Implementation of an education program for recognising and

responding to clinical deterioration

Canberra Population approximately 350,000 Provide services for surrounding NSW region (Population 660 000)

Calvary Health Care Canberra Hospital

University Affiliated Tertiary Hospital 500 beds, 64 000 separations per year

Background

Alice, 17 year old student

• Admitted Saturday Midnight, Paediatric Ward

• EBV Pneumonitis

• During the 28 hour and 25 minute stay prior to ICU:

Nurse review 40

Intern/RMO review 7

Registrar review 10

ICU Registrar 2

Consultant 3

Alice’ Mother

• “I still believe that either someone or something failed my

daughter on that weekend.

• ……..a seemingly total lack of clinical assessment and decision making affording early intervention in order that her deterioration was halted

Alice What did happen:

Patient was “observed” hourly on a ward

Patient was reviewed multiple times

A diagnosis was made

A management plan was in place

What did not happen:

Failed to recognise how unwell the patient was

Failed to provide timely, appropriate management

No ICU senior clinician involved

MET not activated (MEWS/PEWS not in place at time)

Issues in the ACT

• Poorly Recognised

Vital signs not being performed

Inadequate experience/education/training to understand

• Poorly Communicated

Lack of timely communication in event of deterioration

Structure poor, difficult to interpret

• Poorly Managed

Delay in adequate treatment “cycle of futility”

Inappropriate management

Australia Council on Health Care Standards

National Consensus Statement

April 2010, Health Ministers endorsed the Consensus Statement as the national approach for recognising and responding to clinical deterioration in acute care facilities in Australia.

Standard 9

Standard 9 – Recognising and Responding to Clinical Deterioration

Education: • Normal physiology

• What measurements indicate abnormality

• When to escalate

• Who to escalate to

• Appropriate treatment

• Communication & Documentation

2006, ACT Health • No one magic bullet

• Multifaceted intervention

new observation chart

colour coded for a track and trigger system

education package “COMPASS©”

• Project management methodology

• Steering group oversight and project working group

• Huge amount of “pre-work” to facilitate major cultural change

Implementation Phase: Chief Drivers: Project Officer, a clinically experienced ward nurse

Clinical Champion, director of intensive care

Steering Committee: 4 senior clinical leaders (CHC, TCH)

2 senior manager ACT Health

1 consumer representatives

Working Group: Clinical champion

Project officer

Educators

After hours senior nurse

Registrars

Interns & ward nurses,

Observation Charts

Education

Aims

• Accessible

• Delivered in a short timeframe

• Multidisciplinary

• Applicable to all levels

• Adult learning principles

Education

• Pre-learning

– Manual

– DVD

– Quiz

• Face to face education

– Lecture

– Case Studies

Pre-learning

• Physiology to the bed side

– Why are vital signs vital?

– Oxygen delivery chain

– Markers of adequate cardiac output

– Compensation

• Quiz

– Survey monkey

Face-to-face

• Lecture

– Main physiology points

– Vital sign charts

– Escalation protocols

Case Studies

– Variety

– Role play allowed flexibility of delivery

– Testing different escalation points

Train-the-trainer

• Developed a short trainer package

• Identified suitable trainers

• Provided prompts for trainers in the role plays

– Facilitator cards

– Prompt points

– Listed main areas to cover

• Adult learning principles

• Engaging different learners

Training Program

• Executive support

• Mandatory training

• Refresher Program

• Undergraduate program

• COMPASS© Pro

• Maternity MEWS

• Paediatric (PEWS)

Doctors

• ????

• Make applicable

• Appropriate trainers – Medical trainers

• Changed the manual

• Included data

• Additional details on patient management

• Clinical Leadership/engagement

Specialty areas

• Clinically relevant

• Case studies

– Same physiology

– Change background history

– Change medications

– Observations/management adaptable

Evaluation

• Education Evaluation

• Annual Reviews

• New Cases

• Ward audits for compliance

• Medical Emergency Team Case Review

Results: Frequency of Observations Control Period Intervention Period p-value

Number of Patients 414 315

Mean (SE) Mean (SE)

Blood Pressure 3.8 (0.25) 4.5 (0.17) <0.001

Heart Rate 3.7 (0.24) 4.3 (0.17) <0.001

Respiratory Rate 2.4 (0.22) 4.7 (0.21) <0.001

Oxygen Saturation 3.5 (0.22) 4.7 (0.18) <0.001

Temperature 3.5 (0.22) 4.3 (0.16) <0.001

• Mitchell IA et al. Resuscitation 2010;81:658-66.

Results: Patient Outcome Pre Post p-

value

Number of Patients (%) 1157 985

Unplanned ICU admissions 21 (1.9) 5 (0.5) 0.005

Unexpected Hospital Deaths 11 (1.0) 2 (0.2) 0.03

Hospital LOS (days) 4.0 (1.8 to 8.3) 4.8 (2.2 to 9.8) 0.02

Cardiac arrest 4 (0.4) 0 (0.0) 0.13

MET calls 25 (2.2) 38 (397) 0.03

• Mitchell IA et al. Resuscitation 2010;81:658-66

Measure success of the education

• Audits

• Case review

• +/- Assessment

Supported by:

• On going forums & communication

• Regular updates

• Targeted training

Message for others • Back to basic education for front line staff and simple tools

can improve documentation and communication of vital signs

• Accessible, short time frame, flexible set up

• Ongoing support for sustained change is needed, correct escalation of MEWS is still an issue

• Involve local educational institutions

National and International Dissemination

compass.act.gov.au • National

South Australia, Northern Territory [Territory Wide], Queensland, Victoria, Western Australia [State Wide], Tasmania, New South Wales

• International

Papua New Guinea, New Zealand, UK, Oman, Finland

Ireland

Key Lessons Learned Utilisation of Project Management Methodology

– Tight adherence of timelines – Provision of adequate time for planning – Robust communication plan

Formation of an Effective Project Steering and Working Group

– Wide stakeholder steering committee (Clinicians/Consumers/Administrators)

– Senior decision makers to “make it happen” in the event of road blocks

– Clinical working group (nurses, doctors, allied health and educators) developed interventions

Key Lessons Learned

Winning over sceptics

– Make learning applicable

– Credible trainers

– Involve them Ongoing Persistence and Negotiation

– All problems, with persistence, were resolved. – Use of data a powerful tool for influence – Involving a senior clinician to drive and maintain the

upkeep of the intervention – Resourcing to allow for data collection and feedback

critical to sustainability

Call and Respond Early (CARE) for Patient Safety

• Family escalation program

• Responder & Ward training

• Focus on communication

Where to...

• Review of pre-learning

• New cases

• Simulation modalities

• Community MEWS,

• Neonatal Early Warning Scores (NEWS)

None of it would have been possible without:

• A/Prof Imogen Mitchell & Dr Bronwyn Avard (ACT Health Clinical Lead’s ERDP)

• Heather McKay and Alison Kingsbury (ERDP Program Managers)

• Sarah Mamootil (Project officer)

• Chris Perkins, Mary Bodilsen, Penny Giles (Program Officers)

• Trainers

For more info contact us on 02 6207 6827 or compass@act.gov.au