recognition and management of the deteriorating patient: -lessons from the beach cliff hughes ao d...
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Recognition and Management of the Deteriorating Patient:
-lessons from the beach
Cliff Hughes AO D Sc, MB,MS, FRACS, FACS, FACC, FAAQHC, FISQUA, Ad Dip Mgt
Australia?
Australia?
New South Wales
Banality of Error in Practice
Vanessa Anderson:NSW Coronial Report January 2008:
• Golf ball incident – died within 24 hours due to incorrect opiate medication
• Contributing factors: - poor communication between doctors- staffing inadequacies- poor clinical decisions- incorrect decisions by nursing staff
• “Systemic problems existing for a number of years”
The Problem
• Unrecognised deterioration is a
significant problem for patients in all
health systems despite ‘hallmark’ clinical
signs of deterioration.
Respect –Top down or bottom up?• The management/clinician divide.
Justice Peter Garling
• The Great Schism of 1054
Special Commission of Inquiry Acute Care
Services in NSW Public Hospitals 2008
• 1200 submissions
• 61 hospital visits
• 39 public hearings
• 628 witnesses
• 110 meetings
Missed opportunities to:
• prevent
• recognise
• escalate
• respond
The Problem
I was not on duty!
Between the Flags
Why ‘Between the Flags’?
• Only one person has drowned between the
flags on a patrolled beach since 1935
• Keeping patients between the flags, and
initiating a rapid rescue resonates strongly
with clinicians
• The flags are the clearly defined thresholds
for observations
To 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.
Aim
Diagnostic phase
• Understand underlying issues – representative sample of
facilities
• Observation studies of nurse practice
• “Productive ward” concepts of ‘5 S’s’
• Focus groups - process mapping, “ideal ward”
• Brainstorming techniques - clinical observations
• Observation chart audits against criteria agreed with ward
staff
• Review of literature, IIMS and RCA’s
Research Shows
This is a significant problem in NSW and internationally
There are ‘hallmark’ clinical signs that indicate a patient is getting sicker, frequently not recognised
Failure to escalate care
Poor communication is a key factor
Poor documentation is a key factor
Reliability of Observation
Completion of Observations
Themes from analysis of qualitative data
JMO– Ineffective paging systems– Lack of Calling Criteria – Lack of clarity in roles and responsibilities– Inconsistent ward layout despite uniform
architecture – Lack of ward organisation– Lack of documentation– Lack of handover practices
Nursing– Need for more direct patient care time
– Lack of reliable (working and available) equipment
– Need for ‘a place for everything, and everything in it’s place’
– Lack of adequate staff for patient load and acuity– Time consuming patient movements - ‘churn’
– Lack of clear calling criteria– Constant interruptions (telephone calls, on medication
rounds)– Strong reliance on automated observation
equipment
Themes from analysis of qualitative data (cont.)
Intervention on the Slippery Slope
PatientCondition
Time
ClinicalReview
ALS
Prevention
RapidResponse
The Solution
Clinical Review
A, B, C, D approach
Patient ID on all pages of clinical record
Standard Template
Other Charts in Use
Alter Criteria
Vary Frequen
cy
Additional Criteria and Instructions
Stakeholder engagement and consultation is vital
Standard Calling Criteria and ChartsSimple to use- single trigger
Most sensitive indicator of deterioration first
Graphed vs. written observations
Clinical usefulness and relevance
Consolidation of observations for a ‘global’ view.
