Presentation on theme: "Recognition and Management of the Deteriorating Patient:"— Presentation transcript:
1 Recognition and Management of the Deteriorating Patient: Recognition and Management of the Deteriorating Patient: -lessons from the beachCliff Hughes AO D Sc, MB,MS, FRACS, FACS, FACC, FAAQHC, FISQUA, Ad Dip Mgt
5 Banality of Error in Practice Vanessa Anderson: NSW Coronial Report January 2008:Golf ball incident – died within 24 hours due to incorrect opiate medicationContributing 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 ProblemUnrecognised 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 GarlingThe Great Schism of 1054
8 Special Commission of Inquiry Acute Care Services in NSW Public Hospitals 2008 1200 submissions61 hospital visits39 public hearings628 witnesses110 meetings
9 The Problem Missed opportunities to: prevent recognise escalate respondFour (4) main reasons why patients fall through the cracks.BTF addresses the last three.
12 Why ‘Between the Flags’? Only one person has drowned between the flags on a patrolled beach since 1935Keeping patients between the flags, and initiating a rapid rescue resonates strongly with cliniciansThe flags are the clearly defined thresholds for observations
13 AimTo 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 safetyThis is an international problem.Implementing a standard approach to the problem across a state is a world first.
14 Diagnostic phaseUnderstand underlying issues – representative sample of facilitiesObservation studies of nurse practice“Productive ward” concepts of ‘5 S’s’Focus groups - process mapping, “ideal ward”Brainstorming techniques - clinical observationsObservation chart audits against criteria agreed with ward staffReview of literature, IIMS and RCA’sRepresentative sample of facilities chosen through EOI:1 small rural – 40 beds2 rural base hospitals1 metropolitan hospital1 tertiary referral centreObservation studies – time and motion of nurse activity, results fed back to staff5S = Sort, Set Shine, Standardise, SustainBrainstorming 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 ShowsThis is a significant problem in NSW and internationallyThere are ‘hallmark’ clinical signs that indicate a patient is getting sicker, frequently not recognisedFailure to escalate carePoor communication is a key factorPoor documentation is a key factor
18 Themes from analysis of qualitative data JMOIneffective paging systemsLack of Calling CriteriaLack of clarity in roles and responsibilitiesInconsistent ward layout despite uniform architectureLack of ward organisationLack of documentationLack of handover practices
19 Themes from analysis of qualitative data (cont.) NursingNeed for more direct patient care timeLack of reliable (working and available) equipmentNeed for ‘a place for everything, and everything in it’s place’Lack of adequate staff for patient load and acuityTime consuming patient movements - ‘churn’Lack of clear calling criteriaConstant interruptions (telephone calls, on medication rounds)Strong reliance on automated observationequipment
20 Intervention on the Slippery Slope The SolutionPatientConditionTimeClinicalReviewALSPreventionRapidResponseThe 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 approachPatient ID on all pages of clinical recordHere 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 ReviewRapid Response
22 Additional Criteria and Instructions Standard TemplateOther Charts in UseAdditional Criteria and InstructionsVary FrequencyAlter Criteria
23 Stakeholder engagement and consultation is vital CliniciansCoal faceConsult within clinical contextSeek specialist adviceEmergencyMaternityPaediatricsAHSExecutive SponsorsProgramme ManagersEqual representationDoHStatewide ServicesCSQGPSNFamily and Community PartnershipsNaMOChild Health NetworksNSW Ambulance
24 Standard Calling Criteria and Charts Simple to use- single triggerMost sensitive indicator of deterioration firstGraphed vs. written observationsClinical usefulness and relevanceConsolidation of observations for a ‘global’ view.Ordered A-G to support patient assessmentNational standards‘Photocopiable’ (including patient details)
25 Human factors principles Reduce cognitive load and improve functionalityTop left hand corner is processed firstFont size and typeNo overlap of parametersColour choice (emphasis)Colour choice (colour blindness)Consistency in formattingClear and descriptive labelsLow light legibility
26 EDUCATION Tier One – Awareness Training- intern e-orientation Tier Two – DETECT TrainingTier Three – Responder Training
27 Detecting Deterioration, Evaluation, Treatment, Escalation, and Communication in Teams ManualE-learning modulesClinical skills workshopMultidisciplinaryFocus 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 involvementDeal with ‘age old’ issuesReinforce CERSEvaluation CollaborativeMoving upstreamReinforcing 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 worriedDoctors being called when it is not appropriateBreakdown in communication within the teamRostering and skill mixetc.
