Samanatha Rankin - Royal Perth Hospital - STANDARD 9| Recognising and Responding to Deteriorating Data: Embedding a RRCD Program into Clinical Practice at a Tertiary Hospital

Recognising &

Responding to

Deteriorating Data:

Embedding a RRCD program into Clinical Practice in a Tertiary hospital setting

SAMANTHA RANKIN, RN, CHIA

STAFF DEVELOPMENT EDUCATOR, CLINICAL AUDIT

ROYAL PERTH HOSPITAL, WESTERN AUSTRALIA

The Big PictureSandia Peak, Albuquerque, New Mexico, USA – August 2014

Acknowledgments

JUDY SEE – RPH RRCD PROJECT OFFICER

DR. WILHELM SMITHIES – RPH CLINICAL LEAD

RPH DIRECTOR OF CLINICAL SERVICES

RPH RRCD STEERING COMMITTEE

RPH CLINICAL EDUCATORS, WARD LEADERS & AUDITORS

Standard 9:

Our RRCD journey

The first two years of work

Piloting charts, education and training,

monitoring data

Establishing governance and leadership

Changing the clinical culture toward early

warning systems

Developing clinically meaningful metrics

Setting standards and attaching role-based

accountability

Royal Perth Hospital, WA

An organisation in transition

www.rph.gov.au

• Currently the largest Tertiary hospital in WA

• 185 years as a public hospital

• ~ 730 adult multi-day beds

• Two campuses – City + State Rehab

• State Trauma & Burns centre

• Acute Mental Health service

• ~ 250 ED presentations daily

• Sees 2/3rds of rural aeromedical transfers

We are in the midst of change:

• Downsizing to a 450-bed specialist hospital

• Services transitioning to Fiona Stanley Hospital

• Reduction of units, teams and staff

http://www.rph.gov.au/

The Steering CommitteeHaving the right people in the room…

Senior clinical leadership

Executive sponsorship

Sufficient clinical expertise

Clinical Audit expertise

Strong links with:

Resuscitation committee

Clinical Safety & Quality

Senior Educators

Representation to area & state working groups

This evolved and changed over time

The importance of Clinical Audit

El Morro National Monument, New Mexico, USA – August 2014

Evaluate the system Check process adherence Monitor outcomes

Flag areas requiring action…

Engage clinicians with their data

Establish variability in practice

Identify pockets of excellence

Create performance trends

Benchmark & drive improvement

First Pilot & Escalation Mapping 2011

The trigger-happy rainbow

o Worked best in general

medicine and general

surgery

o Specialty areas

experienced challenges

with over and under

triggering of response

o Clinician feedback was

critical

o 2180 observation events

were prospectively

analysed – results aligned

with clinician and

operational experience

2012 – Enter the ADDS chart

The Adult Deterioration

Detection System was

considered a better

alternative for our site

Implemented over a 4 week

period with cascade training

support

Audited at 6 & 12 weeks

50% sample size (~300 charts)

Documentation compliance

Charting accuracy

Process adherence

Escalation of Care

Modifications

Clinical Audit Strategy

Clearly defined standards

Clinically relevant metrics

Cognisant of clinical risk

Congruent with NSQHS Standard 9 requirements

Rapid reporting & feedback

Resource efficient

Retaining a pool of trained auditors

Refining a standardised audit tool

Key elements of success?

