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Presentation on theme: "17 th Sept 2012 IDENTIFYING AND RESPONDING TO DETERIORATING PATIENTS."— Presentation transcript:


2 Harvest learning Create momentum Drive change THIS SESSION...



5 ItemSpeakerTime Welcome & introductions Dr Brian Robson Executive Clinical Director Healthcare Improvement Scotland 9am (10 mins ) The Australian Approach Dr Nicola Dunbar Program Manager Australian Commission on Safety and Quality in Health Care The national approach – policy and standards 9.10am (30 mins) Dr Tony Burrell Director Patient Safety NSW Clinical Excellence Commission Improving recognition in New South Wales The Scottish Approach Martin Carberry Consultant Nurse – Critical Care NHS Lanarkshire How is my Board improving early recognition, rescue and timely, appropriate treatment? 9.40am (15 mins) Ronnie Dornan Clinical Nurse Specialist, Critical Care Outreach NHS Borders 9.55am (15 mins) Ronnie Monaghan Head of E Health Programmes NHS Fife 10.10am (15 mins) The Amber Bundle Dr Elizabeth Ireland National Clinical Lead for Palliative and End of Life Care Scottish Government Supporting end of life decision making & communication – The Amber Bundle. 10.25am (15 mins ) Discussion on Scotland’s approach.All10.40 am Close Dr Brian Robson 10.55 am

6 RELIABLE RESCUE IN SCOTLAND Detection, Planning and Response Phase 2 SPSP: the next steps


8 HSMR TRAJECTORY Dec 2015 20% Reduction in HSMR Phase 2 SPSP - reliable rescue is in the wedge 10.6% Reduction in HSMR



11 A national approach to recognising and responding to clinical deterioration Healthcare Improvement Scotland, 17 September, 2012

12 Where have we come from?  METs spread widely and relatively quickly in Australia Source: Jones et al, Critical Care, 2008

13  Evidence base still developing: increasing focus on recognition of deterioration new questions being identified and answered not yet an agreed best practice approach  Failures still occurring  Lots of local initiatives  Programs at jurisdictional level (eg Between the Flags)  International priority

14 Australian Commission on Safety and Quality in Health Care  Established in 2006 to lead and coordinate safety and quality nationally  Public and private sectors, acute and primary care settings  Key functions: set national standards develop accreditation schemes data and indicator development monitor, report and publish knowledge and leadership for safety and quality  Do this through processes of consultation and collaboration

15 ACSQHC: Recognising and Responding to Clinical Deterioration program  Initial priorities: Consensus Statement regarding essential elements of care for patients whose condition is deteriorating Implementation guide for using the Consensus Statement Evidence-based observation chart to prompt action National Safety and Quality Standard National survey of recognition and response systems

16 National Consensus Statement  Endorsed by Health Ministers in 2010: 1. Measurement and documentation of observations 2. Escalation of care 3. Rapid response systems 4. Clinical communication 5. Organisational supports 6. Education 7. Evaluation, audit and feedback 8. Technological systems and solutions

17 National Safety and Quality Health Service Standards  Health Ministers requested the Commission review safety and quality accreditation standards in 2006  Central components: National Safety and Quality Health Service Standards national coordination of accreditation  Objectives: improve safety and quality for patients using the National Safety and Quality Health Services Standards as the focus for action implement coordinated and consistent accreditation via an Australian Health Services Safety and Quality Accreditation Scheme  Hospitals and day procedure services to be assessed against NSQHS Standards from January 2013

18 Standard 7 Blood and Blood Products Standard 10 Preventing Falls and Harm from Falls Standard 1 Governance for Safety and Quality in Health Service Organisations Standard 2 Partnering with Consumers Standard 4 Medication Safety Standard 3 Healthcare Associated Infections Standard 8 Preventing and Managing Pressure Injuries Standard 9 Recognising and Responding to Clinical Deterioration in Acute Health Care Standard 5 Patient Identification and Procedure Matching Standard 6 Clinical Handover National Safety and Quality Health Service Standards

