deteriorating patients in scotland’s acute hospitals a structured response webex agenda
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Deteriorating Patients in Scotland’s Acute Hospitals A Structured Response WebEx Agenda 10 th April 2013 2 – 3 p.m. WebEx etiquette. Please do not put your phone on hold Use *6 to mute and unmute – please mute when not speaking Please give your name before speaking. - PowerPoint PPT PresentationTRANSCRIPT
Deteriorating Patients in Scotland’s Acute HospitalsA Structured Response
WebEx Agenda10th April 2013
2 – 3 p.m.
Time Topic Speaker
2 p.m. Welcome, Introduction & Apologies• Aim statement
• SPSI outcome measure
Alison Hunter
2.15 p.m. Forth Valley work on deteriorating patients Dan Beckett
2.35 p.m. Feedback on tests• SSR• Measures
GlasgowGrampian
Others
2.55 p.m. Next tests & close Alison Hunter
WebEx etiquette
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AIM PRIMARY DRIVERS SECONDARY DRIVERS
• 50 % reduction in CPR attempts (with
chest compressions) in
general ward setting by December 2015
• 95% of people with physiological
deterioration in acute care will have a
structured response and plan
Early Anticipation, collaborative planning and decision making.
Clarity and understanding about
ceilings of care (homely setting, or
hospital level 1, 2, 3)
Anticipatory planning in Primary Care, manage expectations End of life care at home or in a homely setting Patient and family at the centre of decisions & planning Multidisciplinary care decisions & planning in partnership with patient and family Structured wards rounds in acute care- with prompts for ceilings of care Primary – Secondary Care Communication reliable Assessment of Limited Reversibility - Assessment of functional capability and health trajectory
and detection of limited reversibility when assessing patients (in primary and secondary care) Reliable implementation of DNACPR
Scottish Structured Response Processes Reliably Implemented
Reliable detection of the deteriorating patient using NEWS or local EWS Screen for sepsis & initiate Sepsis Six if appropriate Reliable response to the deteriorating patient by competent teams Ensure senior clinical involvement in care planning Appropriate and timely referral to higher level of care Reliable communication across teams of at risk patients Structured ward rounds Reliable ongoing patient and family communication Reliable multidisciplinary communication Strong safety culture Consider rapid response teams
Infrastructure
Local mortality & morbidity review Measurement framework Use resuscitation officers as resource Organisational priority: Executive Sponsorship, Clinical Leadership Utilise local QI experts Consider use of electronic track & trigger tools to actively measure and manage at risk patients
across the sites. Actively support interventions that generate teamwork Consider hospital rounding huddles to detect & predict deterioration
Reducing cardiac arrests in the Acute Admissions Unit :
A Quality Improvement Journey
Dan Beckett
Consultant in Acute Medicine
Forth Valley Royal Hospital
SPSP Fellow
NHS Forth Valley
• Catchment population 300,000• Annual budget £421 million• Four Community Hospitals• One Acute District General Hospital
– Forth Valley Royal Hospital – Opened July 2011(previously Stirling Royal
Infirmary)– 442 beds
Forth Valley Royal Hospital
Acute Admissions Unit (AAU)
• Combined surgical and medical admissions unit
• 46 beds• Admits 1500 patients per calendar month• In July 2011 moved from Stirling Royal
Infirmary to Forth Valley Royal Hospital
Situation
Stirling Royal Infirmary, 2010
Background
• AAU morbidity and mortality meetings established in 2010– Failure to rescue– Resuscitation attempts undertaken on
patients with terminal illness– Limited learning from adverse outcome
Assessment
• FMEA (Failure Modes Effects Analysis) undertaken– Multidisciplinary team
• Junior and senior medical staff• Nursing staff• Managers
– Recognition 2640– Response 2490
Assessment
• Recognition (2640)– NEWS (NHS Early Warning Score) charts not
filled out correctly– Emergency Department not utilising NEWS– No structured handover between ED and AAU
Assessment
• Response (2490)– No clear evidence of escalation in notes– Nursing staff often did not know who to
contact– Only transient consultant presence in the
ward
