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

51

14161

3

72

33 16

22

5 9 7

0%

10%

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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%

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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%

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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