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
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.
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
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
Physiological Parameter Docmented (%)
0%
April
May
June
Weight
O2 - How? How
much?
Completed
Observations outside
normal range
July
O2 Saturations
Bowels
Pain Score
Temperature
Respiratory Rate
Blood Pressure
Pulse Rate
Observations
graphed, not written
Frequency of
Observations
Date and Time
Patient Label
Reliability of Observation
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
Parameter
Completed
Observations outside normal range
Weight
O2 - How? How much?
O2 Saturations
Bowels
Pain Score
Temperature
Respiratory Rate
Blood Pressure
Pulse Rate
Observations graphed, not written
Frequency of Observations
Date and Time
Patient Label
% Completed
Completion of Observations
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
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
The Solution
Prevention
Clinical
Review
Rapid
Response
Patient
Condition
Intervention on the
Slippery Slope
Time
ALS
A, B, C, D
approach
Rapid
Respons
e
Patient
ID on all
pages of
clinical
record
Clinical
Review
Other
Charts
in Use
Vary
Frequen
cy
Alter
Criteria
Standard
Template
Additional
Criteria and
Instructions
Stakeholder engagement and
consultation is vital
Clinicians
AHS
DoH
• Coal face
• Consult within
clinical context
• Seek specialist
advice
• Emergency
• Maternity
• Paediatrics
• Executive
Sponsors
• Programme
Managers
• Equal
representation
• 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
Moving
further
upstream
(prevention)
Increased
patient and
family
involvement
Evaluation
Collaborative
Management
of Clinical
Deterioration
Reinforce
CERS
Deal with
‘age old’
issues
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
The 5 elements
Governance
Observation
Charts
Frontline Clinicians
Clinical Leads
Awareness,
DETECT, Rapid
Responders
Workforce Managers
Educators
Clinical Leads
Standard
Calling
Criteria
Clinical
Review/Rapid
Response
(CERS)
Clinical
Emergency
Response
Systems
EducationEvaluation
Frontline Clinicians
Rapid Response
Team
CERS Committees
2 KPIs &
Evaluation
Collaborative
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
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
Our BTF clinical lead (champion) has been critical to the uptake and acceptance of the program by clinicians in our dept/unit
Strongly Agree
100%
5
33
Agree
Neutral
Disagree
Strongly Disagree
9
16
7
90%
80%
22
141
3
61
70%
60%
72
50%
40%
122
4
202
30%
51
20%
10%
111
80
2
11
0%
A+B
C,D,F
JH
NSW
ASNSW
Strong executive support is an important part of the success of BTF in our dept/unit
Strongly Agree
100%
4
10
90%
86
Agree
Neutral
Disagree
Strongly Disagree
2
7
3
11
26
80%
4
44
3
89
70%
167
60%
253
50%
40%
30%
20%
214
127
3
41
10%
0%
A+B
C,D,F
JH
NSW
ASNSW
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!
4. With regard to the statewide Between the Flags (BTF) program:
(dept / unit level)
Strongly Agree
Agree
Neutral
0%
Disagree
10%
Strong executive support is an important part of the success of BTF
in our dept/unit
Our BTF clinical lead (champion) has been critical to the uptake and
acceptance of the program by clinicians in our dept/unit
The training was adequate
40%
50%
13%
40%
24%
80%
90% 100%
15%
49%
45%
14%
21%
50%
17%
31%
47%
3% 1%
8%
22%
27%
21%
70%
29%
47%
11%
60%
47%
21%
The red zone on the BTF chart has assisted rapid response to
patients at risk of deteriorating
Overall the BTF has benefitted patient safety in our dept/unit
30%
35%
The yellow zone on the BTF chart has assisted earlier detection and
management of patients at risk of deteriorating
The BTF toolkit was comprehensive and useful for implementation
of the program in our dept/unit
20%
Strongly Disagree
3%
5% 1%
4% 1%
11%
25%
2%
2%
5% 2%
Whatever it takes!
Whatever it takes!
•Thank
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