19 Standard 9: Recognising and responding to clinical deterioration  Health service organisations establish and maintain systems for recognising and responding to clinical deterioration. Clinicians and other members of the workforce use the recognition and response systems.  Two overarching Standards: Standard 1: Governance for Safety and Quality Standard 2: Partnering with Consumers

20 Four criteria 1. Establishing recognition and response systems Organisation-wide systems consistent with the National Consensus Statement are used to support and promote recognition of, and response to, patients whose condition deteriorates in an acute health care facility 2. Recognising clinical deterioration and escalating care Patients whose condition is deteriorating are recognised and appropriate action is taken to escalate care 3. Responding to clinical deterioration Appropriate and timely care is provided to patients whose condition is deteriorating 4. Communicating with patients and carers Patients, families and carers are informed of recognition and response systems and can contribute to the processes of escalating care

21  Standards specify what needs to be achieved – how that occurs depends on context, eg: 9.4.1 Mechanisms are in place to escalate care and call for emergency assistance 9.6.2 A system is in place for ensuring access at all times to at least one clinician, either on-site or in close proximity, who can practise advanced life support  Nature of the recognition and response systems can vary depending on: size and location of the health service nature of health services provided (eg ICU vs no ICU) nature and skill mix of workforce (eg no on-site doctors)

22 Summary  Recognising patients whose condition is deteriorating and responding to their needs in an appropriate and timely way are essential components of safe and high quality care – recognised as a national priority  Purpose of the Standard is to improve outcomes for patients by ensuring that there is a systematic approach in place for recognising and responding to clinical deterioration  

23 SEPSIS KILLS: Partnering with clinicians to improve the recognition and management of sepsis Tony Burrell, Mary Fullick, Lisa Coombs, Ann Callaway

24 Why worry about sepsis? Increasing incidence Estimated 18 million cases per year worldwide > 17,000 cases per year in Australia NSW expected increase by 60% 2011-2036 1 High costs Sepsis ALOS 11.1 days vs 2.9 days in 2009/10 in NSW 1 Difficult to recognise Signs and symptoms of sepsis can be subtle especially in the elderly 40-50% of patients will not have a temperature 1 CEC Cost Effectiveness Analysis: Sepsis Kills – Dec 2011

25 Disease of the elderly

26 Type of physiological abnormality at time of ED patient inclusion in audit (first signs of sepsis) n=626 – median age 73 years Gray et al Emerg Med J 2012

27 In NSW... High number of sepsis adverse events related to delayed or inadequate recognition and management of sepsis CEC Sepsis Clinical Focus Report 2009 No sepsis clinical guidelines in 50% Emergency Departments (CEC, 2010)

28 QSA - Challenges in managing septic patients

29 SEPSIS KILLS program RECOGNISE: Improve the early identification of septic patients RESUSCITATE: Implement best practice with rapid antibiotics and IV fluids REFER: Improve communication and transitions of care Sepsis is a medical emergency!

30 ‘We recommend the protocolised resuscitation of a patient with sepsis- induced shock, defined as tissue hypoperfusion (hypotension persisting after initial fluid challenge or blood lactate concentration 4mmol/L). This protocol should be initiated as soon as hypoperfusion is recognised and should not be delayed pending ICU admission’ ‘We recommend that IV antimicrobial therapy be started as early as possible and within the first hour of recognition of septic shock (1B) and severe sepsis without septic shock (1C)’. –Surviving sepsis 2012 (in draft)

31 Phased implementation Phase 1 Emergency Departments Clinician focused bottom up approach Phase 2.1 Smaller hospitals and Emergency Departments Clinical Governance support, strong clinical leads Bottom up, top down approach Phase 2.2 Large facilities Executive, Clinical governance and clinician support Bottom up, top down approach


