Deteriorating Patients in Scotland’s Acute Hospitals A Structured Response WebEx Agenda

1. Deteriorating Patients in Scotland’s Acute Hospitals A Structured Response WebEx Agenda 10th April 2013 2 – 3 p.m.

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5. Reducing cardiac arrests in the Acute Admissions Unit :A Quality Improvement Journey Dan Beckett Consultant in Acute Medicine Forth Valley Royal Hospital SPSP Fellow

7. NHS Forth Valley • Catchment population 300,000 • Annual budget £421 million • Four Community Hospitals • One Acute District General Hospital • Forth Valley Royal Hospital • Opened July 2011(previously Stirling Royal Infirmary) • 442 beds

8. Forth Valley Royal Hospital

9. Acute Admissions Unit (AAU) • Combined surgical and medical admissions unit • 46 beds • Admits 1500 patients per calendar month • In July 2011 moved from Stirling Royal Infirmary to Forth Valley Royal Hospital

10. Situation Stirling Royal Infirmary, 2010

11. Background • AAU morbidity and mortality meetings established in 2010 • Failure to rescue • Resuscitation attempts undertaken on patients with terminal illness • Limited learning from adverse outcome

12. Assessment • FMEA (Failure Modes Effects Analysis) undertaken • Multidisciplinary team • Junior and senior medical staff • Nursing staff • Managers • Recognition 2640 • Response 2490

13. Assessment • Recognition (2640) • NEWS (NHS Early Warning Score) charts not filled out correctly • Emergency Department not utilising NEWS • No structured handover between ED and AAU

14. Assessment • Response (2490) • No clear evidence of escalation in notes • Nursing staff often did not know who to contact • Only transient consultant presence in the ward

15. Recommendation • Aim statement developed • ‘By December 2011 the cardiac arrest rate in AAU at Stirling Royal Infirmary (Forth Valley Royal Infirmary) will have fallen to <1 per 1000 admissions per month • December 2010 – 4/1000 (cardiac arrests) and 7/1000 (2222 calls)

16. Recommendation • Driver diagram developed • Primary drivers • Recognition and response to the deteriorating patient • Improve learning from adverse events • Improve end of life care including DNACPR • Change package developed • Process, outcome and balancing measures defined

17. Change package • Recognition • ED started totalling NEWS and including as part of a structured SBAR handover • AAU training on Early Warning Scores • Weekly sampling of charts and displayed on newly developed QI dashboard in the relatives waiting room • Recognition checklist stickers developed using the model for improvement and PDSA cycles

19. PART A NEWS 6 or above Response/Escalation v11 Date ___________ Time______________ EWS ___________ Clinician contacted: Name ___________________ Nurse in charge informed  EWARD signifier entered  Hourly observations unit NEWS <4  Start fluid balance chart  Completed by (name) ____________________ PLEASE ENSURE PART B IS COMPLETED BY REVIEWING CLINICIAN. MIDDLE GRADE REVIEW REQUIRED FOR NEWS 6 OR MORE

20. Change package • Response • Response checklist stickers developed using the model for improvement and PDSA cycles • Move to ward based clinical team in July 2011 with move to the new hospital • 3 ANPs and 3 FY1s attached to AAU • Consultant Acute Physician presence 0800-2000 five days per week

21. PART B NEWS 6 or above Response/Intervention v11 • Time attended _____________ Grade ______________ • Nurse in charge and Nurse providing care meet with responding clinician to discuss patient  • Document management plan and set review time  • Due to infection? Y/N Complete sepsis 6 Sticker  • Please document (discuss with senior if required): • a) Ceiling of treatment: Ward level  HDU ICU  Undecided * • b) Resuscitation status: for CPR  DNA CPR Undecided * • *Consider accessing the ECS for Key Information Summary (KIS) or ePCS Signature/Name _____________________________ Mandatory consultant contact if NEWS no better after 60 minutes and no decision made to limit escalation

22. Change package • Improving learning from adverse events • Weekly ‘AAU safety meeting’ • All invited • Cardiac arrests, transfers to critical care • Open forum for all staff • Log-book for those who can’t be present

24. Safety meetings start Rescue stickers start Poor patient flow from AAU starts Move to FVRH

25. Rescue stickers start Safety meetings start Poor patient flow from AAU starts Move to FVRH

26. How did we do? • Cardiac arrest rate in AAU available on the intranet as well as on QI dashboard in relatives waiting room • Also reported to the board monthly, as a board key performance indicator

27. Reflection • Introduction of safety initiatives led to a reduction in the rate of cardiac arrests but nursing staff still used 2222 calls to summon immediate help • Introduction of the ward based team led to a reduction in 2222 calls • Escalation through patient’s own caregivers vs MET • How to deal with the non-believers....

28. Consultant A • ‘The reduction in rate of cardiac arrests in AAU has purely been achieved by moving patients out of AAU earlier so they have their cardiac arrests elsewhere...’

29. Dealing with the non-believers...

30. Consultants A, B, C, D..... • ‘The reduction in rate of cardiac arrests in AAU is due solely to patients having DNACPR decisions made earlier in their admission’

31. Safety initiatives started Move to ward based team at FVRH SIGNIFICANT SHIFT IN MORTALITY

32. 17% DROP IN 30 DAY MORTALITY SINCE MOVING TO FVRH = 16 LIVES SAVED PER MONTH

33. Balancing measure • Admissions to critical care

34. Safety initiatives started Move to ward based team at FVRH

35. Move to ward based team at FVRH Safety initiatives started

36. Lessons learned • Visibility and transparency • Cardiac arrest rate on QI dashboard • Entire team on board • Shared goal • Bottom up approach • Establish a safety culture • The work is never done • FMEA re-scored...

38. Current work • Sepsis

42. Current work • Sepsis • SPICT?

45. Current work • Sepsis • SPICT? • Integrate with work already undertaken – not replace

46. Acknowledgements • Sharon Oswald • Monica Inglis • Iain Wallace • SPSP • The whole AAU multidisciplinary team!