WSLHD Clinical Emergency Response Systems (CERS) Framework

Prepared by WSLHD CERS Working Party

WSLHD January 2019

WSLHD Clinical Emergency Response Systems (CERS)

Framework For Adult Inpatients including Maternity

Final as of 16/1/19

Why is this important?

Rapid Response Rate ↑190%

Cardiac Arrest Rate ↓ 52%

After the BTF program (2010-2013), the same trends continued for all outcomes with an overall (2013 vs 2007) 46% reduction in cardiac arrest rates; a 54% reduction in cardiac arrest related mortality rates; a 19% reduction in hospital mortality; a 35% decrease in failure to rescue rates (all Ps < 0.001) over seven-years. In addition, there was a new 20% (p<0.001) mortality reduction among Low Mortality Diagnostic Related Groups patients (2013 vs 2007) which was never reported before. This reduction amounted to 1580 lives saved in 2013 in NSW alone.

Patient Story

Patient story – written or video

Clinical Emergency Response System CERS are designed to reduce morbidity and mortality

Your compliance is mandatory

District Wide Clinical Emergency Response System

Standardised terminology and response times

Response teams tailored to facility resources

Implementation date 4/2/2019 same as 2222

Refer to local procedures for the following – ED, paediatrics and neonates

How does the key elements line up with survey responses - Did we listen?

33

26 24

17

9 6 5 3

05

101520253035

ClinicalJudgment of

nurses and juniormedical officer's

should not beundervalued.

Bettercompliance of

BTF andalteration criteria

Need for clearguidelines and

education acrossall disciplines

Standardescalation

pathway acrossthe WSLHD

Workload ofmedical officers

Clear mx plan forpatients by

treating team

Standard andeasy to

understandterminology

3 tier system

Nursing / Midwifery

Medical Officers

For nurses/midwives/allied health to be able to use clinical judgement as to when to a Clinical Review is called for patients in the yellow zone 55.42% 51.47%

To have the option for a Registrar / senior MO to review a patient in the red zone with not immediately life threatening observations/additional criteria 51.57% 71.32%

For each facility within WSLHD to have the same response times for Clinical Reviews 50.36% 50.74%

To have the same name for red zone calls at each facility within WSLHD 48.43% 63.24%

2222 New Statewide Internal Emergency

Number CODE RED FIRE OR SMOKE CODE BLUE MEDICAL

EMERGENCY CODE PURPLE BOMB THREAT CODE YELLOW INTERNAL

EMERGENCY CODE BLACK PERSONAL THREAT CODE ORANGE EVACUATION CODE BROWN EXTERNAL

EMERGENCY

New WSLHD CERS Framework Highlights Three tiers, Common calls, Clear response

Yellow Zone Breach • Clinical Review

Mandatory BEDSIDE review by Team Leader to determine if Clinical Review by Medical Officer is required.

Red Zone Breach Not Immediately Life Threatening • Rapid Response

Medical Officer(s) MUST proceed with urgency (AIM < 10 minutes) to complete a BEDSIDE review of the patient

Red Zone Breach Immediately Life Threatening • Code Blue/ ALS

Code Blue / ALS Team MUST proceed immediately to complete a BEDSIDE review of the patient

WSLHD Clinical Review Rapid Response CODE BLUE / ALS When Yellow Zone breach

Not immediately life threatening Red Zone breach

Immediately life threatening Red Zone breach

Action Mandatory BEDSIDE review by Team Leader/ Senior Nurse/Midwife on ward to determine if Clinical Review by Medical Officer is required.



Action Repeat Observations at minimum 30 minutes following Yellow Zone breach.

Repeat Observations at minimum 15 minutes following Rapid Response Call.

Action Medical Officer MUST review the patient: If patient remains in Yellow zone following repeat observations at 30 minutes. Within 30 minutes of Clinical Review request

If Medical Officer(s) have not attended the patient within 30 minutes a CODE BLUE / ALS MUST be activated

Escalate Escalate to Rapid Response or Code Blue/ ALS as appropriate if: Requested Clinical Review has not occurred and now > than 30 minutes since request Patient remains in Yellow Zone 1 hour post Clinical Review Patient has further deterioration while waiting for Clinical Review Patient has further deterioration post Clinical Review Patient has had two Clinical Reviews for yellow zone breach within 24 hours. There is additional Yellow or Red Zone criteria met and or there is concern/serious concern by you, the patient, staff member or family for the patients condition.

