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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”