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Introduction to Standard 9: Recognising and Responding to Clinical Deterioration in Acute Health Care Nicola Dunbar Program Director April 2013.

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Presentation on theme: "Introduction to Standard 9: Recognising and Responding to Clinical Deterioration in Acute Health Care Nicola Dunbar Program Director April 2013."— Presentation transcript:

1 Introduction to Standard 9: Recognising and Responding to Clinical Deterioration in Acute Health Care Nicola Dunbar Program Director April 2013

2 The Standard Standard: Intent: Context:
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. Intent: To ensure that a patient’s deterioration is recognised promptly and appropriate action is taken Context: To be applied in conjunction with Standard 1: Governance for Safety and Quality and Standard 2: Partnering with Consumers Does not apply to deterioration in a patient’s mental state

3 Rationale for the Standard
Evidence base: deterioration is not always recognised or acted on there are early warning signs early intervention can improve outcomes for patients there are well-established strategies that can be implemented Processes of recognising and responding to clinical deterioration are relevant across the hospital – therefore need a systems approach to address

4 Criteria to achieve the Standard
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 Recognising clinical deterioration and escalating care Patients whose condition is deteriorating are recognised and appropriate action is taken to escalate care Responding to clinical deterioration Appropriate and timely care is provided to patients whose condition is deteriorating 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

5 Definitions Recognition and response systems:
Formal systems to support staff to promptly and reliably recognise patients who are deteriorating and to respond appropriately to stabilise the patient Track and trigger system: Tracks changes in physiological parameters over time, includes thresholds for each parameter that indicates abnormality, and describes the response or action when deterioration occurs Escalation protocol: Protocol that sets out the organisational response required for different levels of physiological abnormality or other deterioration Rapid response system: System for providing emergency assistance to patients whose condition is deteriorating (such as medical emergency team)

6 Developmental and not applicable actions
Action 9.3.1: use of a general observation chart that has specified characteristics Item 9.7: informing patients, families and carers Item 9.8: advance care plans and treatment-limiting orders Item 9.9: patient and family escalation Not applicable: Standard 9 not applicable for specialist, non-acute, mothercraft hospitals or services (meets requirements under Action 1.8.3) Items may not be applicable for day procedure services

7 Context National Consensus Statement endorsed by Health Ministers in 2010: sets out essential elements for recognising and responding to clinical deterioration: measurement and documentation of observations escalation of care rapid response systems clinical communication organisational supports education evaluation, audit and feedback technological systems and solutions relates to situations where a patient’s physical condition is deteriorating applies to all patients in an acute healthcare facility

8 Context Flexible standardisation:
Standardisation of processes is an important way of improving safety and quality Needs to reflect context of the health service Contextual issues that will affect the systems that are put in place to meet Standard 9 include: type and size of health service – small or large hospital, day procedure nature of services provided – ICU, no ICU nature and skill mix of workforce – are doctors on site 24/7? existing policies and programs – eg. Between the Flags, Compass, RMDP etc Don’t need to have separate processes and systems for each action in the Standard – consider how activities fit together to coordinate evidence and outcomes

9 Structure of Standard 9 9.3, 9.4 Recognising clinical deterioration and escalating care 9.5, 9.6 Responding to clinical deterioration Communicating with patients and carers 9.1, 9.2 Organisation-wide systems for recognising and responding to clinical deterioration Put the system in place Audit / review performance of or compliance with the system Make improvements based on the results of the audit

10 Organisation-wide systems for recognising and responding to clinical deterioration
Recognition and response systems are relevant across the whole hospital: overarching governance and policy framework should exist at an organisation-wide level there may also be local (department / ward) policies in place about local recognition and response processes examples of where responsibility can sit: senior executive clinical leaders (both medical and nursing) clinical governance and/or quality committees emergency response / resuscitation committees Need a systematic approach: embedded into clinical governance arrangements tailored to local circumstances covering all essential elements in Consensus Statement

11 Observation charts Action 9.3.1 relates to general observation charts:
does not include charts for specific clinical areas – such as neurovascular, cardiothoracic etc for specialist hospitals – these may require specialist paediatric and obstetric charts What chart to use: for jurisdictions that have a state-wide chart, use of this chart is acceptable: NSW, Qld, ACT, WA (SA coming soon...) the Commission has developed four charts that can be customised for local use – these are acceptable also have a chart that has been developed for and trialed in day procedure hospitals for other charts – sites need to demonstrate how they have tested the chart to ensure its safety Fact sheets available on the Commission’s web site

