The Health Roundtable

Early detection of patient deteriopration

Presenter: (delegate name)

Innovation Poster SessionHRT1215 – Innovation AwardsSydney 11th and 12th Oct 2012

13-3c_HRT1215-Session_WARD_TPCH_QLD

The Health Roundtable

KEY PROBLEM

Patient harm due to lack of recognition and appropriate management of the deteriorating patient was repeatedly identified in:

Root Cause Analysis for serious adverse events

Clinical Incident reviews

Review of patients after cardiac arrest or inpatient transfer to ICU 2

The Health Roundtable

KEY CHANGES IMPLEMENTED

Multidisciplinary working party developed:

Standardised minimum observations General Observation Chart incorporating Modified

Early Warning Score (MEWS) Escalation protocol using MEWS score to trigger

review by clinical team ISBAR communication tool Medical Emergency Team (MET) criteria and

participants Education of Medical and Nursing staff (COMPASS –

ACT Health)

December 2009 MET and MEWS commenced3

The Health Roundtable

COMPASS OBSERVATION CHART

adapted for TPCH

Note: pain score, bowels, weight on page 2

4

The Health Roundtable

Ward audit – 10 charts

Episodes of Deterioration and Appropriate Escalation

-1

0

1

2

3

4

5

6

20

-De

c-1

1

13

-Ma

r-1

2

08

-Ap

r-1

2

23

-Ma

y-1

2

18

-Ju

n-1

2

08

-Au

g-1

2

Audit Date

Nu

mb

er

Episodes ofDeterioration

Episodes ofDeteriorationwithAppropriateEscalations

Charts with Observations Correct

0.67CL

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

03

-Au

g-1

01

4-S

ep

-10

02

-Ja

n-1

12

0-J

an

-11

08

-Fe

b-1

10

4-M

ar-

11

04

-Ap

r-1

12

6-A

pr-

11

26

-Ma

y-1

12

6-J

un

-11

14

-Ju

l-1

12

6-J

ul-

11

23

-Au

g-1

11

9-S

ep

-11

24

-Oct-

11

09

-No

v-1

12

0-D

ec-1

10

7-F

eb

-12

13

-Ma

r-1

20

4-A

pr-

12

08

-Ap

r-1

21

9-A

pr-

12

23

-Ma

y-1

20

8-J

un

-12

18

-Ju

n-1

21

7-J

ul-

12

08

-Au

g-1

22

8-A

ug

-12

00

-Ja

n-0

00

0-J

an

-00

00

-Ja

n-0

00

0-J

an

-00

00

-Ja

n-0

00

0-J

an

-00

00

-Ja

n-0

00

0-J

an

-00

00

-Ja

n-0

0

Audit Date

Pro

po

rtio

n o

f C

ha

rts

Au

dit

ed

wit

h a

ll

Ob

s C

orr

ec

t

5

The Health Roundtable

Number of charts audited

Correct Frequency of Observations

Accuracy of ObservationsEscalation of Deterioration

(MEWS >4)

TPCH 515 93% 77% 88%

Wards (compiled in order of Accuracy of Observations)

1 10 100% 100% no identified MEWS >4

2 10 100% 100% 100%

3 10 100% 90% no identified MEWS >4

4 30 97% 90% no identified MEWS >4

5 40 100% 88% no identified MEWS >4

6 8 50% 88% no identified MEWS >4

7 47 98% 87% 86%

8 20 100% 80% 0%

9 40 100% 80% no identified MEWS >4

10 50 98% 80% no identified MEWS >4

11 30 90% 77% 100%

12 40 68% 75% no identified MEWS >4

13 40 88% 70% 100%

14 20 100% 70% no identified MEWS >4

15 40 100% 63% 100%

16 28 93% 61% no identified MEWS >4

17 38 92% 61% 80%

18 10 100% 40% no identified MEWS >4

19 NARR      

20 NARR      

21 NARR      

Monthly report to NUMs and S&Q Committee

6

The Health Roundtable

Number of Arrest & MET calls(2009 - 2011)

MET/MEWSintroduced

7

The Health Roundtable

Inpatient Arrest Calls /1000 separations (2009 – 2012)

MET/MEWSintroduced4.7

3.8

2.9

In 2010:55% of cardiac arrest calls had a confirmed cardiac arrest46% of patients with confirmed cardiac arrest survived to discharge

8

The Health Roundtable

Inpatient MET Calls /1000 separations (2009 -2012)

MET/MEWSintroduced

Average 8.52011 Average 9.1

*Target 26-56/1000seps

* Source: Effectiveness of the Medical Emergency Team: The Importance of Dose. D Jones et. al. Critical Care 2009;13:3139

The Health Roundtable

Hospital Standardised Mortality Rate (2007 – 2011)

MET/MEWSintroduced

12

The Health Roundtable

Mortality Rate / 1000 separations (2008 – 2012) (excluding Palliative Care Unit)

MET/MEWSintroduced

13

The Health Roundtable

SUMMARYThe simultaneous introduction of MEWS and MET resulted in: A low “dose” of MET callsPatents transfers to ICU post arrest/MET call

Reduced in 2nd year of implementation Progressive reduction in LOS (40%)

Improvement in hospital mortality

Underpinning this result: Compliance with observations and MEWSEarly escalation when deterioration occursRapid medical review by the home team

14

The Health Roundtable

I feel Confident in escalating concerns when a patient deteriorates

1 410

72

178

0

20

40

60

80

100

120

140

160

180

200

DisagreeStrongly

Disagree Slightly Neutral Agree Slightly Agree Strongly

No.

res

pons

es

Patient safety culture survey April 2012

15

The Health Roundtable

LESSONS LEARNT

Multidisciplinary team to develop system Education must be ongoing Audit of accuracy of observations and escaltion

necessary Feedback to staff re results essential

16