A new service for patients in acute respiratory distress has improved survival rates
A critical care nurse who devised patient retrieval protocols, pathways, multidisciplinary training and family liaison for a highly specialist, high risk service has been shortlisted for a national award.
Jo-anne Fowles: passionate about education and training. Picture credit: Tim George
Jo-anne Fowles is a finalist in the Teva Innovations in Respiratory category of the Nursing Standard Nurse Awards for her achievements in improving patient care as ExtraCorporeal Membrane Oxygenation (ECMO) lead nurse at Papworth Hospital NHS Foundation Trust.
She will find out if she has won at a ceremony at the Savoy Hotel, London, on May 1, when the Nurse of the Year 2015 will be chosen from the category winners.
Jo-anne was part of the team that put together the successful Papworth Hospital tender to be one of five centres nationally that provide ECMO . It involves the drainage of venous blood, adding oxygen and removing carbon dioxide before returning it to the patient and is used to support patients with acute respiratory distress syndrome.
‘Setting up the service was a huge learning curve,’ says Jo-anne, who was previously a sister on critical care. ‘I had to look at service provision, the referral and retrieval of patients, the ambulance support service and the education of the multidisciplinary team.’
She is responsible for devising the robust referral pathways and ensuring safe repatriation of patients back to a hospital nearer their home when appropriate.
Clinically, she is the lead practitioner on the team, demonstrating a high level of expertise in ECMO practice which includes trouble shooting the circuit and managing patient care including when weaning off ECMO and post-ECMO support.
It is clear Jo-anne is passionate about education and training, which have been tailored for different parts of the team. The Papworth team retrieves patients from its allocated catchment area - Cambridgeshire, Norfolk, Suffolk, Hertfordshire, Bedfordshire, Essex and North East London. As a national centre, Papworth accepts patients from further afield if others are at capacity. The retrieval nurses and medics therefore have a training package specific to transporting patients supported with ECMO.
She has also set up the training programme for the entire multidisciplinary team at Papworth including practical sessions and assessments, training in the clinical area, study days and medical inductions.
‘I felt very strongly that nurses should be well represented in the new service and have enhanced roles in a previously medically led service,’ says Jo-anne.
She is especially proud to have developed the role of the ECMO nurse specialist at Papworth with a programme of study days, annually assessed reflective essays and clinical assessments. ‘It has improved patient care and cost effectiveness – and the course is very over subscribed,’ says Jo-anne.
‘Nurses at the bedside attend study days looking at different types of ECMO, as well as observations and surveillance so they can recognise any deterioration and now work quite independently. They follow the patient journey all the way through.’
As a result, patients’ care is less fragmented and when nurses are supporting relatives they have the knowledge and experience to answer their questions.
The ECMO unit has been a complex service to set up. Jo-anne had to raise awareness of the service - and who could and could not benefit from ECMO support- both within the trust and with others within Papworth's region.
Communication has been crucial. She set up a single contact number at Papworth and the trust’s ECMO website. Flyers and emails were sent to consultants at other trusts, followed up by personal visits, education and training.
There are protocols for keeping in touch with the referring unit while the patient is at Papworth and following their repatriation and letters are sent to the patient’s GP.
Another challenge has been staffing and rotas. One appropriately trained nurse and doctor are always on call and have to be available to go on retrieval while maintaining the necessary skill mix on critical care.
Setting up the retrieval service itself required a tender and contract process for an ambulance company to ensure the 24/7 availability of a ‘fast car’ to get to the referring hospital quickly and then a specially equipped ambulance to bring the patient and team back safely.
Once the patient is ready, they are repatriated to their hospital but Papworth supports the local team with telephone follow up. ‘After six months we invite all patients to our clinic where we do a quality of life assessment using a modified questionnaire from Canada on how they feel that day,’ says Jo-anne. ‘We also take ex-patients and their families to the ICU and show them an ECMO circuit. It is a very important part of the patient’s recovery – and amazing to see their response.’
The follow-up clinics help patients and their families come to terms with their experience. Patients report that they have helped fill in some memory gaps and improved psychological recovery.
Patient satisfaction questionnaires are very positive, as are relative experience questionnaires. Patient/carer information has been made available so relatives can be more informed about the treatment. The nurses that travel with the retrieval team are also trained in family liaison and give families a written leaflet.
Jo-anne feels very privileged to have her role and says she has enjoyed amazing support. ‘I am proud of what I have achieved for patients and nurses.’
But the team is constantly striving to improve. The monthly multidisciplinary meeting includes discussion of untoward incidents and the lessons that can be learnt from them. This approach ensures patient care is constantly improving.
They discuss all referrals, including the appropriateness of the decision to accept or not patients for ECMO and the outcome for those patients not accepted as well as all patients accepted.
‘We look at whole patient experience – from referral to follow up in clinic. We continually assess quality share patient stories and we use family satisfaction surveys to assess patient experience,’ adds Jo-anne. ‘We are always looking at what could have been done better – this is very much a work in progress.’
Chief nurse Josie Rudman says: ‘Before this service was developed patients had to travel miles for ECMO often overseas. This meant that at this critically ill phase they were often separated from their loved ones.'
‘With Jo-anne’s specialised role there has been a focus on improved patient outcome, and indeed many more people are now benefiting from the service, with improved survival rates.’