33 Variations in practice… Variations in empiric antibiotic prescription  guideline for first dose Variations in antibiotic availability particularly in smaller rural hospitals Variations in antibiotic administration - emphasis on infusion - gentamicin particular issue Fluids ־?too much caution ־Awaiting results of ARISE, PROMISE (UK), POCESS (US)

34 NSW time to initiation of antibiotics Jan 2011 –Sept 2012

35 NSW Sepsis Data 2011 (preliminary) Mortality No benefit Antibiotics ≤60 minutes = median 5 days >60 minutes = median 5 days no significant difference in median LOS <60 minutes (mean=5.72hrs) with admission to ICU >60 minutes (mean=6.86hrs) with admission to ICU no significant difference

36 NSW Sepsis Data 2011 – lactate Analysis to date… Confirms value of point of care lactate testing

37 NSW Sepsis Data 2011 Cryptic shock (Normotensive (SBP>90) and lactate >3 (N=86) V. lactate ≤3 (N=356)) 4.8 RR of death with lactate >3 (p<0.000) 2.4 RR of admission to ICU with lactate >3 (p<0.011) Hypotensive (SBP<90) N=94 Death 5.1 times more likely than patients with SBP>90 (25.5% - 24/94) (p=0.000) With triage 3-5, death 4.3 times more likely than patients with SBP>90 and triage 3-5 (p=0.018) No significant difference in death using variables SBP and time to antibiotics (p=0.254)

38 Lessons learnt from phase 1…. 69% > 60 years old Triage category matters 21.5% mortality rate for patients triage 3 Lactate is a valuable investigation Should observations be done routinely at triage? Delay to medical review Delay to antibiotics

39 Phase 2.2 Large facilities Pilot site – now working up project in 2 wards in large teaching hospital Wards complex – diffused responsibility Relationship with BTF, ‘In Safe Hands’ Difficult to coordinate Pharmacy Heads of department IC ID Surveillance

40 Cause and effect diagram – SEPSIS KILLS Delayed recognition and management of sepsis Lack of knowledge in relation to recognition of sepsis Knowledge JMO’s not aware to take a venous blood gas Lack of knowledge and uncertainty about appropriate antibiotic use Pathology Time to pathology results Timely communication of results Skill mix People Education Skill set Failure to take and record vital signs Lack of SEPSIS KILLS Links with DETECT training Failure to escalate deteriorating patients Policy Drug committee sign off IV cannulation Medications Communication Antibiotic availability Lack of understanding of blood results Reduced staffing after hours Delayed charting of IV antibiotics Delays to stat IV antibiotics administration IV antibiotic administration culture Lack of availability of blood culture bottles Measurements Data collection Delays in Rapid Response Lack of venous blood gases in inpatient environment Lack of knowledge in relation to the management of sepsis Antimicrobial stewardship Local pharmacy guidelines

41 Strong Executive Support Strong Clinical Champions/Leads Pharmacy Pathology Heads of Department Infectious Diseases Medical and Nursing staff Rapid Response teams Intensive care Clinical Governance

42 Questions?

43 “Deteriorating Patients” NHS Lanarkshire Martin Carberry Consultant Nurse Critical Care

44 Wishaw Hairmyres Monklands

45 Agenda Brief Overview some work in NHS Lanarkshire 1 Clinical Support Workers Course (CSW): CRASH (Csw Recognition Assessment Support & Help) 2 The use of clinical trigger questions to help identify sick ward based patients

46 CRASH set up Part of a tiered education programme Four hour course / ran monthly HECT (Hospital Emergency Care Team) faculty Short lectures / workshops / group work - Followed by clinical scenarios - look listen & feel approach HECT follow up CSWs to support competencies

47 Why CRASH ? Failure to recognise sick patients HECT Prospective MEWS audits - inaccurate - infrequent - over reliance on “machines” “Non touch ….. non feel” No support for CSW doing the “Obs” No structured Handover / feedback to RGN Bottom of the bed test ?