29 The 5 elements of ‘Between the Flags’ GovernanceCalling Criteria -incorporated into Standard Adult General Observation Chart (SAGO)Clinical Emergency Response Systems (CERS)EducationEvaluation
30 Clinical Emergency Response System Customised response to local service needsAll facilities must have a CERSIncludes networks for advice / referral and retrievalMay include formal assistance / liaison with Ambulance ServiceMinimum skill levelsRapid Response Officer one per shift, 24/7Minimum competenciesMinimum standard of equipment
31 Evaluation Minimum standards for data collection and reporting Key program performance indicatorsDevelopment of state database to collect Rapid Response Team and KPI data
32 Standard Calling Criteria The 5 elementsClinical Review/Rapid ResponseGovernanceObservation Charts(CERS)Clinical Emergency Response SystemsStandard Calling CriteriaFrontline CliniciansRapid Response TeamCERS CommitteesFrontline CliniciansClinical LeadsThere are five elements to the Between the Flags programmeObservation 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 deteriorationClinical 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 identifiedAll clinical staff- Awareness trainingWard staff/ attend clinical review (yellow Zone)- DETECTRapid responders (red zone)- ALS / rapid response trainingEvaluation: 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 Agreements1.11 Rapid response calls per 1000 admissions1.12 Cardiac arrests per 1000 admissionsGovernance: is the key aspect for ensuring success of the programme and will be expanded in the next slide.Awareness, DETECT, Rapid Responders2 KPIs & Evaluation CollaborativeEducationEvaluationWorkforce ManagersEducatorsClinical LeadsClinical Governance UnitsBTF ManagersCERS Committees
33 Governance Chief Executives with backing from Director General Executive Sponsors (DCG’s)Clinical LeadsLearning and Development / Workforce ManagersProject ManagersEducatorsPeak Quality CommitteesFacility CERS committeesThe governance element of the programme is absolutely crucial.The implementation groups that have been most successful are those that have ensuredRepresentation from all the stakeholder groups (nursing, medical, ICU, wards, mental health, midwifery etc)Regular meetingsIdentified leaders at facility/network and area levelProject co-ordination
34 BTF approach Broad clinician engagement and consultation Keep it simpleStandardisation across NSW- one chart for NSWA ‘sick’ person is sick wherever they areAllow facilities to customise their CERS to local needs and resourcesPromote teamworkPromote and support clinical judgement
35 YELLOW ZONE: Clinical Review NovelAims to avoid the “Slippery Slope”Clinical Review within 30 minutesResponsibility of the home teamRequires consultation with Nurse in Charge (allows discretion)
36 RED ZONE: Rapid Response Rapid Response immediatelyBased on pre-existing systems (eg MET)Individual or team with ALS skillsNo discretion about calling
39 Lessons Learned Executive and Clinical Leadership A good plan Branding and marketingPartnership with Department of Health and Local Health DistrictsGovernance structuresAwareness 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 worriedDoctors being called when it is not appropriateBreakdown in communication within the teamEngagement ( WIIFM?)!
41 ConclusionsBetween the Flags has captured the imagination of the staff of NSWBTF is part of the languageStaff believe it is making a differenceEncouraging signs are there that it is indeed reducing cardiac arrestsBTF must now become part of the culture
42 ConclusionsWe need:The vision to see what must be done and what is possibleA plan to make it happenA coalition of the willingThe power of storiesThe courage of leadersWE HAVE ALL THESE!
47 Acknowledgements Professor Clifford Hughes Professor Ken Hillman Professor Deborah PiconeDr Peter KennedyA/Prof Theresa JacquesMs Deb HylandDr Annette PantleProfessor Malcolm FisherDr Paul CurtisMs Kimberley FitzpatrickDr Marino FestaMs Kathleen RyanMs Colette DuffProfessor Les WhiteMs Michelle WensleyMr David PatersonMs Leanne CrittendenMs Mel O’BrienMs Amanda YatesDr Gabriel ShannonMs Jo LeaverDr Danny Stiel...and many more