10 seconds to safety

Linda and Art - resized

What difference can 10 seconds make?

For 40 per cent of residents on Unit 2-6 at Wascana Rehabilitation Centre, 10 seconds may be the difference between life and serious injury or death.

These residents – 14 in all – receive mechanical ventilation, either full or part-time. Each of them is connected by a breathing tube to a ventilator which moves air into and out of their lungs. If their tube isn’t properly connected to the ventilator, they either can’t breathe, or their breathing is compromised.

Ten seconds is the length of time each staff member now takes – every time a continuing care assistant, a nurse, the resident care coordinator or a registered respiratory therapist has contact with a resident – to ensure that the resident’s ventilator is operating properly.

“Everyone’s got 10 seconds. The onus is on everyone to keep residents safe.”
(Ann Ritson, member of respiratory therapy team that supports Unit 2-6)

The 10-second ventilator check was implemented in September.  At that time, staff was able to correctly complete seven per cent of the required steps. When audited again in November, staff completed 100 per cent of the steps correctly.

The ventilator check was the result of a Ministry of Health/3S mistake proofing project hosted by Regina Qu’Appelle Health Region. A team of four participants from the Ministry of Health and 3SHealth worked with Unit 2-6 staff and managers over several months to understand the root causes of the oxygen defects they were experiencing and trial new ideas for improvement.

The overall goal of mistake proofing work is to achieve zero harm to residents and staff. Defects, reported in the system as “occurrences”, were defined as either the oxygen or humidity (which keeps the air moist) being turned off or the ventilator tubing being disconnected from the machine.  From January to June, the unit documented 34 occurrences of oxygen delivery defects. No critical incidents have been recorded.

“The vent check is a hands-on touch of the connections,” said Carla Wekerle, unit manager, who noted that residents can have multiple connects and disconnects throughout the day as they move from their bed and bedside ventilator to their wheelchair and a portable ventilator and back to their bed again. “Sometimes a tube can be connected but loose. By touching, staff can ensure all connections are sound.”

To help staff adapt, the team created posters about the new process to encourage discussion and a pocket checklist for newer staff to follow. Registered respiratory therapists do an education blitz one week each month.

“We’re seeing a difference. Seasoned staff are teaching new staff and staff are picking up errors before they become a crisis.”
(Carla Wekerle, unit manager)

Occurrences numbered 16 between July and November.

The most important change taking place, said Wekerle, is the culture shift. Staff now discuss occurrences at their daily huddle. “People now feel safe to talk.”

Linda Trail, a continuing care aide, said “Things have changed. If there were incidents before, we didn’t hear about them.” Checks were the responsibility of registered nurses, who conducted them three times every 24 hours.

Wekerle, who became unit manager in June, said as a result of the mistake proofing project, she now tracks occurrences and their causes.

The need for rigour around vent checks has become increasingly important as Unit 2-6’s population changes, said Ritson. “We’re seeing more acutely ill people. Four years ago, it was rare for a resident to be on oxygen. Now it’s rare not to be.”

Photo Caption: Linda Trail, a continuing care aide on Unit 2-6, checks resident Art Desnomie’s ventilator connections. Photo credit: Medical Media Services

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