Escalate to Code Blue/ ALS if: Rapid Response has not occurred within 30 minutes Patient has further deterioration while waiting for Rapid Response Patient has further deterioration post Rapid Response

Responders Per facility Per facility Per facility

WSLHD CERS Response Matrix – Adult Inpatients (maternity included)

WSLHD CERS working group Version 2.0 January 2019

Swing Card Resource - ADULT Late signs of clinical deterioration

Side A Side B

Swing Card Resource – Maternity Late warning signs of deterioration

Side A Side B

Consequences? 27yrs male

Hx: Cystic Fibrosis + associated problems

Recurrent bowel obstructions, 2x previous laparotomy

Current admission: abdominal pain/?SBO

Findings under s 81 (1) of the Coroners Act 2009

Manner of death

“Failure to diagnose clinical deterioration whilst

receiving treatment…..”

“I find there was a failure in the monitoring and medical

reviews of Malay on the evening of 27 April and the early

morning of 28 April by medical and nursing staff…. That

failure to properly diagnose and provide adequate medical

treatment to Malay resulted in his clinical deterioration and

death” State Coroner Les Mabbutt

Dr Malay Rana R.I.P

Yellow Zone Breach – Clinical Review • 1st breach:

• Discretionary • Mandatory BEDSIDE review with Team Leader to determine if Clinical Review

required • Repeat observations within 30 minutes

• Still in the Yellow Zone - mandatory Clinical Review required • Response time: within 30 minutes • Activation processes as per local facility • Notifier to complete the Yellow Zone eForm for all Yellow Zone Breaches • Responders to complete the Clinical Review Responder eForm • Patient and family/carer notified:

• Clinical Review activated • Outcomes

• Attending Medical Officer notified • Observations or precipitation problem resolved within 1 hour - No

• Escalate to Rapid Response or Code Blue/ALS • If at any time the patient deteriorates you must immediately escalate to the next

Calling level

Forms in eMR – found in links at bottom of page

Yellow Zone eForm

To be completed for all Yellow Zone Breaches Replaces eMR contemporaneous documentation in patient progress notes If CERS call selected, appropriate eForm is launched

Clinical Review Responder eForm

To be completed by Responders reviewing a Yellow Zone Breach i.e Clinical Review

Replaces eMR contemporaneous documentation in patient progress notes

3 pages associated with form (top image page 1, Bottom image page 3)

Red Zone Breach: You determine Rapid Response or Code Blue/ALS?

Rapid Response

YES or “potentially” NO

Code Blue/ALS

Dial 2222

Dial 2222 AND

Press wall emergency button

Is your patients condition immediately life threatening?

Red Zone Breach – Rapid Response Not Immediately Life Threatening

• Observations or Additional Criteria in the Red Zone that are not immediately life threatening

• Name: Rapid Response

• 2222 to activate Rapid Response call

• Response Time: AIM <10 minutes within 30 minutes

• Repeat observations to occur within 15 minutes

• Responders per facility

• Provide treatment including an Arterial or Venous Blood Gas

• Notifier to complete Red Zone eForm when able

• Responder to complete Rapid Response Responder eForm

• Patient and Family/carer notified:

• Rapid Response activated

• What the outcomes where • Attending Medical Officer notified as soon as practicable • Observations or precipitation problem resolved within 1 hour - No

• Escalate Code Blue/ALS • If at any time the patient deteriorates you must immediately escalate to the next Calling level • Adult Resuscitation Chart (paper form) used if required

Red Zone Breach – Code Blue/ALS Immediately Life Threatening

• Observations or Additional Criteria in the Red Zone that is IMMEDIATELY life threatening

• Name: Code Blue/ALS • Response Time: IMMEDIATE to patient • Must precede immediately for Code Blue/ALS team bedside review • Repeat observations frequently (as appropriate) • Full team response - Responders per facility • Immediately attend the patient • Provide treatment/interventions and ongoing assessment • Notifiers must complete the Red Zone eForm • Responders must complete the Rapid Response Responder eForm • Live scribing using Adult Resuscitation Chart (paper form) required

Red Zone eForm To be completed by staff initiating call This form is used for both Rapid Response AND Code Blue/ALS Replaces eMR contemporaneous documentation in patient progress notes 2 pages associated with this form Note: serious concerns by Family/patient –demonstrates REACH call

Rapid Response Responder eForm Should be completed by medical registrar or medical team leader

To be completed by staff responding to call

Replaces eMR contemporaneous documentation in patient progress notes

3 pages associated with this form (only page 1 displayed)

This form is used for both Rapid Response AND Code Blue/ALS

Note: serious concerns by Family/patient –demonstrates REACH call

Red Zone Breach “Live” Documentation (Scribe)

Once signed by the medical officer, the Adult Resuscitation Chart is an endorsed prescription of medications administered during the resuscitation event.

