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Samanatha Rankin delivered the presentation at the 2014 Clinical Audit Improvement Conference. The Clinical Audit Improvement Conference explored the role of clinical audit in the new era of National Care Standards. For more information about the event, please visit: http://bit.ly/clinicalaudit14
Citation preview
Recognising &
Responding to
Deteriorating Data:
Embedding a RRCD program into Clinical Practice in a Tertiary hospital setting
SAMANTHA RANKIN, RN, CHIA
STAFF DEVELOPMENT EDUCATOR, CLINICAL AUDIT
ROYAL PERTH HOSPITAL, WESTERN AUSTRALIA
The Big PictureSandia Peak, Albuquerque, New Mexico, USA – August 2014
Acknowledgments
JUDY SEE – RPH RRCD PROJECT OFFICER
DR. WILHELM SMITHIES – RPH CLINICAL LEAD
RPH DIRECTOR OF CLINICAL SERVICES
RPH RRCD STEERING COMMITTEE
RPH CLINICAL EDUCATORS, WARD LEADERS & AUDITORS
Standard 9:
Our RRCD journey
The first two years of work
Piloting charts, education and training,
monitoring data
Establishing governance and leadership
Changing the clinical culture toward early
warning systems
Developing clinically meaningful metrics
Setting standards and attaching role-based
accountability
Royal Perth Hospital, WA
An organisation in transition
www.rph.gov.au
• Currently the largest Tertiary hospital in WA
• 185 years as a public hospital
• ~ 730 adult multi-day beds
• Two campuses – City + State Rehab
• State Trauma & Burns centre
• Acute Mental Health service
• ~ 250 ED presentations daily
• Sees 2/3rds of rural aeromedical transfers
We are in the midst of change:
• Downsizing to a 450-bed specialist hospital
• Services transitioning to Fiona Stanley Hospital
• Reduction of units, teams and staff
The Steering CommitteeHaving the right people in the room…
Senior clinical leadership
Executive sponsorship
Sufficient clinical expertise
Clinical Audit expertise
Strong links with:
Resuscitation committee
Clinical Safety & Quality
Senior Educators
Representation to area & state working groups
This evolved and changed over time
The importance of Clinical Audit
El Morro National Monument, New Mexico, USA – August 2014
Evaluate the system Check process adherence Monitor outcomes
Flag areas requiring action…
Engage clinicians with their data
Establish variability in practice
Identify pockets of excellence
Create performance trends
Benchmark & drive improvement
First Pilot & Escalation Mapping 2011
The trigger-happy rainbow
o Worked best in general
medicine and general
surgery
o Specialty areas
experienced challenges
with over and under
triggering of response
o Clinician feedback was
critical
o 2180 observation events
were prospectively
analysed – results aligned
with clinician and
operational experience
2012 – Enter the ADDS chart
The Adult Deterioration
Detection System was
considered a better
alternative for our site
Implemented over a 4 week
period with cascade training
support
Audited at 6 & 12 weeks
50% sample size (~300 charts)
Documentation compliance
Charting accuracy
Process adherence
Escalation of Care
Modifications
Clinical Audit Strategy
Clearly defined standards
Clinically relevant metrics
Cognisant of clinical risk
Congruent with NSQHS Standard 9 requirements
Rapid reporting & feedback
Resource efficient
Retaining a pool of trained auditors
Refining a standardised audit tool
Key elements of success?
