Page 73 - ACCCN's Critical Care Nursing

50 S C O P E O F C R I T I C A L C A R E

organisation, with subsequent activities aimed at improv- these skills can be learned. For example, the Anaesthetists’
ing components of this culture. Non-Technical Skills (ANTS) is a training program
developed in Scotland, that focuses on task management,
SAFETY CULTURE team working, situational awareness and decision
making. 127 A second training program, Team Strategies
Measurement of the baseline safety culture facilitates an and Tools to Enhance Performance and Patient Safety
action plan for improvement. Safety culture has been (TeamSTEPPS), developed in the US, is designed to
defined as ‘the product of individual and group values, develop competency in four areas: team leadership, situ-
attitudes, perceptions, competencies, and patterns of ational monitoring, mutual support (or back-up beha-
behaviour that determine the commitment to, and the viours) and communication. 128 Thus, training programs
style and proficiency of, an organisation’s health and can be used to help develop various non-technical skills,
121
safety management.’ It is commonly referred to as ‘the ultimately promoting a culture of safety within the criti-
122
way we do things around here.’ A widely used instru- cal care environment.
ment to measure safety culture, the Safety Attitudes Ques-
tionnaire (SAQ), focuses on six domains: teamwork RAPID RESPONSE SYSTEMS
climate, safety climate, job satisfaction, perceptions of
management, working conditions and stress recogni- Rapid Response Systems (RRS) are systems that have
tion. 123 Interestingly, two studies in the USA that used the developed to first recognise, and then to provide emer-
SAQ showed that nurses and doctors differed in their gency response to, patients who experience acute
129,130
perceptions of safety culture. 124,125 deterioration. The Australian Commission on Safety
and Quality in Health Care have identified eight essential
One strategy to improve the safety culture has involved elements in a RRS (Table 3.8). 129
identifying factors that make organisations safe, which in
turn allows initiatives to be developed that target areas of Recently, the recognition aspect of RRS has been referred
specific need. For example, five characteristics of organisa- to as the afferent limb, whereas the response aspect has
131
tions that have been able to achieve high reliability been called the efferent limb. The afferent limb involves
include: 126 the use of various track and trigger systems to identify
patients at risk of deterioration. The efferent limb is com-
1. safety viewed as a priority by leaders prised of teams of specialists who provide treatment and
2. flattened hierarchy that promotes speaking up care to the deteriorating patient. Each of these compo-
about concerns nents is briefly described.
3. regular team training
4. use of effective methods of communicating Afferent Limb
5. standardisation.
Recognising the deteriorating patient, the afferent limb
Many of these five factors fall under the category of has focused on measuring clinical signs including vital
‘non-technical’ skills. 127 Other non-technical skills include signs, level of consciousness and oxygenation as well as
situational awareness and decision making. Importantly acting on abnormalities in these measurements. 129,130 A

TABLE 3.8 Essential elements of a rapid response system 129
Domain Element Description
Clinical Measurement and Vital signs, oxygen saturation and level of consciousness should be undertaken
processes documentation regularly on all acute care patients
Escalation of care A protocol for the organisation’s response in dealing with abnormal physiological
measures and observations including appropriate modifications to nursing care,
increased monitoring, medical review and calling for assistance.
Rapid response systems When severe deterioration occurs, medical emergency teams, outreach teams or
liaison nurses are available to respond.
Clinical communication Structured communication protocols are used to hand over information about the
patient.
Organisational Organisational supports Executive and clinical leadership support and a formal policy framework for
prerequisites recognition and response systems should exist.
Education Education should cover clinical observation, identification of deterioration, escalation
protocols, communication strategies, and skills in initiating early interventions.
Evaluation, audit and Ongoing monitoring and evaluation are required to track changes in outcomes over
feedback time and to check that the RRS is operating as planned.
Technological systems As relevant technologies are developed, they should be incorporated into service
and solutions delivery, after considering evidence of their efficacy and cost as well as potential
unintended consequences.