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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.

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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:

1 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?


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 Missed opportunities to: prevent recognise escalate respond The Problem

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 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

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

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 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.)

20 Intervention on the Slippery Slope Patient Condition Time Clinical Review ALS Prevention Rapid Response The Solution

21 Clinical Review A, B, C, D approach Patient ID on all pages of clinical record

22 Standard Template Other Charts in Use Alter Criteria Vary Frequen cy Additional Criteria and Instructions

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

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 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

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

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 Thank you!


47 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

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