48 CRASH Evaluation CRASH - Evaluations (Data to follow) CSWs - value system for CSWs - culture change - Follow up and feel supported MEWS - repeat audits pre and post CRASH - improved ? - sustained? “ in it for the long haul ”


50 CSW Quotes Re : CRASH “ Why can’t there be more like this” “ Learned about sepsis ” “ Should be rolled out to all the wards” “ More about Sepsis” “ Importance of respiratory rate ” “ More aware of MEWS ” “ The effective use of SBAR ” “ Small details count make you look at the big picture “

51 HECT “Clinical Trigger Questions” HECT nurse will ask ward nurses at every ward trawl: 1. Increasing frequency : Observations / MEWS 2. O2 - high flow 3. Out of hours review (or any ITU) 4. Fast fluids / Blood / Drug Infusions HECT nurse will then decide if the patient requires assessment / intervention / referral

52 Why Trigger Questions? Examples of good work other Health boards Evidence base (e.g. NCEPOD) Failure to Flag up on routine trawls “Any patients you are worried about ? ” MEWS only ? - patients compensating - score of < 4 - but sick … or SIRS? Support ward staff - use of O2, IV drug infusions - opportunity for clinical teaching

53 Trigger Question Evaluation Study (2012 ) Aims To determine nursing staff awareness of T/Q To determine nursing staff usefulness & value of T/Q To determine HECT nurse frequency of using T/Q Methods Mail shot questionnaire Three acute hospitals 12 questions - based on content / construct validity

54 Trigger Question Response Rates RGN Population n=633 Monklands n=149 (38.3%) Experience > 6yr n=99 (66.4%) Hairmyres n=137 (35.2%) Experience > 6yr N=94 (68.6%) Wishaw n=103 (26.4%) Experience > 6yr n=77 (74.7%) Non responders/ Incomplete n=244 Responders n = 389 (61%)

55 Trigger Question (T/Q) study - some results Yes % (n) No % (n) Not Spec Can you recall all four T/Q81.2% (n=315) 15.5% (n=60) 2.6% (n=10) Did the T/Q change your perception of what makes a patient at risk of deterioration 56.8% (n=219) 42.0% (n=162) 1.0% (n=4) Do you think the T/Q improve the identification of sick patients 85.7% (n=330) 13.5% (n=52) 0.7% (n=3) Do you think the T/Q improve referral of sick patients to HECT 87.5% (n=337) 12% (n=46) 0.5% (n=2) Are T/Q useful in helping student nurses recognise sick patients 96.1% (n=370) 3.4% (n=13) 0.5% (n=2)

56 T/Q Study Staff Quotes “ Fantastic tool though clinical judgement comes with experience ” “ Feel the tool is most helpful to less experienced staff ” “ I would expect senior staff nurses and above to recognise a sick patient ” “ Factors out with trigger questions may influence review ” “ Do the student nurses know the trigger questions ” “ I find them a really useful prompt ” “ Its becoming a habit to think of them.. ”

57 T/Q Study Limitations One study one Health Board Hawthorne effect Hect influence - response rate - bias

58 Trigger Questions : referrals HECT and cardiac arrest rates S/A = Short Assessments performed by the HECT nurse: - Asked to see patients by ward staff - ITU follow up - Planned review (already on case load)

59 Pilot trigger questions



62 In Summary CRASH - hands on approach working well - CSW follow up is key to sustainability Trigger Questions - perceived improved identification & handover - perceived as important tool for less experienced staff - staff feel valued & supported - no change in arrest calls during this period - increased referrals & interventions to HECT

