An after hours, multidisciplinary team based approach to care for Patients of Concern. Facilitated by the introduction of new nursing and medical leadership positions to provide: proactive clinical review for Patients of Concern; mentorship and support to more junior after hours staff; and new educational initiatives to improve staff recognition and response to clinical deterioration.
Up Late: An after-hours, team-based approach for patients of concern
Initiative Type
Service Improvement
Status
Close
Added
Last updated
Summary
Key dates
Aug 2018
Jun 2019
Implementation sites
RBWH
Partnerships
Consumer engagement informed the development of the service and were involved in project governance. Extensive interdepartmental collaboration drives the service (nursing, ICU, medicine in particular). External partnership with AusHSI assisted with rigo
Aim
- improve clinical outcomes for Patients of Concern
- improve patient perceptions of after hours care and safety
- improve after hours staff satisfaction
Benefits
- improved patient safety
- improved staff and patient perceptions of after hours care
- improved education in recognising and responding to acute deterioration
- improved governance with numerous quality improvement initiatives that have been able to be supported through greater visibility and measurement of problems
- outline in detail in the attached report
Background
An after hours, multidisciplinary team based approach to care for Patients of Concern. Facilitated by the introduction of new nursing and medical leadership positions to provide: proactive clinical review for Patients of Concern; mentorship and support to more junior after hours staff; and new educational initiatives to improve staff recognition and response to clinical deterioration.
Solutions Implemented
Senior clinical leadership positions are now established on evening and night shifts seven days a week. Enhanced Advanced Life Support Team (ALS) and Medical Emergency Response Team (MERT) training programs now exist for MERT leaders. Structured ward call education program with comprehensive curriculum and positive evaluation. Improved clinical handover across after hours shifts, particularly focussed on Patients of Concern and multidisciplinary in nature.
Evaluation and Results
A comprehensive evaluation strategy was undertaken with a pre-specified, mixed-methods protocol. External support was garnered from the health services research organisation AusHSI. Significant gains were made with respect to patient safety, in particular sustained improvements in the RBWH Hospital Diagnosis Sustained Mortality Ratio (86% pre / 75% post) with notable mortality risk reductions for Patient of Concern cohorts (inter hospital transfer and after hours admissions). Strong and sustained improvement in patient perceptions of after hours care were realised. Staff satisfaction and perceptions of after hours care also demonstrated improvements on repeated survey, with further supporting evidence in reduced unplanned leave and overtime for junior medical officers.
Lessons Learnt
Numerous cultural barriers to enhanced senior medical presence after hours have been encountered and challenged over the course of the project, with pragmatic compromise reached to maximise outcomes for more junior staff and our patients. Necessity of expertise to measure outcomes of a complex intervention such as UP LATE and convey in a manner that can convince decision-makers of the value proposition. Multi-layered interventions that enhance capability of after hours clinicians broadly, e.g. educational initiatives, are an important driver of outcomes - not just the addition of further clinician numbers.