Appendix D – Auburn Designated Responders Designated responders – Auburn Hospital Response Level How to activate In hours 08:00-16:30

Monday –Friday Levels 3, 4 & 5

In hours 08:00-16:30 Monday –Friday Levels 1, 2 & hospital grounds

Out of hours 17:00-08:00 Monday-Friday, weekends & public holidays Levels 1- 5 and hospital grounds

Clinical Review N.B. Clinician activating clinical review must be familiar with the clinical situation

In hours – Page Team Intern or Resident Medical Officer

Team Intern or Resident Medical Officer N.B. The Team Registrar must attend the patient if called by the Team Intern or Resident Medical Officer

After hours on duty Intern or Resident Medical Officer N.B. MOIC must attend the patient if called by the on duty Intern or Resident Medical Officer

After hours – Page on duty Intern or Resident Medical Officer

Rapid Response N.B. Do not call the Intern or Resident Medical Officer

Dial 2222 State:

• Rapid Response Call • Consultants name • Ward • Patient bed number • Callers Name • Ward telephone

number

The Primary Team Intern or Resident Medical Officer AND Registrar If the Registrar is unable to attend within 30 minutes they may nominate another Registrar from within the speciality to review the patient. If there is no available Registrar a Code Blue/ALS must be immediately initiated.

1. After hours on duty Intern or Resident Medical Officer

2. MOIC 3. COU ALS Nurse

Code Blue/ALS Dial 2222 State:

• Code Blue/ALS call • Ward • Patient bed number

Press wall emergency buzzer if available. N.B. Dial 111 still required when Emergency buzzer used

1. COU Hospitalist – Resuscitation Team Leader

2. Anaesthetic Registrar

3. Team Registrar 4. Team Intern or

Resident Medical Officer

5. COU ALS Nurse 6. Patient Flow

Manager 7. Wardsperson

1. COU Hospitalist – Resuscitation Team Leader

2. ED ALS Doctor – Resuscitation Team Leader for ED patients

3. Anaesthetic Registrar 4. ED Intern or Resident Medical

Officer as directed by ED Senior Medical Officer

5. ED ALS Nurse 6. Patient flow Manager 7. Wardsperson

1. MOIC – Resuscitation Team Leader

2. ED ALS Doctor – Resuscitation Team Leader for ED patients

3. ED Intern or Resident Medical Officer as directed by ED Senior Medical Officer

4. COU ALS Nurse 5. ED ALS Nurse 6. After hours Nurse Manager 7. Wardsperson

Key: MOIC: The Medical Officer in Charge COU: Close Observation Unit

Appendix E – Blacktown Designated Responders Designated responders – Blacktown Hospital Response Level How to activate In hours

08:00-17:00 Monday –Friday Out of hours 17:00-08:00 Monday-Friday, weekends & public holidays

Clinical Review Dial 2222 - State: • Clinical Review • Consultants name • Ward • Patient bed number

Team Registrar Medical Registrar or Surgical Registrar

Rapid Response Dial 2222 - State: • Rapid Response call • Consultants name • Ward • Patient bed number • Callers Name • Ward telephone

number Press staff assist wall button where available and if required

Team Registrar ALS nurse (see below for areas covered)

Medical Registrar or Surgical Registrar ALS nurse (see below for areas covered)

Cardiology ALS Nurse

ICU ALS Nurse ED ALS Nurse Cardiology ALS Nurse

ICU ALS Nurse

ED ALS Nurse

Clinical Services Building on levels 4, 5, 6, 7 (A and C Block)

ICU Operating theatres Building B 1, 2 and 4. Level 1 and 2 tunnels between Building B and Clinical Services Building (B Block)

Emergency Department, Level 3 in Clinical Services Building, All buildings on hospital grounds and surrounding areas including: Methadone clinic, Imaging department Link Bridges Hospital Street Melaleuca and Bungarribee House All other satellite buildings and/or units Hospital carparks

