1. Recognition and Management of the Deteriorating Patient:
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

2. Australia?

3. Australia?

4. New South Wales

5. 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”

6. The Problem
Unrecognised deterioration is a significant problem for patients in all health systems despite ‘hallmark’ clinical signs of deterioration.

7. Respect –Top down or bottom up?
The management/clinician divide.
Justice Peter Garling
The Great Schism of 1054

8. Special Commission of Inquiry Acute Care Services in NSW Public Hospitals 2008
1200 submissions
61 hospital visits
39 public hearings
628 witnesses
110 meetings

9. The Problem Missed opportunities to: prevent recognise escalate
respond
Four (4) main reasons why patients fall through the cracks.
BTF addresses the last three.

10. I was not on duty!

11. Between the Flags

12. 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

13. Aim
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.
Failure to recognise and respond to clinical deterioration is the biggest risk to patient safety
This is an international problem.
Implementing a standard approach to the problem across a state is a world first.

14. 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
Representative sample of facilities chosen through EOI:
1 small rural – 40 beds
2 rural base hospitals
1 metropolitan hospital
1 tertiary referral centre
Observation studies – time and motion of nurse activity, results fed back to staff
5S = Sort, Set Shine, Standardise, Sustain
Brainstorming techniques used to define what clinical staff felt were key observations that need to be done on each patient, audited against those criteria and fed results back to staff – generally 0% compliance

15. 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

16. Reliability of Observation

17. Completion of Observations

18. 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

19. Themes from analysis of qualitative data (cont.)
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

20. Intervention on the Slippery Slope
The Solution
Patient
Condition
Time
Clinical
Review
ALS
Prevention
Rapid
Response
The slippery slope illustrates that the trajectory of clinical deterioration often starts as a slow decline.
Traditional approaches focussed on resuscitation (Advanced Life Support- ALS) of patients who have already experienced cardiac arrest.
The MET approach moved up the slippery slope somewhat and has been successful in preventing cardiac arrests. However MET is based on ‘late’ signs of clinical deterioration, and patients are often extremely unwell by the time they meet the escalation call criteria.
The implementation of the Clinical Review as part of Between the Flags, assists clinicians to identify early warning signs of deterioration and provides an opportunity to intervene before the patient becomes extremely unwell.
Intervention on the Slippery Slope

21. Patient ID on all pages of clinical record
A, B, C, D approach
Patient ID on all pages of clinical record
Here is the SAGO, demonstrate some of the features.
The patient ID section is included on all pages that are written on a part of the clinical record.
This is because of the reality that charts will be photocopied particularly where patients are transferred, the reality is that most clinical units will have access to A4 photocopiers/scanner only.
Clinical Review
Rapid Response

22. Additional Criteria and Instructions
Standard Template
Other Charts in Use
Additional Criteria and Instructions
Vary Frequency
Alter Criteria

23. 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

24. 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)

25. 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

26. EDUCATION Tier One – Awareness Training- intern e-orientation
Tier Two – DETECT Training
Tier Three – Responder Training

27. 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

28. 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
Moving upstream
Reinforcing the Red Zone (Rapid Response team)
Introducing a Yellow Zone (Clinical Review by the ‘home team’)
What about families?
What about prevention?
An opportunity to deal with 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
Rostering and skill mix
etc.

29. 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

30. 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

31. Evaluation Minimum standards for data collection and reporting
Key program performance indicators
Development of state database to collect Rapid Response Team and KPI data

32. Standard Calling Criteria
The 5 elements
Clinical Review/Rapid Response
Governance
Observation Charts
(CERS)
Clinical Emergency Response Systems
Standard Calling Criteria
Frontline Clinicians
Rapid Response Team
CERS Committees
Frontline Clinicians
Clinical Leads
There are five elements to the Between the Flags programme
Observation charts for adult, paediatric and maternity patients have been developed. These charts have colour coded zones representing the early and late warning signs for clinical deterioration
Clinical Emergency Response System (CERS)- includes the clinical review and rapid response. All facilities in NSW have a clearly defined CERS policy. Rural facilities may have a CERS Assist arrangement with NSW Ambulance.
Education: three target groups for education have been identified
All clinical staff- Awareness training
Ward staff/ attend clinical review (yellow Zone)- DETECT
Rapid responders (red zone)- ALS / rapid response training
Evaluation: a formal evaluation will be conducted, all LHN’s will participate in the evaluation collaborative. 2 KPI’s have been formalised as part of the Chief Executive Agreements
1.11 Rapid response calls per 1000 admissions
1.12 Cardiac arrests per 1000 admissions
Governance: is the key aspect for ensuring success of the programme and will be expanded in the next slide.
Awareness, DETECT, Rapid Responders
2 KPIs & Evaluation Collaborative
Education
Evaluation
Workforce Managers
Educators
Clinical Leads
Clinical Governance Units
BTF Managers
CERS Committees

33. 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
The governance element of the programme is absolutely crucial.
The implementation groups that have been most successful are those that have ensured
Representation from all the stakeholder groups (nursing, medical, ICU, wards, mental health, midwifery etc)
Regular meetings
Identified leaders at facility/network and area level
Project co-ordination

34. 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

35. 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)

36. RED ZONE: Rapid Response
Rapid Response immediately
Based on pre-existing systems (eg MET)
Individual or team with ALS skills
No discretion about calling

39. 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

40. 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?)!

41. 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

42. 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!

44. Whatever it takes!

45. Whatever it takes!
Thank you!

47. Acknowledgements Professor Clifford Hughes Professor Ken Hillman
Professor Deborah Picone
Dr Peter Kennedy
A/Prof Theresa Jacques
Ms Deb Hyland
Dr Annette Pantle
Professor Malcolm Fisher
Dr Paul Curtis
Ms Kimberley Fitzpatrick
Dr Marino Festa
Ms Kathleen Ryan
Ms Colette Duff
Professor Les White
Ms Michelle Wensley
Mr David Paterson
Ms Leanne Crittenden
Ms Mel O’Brien
Ms Amanda Yates
Dr Gabriel Shannon
Ms Jo Leaver
Dr Danny Stiel
...and many more