Implementation of the NICE Guidance (50) in Wales Chris Subbe, Wrecsam

Changing clinical practice To ensure early identification of the acutely ill patient and prevent deterioration of clinical condition. To reduce patient mortality, morbidity and length of stay. To reduce ICU admissions and re-admission. NOTES FOR PRESENTERS: Any patient in hospital may become acutely ill. The ageing population, increasing complexity of medical and surgical interventions and shorter inpatient stays have meant that patients in hospital are at increasing risk of becoming acutely ill and may require admission to critical care areas. The 'National Confidential Enquiry into Patient Outcome and Death' (NCEPOD 2005) reported that the recognition of deteriorating health is often delayed and may be managed inappropriately. This may result in late referral and avoidable admissions to critical care. It may lead to unnecessary patient deaths, particularly when the initial standard of care is suboptimal. The guideline recommendations aim to improve the care of acutely ill patients in hospital by providing evidence based guidance on the best way to identify and manage this group of patients to reduce mortality, morbidity and length of stay both in the hospital overall and in a critical care area should they be admitted to critical care. It is apparent that such interventions could potentially have substantial health economic implications, through, for example, reductions in ICU admission and re- admission. The National Confidential Enquiry into Patient Outcome and Death report (2005) found that admission to an intensive care unit (ICU) was thought to have been avoidable in 21% of cases, and that sub-optimal care contributed to about a third of the deaths that occurred.

Sick patients & Cardiac arrests Near all arrests in patients known to be unstable. Patients with dyspnea are at increased risk. Sax FL, Medical patients at high risk for catastrophic deterioration, Critical Care Medicine, 1987 84% of cardiac arrests are proceeded by deterioration of respiratory and mental function. Schein RMH, Clinical Antecedents to in-Hospital Cardiopulmonary Arrest, Chest, 1990 66% of cardiac arrests have documented deterioration 6 hours pre-arrest. Franklin C, Developing strategies to prevent inhospital cardiac arrest, Critical Care Medicine, 1994 We have been lucky, we did not have to start from scratch. If we want to identify Critically Ill patients, patients with Cardiac Arrest might serve as a useful Surrogate Marker 1. Prospective study from New York: 544 pat./20 arrest 2. Miami: 64 arrests: 38% Respirat., 11% Metabolic., 9% Cardiac., 6% Neurolog., 70% Resp or Mental changes within 8 hours prior to arrest, mean RR 29/min 3. Chicago: 150 arrest, 91% dead 4. 100 ICU admissions from Portsmouth and Southampton: 2 59% too late to ICU. Causes: failure of organisation, lack of knowledge, failure to appreciate clinical urgency, lack of supervision, failure to seek advice Lets translate McQ’s data into our ICU practice

McQuillan

Abnormalities up to 72 hours pre-ICU Physiological abnormalities against predefined parameters were present for up to 72 hours prior to referral and admissions to intensive care

100,000 Lives Campaign Rapid Response Team Acute Myocardial Infarction Adverse Drug Events (ADEs) Central Line Infections Surgical Site Infections Ventilator-Associated Pneumonia Deploy Rapid Response Teams…at the first sign of patient decline Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction…to prevent deaths from heart attack Prevent Adverse Drug Events (ADEs)…by implementing medication reconciliation Prevent Central Line Infections…by implementing a series of interdependent, scientifically grounded steps Prevent Surgical Site Infections…by reliably delivering the correct perioperative antibiotics at the proper time Prevent Ventilator-Associated Pneumonia…by implementing a series of interdependent, scientifically grounded steps

Assessment and monitoring Adult patients in acute hospital settings, including patients in the emergency department for whom a clinical decision to admit has been made, should have: physiological observations recorded a clear written monitoring plan Physiological observations should be recorded and acted upon by staff who have been trained and are competent. NOTES FOR PRESENTERS: The guideline recommendation in full says: ● Adult patients in acute hospital settings, including patients in the emergency department for whom a clinical decision to admit has been made, should have: – physiological observations recorded at the time of their admission or initial assessment - a clear written monitoring plan that specifies which physiological observations should be recorded and how often. The plan should take account of the patient’s diagnosis, presence of comorbidities and agreed treatment plan. Physiological observations should be recorded and acted upon by staff who have been trained and are competent to undertake these procedures and understand their clinical relevance.

Assessment and monitoring: physiological observations Initial assessment should include at least: heart rate respiratory rate systolic blood pressure level of consciousness oxygen saturation temperature. NOTES FOR PRESENTERS: Initial assessment of the patient should include the above. The next slide indicates the monitoring frequency of these and other observations

EWS - How to find the sick? Cytokine-cascade Uniform physiological response Gaps? Score = 1+3+3+0+0=7

Sick patients & MET Medical Emergency Team replaces Arrest Team (1990) Criteria for Call out Anybody can call Hourihan F, The medical emergency team: a strategy to identify and intervene in high risk patients, Clin Intensive Care, 1995 Reduction in Cardiac Arrest Parr MJA, The Medical Emergency Team: 12 month analysis of reasons for activation, immediate outcome and not-for resuscitation orders, Resuscitation, 2001 Criteria for MET alert Airway Threatened Breathing Respiratory arrest RR < 5, RR > 36 Circulation Cardiac arrest PR < 40, PR > 140 BP < 90 mmHg Neurology Sudden  LOC GCS  >2 Repeat. or prolonged seizure Other Any U R seriously worried about