Clinical Services Building on levels 4, 5, 6, 7 (A and C Block)

ICU Acute Services Building (ASB) except ED and paediatrics All of level 3 internally B Block (Level 3 and 4)

Emergency Department, Level 3 in Clinical Services Building, All buildings on hospital grounds and surrounding areas including: Methadone clinic, Imaging department Link Bridges Hospital Street Melaleuca and Bungarribee House All other satellite buildings and/or units Hospital carparks

Code Blue/ALS Dial 2222 - State: • Code Blue/ALS • Ward • Patient bed number

Press wall emergency button if available

Team Registrar Medical Registrar or Surgical Registrar - Resuscitation Team Leader Anaesthetic Registrar ICU registrar – Resuscitation Coordinator ALS Nurse

Medical Registrar or Surgical Registrar - Resuscitation Team Leader Anaesthetic Registrar ICU registrar – Resuscitation Coordinator ALS Nurse HDM

Appendix F – Cumberland Designated Responders Designated responders – Cumberland Hospital Response Level

How to activate In hours 08:30-17:00 Monday –Friday

Out of hours 17:00-08:30 Monday-Friday, weekends & public holidays

Clinical Review

Page # Treating Medical Officer/Consultant

• Clinical Review • Consultants

name • Ward • Patient name and

location

Treating Team Medical Officer/Registrar

Duty Medical Officer/Code Blue Medical Officer

Rapid Response

Dial 2222 - State: • Rapid Response

call • Ward • Patient name and

location • Callers Name • Ward telephone

number Activate duress alarm

Code Blue Medical Officer Code Blue Staff:

• Willow unit • Waratah unit • Bunya unit

Security – transport staff/equipment to area.

Duty Medical Officer/Code Blue Medical Officer Code Blue Staff:


Security – transport staff/equipment to area.

Code Blue/ALS

Dial 2222 - State: • Code Blue/ALS • Ward • Patient name and

location • Ward telephone

number • Call 000 –

Ambulance Activate duress alarm

Code Blue Medical Officer Code Blue Staff:


Security – transport staff/equipment to area. Duty Nurse Manager Ambulance

Duty Medical Officer/Code Blue Medical Officer Code Blue Staff:


Security – transport staff/equipment to area. Duty Nurse Manager Ambulance

Appendix G – Mount Druitt Designated Responders Designated responders – Mount Druitt Hospital Response Level



Clinical Review

Dial 2222 - State: • Clinical Review • Consultants name • Ward • Patient bed number

Ward RMO Primary team

Ward RMO

Rapid Response

Dial 2222 - State: • Rapid Response call • Consultants name • Ward • Patient bed number • Callers Name • Ward telephone number

Press staff assist wall button where available and if required

ED MO Ward RMO Primary team ALS nurse

ED MO Ward RMO ALS nurse

Code Blue/ALS

Dial 2222 - State: • Code Blue/ALS • Ward • Patient bed number

Press wall emergency button if available

ED MO Ward RMO Primary team Anaesthetics ALS nurse

ED MO Ward RMO ALS nurse

Appendix H – Westmead Designated Responders Designated responders – Westmead Hospital Response Level



Clinical Review

Page RMO Clinician calling the resident must be familiar with the clinical situation

Team Resident Medical Officer

After hours Resident

Note: The Registrar must attend the patient if called by the RMO

Rapid Response

Dial 2222 State:

• Rapid Response call

• Consultants name • Ward • Patient bed number • Callers Name • Ward telephone

number Note: Do not call the intern or resident

The Primary Team Registrar or If the Registrar is unable to attend within 30 minutes they may nominate another Registrar from within the speciality to review the patient. If there is no available Registrar a Code Blue/ALS must be immediately initiated.

On site Registrar for Medical/Surgical/O&G This is determined by the Consultants name provided at the time of the Rapid Response call.

