improving the effectiveness of news, improving care … · improving the effectiveness of news,...

Improving the Effectiveness of NEWS,

Improving Care for Deteriorating Patients

John Welch, Consultant Nurse, Critical Care & Critical Care Outreach

Declaration of interest

http://www.nightingale-h2020.eu/

Subbe CP, Welch JR. Clin Risk. 2013. 19(1):6-11.

Record - Recognise - Report - Respond

The deteriorating patient journey

Potential problems

• Lack of knowledge of all inherent risk factors, frailty, etc

• Deciding, agreeing, documenting most appropriate care

• Incomplete vital signs, insufficiently frequent vital signs

• Inadequate understanding of abnormal vital signs

• Failure to effectively escalate abnormal vital signs

• Delayed response to escalation

• Delayed treatment

• Too much treatment – or too little

• Delayed re-checking that treatment has worked

Potential problems

• Lack of knowledge of all inherent risk factors, frailty, etc

• Deciding, agreeing, documenting most appropriate care

• Incomplete vital signs, insufficiently frequent vital signs

• Inadequate understanding of abnormal vital signs

• Failure to effectively escalate abnormal vital signs

• Delayed response to escalation

• Delayed treatment

• Too much treatment – or too little

• Delayed re-checking that treatment has worked

Subbe CP, Welch JR. Clin Risk. 2013. 19(1):6-11.

Record - Recognise - Report -

Respond

The deteriorating patient journey

Record & Recognise: The National Early Warning Score

NEWS scores & risk of arrest, ICU, death

Smith GB, et al. Resuscitation. 2013. 84(4):465-70.

In four years, ¾ of hospitals are using NEWS …

(36% are using some type of electronic system)

Record & Recognise: The National Early Warning Score

New news about NEWS vs Medical Emergency Team criteria

• Single centre study, 103,998 admissions • NEWS has higher specificity and generates less of a workload

Smith GB, et al. Crit Care Med. 2016. 44(12):2171-2181.

New news about NEWS and sepsis risk prediction

• Single centre study, 30,677 patients; 7,385 (24%) died or transferred to ICU

Churpek MM, et al. Am J Respir Crit Care Med. 2016 Sep 20.

New news about NEWS for non-elective medical & surgical patients

• Single centre study, 65,896 admissions • NEWS performed equally well, or better, for surgical as for medical patients

Kovacs C, et al. Br J Surg. 2016. 103(10):1385-93.

New news about NEWS for Emergency Department triage

• Single centre study, 500 patients; 27 (5.4%) with severe sepsis • The area under the curve for NEWS to identify risk of severe sepsis is 0.89

Keep JW, et al. Emerg Med J. 2016. 33(1):37-41.

Corfield AR, et al. Emerg Med J. 2014. 31(6):482-7.

• Multi centre study

• 2003 patients with sepsis

• ↑ NEWS = ↓outcomes (AUC 0.7)

Just one NEWS at ED triage is predictive

Initial NEWS & mortality in patients with sepsis

Initial NEWS 30-day mortality 0–4 5.5% 5–6 11.3% 7–8 13.3% 9–20 27.6%

NEWS: how to do it (my personal view)

1. “Tell and sell” the concept - tailored to the audience

2. Compare and contrast with the existing ‘track and trigger’ system

3. Set it out as a progressive development

4. Facilitate and support ward staff to input

5. Try out good ideas, e.g., with PDSA cycles

6. Challenge resistors: get data

7. Measure processes and outcomes

What’s new – on the front – “New Confusion” added to AVPU

(scores 3: needs urgent assessment)

18

What’s new – on the back – “New Confusion”:

think about delirium (pain, infection (sepsis), etc)

What’s new – on the front – “New Confusion” added to AVPU

(scores 3: needs urgent assessment)

20

What’s new – on the back – “New Confusion”:

think about delirium (pain, infection (sepsis), etc)

21

What’s new – on the front – modified approach to Sepsis

Subbe CP, Welch JR. Clin Risk. 2013. 19(1):6-11.

