A / Prof Arthas Flabouris - Queensland Health RRCD - OPENING KEYNOTE ADDRESS | Observing the Observation Chart - The Introduction of a Multi-Tiered Patient Observation Chart

Observing the Observation Chart

Introducing a Multi-tiered Patient Observation Chart

A/Prof Arthas Flabouris

Intensive Care Unit, Royal Adelaide Hospital

[email protected]

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Occurrence of RR > 36 within the 24 hour period prior to events (columns labelled with actual documented RR).

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Occurrence of SBP<90 mmHg within the 24 hour period prior to events (columns labelled with actual documented SBP).

Trinkle RM, et al. Resuscitation 2011;82:810-14

Recognizing and Responding to Clinical Deterioration

• Adult general observation chart • a system for recording patient observations

• a system for displaying thresholds for each observation

• specifies escalation of care when threshold is encroached.

• Designed to record • Respiratory Rate

• Oxygen saturation

• Heart Rate

• Blood Pressure

• Temperature

• Consciousness Level

Observation Charts

Observation charts design is important to how vital signs are recorded and failure to interpret and detect critical values Five different charts within one hospital, found that the design of the charts had a significant effect detection of patient deterioration

Chatterjee MT, et al. Postgraduate Medical Journal. 2005;81:663-6. Preece MHW, et al. Resuscitation 2012;83:1111-1118

Post Track and Trigger Systems

• Implementation of MEWS and MET using COMPASS education program

• Increased vital sign recordings in post ICU discharge group, but not for unplanned admissions

• 25% of observations not recorded in full • Hammond N, et al. Australian Critical Care, 2013:26;18-22

• Only 38% of patients with abnormal MEWS were escalated

• Niegsch M, etal PLoS ONE 8(7):e70068

Observation Charts

Recording Patient Observations

Observation of Patient Observation Charts

Incidence (N=206 patients)

Prevalence (N=416 patients)

Gender (Female) 98 (52.4%) 210 (50.4%)

Age (median, IQR) 72 (59, 85) 76 (62, 85)

NFR 69 (33.5%) 95 (22.8%)

Medical Surgical

135 (65.5%) 71 (34.5%)

321 (77.2%) 95 (22.8%)

Patient Observation Charts - Triggers



MER Trigger 83 (40.3%) 17 (4.1%)

MDT Trigger 103 (50%) 45 (10.8%)

Nurse Trigger 154 (74.8%) 178 (42.8%)

Any Trigger 166 (80.6%) 193 (46.4%)

Incidence (N=3465 triggers)

Prevalence (N=559 triggers)

MER Trigger 285 (8.2%) 34 (6.1%)

MDT Trigger 825 (23.8%) 87 (15.6%)

Nurse Trigger 2355 (68%) 438 (78.4%)

Patient Observation Charts - Triggers

Incidence (All patients N= 206)

Hospital Discharge Alive

(N=177)

Hospital Discharge Dead

(N=29)

P value

MER Trigger 64 (36.2%) 21 (72.4%) <0.001

MDT Trigger 80 (45.2%) 23 (79.3%) 0.001

Nurse Trigger 128 (72.3%) 25 (86.2%) 0.113

Any Trigger 140 (79.1%) 26 (89.7%) 0.183

Impact of Patient Observation Charts

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RRT calls by 1000 Overnight stay

45.1 calls/1000 OS

82.7 calls/1000 OS


• 14.3 -> 21.2/1000 hospital admissions increase in RRT activity

• Almost twice as many more calls for patients who were admitted to hospital within 24 hours and for patients who were transferred from acute care areas within 24 hours

• Almost three times as many more repeat calls for the same patient

• Amit Kansal, et al. Crit Care Resusc 2012; 14: 38–43

Patient Observation Charts - Calls



MER Call 62 (30.1%) 7 (1.7%)

MDT Call 63 (30.6%) 19 (4.6%)

Nurse Call 92 (44.7%) 48 (11.5%)

Any Call 122 (59.2%) 60 (14.4%)



