1. Introduction to Standard 9: Recognising and Responding to Clinical Deterioration in Acute Health Care
Nicola Dunbar Program Director April 2013

2. The Standard Standard: Intent: Context:
Health service organisations establish and maintain systems for recognising and responding to clinical deterioration. Clinicians and other members of the workforce use the recognition and response systems.
Intent:
To ensure that a patient’s deterioration is recognised promptly and appropriate action is taken
Context:
To be applied in conjunction with Standard 1: Governance for Safety and Quality and Standard 2: Partnering with Consumers
Does not apply to deterioration in a patient’s mental state

3. Rationale for the Standard
Evidence base:
deterioration is not always recognised or acted on
there are early warning signs
early intervention can improve outcomes for patients
there are well-established strategies that can be implemented
Processes of recognising and responding to clinical deterioration are relevant across the hospital – therefore need a systems approach to address

4. Criteria to achieve the Standard
Establishing recognition and response systems
Organisation-wide systems consistent with the National Consensus Statement are used to support and promote recognition of, and response to, patients whose condition deteriorates in an acute health care facility
Recognising clinical deterioration and escalating care
Patients whose condition is deteriorating are recognised and appropriate action is taken to escalate care
Responding to clinical deterioration
Appropriate and timely care is provided to patients whose condition is deteriorating
Communicating with patients and carers
Patients, families and carers are informed of recognition and response systems and can contribute to the processes of escalating care

5. Definitions Recognition and response systems:
Formal systems to support staff to promptly and reliably recognise patients who are deteriorating and to respond appropriately to stabilise the patient
Track and trigger system:
Tracks changes in physiological parameters over time, includes thresholds for each parameter that indicates abnormality, and describes the response or action when deterioration occurs
Escalation protocol:
Protocol that sets out the organisational response required for different levels of physiological abnormality or other deterioration
Rapid response system:
System for providing emergency assistance to patients whose condition is deteriorating (such as medical emergency team)

6. Developmental and not applicable actions
Action 9.3.1: use of a general observation chart that has specified characteristics
Item 9.7: informing patients, families and carers
Item 9.8: advance care plans and treatment-limiting orders
Item 9.9: patient and family escalation
Not applicable:
Standard 9 not applicable for specialist, non-acute, mothercraft hospitals or services (meets requirements under Action 1.8.3)
Items may not be applicable for day procedure services

7. Context
National Consensus Statement endorsed by Health Ministers in 2010:
sets out essential elements for recognising and responding to clinical deterioration:
measurement and documentation of observations
escalation of care
rapid response systems
clinical communication
organisational supports
education
evaluation, audit and feedback
technological systems and solutions
relates to situations where a patient’s physical condition is deteriorating
applies to all patients in an acute healthcare facility

8. Context Flexible standardisation:
Standardisation of processes is an important way of improving safety and quality
Needs to reflect context of the health service
Contextual issues that will affect the systems that are put in place to meet Standard 9 include:
type and size of health service – small or large hospital, day procedure
nature of services provided – ICU, no ICU
nature and skill mix of workforce – are doctors on site 24/7?
existing policies and programs – eg. Between the Flags, Compass, RMDP etc
Don’t need to have separate processes and systems for each action in the Standard – consider how activities fit together to coordinate evidence and outcomes

9. Structure of Standard 9
9.3, 9.4 Recognising clinical deterioration and escalating care
9.5, 9.6 Responding to clinical deterioration
Communicating with patients and carers
9.1, 9.2 Organisation-wide systems for recognising and responding to clinical deterioration
Put the system in place
Audit / review performance of or compliance with the system
Make improvements based on the results of the audit

10. Organisation-wide systems for recognising and responding to clinical deterioration
Recognition and response systems are relevant across the whole hospital:
overarching governance and policy framework should exist at an organisation-wide level
there may also be local (department / ward) policies in place about local recognition and response processes
examples of where responsibility can sit:
senior executive clinical leaders (both medical and nursing)
clinical governance and/or quality committees
emergency response / resuscitation committees
Need a systematic approach:
embedded into clinical governance arrangements
tailored to local circumstances
covering all essential elements in Consensus Statement

11. Observation charts Action 9.3.1 relates to general observation charts:
does not include charts for specific clinical areas – such as neurovascular, cardiothoracic etc
for specialist hospitals – these may require specialist paediatric and obstetric charts
What chart to use:
for jurisdictions that have a state-wide chart, use of this chart is acceptable:
NSW, Qld, ACT, WA (SA coming soon...)
the Commission has developed four charts that can be customised for local use – these are acceptable
also have a chart that has been developed for and trialed in day procedure hospitals
for other charts – sites need to demonstrate how they have tested the chart to ensure its safety
Fact sheets available on the Commission’s web site

