Improving Care for Deteriorating Patients

Transcription

1 Improving the Effectiveness of NEWS, Improving Care for Deteriorating Patients John Welch, Consultant Nurse, Critical Care & Critical Care Outreach

2 Declaration of interest

3

4 The deteriorating patient journey Record - Recognise - Report - Respond Subbe CP, Welch JR. Clin Risk (1):6-11.

5 Potential problems Lack of knowledge of all inherent risk factors, frailty, etc Deciding, agreeing, documenting most appropriate care Incomplete vital signs, insufficiently frequent vital signs Inadequate understanding of abnormal vital signs Failure to effectively escalate abnormal vital signs Delayed response to escalation Delayed treatment Too much treatment or too little Delayed re-checking that treatment has worked

6 Potential problems Lack of knowledge of all inherent risk factors, frailty, etc Deciding, agreeing, documenting most appropriate care Incomplete vital signs, insufficiently frequent vital signs Inadequate understanding of abnormal vital signs Failure to effectively escalate abnormal vital signs Delayed response to escalation Delayed treatment Too much treatment or too little Delayed re-checking that treatment has worked

7 The deteriorating patient journey Record - Recognise - Report - Respond Subbe CP, Welch JR. Clin Risk (1):6-11.

8 Record & Recognise: The National Early Warning Score

9 NEWS scores & risk of arrest, ICU, death Smith GB, et al. Resuscitation (4):

10 Record & Recognise: The National Early Warning Score In four years, ¾ of hospitals are using NEWS (36% are using some type of electronic system)

11 New news about NEWS vs Medical Emergency Team criteria Single centre study, 103,998 admissions NEWS has higher specificity and generates less of a workload Smith GB, et al. Crit Care Med (12):

12 New news about NEWS and sepsis risk prediction Single centre study, 30,677 patients; 7,385 (24%) died or transferred to ICU Churpek MM, et al. Am J Respir Crit Care Med Sep 20.

13 New news about NEWS for non-elective medical & surgical patients Single centre study, 65,896 admissions NEWS performed equally well, or better, for surgical as for medical patients Kovacs C, et al. Br J Surg (10):

14 New news about NEWS for Emergency Department triage Single centre study, 500 patients; 27 (5.4%) with severe sepsis The area under the curve for NEWS to identify risk of severe sepsis is 0.89 Keep JW, et al. Emerg Med J (1):37-41.

15 Just one NEWS at ED triage is predictive Multi centre study 2003 patients with sepsis NEWS = outcomes (AUC 0.7) Initial NEWS & mortality in patients with sepsis Initial NEWS 30-day mortality % % % % Corfield AR, et al. Emerg Med J (6):482-7.

16 NEWS: how to do it (my personal view) 1. Tell and sell the concept - tailored to the audience 2. Compare and contrast with the existing track and trigger system 3. Set it out as a progressive development 4. Facilitate and support ward staff to input 5. Try out good ideas, e.g., with PDSA cycles 6. Challenge resistors: get data 7. Measure processes and outcomes

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18 What s new on the front New Confusion added to AVPU (scores 3: needs urgent assessment) What s new on the back New Confusion : think about delirium (pain, infection (sepsis), etc) 18

19 What s new on the front New Confusion added to AVPU (scores 3: needs urgent assessment)

20 What s new on the back New Confusion : think about delirium (pain, infection (sepsis), etc) 20

21 What s new on the front modified approach to Sepsis 21

22 The deteriorating patient journey Record - Recognise - Report - Respond Subbe CP, Welch JR. Clin Risk (1):6-11.

23 89% of hospitals have Outreach

24 89% of hospitals have Outreach - 49% have 24/7 Outreach

25 89% of hospitals have Outreach - 49% have 24/7 Outreach - 97% of teams are nurse only

26 Is it ok that UK teams are nurse only? RRSs were associated with a reduction in hospital mortality and cardiopulmonary arrest. Meta-regression did not identify the presence of a physician in the RRS to be significantly associated with a mortality reduction. Crit Care :254.

