keeping patients safe – ‘between the flags’
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Keeping patients safe -
„Between the Flags‟
Malcolm Green
Program Lead, Between the Flags
Clinical Excellence Commission
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 Professor Les White Ms Kathleen Ryan
Ms Colette Duff Ms Leanne Crittenden Ms Michelle Wensley
Mr David Paterson Dr Danny Stiel Ms Mel O‟Brien
Ms Amanda Yates Dr Gabriel Shannon
Ms Jo Leaver Dr Tony Penna ...and many, many more
Dr Charles Pain Dr Marino Festa
Mr Paul Hudson
Outline
• The Past
• The Present
• The Future
A message from Cliff…
https://vimeo.com/user19020418/review/7
0600926/3b3594eba4
The past (BBTF) Pre 2010
Peter Safar - 1974
“The most sophisticated
intensive care often becomes
unnecessarily expensive
terminal care when the pre-ICU
system fails”
The Slippery Slope
(the Problem)
Patient
Condition
Time
ALS
Death
There‟s a problem…
Source: Dr Charles Pain
What‟s the problem?
• Serious adverse events are common in
hospitalized patients around the world 1-4
• Documented warning signs in up to 80% 5-9
• Early recognition and intervention improves
outcomes 10-13
1 - 4 Wilson et al MJA 1992, Davis et al NZ Med J 1998, Brennan / Leape 1984, Baker etal 2000
5 - 9 Schein et al, Chest 1990, Buist et al MJA 1999, Hodgets et al Resus 2002, Nurmi et al Act Anaes Scan 2005, Bell et al Resus 2006
10 - 13 GISSI Am Heart J 1999, Rivers NEJM 2001, Nardi Min. Anest 2002, NINDS NEJM 1995
The solution
• Medical Emergency Team (MET) concept
developed by Professor Ken Hillman 1
• MET and Rapid Response Systems catch
on across Australia, the US and the UK 2-4
1. Lee et al, Anaesth Intensive Care 1995
2. Ball et al, BMJ 2003
3. England et al, Critical Care 2008
4. IHI, 100,1000 lives campaign 2006
The solution?
Patient
Condition
Time
ALS
MET
Death
Source: Dr Charles Pain
The Slippery Slope
(the Problem)
But there‟s still a problem….
• Failure to recognise and respond to
deteriorating patients is a significant issue1-3
• Imbalance between patient needs and
available resources4
1. McQuillan et al BMJ 1998 (UK)
2. Buist et al MJA 1999 (Australia)
3. Bell et al Resus 2006 (Sweden)
4. Devita et al 2006
The present (BTF) 2010 -
Design a system to improve:
• prevention
• recognition
• escalation
• response
Introduced in January 2010
The NSW solution
A Safety Net
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.
Programme Aim
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 and support clinical judgement
• Multivalent approach (5 elements)
Striking the right balance
Clinical
judgement Rule-based
approach
Source: Dr Charles Pain
Governance
Standard
Calling
Criteria
(CERS)
Clinical
Emergency
Response
Systems
Education Evaluation
The 5 Elements
Standard
Observation
Charts
Clinical Review &
Rapid Response
Awareness, DETECT,
Rapid Responders
2 KPIs
Evaluation
Collaborative
QSA
Source: Colette Duff
Policy &
Governance Plan
DCG‟s
Standard Adult General Observation Chart
Red Zone
Late warning
signs
Yellow Zone
Early warning
signs
Observation Charts
5 Paediatric Charts
Neonatal
Maternity
Emergency Dept.
Vital Sign Value (e.g. Respiratory rate)
Ris
k o
f a
dve
rse
ou
tco
me
Setting Vital Sign Escalation Thresholds
Source: Dr Charles Pain
Clinical Emergency Response
Systems (CERS)
CERS – the response
Rapid
Response
Clinical
Review
Education
Striking the right balance
Clinical
judgement Rule-based
approach
Discretion in
Yellow Zone
No discretion in
Red Zone
Source: Dr Charles Pain
Evaluation
Key Performance Indicators
• Rapid Response calls / 1000 admissions
• Cardiac Arrests calls / 1000 admissions
Quality Systems Assessment (QSA) reports
Hospital visits
Standard Observation Chart audit tools
Academic Research Partners - UNSW
The past
Patient
Condition
Time
ALS
MET
Death
Source: Dr Charles Pain
The Slippery Slope
(the Problem)
The Safety Net
(the Solution)
Patient
Condition
Time
Clinical
Review
ALS
Rapid
Response
Death
Source: Dr Charles Pain
The present
The Safety Net
(the Solution)
Patient
Condition
Time
Clinical
Review
ALS
Rapid
Response
Death
Source: Dr Charles Pain
The future
IS IT WORKING?
Benefit to Patients:
% Strongly Agreeing & Agreeing
21% 25%
44%
47% 48%
38%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Overall the BTF has benefittedpatient safety in our
department/unit (Adults)
Overall the BTF program hasbenefitted patient safety in our
department / unit (Paeds)
Overall the BTF program hasbenefitted patient safety in ourdepartment / clinical unit (all)
2010 2011 2012
Strongly agree Agree
Source: Quality Systems Assessment
“…for the junior staff it has been
fantastic. It gives them
"empowerment" to make a call if the
patient falls outside the "BTF".
BTF…“Is clear, easily
understood by colleagues and
is objective in defining if
deterioration is occurring.”
What staff say…
“Made it easier to identify where
observations fall outside regular
parameters. Clear guidelines for
what to do in certain situations,
and who to call.”
“In the last 13 years I cannot
remember a time when
I‟ve been to fewer cardiac
arrests..”
Rapid Response Rate per 1000
Separations, NSW Hospitals
+24.9%
Cardiorespiratory Arrest Rate per
1000 Separations, NSW Hospitals
- 38.5%
Estimate of benefits
• 940 fewer unexpected cardio-respiratory
arrests
• 800 fewer deaths in patients without an NFR
order
What we don‟t know…
• Morbidity prevented?
• Impact on mortality?
• What impact has the Yellow Zone had and
the numbers of Clinical Review calls across
NSW?
The Future
Casting the safety net wider
BTF in the electronic Medical Record
Source: Dr Karen Luxford, Director Patient Based Care
Patient and family escalation
Sepsis
End of Life care planning
Lessons
Build a coalition
Lay foundations of governance
Develop the tools
Strike the right balance:
• standardise AND localise
• discretion AND rules
• home teams AND rapid responders
We gratefully acknowledge
“Always swim between the red and yellow flags”
For further information
www.cec.health.nsw.gov.au
Betweentheflags@cec.health.nsw.gov.au
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