Matt Inada-Kim, Acute Physician, Hampshire Hospitals ReSPECT The art of living well and dying well are one Death Review Home Baseline Death Transfer Admission AMBULANCE Review Home Baseline How can we prove good processes improve outcomes, and what strategies can be employed to implement system wide improvements? Matt Inada-Kim, Acute Physician, Hampshire Hospitals National Clinical Advisor, Clinical Lead for Physical Deterioration & Sepsis, Wessex PSC

DETerioration Sepsis Escalation Planning Resuscitation, Admission & Treatment status Deterioration Trauma Vascular Infection Frailty Sepsis Opportunity 1- to bring sepsis into the realm of deterioration, and ensure that its thought of with same prioritisation of other time sensitive emergency conditions It’s a heterogeneous, non-specific condition and doesn’t have the labels that ST elevation brings to cardiac chest pain or that a hemiparesis brings to stroke. Has there been Deterioration, could this be Sepsis, what is Appropriate?

Collaboration Preparedness Standardisation Disclaimer: The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these root cause data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of root causes or trends in root causes over time. Improving caregiver communication is essential because, as you can see, communication failures are the primary root cause of sentinel events – that is, the most serious— often fatal— preventable adverse events in hospitals. ADDITIONAL INFORMATION AND REFERENCE MATERIAL: The reason that improving caregiver communication has been so heavily emphasized within the patient safety movement becomes apparent when one looks at the underlying causes of medical error. Using root cause analysis to determine contributing factors shows that of sentinel events that were voluntarily reported to JCAHO over a ten year period, the top contributing factor representing nearly 2/3 of all cases was found to be inadequate communication amongst providers. Joint Commission. (2011). Sentinel Event Statistics Data - Root Causes by Event Type

Dialects & Tribes A Collaborative improvement strategy for Physical Deterioration Ambulance Better outcomes Hospital Community System The same language Standardisation Integrated pathways co designed A single tool Ownership Patient centred care Collaboration pan pathway Seamless transitions of care Strategy Align Hospitals Implement in Ambulances Disseminate into Community Each ambulance trust feeds into >10 acute hospitals, Communication is the largest cause of sentinel adverse events