Implementing a Deteriorating Patient Program: a personal perspective

Dr Paul Curtis

Director Clinical Governance

24 Apr 13

NSW: a large state

NSW

• Area = 809,000 km2

• Population = 7.25 m

• Pop density = 9.1/km2• Population of Sydney,

Newcastle and Wollongong =

5.4m (74%)

• 200 hospitals

• Health budget = $17.3 b

Scotland

• Area = 79,000 km2

• Population = 5.25 m

• Pop density = 67.5/km2

• 130 hospitals

• 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

AimTo 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.

Between the Flags Program

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

Intervention on the Slippery Slope

PatientCondition

Time

ClinicalReview

ALS

Prevention

RapidResponse

The Solution

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

Intervention on the Slippery Slope

PatientCondition

Time

ClinicalReview

ALS

Prevention

RapidResponse

The Solution

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

95100 195

202

185387

113

67180

2613 39

10 6 16

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Metro Rural / Regional State

Overall the BTF has benefitted patient safety in our dept/unit

Strongly Agree Agree Neutral Disagree Strongly Disagree

Element 5: Evaluation - QSA

QSA: benefitted pt safety

14% reduction in RCAs

On line survey by UNSWQuestions 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

82%

% of staff that use ISBAR as the communication tool for handover 85%

% 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%

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”