Introduction to Standard 9: Recognising and Responding to Clinical

Deterioration in Acute Health Care

Nicola DunbarProgram DirectorApril 2013

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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

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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

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Criteria to achieve the Standard

1. 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

2. Recognising clinical deterioration and escalating care• Patients whose condition is deteriorating are recognised and appropriate

action is taken to escalate care

3. Responding to clinical deterioration• Appropriate and timely care is provided to patients whose condition is

deteriorating

4. 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

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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)

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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

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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

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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

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Structure of Standard 9

9.1, 9.2 Organisation-wide systems for recognising and responding to clinical deterioration

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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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