63 Thank you … Questions ? Acknowledgement Dr Sanjiv Chohan (Data analysis)

64 Borders General Hospital Population 112,870 Ronnie Dornan Clinical Nurse Specialist Critical Care Outreach Team


66 SBAR Cards S Situation Immediate Help Name Ward Reason for referral HR, RR,T, WCC, BP, SpO2, GCS, UO Resuscitation Status BBackground Admission Date & Time Reason for Admission Treatment AAssessment State what you think the problem is : Respiratory Genitourinary Cardiac Neurological Gastrointestinal Pain R Recommendation State what you want done Time frame, ABG, U&E, FBC, Lactate, CXR Critical Care Outreach Referral

67 Critical Care Outreach Nurses Hospital at Night Patients & Relatives DoctorsPhysiotherapists Acute Pain Service Critical Care Outreach Anaesthetists

68 Review all patients who trigger 2 boxes on SIRS/Shock chart Non judgemental, non punitive response to all referrals Hospital wide approach to early identification Follow up of all patients discharged from ITU (Discharge Summary) Proactive approach to the identification of the at risk patient Induction programme on the “at risk” early warning scoring system for nurses, doctors and students High Dependency Nursing Skills Course for nurses, midwives, AHP Medical and Nursing Student placements with Outreach Team Monthly case note review of all arrest calls Monthly random case note review (Scottish Patient Safety Programme)


70 Automated clinical alerts NHS Fife DECT Phones On ward observation capture and real time EWS At a glance ward & hospital(s) view Flexible reports Patientrack Current Scope 24 X 7 mobile chart

71 Opportunities  Assessments and Screenings  Information sharing “beyond the walls of the hospital”  Collaboration and Research

72 Assessments & Screenings  Part of national, regional and local safety and quality initiatives (NHS Scotland Collaborative on Sepsis and VTE, CQUIN, QIPP, Harmfreecare...)  Typically, implemented using paper forms and manual processes - tends to be time-consuming and resource-intensive, with the potential for late of missed assessments and errors  Sharing of data between assessments, and with teams, is problematic  Opportunity to create a database for monitoring, notifications, review, planning, research and improvement is lost

73 Assessments & Screenings Reports and extracts Patientrack & Assessments Database Timed Events & Workflow Engine Opportunity - Simple Add-On to the Existing Patientrack System Composite ward / hospital view of all assessments for patients; when scheduled and when due / missed Pick assessment required based on local rules Same on ward devices and log-ons as for Patientrack Embedded logic and “show hide”. Data gathering easy and quick at the bedside

74 Assessments & Screenings VTE Example Define the internal and external reports and extracts that may be required Use national and local VTE assessment policy to define the clinical workflow and data capture logic Configure the workflow, such as the rules for which patients are to receive assessments, and what events (e.g. on admission) or timings (e.g. 24 hours post admission) initiate the assessment Configure the on- form logic and flow, such as the mandatory fields and the “show hide” for sections of the assessment or individual values

75 Assessments & Screenings VTE Example Allows VTE Assessment to be made on admission and then at any point necessary on the patient journey, using hospitals own rules On Admission VTE Assessment Discharge Patients Details VTE Assessment Reports and Extracts e.g. Report on VTEs required or compliance with VTE protocol e.g. Extract to portal Optional or Trigger Event (e.g. 24 hours following admission) Clerking In GP Discharge Report Patientrack Database

76 Assessments & Screenings  A number of assessments are available “out of the box”  VTE, Sepsis, Fluid Balance, Peripheral & Central IV Line Management, Urinary Catheter Management, Blood Sugar & Urinary Ketones, Nutritional (MUST) Assessment, MRSA Screening, Stool Chart & C. Diff Screening  New assessments are planned or can be quickly developed  Falls, Pressure Ulcers, Dementia  Toolkit available for sites to develop their own assessments

77 Information Sharing Patientrack & Assesments Database Community Health Partnership Push and Pull Access Services GPs Information collected in hospital that is appropriate and useful to other organisations is made available; for example to GPs, Community Health Partnerships or other Health Boards Secure Access Augmented Discharge Summary On discharge VTE or Dementia Assessment

