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Lynette Adams, Principal Project Officer, Patient Safety Unit, QLD Healthdelivered this presentation at the 2013 Managing the Deteriorating Patient conference. The management of patients in clinical deterioration has become a chief concern for Australian hospitals, with a patient’s potential for deterioration existing in every hospital ward and health service across the country. This annual event focusses on improving education for staff caring for these patients, and improving the policies and protocols in place to maintain patient safety. For more information, please visit the event website: www.healthcareconferences.com.au/deterioratingpatients
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Early Warning and Response System Tools
and Hospital in the Home
Patient Safety Unit, HSIB
Overview
• CEWT and Q-ADDS development
• HITH
– Background
– Development CEWT and Q-ADDS HITH
– Trial
– Outcomes
– Lessons
• Future work
Background
• Children’s Early Warning Tool (CEWT)
• Queensland- Adult Deterioration Detection
System (Q-ADDS)
Children’s Early Warning Tool
(CEWT)
Blue Sky View
Tertiary Paediatric Facility
• CEWT
• Admissions unit
•Outreach / MET team
• HDU
• PLS / APLS
Regional Paediatric Facility
• CEWT
• Adult ICU links
• Admissions unit
•HDU / telepaediatric bed
• PLS / APLS
Rural Paediatric Facility
• CEWT
• PLS / APLS
Retrieval service
Retrieval service
Telepaediatrics
Clinical networks
Telepaediatrics
Clinical networks
Paediatric Mortality Committee
Bronchiolitis <1yr (mean +/- CI95%)
0
1
2
3
4
5
6
7
8
9
10
0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48
Time (hours)
CE
WT
sco
re
PICU n=34
Retrospective no PICU n=23
Prospective no PICU n=86
Retrieval n=17
Median ICU admission time P < 0.05
Bronchiolitis < 1yr PICU vs no PICU: Respiratory Rate (mean +/- CI 95%)
0
10
20
30
40
50
60
70
80
90
100
0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57
Time (hours)
Resp
irato
ry r
ate
(b
reath
s/m
in)
Retrospective PICU n=19
Retrospective - No PICU n=12
Prospective no PICU n=86
Median ICU admission time
0
20
40
60
80
100
120
0 10 20 30 40 50 60 70
Time (hours)
Re
sp
ira
tory
ra
te
Bronchiolitis <1yr: PICU vs no PICU Heart Rate
80
90
100
110
120
130
140
150
160
170
180
0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57
Time (hours)
Hea
rt r
ate
(b
ea
ts/m
in)
Retrospective - PICU n=19
Retrospective - No PICU n=12
Prospective n=86
Median ICU admission time
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0 0.2 0.4 0.6 0.8 1
Sen
siti
vity
1 - specificity
ROC curves: Australasian Paediatric response tools (patients, bronchiolitis<1yr)
CEWT
MET
BTF
Paed Compass
Maximum CEWT score
0
100
200
300
400
500
600
0 1 2 3 4 5 6 7 8 9 10 11 12 13
CEWT score
Pa
tie
nts
83%
n =1886
Split the under ones?
0
10
20
30
40
50
60
70
Re
sp
ira
tory
ra
te (
bre
ath
s/m
in)
Time (Hours)
Bronchiolitis Respiratory Rate <4mths vs. 4-12 mths
RR <4 mths
RR <4mths
RR 4-12 mths
RR 4-12 mths
0
20
40
60
80
100
120
140
160
180
0 1 2 3 4 5 6 7 8 9 101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
< 4 months
4 to 12
Bronchiolitis HR <4/12 vs >4/12
Q-ADDS
Variants
• Emergency Department (adult trial; RR/PHC trial)
• Mental Health
• Maternity (trial)
Hospital in the Home (HITH)
• Care in community setting
• Acute conditions -clinical governance,
monitoring &/or input
• Otherwise require treatment in inpatient
hospital bed.
• Similar standard of care
HITH-Patient and system
benefits
• Patients improved outcomes & recovery at
home, fewer complications1
• Qld target- 1.5% of total hospital
separations HITH (0.3% 2012, 0.6% 2013)
• Significant growth required
• Outsourcing of services
1- Deloitte Access Economics 2011
HITH
• Nurse
• Medical Officer and/or
• Allied health professional
• Admin
• Daily or twice daily service -7 days
DRGs
• cellulitis;
• venous thrombosis;
• pulmonary embolus;
• respiratory infection/inflammation;
• chronic obstructive pulmonary disease
(COPD);
• knee replacement.
Safety-Patient cared for by HITH
• Phone MO- Saturday- “Sit on them”
• Phone MO- Sunday “Team can review tomorrow”
• Monday- renal failure due to medication allergy
• RCA – EWARS would have flagged
– Clinicians involved thought EWARS would have been beneficial
– Using inpatient EWARS tool or NO observation tool
Safety
• Receive equivalent care
– Screening & assessment
– Education- patients/ carers & staff
– 24 hr phone support
– Introduce a HITH specific EWARS
Needs of HITH EWARS
• CEWT or Q-ADDS scoring “guts”
• Responses tailored to HITH
• Interface smoothly with inpatient CEWT and Q-ADDS
• Address Pain assessment and analgesia
• Human factors design principles
Development
• Statewide working group
• Steering Committee
• Guidance on what could / could not be
changed
• Clinician engagement
• Explanation of decisions
• Patient Safety to approve
Actions for HITH
Total CEWT Score
• Minimum daily full CEWT score
Total CEWT Score 1–3
• Manage anxiety / fever / pain (pain tool overleaf)
• Review oxygen requirement (if applicable)
• Notify medical officer for advice
• Educate patient/carer regarding signs of deterioration
• Notify team leader / nurse manager
• Document interventions
Total CEWT Score 4–5
• Consider anaphylaxis and follow local
protocol
• Notify medical officer of planned transfer for
face-to-face medical officer review (seek
advice on transfer method)
• Stay with patient until transfer
• Obtain a full CEWT score at least every 30
minutes
• Notify team leader / nurse manager
• Document interventions
HITH
trial
sites
Audit results
• Modifications (chronic) rare 1.6%
• Patient identification- 85% all pg
Observation completeness (n=129)
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
Respiratory Rate O2 Saturation O2 Flow Rate Systolic BP Heart Rate Temperature Consciousness
Highest HITH score (n=129)
Pain score with obs (n=129)
EWARS Score accuracy %
129 2250 1500 349
Score inaccurate
Feedback
• Report of scores triggering patient medical
r/v & admission to hospital
• Staff report
– “really beneficial”,
– “flag patients earlier than they would pick for
review” (+ve way)
– “actions are really helpful & relevant”
– “clear trend helpful”
– “move specific obs near main obs”
– “calling a discretionary for scores ≤3”
Lessons
• Importance of involving local clinicians
• Adaptations can go well
• Audits-(1 pt score 4- rest 0 however 20
incorrect score)
• Continued supply of EWARS post trial
Future work
HR
Te
mp
R
R
BP
U
.O.
Hb
Pa
in
Acknowledgements • HITH- Laureen Hines, Amanda Kivic & HITH
clinicians
• Kevin McCaffery,
• PSU- Shaune Gifford, Kate Smith, Jillann
Farmer, Rowena Richardson, Alexis Stockwell,
Matt Page, Hamish Yeates
• UQ- Marcus, Mark, Andrew, Megan and Melanie
• Steering Committee, working groups and
clinicians
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