1. ©2013 MFMER | slide-1 Clinical Nurse Specialist Driven Practice Change: Standardizing Vital Sign and Oxygen Saturation Monitoring Practices Kelly Derby, APRN, CNS Sherry Wolf, APRN, CNS Heather Zak, APRN, CNS

2. ©2013 MFMER | slide-2 Objectives: 1. Identify key drivers for change in nursing practice related to vital sign reassessment. 2. Examine factors contributing to variances in vital sign monitoring practice. 3. Describe actionable strategies for improving patient safety through vital sign reassessment.

3. ©2013 MFMER | slide-3 Background Failure to rescue = “the inability of clinicians to save a patient’s life by timely diagnosis and treatment when a complication develops” (Gephart, McGrath, & Effken, 2011, p.275) Patient’s display signs and symptoms of impending arrest as early as 72 hours prior to an arrest (Subbe & Welch, 2013)

4. ©2013 MFMER | slide-4 Failure to Rescue Where do we fail? Failure to recognize clinical deterioration Failure to escalate concerns Failure to physically assess the patient Failure to diagnose and treat appropriately (Moldenhauer, Sabel, Chu, & Mehler, 2009) Activities to prevent FTR events: Surveillance Timely identification of complications Taking action Activating a team response (Gephart et al., 2011)

5. ©2013 MFMER | slide-5 DMAIC - Define To standardize frequency of vital sign monitoring of general care/progressive care patients following admission or transfer to a lower level of care and prior to dismissal To provide guidance for reassessment of patients with abnormal vital signs Vital signs Temperature Systolic blood pressure Heart rate Respiratory rate Oxygen saturation

6. ©2013 MFMER | slide-6 Scope Inpatient general and progressive care areas Adult Registered nurses Patient care assistants - PCA

7. ©2013 MFMER | slide-7 DMAIC - Measure Mortality reviews revealed a gap in recognition of patient deterioration, specifically a gap in vital sign and oxygen saturation obtainment and reassessment Counterbalance measure: RRT calls

8. ©2013 MFMER | slide-8 DMAIC - Analyze Literature review Internal Practice Benchmarking Reassessment

9. ©2013 MFMER | slide-9 DMAIC - Improve Development of algorithm Input from stakeholders Pilot Education/roll out Development of new standards

10. ©2013 MFMER | slide-10 DMAIC - Control Outcomes Mortality review RRT Process measures (monthly compliance reports) Data audits Every 4 hours at admission Every 4 hours with transfer to a lower level of care Full set of VS within 30 minutes of any abnormal VS TID as routine practice Within 2 hours of discharge Orientation Reiterating processes Practice convergence Continuing to monitor

11. ©2013 MFMER | slide-11 Takeaways Assess for inconsistencies in your organization’s practice Seek opportunities for standardization Engage the bedside nurse Evaluate processes Embrace rapid cycles of improvement

12. ©2013 MFMER | slide-12 Vital Signs. Skipping just one could cost a person their life.

13. ©2013 MFMER | slide-13 Questions & Discussion

14. ©2013 MFMER | slide-14 References Barfod, C., Lauritzen, M. M., Danker, J. K., Soletormos, G., Forberg, J. L., Berlac, P. A.,... Lange, K. H. (2012). Abnormal vital signs are strong predictors for intensive care unit admission and in-hospital mortality in adults triaged in the emergency department - a prospective cohort study. Scand J Trauma Resusc Emerg Med, 20, 28. doi: 10.1186/1757-7241-20-28 Brown, H., Terrence, J., Vasquez, P., Bates, D. W., & Zimlichman, E. (2014). Continuous monitoring in an inpatient medical-surgical unit: a controlled clinical trial. Am J Med, 127(3), 226-232. doi: 10.1016/j.amjmed.2013.12.004 Hands, C., Reid, E., Meredith, P., Smith, G. B., Prytherch, D. R., Schmidt, P. E., & Featherstone, P. I. (2013). Patterns in the recording of vital signs and early warning scores: compliance with a clinical escalation protocol. BMJ Qual Saf, 22(9), 719-726. doi: 10.1136/bmjqs-2013-001954 Garvey, P. K. (2015). Failure to Rescue: The Nurse's Impact. Medsurg Nurs, 24(3), 145-149. Gawande, A. The Checklist Manifesto: How to Get Things Right. Metropolitan Books; 2009 Gephart, S. M., McGrath, J. M., & Effken, J. A. (2011). Failure to rescue in neonatal care. J Perinat Neonatal Nurs, 25(3), 275-282. doi: 10.1097/JPN.0b013e318227cc03 Moldenhauer, K., Sabel, A., Chu, E. S., & Mehler, P. S. (2009). Clinical triggers: an alternative to a rapid response team. Jt Comm J Qual Patient Saf, 35(3), 164-174. Subbe, C.P., Welch, J.R. (2013). Failure to Rescue: Using rapid response systems to improve care of the deteriorating patient in the hospital. Clinical Risk, 19, 6-11. Yoder, J. C., Yuen, T. C., Churpek, M. M., Arora, V. M., & Edelson, D. P. (2013). A prospective study of nighttime vital sign monitoring frequency and risk of clinical deterioration. JAMA Intern Med, 173(16), 1554-1555. doi: 10.1001/jamainternmed.2013.7791