Ryan’s Rule:

Patient, family and carer

escalation

Lynette Adams

Patient Safety Unit

Overview

• Background

• Method

• Results

• Evaluation

Background

• Ryan Saunders died in a

Queensland Health facility

2007

• Coroner found his death to

be in “all likelihood

preventable”

• Commitment to Saunders

family-create Ryan’s Rule

Method

• Literature review

• Liaison with NSW & ACT

• Clinician and consumer focus group

• Extensive statewide consultation

• Development of resources

• Consumer testing (n=116)

• Pre-implementation piloting

Focus group

• Feb 2012

– 8 consumers

– 24 Clinicians/ clinical leads (23 sites)

– 6 Corporate staff

• Development of core principles to

underpin system

Resource development

• Consumer

– Brochure

– Posters

• Staff

– Model guidelines

– Staff information sheet

– Education

– Web banners,spotlights

An idea

• Why not introduce a single call number?

• Investigation of options

• 13HEALTH – current 24/7 advice line

• Call centre staffed by all of government

centre

Consultation

• Brochure

– reviewed across state

– Clinicians- extensive consultation and 2

working groups- much debate over language

– Consumer testing-116 patients/ family

members/ carers

Process

• 3 step process

• Single state-wide phone

number

• Warm transfer of call

• Email notification to

Patient Safety Unit and

facility

• Evaluation online via

MARS

Facility requirements

• Identify 3 positions to take call- available

24/ 7

• Educate at least 80% of staff

• Governance

– Accountable committee

– Approved internal procedure and

documentation

• Pass testing of system

• 67 facilities

• 8 HHSs

• Remainder

state by

end 2014

Results• Commenced in Dec 2013

• 79 calls to date (7.9/mth) (email

notification)

• Evaluation within 3 week days

• Statewide data capture- online data-MARS

• 52 calls evaluated

• Calls -DMS, Bed manager, ICU liaison,

CTC, MET, DON, EDMS

0 10 20 30 40 50 60

Family

Patient

Other- staff

Other- partner

Carer

Other- friend

Caller

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Caller's needs Patient's needs Use Ryan's Rule again

Feedback

Negative Neutral Positive

0 5 10 15 20 25

No clinical intervention, remained on ward

Other - specify

Clinical intervention, remained on ward

Transfer to another facility

Transferred to another ward

Retrieval to another facility

Transferred to ICU/HDU/CCU

Outcome of Ryan's Rule call

0

5

10

15

20

25

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Time of call day of week- In hours/ Out of hours

In hours Out of hours

In hrs = 0800 to 1700

Out hrs = 1701 to 0759

Calls

• Appropriate use

• Initial response from facilities that the calls

aren’t true Ryan’s Rule calls if no clinical

deterioration

• After evaluation a few calls shifts to

understand and value the use of Ryan’s

Rule

• Ave 45 mins r/v patient

• 2 out 52 calls met review criteria

Calls

• Initially concerns around communication

but in family meeting apparent wife

struggling with husband’s deteriorating

condition.

– Social work support for end of life care

• Concerned about husband -need to be in

tertiary hospital due to spinal injury-

– on review patient transferred

Calls

• Concerned her husband’s condition was

deteriorating (in ED)- On review

– CT scan,

– Admission to HDU, and then

– Retrieval to another facility

– Positive feedback from caller

Case Study

• A woman in labour requested a Ryan’s

Rule review “they’re not listening to me”

and she felt she was “going to have a

heart attack”.

• On r/v- BP190/115 mmHg – emergency

criteria & without an emergency call/

medical review for a number hours.

• Good outcome for mum and baby

Case study cont.

• Analysis -midwives had assumed her

hypertension was related to anxiety so did

place an emergency call or seek medical

input

• The patient had a history of mild

depression

Challenges

• Refining process at 13HEALTH- copying

facilities

• Initial negative feedback from a few sites

– You should take down some posters, too

many calls (after 2nd call)

– Not a “true” Ryan’s Rule call

– Can you screen the calls (to ensure patient

has deteriorated)?

Some comments

• You should take down some posters, we

must have too many up (after 2nd call)

• Not a “true” Ryan’s Rule call

• Can you screen the calls (to ensure

patient has deteriorated)

Ongoing work

• Feedback on why call was required

• Feedback on why caller/patient

dissatisfied with Ryan’s Rule Clinical

Evaluation

Acknowledgements

• Shaune Gifford, Kate Smith and other

PSU staff

• Clinicians and consumers across Qld

• CEC NSW & ACT Health

Questions

???