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Published byJoleen Perry Modified over 6 years ago
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Engaging junior doctors and nurses in a patient safety project
Deteriorating Patient Care Pathway Chris Morley Deputy Chief Nurse
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Introduction Recognising and responding to deteriorating patients was established as a patient safety project in 2010 Established alongside projects in other areas such as medication safety, falls, ventilator acquired pneumonia etc
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23,000 preventable Cardiac Arrests
Background Failure to recognise deterioration 23,000 preventable Cardiac Arrests 20,000 admissions to ITU per year deemed preventable Parliamentary Health Committee (2009)
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Background Failure to respond to deterioration
ICU mortality 25% if deteriorating patients receive good ward care ICU mortality 50% if patient received sub optimal care on the ward Confidential inquiry into quality of care before admission to intensive care (1998)
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Deteriorating Patient Project
Early recognition, treatment, escalation improves survival Known policies in place: Sheffield Hospitals Early Warning Score (SHEWS) Bleep Escalation Policy Audit showed inconsistent compliance
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Deteriorating Patient Project
Score 3 2 1 Resp Rate 8 or less 9 to 18 19-24 25 to 29 30 or more Oxygen Saturation 90% 61% O2 Pulse Rate 40 41 to 49 50 to 99 100 to 129 130 or more Systolic BP 90 91 to 100 101 to 199 200 Urine Output over 2hrs 20mls/hr 30mls/hr or less More than 30mls/hr Conscious Level New Confusion /agitation Alert Responds to Voice Responds to Pain Un-responsive 6
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Deteriorating Patient Project
Project focused on improvement with individual clinical teams Multidisciplinary improvement group Consultants Senior Sisters/Charge Nurses & Matrons Junior doctors Junior nursing staff
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Staff Engagement Highlight the scale of the issue in relation to patient safety Recognise how the abnormal becomes normalised Discuss barriers to effective implementation of protocols/procedures Communication issues
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Staff Involvement Staff audited care in their area
Audit results discussed and changes proposed In conjunction with frontline clinical staff a care pathway was designed and implemented
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Importance of data Key to engagement
“Very compelling data from the rest of surgery and concerning pre audit data in Orthopaedics. This further convinces me we need to get on.” Consultant Orthopaedic Surgeon
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Importance of Local Leadership
Areas which have achieved more and faster have had the project championed by leaders in the clinical area
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Importance of Context The use during training of a local example:
Deterioration over 12 hours 30yr old male Poor compliance with observations Sub-optimal medical assessment Inadequate documentation Ultimately transferred to ITU
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Importance of Context Provides a ‘shock’ reaction during the training
Important that these events do happen within the organisation Leads into raising awareness of human factors
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Results
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Results
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Results
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Summary Important aspect of Patient Safety
Project team was multi-disciplinary Active involvement of clinical staff of all levels critical to gain true engagement Project continues particularly looking to explore medical documentation
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