MER Call (% MER Triggers) 99 (34.7%) 8 (23.5%)

MDT Call (% MDT Triggers) 180 (21.8%) 26 (29.9%)

Nurse Call (% Nurse Triggers) 330 (14%) 74 (16.9%)

Any Call (% all Triggers) 609 (17.6%) 108 (19.3%)

Patient Observation Charts - Calls


Hospital Discharge

Alive (N=177)

Hospital Discharge

Dead (N=29)

P value

MER Call 49 (27.7%) 12 (41.4%) 0.134

MDT Call 53 (29.9%) 11 (37.9%) 0.389

Nurse Call 82 (46.3%) 9 (31%) 0.124

Any Call 102 (57.6%) 20 (69%) 0.249


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Daily Distribution of RRT Calls

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Criteria for RRT Calls - Pre and Post Chart

HighResp Pulse140

SBP80_90 LowConsciousness

Worried_All Pulse40

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Criteria for RRT Calls - Pre and Post Chart

HighResp Pulse140

SBP80_90 LowConsciousness

Worried_All Pulse40


Amit Kansal, et al. Crit Care Resusc 2012; 14: 38–43


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Cardiac Arrests, Unanticipated Intensive Care admits and Deaths by 1000 Overnight stay

CA calls by 1000 Overnight stay ICU_by1000Overnight_stay Deaths_by1000Overnight_stay

3.3 vs 3.2 calls/1000 OS, p=0.65

16.8 vs 17.2 admits/1000 OS, p=0.72

22.5 vs 22.8 deaths/1000 OS, p=0.71


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Outcome of RRT Call

Died ICU-SDU LeftInWard

68 year old male admitted to ICU from ED with pneumonia Extubated 4 days ago No other organ failure Mobile to chair RR=26 SaO2=96% O2=3L/nasal specs SBP=130 PR=102 GCS=15 Ready for ward?

Patient observation charts - Modifications



MER Modification 30 (14.6%) 11 (2.6%)

MDT Modification 58 (28.2%) 21 (5%)

Nurse Modification 66 (32%) 57 (13.7%)

Any Modification 91 (44.2%) 72 (17.3%)



MER Modification (% MER Triggers) 122 (42.8%) 23 (67.6%)

MDT Modification (% MDT Triggers) 325 (39.4%) 41 (47.1%)

Nurse Modification (% Nurse Triggers) 624 (26.5%) 156 (35.6%)

Any Modifications (% all Triggers) 1071 (30.9%) 220 (39.4%)

Patient Observation Charts - Modifications


Hospital Discharge

Alive (N=177)

Hospital Discharge

Dead (N=29)

P value

MER Modifications 17 (9.6%) 14 (48.3%) <0.001

MDT Modifications 42 (23.7%) 14 (48.3%) 0.006

Nurse Modifications 57 (32.2%) 11 (37.9%) 0.543

Any Modification 72 (40.7%) 19 (65.5%) 0.013

Afferent Limb Failure Trinkle RM, et al. Resuscitation 2011;82:810-14

• Of 575 events, 131 (22.8%) had documented ALF

• of which 47/131 (35.9%) had more than one documented ALF within 24 hour period

• Patients with ALF, compared to those without ALF, were significantly more likely to have an unanticipated ICU admission

• 45/131 (34.4%) vs 100/443 (22.5%), p=0.01

Patient Observation Charts - Afferent Limb Failure



MER ALF 30 (14.6%) 4 (1%) MDT ALF 67 (32.5%) 16 (3.8%) Nurse ALF 128 (62.1%) 111 (26.7%) Any ALF 140 (68%) 118 (28.4%)



MER ALF 42.3% 45.5% MDT ALF 66.4% 52.2% Nurse ALF 80.9% 75.5% Any ALF 75.2% 71.4%

Impact of Patient Observation Charts - Afferent Limb Failure


Hospital Discharge

Alive (N=177)

Hospital Discharge

Dead (N=29)

