Recognising and Responding to Clinical Deterioration in Acute Health Care

Introduction to Standard 9: Recognising and Responding to Clinical Deterioration in Acute Health Care Nicola DunbarProgram DirectorApril 2013

The Standard • Standard: • Health service organisations establish and maintain systems for recognising and responding to clinical deterioration. Clinicians and other members of the workforce use the recognition and response systems. • Intent: • To ensure that a patient’s deterioration is recognised promptly and appropriate action is taken • Context: • To be applied in conjunction with Standard 1: Governance for Safety and Quality and Standard 2: Partnering with Consumers • Does not apply to deterioration in a patient’s mental state

Rationale for the Standard • Evidence base: • deterioration is not always recognised or acted on • there are early warning signs • early intervention can improve outcomes for patients • there are well-established strategies that can be implemented • Processes of recognising and responding to clinical deterioration are relevant across the hospital – therefore need a systems approach to address

Criteria to achieve the Standard • Establishing recognition and response systems • Organisation-wide systems consistent with the National Consensus Statement are used to support and promote recognition of, and response to, patients whose condition deteriorates in an acute health care facility • Recognising clinical deterioration and escalating care • Patients whose condition is deteriorating are recognised and appropriate action is taken to escalate care • Responding to clinical deterioration • Appropriate and timely care is provided to patients whose condition is deteriorating • Communicating with patients and carers • Patients, families and carers are informed of recognition and response systems and can contribute to the processes of escalating care

Definitions • Recognition and response systems: • Formal systems to support staff to promptly and reliably recognise patients who are deteriorating and to respond appropriately to stabilise the patient • Track and trigger system: • Tracks changes in physiological parameters over time, includes thresholds for each parameter that indicates abnormality, and describes the response or action when deterioration occurs • Escalation protocol: • Protocol that sets out the organisational response required for different levels of physiological abnormality or other deterioration • Rapid response system: • System for providing emergency assistance to patients whose condition is deteriorating (such as medical emergency team)

Developmental and not applicable actions • Developmental: • Action 9.3.1: use of a general observation chart that has specified characteristics • Item 9.7: informing patients, families and carers • Item 9.8: advance care plans and treatment-limiting orders • Item 9.9: patient and family escalation • Not applicable: • Standard 9 not applicable for specialist, non-acute, mothercraft hospitals or services (meets requirements under Action 1.8.3) • Items 9.7-9.9 may not be applicable for day procedure services

Context • National Consensus Statement endorsed by Health Ministers in 2010: • sets out essential elements for recognising and responding to clinical deterioration: • measurement and documentation of observations • escalation of care • rapid response systems • clinical communication • organisational supports • education • evaluation, audit and feedback • technological systems and solutions • relates to situations where a patient’s physical condition is deteriorating • applies to all patients in an acute healthcare facility

Context • Flexible standardisation: • Standardisation of processes is an important way of improving safety and quality • Needs to reflect context of the health service • Contextual issues that will affect the systems that are put in place to meet Standard 9 include: • type and size of health service – small or large hospital, day procedure • nature of services provided – ICU, no ICU • nature and skill mix of workforce – are doctors on site 24/7? • existing policies and programs – eg. Between the Flags, Compass, RMDP etc • Don’t need to have separate processes and systems for each action in the Standard – consider how activities fit together to coordinate evidence and outcomes

Structure of Standard 9 9.3, 9.4 Recognising clinical deterioration and escalating care 9.5, 9.6 Responding to clinical deterioration 9.7-9.9 Communicating with patients and carers Put the system in place Audit / review performance of or compliance with the system Make improvements based on the results of the audit 9.1, 9.2 Organisation-wide systems for recognising and responding to clinical deterioration

Organisation-wide systems for recognising and responding to clinical deterioration • Recognition and response systems are relevant across the whole hospital: • overarching governance and policy framework should exist at an organisation-wide level • there may also be local (department / ward) policies in place about local recognition and response processes • examples of where responsibility can sit: • senior executive clinical leaders (both medical and nursing) • clinical governance and/or quality committees • emergency response / resuscitation committees • Need a systematic approach: • embedded into clinical governance arrangements • tailored to local circumstances • covering all essential elements in Consensus Statement

Observation charts • Action 9.3.1 relates to general observation charts: • does not include charts for specific clinical areas – such as neurovascular, cardiothoracic etc • for specialist hospitals – these may require specialist paediatric and obstetric charts • What chart to use: • for jurisdictions that have a state-wide chart, use of this chart is acceptable: • NSW, Qld, ACT, WA (SA coming soon...) • the Commission has developed four charts that can be customised for local use – these are acceptable • also have a chart that has been developed for and trialed in day procedure hospitals • for other charts – sites need to demonstrate how they have tested the chart to ensure its safety • Fact sheets available on the Commission’s web site

