Escalations of Care The Impact of Delayed Diagnosis of Sepsis and Pneumonia

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1 #MakingEveryBreathCount Escalations of Care The Impact of Delayed Diagnosis of and Improving patient flow, improved healthcare economics Your hospital could be measuring respiratory rate incorrectly and missing an opportunity to reduce preventive events by 5%.

2 , and the NHS is a leading cause of morbidity and mortality in the UK, costing the NHS 15 billion annually (1) Early detection and timely interventions reduce complications of sepsis such as organ failure and need for ICU transfer most commonly presents in the emergency department or general wards, and initially manifests as abnormalities in vital signs, particularly respiratory rate Improved monitoring of the respiratory rate of patients at risk of developing sepsis on general wards will expedite interventions and improve patient outcomes Risk stratification of people with Community-Acquired (CAP) is essential for effective use of NHS resources Deterioration of a patient with CAP can happen rapidly, requiring timely intervention for improved outcomes to be achieved Decline in vital signs such as respiratory rate commonly precede deterioration in patients Currently, respiratory rate is poorly monitored in general wards, resulting in suboptimal care through delayed detection of deterioration in CAP patients 1. York Health Economics Consortium (17). The Cost of in the UK. Retrieved from 9 May 17.

3 Comparison of and Total Annual Cost 15Bn 440M (2) Admissions 260, ,000 (3) (4) Incidence of Escalation in General Ward up to 50% (5) up to 14% (6) Cost of an Escalation 25,000 (7) 2. Department of Health. NHS Reference Costs 15/16. Department of Health. Available from publications/nhs-reference-costs-15-to-16 Accessed March 27, York Health Economics Consortium (17). The Cost of in the UK. Retrieved from uploads/17/02/yhec--report final.pdf 9 May National Institute for Health and Care Excellence. (16). in adults (Quality standard [QS110]). Retrieved from www. nice.org.uk/guidance/qs May 17. 8,969 (8) 5. Churpek MM, Zadravecz FJ, Winslow C, Howell MD, Edelson DP. Incidence and prognostic value of the systemic inflammatory response syndrome and organ dysfunctions in ward patients. Am J Respir Crit Care Med 15; 192(8): National Institute for Health and Care Excellence. (16). in adults (Quality standard [QS110]). Retrieved from www. nice.org.uk/guidance/qs May The UK Trust. Retrieved from 9 May Department of Health. NHS Reference Costs 15/16. Department of Health. Available from publications/nhs-reference-costs-15-to-16 Accessed March 27, 17.

4 Case Study The patient: admission, suffering two Pulmonary Edema events within a 24 hour period. The outcome: RespiraSense showed signs of deterioration 6 and 12 hours prior to intervention, compared to the standard of care Oxygen Treatment Young Doc - D-dimer test High Blood Pres - Furomedid, Digoxin Low Saturation Cardio Review Patient Tired +ve blood culture - increased antibiotic Fall in blood pres. - 1 L of fluid given. Doctor examination Increase BP, decrease O2, Furosemid, Salbutamol Heart scan ordered Furosemid repeated RespiraSense Spot RR - Nurse Clinical Input Arthritis suspected - steroid 01-19: : : : : : : :00 Trending Respiratory rate, abnormal RR identified 6 hours and 12 hours prior to each event hrs RR as measured by RespiraSense trended upwards 12 hrs before the second Pulmonary Edema event RR as measured by RespiraSense trended upwards 6 hrs before the first Pulmonary Edema event 12 hrs 01-19: : : : : : : :00 RespiraSense registered the increasing RR trend hours before the staff noticed that the patient s condition worsened. Hospital South West Jutland, Denmark 17

5 Budget Impact Analysis Admissions Total HRG WJ06 Admissions Total HRG DZ11 Admissions 1,000 1,000 Number of Escalated Patients Avg. Escalation Rate 10% days 4 days Total Extra Bed Days Cost of Escalation per Patient (9) 25k 9k Total Cost of Escalations 2.5M 900k 9. NHS Level Data - Source Improving Outcomes Improving Patient Flows 5 prevented escalations 125K saved 100 Extra Length of Stay per Patient Hospital Impact from RR Monitoring based on 5% Lower Escalation Rate bed days saved (9) 5 prevented escalations 45K saved bed days saved

6 Number of Cases Hospitals Recording of Respiratory Rate Globally is Poor Hutchinson 1,714 patients reported in 1846 Since 1846, when Sir John Hutchinson first observed respiratory rate measurements, it was evident respiratory rate is often estimated or commonly assigned one of three denoting states: stable, unwell or high risk. Commonly noted RR manual observations include: 14, 18, and 24 breaths per minute. 170 Years Later Breaths per minute BMJ Quality 39,000 patients reported in 17 BMJ Quality just published a 39,000 admission study that demonstrates little change in observed respiratory rate measurements since Hutchinson s study over 170 years ago. 500 Percent of Patients Respiratory Rate (Breaths per minute)

7 Check your hospital s quality of respiratory rate measurement and reduce events by 5%.

8 Contact PMD Solutions to find out more on the value of continuous monitoring of RR. Goldhill and colleagues reported that 21% of ward patients with a respiratory rate of breaths/minute assessed by a critical care outreach service died in a hospital Recent evidence suggests that an adult with a respiratory rate of over breaths/ minute is probably unwell, and an adult with a respiratory rate of over 24 breaths/ minute is likely to be critically ill In another study, just over half of all patients suffering a serious adverse event on the general wards (such as a cardiac arrest or ICU admission) had a respiratory rate greater than 24 breaths/minute These patients could have been identified as high risk up to 24 hours before the event with a specificity of over 95% In 1993, Fieselmann and colleagues reported that a respiratory rate higher than 27 breaths/minute was the most important predictor of cardiac arrest in hospital wards Subbe and colleagues found that, in unstable patients, relative changes in respiratory rate were much greater than changes in heart rate or systolic blood pressure, and thus that the respiratory rate was likely to be a better means of discriminating between stable patients and patients at risk. PMD_Respiratory