Presentation on theme: "Recognition and Management of the Deteriorating Patient: -lessons from the beach Cliff Hughes AO D Sc, MB,MS, FRACS, FACS, FACC, FAAQHC, FISQUA, Ad Dip."— Presentation transcript:
Recognition and Management of the Deteriorating Patient: -lessons from the beach Cliff Hughes AO D Sc, MB,MS, FRACS, FACS, FACC, FAAQHC, FISQUA, Ad Dip Mgt
New South Wales
Banality of Error in Practice Vanessa Anderson: NSW Coronial Report January 2008: Golf ball incident – died within 24 hours due to incorrect opiate medication Contributing factors: - poor communication between doctors - staffing inadequacies - poor clinical decisions - incorrect decisions by nursing staff “Systemic problems existing for a number of years”
The Problem Unrecognised deterioration is a significant problem for patients in all health systems despite ‘hallmark’ clinical signs of deterioration.
Respect –Top down or bottom up? The management/clinician divide. Justice Peter Garling The Great Schism of 1054
Special Commission of Inquiry Acute Care Services in NSW Public Hospitals submissions 61 hospital visits 39 public hearings 628 witnesses 110 meetings
Missed opportunities to: prevent recognise escalate respond The Problem
I was not on duty!
Between the Flags
Why ‘Between the Flags’? Only one person has drowned between the flags on a patrolled beach since 1935 Keeping patients between the flags, and initiating a rapid rescue resonates strongly with clinicians The flags are the clearly defined thresholds for observations
To improve early recognition and response to clinical deterioration and thereby reduce potentially preventable deaths and serious adverse events in patients who receive their care in NSW public hospitals. Aim
Diagnostic phase Understand underlying issues – representative sample of facilities Observation studies of nurse practice “Productive ward” concepts of ‘5 S’s’ Focus groups - process mapping, “ideal ward” Brainstorming techniques - clinical observations Observation chart audits against criteria agreed with ward staff Review of literature, IIMS and RCA’s
Research Shows This is a significant problem in NSW and internationally There are ‘hallmark’ clinical signs that indicate a patient is getting sicker, frequently not recognised Failure to escalate care Poor communication is a key factor Poor documentation is a key factor
Reliability of Observation
Completion of Observations
Themes from analysis of qualitative data JMO –Ineffective paging systems –Lack of Calling Criteria –Lack of clarity in roles and responsibilities –Inconsistent ward layout despite uniform architecture –Lack of ward organisation –Lack of documentation –Lack of handover practices
Nursing –Need for more direct patient care time –Lack of reliable (working and available) equipment –Need for ‘a place for everything, and everything in it’s place’ –Lack of adequate staff for patient load and acuity –Time consuming patient movements - ‘churn’ –Lack of clear calling criteria –Constant interruptions (telephone calls, on medication rounds) –Strong reliance on automated observation equipment Themes from analysis of qualitative data (cont.)
