Staff Rescue Doctor Using Allergic Reaction Kit He Helped Design

Thank you to the team at Hamilton Health Sciences for sharing your safety story with our Subscriber community. Through sharing experiences and successes, our Subscriber community can scale learnings across the Reciprocal. If your organization has a story, reach out to us at [email protected].

Earlier this year, Dr. Ian Jones was working as a resident in Hamilton Health Sciences’ (HHS) Hamilton General Hospital’s intensive care unit. In the staff break room, he snacked on a piece of chocolate that, unbeknownst to him, contained peanuts. He started to have difficulty breathing and signaled for help. He knew he was experiencing serious allergic reaction.

Staff in the area immediately hurried to the Omnicell, a secure tower where drugs are stored on each unit, to get the anaphylaxis kit and administer a dose of Epinephrine, the recommended first-line treatment for life-threatening allergic reactions.

A Full-circle Moment

Amazingly, five years earlier when Jones was working as a medical student in HHS’ McMaster Children’s Hospital’s pediatric intensive care unit (PICU), he helped lead a Quality Improvement project to develop this very kit that would later save his life.

He joined the PICU while they were exploring how to improve timely treatment with Epinephrine for patients experiencing acute anaphylaxis. Anaphylaxis is a severe and potentially life-threatening condition when the throat closes during an allergic reaction and can cause a person to stop breathing. When severe anaphylaxis is happening, treatment with Epinephrine is required immediately.

The project was part of HHS’ Continuous Quality Improvement (CQI) initiative, which empowers front-line staff to find solutions to everyday issues – a bottom-up approach to problem-solving. Since launching almost 10 years ago, CQI has expanded across HHS and has launched more than 6500 improvements.

“Ian helped us develop, design, test, and implement a pediatric anaphylaxis kit,” says Filomena Canci Tavares, clinical manager of the PICU. “The goal was to create a kit that had all the necessary supplies as well as clear messaging on how to administer the correct dose. Since Ian has a peanut allergy, he was keen to help develop something that could help others who suffered from severe allergies. Never did he imagine one day he would urgently need Epinephrine from the same kit he helped to create as a quality improvement project.”

Motivated By a Code Blue

After a code blue event at MCH – which happens when a patient requires critical resuscitation support because they stop breathing or their heart stops beating – staff identified a CQI opportunity to improve how allergic reaction medication was administered during anaphylaxis. Having one kit with all the necessary supplies for anaphylaxis would help clinicians administer the correct Epinephrine dose as quickly and safely as possible to help immediately reverse the severe and potentially life-threatening throat swelling and trouble breathing that can happen during a severe anaphylactic reaction.

There was an existing pediatric anaphylaxis kit being used at MCH but it needed improvement. The kit contained three types of drugs, but did not the contain the necessary supplies to administer the medications, such as syringes and needles. This could cause critical delays in administration as staff would need to locate the right supplies. Epinephrine is a powerful medication that has different routes of administration and dosing ranges depending on the indication needed. Other improvements the team targeted is kit labelling to help ensure the correct dose, concentration, and route for anaphylaxis was delivered to a person in need, quickly.

“The goal was to ensure timely administration of the correct dose, via the correct route, at the right time,” says Tavares.

Continuous Quality Improvement Process Makes Changes for the Better

The CQI process involved assessing the problem (current state) and the desired outcome (target state), consulting with more than 20 stakeholders from different areas across the hospital, and undergoing simulation testing.

Part of Jones’s role was to have nurses test the draft kits using different instruction labels and different supplies to see which options resulted in the quickest and most accurate dose. The team wanted to understand which labels were most clear, to ensure the contents of the kit were easy to use, and to time how long the process took.

The result was an improved kit with only one first-line medication, Epinephrine, along with the right supplies to give the drug, and a label with a clear visual representation of the appropriate dose and administration instructions.

Simulation testing of the new kit versus the old kit with nurses demonstrated quicker administration times when the new kit with all necessary supplies was used and that no errors in dosing or route were observed.

The kit has supplies and medication to support very small to adult-sized patients. Given its low cost, ease of use, and the ability to be used on all size patients, the kit was rolled out across all of HHS in multiple sites in 2020.

Professional Becomes Personal

While Jones never expected to have to use it, he’s grateful it was improved and easy to use.

