1. 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

2. 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?

3. 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

4. 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