Escalation protocols • Escalation policies and protocols that contain information about what to do if deterioration occurs reduce the risk of delays in providing appropriate care • Escalation protocol needs to: • be tailored to the facility – size, location, skill mix, resources • included a graded response – different types of responses depending on the level of abnormality • include an option for emergency assistance • include an option for clinicians to escalate care based only their concern for the patient • be regularly reviewed

Escalation protocols • Developing triggers and responses for an escalation protocol: • How many levels of abnormality? • What physiological observation thresholds trigger abnormality? • What actions/treatments are required? • Who can provide this treatment? • Responsibilities of responding clinicians? • How will the system operate? • Planning tool on the Commission’s web site

Rapid response systems • Need a system to provide appropriate emergency assistance in a timely way when severe deterioration occurs • Rapid response systems have been shown to reduce cardiac arrests, unplanned ICU admissions, and deaths • Models for rapid response systems: • medical emergency teams / rapid response teams • ICU liaison / critical care outreach • nursing and medical staff trained in advanced life support – ED, anaesthetics etc • advanced practice nursing roles • local GPs or VMOs • local ambulance

Clinical workforce that can respond • Everyone needs to know how to call for emergency assistance • All clinicians should be able to implement basic life support while waiting for emergency assistance: • includes nurses, allied health providers, doctors • Non-technical skills also important – leadership, team work, communication, task management • A system needs to be in place to ensure access at all times to at least one clinician who can practice advanced life support • Need to maintain competency – Commission does not specify how this should occur

Communicating with patients and carers • Why is this important? • patients, families and carers are part of the healthcare team and can help ensure best understanding of clinical circumstances • patients, families and carers generally want to know when deterioration is occurring • Communication with families and carers about: • the importance of communicating concerns and signs/symptoms of deterioration • how they can raise their concerns • local systems for responding to deterioration • Opportunities for communication: • on presentation in acute care • at regularly scheduled intervals during admission • during healthcare team rounds • during bedside handover

Advance care plans and treatment-limiting orders • Advance care preferences and treatment-limiting decisions need to be considered when deterioration occurs • Most states and territories have legislation and policy regarding advanced care directives that will need to be reflected in local policies and processes • Standard covers both advanced care plans and other treatment-limiting orders - e.g. NFR, DNR etc

Family and patient escalation of care • Patients experience delays in treatment despite reporting concerns about deterioration • Families and carers are well placed to identify signs of deterioration • New models of family escalation now being introduced: • what are the triggers for families to escalate care • how will the response be activated • what will the response be • how to inform about the new system

Family and patient escalation of care • More than existing processes for calling for assistance – such as the call bell • Is a formal process that acts in a similar way to escalation protocols triggered by health professionals • Patient, family member or carer can escalate care directly to request review / emergency assistance • Should be built into existing recognition and response system

Data collection processes • Collection of feedback from clinical workforce (9.2.1): • surveys, focus groups to get information from a number of people • peer review processes such as morbidity and mortality meetings to get feedback on individual events • Review of cardiac arrests and deaths without a treatment-limiting order (9.2.2): • routine reviews of in-hospital cardiac arrests • reviews of unexpected deaths to identify failures of escalation and systems issues • identification of patients with and without a treatment-limiting order • Completion of observation charts (9.3.2): • audits of observation charts against local policy and monitoring plan

Data collection processes • Use of escalation processes, including failures to call and calls for emergency assistance (9.4.2, 9.5.2): • audit of observation charts to identify triggers for escalation and actions taken • number and circumstances of rapid response calls • outcomes measures such as cardiac arrests, unplanned admissions to ICU, deaths • Performance of family escalation processes (9.9.3): • surveys, interviews, focus groups to get information about knowledge and views of patients, families and carers, and workforce • records of family escalation calls • clinical record regarding circumstances of calls • Quality measures and audit tools are on the Commission’s web site

Resources • Safety and Quality Improvement Guide for Standard 9 • National Consensus Statement – and supporting implementation guides • Observation charts • Fact sheets, planning and audit tools • Jurisdictional programs

Summary • Recognising patients whose condition is deteriorating and responding to their needs in an appropriate and timely way are essential components of safe and high quality care • Purpose of the Standard is to improve outcomes for patients by ensuring that there is a systematic approach in place for recognising and responding to clinical deterioration • Outcomes to be achieved are clear – methods to get there will vary depending on context

Recognising and Responding to Clinical Deterioration in Acute Health Care