Implementing a Deteriorating
Patient Program: a personal
perspective
Dr Paul Curtis
Director Clinical Governance
24 Apr 13
NSW: a large state
NSW
Scotland
• Area = 809,000 km2
• Area = 79,000 km2
• Population = 7.25 m
• Population = 5.25 m
• Pop density = 9.1/km2
• Pop density = 67.5/km2
•
Population of Sydney,
Newcastle and Wollongong =
5.4m (74%)
• 200 hospitals
• 130 hospitals
• Health budget = $17.3 b
• NHS budget = $11.3 b
17 Local Health Districts
Clinical Excellence
Commission
Mission
To build confidence in healthcare in NSW, by making
it demonstrably better and safer for patients and a
more rewarding workplace.
Vision
To be the publicly respected voice providing the
people of NSW with assurance of improvement in
the safety and quality of healthcare.
CEC programs include
•
•
•
•
•
•
•
•
Partnering with patients
BTF
HAI
• Hand hygiene
• AMS & QUAIC
• CLAB
Sepsis
Special Committees
• CHASM, SCIDUA
Clinical Leadership
Blood watch
Patient Identification Policy
•
•
•
•
•
•
Falls prevention
Medication Safety
Children’s emergency care
QSA
Chartbook
‘Patient safety’
• IIMS
• RCA Review
• Supervision
•
•
•
National Accreditation
NSW Safety Checklist
Pressure Injury
www.cec.health.nsw.gov.au
Between the Flags Program
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.
Recurring theme locally & from
around the world:
• Failure to recognise and respond to clinical
deterioration: number one clinical risk to patients
(NSW Patient Safety Programme)
• Clinical signs of deterioration are the same
everywhere
• Urgent action was needed
• The solution needed to meet the needs of patients
and clinicians
• One size CERS would not fit all
The Solution
Prevention
Clinical
Review
Rapid
Response
Patient
Condition
Intervention on the
Slippery Slope
ALS
Time
CEC approach
• Broad clinician engagement and
consultation
• Keep it simple
• Standardisation across NSW
• A ‘sick’ person is sick wherever they are
• Allow facilities to customise their CERS
• Promote teamwork
• Promote and support clinical judgement
Interlude 1: Not plain sailing
• Delay in developing program – mid 2009
• Director General mandate:
•
31/10/09
•
“Core business”
• Clinician engagement
•
“Ownership”
• Department-CEC partnership
5 elements
Governance
Standard Calling Criteria
Clinical Emergency Response System
Education
Evaluation
Element 1: Governance
State wide policy and mandated
implementation but local ownership with
executive sponsorship and a facility based
committee for oversight, education, rollout
and ongoing auditing
Element 2: Standard Calling
Criteria and Charts
• Simple to use - single trigger for escalation of care
• Most sensitive indicator of deterioration first
• Graphed vs. written observations (“track and trigger”)
Observation Charts
5 Paediatric Charts
Maternity
Emergency Dept
eMR
Standard Calling Criteria and Charts
• Simple to use - single trigger for escalation of care
• Most sensitive indicator of deterioration first
• Graphed vs. written observations (“track and trigger”)
• Clinical usefulness and relevance
• Consolidation of observations for a ‘global’ view.
• Ordered ABCDEFG to support patient assessment
• ‘Photocopiable’ (including patient details)
Element 3: Escalation: Clinical
Emergency Response System
•
Unique – 2 thresholds:
•
Yellow – sick patient – clinical review by
home team. Some local discretion
•
Red – very sick – Rapid Response
Teams. No discretion
•
Built into chart
•
Formalise staff concerns as a legitimate
triggering mechanism
The Solution
Prevention
Clinical
Review
Rapid
Response
Patient
Condition
Intervention on the
Slippery Slope
ALS
Time
Element 4: Education
•65,000 clinical staff
•Tier One – Awareness Training
•Tier Two – DETECT Training
•eLearning
•Face to face
•Tier Three – Responder Training
Patient/carer activation
• Piloting in some organisatons
•
R – recognise
•
E – engage
•
A – Act
•
C – call
•
H – help in on the way
• About 1 call per month
Element 5: Evaluation - QSA
Overall the BTF has benefitted patient safety in our dept/unit
Strongly Agree
100%
10
26
Agree
Neutral
Disagree
6
13
Strongly Disagree
16
39
90%
67
80%
180
113
70%
60%
185
50%
387
202
40%
30%
20%
10%
95
100
195
0%
Metro
Rural / Regional
State
QSA: benefitted pt safety
Strongly agree
Agree
90%
80%
70%
38%
60%
50%
48%
47%
40%
30%
44%
20%
10%
21%
25%
0%
Overall the BTF has benefitted patient safety
in our department/unit (Adults)
Overall the BTF program has benefitted
patient safety in our department / unit
(Paeds)
Overall the BTF program has benefitted
patient safety in our department / clinical unit
(all)
2010
2011
2012
14% reduction in RCAs
Rapid Response
Cardiorespiratory Arrest
Linear (Rapid Response)
Linear (Cardiorespiratory Arrest)
01-Sep-2012
01-Aug-2012
01-Jul-2012
01-Jun-2012
01-May-2012
01-Apr-2012
01-Mar-2012
01-Feb-2012
01-Jan-2012
01-Dec-2011
01-Nov-2011
01-Oct-2011
01-Sep-2011
01-Aug-2011
01-Jul-2011
01-Jun-2011
01-May-2011
01-Apr-2011
01-Mar-2011
01-Feb-2011
01-Jan-2011
01-Dec-2010
01-Nov-2010
01-Oct-2010
01-Sep-2010
01-Aug-2010
Rapid Response Call Rate v Cardio-respiratory Call rate
(per 1000 acute separations)
30
1.4
25
1.2
1
20
0.8
15
0.6
10
0.4
5
0.2
0
0
On line survey by UNSW
Questions
Response
% of staff that agreed/strongly agreed that Yellow Zone assisted in earlier
detection & management of patients at risk of deterioration
87%
% of staff that agree/strongly agree that the extra tier (Clinical Review) has
improved patient safety overall
% of staff that use ISBAR as the communication tool for handover
82%
% of staff that agree/strongly agree that the Clinical Review component of
the CERS has contributed to meeting the aim of the BTF program
77%
% of staff that have completed DETECT training
87%
% of staff that agreed/strongly agreed that DETECT training improved their
knowledge & skills in recognising and responding to the deteriorating
patient
73%
85%
ADULT SEPSIS PATHWAY
Does your patient have risk factors, signs or symptoms of infection?
