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Standard 9: Recognising and Responding to Clinical Deterioration in Acute Health Care

Standard 9: Recognising and Responding to Clinical Deterioration in Acute Health Care. Nicola Dunbar, Accrediting Agencies Surveyor Workshop, 10 July 2012. Why have a Standard about recognising and responding to clinical deterioration?. Evidence base:

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Standard 9: Recognising and Responding to Clinical Deterioration in Acute Health Care

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  1. Standard 9: Recognising and Responding to Clinical Deterioration in Acute Health Care Nicola Dunbar, Accrediting Agencies Surveyor Workshop, 10 July 2012

  2. Why have a Standard about recognising and responding to clinical deterioration? • 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

  3. 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

  4. 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)

  5. The 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. • Two overarching Standards: • Standard 1: Governance for Safety and Quality • Standard 2: Partnering with Consumers

  6. Four criteria • 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

  7. 1. Establishing recognition and response systems • 9.1: Developing, implementing and regularly reviewing the effectiveness of governance arrangements and the policies, procedures and/or protocols that are consistent with the requirements of the National Consensus Statement • Why? • Systems for recognising and responding to clinical deterioration need organisational support and executive and clinical leadership to be successful • Recognition and response systems need to be embedded in governance frameworks to ensure that risks are identified and continuous improvement occurs

  8. 1. Establishing recognition and response systems • What? • Identify suitable individual / group / committee to take responsibility for governance of recognition and response systems (9.1.1) • Develop / adapt and implement policies and procedures across the organisation in the areas of (9.1.2): • measurement and documentation of observations • escalation of care • establishment of a rapid response system • communication about clinical deterioration

  9. 1. Establishing recognition and response systems • 9.2: Collecting information about the recognition and response systems, providing feedback to the clinical workforce, and tracking outcomes and changes in performance over time • Why? • Evaluation of new systems needed to establish efficacy and determine changes needed to optimise performance • Ongoing monitoring needed to track changes over time and ensure that systems operate effectively

  10. 1. Establishing recognition and response systems • What? • Develop and implement processes for: • collecting and using information from the workforce about recognition and response systems (9.2.1) • reviewing deaths and cardiac arrests in patients without treatment-limiting orders (9.2.2) • providing data about recognition and response systems to clinical workforce in a timely way (9.2.3) • Use data from recognition and response systems to improve performance (9.2.4)

  11. 2. Recognising clinical deterioration and escalating care • 9.3: Implementing mechanism(s) for recording physiological observations that incorporate triggers to escalate care when deterioration occurs • Why? • Including track and trigger systems in observation charts streamlines identification of deterioration and action • Charts designed according to human factors principles –faster and more accurate in identifying deterioration • What? • Put in place a general observation chart that meets the criteria specified in the standard (9.3.1) • Audit completion of observation charts (9.3.2) • Take action to improve completion of observation charts (9.3.3)

  12. 2. Recognising clinical deterioration and escalating care • 9.4 Developing and implementing mechanisms to escalate care and call for emergency assistance where there are concerns that a patient’s condition is deteriorating • Why? • Escalation policies and protocols that contain information about what to do if deterioration occurs reduce the risk of delays in providing appropriate care • What? • Put in place systems for escalating care and calling for emergency assistance (9.4.1) • Develop and implement mechanisms to evaluate escalation processes (9.4.2) • Take action to improve escalation processes (9.4.3)

  13. 3. Responding to clinical deterioration • 9.5 Using the system in place to ensure that specialised and timely care is available to patients whose condition is deteriorating • Why? • 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 • What? • Agree on criteria for calling for emergency assistance and include in escalation protocol (9.5.1) • Develop and implement mechanisms to review calls for emergency assistance (9.5.2)

  14. 3. Responding to clinical deterioration • 9.6 Having a clinical workforce that is able to respond appropriately when a patient’s condition is deteriorating • Why? • Treatment of deterioration can be delayed if workforce cannot identify deterioration and do not know how to respond • What? • Develop / adapt / provide access to basic life support training (9.6.1) • Develop and implement mechanism that ensure access at all times to at least one clinician who can practise advanced life support (9.6.2)

  15. 4. Communicating with patients and carers • 9.7 Ensuring patients, families and carers are informed about, and are supported so that they can participate in recognition and response systems and processes • Why? • 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 • What? • Develop / adapt mechanisms for informing patients, families and carers about how to raise potential concerns about deterioration and the importance of doing so (9.7.1)

  16. 4. Communicating with patients and carers • 9.8 Ensuring that information about advance care plans and treatment-limiting orders is in the patient clinical record, where appropriate • Why? • Advance care preferences and treatment-limiting decisions need to be considered when responding to deterioration • What? • Develop and implement a mechanism for receiving and preparing advance care plans in partnership with patients, families and carers (9.8.1) • Document advance care plans and other treatment-limiting orders in the clinical record (9.8.2)

  17. 4. Communicating with patients and carers • 9.9 Enabling patients, families and carers to initiate an escalation of care response • Why? • Patients experience delays in treatment despite reporting concerns about deterioration • Families and carers are well placed to identify signs of deterioration • What? • Put in place systems for patients, families and carers to independently escalate care (9.9.1) • Provide information about family escalation of care (9.9.2) • Review performance of family escalation system (9.9.3) • Take action to improve family escalation system (9.9.4)

  18. General issues – 1 • 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 • Documentation could include: • committee papers and terms of reference • clinical / organisational governance frameworks • position descriptions

