1. Saving lives and supporting “good” deaths in hospital
John Welch
University College London Hospitals

2. 300 219 deaths following time in English hospitals
131 Trusts,
2,292 deaths each

3. PLoS Med. 2014;11(6): e

4. A 45 year old presents with pancreatitis
Bloods not escalated to senior doctor, nurse or PERRT.
17:00: blood pressure low, blood sugar high; sign of shock, significant pancreatitis.
BM 25 mmol/L,

5. A 45 year old presents with pancreatitis
He’s admitted, has Consultant review, is handed over to next day’s medical team as being “fine”.
08:00: Medical FY1 is asked to look after patient.
Patient is in severe pain and has low urine output.
iv fluid and pain killers are given. No improvement.
Referral to gastroenterologist; advises examination of the patient and review of the history.
Respiratory and heart rate rise, urine output falls further, pain worsens; all is not well.
Bloods not escalated to senior doctor, nurse or PERRT.
17:00: blood pressure low, blood sugar high; sign of shock, significant pancreatitis.
BM 25 mmol/L,

6. 17:00: blood pressure low, blood sugar high.
Patient says the catheter hurts; it’s removed - losing important monitoring.
Blood tests show significant kidney and liver problems. These are not escalated to senior staff.
17:00: blood pressure low, blood sugar high.
Patient is cold and clammy (shocked); and the iv cannula is failing (i.e., the main means of treatment).
FY1 seeks help from FY2 and anaesthesia to re-site cannula. They’re busy.
When visited at 19:25, the patient is not in bed. Other patients say he’s gone to the toilet.
No answer from the toilet.
Bloods not escalated to senior doctor, nurse or PERRT.
17:00: blood pressure low, blood sugar high; sign of shock, significant pancreatitis.
BM 25 mmol/L,

7. There were signs of respiratory, circulatory, kidney, liver and clotting problems thro’ the day …
RR 28/min, heart rate 135/min

8. There were signs of respiratory, circulatory, kidney, liver and clotting problems thro’ the day …
But it’s not straightforward
The FY1 is a new doctor, who’d had panic attacks just coming to work. The nurse was new too.
The nurse had four other patients; three on the other side of the ward, one with recurrent hypoglycaemia, one being prepared for theatre.
The nurse didn't have a lunch break until 16:00.
The Registrar was also new, still learning.
Support was requested from Gastroenterology (unhelpful) and Anaesthesia (unable).
RR 28/min, heart rate 135/min

9. Chain of Survival for Deteriorating Patient
Subbe CP, Welch JR. Clin Risk. 2013;19(1):6-11.

10. Recognition of Deterioration
↑ NEWS = ↓ outcomes (AUC 0.7)
Initial NEWS
30-day mortality
0–4
5.5%
5–6
11.3%
7–8
13.3%
9–20
27.6%
Corfield AR, et al.
Emerg Med J.
(6):482-7.

11. But it’s more than just T, P, R, BP, SpO2, A-nC-V-P-U …

12. Patient- and relative-activated outreach: seven years of data
referrals a year for clinical concern, early warning score breaches
0.8% were Call 4 Concern referrals, involving 312 patients
Odell M. Br J Nurs. 2019;28(2):

14. Thinking about deaths again

15. How many patients can be saved?
Clark D, et al. Palliat Med. 2014;28(6):

16. Deteriorating Patients Care Bundle
Treatment escalation plan in place - or similar
Vital Signs recorded as per local policy in 6 hours before event
Timely referral as per local policy
e.g., within 15 mins of NEWS score ≥ 5
SBAR or similar used in referral
(not applicable in cardiac arrest)
Timely response as per local policy
e.g., in 30 mins with NEWS score 5, or in 10 mins with NEWS score 7
Timely delivery of required treatment
e.g., Sepsis 6 in 60 mins
or Timely transfer to ICU e.g., in 60 mins
or Palliative Care
Example patient No
Yes
N/a
Patient 1
Patient 2
Patient 3
Patient 4
Patient 5
Review five cases: new referrals to Outreach and/or unplanned admissions to ICU and/or cardiac arrests and/or patient deaths