12. Escalation protocols
Escalation policies and protocols that contain information about what to do if deterioration occurs reduce the risk of delays in providing appropriate care
Escalation protocol needs to:
be tailored to the facility – size, location, skill mix, resources
included a graded response – different types of responses depending on the level of abnormality
include an option for emergency assistance
include an option for clinicians to escalate care based only their concern for the patient
be regularly reviewed

13. Escalation protocols
Developing triggers and responses for an escalation protocol:
How many levels of abnormality?
What physiological observation thresholds trigger abnormality?
What actions/treatments are required?
Who can provide this treatment?
Responsibilities of responding clinicians?
How will the system operate?
Planning tool on the Commission’s web site

14. Rapid response systems
Need a system to provide appropriate emergency assistance in a timely way when severe deterioration occurs
Rapid response systems have been shown to reduce cardiac arrests, unplanned ICU admissions, and deaths
Models for rapid response systems:
medical emergency teams / rapid response teams
ICU liaison / critical care outreach
nursing and medical staff trained in advanced life support – ED, anaesthetics etc
advanced practice nursing roles
local GPs or VMOs
local ambulance

15. Clinical workforce that can respond
Everyone needs to know how to call for emergency assistance
All clinicians should be able to implement basic life support while waiting for emergency assistance:
includes nurses, allied health providers, doctors
Non-technical skills also important – leadership, team work, communication, task management
A system needs to be in place to ensure access at all times to at least one clinician who can practice advanced life support
Need to maintain competency – Commission does not specify how this should occur

16. Communicating with patients and carers
Why is this important?
patients, families and carers are part of the healthcare team and can help ensure best understanding of clinical circumstances
patients, families and carers generally want to know when deterioration is occurring
Communication with families and carers about:
the importance of communicating concerns and signs/symptoms of deterioration
how they can raise their concerns
local systems for responding to deterioration
Opportunities for communication:
on presentation in acute care
at regularly scheduled intervals during admission
during healthcare team rounds
during bedside handover

17. Advance care plans and treatment-limiting orders
Advance care preferences and treatment-limiting decisions need to be considered when deterioration occurs
Most states and territories have legislation and policy regarding advanced care directives that will need to be reflected in local policies and processes
Standard covers both advanced care plans and other treatment-limiting orders - e.g. NFR, DNR etc

18. Family and patient escalation of care
Patients experience delays in treatment despite reporting concerns about deterioration
Families and carers are well placed to identify signs of deterioration
New models of family escalation now being introduced:
what are the triggers for families to escalate care
how will the response be activated
what will the response be
how to inform about the new system

19. Family and patient escalation of care
More than existing processes for calling for assistance – such as the call bell
Is a formal process that acts in a similar way to escalation protocols triggered by health professionals
Patient, family member or carer can escalate care directly to request review / emergency assistance
Should be built into existing recognition and response system

20. Data collection processes
Collection of feedback from clinical workforce (9.2.1):
surveys, focus groups to get information from a number of people
peer review processes such as morbidity and mortality meetings to get feedback on individual events
Review of cardiac arrests and deaths without a treatment-limiting order (9.2.2):
routine reviews of in-hospital cardiac arrests
reviews of unexpected deaths to identify failures of escalation and systems issues
identification of patients with and without a treatment-limiting order
Completion of observation charts (9.3.2):
audits of observation charts against local policy and monitoring plan

21. Data collection processes
Use of escalation processes, including failures to call and calls for emergency assistance (9.4.2, 9.5.2):
audit of observation charts to identify triggers for escalation and actions taken
number and circumstances of rapid response calls
outcomes measures such as cardiac arrests, unplanned admissions to ICU, deaths
Performance of family escalation processes (9.9.3):
surveys, interviews, focus groups to get information about knowledge and views of patients, families and carers, and workforce
records of family escalation calls
clinical record regarding circumstances of calls
Quality measures and audit tools are on the Commission’s web site

22. Resources Safety and Quality Improvement Guide for Standard 9
National Consensus Statement – and supporting implementation guides
Observation charts
Fact sheets, planning and audit tools
Jurisdictional programs

23. Summary
Recognising patients whose condition is deteriorating and responding to their needs in an appropriate and timely way are essential components of safe and high quality care
Purpose of the Standard is to improve outcomes for patients by ensuring that there is a systematic approach in place for recognising and responding to clinical deterioration
Outcomes to be achieved are clear – methods to get there will vary depending on context