Urgent Clinical Review

- The Step before MET

Presented by: Melodie Heland

Director, Surgical Clinical Service Unit

Chair, Austin Health Deteriorating Patient Committee

September 2013

Overview

• Background

• Why UCR is necessary?

• The triggers, calling and documentation processes

• The challenges encountered during introduction

• Audit and data collected to inform improvement

Background – Deteriorating Patient Committee

The Deteriorating Patient Committee (DPC) will

- provide leadership and coordination to improve detection,

recognition and escalation of care for patients who

deteriorate across Austin Health.

- through compliance with relevant national documents,

including the National Consensus Statement Essential

elements for recognising and responding to clinical

deterioration and Standard 9 of the National Safety and

Quality Health Service Standards.

Escalation policy

In our establishment of an ‘Escalation policy for care of

deteriorating patients’ we queried if MET was providing the

best method of early recognition and response.

Is MET the solution?

Hospital

inpatient Abnormal

vital signs

MET

call

Cardiac

arrest

Mortality 2% Mortality 25% Mortality 80%

Old paradigm Current

paradigm Urgent Clinical

Review

ICU intervention Parent Unit intervention

Urgent Clinical Review

• Gradual development of processes, audit, education and

systems to introduce this new response

• The experiences of the MET, feedback by ward staff and

recent data have confirmed the need for earlier intervention

Review of 14 months MET calls 1/4/12 – 31/5/13

• 2,756 MET calls = 197 per month

• Top five reasons for call: tachycardia, hypotension, Low SpO2,

high respiratory rate, change in conscious state

• Notable: 37.5% of calls with a limitation of medical therapy

• Austin rate higher than published studies (30.7%)

• Notable: 31.5% were repeat calls

• This was higher than our 2006 rate of 25.6% repeat calls

More MET calls per year than ICU admissions

Patient outcome 2,756 MET calls (14 mths.)

LOMT % by Unit

Urgent Clinical Review (UCR)

• Introduced to alert parent unit earlier to patient deterioration

• Built into Observation and response chart and Escalation policy

• Part of education process and auditing

• We are in the process of developing our UCR policy further and

improving documentation of UCR

Suite of documents agreed and developed

Vital signs policy and

flowchart developed

Flowchart:

Escalating response to

patient deterioration

Early snapshot audit of UCR showed:

• Of 22 UCR calls audited, 77% required clinical intervention

• Majority of calls on surgical wards

• Documentation of call time was high, but documentation of the time to

medical response was poor

• When time was documented, 86% of pts were seen within 30 mins

Early snapshot audit of UCR showed:

• Doctor documented their review and its outcome less than 50% of the

time

• Sometimes the Dr reviewed in person, sometimes by phone

• Nursing usually completed documentation

• The designation of the doctor who responded was poorly documented

• The completion of modified UCR and / or MET criteria was patchy

Feedback from Junior medical staff

• JMOs ring the ward when a UCR is called and have trouble

getting on to the person who called it

• The message that a UCR is needed is lost in other pages

and information they receive on the page is variable

________________________________________________

ACTIONS………….

Urgent Clinical Review policy drafted

Purpose

Early patient assessment and management of patient deterioration by the parent unit and ward staff, and a process for escalation of patient care will reduce the chance of life threatening complications.

Austin Health has a Parent Unit response to early deterioration called an Urgent Clinical Review. This system responds to early physiological instability (i.e. pre-MET) in any patient at Austin Health using vital sign measurements on the track and trigger Observation & Response chart

Urgent Clinical Review policy (cont)

UCR medical record

Other supportive changes

• Dedicated cordless phone introduced

• Specific script for paging UCR

“Ext 5436 – URGENT REVIEW – Hypoxia – Jones – 326589 - 8E –Bed 5”

Other

supportive

changes

Provision of MET data to Units

Organisational audit policy developed.

If units are to get involved in UCR, they

need to know what is happening

regarding patient deterioration.

Riskman enables us to report MET calls

by unit, by day and by patient.

Example: 104 MET calls in the ortho unit

Subacute campus emergency responses

0

5

10

15

20

25

30

35

Mar-12 Mar-13 Apr-12 Apr-13 May-12 May-13 TOT '12 TOT'13

Subacute

TSC

Outpatients

RDU

56% reduction

March-May 2013

vs

March-May 2012

0

5

10

15

20

25

30

Dec 09-May 10 Dec 11-May12 Dec12-May13

Nu

mb

er

of

Eve

nts

Mental Health Outcomes emergency responses

Total Calls

Transferred

ROW

UNK

• Empowered / educated staff early identification & management deterioration

(ORC, COMPASS, ACCESS).

• Promotion UCR response in MHP

(Parent unit response to manage patient deterioration).

2012 = 27

2013 = 5

81% calls

87% transfers

Continuing development

Continuing development

Summary

A patient who has a MET call has a 25% likelihood of mortality.

Higher if they have multiple calls

The response process is owned by ICU and not the parent unit

Urgent clinical review provides an earlier warning of deterioration

and place the onus on the unit to manage the situation

Robust processes and continuous improvement are required to

implement this new response