Communication
Planning
Contingency
Simplicity
Pragmatism
Consideration of
clinical loads and
competing demands
Communication
Interesting findings:On any given day…
~ 40% of our patients trigger an EOC
90-95% of EOC's are ADDS score 1-3
Trigger rates double for patients on
oxygen
Key challenges involve:
Effective documentation of EOC
Safe practice for modification of care
Results & Reporting
Multiple levels of reporting:• Ward level
• Survey Monkey PDF extract• Service Level reports
• One and two-page dashboards• High-level reports
• Rolled up overall performance
Reporting is modified to meet stakeholder needs and align with area-level reporting benchmarks
Reporting templatesCompliance Measure Audit Period Jan-13 Feb-13 Jun-13 Sep-13 Dec-13 Mar-14 Jun-14
Numerator 0 0 0 0 0 0 0
Denominator 0 0 0 0 0 0 0
Compliance % #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
Numerator 0 0 0 0 0 0 0
Denominator 0 0 0 0 0 0 0
Compliance % #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
Numerator 0 0 0 0 0 0 0
Denominator 0 0 0 0 0 0 0
Compliance % #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
Numerator 0 0 0 0 0 0 0
Denominator 0 0 0 0 0 0 0
Compliance % #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
Numerator 0 0 0 0 0 0 0
Denominator 0 0 0 0 0 0 0
Compliance % #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
Numerator 0 0 0 0 0 0 0
Denominator 0 0 0 0 0 0 0
Compliance % #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
Numerator 0 0 0 0 0 0 0
Denominator 0 0 0 0 0 0 0
Compliance % #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
Numerator 0 0 0 0 0 0 0
Denominator 0 0 0 0 0 0 0
Compliance % #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
Numerator 0 0 0 0 0 0 0
Denominator 0 0 0 0 0 0 0
Compliance % #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
The monitoring plan is adhered to
= number where observations adhere to monitoring plan
---------------------------------------
number with a documented monitoring plan
Escalation of Care (EoC) actioned as per protocol
= number where EoC is actioned as per protocol
---------------------------------------
number where EoC is triggered
Modifications are authorised as per RPH guideline
= number Modifications with authorisation
---------------------------------------
number where Modifications are documented
Embedding Use of the A-ORC
= number with ADDS chart
---------------------------------------
number audited
Completeness of Observation Documentation(RPH - INCLUDES Pain & Urine Output observations)
= number with a complete set of Observations
---------------------------------------
number with A-ORC
Completeness of Observation Documentation (SMHS - EXCLUDES Pain & Urine Output observations)
= number with a complete set of Observations
---------------------------------------
number with A-ORC
Completion of ADDS score on last set of
observations = number with an ADDS score documented
---------------------------------------
number with A-ORC chart
Accuracy of ADDS on last set of observations = number with ADDS scored correctly
---------------------------------------
number with ADDS scored
A monitoring plan is documented
= number with a documented monitoring plan
---------------------------------------
number of patients with an A-ORC
Dashboard development
SERVICE RPH WARDTotal ADDS
charts audited
Full set of
observations
documented
(n)
% set of
observations
documented
ADDS score
documented
on last Obs
(n)
% ADDS score
documented
Monitoring
Plan in Place
(n)
% Monitoring
Plan in Place
Number with
Escalation of Care
in last 24 hrs
Care escalated
according to
escalation protocol
(n)
% Care escalated
according to
escalation protocol
Number with
Modifications
% Modifications
according to site
policy
1 3K #DIV/0! #DIV/0! #DIV/0! #DIV/0!
1 4F #DIV/0! #DIV/0! #DIV/0! #DIV/0!
1 6A #DIV/0! #DIV/0! #DIV/0! #DIV/0!
1 6G #DIV/0! #DIV/0! #DIV/0! #DIV/0!
1 9A #DIV/0! #DIV/0! #DIV/0! #DIV/0!
1 9B #DIV/0! #DIV/0! #DIV/0! #DIV/0!
1 9C #DIV/0! #DIV/0! #DIV/0! #DIV/0!
1 10A #DIV/0! #DIV/0! #DIV/0! #DIV/0!
1 10C #DIV/0! #DIV/0! #DIV/0! #DIV/0!
1 BMTU #DIV/0! #DIV/0! #DIV/0! #DIV/0!
1 CTUP #DIV/0! #DIV/0! #DIV/0! #DIV/0!
TOTAL SERVICE 1 0 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 0 #DIV/0! 0
2 4A4B #DIV/0! #DIV/0! #DIV/0! #DIV/0!
TOTAL SERVICE 2 0 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 0 #DIV/0! 0
3 2K #DIV/0! #DIV/0! #DIV/0! #DIV/0!
TOTAL SERVICE 3 0 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 0 #DIV/0! 0
4 S09/HDU #DIV/0! #DIV/0! #DIV/0! #DIV/0!
4 5A #DIV/0! #DIV/0! #DIV/0! #DIV/0!