27 We ve an efficient National Early Warning Score Prytherch DR, et al. Resuscitation (8):932-7.

28 and we ve some ideas about more soft alerts Call 4 Concern enables patients and families to call for immediate help and advice when they feel concerned that the health care team has not recognised their own or their loved one s changing condition. The Outreach team can be contacted directly if: 1. A noticeable change in the patient occurs and the health care team is not recognising your concern. Odell M, et al. Br J Nurs. 2010;19(22): You feel there is confusion over what needs to be done for the patient.

29 and we ve more ideas about more soft alerts Odell M, et al. Br J Nurs Dec Jan 13;19(22): Douw G, et al. Int J Nurs Stud. 2016;59:

30 More recent developments

31 Adjusted mortality rates at Queen Alexandra Hospital (top) and University Hospital Coventry (bottom). Schmidt PE, et al. BMJ Qual Saf 2015;24:10-20.

32 Measuring processes & outcomes

33 Four key questions Do you know how good you are? Do you know where you stand relative to the best? Do you know about variation in your system? Do you know how things change over time? After Maureen Bisognano, IHI President/CEO.

34 Multi-disciplinary Audit EvaLuating Outcomes of Rapid Response = MAELOR Outcomes Positive Negative Transfer to ICU, or Theatre 1. Timely transfer, e.g., < 4 hours after the first trigger 2. Delayed transfer, e.g., > 4 hours after first trigger Alive on ward 3. No longer triggering 4. Still triggering Deceased Others 5. On terminal care pathway / with DNAR order 7. Alive with documented treatment limits / DNAR order 8a) Trigger from new pathology unrelated to previous call-out 8b) Chronic condition leading to continuous trigger 8c) Discharged from hospital 6. Following cardio-pulmonary arrest 9. Outcome unknown Morris A, et al. Crit Care Resusc. 2013;15(1):33-9.

35 Four key questions Do you know how good you are? Do you know where you stand relative to the best? Do you know about variation in your system? Do you know how things change over time? After Maureen Bisognano, IHI President/CEO.

36 Resuscitation. 2016;107: Hospitals Australia, Denmark, Netherlands, UK, USA

37 Ward referrals to UCH Outreach Team 34 referrals / 1000 admissions, 23% ICU average NEWS at referral = % hospital mortality

38 Four key questions Do you know how good you are? Do you know where you stand relative to the best? Do you know about variation in your system? Do you know how things change over time? After Maureen Bisognano, IHI President/CEO.

39 Completeness of NEWS scoring at UCH 91% of referrals had all seven vital signs and NEWS scores completed.

40 Accuracy of NEWS scoring at UCH 95% of referrals had accurate NEWS scores. There were two outliers.

41 Timeliness of referral to UCH Outreach Overall, 91% of referrals were timely, with only one outlier.

42 Use of SBAR 42

43 Timeliness of response from UCH Outreach 95% of patient referrals were responded to in a timely way. There are no outliers. 43

44 Timely transfer to ICU For patients transferred to ICU following referral to PERRT, 89% are transferred within 4 hours.

45 Multi-disciplinary Audit EvaLuating Outcomes of Rapid Response = MAELOR Outcomes Positive Negative Transfer to ICU, or Theatre 1. Timely transfer, e.g., < 4 hours after the first trigger 2. Delayed transfer, e.g., > 4 hours after first trigger Alive on ward 3. No longer triggering 4. Still triggering Deceased Others 5. On terminal care pathway / with DNAR order 7. Alive with documented treatment limits / DNAR order 8a) Trigger from new pathology unrelated to previous call-out 8b) Chronic condition leading to continuous trigger 8c) Discharged from hospital 6. Following cardio-pulmonary arrest 9. Outcome unknown Morris A, et al. Crit Care Resusc.2013;15(1):33-9.