Intervention on the Slippery Slope Patient Condition Time Clinical Review ALS Prevention Rapid Response The Solution
Clinical Review A, B, C, D approach Patient ID on all pages of clinical record
Standard Template Other Charts in Use Alter Criteria Vary Frequen cy Additional Criteria and Instructions
Stakeholder engagement and consultation is vital Clinicians Coal face Consult within clinical context Seek specialist advice Emergency Maternity Paediatrics AHS Executive Sponsors Programme Managers Equal representation DoH Statewide Services CSQG PSN Family and Community Partnerships NaMO Child Health Networks NSW Ambulance
Standard Calling Criteria and Charts Simple to use- single trigger Most sensitive indicator of deterioration first Graphed vs. written observations Clinical usefulness and relevance Consolidation of observations for a ‘global’ view. Ordered A-G to support patient assessment National standards ‘Photocopiable’ (including patient details)
Human factors principles Reduce cognitive load and improve functionality –Top left hand corner is processed first –Font size and type –No overlap of parameters –Colour choice (emphasis) –Colour choice (colour blindness) –Consistency in formatting –Clear and descriptive labels –Low light legibility
EDUCATION Tier One – Awareness Training- intern e-orientation Tier Two – DETECT Training Tier Three – Responder Training
Detecting Deterioration, Evaluation, Treatment, Escalation, and Communication in Teams Manual E-learning modules Clinical skills workshop Multidisciplinary Focus on improving the ability of clinicians to recognise and respond to clinical deterioration at the ward level
The future for BTF Management of Clinical Deterioration Moving further upstream (prevention) Increased patient and family involvement Deal with ‘age old’ issues Reinforce CERS Evaluation Collaborative
The 5 elements of ‘Between the Flags’ Governance Calling Criteria -incorporated into Standard Adult General Observation Chart (SAGO) Clinical Emergency Response Systems (CERS) Education Evaluation
Clinical Emergency Response System Customised response to local service needs All facilities must have a CERS Includes networks for advice / referral and retrieval May include formal assistance / liaison with Ambulance Service Minimum skill levels Rapid Response Officer one per shift, 24/7 Minimum competencies Minimum standard of equipment
Evaluation Minimum standards for data collection and reporting Key program performance indicators Development of state database to collect Rapid Response Team and KPI data
Governance Standard Calling Criteria (CERS) Clinical Emergency Response Systems EducationEvaluation The 5 elements Frontline Clinicians Clinical Leads Frontline Clinicians Rapid Response Team CERS Committees Workforce Managers Educators Clinical Leads Clinical Governance Units BTF Managers CERS Committees Observation Charts Clinical Review/Rapid Response Awareness, DETECT, Rapid Responders 2 KPIs & Evaluation Collaborative
Governance Chief Executives with backing from Director General Executive Sponsors (DCG’s) Clinical Leads Learning and Development / Workforce Managers Project Managers Educators Peak Quality Committees Facility CERS committees
BTF approach Broad clinician engagement and consultation Keep it simple Standardisation across NSW- one chart for NSW A ‘sick’ person is sick wherever they are Allow facilities to customise their CERS to local needs and resources Promote teamwork Promote and support clinical judgement
YELLOW ZONE: Clinical Review Novel Aims to avoid the “Slippery Slope” Clinical Review within 30 minutes Responsibility of the home team Requires consultation with Nurse in Charge (allows discretion)
RED ZONE: Rapid Response Rapid Response immediately Based on pre-existing systems (eg MET) Individual or team with ALS skills No discretion about calling
Lessons Learned Executive and Clinical Leadership A good plan Branding and marketing Partnership with Department of Health and Local Health Districts Governance structures Awareness and Education
Lessons Learned (cont.) An opportunity to deal with all the age old issues: Nurses unable to get a response when they are worried Doctors being called when it is not appropriate Breakdown in communication within the team Engagement ( WIIFM?)!
Conclusions Between the Flags has captured the imagination of the staff of NSW BTF is part of the language Staff believe it is making a difference Encouraging signs are there that it is indeed reducing cardiac arrests BTF must now become part of the culture
Conclusions We need: The vision to see what must be done and what is possible A plan to make it happen A coalition of the willing The power of stories The courage of leaders WE HAVE ALL THESE!
Whatever it takes!
Acknowledgements Professor Clifford HughesProfessor Ken HillmanProfessor Deborah Picone Dr Peter KennedyA/Prof Theresa JacquesMs Deb Hyland Dr Annette PantleProfessor Malcolm FisherDr Paul Curtis Ms Kimberley FitzpatrickDr Marino FestaMs Kathleen Ryan Ms Colette DuffProfessor Les WhiteMs Michelle Wensley Mr David PatersonMs Leanne CrittendenMs Mel O’Brien Ms Amanda YatesDr Gabriel Shannon Ms Jo LeaverDr Danny Stiel...and many more