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Nicole Slater presented this at the 2014 Managing the Deteriorating Patient Conference. The conference discussed the latest strategies to recognise and respond to the acute patient in clinical deterioration. You can find out more about next year's conference at http://bit.ly/1sjQubi
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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