Ordered A-G to support patient assessment
National standards
‘Photocopiable’ (including patient details)
Human factors principles
Reduce cognitive load and improve functionality– Top left hand corner is processed first– Font size and type– No overlap of parameters– Colour choice (emphasis)– Colour choice (colour blindness)– Consistency in formatting– Clear and descriptive labels– Low light legibility
EDUCATION
• Tier One – Awareness Training- intern e-orientation
• Tier Two – DETECT Training
• Tier Three – Responder Training
Detecting Deterioration, Evaluation, Treatment, Escalation, and Communication in Teams• Manual• E-learning modules• Clinical skills workshop
Multidisciplinary
Focus on improving the ability of clinicians to recognise and respond to clinical deterioration at the ward level
The future for BTF
The 5 elements of ‘Between the Flags’• Governance
• Calling Criteria -incorporated into Standard
Adult General Observation Chart (SAGO)
• Clinical Emergency Response Systems
(CERS)
• Education
• Evaluation
Clinical Emergency Response System
• Customised response to local service needs
• All facilities must have a CERS
• Includes networks for advice / referral and
retrieval
• May include formal assistance / liaison with
Ambulance Service
• Minimum skill levels
• Rapid Response Officer one per shift, 24/7
• Minimum competencies
• Minimum standard of equipment
Evaluation
• Minimum standards for data collection and
reporting
• Key program performance indicators
• Development of state database to collect
Rapid Response Team and KPI data
Governance
Standard Calling Criteria
(CERS)Clinical
Emergency Response
Systems
EducationEvaluation
The 5 elements
Frontline CliniciansClinical Leads
Frontline CliniciansRapid Response
TeamCERS Committees
Workforce ManagersEducators
Clinical Leads
Clinical Governance UnitsBTF Managers
CERS Committees
Governance
• Chief Executives with backing from Director
General
• Executive Sponsors (DCG’s)
• Clinical Leads
• Learning and Development / Workforce Managers
• Project Managers
• Educators
• Peak Quality Committees
• Facility CERS committees
BTF approach
• Broad clinician engagement and consultation
• Keep it simple
• Standardisation across NSW- one chart for NSW
• A ‘sick’ person is sick wherever they are
• Allow facilities to customise their CERS to local needs
and resources
• Promote teamwork
• Promote and support clinical judgement
YELLOW ZONE:Clinical Review
• Novel
• Aims to avoid the “Slippery Slope”
• Clinical Review within 30 minutes
• Responsibility of the home team
• Requires consultation with Nurse in
Charge (allows discretion)
RED ZONE:Rapid Response
• Rapid Response immediately
• Based on pre-existing systems (eg MET)
• Individual or team with ALS skills
• No discretion about calling
11180
2
11
202
1224
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14161
3
72
33 16
22
5 9 7
0%
10%
20%
30%
40%
50%
60%
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90%
100%
A+B C,D,F JH ASNSW
NSW
Our BTF clinical lead (champion) has been critical to the uptake and acceptance of the program by clinicians in our dept/unit
Strongly Agree Agree Neutral Disagree Strongly Disagree
214 1273
41
253167
3 89
8626
4 44
10 711
4 2 3
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
A+B C,D,F JH ASNSW
NSW
Strong executive support is an important part of the success of BTF in our dept/unit
Strongly Agree Agree Neutral Disagree Strongly Disagree
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?)!
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 that it is indeed
reducing cardiac arrests
• BTF must now become part of the culture
Conclusions
• We need:
• The vision to see what must be done and what is
possible
• A plan to make it happen
• A coalition of the willing
• The power of stories
• The courage of leaders
WE HAVE ALL THESE!
35%
21%
13%
24%
27%
11%
21%
47%
40%
47%
49%
50%
45%
47%
15%
29%
22%
21%
17%
31%
25%
3%
8%
14%
5%
4%
11%
5%
1%
2%
3%
1%
1%
2%
2%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Strong executive support is an important part of the success of BTF in our dept/unit
Our BTF clinical lead (champion) has been critical to the uptake and acceptance of the program by clinicians in our dept/unit
The training was adequate
The yellow zone on the BTF chart has assisted earlier detection and management of patients at risk of deteriorating
The red zone on the BTF chart has assisted rapid response to patients at risk of deteriorating
The BTF toolkit was comprehensive and useful for implementation of the program in our dept/unit
Overall the BTF has benefitted patient safety in our dept/unit
4. With regard to the statewide Between the Flags (BTF) program:(dept / unit level)
Strongly Agree Agree Neutral Disagree Strongly Disagree
Whatever it takes!
Whatever it takes!
•Thank you!
Acknowledgements
Professor Clifford Hughes Professor Ken Hillman Professor Deborah Picone
Dr Peter Kennedy A/Prof Theresa Jacques Ms Deb Hyland
Dr Annette Pantle Professor Malcolm Fisher Dr Paul Curtis
Ms Kimberley Fitzpatrick Dr Marino Festa Ms Kathleen Ryan
Ms Colette Duff Professor Les White Ms Michelle Wensley
Mr David Paterson Ms Leanne Crittenden Ms Mel O’Brien
Ms Amanda Yates Dr Gabriel Shannon
Ms Jo Leaver Dr Danny Stiel ...and many more