Recommendation
• Aim statement developed• ‘By December 2011 the cardiac arrest rate
in AAU at Stirling Royal Infirmary (Forth Valley Royal Infirmary) will have fallen to <1 per 1000 admissions per month
• December 2010 – 4/1000 (cardiac arrests) and 7/1000 (2222 calls)
Recommendation
• Driver diagram developed– Primary drivers
• Recognition and response to the deteriorating patient
• Improve learning from adverse events• Improve end of life care including DNACPR
– Change package developed– Process, outcome and balancing measures
defined
Change package
• Recognition– ED started totalling NEWS and including as
part of a structured SBAR handover– AAU training on Early Warning Scores
• Weekly sampling of charts and displayed on newly developed QI dashboard in the relatives waiting room
– Recognition checklist stickers developed using the model for improvement and PDSA cycles
Date ___________ Time______________
EWS ___________
Clinician contacted: Name ___________________
Nurse in charge informed
EWARD signifier entered
Hourly observations unit NEWS <4
Start fluid balance chart
Completed by (name) ____________________
PLEASE ENSURE PART B IS COMPLETED BY REVIEWING CLINICIAN. MIDDLE GRADE REVIEW REQUIRED FOR NEWS 6 OR MORE
PART A NEWS 6 or above Response/Escalation v11
Change package
• Response– Response checklist stickers developed using
the model for improvement and PDSA cycles– Move to ward based clinical team in July 2011
with move to the new hospital• 3 ANPs and 3 FY1s attached to AAU• Consultant Acute Physician presence 0800-2000
five days per week
PART B NEWS 6 or above Response/Intervention
v111. Time attended _____________ Grade ______________
2. Nurse in charge and Nurse providing care meet with responding clinician to discuss patient
3. Document management plan and set review time
4. Due to infection? Y/N Complete sepsis 6 Sticker
5. Please document (discuss with senior if required): a) Ceiling of treatment: Ward level HDU ICU Undecided *
b) Resuscitation status: for CPR DNA CPR Undecided *
*Consider accessing the ECS for Key Information Summary (KIS) or ePCS
Signature/Name _____________________________
Mandatory consultant contact if NEWS no better after 60 minutes and no decision made to limit escalation
Change package
• Improving learning from adverse events– Weekly ‘AAU safety meeting’ – All invited – Cardiac arrests, transfers to critical care– Open forum for all staff– Log-book for those who can’t be present
Cardiac arrests in AAU per 1000 admissions
UCL
LCL0
1
2
3
4
5
6
7
8
9A
ug-1
0
Sep
-10
Oct
-10
Nov
-10
Dec
-10
Jan-
11
Feb-
11
Mar
-11
Apr
-11
May
-11
Jun-
11
Jul-1
1
Aug
-11
Sep
-11
Oct
-11
Nov
-11
Dec
-11
Jan-
12
Feb-
12
Mar
-12
Apr
-12
May
-12
Jun-
12
Jul-1
2
Aug
-12
Sep
-12
Oct
-12
Nov
-12
Dec
-12
Jan-
13
Feb-
13
Mar
-13
Rate
Safety meetings start
Rescue stickers start
Move to FVRH
Poor patient flow from AAU
starts
All 2222 calls in AAU, per 1000 admissions
UCL
LCL0
2
4
6
8
10
12
14A
ug-1
0
Sep
-10
Oct
-10
Nov
-10
Dec
-10
Jan-
11
Feb-
11
Mar
-11
Apr
-11
May
-11
Jun-
11
Jul-1
1
Aug
-11
Sep
-11
Oct
-11
Nov
-11
Dec
-11
Jan-
12
Feb-
12
Mar
-12
Apr
-12
May
-12
Jun-
12
Jul-1
2
Aug
-12
Sep
-12
Oct
-12
Nov
-12
Dec
-12
Jan-
13
Feb-
13
Mar
-13
Rate
Safety meetings start
Rescue stickers start
Move to FVRH
Poor patient flow from AAU
starts
How did we do?
• Cardiac arrest rate in AAU available on the intranet as well as on QI dashboard in relatives waiting room
• Also reported to the board monthly, as a board key performance indicator
Reflection
• Introduction of safety initiatives led to a reduction in the rate of cardiac arrests but nursing staff still used 2222 calls to summon immediate help
• Introduction of the ward based team led to a reduction in 2222 calls
• Escalation through patient’s own caregivers vs MET
• How to deal with the non-believers....
Consultant A
• ‘The reduction in rate of cardiac arrests in AAU has purely been achieved by moving patients out of AAU earlier so they have their cardiac arrests elsewhere...’
Dealing with the non-believers...2222 call rate outwith AAU per 1000 admissions
UCL
LCL
0
1
2
3
4
5
6
7
8
9
10
Aug-
10
Sep-
10
Oct
-10
Nov
-10
Dec
-10
Jan-
11
Feb-
11
Mar
-11
Apr-1
1
May
-11
Jun-
11
Jul-1
1
Aug-
11
Sep-
11
Oct
-11
Nov
-11
Dec
-11
Jan-
12
Feb-
12
Mar
-12
Apr-1
2
May
-12
Jun-
12
Jul-1
2
Aug-
12
Rate
Consultants A, B, C, D.....