46 Quality of Outreach Response 823 UCH Patient Emergency Response & Resuscitation Team referrals (2015) Outcomes Positive PERRT +ve results Transfer to ICU / Theatre Alive on Ward Patient deceased Other Alive 1. Timely transfer (<4 hours) 3. No longer triggering 5. On terminal care pathway / DNAR order 7. with treatment limitations / DNAR 165 (89%) 494 (94%) Negative 2. Delayed (>4 hours) 4. Still triggering 6 6. Following CPR PERRT ve results Totals 21 (11%) (6%) Totals 761 (92%) Of patients judged fit to stay on ward for active treatment,494 of 528 were improved next day. 165 of 186 transfers to ICU occurred in <4 hours. 62 (8%) 823 Positive and negative outcomes 92%+ve 8%-ve

47 We can count and case-mix adjust deaths

48 Counting deaths or, better, learning from them Hogan H, et al. BMJ Qual Saf. 2012;21(9): Hogan H, et al. BMJ. 2015;351:h3239.

49 Deteriorating Patients Care Bundle Review sample of referrals to Outreach / unplanned transfers to ICU / arrests / deaths 49

50 National, standardised, structured death reviews: framework of factors contributing to patient safety Lawton R, et al BMJ Qual Saf. 2012; 21(5):

51 Remember, nothing is certain, except (10,743 patients, 31/03/2010) Clark D, et al. Palliat Med. 2014;28(6):

52 Outreach moves things along GSTT: Cardiac Arrests per month and Wards that have implemented AMBER AMBER Wards: GSTT Arrest Data: GSTT Critical Care Outreach PDN meeting Month Se p ay M M Fe b c-1 De Au g11 2 Ju l Ju n Ap r ar Ja n No v10 14 Oc t Amber Wards 18 8 Se p Cardiac Arrest 9 Thanks to Adrian Hopper, GSTT

53 Outreach moves things along GSTT: Cardiac Arrests per month and Wards that have implemented AMBER AMBER Wards: GSTT Arrest Data: GSTT Critical Care Outreach PDN meeting Month Se p ay M M Fe b c-1 De Au g11 2 Ju l Ju n Ap r ar Ja n No v10 14 Oc t Amber Wards 18 8 Se p Cardiac Arrest 9 Thanks to Adrian Hopper, GSTT

54 and we ve a new, national combined ECTP/DNACPR form Emergency Care & Treatment Plan Name: Date of Birth: Hospital/NHS numbers: Address: 1 Date: / / Does the (adult) individual have capacity? (see guidance notes) YES NO Do they have a valid advance directive or ADRT? YES NO If so, record details in box 5 Do they have a representative with legal authority to make decisions? YES NO (e.g. Welfare Attorney, Guardian, person with Lasting Power of Attorney for Health and Welfare) If so, record their contact details and document details of discussion below. 7 2 Relevant information about the individual s diagnosis, situation, ability to communicate, and reasons for the chosen plan. The clinician signing this ECTP is confirming that these decisions: 1. have been discussed with and agreed with the individual; or 2. have been made in accordance with capacity law; or 3. in the case of a child, the person holding parental responsibility/court order. Date of discussion: / / Names of those present: Full documentation of discussion can be found in: 3 The following treatment plan should be used as clinical guidance and is not a substitute for ongoing consultation and shared decision-making wherever possible. The clinician should initial ONE of the patient s priority boxes below, add relevant guidance in the large box and initial a CPR decision. The form must be signed, named and dated on the reverse. The priority is to get better. Please consider all treatment to prolong life The priority is to achieve a balance between getting better and ensuring good quality of life. Please consider selected treatments Initials:.. Initials: Further conversations occurred on the following dates (state where details are recorded): 8 The priority is comfort. Please consider all treatments aimed at symptom control Initials:.. If there has been no shared decision-making with the individual, no shared decision-making with a representative with legal authority to make decisions or no best-interests meeting for the individual who lacks capacity, document a full explanation and a clear plan to address this in the clinical records. Summarise the reason (e.g. describe any potential to cause harm) here: 4 9 Designation (Grade and specialty) Please provide clinical guidance on specific interventions that may or may not be wanted or clinically appropriate in community, hospital and critical care settings: Print name & professional registration number Senior Responsible Clinician Signature Date and time 10 Plan review: If the individual s condition changes (i.e. deterioration OR improvement) review the decisions on this ECTP. Document further conversations in box 8. If necessary, complete a new form, and write CANCELLED clearly across both sides of this form with signature and date. The decisions on this form should be reviewed specifically before any procedure during which abrupt deterioration or cardiac arrest may occur (e.g. endoscopy, cardiac pacing, angiography, surgery or anaesthesia). Make an agreed plan on whether or not to revoke temporarily the decisions on this form and, if so, on the treatments that will be considered if abrupt deterioration or cardiac arrest occurs. 11 Provide details of other relevant care planning documents and/or documented wishes about organ/tissue donation (name and where held): 5 Emergency contacts This individual is FOR attempted CARDIOPULMONARY RESUSCITATION Signature 6 This individual is NOT FOR attempted CARDIOPULMONARY RESUSCITATION Signature If the patient dies in transit please take to: Telephone numbers Other relevant details Family/friend GP 6 Lead Consultant Specialist worker/key worker Turn over to complete this ECTP Name Welfare Attorney, Guardian etc. 12

