Nicole Slater - Quality & Safety, ACT Health - Monitoring the Program and Challenges around...

Nicole Slater – ERDP Program Manager

ACT Health

Background for the Canberra Hospital

• University Affiliated Tertiary Hospital

• 500 beds

• Serves ACT and GSAHS population (660 000)

• 64 000 separations per year

• 17 year old female, presented to Emergency Department

• Diagnosis: Glandular fever and Bilateral Pneumonia

• Admitted to a ward overnight and then deteriorated.

22 Dr reviews but no definitive management plan in 28 hours

No MET call even when vital signs fulfilled MET criteria.

• An unexpected admission and long stay in ICU.

Example in the ACT of cases where Family/ Carer

escalation system could have had a positive

outcome:

Mother’s comment “My daughter was so very ill and I felt completely powerless to have someone, anyone do anything other than simply look at the monitor and walk out of the room and leave me with her. I was anxious and fearful. It was not until I asked “does my daughter have to have a respiratory arrest before someone will do something?” that action was taken”

Australia Council on Health Care Standards

CARE for Patient Safety

Aim To develop an escalation process that

builds upon current communication pathways to allow patients, their families and carers to articulate their concerns over care being delivered.

CARE for Patient Safety

Families and Carers are ideally placed to identify signs of clinical deterioration

They spend more time with the patient and know them best, therefore any subtle changes may be identified early by family and carers

CARE for Patient Safety What is the evidence?

• Overseas experiences

– Condition H(elp) • Josie King

– Call for Concern (C4C)

CARE for Patient Safety

3 Step Process

AIM:

To develop an escalation process that builds upon current communication pathways to allow patients, their families and carers to articulate their concerns over patient’s clinical deterioration.

CARE for Patient Safety Method • Literature Review

• Focus Groups

• Steering Committee - 50% delegates being consumers

• Project Team

• Development of Family Escalation Pathway

• Roll out of ward education

• Deployment of CARE brochures and posters

• Development and delivery of CARE responders education program

• Development of Survey for families and staff

• Developments of Guidelines for CARE responders

Method

• Prospective before and after intervention trial

• Conducted over two, three month periods on three wards.

• Data Collected

Demographic data

Number of MET calls

Number and Reason for CARE Calls

Outcome of Care Calls

Family awareness of CARE escalation pathway

Family awareness of who was caring for them

• Primary Outcome measures:

Incidence of CARE Calls

• Secondary Outcome Measures

Incidence of MET Calls

CARE for Patient Safety

EDUCATION

• Responders

• Team Leaders

• Ward Staff

STEP 3 RESPONDERS

Business Hours

• MET Nurses Business Hours

STEP 3 RESPONDERS

After Hours

• Afterhours CNC’s including weekends & public holidays

• Adult Medical Ward

•Adolescence Ward • Paediatric Ward

Pilot Wards

CARE for Patient Safety

Weekly surveys of patients, families and carers on the process

Survey patient, family or carer in the event of a call

Survey nursing staff on the ward in the event of a call

CARE responder notification

Evaluation

5 calls

4 clinical related calls

1 complaint

All outcomes resolved

Results

CARE for Patient Safety

•Calls consistent with similar programs internationally •Communication pathways improved •Informing patients & families about the process remains a consideration

Calls 2013-2014

6% 3%

8%

19%

3% 3%

44%

14%

Activation by Division

Unknown Other Critical Care Medicine MHJDAS RACC Surgery WY&C

Time of the Day

69%

31%

Calls (n=36) Median time 51 mins

07:00-16:59 17:00-06:59

Caller

28%

23% 20%

20%

6% 3%

Patient Daughter/Son Parent Partner/Husband/Wife Other Sibling

Reason for Calls

33%

28%

14%

14%

11%

(calls n=36)

Communication Complaint Clinical Deterioration Other Pain Management

Team leader Notified Prior

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Yes No

Treating Team Notified Prior

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Yes No

Initial Outcome

Referral to Nursing Staff 36%

Referral to JMO 25%

Referral to Registrar 14%

Nil intervention 11%

Other 8%

Referral to Consumer Engagement

6%

(Calls n=36)

Referral to Nursing Staff Referral to JMO Referral to Registrar Nil intervention Other Referral to Consumer Engagement

Audits

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14

Aware of the program

Audits

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14

Program Explained

Program Continues

• Across all inpatient areas of CHHS

• Recently rolled out across Calvary Healthcare Bruce, ACT.

• Ongoing audit

• Ongoing review of calls and processes

• Plan to expand to other areas such as ED, ICU, Mental Health and Birthing Services.

Challenges • Cultural change in how we do business

• Ensuring 24 hr/7 day per week cover

• Patients receiving the brochure/explanation

• Improving communication for Steps 1 & 2

None of it would have been possible without:

• Sarah Mamootil (Project officer)

• Prof Frank Bowden (Clinical Lead – Family Escalation)

• A/Prof Imogen Mitchell (Clinical Lead ERDP)

• Heather McKay, Alison Kingsbury and Nicole Slater (ERDP Program Managers)

• The Steering Committee- in particular the consumer representatives

• CHHS MET nurses and After hours Clinical Nurse Consultants

• The clinical staff on the pilot wards