Code Blue/ALS

Dial 2222 State:

• Code Blue/ALS call • Ward • Patient bed number

Press wall emergency bedside button if available

1. ICU Registrar – Resuscitation Team Leader 2. Anaesthetic Registrar 3. Medical Registrar – Resuscitation Coordinator (for areas

covered see below) 4. Resident Medical Officer 5. 1 ALS Nurse

1. ICU Registrar – Resuscitation Team Leader 2. Anaesthetic Registrar 3. Medical Registrar – Resuscitation Coordinator

(for areas covered see below) 4. Resident Medical Officer 5. 1 ALS Nurse

Cardiology Registrar Emergency Department Registrar or Consultant

Cardiology Registrar Emergency Department Registrar or Consultant

a) Levels 3-6 main building b) Levels 3 & 4 G Block

(Women’s Health) including Delivery Suite.

a) Levels 1-2 in the main building

b) the hospital grounds and peripheral buildings

c) Levels 1 & 2 outpatients

d) Levels 1 & 2 G Block (Women’s Health)

e) Dental School all levels

a) Levels 3-6 main building

b) Levels 3 & 4 G Block (Women’s Health) including Delivery Suite.

a) Levels 1-2 in the main building

b) the hospital grounds and peripheral buildings

c) Levels 1 & 2 G Block (Women’s Health)

d) Dental School all levels

Altering calling Criteria In consultation with the AMO standard calling criteria can be altered for Yellow or Red Zone observations on the appropriate Standard Observation Chart.

Altered Calling Criteria should be considered for patients who have presented with:

an acute condition where their observations will fall outside the flags for a defined period of time while treatment is taking effect

a chronic condition whose normal observation parameters fall outside the flags

Altered calling criteria should be formally reviewed as per the time frames on the Standard Observation Charts by the Attending Medical Team.

SAGO chart within 72 hours or earlier if clinically indicated

SMOC chart within 36 hours or earlier if clinically indicated

Calling Criteria that is not reviewed within the timeframe designated should be considered to have reverted to the standard Yellow and Red Zone parameters for the chart in use at the review time specified on the altered calling criteria, or for the SAGO at 72 hours and the SMOC at 36 hour if the timeframe is not specified.

WSLHD Clinical Review Rapid Response CODE BLUE / ALS When Yellow Zone breach

Not immediately life threatening Red Zone breach

Immediately life threatening Red Zone breach

Action Mandatory BEDSIDE review by Team Leader/ Senior Nurse/Midwife on ward to determine if Clinical Review by Medical Officer is required.



Action Repeat Observations at minimum 30 minutes following Yellow Zone breach.

Repeat Observations at minimum 15 minutes following Rapid Response Call.

Action Medical Officer MUST review the patient: If patient remains in Yellow zone following repeat observations at 30 minutes. Within 30 minutes of Clinical Review request

If Medical Officer(s) have not attended the patient within 30 minutes a CODE BLUE / ALS MUST be activated

Escalate Escalate to Rapid Response or Code Blue/ ALS as appropriate if: Requested Clinical Review has not occurred and now > than 30 minutes since request Patient remains in Yellow Zone 1 hour post Clinical Review Patient has further deterioration while waiting for Clinical Review Patient has further deterioration post Clinical Review Patient has had two Clinical Reviews for yellow zone breach within 24 hours. There is additional Yellow or Red Zone criteria met and or there is concern/serious concern by you, the patient, staff member or family for the patients condition.

Escalate to Code Blue/ ALS if: Rapid Response has not occurred within 30 minutes Patient has further deterioration while waiting for Rapid Response Patient has further deterioration post Rapid Response

Responders Per facility Per facility Per facility

WSLHD CERS Response Matrix – Adult Inpatients (maternity included)

WSLHD CERS working group Version 2.0 January 2019

Summary Compliance with CERS reduces morbidity and mortality

Early escalation is vital and you do not require any authority or permission to escalate treatment

Adult Inpatient CERS Go Live 4/2/2019

Coincides with Internal Emergency Response Number (2222) State wide

Standardised terminology, escalation process and response times across the district.

Refer to Policy compliance Procedure for further details. Activation and Responder Team Details for each facility provided in appendix

Local contacts Auburn Hospital Blacktown and Mount

Druitt Hospitals Cumberland Hospital Westmead Hospital

Leah Fuller 0427 404 341 NE – simulation Auburn Hospital

Sue Maitland 0430 044 778 NE - Division 2

David Nicholls 98403528 Nurse Manager

Richard Conway 0422 008 342 CNC CERS

Additional Information

https://www.surveymonkey.com/r/WSLHDCERS-Feb2019

Intranet pages link

CSK codes – MyHealthLearning

Allied Health – CSK14601

Nursing – CSK14600

Medical – CSK 14599

Non-Clinical - 14598

https://www.surveymonkey.com/r/WSLHDCERS-Feb2019

Questions

WSLHD Clinical Emergency Response Systems (CERS) Framework

Documents

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