Keeping patients safe -

„Between the Flags‟

Malcolm Green

Program Lead, Between the Flags

Clinical Excellence Commission

Acknowledgements

Professor Clifford Hughes Professor Ken Hillman Professor Deborah Picone

Dr Peter Kennedy A/Prof Theresa Jacques Ms Deb Hyland

Dr Annette Pantle Professor Malcolm Fisher Dr Paul Curtis

Ms Kimberley Fitzpatrick Professor Les White Ms Kathleen Ryan

Ms Colette Duff Ms Leanne Crittenden Ms Michelle Wensley

Mr David Paterson Dr Danny Stiel Ms Mel O‟Brien

Ms Amanda Yates Dr Gabriel Shannon

Ms Jo Leaver Dr Tony Penna ...and many, many more

Dr Charles Pain Dr Marino Festa

Mr Paul Hudson

Outline

• The Past

• The Present

• The Future

A message from Cliff…

https://vimeo.com/user19020418/review/7

0600926/3b3594eba4

The past (BBTF) Pre 2010

Peter Safar - 1974

“The most sophisticated

intensive care often becomes

unnecessarily expensive

terminal care when the pre-ICU

system fails”

The Slippery Slope

(the Problem)

Patient

Condition

Time

ALS

Death

There‟s a problem…

Source: Dr Charles Pain

What‟s the problem?

• Serious adverse events are common in

hospitalized patients around the world 1-4

• Documented warning signs in up to 80% 5-9

• Early recognition and intervention improves

outcomes 10-13

1 - 4 Wilson et al MJA 1992, Davis et al NZ Med J 1998, Brennan / Leape 1984, Baker etal 2000

5 - 9 Schein et al, Chest 1990, Buist et al MJA 1999, Hodgets et al Resus 2002, Nurmi et al Act Anaes Scan 2005, Bell et al Resus 2006

10 - 13 GISSI Am Heart J 1999, Rivers NEJM 2001, Nardi Min. Anest 2002, NINDS NEJM 1995

The solution

• Medical Emergency Team (MET) concept

developed by Professor Ken Hillman 1

• MET and Rapid Response Systems catch

on across Australia, the US and the UK 2-4

1. Lee et al, Anaesth Intensive Care 1995

2. Ball et al, BMJ 2003

3. England et al, Critical Care 2008

4. IHI, 100,1000 lives campaign 2006

The solution?

Patient

Condition

Time

ALS

MET

Death

Source: Dr Charles Pain

The Slippery Slope

(the Problem)

But there‟s still a problem….

• Failure to recognise and respond to

deteriorating patients is a significant issue1-3

• Imbalance between patient needs and

available resources4

1. McQuillan et al BMJ 1998 (UK)

2. Buist et al MJA 1999 (Australia)

3. Bell et al Resus 2006 (Sweden)

4. Devita et al 2006

www.safetyandquality.gov.au/

The present (BTF) 2010 -

Design a system to improve:

• prevention

• recognition

• escalation

• response

Introduced in January 2010

The NSW solution

A Safety Net

To improve early recognition and response

to clinical deterioration and thereby reduce

potentially preventable deaths and serious

adverse events in patients who receive their

care in NSW public hospitals.

Programme Aim

CEC approach

• Broad clinician engagement and consultation

• Keep it simple

• Standardisation across NSW

• A „sick‟ person is sick wherever they are

• Allow facilities to customise their CERS

• Promote and support clinical judgement

• Multivalent approach (5 elements)

Striking the right balance

Clinical

judgement Rule-based

approach

Source: Dr Charles Pain

Governance

Standard

Calling

Criteria

(CERS)

Clinical

Emergency

Response

Systems

Education Evaluation

The 5 Elements

Standard

Observation

Charts

Clinical Review &

Rapid Response

Awareness, DETECT,

Rapid Responders

2 KPIs

Evaluation

Collaborative

QSA

Source: Colette Duff

Policy &

Governance Plan

DCG‟s

Standard Adult General Observation Chart

Red Zone

Late warning

signs

Yellow Zone

Early warning

signs

Observation Charts

5 Paediatric Charts

Neonatal

Maternity

Emergency Dept.

Vital Sign Value (e.g. Respiratory rate)

Ris

k o

f a

dve

rse

ou

tco

me

Setting Vital Sign Escalation Thresholds

Source: Dr Charles Pain

Clinical Emergency Response

Systems (CERS)

CERS – the response

Rapid

Response

Clinical

Review

Education

Striking the right balance

Clinical

judgement Rule-based

approach

Discretion in

Yellow Zone

No discretion in

Red Zone

Source: Dr Charles Pain

Evaluation

Key Performance Indicators

• Rapid Response calls / 1000 admissions

• Cardiac Arrests calls / 1000 admissions

Quality Systems Assessment (QSA) reports

Hospital visits

Standard Observation Chart audit tools

Academic Research Partners - UNSW

The past

Patient

Condition

Time

ALS

MET

Death

Source: Dr Charles Pain

The Slippery Slope

(the Problem)

The Safety Net

(the Solution)

Patient

Condition

Time

Clinical

Review

ALS

Rapid

Response

Death

Source: Dr Charles Pain

The present

The Safety Net

(the Solution)

Patient

Condition

Time

Clinical

Review

ALS

Rapid

Response

Death

Source: Dr Charles Pain

The future

IS IT WORKING?

Benefit to Patients:

% Strongly Agreeing & Agreeing

21% 25%

44%

47% 48%

38%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Overall the BTF has benefittedpatient safety in our

department/unit (Adults)

Overall the BTF program hasbenefitted patient safety in our

department / unit (Paeds)

Overall the BTF program hasbenefitted patient safety in ourdepartment / clinical unit (all)

2010 2011 2012

Strongly agree Agree

Source: Quality Systems Assessment

“…for the junior staff it has been

fantastic. It gives them

"empowerment" to make a call if the

patient falls outside the "BTF".

BTF…“Is clear, easily

understood by colleagues and

is objective in defining if

deterioration is occurring.”

What staff say…

“Made it easier to identify where

observations fall outside regular

parameters. Clear guidelines for

what to do in certain situations,

and who to call.”

“In the last 13 years I cannot

remember a time when

I‟ve been to fewer cardiac

arrests..”

Rapid Response Rate per 1000

Separations, NSW Hospitals

+24.9%

Cardiorespiratory Arrest Rate per

1000 Separations, NSW Hospitals

- 38.5%

Estimate of benefits

• 940 fewer unexpected cardio-respiratory

arrests

• 800 fewer deaths in patients without an NFR

order

What we don‟t know…

• Morbidity prevented?

• Impact on mortality?

• What impact has the Yellow Zone had and

the numbers of Clinical Review calls across

NSW?

The Future

Casting the safety net wider

BTF in the electronic Medical Record

Source: Dr Karen Luxford, Director Patient Based Care

Patient and family escalation

Sepsis

End of Life care planning

Lessons

Build a coalition

Lay foundations of governance

Develop the tools

Strike the right balance:

• standardise AND localise

• discretion AND rules

• home teams AND rapid responders

We gratefully acknowledge

“Always swim between the red and yellow flags”

For further information

www.cec.health.nsw.gov.au

Betweentheflags@cec.health.nsw.gov.au