4 5B #DIV/0! #DIV/0! #DIV/0! #DIV/0!
4 ASU/AMU2 #DIV/0! #DIV/0! #DIV/0! #DIV/0!
4 5G #DIV/0! #DIV/0! #DIV/0! #DIV/0!
4 5H #DIV/0! #DIV/0! #DIV/0! #DIV/0!
4 6H #DIV/0! #DIV/0! #DIV/0! #DIV/0!
4 7A #DIV/0! #DIV/0! #DIV/0! #DIV/0!
4 8A #DIV/0! #DIV/0! #DIV/0! #DIV/0!
4 AMU #DIV/0! #DIV/0! #DIV/0! #DIV/0!
4 BURNS #DIV/0! #DIV/0! #DIV/0! #DIV/0!
4 EMW #DIV/0! #DIV/0! #DIV/0! #DIV/0!
4 SMTU #DIV/0! #DIV/0! #DIV/0! #DIV/0!
TOTAL SERVICE 4 0 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 0 #DIV/0! 0
5 S01 #DIV/0! #DIV/0! #DIV/0! #DIV/0!
5 S02 #DIV/0! #DIV/0! #DIV/0! #DIV/0!
5 S06/8 #DIV/0! #DIV/0! #DIV/0! #DIV/0!
5 S10 #DIV/0! #DIV/0! #DIV/0! #DIV/0!
5 S11 #DIV/0! #DIV/0! #DIV/0! #DIV/0!
TOTAL SERVICE 5 0 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 0 #DIV/0! 0
TOTAL RPH 0 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 0 #DIV/0! 0
[xxx to xxx] Quarter 2014 - Summary of Performance Indicator Data
Standard 9: Recognising and Responding to Clinical Deterioration
Dashboard Development3K
4F
5A
5B
6A
6G
9A
9B
9C
10A
10C
BM
TU
CT
UP
4A
4B
2K
S09/H
DU
AS
U/A
MU
2
5G
5H
6H
7A
8A
AM
U
BU
RN
S
EM
W
SM
TU
S01
S02
S06/8
S10
S11
RP
H
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Co
mp
lian
ce %
Clinical Area
For last set of observations:Percentage of Complete Observations
3K
4F
5A
5B
6A
6G
9A
9B
9C
10A
10C
BM
TU
CT
UP
4A
4B
2K
S09/H
DU
AS
U/A
MU
2
5G
5H
6H
7A
8A
AM
U
BU
RN
S
EM
W
SM
TU
S01
S02
S06/8
S10
S11
RP
H
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Co
mp
lian
ce %
Clinical Area
Percentage of Patients with a Monitoring Plan
3K
4F
5A
5B
6A
6G
9A
9B
9C
10A
10C
BM
TU
CT
UP
4A
4B
2K
S09/H
DU
AS
U/A
MU
2
5G
5H
6H
7A
8A
AM
U
BU
RN
S
EM
W
SM
TU
S01
S02
S06/8
S10
S11
RP
H
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Co
mp
lian
ce %
Clinical Area
For last set of observations:Percentage of ADDS Scores Documented
3K
4F
5A
5B
6A
6G
9A
9B
9C
10A
10C
BM
TU
CT
UP
4A
4B
2K
S09/H
DU
AS
U/A
MU
2
5G
5H
6H
7A
8A
AM
U
BU
RN
S
EM
W
SM
TU
S01
S02
S06/8
S10
S11
RP
H
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Co
mp
lian
ce %
Clinical Area
Compliance with Escalation of Care Protocolin the highest scoring ADDS in past 24 hours
(Only in areas where EoC captured at audit)
Data Integration
Shared audit tool
MET call database
Incident management
Benchmarking between sites
Informing clinicians about
local clinical risks
Involving patients & carers
Summary thoughts
• Heuristic track & trigger
charts are the way that
we do business
• Bringing together expert
clinicians, clinical leaders
and educators has driven
cultural change
• More change is on the
horizon… so it’s a long
roadSalt River Canyon, Arizona-New Mexico border – July 2013