Managing the Deteriorating Patient in Community Care – Adapting the QLD Health Patient Safety...
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Transcript of Managing the Deteriorating Patient in Community Care – Adapting the QLD Health Patient Safety...
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Early Warning and Response System Tools
and Hospital in the Home
Patient Safety Unit, HSIB
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Overview
• CEWT and Q-ADDS development
• HITH
– Background
– Development CEWT and Q-ADDS HITH
– Trial
– Outcomes
– Lessons
• Future work
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Background
• Children’s Early Warning Tool (CEWT)
• Queensland- Adult Deterioration Detection
System (Q-ADDS)
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Children’s Early Warning Tool
(CEWT)
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Blue Sky View
Tertiary Paediatric Facility
• CEWT
• Admissions unit
•Outreach / MET team
• HDU
• PLS / APLS
Regional Paediatric Facility
• CEWT
• Adult ICU links
• Admissions unit
•HDU / telepaediatric bed
• PLS / APLS
Rural Paediatric Facility
• CEWT
• PLS / APLS
Retrieval service
Retrieval service
Telepaediatrics
Clinical networks
Telepaediatrics
Clinical networks
Paediatric Mortality Committee
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Bronchiolitis <1yr (mean +/- CI95%)
0
1
2
3
4
5
6
7
8
9
10
0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48
Time (hours)
CE
WT
sco
re
PICU n=34
Retrospective no PICU n=23
Prospective no PICU n=86
Retrieval n=17
Median ICU admission time P < 0.05
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Bronchiolitis < 1yr PICU vs no PICU: Respiratory Rate (mean +/- CI 95%)
0
10
20
30
40
50
60
70
80
90
100
0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57
Time (hours)
Resp
irato
ry r
ate
(b
reath
s/m
in)
Retrospective PICU n=19
Retrospective - No PICU n=12
Prospective no PICU n=86
Median ICU admission time
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0
20
40
60
80
100
120
0 10 20 30 40 50 60 70
Time (hours)
Re
sp
ira
tory
ra
te
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Bronchiolitis <1yr: PICU vs no PICU Heart Rate
80
90
100
110
120
130
140
150
160
170
180
0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57
Time (hours)
Hea
rt r
ate
(b
ea
ts/m
in)
Retrospective - PICU n=19
Retrospective - No PICU n=12
Prospective n=86
Median ICU admission time
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0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0 0.2 0.4 0.6 0.8 1
Sen
siti
vity
1 - specificity
ROC curves: Australasian Paediatric response tools (patients, bronchiolitis<1yr)
CEWT
MET
BTF
Paed Compass
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Maximum CEWT score
0
100
200
300
400
500
600
0 1 2 3 4 5 6 7 8 9 10 11 12 13
CEWT score
Pa
tie
nts
83%
n =1886
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Split the under ones?
0
10
20
30
40
50
60
70
Re
sp
ira
tory
ra
te (
bre
ath
s/m
in)
Time (Hours)
Bronchiolitis Respiratory Rate <4mths vs. 4-12 mths
RR <4 mths
RR <4mths
RR 4-12 mths
RR 4-12 mths
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0
20
40
60
80
100
120
140
160
180
0 1 2 3 4 5 6 7 8 9 101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
< 4 months
4 to 12
Bronchiolitis HR <4/12 vs >4/12
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Q-ADDS
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Variants
• Emergency Department (adult trial; RR/PHC trial)
• Mental Health
• Maternity (trial)
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Hospital in the Home (HITH)
• Care in community setting
• Acute conditions -clinical governance,
monitoring &/or input
• Otherwise require treatment in inpatient
hospital bed.
• Similar standard of care
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HITH-Patient and system
benefits
• Patients improved outcomes & recovery at
home, fewer complications1
• Qld target- 1.5% of total hospital
separations HITH (0.3% 2012, 0.6% 2013)
• Significant growth required
• Outsourcing of services
1- Deloitte Access Economics 2011
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HITH
• Nurse
• Medical Officer and/or
• Allied health professional
• Admin
• Daily or twice daily service -7 days
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DRGs
• cellulitis;
• venous thrombosis;
• pulmonary embolus;
• respiratory infection/inflammation;
• chronic obstructive pulmonary disease
(COPD);
• knee replacement.
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Safety-Patient cared for by HITH
• Phone MO- Saturday- “Sit on them”
• Phone MO- Sunday “Team can review tomorrow”
• Monday- renal failure due to medication allergy
• RCA – EWARS would have flagged
– Clinicians involved thought EWARS would have been beneficial
– Using inpatient EWARS tool or NO observation tool
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Safety
• Receive equivalent care
– Screening & assessment
– Education- patients/ carers & staff
– 24 hr phone support
– Introduce a HITH specific EWARS
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Needs of HITH EWARS
• CEWT or Q-ADDS scoring “guts”
• Responses tailored to HITH
• Interface smoothly with inpatient CEWT and Q-ADDS
• Address Pain assessment and analgesia
• Human factors design principles
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Development
• Statewide working group
• Steering Committee
• Guidance on what could / could not be
changed
• Clinician engagement
• Explanation of decisions
• Patient Safety to approve
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Actions for HITH
Total CEWT Score
• Minimum daily full CEWT score
Total CEWT Score 1–3
• Manage anxiety / fever / pain (pain tool overleaf)
• Review oxygen requirement (if applicable)
• Notify medical officer for advice
• Educate patient/carer regarding signs of deterioration
• Notify team leader / nurse manager
• Document interventions
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Total CEWT Score 4–5
• Consider anaphylaxis and follow local
protocol
• Notify medical officer of planned transfer for
face-to-face medical officer review (seek
advice on transfer method)
• Stay with patient until transfer
• Obtain a full CEWT score at least every 30
minutes
• Notify team leader / nurse manager
• Document interventions
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HITH
trial
sites
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Audit results
• Modifications (chronic) rare 1.6%
• Patient identification- 85% all pg
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Observation completeness (n=129)
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
Respiratory Rate O2 Saturation O2 Flow Rate Systolic BP Heart Rate Temperature Consciousness
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Highest HITH score (n=129)
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Pain score with obs (n=129)
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EWARS Score accuracy %
129 2250 1500 349
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Score inaccurate
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Feedback
• Report of scores triggering patient medical
r/v & admission to hospital
• Staff report
– “really beneficial”,
– “flag patients earlier than they would pick for
review” (+ve way)
– “actions are really helpful & relevant”
– “clear trend helpful”
– “move specific obs near main obs”
– “calling a discretionary for scores ≤3”
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Lessons
• Importance of involving local clinicians
• Adaptations can go well
• Audits-(1 pt score 4- rest 0 however 20
incorrect score)
• Continued supply of EWARS post trial
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Future work
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HR
Te
mp
R
R
BP
U
.O.
Hb
Pa
in
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Acknowledgements • HITH- Laureen Hines, Amanda Kivic & HITH
clinicians
• Kevin McCaffery,
• PSU- Shaune Gifford, Kate Smith, Jillann
Farmer, Rowena Richardson, Alexis Stockwell,
Matt Page, Hamish Yeates
• UQ- Marcus, Mark, Andrew, Megan and Melanie
• Steering Committee, working groups and
clinicians