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Successful strategies to implement a
recognition and response system for early
detection of deteriorating patients
Dr Beverley Duff & Russell Gooch
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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
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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
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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
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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
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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
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Aim to improve detection
limb
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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!
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Medical Emergency Advisory Committee
(MEAC)
Developed or influenced:
Educational programs
Procedural changes
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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
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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
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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!
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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:
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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
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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
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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:
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Other learning goals:
To integrate early
detection of deteriorating
patient principles into all:
• Simulation sessions
• Leadership training and
• Orientation programs
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Results
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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
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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
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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’
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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’
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Questionnaire results: Three months post workshop feedback
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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 %
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• Future further research
Conduct
further
studies.
Permission
given to use
interstate
survey tool.
Collaboration
with Sunshine
Coast
University.
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THANK YOU!
Acknowledgements:
Practice Development Team, Medical Emergency Advisory Committee,
NGH