1. Standard 9: Recognising and Responding to Clinical Deterioration in Acute Health Care Nicola Dunbar, Accrediting Agencies Surveyor Workshop, 10 July 2012

2. Why have a Standard about recognising and responding to clinical deterioration?  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

3. 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

4. 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)

5. The Standard  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.  Two overarching Standards: Standard 1: Governance for Safety and Quality Standard 2: Partnering with Consumers

6. Four criteria 1. 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 2. Recognising clinical deterioration and escalating care Patients whose condition is deteriorating are recognised and appropriate action is taken to escalate care 3. Responding to clinical deterioration Appropriate and timely care is provided to patients whose condition is deteriorating 4. 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

7. 1. Establishing recognition and response systems  9.1: Developing, implementing and regularly reviewing the effectiveness of governance arrangements and the policies, procedures and/or protocols that are consistent with the requirements of the National Consensus Statement  Why? Systems for recognising and responding to clinical deterioration need organisational support and executive and clinical leadership to be successful Recognition and response systems need to be embedded in governance frameworks to ensure that risks are identified and continuous improvement occurs

8. 1. Establishing recognition and response systems  What? Identify suitable individual / group / committee to take responsibility for governance of recognition and response systems (9.1.1) Develop / adapt and implement policies and procedures across the organisation in the areas of (9.1.2): measurement and documentation of observations escalation of care establishment of a rapid response system communication about clinical deterioration

9. 1. Establishing recognition and response systems  9.2: Collecting information about the recognition and response systems, providing feedback to the clinical workforce, and tracking outcomes and changes in performance over time  Why? Evaluation of new systems needed to establish efficacy and determine changes needed to optimise performance Ongoing monitoring needed to track changes over time and ensure that systems operate effectively

10. 1. Establishing recognition and response systems  What? Develop and implement processes for: collecting and using information from the workforce about recognition and response systems (9.2.1) reviewing deaths and cardiac arrests in patients without treatment- limiting orders (9.2.2) providing data about recognition and response systems to clinical workforce in a timely way (9.2.3) Use data from recognition and response systems to improve performance (9.2.4)

11. 2. Recognising clinical deterioration and escalating care  9.3: Implementing mechanism(s) for recording physiological observations that incorporate triggers to escalate care when deterioration occurs  Why? Including track and trigger systems in observation charts streamlines identification of deterioration and action Charts designed according to human factors principles – faster and more accurate in identifying deterioration  What? Put in place a general observation chart that meets the criteria specified in the standard (9.3.1) Audit completion of observation charts (9.3.2) Take action to improve completion of observation charts (9.3.3)

12. 2. Recognising clinical deterioration and escalating care  9.4 Developing and implementing mechanisms to escalate care and call for emergency assistance where there are concerns that a patient’s condition is deteriorating  Why? Escalation policies and protocols that contain information about what to do if deterioration occurs reduce the risk of delays in providing appropriate care  What? Put in place systems for escalating care and calling for emergency assistance (9.4.1) Develop and implement mechanisms to evaluate escalation processes (9.4.2) Take action to improve escalation processes (9.4.3)

13. 3. Responding to clinical deterioration  9.5 Using the system in place to ensure that specialised and timely care is available to patients whose condition is deteriorating  Why? 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  What? Agree on criteria for calling for emergency assistance and include in escalation protocol (9.5.1) Develop and implement mechanisms to review calls for emergency assistance (9.5.2)

14. 3. Responding to clinical deterioration  9.6 Having a clinical workforce that is able to respond appropriately when a patient’s condition is deteriorating  Why? Treatment of deterioration can be delayed if workforce cannot identify deterioration and do not know how to respond  What? Develop / adapt / provide access to basic life support training (9.6.1) Develop and implement mechanism that ensure access at all times to at least one clinician who can practise advanced life support (9.6.2)

15. 4. Communicating with patients and carers  9.7 Ensuring patients, families and carers are informed about, and are supported so that they can participate in recognition and response systems and processes  Why? 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  What? Develop / adapt mechanisms for informing patients, families and carers about how to raise potential concerns about deterioration and the importance of doing so (9.7.1)

16. 4. Communicating with patients and carers  9.8 Ensuring that information about advance care plans and treatment- limiting orders is in the patient clinical record, where appropriate  Why? Advance care preferences and treatment-limiting decisions need to be considered when responding to deterioration  What? Develop and implement a mechanism for receiving and preparing advance care plans in partnership with patients, families and carers (9.8.1) Document advance care plans and other treatment- limiting orders in the clinical record (9.8.2)

17. 4. Communicating with patients and carers  9.9 Enabling patients, families and carers to initiate an escalation of care response  Why? Patients experience delays in treatment despite reporting concerns about deterioration Families and carers are well placed to identify signs of deterioration  What? Put in place systems for patients, families and carers to independently escalate care (9.9.1) Provide information about family escalation of care (9.9.2) Review performance of family escalation system (9.9.3) Take action to improve family escalation system (9.9.4)

18. General issues – 1  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 Documentation could include: committee papers and terms of reference clinical / organisational governance frameworks position descriptions