Can we identify sick medical patients? Prospective study Medical admissions MEWS > 4: risk of HDU ICU Death 1 2 3 4 5 6 7 8 9 HDU ICU Death Scores

NEW score “We recommend that the physiological assessment of all patients should be standardised across the NHS with the recording of a minimum clinical data set result in an NHS early warning (NEW) score.” To …”be used at all stages in the acute care pathway, including pre-hospital assessment, eg by the GP, ambulance service or other healthcare professionals.“

Graded response strategy Low-score group Increase frequency of observations and alert the nurse in charge Medium-score group Urgent call to team with primary medical responsibility for the patient Simultaneous call to personnel with core competencies for acute illness High-score group Emergency call to team with critical care competencies and diagnostic skills NOTES FOR PRESENTERS: For patients identified in the low-score group it is recommended that the frequency of observations is increased and the nurse in charge alerted. For patients identified in the medium-score group two responses are needed, firstly an urgent call to the team with primary medical responsibility for the patient, and simultaneously a call to personnel with core competencies for acute illness. These competencies can be delivered by a variety of models at a local level, such as a critical care outreach team, a hospital-at-night team or a specialist trainee in an acute medical or surgical specialty. Appropriate interventions should be initiated. For those identified with a high score, the response required is an emergency call to the team with critical care competencies and diagnostic skills. The team should include a medical practitioner skilled in the assessment of the critically ill patient, who possesses advanced airways management and resuscitation skills. There should be an immediate response and the appropriate interventions initiated.

Critical Care Outreach Ward-randomized trial of phased introduction in a general hospital York, 800 bedded, 16 wards, 32 wks Gradual introduction, paired wards 7450 patients, 2903 eligible Pre/Post vs Control/Intervention Hospital mortality 0.52 (0.32-0.85) Priestley et al. Intensive Care Med 2004; 30: 1398-1404

Hillman K, ICS State of the Art meeting 2004 MET & mortality V RCT of 23 hospitals 13.142 events, 700.000 patients Outcomes [Control vs MET] Cardiac arrests 2.6 vs1.6/1000 admissions ICU admissions (unplanned) 4.9 vs 4.2 Death 1.2 vs 1.1 No significant difference ….. But Very poor compliance with call-out criteria [50% of patients with adverse events] Hillman K, ICS State of the Art meeting 2004

MERIT - Methods 23 Australian hospitals Cluster randomization Cardiac arrests vs MET 2 month baselines, 4 months education, 6 months collection Improvement in all hospitals re-CPR & unexpected admissions to ICU Hillman et al, Lancet, 365: 2091-97

MET informed if 15 min abnormal? Control (no MET) Intervention (MET) Cardiac arrests 96% 95% Unplanned ICU 9% 30% Unexpected death 25% 8%

Bellomo, MET conference 2006

Size of team?

Models MET Outreach led Outreach supported Research Trial RCT ? Identification MET criteria Score Intervention Intensivist team Intensive care skills Practitioners Own team Quality control Outreach

Model The job …

Vital elements Reliable identification Trained staff Reliable response System that is credible Sensitivity/specificity? Trained staff MET Outreach ALERT Ward staff (?) Reliable response

Training and competencies Staff need to be competent in using the locally agreed 'track and trigger' system. Use baseline assessment to check use of track and trigger systems. Use existing team and network meetings to communicate agreed response strategy. Use Department of Health competencies and training matrix to implement training plan for staff. NOTES FOR PRESENTERS:The delivery of education and training of ward staff is of key importance in ensuring that staff have the appropriate competencies to correctly measure the appropriate physiological variables, correctly use the 'track and trigger' system agreed locally and to identify and enact the correct response to a patient at risk of clinical deterioration. Staff working with acutely ill patients on general wards should also receive education and training that helps them to recognise and understand the physical, psychological and emotional needs of their patients on discharge from critical care areas and provide appropriate care. NICE implementation advice suggests that we: Use our baseline assessment to ensure that track and trigger systems used are multi-parameter or are aggregated weighted scoring systems. Use our existing team meetings and network meetings to ensure that the agreed local track and trigger system is communicated to staff and the graded response strategy is implemented effectively with the appropriate audiences Review current education and training programmes for staff working within critical care and general medical and surgical ward areas to reflect recommendations including how to provide information to patients and work with local education and training providers in this area to ensure that future programmes are designed to reflect recommendations Note: The Department of Health competencies and training matrix is due to be published late in 2007

Who is who?

Conclusion No comparative data, but … Simple scores more reproducible Pros beat amateurs most times

Resources from NICE www.nice.org.uk/CG050 Costing tools costing report costing template Implementation advice Audit criteria NOTES FOR PRESENTERS: NICE has developed tools to help organisations implement this guidance, which can be found on the NICE website. Costing tools – a costing report giving the background to the national savings and costs associated with implementation, and a costing template to estimate the local costs and savings involved. • The implementation advice gives details of how to put the guidance into practice and national initiatives that support this locally Audit criteria assist NHS trusts to determine whether the service is implementing, and is in compliance with, the NICE clinical guideline www.nice.org.uk/CG050