55 What s new in NEWS 2 Re-ordering of the chart layout Recording of oxygen therapy Consideration of chronic respiratory disease Highlighting of new confusion / delirium Sepsis

56 What else?

57 Thinking about the whole system

58 Continuous improvement Clear policy & procedure; new NEWS chart(s) Monthly e-audits Care thermometer wards know how they re doing Frontline comms: Message of the week PERRT training Ward safety huddles each shift 58

59 Key: ward staff and the patients know how they re doing more or less in real time

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61 Huddles to improve Teamwork and Communication.

62 Learning from serious incidents 62

63 AAR: The Four Steps What was EXPECTED Before the event, what was the objective, plan or expected outcome? It could be a shared plan, a formal agreement, a guideline, a personal expectation, or simply regular practice. What ACTUALLY happened After event, each participant describes: What they did, saw or experienced During the event. Explore the facts, while acknowledging the perspective and feelings of others. WHY there was a difference Why was there a difference between the expected outcome and the reality of the moment? Check if expectations were properly shared, and what constraints on people, time or resource prevented expectation being realised. What can be LEARNED Learning is the prime action within an AAR. What will be different next time? It may be a change in practice or policy, or a change in attitude, behaviour, shared understanding or greater insight. Direct the collective wisdom to improving future performance.

64 Thinking about BARRIERS Steinmo S, et al. Implement Sci. 2015;10:111. Knowledge: Confusion over how to treat complicated patients (fluid balance, long term in-patients) Beliefs about consequences: Fear of harming patients with Sepsis Six, lack of confidence in the evidence Social Influences: Lack of communication: Is this patient on the pathway or not?, conflict between Drs and Nurses

65 and LEVERS Steinmo S, et al. Implement Sci. 2015;10:111. Memory and Attention: Sepsis Six branding and marketing, plus prompts and reminders Beliefs about consequences: seeing health improve immediately, following-up specific patients Environment: Materials and resources immediately available Social influences: Superiors commitment; reciprocal feedback It s our pathway and we re being listened to.

66 Focused training

67 Technological aids in crises

68 and data and analytics

69 is something else

70 - derived from analysis of 5 million patient encounters in a wide range of hospitalsepsis is likely Singer M, with et al. JAMA. 2016;315(8): infection and 2 of RR 22, SBP 100, altered mentation -

71 Artificial Intelligence 4, Human Champion 1

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73 The whole system needs to be right Record - Recognise - Report - Respond Subbe CP, Welch JR. Clin Risk (1):6-11.

74 Four key questions Do you know how good you are? Do you know where you stand relative to the best? Do you know about variation in your system? Do you know how things change over time? After Maureen Bisognano, IHI President/CEO.

75 Thanks!