Immunocompromised
Skin: cellulitis, wound
Indwelling medical device
Urine: dysuria, frequency, odour
Recent surgery/invasive procedure
Abdomen: pain, peritonism
History of fever or rigors
Chest: cough, shortness of breath
Red Flags in ambulance handover
Neuro: decreased mental alertness,
neck stiffness, headache
AND
Does your patient have 2 or more yellow criteria?
R ECOGNISE
Respirations ≤ 10 or ≥ 25 per minute
Sp02 < 95%
Re-assess
Systolic blood pressure ≤ 100 mmHg Pulse ≤ 50 OR ≥ 120 per minute
Altered LOC or change in cognitive status
NO
Treat and re-assess
simultaneously:
Sepsis may still
be a concern
Temp ≤ 35.5 or ≥ 38.5OC
YES
Perform venous blood gas if available
Respond and Escalate
Does your patient have any red criteria?
SBP ≤ 90mmHg Lactate ≥ 4 mmol/L
Age > 65 years
Immunocompromised
Base Excess < - 5.0
NO
YES
This patient may have SEPSIS:
This patient has SEVERE SEPSIS
or SEPTIC SHOCK until proven
otherwise:
•
Inform the doctor-in-charge
•
Monitor vital signs & fluid balance
•
Obtain blood cultures x 2 sets
• Investigate source of infection: e.g.
urinalysis, urine M/C/S, chest x-ray
•
Obtain IV access and start IV fluids
•
Administer empiric antibiotics within
one hour unless another diagnosis is
more likely Refer to Therapeutic Guidelines:
Antibiotic, version 14
http://proxy9.use.hcn.com.au/
•
Refer / communicate with admitting team
•
Inform the doctor-in-charge
•
Expedite transfer to a resuscitation
area or equivalent
•
Turn over page for Resuscitation
Guideline
CONSIDER ELIGIBILITY for ARISE
ADULT SEPSIS PATHWAY: Resuscitation Guideline
Does the patient have an Advance Care Directive? Are there treatment limitations?
R E-ASSESS
R E S U S C I TA T E
• Patient assessment and treatment proceeds simultaneously
• Maintain SpO2 ≥ 95% • Monitor respiratory rate, SpO2, heart rate and rhythm, blood pressure, temp, fluid balance
• Obtain intravenous access
Take two sets of blood cultures, FBC including lactate OR venous blood gas for lactate,
EUC, LFT, coagulation & glucose (glucometer or formal)
• Fluid resuscitate
i.
ii.
iii.
Give 20mL/kg of 0.9% sodium chloride STAT fluid challenge
If no response, repeat 20mL/kg once (unless there are signs of pulmonary oedema)
If no response, insert IDC and commence vasopressors (as per
local protocol)
to achieve a MAP of ≥ 65mmHg in consultation with Doctor-in-Charge
Start IV antibiotics within 60 minutes
** Do not wait for results of investigations **
• Investigate source of infection e.g. urine M/C/S, chest x-ray, sputum, wound
• Refer /communicate with admitting team and ICU
IS YOUR PATIENT RESPONDING TO RESUSCITATION?
Signs of improvement
If improving take the following action:
MAP ≥ 65mmHg
• Continue monitoring vital signs closely
Urine Output > 0.5mL/kg/hr
• Strict monitoring of fluid balance
SpO2 ≥ 95%
Decreasing serum lactate level
• Investigate and treat the source of
infection
Improving LOC
R EFER
IS YOUR PATIENT
RESPONDING
TO RESUSCITATION?
IF NO IMPROVEMENT
INTENSIVE
CARE MANAGEMENT
IS REQUIRED
1. Reassess suitability to continue resuscitation
2. Request review by ICU doctor to occur within 30 minutes
3. If you do not have an ICU at your facility, seek advice immediately from the
ADULT MEDICAL RETRIEVAL SERVICE 1800 650 004 or
the local Critical Care Advisory Service
Minimum requirements for patient monitoring:
• Continuous blood pressure, continuous urine output via IDC
• Repeat serum lactate every 4 hours
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?)!
Interlude 2
• Patient observations still issue
• Patients with clinical deterioration still are
not recognised/ responded to
• Changing calling criteria
• IP issues
• Sustainability
• End of life issues
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 is indeed a negative
correlation between Rapid Response Rate and
Cardiac Arrest Rate
• BTF is unmasking the age old barriers to responding
to end of life issues - the next challenge
We gratefully acknowledge
Remember “Always swim between the red and yellow flags”