Record - Recognise - Report -

Respond

The deteriorating patient journey

89% of hospitals have Outreach

89% of hospitals have Outreach - 49% have 24/7 Outreach

89% of hospitals have Outreach - 49% have 24/7 Outreach

- 97% of teams are nurse only

Is it ok that UK teams are nurse only? “RRSs were associated with a reduction in hospital mortality and cardiopulmonary arrest.

Meta-regression did not identify the presence of a physician in the RRS to be significantly associated with a mortality reduction.” Crit Care. 2015. 19:254.

We’ve an efficient National Early Warning Score

Prytherch DR, et al. Resuscitation. 2010. 81(8):932-7.

Call 4 Concern© enables patients and families

to call for immediate help and advice when

they feel concerned that the health care team

has not recognised their own or their loved

one’s changing condition. The Outreach team

can be contacted directly if:

1. A noticeable change in the patient occurs

and the health care team is not recognising

your concern.

2. You feel there is confusion over what needs

to be done for the patient.

… and we’ve some ideas about more “soft” alerts

Odell M, et al. Br J Nurs. 2010;19(22):1390-5.

… and we’ve more ideas about more “soft” alerts

Odell M, et al. Br J Nurs. 2010 Dec 9-2011 Jan 13;19(22):1390-5.

1 Douw G, et al. Int J Nurs Stud. 2016;59:134-40.

More recent developments

Adjusted mortality rates at Queen Alexandra Hospital (top) and University Hospital Coventry (bottom). Schmidt PE, et al. BMJ Qual Saf 2015;24:10-20.

Measuring processes & outcomes

Four key questions

• Do you know how good you are?

• Do you know where you stand relative to the best?

• Do you know about variation in your system?

• Do you know how things change over time?

After Maureen Bisognano, IHI President/CEO.

‘Multi-disciplinary Audit EvaLuating Outcomes of Rapid Response’ = MAELOR

Outcomes Positive Negative

Transfer to ICU, or Theatre

1. Timely transfer, e.g., < 4 hours after the first trigger

2. Delayed transfer, e.g., > 4 hours after first trigger

Alive on ward 3. No longer triggering 4. Still triggering

Deceased 5. On terminal care pathway / with DNAR order

6. Following cardio-pulmonary arrest

Others 7. Alive with documented treatment limits / DNAR order

8a) Trigger from new pathology unrelated to previous call-out

8b) Chronic condition leading to continuous trigger

8c) Discharged from hospital

9. Outcome unknown

Morris A, et al. Crit Care Resusc. 2013;15(1):33-9.

Four key questions

• Do you know how good you are?

• Do you know where you stand relative to the best?

• Do you know about variation in your system?

• Do you know how things change over time?

After Maureen Bisognano, IHI President/CEO.

51 Hospitals Australia, Denmark, Netherlands, UK, USA

Resuscitation. 2016;107:7-12.

Ward referrals to UCH Outreach Team

• 34 referrals / 1000 admissions, 23% ICU • average NEWS at referral = 6.31 • 20.4% hospital mortality

Four key questions

• Do you know how good you are?

• Do you know where you stand relative to the best?

• Do you know about variation in your system?

• Do you know how things change over time?

After Maureen Bisognano, IHI President/CEO.

Completeness of NEWS scoring at UCH 91% of referrals had all seven vital signs and NEWS scores completed.

Accuracy of NEWS scoring at UCH 95% of referrals had accurate NEWS scores. There were two outliers.

Timeliness of referral to UCH Outreach Overall, 91% of referrals were timely, with only one outlier.

Use of SBAR

42

Timeliness of response from UCH Outreach 95% of patient referrals were responded to in a timely way. There are no outliers.

43

Timely transfer to ICU For patients transferred to ICU following referral to PERRT, 89% are transferred within 4 hours.

‘Multi-disciplinary Audit EvaLuating Outcomes of Rapid Response’ = MAELOR

Outcomes Positive Negative

Transfer to ICU, or Theatre

1. Timely transfer, e.g., < 4 hours after the first trigger

2. Delayed transfer, e.g., > 4 hours after first trigger

Alive on ward 3. No longer triggering 4. Still triggering

Deceased 5. On terminal care pathway / with DNAR order

6. Following cardio-pulmonary arrest

Others 7. Alive with documented treatment limits / DNAR order

8a) Trigger from new pathology unrelated to previous call-out

8b) Chronic condition leading to continuous trigger

8c) Discharged from hospital

9. Outcome unknown

Morris A, et al. Crit Care Resusc.2013;15(1):33-9.