P value

MER ALF 22 (12.4%) 8 (27.6%) 0.032

MDT ALF 58 (32.8%) 9 (31%) 0.853

Nurse ALF 105 (59.3%) 23 (79.3%) 0.040

Any ALF 117 (66.1%) 23 (79.3%) 0.158

Post Track and Trigger Systems

Time to intervene? A review of patients who underwent cardiopulmonary resuscitation as a result of an in-hospital cardiorespiratory arrest. A report by the National Confidential Enquiry into Patient Outcome and Death (2012) 526 case notes

Observation Charts

Triggers

Trigger Category

Trigger Total % Calls % Modification % ALF

Nurse SaO2=90-94% 658 7.6% 38.3% 87.7%

Nurse RR=21-25 422 9.0% 35.8% 86.0%

Nurse Pulse=100-120 381

13.4% 30.7% 80.7%

Nurse Pain Score = 5-7 314

49.0% 0.0% 51.0%

MDT SBP=90-100 263 12.2% 39.5% 79.9%

MDT SBP=180-200 176

24.4% 30.7% 64.8%

Nurse Pulse=50-60 176

13.6% 27.8% 81.1%

Nurse SBP=170-180 150 17.3% 18.7% 78.7%

MDT Pulse=120-140 124

21.8% 52.4% 54.2%

MDT RR=26-30 122 21.3% 52.5% 55.2%

MER SBP<90 98

36.7% 39.8% 39.0%

Nurse Conscious=2 81 13.6% 8.6% 85.1%

Trigger Category

Trigger Total % Calls %

Modification % ALF

Nurse Worried 2 100.0% 0.0% 0.0%

MER Cardiac Arrest 2 100.0% 0.0% 0.0%

MER Pulse<40 2

100.0% 0.0% 0.0%

MER Worried 2

100.0% 0.0% 0.0%

MER Pulse>140 26 53.8% 50.0% 0.0%

MDT Pain Score = 8-10 69 52.2% 4.3% 45.5%

Nurse Pain Score = 5-7 314 49.0% 0.0% 51.0%

MER SBP>200 41 39.0% 29.3% 44.8%

MER Conscious=3 8

37.5% 62.5% 0.0%

MER SBP<90 98 36.7% 39.8% 39.0%

MDT O2 flow > 6l/min 9 33.3% 44.4% 40.0%

MDT Temp>38.6 30 30.0% 3.3% 69.0%

Trigger Category


MDT RR=8-10 7 14.3% 71.4% 50.0%

MER Conscious=3 8 37.5% 62.5% 0.0%

MDT Pulse=40-50 21

9.5% 61.9% 75.0%

MDT RR=26-30 122

21.3% 52.5% 55.2%

MDT Pulse=120-140

124 21.8%

52.4% 54.2%

MER Pulse>140 26 53.8% 50.0% 0.0%

MER RR>30 41 29.3% 48.8% 42.9%

MER SaO2<90% 65 18.5% 47.7% 64.7%

MDT O2 flow > 6l/min

9 33.3%

44.4% 40.0%

MER SBP<90 98 36.7% 39.8% 39.0%

MDT SBP=90-100 263 12.2% 39.5% 79.9%

Nurse SaO2=90-94% 658 7.6% 38.3% 87.7%

Trigger Category


Nurse SaO2=90-94% 658 7.6% 38.3% 87.7%

Nurse RR=21-25 422 9.0% 35.8% 86.0%

Nurse Conscious=2 81

13.6% 8.6% 85.1%

Nurse O2 flow = 6l/min 59

11.9% 22.0% 84.8%

Nurse Pulse=50-60 176 13.6% 27.8% 81.1%

Nurse Pulse=100-120 381 13.4% 30.7% 80.7%

MDT SBP=90-100 263 12.2% 39.5% 79.9%

Nurse SBP=170-180 150 17.3% 18.7% 78.7%

Nurse Temp=35.1 - 35.5 17

23.5% 0.0% 76.5%

MDT Pulse=40-50 21 9.5% 61.9% 75.0%

Nurse Temp=38.1 - 38.6 70 22.9% 10.0% 74.6%

MDT Temp>38.6 30 30.0% 3.3% 69.0%

Observation Charts

Escalation

Adverse Event Hospital Outcome p-Value Alive Dead

All Events CCR 55 (69.6%) 24 (30.4%) CCD 135 (75.4%) 44 (24.6%) HTR-Only 188 (56.5%) 145 (43.5%) < 0.001