19. General issues – 2  Nature of the recognition and response systems can vary depending on: Size and location of the health service Nature of health services provided (eg ICU vs no ICU) Nature and skill mix of workforce (eg no on-site doctors)  Some jurisdictions have programs in this area – will determine nature of recognition and response systems: NSW – Between the Flags Queensland – Recognition and Management of the Deteriorating Patient (RMDP) ACT – Compass WA – Recognising and Responding to Clinical Deterioration (RRCD)

20. General issues – 3  The structure of most criteria is to: Develop and implement a policy / protocol / process Audit / review effectiveness of process Undertake improvement processes based on audit results

21. General issues – 4  Documentation of these steps: Development and implementation of policy / protocol / process: policy documents, protocols, tools, templates, materials to inform workforce and patients Audit / review effectiveness of process: policies / protocols about audit processes evaluation plans and audit schedules reports on audits / reviews Undertake improvement processes based on audit results: documentation of quality improvement processes examples of actions and improvement activities training and education material and records feeding back information to workforce

22. General issues – 5  What data collection processes need to be in place? 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

23. General issues – 6  What data collection processes need to be in place? (cont) 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

24. Specific issues – 1  Policies, procedures and protocols required (9.1.2): Measurement and documentation of observations: minimum frequencies and duration for core observations in all acute care areas additional observations or assessments for specific patient groups process for documenting a monitoring plan for all patients observation charts that include a track and trigger system (9.3.1)

25. Specific issues – 2  Policies, procedures and protocols required (9.1.2) (cont): Escalation of care: escalation policy – level of care that can safely be provided, when care should be escalated to a higher level, location and availability of services (9.4.1) escalation protocol with a graded response system – including escalation based only on concern (9.4.1) processes to individualise triggers and responses for patients with treatment-limiting orders processes for informing patients, families and carers about how to escalate care (9.7.1)

26. Specific issues – 3  Policies, procedures and protocols required (9.1.2) (cont): Rapid response systems: protocol that outlines use of rapid response system included in escalation protocol (9.5.1) emergency assistance treatment protocols and algorithms use of agreed communication processes when deterioration occurs Clinical communication: roles and responsibilities related to communication included in the escalation protocol (9.4.1) processes for communicating with patients, families and carers about deterioration

27. Specific issues – 4  Observation chart that: (i) is designed according to human factors principles; (ii) includes capacity to record observations graphically (iii) includes a track and trigger system (9.3.1): Focus is on general observation charts – not charts for specific clinical areas (such as neurovascular, cardiothoracic etc) For specialist hospitals – these may require paediatric and obstetric charts

28. Specific issues – 5  Observation chart that: (i) is designed according to human factors principles; (ii) includes capacity to record observations graphically (iii) includes a track and trigger system (9.3.1): 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

29. ACT NSW QldWA

31. Specific issues – 8  Observation chart that: (i) is designed according to human factors principles; (ii) includes capacity to record observations graphically (iii) includes a track and trigger system (9.3.1): Demonstration of testing of chart is a complex process that should: involve evaluating performance of alternative versions of the chart on key functions (such as ability of clinicians to identify abnormal observations) be conducted with appropriate methodology to ensure results are reliable – specialist advice may be required (Commission has a fact sheet on the required process)

32. Specific issues – 9  Clinical workforce trained and proficient in basic life support (9.6.1): All clinicians should be able to implement basic life support measures – doctors, nurses and allied health Does not need to be developed or delivered internally – there are many external providers As well as training records and attendance records, documentation should also include records of achievement of competency

33. Specific issues – 10  Access at all times to at least one clinician who can practise advanced life support (9.6.2): Models for rapid response systems that ensure this kind of expertise vary depending on context and can include: 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 retrieval services Documentation can include: records of currency of advanced life support certification rosters or evidence that demonstrates 24 hour access to clinician

34. Specific issues – 11  Providing information to patients, families and carers (9.7.1): Documentation can include: material for patients, families and carers about how to raise concerns about deterioration and the importance of doing so policies about processes for involving patients, families and carers in communication about deterioration, eg during rounds, bedside handover

35. Specific issues – 12  Advanced care plans and treatment-limiting orders (9.8.1, 9.8.2): Most states and territories have legislation and policy regarding advanced care directives that will need to be reflected in local policies and processes Need to demonstrate policies and processes for: receiving advanced care plans that have been developed elsewhere (such as in the community, with a GP) developing new advanced care plans within the health service involving patients, families and carers in the development of the advanced care plan documenting the advanced care plan in the patient’s clinical record Standard covers both advanced care plans and other treatment-limiting orders - eg NFR, DNR etc

36. Specific issues – 13  Family escalation of care (9.9.1 – 9.9.4): 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

37. Specific issues – 14  Family escalation of care (9.9.1 – 9.9.4): Documentation should include: policies and procedures that describe process for family escalation information for patients, families and carers about when and how to escalate care and call for assistance evaluation plans and audit schedules for reviewing the effectiveness of family escalation processes data from reviews of family escalation processes – including reviews of calls and views of patients and families training materials for staff about family escalation actions taken to improve family escalation processes following review

38. 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

39. 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