78 Collaboration and Research Maintained Database Environment Western Sussex Extract, Translate & Load (ETL) Services Academic Institutions Analytics Toolkit Extracts & Analyses Secure Access NHS Fife Central Manchester  Determine research interests alongside other sites  Develop joint proposals for funding  Share research Research Access

79 Implementing the AMBER care bundle in your hospital 29 th March 2012

80 80 Objectives how to implement and sustain the AMBER care bundle in your hospital build on your experience of implementing LCP / or equivalent be aware of the available materials and resources understand the AMBER network: support and expectations

81 81 Patients whose recovery is uncertain

82 82

83 83 And daily ACT: Day one: identification and initiation AMBER follow-up A “Is patient still A MBER?” C “Has medical plan C hanged?” T T ouch base with carers - Is everything OK?”

84 84 Impact What we found out: Medical decision making inconsistent Ineffective communication within team Patient/carer discussions did not include: –Preferences –Uncertainty What we’re doing differently: Generating multidisciplinary team discussion and understanding Consultant support for escalation framework where uncertainty exists Early pro-active patient/ carer discussions about uncertain recovery and preferences Systematic follow-up Reliability

85 85 76 year old man with pulmonary fibrosis and exacerbation of COPD. Deterioration, extreme shortness of breath, poor prognosis, had capacity. Patient aware of illness however was not aware of the severity. Relatives lived far away and had not been informed of admission. Patient identified as AMBER. Discussion with patient and team took place. Following patient consent relatives were contacted. Case study

86 86 Case study Comments from Patients/Staff/Relatives: “ AMBER helped us to address issues in a timely manner. It was so great to be able to get the patient home. “ I think AMBER has helped staff to escalate decisions and has highlighted the importance of communication at all levels. “ We had no idea that Bill was so unwell. At least now we can help him sort things out” “ I have not been well for a while. I didn’t know how to tell my family. I just really want to get home, I do not want to die in hospital. nurse relative patient consultant

87 87

88 AMBER 1st January ’10 – 29 th February ’12 Total AMBER patients Median no. of days on AMBER 757 7.0 Still in ward Died in hospital on AMBER Died in hospital on LCP Discharged to community 6 125 201 415 0.7% 16.5% 26.6% 54.8% Recovered Other 7 3 0.9% 0.4% Hospital survival rate >2 weeks 26% >1 month 10% >2 months 3%

89 89

90 90 Hospital survival rates: Jan 2010-Jun 2011

91 91 Hospital and community survival rates: Jan 2010-Jan 2011

92 92 Outcomes Emergency readmissions (30d): 14% vs 35%* >70% die in their preferred place of care *2010 figures GSTT

93 In-patient deaths: monthly Statistically significant shift p < 0.0005 Median=83 Median=91

94 Interface: the AMBER care bundle, LCP and in-patient mortality

95 Hospital wide implementation Adrian Hopper

96 96 Hospital ready for change  Senior leaders demonstrate support  Need for AMBER is recognised  Fits into hospital initiatives  LCP established / palliative care influential  Practical support / project support in place

97 97 1. Hospital wide engagement 2. Hospital wide preparation 3. Ward / team implementation 4. Making it stick: ward sustainability 5. Making it stick: hospital sustainability Tools Guidance Resources Experience Website AMBER Network Guidance

98 98 Engagement 1.Who 2.Where –Heat map –Enthusiasm –Local priority –Specialty (oncology, older person, acute med) 3. How - Patient stories / sentinel events

99 99 Interfaces LCP Critical care outreach Hospital at night Others: COPD outreach, Older Person’s liaison Productive ward

100 100 Board Another group to influence - Their duty to improve EOLC - Patient stories - Data Connect to the strategic agenda Business case

101 101 Cardiac arrests GSTT (excluding CCU and ICU)

102 102 Contacts



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