Quality of Outreach Response 823 UCH Patient Emergency Response & Resuscitation Team referrals (2015)

Outcomes Positive PERRT +ve results

Negative PERRT –ve results

Totals

Transfer to ICU / Theatre

1. Timely transfer (<4 hours)

165 (89%)

2. Delayed (>4 hours)

21 (11%) 186

Alive on Ward 3. No longer triggering

494 (94%)

4. Still triggering

34 (6%) 528

Patient deceased 5. On terminal care pathway / DNAR order

6 6. Following CPR

7 13

Other Alive 7. with treatment limitations / DNAR

96 96

Totals 761 (92%)

62 (8%) 823

Positive and

negative outcomes

92%+ve 8%-ve

Of patients judged fit to stay on ward for active

treatment,494 of 528 were improved next day.

165 of 186 transfers to ICU occurred in <4

hours.

We can count and case-mix adjust deaths

Counting deaths … or, better, learning from them

Hogan H, et al. BMJ Qual Saf. 2012;21(9):737-45.

Hogan H, et al. BMJ. 2015;351:h3239.

Review sample of referrals to Outreach / unplanned transfers to ICU / arrests / deaths

49

Deteriorating Patients Care Bundle

Lawton R, et al. 369-80. BMJ Qual Saf. 2012; 21(5):369-80.

National, standardised, structured death reviews: framework of factors contributing to patient safety

Remember, nothing is certain, except …

Clark D, et al. Palliat Med.

2014;28(6):474-479.

(10,743 patients, 31/03/2010)

GSTT: Cardiac Arrests per month and Wards that have implemented AMBER

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AMBER Wards: GSTT Arrest Data: GSTT

Critical Care Outreach

PDN meeting

Thanks to Adrian Hopper, GSTT

Outreach moves things along

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Critical Care Outreach

PDN meeting

Thanks to Adrian Hopper, GSTT

Outreach moves things along

The following treatment plan should be used as clinical guidance and is not a substitute for ongoing consultation and shared decision-making wherever possible. The clinician should initial ONE of the patient’s priority boxes below, add relevant guidance in the large box and initial a CPR decision. The form must be signed, named and dated on the reverse.

Name:

Date of Birth: Hospital/NHS numbers:

Address:

1

This individual is FOR attempted CARDIOPULMONARY RESUSCITATION

Signature 6

This individual is NOT FOR attempted CARDIOPULMONARY RESUSCITATION Signature

If the patient dies in transit please take to: 6

Please provide clinical guidance on specific interventions that may or may not be wanted or clinically appropriate in community, hospital and critical care settings:

Provide details of other relevant care planning documents and/or documented wishes about organ/tissue donation (name and where held):

5

The priority is to get better. Please consider all treatment

to prolong life

Initials: .. . 4

The priority is to achieve a balance between getting better and ensuring good

quality of life. Please consider selected treatments

Initials: .. 4

The priority is comfort. Please consider all treatments aimed

at symptom control

Initials: .. 4

Turn over to complete this ECTP

Relevant information about the individual’s diagnosis, situation, ability to communicate, and reasons for the chosen plan.

3

Emergency Care & Treatment Plan

Date: __/__/____ 2

Designation - (Grade and specialty)

Print name & professional registration number

Signature Date and time

Senior Responsible Clinician

10

Plan review: If the individual’s condition changes (i.e. deterioration OR improvement) review the decisions on this ECTP. Document further conversations in box 8. If necessary, complete a new form, and write “CANCELLED” clearly across both sides of this form with signature and date. The decisions on this form should be reviewed specifically before any procedure during which abrupt deterioration or cardiac arrest may occur (e.g. endoscopy, cardiac pacing, angiography, surgery or anaesthesia). Make an agreed plan on whether or not to revoke temporarily the decisions on this form and, if so, on the treatments that will be considered if abrupt deterioration or cardiac arrest occurs. 11

Emergency contacts Name Telephone numbers Other relevant details

Welfare Attorney, Guardian etc.