“We spent a lot of time making sure the kit was optimized so it could be used quickly and easily when emotions were running high. When they ended up using it on me, it was very fast and efficient. It was cool to see what we put a lot of energy into came out successful in the end,” he says.

“From a clinical perspective, anaphylaxis is life-threatening, very fast developing and can be very significant. From a personal standpoint, I also have a severe peanut allergy so the project was near and dear to me.”
 

This story is one great example of the importance of quality improvement initiatives, so we wanted to learn more about HHS’s Continuous Quality Improvement (CQI) program. We asked HHS a few more questions about it, and Diane Miller, Hamilton Health Sciences Senior Improvement Advisor, answered them below.

HIROC loves to hear about our Subscribers’ safety initiatives as we are committed to sharing knowledge to help create the safest healthcare system. How does HHS’s CQI program improve safety across the organization, and why are programs like this important?

The CQI management system improves safety across the organization by providing staff with a standardized way to identify their safety concerns on a daily basis. Staff identify safety opportunities on a visual huddle board to be prioritized and worked by the team. The team huddle creates a safe space to share issues with principles of respect built into the system from leader coaching to group problem solving.

The organization’s corporate strategy includes several safety indicators (as aligned with HHS’s Quality Improvement Plan), such as sepsis rate, pressure injuries, and hand hygiene, that are also worked through CQI huddle boards at a unit level so that teams can work towards improving those safety metrics with local improvements. The CQI management system embeds key leadership principles and behaviours aimed at influencing an ideal improvement culture at all levels of the organization.

The standardized huddle across the organization allows staff to know that anywhere they go in the organization they have an opportunity to identify and work safety opportunities. Staff, patients, and families can visually see what teams are doing to improve safety. These programs are important to help empower improvement work across the organization to be driven by those closest to the work.

What’s your approach to communicating the CQI program to staff in a way that motivates and gets them to bring other ideas forward for improvement projects?

Constancy of purpose. It has been almost 10 years since HHS started CQI, and it has now been implemented in over 150 areas across the organization. It is clear we take quality and safety work seriously with our commitment to empowering staff to work improvement opportunities in all areas of the hospital. 

There are key principles built and taught as part of the CQI system. One key principle is respect, and it’s emphasized in the huddle in several ways, such as those closest to the work knowing it best and by asking questions to understand problems and processes. Within this context staff generally feel comfortable to identify safety issues and be part of the teams to solve problems. Staff can visually track the movement of their identified issues on the huddle board (it’s about transparency and issues not piling up on a manager’s desk) and even though it often takes time and is hard work to solve problems, they can eventually see improvements in opportunities that are both important to them and to patients. 

We have consistent and focused communication for those teams implementing or sustaining and maturing their use of the CQI management system. The communication focuses on a clear vision for the management system, demonstrating how leaders and teams can align their work and accomplish their work through the management system, and providing the tools within the system needed to enable the work. Communication strategies are enhanced by comprehensive, ongoing educational offerings for both staff and leaders and a team of coaches whose role is to guide teams in their use of the management system and best practices for the system. The way tools are designed for the management system ensures multiple ways that communication within and between teams is supported, enhanced through visual management, and consistently structured to embody the key principles and behaviours that underlie the system.

The CQI program has had great success, so with knowledge-sharing in mind, what is your advice for other healthcare organizations starting their own quality improvement programs?

One very important element for organizations starting on their own quality improvement journey is having the commitment of senior leaders. Senior leaders that support the systems that allow teams to identify and solve problems moved us closer to a culture of continuous improvement. Beyond foundational executive sponsorship, this has meant that senior leaders demonstrate and live the key behaviours and tools within their own daily work, setting the pace and expectations within their portfolios. 

The introduction of CQI was part of a long-term corporate strategy signaling to staff the importance of quality and safety within the organization. The intertwining of principles with tools is a fundamental part of our CQI system’s success.

Other key points:

• The CQI management system brings together principles and tools that focus on setting up our people and our processes for success in providing quality care to patients.
• The huddle highlighted above is just one of the tools within the CQI system. Other tools include Status Sheet, Leadership Teams and Scorecards, and Gemba Walks.

If your organization has a story, reach out to us at [email protected]. Together we can turn the corner on patient safety.