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Early detection of patient deteriopration Presenter: (delegate name)

Innovation Poster Session HRT1215 – Innovation Awards Sydney 11 th and 12 th Oct 2012. Early detection of patient deteriopration Presenter: (delegate name). 3-3c_HRT1215-Session_WARD_TPCH_QLD. KEY PROBLEM.

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Early detection of patient deteriopration Presenter: (delegate name)

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  1. Innovation Poster Session HRT1215 – Innovation Awards Sydney 11th and 12th Oct 2012 Early detection of patient deterioprationPresenter: (delegate name) 3-3c_HRT1215-Session_WARD_TPCH_QLD

  2. KEY PROBLEM Patient harm due to lack of recognition and appropriate management of the deteriorating patient was repeatedly identified in: Root Cause Analysis for serious adverse events Clinical Incident reviews Review of patients after cardiac arrest or inpatient transfer to ICU

  3. KEY CHANGES IMPLEMENTED Multidisciplinary working party developed: Standardised minimum observations General Observation Chart incorporating Modified Early Warning Score (MEWS) Escalation protocol using MEWS score to trigger review by clinical team ISBAR communication tool Medical Emergency Team (MET) criteria and participants Education of Medical and Nursing staff (COMPASS – ACT Health) December 2009 MET and MEWS commenced

  4. COMPASS OBSERVATION CHART adapted for TPCH Note: pain score, bowels, weight on page 2

  5. Ward audit – 10 charts

  6. Monthly report to NUMs and S&Q Committee

  7. Number of Arrest & MET calls(2009 - 2011) MET/MEWS introduced

  8. Inpatient Arrest Calls /1000 separations (2009 – 2012) In 2010: 55% of cardiac arrest calls had a confirmed cardiac arrest 46% of patients with confirmed cardiac arrest survived to discharge MET/MEWS introduced 4.7 3.8 2.9

  9. Inpatient MET Calls /1000 separations (2009 -2012) *Target 26-56/1000seps Average 8.5 2011 Average 9.1 MET/MEWS introduced * Source: Effectiveness of the Medical Emergency Team: The Importance of Dose. D Jones et. al. Critical Care 2009;13:313

  10. Hospital Standardised Mortality Rate(2007 – 2011) MET/MEWS introduced

  11. Mortality Rate / 1000 separations(2008 – 2012) (excluding Palliative Care Unit) MET/MEWS introduced

  12. SUMMARY The simultaneous introduction of MEWS and MET resulted in: • A low “dose” of MET calls • Patents transfers to ICU post arrest/MET call • Reduced in 2nd year of implementation • Progressive reduction in LOS (40%) • Improvement in hospital mortality Underpinning this result: • Compliance with observations and MEWS • Early escalation when deterioration occurs • Rapid medical review by the home team

  13. Patient safety culture survey April 2012

  14. LESSONS LEARNT Multidisciplinary team to develop system Education must be ongoing Audit of accuracy of observations and escaltion necessary Feedback to staff re results essential

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