often involving multiple medical teams)

Bedside nurse

Intern

Family concerns

High risk therapies

Watcher

Early Warning Score ≥5

Communication concern

Bedside Team

Identify

Tested on 1 general pediatric unit using Model for Improvement and Plan-Do-Study-Act (PDSA) cycles

Teaching Identification

• Once identified, each risk is tied to specific and standardized actions– Support is built in to system

• No news is not good news• Opportunity to identify learners in need of

assistance• “Trusting your gut” does not come naturally

– What is different?

Bedside nurse

InternWatchstander

Senior Resident

WatchstanderCharge Nurse

Family concerns

High risk therapies

Watcher

Early Warning Score ≥5

Communication concern Attending

Bedside Team

Unit Team

Identify Mitigate

Tested on 4 nursing units with learning and adaptations

Teaching Mitigation Plans

• Learners (intern and new bedside nurses) communicate using SBAR– Situation

– Background

– Assessment

– Recommendation/Plan

• Mitigation occurs with interprofessional team bedside

• Made explicit if each member believes plan “fully addresses” patient risk

Bedside nurse

InternWatchstander

Senior Resident

WatchstanderCharge Nurse

Safety Team(Nurse Manager

and Safety Officer)

Family concerns

High risk therapies

Watcher

Early Warning Score ≥5

Communication concern

Medical Response

Team (MRT)

Attending

Bedside Team

Unit Team

OrganizationTeam

Identify Mitigate Escalate

Tested on 4 nursing units then spread on 3/22/10

Proactive Safety Team

• Three times daily discussion of any concerns not fully addressed and any predicted calls of Medical ResponseTeam

• Includes:– Charge nurse from

each unit– Nurse manager– Senior attending

Safety Officer

Teaching Escalation

• Opportunity to model best practices• Accountable to peers/leaders

– “I don’t know” who is sickest patient went from common answer to embarrassing one

• Culture of independence to culture of interdependence

• Escalation is “how we do things here”• Celebrate successes

Median: 5 days

Desired direction of change

Pilot testing

Phase 2 begins

SA testing begins

SA testing begins

Identifying is only the start

• First year of journey moved from relying on individual clinicians to a system that identified >90% of patients who had UNSAFE transfers– BUT in many cases risk was not successfully

mitigated/reversed – AND risk was not escalated even when patient

was not improving

• Watching the “watchers”

SMART Aim

• S - Specific• M - Measurable• A – Actionable• R – Relevant• T – Time bound

• “Some is not a number. Soon is not a time.”– Don Berwick

• Identifying the problem or concern

• Making responsible parties aware

• Forming a plan• Predicting an expected

outcome within a fixed amount of time

• Deciding on an escalation plan if outcome is not met in time

Robust plan PDSAs began

Shared Mental Model

• “The perception of, understanding of, or knowledge about a situation or process that is shared among team members through communication”– AHRQ

• Also called Shared SA

High-Risk Patients Throughout Hospital

High Reliability Teams

High Reliability Teams in Healthcare

Doc Right Doc Left

Airway

Nurse Right Nurse Left

Team Leader

Recorder

Thank you

• Mentors– Patrick Conway– Tom DeWitt– Gerry Fairbrother– Uma Kotagal– Steve Muething– Derek Wheeler

• Grant support: NRSA T32

• QI Team– Marshall Ashby– Victoria DeCastro– Regan Gallagher– Maria Geiser– Marty Goodfriend– Dawn Hall– Jason Olivea– Christy White

• Reference slides follow

Total Number of Times each Safety Element Failed(FY07 – Jan. 2010)

Failure Type % of times this failure occurred

Situation Awareness 45%

Coordination of Care 45%

Reliable Escalation 24%

Family Engagement 21%

Any of the 4 above 62%

Serious Safety Event Root Causes

Background

Time Setting Attendees Topics

8:00 Conference room

Safety officer, nurse manager, charge nurse on each unit

Any SA concerns not fully addressed, predicted MRTs

16:00 Rounds on unit → conf. room Any SA concerns not

fully addressed, follow-up1:00 Rounds on

unitNurse manager, charge nurse on each unit

Methods

SMART AIM

KEY DRIVERSINTERVENTIONS

For identified watchers on TCC, wewill increase

to 100% those thathave a robust

mitigation/escalation plan* in place by

7/1/2011

Reliable tools to support robust planning

Charge RN, MPS, and SOD coaching

System to supportrapid learning on unit

KeyDotted box = Placeholder for future additionsGreen shaded = Current or Past Work

Revision Date: 6-2-2011

GLOBAL AIM

Root Cause1). There was ineffective identification, mitigation and escalation on TCC

Clarity of what is alwaysescalated

Knowledgeable and engagedstaff

Comfort and confidence to escalate

*robust plan includes: new change in management, prediction, contingency plan, and clear criteria to escalate

Eliminate SSEs and MRT-preventable codes and reduce by half UNSAFE transfers across inpatient

Proper identification of watchers patients

Robust Plan Form (LOR 2)

Team huddle form changed to include all members

contact info (LOR 2)

Standardized Vocabulary

Unit Wide Training Blitz – June 2011

Charge RN Focused Training – July 2011

Data System

• Tools and database designed to assess both the reliability of the identify and mitigate/escalate process as well as UNSAFE transfers

• Apparent Cause Analysis form completed on each floor to ICU transfer

• Data distributed (with patient-level story) each week to Microsystem leaders in weekly report

• Control Plan designed with Mesosystem leaders to identify special cause and target interventions

Methods

Safety Attitudes(AHRQ Safety Culture Survey)

Safety Behaviors(Identify, Mitigate, and Escalate)

Near Misses

UNSAFE Transfers(UNrecognized Situation

Awareness Failure Events)

Arrest

Methods: Measure

What about breakdowns in steps of process?

Barriers to problem detection in teams

• Production pressure discourages vigilance• High cost of conveying information• Team member may think team already knows• Inexperienced members may miss early signs• Team may not realize common understanding

is lost

-Klein. Cogn Tech Work 2006