Nurse Practitioners aren’t built in a day. Anna Green Nurse Practitioner – ICU Liaison Nurse Practitioner Project Officer Western Health, Australia

Map of Australia Melbourne If you are planning on coming to Australia then your visit would not be complete without a stay in Melbourne. We pride ourselves on our sporting venues which includes the formula 1 Grand Prix, the Melbounre Cup HorseRace, and our own brand of football known as Aust. Fooltball League. Melbourne is also renown for its arts and culture centres and not to mention exquisite dining venues. Melbourne

Leadership core competencies Visionary Idea Commitment Energising When researching up on leadership skills The common theme was these core leadership competencies were repeated again and again and can be best summarized by Jodie McLeod in her article in Human Capital Issue as: creating a vision around where you need to go Energising people to ensure that they’re empowered to come on board with you and follow you Building commitment to the vision… Given what I have said about leadership how does this differ to what I do normally. Empowerment McLeod J. Leaders aren’t built in a day. Human Capital Issue 3.1: 24-27

ICU Liaison Nurse Role Case-Manage patients post ICU discharge Accept referrals for unstable patients Rapid Response System - respond to clinical marker referrals Initially established to only case manage pts post ICU discharge Within 3 months of commencing in this role we started receiving referrals from nursing and allied health staff for other patients on the wards who were clinically deteriorating. It wasn’t long after this that referrals from medical staff started to occur and has continued to increase each year of operation. It is not uncommon to be asked by the ICU medical staff or ward medical staff to review clinically unstable patients on the ward, to assess if ICU admission is required. Whilst we receive a large proportion of referrals for unstable patients in the ward there are still others who are admitted to ICU from the ward where we have had no involvement with and have shown significant signs of clinical instability for several hours and in some cases days. It was these patients we were not referred to us that led us to come up with the clinical marker referral system. This system is based on the MET. The MET in some hospitals in Australia, has replaced the traditional resuscitation team and respond to emergency calls for all pts showing signs of pre-determine vital sign abnormality. Our clinical markers that are based on the MET criteria have been modified following a 3 month review of all unplanned admissions unto ICU to identify earlier signs of deterioration than pre arrest criteria.

ICU Liaison hours worked Two full time EFT 7 day a week cover 8am to 6pm One day a week allocated to non clinical work Research Leadership Education Meetings/Committee Working towards 24 hour service Expanding service throughout the network

Leadership development Internal External 1996 1998 Obtaining an office and equipment Changes to the reporting structure of the role Meeting organisational demands that were separate to individual demands Complex care course Process improvement team Policy and procedure manual Rewarded with leadership development course Extending hours to full time Self Leadership skills

Goal achievement Australia's First Critical Care NURSE PRACTITIONER 2004 My application to the NBV was back in May 2002 and it was 2 1/2 years later that I was finally endorsed. Waiting that length of time was frustrating however, it was more important to get the process right. All of us who have gone through the endorsement process in Victoria have an immense sense of achievement and are very proud of the commitment of not only ourselves but also the NBV and the DHS Victoria. So in essence my training in becoming a NP whilst working in an advanced practice role took 6 years which does not take in account 10 years previously of working in my specialty area of critical care.

Three Fundamental Problems Failure in planning Failure to Rescue Failure to communicate In the 100,000 Lives Campaign they report on three main systemic issues contributing to the problem of failure to rescue. The first is failure in planning which includes assessments, treatments and goals The second is failure to communicate including patient to staff, staff to staff, and staff to physician etc) The last is a failure to recognise the deteriorating patient And all of these contribute to fail to rescue Hence the rapid proliferation of MET, Outreach Teams and the ICU Liaison Teams. Failure to recognise deteriorating patient condition http://www.ihi.org

What is a Rapid Response System? Medical Emergency Team Outreach Team ICU Liaison Team A rapid response system (RRS) involves the utilisation of a variety of hospital resources, for the detection and treatment of patients in crisis, to prevent deterioration, morbidity or death. MET – Liverpool Hospital 1990 ICU Liaison – Western Hospital 1996 Outreach Team – UK Late 1990’s early 2000 MET & Liaison – The aim of implementing a RRS is to reduce the number of unexpected in-patient deaths. MET & ICU Liaison Service

What are these warning signs? Altered CNS Fall in GCS of >2 points Heart Rate >120 per minute Systolic blood pressure <90mm Hg Respiratory Rate >30 breaths per minute Sa02 >90% on oxygen Difficulty in breathing UO <60mls for 2 hours “Worried Staff” (Green & Williams 2006) These criteria are the MET criteria for Liverpool Hospital These reportable ranges vary depending on the individual hospital. In the UK the criteria used are based on Franklins article that identified warning signs 6hrs of arrest. Differences include Lowering the upper range of heart rate to 125 Lowering the upper range of respiratory rate to 30 breaths/minute

Changes to criteria ranges New criteria Omitted criteria

What difference Can a NP led Rapid Response Team Make? Fast Track Patients to the ICU Decreased cardiac arrest calls Increased medical emergency calls Improved survival for medical emergencies +/- reduction in readmissions (Ball et al., 2003; Pittard, 2003) +/- reduction in ICU patient mortality (Ball et al., 2003; Garcea et al., 2004; Priestly et al., 2004) +/- decrease ICU LofS (Green & Williams, 2006)

Survey Responses Clear Guidelines Prompt Support ‘Back-up’ (Green & Williams, 2006)

Survey Response Disagreement with parameters Overstepping boundaries Increased workload for ICU MO Poor response from MO when called Further education (Green & Williams, 2006)

What extended practices do I need Referral to ICU consultants Ordering of diagnostic tests Ordering of radiological tests Limited prescribing rights Admission / Discharge

ICU Liaison – extensions to practice Limited Prescribing Counselling Clinical Practice Initiate Diagnostics Admit / Discharge Management Policy Research Direct referral to Medical Specialists Education Conference

Reflecting on my achievements Pioneered the ICU Liaison Role Implemented Nurse-led Rapid Response Team Australia’s 1st Critical Care NP Published 5 Papers National / International Guest Speaker Founding Member of the Victorian NP Group

Future Endeavour's Expansion Succession Planning Victorian NP Group Australian Network

Concluding remarks: leadership tips for the Nurse Practitioner Reenergize via successful results Leave your comfort zone Do not avoid conflict Benefit the organisation Recognise when change needs to occur and acting upon it