Communication

Planning

Contingency

Simplicity

Pragmatism

Consideration of

clinical loads and

competing demands

Communication

Interesting findings:On any given day…

~ 40% of our patients trigger an EOC

90-95% of EOC's are ADDS score 1-3

Trigger rates double for patients on

oxygen

Key challenges involve:

Effective documentation of EOC

Safe practice for modification of care

Results & Reporting

Multiple levels of reporting:• Ward level

• Survey Monkey PDF extract• Service Level reports

• One and two-page dashboards• High-level reports

• Rolled up overall performance

Reporting is modified to meet stakeholder needs and align with area-level reporting benchmarks

Reporting templatesCompliance Measure Audit Period Jan-13 Feb-13 Jun-13 Sep-13 Dec-13 Mar-14 Jun-14

Numerator 0 0 0 0 0 0 0

Denominator 0 0 0 0 0 0 0

Compliance % #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

Numerator 0 0 0 0 0 0 0



Numerator 0 0 0 0 0 0 0



Numerator 0 0 0 0 0 0 0



Numerator 0 0 0 0 0 0 0



Numerator 0 0 0 0 0 0 0



Numerator 0 0 0 0 0 0 0



Numerator 0 0 0 0 0 0 0



Numerator 0 0 0 0 0 0 0



The monitoring plan is adhered to

= number where observations adhere to monitoring plan

---------------------------------------

number with a documented monitoring plan

Escalation of Care (EoC) actioned as per protocol

= number where EoC is actioned as per protocol

---------------------------------------

number where EoC is triggered

Modifications are authorised as per RPH guideline

= number Modifications with authorisation

---------------------------------------

number where Modifications are documented

Embedding Use of the A-ORC

= number with ADDS chart

---------------------------------------

number audited

Completeness of Observation Documentation(RPH - INCLUDES Pain & Urine Output observations)

= number with a complete set of Observations

---------------------------------------

number with A-ORC

Completeness of Observation Documentation (SMHS - EXCLUDES Pain & Urine Output observations)

= number with a complete set of Observations

---------------------------------------

number with A-ORC

Completion of ADDS score on last set of

observations = number with an ADDS score documented

---------------------------------------

number with A-ORC chart

Accuracy of ADDS on last set of observations = number with ADDS scored correctly

---------------------------------------

number with ADDS scored

A monitoring plan is documented

= number with a documented monitoring plan

---------------------------------------

number of patients with an A-ORC

Dashboard development

SERVICE RPH WARDTotal ADDS

charts audited

Full set of

observations

documented

(n)

% set of

observations

documented

ADDS score

documented

on last Obs

(n)

% ADDS score

documented

Monitoring

Plan in Place

(n)

% Monitoring

Plan in Place

Number with

Escalation of Care

in last 24 hrs

Care escalated

according to

escalation protocol

(n)

% Care escalated

according to

escalation protocol

Number with

Modifications

% Modifications

according to site

policy

1 3K #DIV/0! #DIV/0! #DIV/0! #DIV/0!

1 4F #DIV/0! #DIV/0! #DIV/0! #DIV/0!

1 6A #DIV/0! #DIV/0! #DIV/0! #DIV/0!

1 6G #DIV/0! #DIV/0! #DIV/0! #DIV/0!

1 9A #DIV/0! #DIV/0! #DIV/0! #DIV/0!

1 9B #DIV/0! #DIV/0! #DIV/0! #DIV/0!

1 9C #DIV/0! #DIV/0! #DIV/0! #DIV/0!

1 10A #DIV/0! #DIV/0! #DIV/0! #DIV/0!

1 10C #DIV/0! #DIV/0! #DIV/0! #DIV/0!

1 BMTU #DIV/0! #DIV/0! #DIV/0! #DIV/0!

1 CTUP #DIV/0! #DIV/0! #DIV/0! #DIV/0!

TOTAL SERVICE 1 0 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 0 #DIV/0! 0

2 4A4B #DIV/0! #DIV/0! #DIV/0! #DIV/0!


3 2K #DIV/0! #DIV/0! #DIV/0! #DIV/0!


4 S09/HDU #DIV/0! #DIV/0! #DIV/0! #DIV/0!

4 5A #DIV/0! #DIV/0! #DIV/0! #DIV/0!

4 5B #DIV/0! #DIV/0! #DIV/0! #DIV/0!

4 ASU/AMU2 #DIV/0! #DIV/0! #DIV/0! #DIV/0!

4 5G #DIV/0! #DIV/0! #DIV/0! #DIV/0!

