Care – Monitoring

Patient/Client monitoring is largely dependent on intermittent observations and measurements of variables, such as blood pressure, heart rate and temperature, by the healthcare team. Early identification and detection of patients at high risk or in the early stages of deterioration can trigger the appropriate notification to members of the healthcare team, in hospital or community settings, and/or rapid response team and affect changes to the plan of care. This document contains information entered by HIROC Subscriber healthcare organizations (acute and non-acute) in the Risk Register application to help you in your assessment of this risk.

Key Controls/Mitigation Strategies

• Policy and Processes
  • Physical Head to Toe assessments on regular basis, documentation of same 
  • Triage screener to screen patients in line up for initial triage, and reassessment protocol to monitor higher acuity patients 
  • Clinical escalation policy and algorithm 
  • Increased monitoring and available supports in patient waiting areas 
  • Process and checklist for patient transfers to higher acuity sites to identify medical needs and criteria for support.
  • Virtual assessments, monitoring, and processes to manage deterioration of patient condition 
  • Established criteria for utilization of Rapid Response Team or Rapid Response Nurse circulating through organization
  • Early Warning System capacity in newly installed vital signs equipment at the bedside
  • Performance Management Framework 
  • Alignment of organization’s Quality Improvement Plan (QIP) with community Service Provider Organizations (SPO) QIP
  • Include Risk Management Strategies within Procedures (client assessment, home/environment assessment, chart reviews, client concerns, event reports, health/safety reports)
  • Requirements in Service Provider Organizations (SPO) contracts for specializations and skills across service types
  • Care Coordinator process and monitoring (including linking patients with family physicians) 
  • Development of a community-based post operative surveillance program with paramedics 
  • Patient Safety event reporting, tracking and debriefing 
• Tools 
  • Visual cues for identified patients at risk (e.g. falls armbands, red socks etc.)
  • Additional team attendants on days within medical imaging to provide dedicated portering support
  • Crash carts stocked and accessible to waiting areas 
  • Closed-circuit television (CCTV) cameras in Emergency Room (ER) and Triage area 
  • Implementation of call bells in stretcher bays
  • Use of Falls Screening tool
  • Sepsis protocol and implementation of automated triggers
  • Acute Respiratory Illness Surveillance policy 
  • Assess receiving facilities ability to accommodate patient’s medical needs
• Pediatric/Neonate Hyperbilirubinemia specific
  • Implementation of the Neonatal Jaundice Quality Based Procedure (QBP) Handbook
  • Implementation of standardized policies, processes, and algorithms to support the Clinical Guidelines for Screening and Management of Hyperbilirubinemia in Term and Late Pre-Term Infants
  • Comprehensive ambulatory post discharge services available 7 days a week for Neonate Hyperbilirubinemia follow up and breast feeding
  • Comprehensive Newborn Discharge Summary provided for all families at discharge, detailing follow-up appointments 
  • Annual completion of relevant HIROC Risk assessment checklists and self-assessment of HIROC Risk Reference Sheets 
• Communication
  • Notification to appropriate healthcare provider when changes noted in patient’s physical status
  • Communicate patient medical needs and criteria for support with physicians during transfer preparation 
  • Safety huddles and team debriefing
  • Communicating shared monitoring expectations within the healthcare team 
  • Enhanced communication between Medical Imaging and Patient Care Units
  • White board communication process in high-risk areas (e.g. computerized tomography - CT)
• Education/Training
  • Education of nurses regarding the right nurse, looking after the right patient, in the right environment, to foster appropriate patient assignment
  • Registered Nurse (RN) and Medical Radiology Technician (MRT) training on monitoring
  • Increase staff awareness of Rapid Response Team or other organizational specific response team or resources for care in the community and how to access them
  • Share review summaries or recommendations to staff to facilitate learning
  • Simulation lab and mock codes 
  • Clinical education skills day and mentoring opportunities

Monitoring/Indicators

• Trend data already available, utilize to monitor, improve and target
• Sepsis protocol triggers (number of times the flag is raised; use of the secondary screen in Electronic Medical Record (EMR); number of outreach calls)
• Review of all Code Blue cases for potential failure to recognize deterioration and other learning opportunities
• Percent of staff who completed fetal monitoring certification
• Patient safety incident reporting
  • Number of incidents related to monitoring/patient deterioration
  • Number of hospital readmission and emergency room visits for post operative patients followed by home discharge program 
  • Number of near misses, adverse events, and critical incidents with unrecognized patient deterioration themes
  • Tracking of Emergency Department (ED) patients who left without being seen 
  • Number of complaints related to inadequate assessment and clinical surveillance
  • Code Pink exercises completed per quarter Monitor ICU admissions from inpatient units
• Audit of:
  • Emergency records to ensure Canadian Emergency Department Triage and Acuity Scale (CTAS) is appropriate and complete 
  • Track time of arrival to “seen by physician” 
  • Patients who have a falls risk assessment completed on every shift
  • Progress notes for appropriate documentation of physical assessments
  • Door to drug time for patients with sepsis in the Emergency Department (ER)
  • Process to ensure security/identification bands are numbered and placed in the system with babies names
  • Adherence to fetal status interpretation, response to abnormal fetal health status and adherence to oxytocin protocols 
  • Quarterly audits on adherence to Obstetrical (OBS) chain of command protocols for calling physicians