• ‘The reduction in rate of cardiac arrests in AAU is due solely to patients having DNACPR decisions made earlier in their admission’
30 day mortality - all patients CAU/AAU
UCL
LCL
0%
1%
2%
3%
4%
5%
6%
7%
8%M
ay-1
0
Jun-
10
Jul-1
0
Aug
-10
Sep
-10
Oct
-10
Nov
-10
Dec
-10
Jan-
11
Feb-
11
Mar
-11
Apr
-11
May
-11
Jun-
11
Jul-1
1
Aug
-11
Sep
-11
Oct
-11
Nov
-11
Dec
-11
Jan-
12
Feb-
12
Mar
-12
Apr
-12
May
-12
Jun-
12
Jul-1
2
Aug
-12
Sep
-12
Oct
-12
Nov
-12
Dec
-12
Jan-
13
Percent
Move to ward based
team at FVRH
Safety initiatives
started
SIGNIFICANT SHIFT IN MORTALITY
30 day mortality - all patients CAU/AAU
UCL
LCL
0%
1%
2%
3%
4%
5%
6%
7%
8%
May
-10
Jun-
10
Jul-1
0
Aug
-10
Sep
-10
Oct
-10
Nov
-10
Dec
-10
Jan-
11
Feb-
11
Mar
-11
Apr
-11
May
-11
Jun-
11
Jul-1
1
Aug
-11
Sep
-11
Oct
-11
Nov
-11
Dec
-11
Jan-
12
Feb-
12
Mar
-12
Apr
-12
May
-12
Jun-
12
Jul-1
2
Aug
-12
Sep
-12
Oct
-12
Nov
-12
Dec
-12
Jan-
13
Percent
17% DROP IN 30 DAY MORTALITY SINCE MOVING TO FVRH
=
16 LIVES SAVED PER MONTH
Balancing measure
• Admissions to critical care
Total number of admissions to critical care per month
0
20
40
60
80
100
120
140Au
g-10
Sep-
10
Oct
-10
Nov
-10
Dec
-10
Jan-
11
Feb-
11
Mar
-11
Apr-1
1
May
-11
Jun-
11
Jul-1
1
Aug-
11
Sep-
11
Oct
-11
Nov
-11
Dec
-11
Jan-
12
Feb-
12
Mar
-12
Apr-1
2
May
-12
Jun-
12
MedianMeasure
Move to ward based
team at FVRH
Safety initiatives
started
Proportion of patients admitted to critical care on Day 0
UCL
LCL
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%Au
g-10
Sep-
10
Oct
-10
Nov
-10
Dec
-10
Jan-
11
Feb-
11
Mar
-11
Apr-1
1
May
-11
Jun-
11
Jul-1
1
Aug-
11
Sep-
11
Oct
-11
Nov
-11
Dec
-11
Jan-
12
Feb-
12
Mar
-12
Apr-1
2
May
-12
Jun-
12
Percent
Safety initiatives
started
Move to ward based
team at FVRH
Lessons learned
• Visibility and transparency– Cardiac arrest rate on QI dashboard
• Entire team on board– Shared goal– Bottom up approach
• Establish a safety culture• The work is never done
– FMEA re-scored...
Current work
• Sepsis
Patients with NEWS4 sepsis getting the sepsis6 bundle within 60 minutes
UCL
LCL0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%O
ct-1
1
Nov
-11
Dec
-11
Jan-
12
Feb-
12
Mar
-12
Apr
-12
May
-12
Jun-
12
Jul-1
2
Aug
-12
Sep
-12
Oct
-12
Nov
-12
Dec
-12
Jan-
13
Feb-
13
Mar
-13
Percent
SEPSIS6 - ED vs CAU/AAU February 2013
0
10
20
30
40
50
60
70
80
90
100
O2 Bloodcultures
IV antibiotics Lactate IV fluid Urine output SEPSIS6
%
ED CAU/AAU
Current work
• Sepsis• SPICT?
Number of patients referred to palliative care
0
10
20
30
40
50
60
70
80Ja
n-1
1
Fe
b-1
1
Ma
r-1
1
Ap
r-1
1
Ma
y-1
1
Jun
-11
Jul-
11
Au
g-1
1
Se
p-1
1
Oct
-11
No
v-1
1
De
c-1
1
Jan
-12
Fe
b-1
2
Ma
r-1
2
Ap
r-1
2
Ma
y-1
2
Jun
-12
Jul-
12
Au
g-1
2
Se
p-1
2
Oct
-12
No
v-1
2
De
c-1
2
Jan
-13
Fe
b-1
3
Ma
r-1
3
MedianMeasure
Current work
• Sepsis• SPICT?• Integrate with work already undertaken –
not replace
Acknowledgements
• Sharon Oswald• Monica Inglis• Iain Wallace• SPSP• The whole AAU multidisciplinary team!