Successful strategies to implement a

recognition and response system for early

detection of deteriorating patients

Dr Beverley Duff & Russell Gooch

Sunshine Coast, Queensland

• The Sunshine Coast Hospital and Health Service

• Serves an approximate population of 390,000

• Covers approximately 6,093 square kilometres

• One of the fastest growing populations in Queensland

Evidence: Local and international

1

2

3

4

5

Need to standardise early recognition and

rapid response to deteriorating patients

Need to enhance nurses’ ability to anticipate & recognise changes in patient status

Increased complexity of care lends renewed urgency to this challenge

When to prioritise and communicate

clinical urgency important

Rising patient acuity and decreasing length of stay contribute

to an environment that challenges even experienced nurses

long recognised as strong critical thinkers

Background (Nambour Hospital)

2009

2 tier system 1. MET call = JHO

2. Code Blue = team….......... failed

2010

Single response - MET or Code Blue ……….. resource

problem

Dec 2011--Feb 2012

The Q-ADDS observation forms based on behavioral research

by the University of Queensland introduced

Queensland Adult Deterioration

Detection system

Introduced to Public

Hospitals in 2011 via a

State Reference Group 1

Other processes in QLD

include:

• CEWT

• MEWT

• + entry into

Emergency

Departments

2

System Development

Aim is to ensure patient safety, but should also

Be tailored & optimise resource use

Protect inexperienced medical and nursing staff

Minimise under-skilling / de-skilling of staff

Historically, measurement of the effectiveness of these systems

has been controversial, as many relevant outcomes (eg- hospital

mortality, unplanned ICU admissions, cardiac arrests) are

influenced by multiple factors

Our primary indicator was number of activations

Aim to improve detection

limb

Initial response to introduction of Q-ADDS

(Funded and directed by State wide group)

Results

Data collection

Measured by numbers of MET and

Code Blue calls,

Activations at Nambour Hospital (

375 beds) remained at less than 20

calls per month

2

There was expected to be a rapid

increase in activations following

Q-ADDS introduction

1

We needed to fix this!

Medical Emergency Advisory Committee

(MEAC)

Developed or influenced:

Educational programs

Procedural changes

Challenges

A health service with four separate facilities

undergoing rapid growth to accommodate

services for 600 + beds / 40 bed ICU hospital

in 2016

Adult, paediatric, neonatal, obstetric and

psychiatric

Problems detected Within the Sunshine Coast Hospital & Health Service

1

2

3

4

Executive resistance

Nursing resistance (fear of negative medical

response)

Responder resistance

( Non acute calls)

Home team

resistance

Problems detected contd;

--

5

6

7

8

Education- large cohort,

medical and nursing, allied health and

operational staff

De-skilling

Medical and nursing fear of de-skilling at unit level-

perceived loss of clinical respect

Resources

Responding units resource poor

Initial and ongoing educational resources not

provided in initial rollout

Resistance to change!

Reasons for successful change

1. Enforcement of National Standard 9.

‘Recognising and Responding to Clinical Deterioration in

Acute Health Care’

2. Process for activation made mandatory for all clinicians

3. Involvement of entire interdisciplinary group to

collectively resolve practice issues

4. Executive financial support. (extra ICU and Medical hours)

Strategies:

Educational Pathways to Improvement

• Broad sustained nursing

educational support Nurse educators ( practice

development philosophy)

Clinical Coaches

Unit based life support

champions

Integration of emergency

response into all education

• Interdisciplinary collaboration

• Collegial endorsement of

processes

Educational Pathways to Improvement

• Regular workshops using simulation,

debriefing and reflective feedback

• Support and guidance with nurse

clinicians by ward coaches and

educators

• Continual review of processes with

interdisciplinary clinician input

• Modification of Q-ADDs tool

Combined educational strategies & workshop

attendance improved patient outcomes

Clinical coach and Nurse educator

framework

Overlap education programs

Review and feedback sessions

• Post workshop strategies:

Post workshop

strategies:

Other learning goals:

To integrate early

detection of deteriorating

patient principles into all:

• Simulation sessions

• Leadership training and

• Orientation programs

Results

0

20

40

60

80

100

120

140

Bli

tz o

n E

du

cati

on

Ro

ll o

ut

of

AD

DS

Nambour Hospital Emergency Activations January 2010-----December 2013

Decrease in overall hospital mortality

• Mortality per admission decreased despite an

increase in admission numbers for overnight stays

for patients >= 15years

Date Total number

admissions

Total Deaths Percentage

deaths to

admissions

2010 18,670 347 1.8

2011 19,914 361 1.8

2012 23,225 394 1.6

1/7/12—

30/6/13

24,112 376 1.5

1death / 57 admissions

versus

1 death / 64 admissions

p=0.03

Post Workshop feedback

1

2

3

4

Self reported practice changes implemented in clinical practice

as a result of workshop participation

Greater awareness of detecting unstable patients: understanding

how systems all connect and effect each other’

‘Recognition of deterioration; being more diligent in prevention;

early notification; increased monitoring’

Looking at the individual not the equipment; not afraid to ask

questions to define outcome

‘Paid much closer attention to respiratory rate as a clinical

indicator; particularly useful on night duty when patient asleep and

other indicators (visual or patient activity) absent’

Post Workshop feedback contd;

5

6

7

‘Check neuro obs at CBH with oncoming staff’

‘Much more confident when using ISBAR to call a doctor about a

patient’

‘Documentation practice and communication skills have improved

greatly’

Questionnaire results: Three months post workshop feedback

Questionaire results Assessment of patients using primary and secondary survey

Use of primary & secondary survey assessment techniques

Never

Daily

Weekly

Monthly

Missing

Percentages

Daily = 66.7%

Weekly = 6.7 %

Monthly = 3.3 %

Never = 10 %

Missing = 10 %

• Future further research

Conduct

further

studies.

Permission

given to use

interstate

survey tool.

Collaboration

with Sunshine

Coast

University.

THANK YOU!

Acknowledgements:

Practice Development Team, Medical Emergency Advisory Committee,

NGH