12 Escalation protocols Escalation policies and protocols that contain information about what to do if deterioration occurs reduce the risk of delays in providing appropriate care Escalation protocol needs to: be tailored to the facility – size, location, skill mix, resources included a graded response – different types of responses depending on the level of abnormality include an option for emergency assistance include an option for clinicians to escalate care based only their concern for the patient be regularly reviewed

13 Escalation protocols Developing triggers and responses for an escalation protocol: How many levels of abnormality? What physiological observation thresholds trigger abnormality? What actions/treatments are required? Who can provide this treatment? Responsibilities of responding clinicians? How will the system operate? Planning tool on the Commission’s web site

14 Rapid response systems
Need a system to provide appropriate emergency assistance in a timely way when severe deterioration occurs Rapid response systems have been shown to reduce cardiac arrests, unplanned ICU admissions, and deaths Models for rapid response systems: medical emergency teams / rapid response teams ICU liaison / critical care outreach nursing and medical staff trained in advanced life support – ED, anaesthetics etc advanced practice nursing roles local GPs or VMOs local ambulance

15 Clinical workforce that can respond
Everyone needs to know how to call for emergency assistance All clinicians should be able to implement basic life support while waiting for emergency assistance: includes nurses, allied health providers, doctors Non-technical skills also important – leadership, team work, communication, task management A system needs to be in place to ensure access at all times to at least one clinician who can practice advanced life support Need to maintain competency – Commission does not specify how this should occur

16 Communicating with patients and carers
Why is this important? patients, families and carers are part of the healthcare team and can help ensure best understanding of clinical circumstances patients, families and carers generally want to know when deterioration is occurring Communication with families and carers about: the importance of communicating concerns and signs/symptoms of deterioration how they can raise their concerns local systems for responding to deterioration Opportunities for communication: on presentation in acute care at regularly scheduled intervals during admission during healthcare team rounds during bedside handover

17 Advance care plans and treatment-limiting orders
Advance care preferences and treatment-limiting decisions need to be considered when deterioration occurs Most states and territories have legislation and policy regarding advanced care directives that will need to be reflected in local policies and processes Standard covers both advanced care plans and other treatment-limiting orders - e.g. NFR, DNR etc

18 Family and patient escalation of care
Patients experience delays in treatment despite reporting concerns about deterioration Families and carers are well placed to identify signs of deterioration New models of family escalation now being introduced: what are the triggers for families to escalate care how will the response be activated what will the response be how to inform about the new system

19 Family and patient escalation of care
More than existing processes for calling for assistance – such as the call bell Is a formal process that acts in a similar way to escalation protocols triggered by health professionals Patient, family member or carer can escalate care directly to request review / emergency assistance Should be built into existing recognition and response system

20 Data collection processes
Collection of feedback from clinical workforce (9.2.1): surveys, focus groups to get information from a number of people peer review processes such as morbidity and mortality meetings to get feedback on individual events Review of cardiac arrests and deaths without a treatment-limiting order (9.2.2): routine reviews of in-hospital cardiac arrests reviews of unexpected deaths to identify failures of escalation and systems issues identification of patients with and without a treatment-limiting order Completion of observation charts (9.3.2): audits of observation charts against local policy and monitoring plan

21 Data collection processes
Use of escalation processes, including failures to call and calls for emergency assistance (9.4.2, 9.5.2): audit of observation charts to identify triggers for escalation and actions taken number and circumstances of rapid response calls outcomes measures such as cardiac arrests, unplanned admissions to ICU, deaths Performance of family escalation processes (9.9.3): surveys, interviews, focus groups to get information about knowledge and views of patients, families and carers, and workforce records of family escalation calls clinical record regarding circumstances of calls Quality measures and audit tools are on the Commission’s web site

22 Resources Safety and Quality Improvement Guide for Standard 9
National Consensus Statement – and supporting implementation guides Observation charts Fact sheets, planning and audit tools Jurisdictional programs

23 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 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 Outcomes to be achieved are clear – methods to get there will vary depending on context

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