1. Emma McKay Dr Jonathan Albrett
Management of hypotension by RMOs out of hours at Taranaki Base Hospital
Emma McKay
Dr Jonathan Albrett

2. Introduction
Originally designed to assess the effectiveness of a teaching program implemented by an ICU SMO
Junior RMOs manage all wards outside of “working” hours
One house officer to cover surgical/orthopaedic/specialties wards and one to cover medical/OPHRS/TPW
Overnight one house officer covers entire hospital
Supported by a mixture of on- and off-site registrars
Level of direct oversight is extremely variable

3. Introduction
Management of hypotension chosen as a common ward job with clearly definable objective outcome measures
No available literature on acceptable “times to treatment” or looking at the performance of junior staff after-hours

4. Aims
To assess the effectiveness of a directed teaching program on “real world” management of a common ward issue
To quantify short- and long-term mortality outcomes for these patients
To provide a “snap-shot” of what occurs on our wards out of hours

5. Method Retrospective audit looking at two six month cohorts:
Jun-Nov 2014 (pre-teaching program)
Jun-Nov 2015
Best attempts to gather objective outcome measures
In-hospital: rate of IV fluid use, time from BP measured low to IV fluids, time to BP improving, escalation of care etc.
Survival to discharge and at one year

6. Method Task manager used as a reservoir of “cases”
Computer program used across entire hospital where nurses can log tasks for the RMO on call
Allows prioritisation of tasks
In highest acuity situations there is an expectation nursing staff will contact the RMO by the direct paging system

9. Cohort 2014 2015 Excluded: Task manager jobs screened
= 9,223
Task manager jobs screened
= 10,231
Excluded:
Palliative patients
Parameters adjusted to accept a lower BP
Never SBP>90 (incl. from ED)
Physical notes reviewed
= 336
Physical notes reviewed
= 818
Included cases
Total 206
Individual patients 163
Included cases
Total 184
Individual patients 131

10. Patients by Specialty 2014 2015 Medical 47 51 Surgical 31 19 Ortho 12%
Medical 47 51
Surgical 31 19
Ortho 12
OPHRS 8 4
Psych 1
Urology

11. Basic management 2014 2015 % IV fluids received Senior advised
Yes 28 33 No 61 58
Missing data 12 9
Senior advised 11 87 86 2
Transfer to HDU
0.5 1 97
Already in HDU
777 Call 98

12. Fluid administration
Time from BP recorded low to IVF administration (minutes)
2014
2015
Mean 99
122
Median 82 80
Minimum 10
Maximum
450
987
Missing data (n) 27 24
Time from BP recorded low to next SBP>90 (minutes)
2014
2015
Mean
190
286
Median
130
150
Minimum 10 5
Maximum
1260
4140

13. Difficult patient excluded
EDG7077 admission with RHF, severe pulmonary hypertension, CLL, LRTI, C. diff +ve…
Parameters SBP<85 on 6/11
SBP<70 on 26/11
Time from BP recorded low to IVF administration (minutes)
2014
2015
2015 EDG7077 Removed
Mean 99
122
108
Median 82 80 83
Minimum 10
Maximum
450
987
530
Missing data (n) 27 24 23
Time from BP recorded low to next SBP>90 (minutes)
2014
2015
2015 EDG7077 Removed
Mean
190
286
240
Median
130
150
Minimum 10 5
Maximum
1260
4140
2270

14. Patient outcomes 2014 2015 Survival to discharge Survival to one year%
Survival to discharge
Yes 91 94 No 9 6
Survival to one year 64 36 29

15. Discussion Similar outcomes across both years
However this obviously does not discredit value of teaching program
No standard to compare whether times to treatment are “acceptable”
At face value these results are longer than expected
Mortality data unexpectedly high given these are “low acuity” patients

16. Discussion Do we provide adequate oversight for our most junior staff?
Are our feedback systems robust enough? Do we need to think more about the feedback that is provided?
How can we improve this?

17. Limitations Retrospective chart review Auditor bias?
Unable to capture higher acuity patients where direct paging has been used (i.e. not task manager)
Does not inform where or why delays may have occurred in time to treatment

18. Conclusion
Hypotension is a common ward problem that is objectively and easily audited
Times to treatment are often seemingly prolonged and even “low-acuity” patients have a high one-year mortality rate
Could we do more to protect and educate our junior RMOs?