17. Outreach Teams diagnose dying …
22% go to ICU, 78% stay
8.4% die in a day
24% get care limits
Outreach Teams diagnose dying …
We performed an international prospective study of Rapid Response Team (RRT) activity over a 7-day period in February Investigators at 51 acute hospitals across Australia, Denmark, the Netherlands, USA and United Kingdom (40 sites) collected data on all patients triggering RRT review concerning the nature, trigger and immediate outcome of RRT review. Further follow-up at 24h following RRT review focused on patient orientated outcomes including need for admission to critical care, change in limitations of therapy and all cause mortality.
RESULTS:
We studied 1188 RRT activations. Derangement of vital signs as measured by the National Early Warning Score (NEWS) was more common in non-UK hospitals (p=0.03). Twenty four hour mortality after RRT review was 10.1% (120/1188). Urgent transfer to ICU or the operating theatre occurred in 24% (284/1188) and 3% (40/1188) of events, respectively. Patients in the UK were less likely to be admitted to ICU (31% vs. 22%; p=0.017) and their median (IQR) time to ICU admission was longer [4.4 ( ) vs. 1.5 ( )h; p<0.001]. RRT involvement lead to new limitations in care in 28% of the patients not transferring to the ICU; in the UK such limitations were instituted in 21% of patients while this occurred in 40% of non-UK patients (p<0.001).
CONCLUSION:
Among patients triggering RRT review, 1 in 10 died within 24h; 1 in 4 required ICU admission, and 1 in 4 had new limitations in therapy implemented.
Bannard-Smith J, et al. Resuscitation. 2016;107:7-12.

18. “Elderly people who are dying need to be protected from heroic but intrusive live-saving hospital interventions that often only prolong suffering rather than enhance quality of remaining life.”

21. What does good look like?

22. The acute medical unit (AMU) has had 119 days without a cardiac arrest.
Previously, the AMU record stood at 86 days in 2016.
Jillian Hartin, senior Patient Emergency Response and Resuscitation Team PERRT nurse, said: “Massive congratulations to the AMU and medicine board.
“There has been real engagement with learning from cardiac arrest events, and a clear commitment to improve outcomes for our patients, including improving end of life conversations.
“The nursing and medical leadership and team working has been key in achieving these results.”
The record-breaking run has been put down to better decision-making, clear treatment escalation planning and Do Not Attempt CPR decisions, sepsis management, better vital sign recording and using the National Early Warning Score (NEWS), and timely escalation to critical care.
The emergency department now refers patients to PERRT if they are transferring to a ward with NEWS of five or more, have high lactate levels in their bodies. This means patients who are at risk of deterioration can be identified and managed as early as possible.
T07, care of the elderly ward have had one cardiac arrest in the past 12 months.
The T08 medicine ward has also done fantastic work. Their last cardiac arrest was 5 September this patient is still alive and attended outpatients this week!
Chris Laing, DCD for emergency services, said: “This is a fantastic achievement for the AMU multidisciplinary team and the PERRT team.
“Praise must also go to the ED team for their strong handover processes in the acute medical unit and for the wider UCLH team working on clinical deterioration.
“The AMU is one of our busiest clinical areas cares for some of our sickest and most acute patients. For us to have gone for nearly 4 months without a cardiac arrest is an outstanding achievement in patient safety.”

23. The UCH acute medical unit has had 138 days without a cardiac arrest …
“nursing and medical leadership and team working has been key”
“better decision-making, clear treatment escalation planning and DNAPR decisions, sepsis management, better vital sign recording, using the NEWS, and timely escalation to critical care
“There has been real engagement with learning from cardiac arrests, and a clear commitment to improve outcomes for our patients, including improving end-of-life conversations.”

24. Multi professional change: “Talking DNACPR”
Outreach Team (PERRT)
Psychologists
Educationalists
Lawyers, Ethicists
Palliative Care
Critical Care
Patients ,

25. Multi professional change: “Talking DNACPR”,

26. What are your thoughts?

27. Measure / evaluate
Cardiac arrests - and potentially avoidable cardiac arrests
Timeliness of response to deterioration
Timeliness of critical care interventions
Whether patients with breach of escalation criteria have timely documentation of goals of care

28. Measure / evaluate
Whether means are provided for patients and family members to activate the Outreach Team - and the frequency of activation
The safety culture in relation to deteriorating patients and their care
Length of stay on wards of patients with breach of escalation criteria
Length of ICU stay of patients transferred to ICU following breach of escalation criteria

30. Rapid Response Systems (Outreach) & End of Life Care
Rapid Response Systems
In-hospital end of life care
Observed problem
Cardiac arrests, unplanned ICU admissions, unexpected deaths 
1 in 3 RRS cases have end of life care issues
Adverse events
Potentially avoidable morbidity and mortality 
Potential for poor end of life care
Recognition
Ward staff do not reliably recognise deterioration
Ward staff do not reliably recognise dying
Potential benefits of early intervention
Fewer adverse events
Improved palliative / end of life care, better patient experience and staff satisfaction
Available interventions
Critical Care Outreach / Rapid Response Teams
Palliative care services, ReSPECT process
Antecedents, warning signs
Physiological deterioration; abnormal vitals 
None validated …
Recommended Summary Plan for Emergency Care and Treatment
Jones D et al. Curr Opin Crit Care. 2013;19(6):

31. 46% of all deaths occur in hospital …
Did patient die in right place?

32. 46% of all deaths occur in hospital …
Did patient die in right place?
Quality of care by place of death