  19. General issues – 2 • Nature of the recognition and response systems can vary depending on: • Size and location of the health service • Nature of health services provided (eg ICU vs no ICU) • Nature and skill mix of workforce (eg no on-site doctors) • Some jurisdictions have programs in this area – will determine nature of recognition and response systems: • NSW – Between the Flags • Queensland – Recognition and Management of the Deteriorating Patient (RMDP) • ACT – Compass • WA – Recognising and Responding to Clinical Deterioration (RRCD)

  20. General issues – 3 • The structure of most criteria is to: • Develop and implement a policy / protocol / process • Audit / review effectiveness of process • Undertake improvement processes based on audit results

  21. General issues – 4 • Documentation of these steps: • Development and implementation of policy / protocol / process: • policy documents, protocols, tools, templates, materials to inform workforce and patients • Audit / review effectiveness of process: • policies / protocols about audit processes • evaluation plans and audit schedules • reports on audits / reviews • Undertake improvement processes based on audit results: • documentation of quality improvement processes • examples of actions and improvement activities • training and education material and records • feeding back information to workforce

  22. General issues – 5 • What data collection processes need to be in place? • 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

  23. General issues – 6 • What data collection processes need to be in place? (cont) • 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

  24. Specific issues – 1 • Policies, procedures and protocols required (9.1.2): • Measurement and documentation of observations: • minimum frequencies and duration for core observations in all acute care areas • additional observations or assessments for specific patient groups • process for documenting a monitoring plan for all patients • observation charts that include a track and trigger system (9.3.1)

  25. Specific issues – 2 • Policies, procedures and protocols required (9.1.2) (cont): • Escalation of care: • escalation policy – level of care that can safely be provided, when care should be escalated to a higher level, location and availability of services (9.4.1) • escalation protocol with a graded response system – including escalation based only on concern (9.4.1) • processes to individualise triggers and responses for patients with treatment-limiting orders • processes for informing patients, families and carers about how to escalate care (9.7.1)

  26. Specific issues – 3 • Policies, procedures and protocols required (9.1.2) (cont): • Rapid response systems: • protocol that outlines use of rapid response system included in escalation protocol (9.5.1) • emergency assistance treatment protocols and algorithms • use of agreed communication processes when deterioration occurs • Clinical communication: • roles and responsibilities related to communication included in the escalation protocol (9.4.1) • processes for communicating with patients, families and carers about deterioration

  27. Specific issues – 4 • Observation chart that: (i) is designed according to human factors principles; (ii) includes capacity to record observations graphically (iii) includes a track and trigger system (9.3.1): • Focus is on general observation charts – not charts for specific clinical areas (such as neurovascular, cardiothoracic etc) • For specialist hospitals – these may require paediatric and obstetric charts

  28. Specific issues – 5 • Observation chart that: (i) is designed according to human factors principles; (ii) includes capacity to record observations graphically (iii) includes a track and trigger system (9.3.1): • 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

  29. ACT NSW Qld WA

  30. Specific issues – 8 • Observation chart that: (i) is designed according to human factors principles; (ii) includes capacity to record observations graphically (iii) includes a track and trigger system (9.3.1): • Demonstration of testing of chart is a complex process that should: • involve evaluating performance of alternative versions of the chart on key functions (such as ability of clinicians to identify abnormal observations) • be conducted with appropriate methodology to ensure results are reliable – specialist advice may be required (Commission has a fact sheet on the required process)

  31. Specific issues – 9 • Clinical workforce trained and proficient in basic life support (9.6.1): • All clinicians should be able to implement basic life support measures – doctors, nurses and allied health • Does not need to be developed or delivered internally – there are many external providers • As well as training records and attendance records, documentation should also include records of achievement of competency

  32. Specific issues – 10 • Access at all times to at least one clinician who can practise advanced life support (9.6.2): • Models for rapid response systems that ensure this kind of expertise vary depending on context and can include: • 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 • retrieval services • Documentation can include: • records of currency of advanced life support certification • rosters or evidence that demonstrates 24 hour access to clinician

  33. Specific issues – 11 • Providing information to patients, families and carers (9.7.1): • Documentation can include: • material for patients, families and carers about how to raise concerns about deterioration and the importance of doing so • policies about processes for involving patients, families and carers in communication about deterioration, eg during rounds, bedside handover

  34. Specific issues – 12 • Advanced care plans and treatment-limiting orders (9.8.1, 9.8.2): • Most states and territories have legislation and policy regarding advanced care directives that will need to be reflected in local policies and processes • Need to demonstrate policies and processes for: • receiving advanced care plans that have been developed elsewhere (such as in the community, with a GP) • developing new advanced care plans within the health service • involving patients, families and carers in the development of the advanced care plan • documenting the advanced care plan in the patient’s clinical record • Standard covers both advanced care plans and other treatment-limiting orders - eg NFR, DNR etc

  35. Specific issues – 13 • Family escalation of care (9.9.1 – 9.9.4): • 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

  36. Specific issues – 14 • Family escalation of care (9.9.1 – 9.9.4): • Documentation should include: • policies and procedures that describe process for family escalation • information for patients, families and carers about when and how to escalate care and call for assistance • evaluation plans and audit schedules for reviewing the effectiveness of family escalation processes • data from reviews of family escalation processes – including reviews of calls and views of patients and families • training materials for staff about family escalation • actions taken to improve family escalation processes following review

  37. 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

  38. 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

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