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

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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!