4 5H #DIV/0! #DIV/0! #DIV/0! #DIV/0!

4 6H #DIV/0! #DIV/0! #DIV/0! #DIV/0!

4 7A #DIV/0! #DIV/0! #DIV/0! #DIV/0!

4 8A #DIV/0! #DIV/0! #DIV/0! #DIV/0!

4 AMU #DIV/0! #DIV/0! #DIV/0! #DIV/0!

4 BURNS #DIV/0! #DIV/0! #DIV/0! #DIV/0!

4 EMW #DIV/0! #DIV/0! #DIV/0! #DIV/0!

4 SMTU #DIV/0! #DIV/0! #DIV/0! #DIV/0!


5 S01 #DIV/0! #DIV/0! #DIV/0! #DIV/0!

5 S02 #DIV/0! #DIV/0! #DIV/0! #DIV/0!

5 S06/8 #DIV/0! #DIV/0! #DIV/0! #DIV/0!

5 S10 #DIV/0! #DIV/0! #DIV/0! #DIV/0!

5 S11 #DIV/0! #DIV/0! #DIV/0! #DIV/0!


TOTAL RPH 0 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 0 #DIV/0! 0

[xxx to xxx] Quarter 2014 - Summary of Performance Indicator Data

Standard 9: Recognising and Responding to Clinical Deterioration

Dashboard Development3K

4F

5A

5B

6A

6G

9A

9B

9C

10A

10C

BM

TU

CT

UP

4A

4B

2K

S09/H

DU

AS

U/A

MU

2

5G

5H

6H

7A

8A

AM

U

BU

RN

S

EM

W

SM

TU

S01

S02

S06/8

S10

S11

RP

H

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Co

mp

lian

ce %

Clinical Area

For last set of observations:Percentage of Complete Observations

3K

4F

5A

5B

6A

6G

9A

9B

9C

10A

10C

BM

TU

CT

UP

4A

4B

2K

S09/H

DU

AS

U/A

MU

2

5G

5H

6H

7A

8A

AM

U

BU

RN

S

EM

W

SM

TU

S01

S02

S06/8

S10

S11

RP

H

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Co

mp

lian

ce %

Clinical Area

Percentage of Patients with a Monitoring Plan

3K

4F

5A

5B

6A

6G

9A

9B

9C

10A

10C

BM

TU

CT

UP

4A

4B

2K

S09/H

DU

AS

U/A

MU

2

5G

5H

6H

7A

8A

AM

U

BU

RN

S

EM

W

SM

TU

S01

S02

S06/8

S10

S11

RP

H

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Co

mp

lian

ce %

Clinical Area

For last set of observations:Percentage of ADDS Scores Documented

3K

4F

5A

5B

6A

6G

9A

9B

9C

10A

10C

BM

TU

CT

UP

4A

4B

2K

S09/H

DU

AS

U/A

MU

2

5G

5H

6H

7A

8A

AM

U

BU

RN

S

EM

W

SM

TU

S01

S02

S06/8

S10

S11

RP

H

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Co

mp

lian

ce %

Clinical Area

Compliance with Escalation of Care Protocolin the highest scoring ADDS in past 24 hours

(Only in areas where EoC captured at audit)

Data Integration

Shared audit tool

MET call database

Incident management

Benchmarking between sites

Informing clinicians about

local clinical risks

Involving patients & carers

Summary thoughts

• Heuristic track & trigger

charts are the way that

we do business

• Bringing together expert

clinicians, clinical leaders

and educators has driven

cultural change

• More change is on the

horizon… so it’s a long

roadSalt River Canyon, Arizona-New Mexico border – July 2013

Business

Samanatha Rankin - Royal Perth Hospital - STANDARD 9| Recognising and Responding to Deteriorating Data: Embedding a RRCD Program into Clinical Practice at a Tertiary Hospital