Cardiac Arrest CCR 2 (66.7%) 1 (33.3%) CCD 0 (0.0%) 9 (100.0%) HTR-Only 2 (10.0%) 18 (90.0%) -

MET Call CCR 29 (72.5%) 11 (27.5%) CCD 103 (80.5%) 25 (19.5%) HTR-Only 139 (60.4%) 91 (39.6%) < 0.001

Unanticipated ICU Admission CCR 24 (66.7%) 12 (33.3%) CCD 32 (76.2%) 10 (23.8%) HTR-Only 47 (56.6%) 36 (43.4%) 0.092

• In the 24 hours prior to an adverse event – 13% have a RRT – 30% discharged from

critical care area – 58% reviewed by Home

Team only – 98% have a review/critical

care discharge

• Type of response to patient clinical deterioration contributes to patient outcomes.

• Trinkle R, et al.Resuscitation 82 (2011) 810–814

Reviews and adverse events

Summary for Observation Charts

• Design features of patient observation charts has improved compliance with documentation of vital signs

• Completeness and accuracy, improved but still remain in question

• Increased RRT “dose” • Should be a good thing, but…

• Uncertain evidence if associated with improved outcomes

• Resource implications


• Afferent Limb Failure • Is proven to be harmful • Is still a problem not solved solely by the charts • Does chart design contribute to Afferent Limb Failure? Possibly

yes through the type of trigger and threshold selected

• New phenomena of “documented modifications”

• Is it good? May be bad • Are “modifications” another form of Afferent Limb Failure? • Does chart design contribute to modifications / Afferent Limb

Failure? • Objective or subjective modifications?


• Escalation response • Multi or Single tiered?

• Graded?

• Timely

• Level of seniority

• Expertise – Critical Care? Other? Multidisciplinary?

Patient Observation Charts and their limitations in the detection

and response to the deteriorating patient

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Distribution of lowest systolic blood pressure

Cretikos M, et al Resuscitation 2007;73:62-72

Do Observation Charts provide adequate warning?

27.4% did not have any criteria present in the 48 hrs prior

Patient Observation Charts – is their a “downward spiral”?

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In the 24 hours prior to a RRT calls: • 12.8% have had a

previous RRT • 5.8% have had a

prior MDT • 5% had a Nurse

Review

Patient Observation Charts – not the most important factor

More than one way to detect the deteriorating patient

• Intuition or knowing that something is not right • Knowing the patient and recognizing changes in behaviour

or physical signs

• Pattern recognition, where nurses, through repeated exposure recognize deviations from the normal clinical course

• Most common means, but also the most challenged by the hospital environment

• Patient and/or family raising concerns

• Coming across the patient through routine observation

Odell M, et al Journal of Advanced Nursing 2009;65(10), 1992–2006.

• Routine recording of vital signs has become ritualistic and more task oriented

• Delegated to the most junior staff

• Over reliance on, and a miss-understanding of the limitations of, equipment

• Insufficient time, training, experience to undertake a more thorough assessment beyond that of vital signs

Change in culture as to how we observe patients

Patient Observation Charts and the evolving hospital

environment

Admit via ED and RRT calls

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Median time to RRT - Pre chart period 68:25, Post Chart Period 58:24, p=0.05

Number and time to RRT call of patients admitted rom the Emergency Department

RRT Calls ED to RRT Time

Correlation of EDLOS and time to first RRT following admission from the ED = - 0.055, p=0.03

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The End

QUESTIONS and COMMENTS

Health & Medicine

A / Prof Arthas Flabouris - Queensland Health RRCD - OPENING KEYNOTE ADDRESS | Observing the Observation Chart - The Introduction of a Multi-Tiered Patient Observation Chart