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

Australia?

Australia?

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 2008 1200 submissions 61 hospital visits 39 public hearings 628 witnesses 110 meetings

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

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

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.

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

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

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

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

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

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

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 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.

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

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

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

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!

Whatever it takes! Thank you!

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