Family/friend

GP

Lead Consultant

Specialist worker/key worker 12

Does the (adult) individual have capacity? (see guidance notes) YES NO

Do they have a valid advance directive or ADRT? YES NO

If so, record details in box 5

Do they have a representative with legal authority to make decisions? YES NO

(e.g. Welfare Attorney, Guardian, person with Lasting Power of Attorney for Health and Welfare)

If so, record their contact details and document details of discussion below. 7

The clinician signing this ECTP is confirming that these decisions: 1. have been discussed with and agreed with the individual; or 2. have been made in accordance with capacity law; or 3. in the case of a child, the person holding parental responsibility/court order. Date of discussion: __/__/____ Names of those present:

Full documentation of discussion can be found in:

Further conversations occurred on the following dates (state where details are recorded):

8

If there has been no shared decision-making with the individual, no shared decision-making with a

representative with legal authority to make decisions or no best-interests meeting for the individual who

lacks capacity, document a full explanation and a clear plan to address this in the clinical records.

Summarise the reason (e.g. describe any potential to cause harm) here:

9

and we’ve a new, national combined ECTP/DNACPR form

What’s new in NEWS 2

• Re-ordering of the chart layout

• Recording of oxygen therapy

• Consideration of chronic respiratory disease

• Highlighting of new confusion / delirium

• Sepsis …

What else?

Thinking about the whole system

Clear policy & procedure; new NEWS chart(s)

Monthly e-audits → Care thermometer

wards ‘know how they’re doing’

Frontline comms: ‘Message of the week’

PERRT training

Ward safety huddles each shift

58

Continuous improvement …

Key: ward staff – and the patients – know

how they’re doing more or less in real time

Huddles to improve Teamwork and

Communication

.

Learning from serious incidents

62

AAR: The Four Steps What was EXPECTED What ACTUALLY happened

WHY there was a difference What can be LEARNED

Before the event, what was the

objective, plan or expected outcome?

It could be a shared plan, a formal

agreement, a guideline, a personal

expectation, or simply regular practice.

After event, each participant describes:

What they did, saw or experienced

During the event.

Explore the facts, while acknowledging the

perspective and feelings of others.

Why was there a difference between

the expected outcome and the reality

of the moment?

Check if expectations were properly

shared, and what constraints on people,

time or resource prevented expectation

being realised.

Learning is the prime action within an

AAR. What will be different next time?

It may be a change in practice or policy, or

a change in attitude, behaviour, shared

understanding or greater insight. Direct the

collective wisdom to improving future

performance.

Thinking about BARRIERS

Knowledge: Confusion over how to treat complicated patients

(fluid balance, long term in-patients)

Social Influences: Lack of communication: ‘Is this patient on the pathway or not?’, conflict between Drs

and Nurses

Beliefs about consequences: Fear of harming patients with Sepsis Six,

lack of confidence in the evidence

Steinmo S, et al. Implement Sci. 2015;10:111.

and LEVERS

Memory and Attention: Sepsis Six ‘branding and marketing’,

plus prompts and reminders

Environment: Materials and resources immediately available

Social influences: Superiors’ commitment; reciprocal feedback ‘It’s our pathway and

we’re being listened to’.

Beliefs about consequences: seeing health improve immediately,

following-up specific patients

Steinmo S, et al. Implement Sci. 2015;10:111.

Focused training

Technological aids in crises

and data and analytics

is something else

- derived from analysis of 5 million patient encounters in a wide range of hospitalsepsis is likely with

- infection and ≥2 of RR ≥22, SBP ≤100, altered mentation

-

Singer M, et al. JAMA. 2016;315(8):801-10.

Artificial Intelligence 4, Human Champion 1

Subbe CP, Welch JR. Clin Risk. 2013. 19(1):6-11.

Record - Recognise - Report - Respond

The whole system needs to be right …

Four key questions

• Do you know how good you are?

• Do you know where you stand relative to the best?

• Do you know about variation in your system?

• Do you know how things change over time?

After Maureen Bisognano, IHI President/CEO.

Thanks!