1 / 15

Deterioration and failure to rescue

Deterioration and failure to rescue. Dr Sharon Hamilton Dr Isabel M Gonzalez Director, Centre for Health & Social Evaluation Consultant Critical Care and Anaesthesia   Teesside University General Intensive Care Unit

elina
Download Presentation

Deterioration and failure to rescue

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Deterioration and failure to rescue Dr Sharon Hamilton Dr Isabel M Gonzalez Director, Centre for Health & Social Evaluation Consultant Critical Care and Anaesthesia   Teesside University General Intensive Care Unit Middlesbrough. UK The James Cook University Hospital Sharon.Hamilton@tees.ac.ukisabel.gonzalez@nhs.net

  2. Patients admitted to hospital expect to be safe; their condition to be monitored closely, any changes detected early and appropriate action taken quickly. However…..

  3. Failure to recognise patient deterioration and to respond in an appropriate and timely manner is a contributory factor to many adverse events This is a global issue – not just a UK issue

  4. Context: unexpected deaths in hospital • National Patient Safety Agency in UK reviewed 1,804 serious incidents leading to patient deaths • 576 were avoidable • 66 (11%) related to patient deterioration that was not recognised or acted upon

  5. Undetected deterioration • Deterioration often occurs over a period of time • Recognisable changes in routine observations can be seen up to 24 hrs prior to event in around 60% of patients • Action taken in early stages can prevent deterioration progressing to cardiac arrest and unplanned admissions to ICU

  6. Clinical Excellence Commission. Between the Flags. 2010

  7. Melodie Heland: Austin Health, Melbourne, 2013http://www.slideshare.net/informaoz/melodie-heland-austin-health

  8. Strategic approach to facilitate early recognition and response to deterioration has been adopted in many countries including UK UK example: • NICE 50 Guidelines – acutely ill patient (2007) • Patient Safety First Programme (2008) • ‘How to’ guide on deterioration (2008) • NEWS RCoP 2012 • SIGN Consensus Recommendations (2014)

  9. Key clinical points • Monitoring plan should be in place to identify observations and their frequency • MEWS/NEWS to Track the patient’s condition and Trigger a response when necessary (pre-determined protocol and clinical judgement) Physiological observations to be recorded (including respirations) Monitoring plan should be in place to identify observations and frequency MEWS/NEWS/T&T should be used

  10. Physiological observations to be recorded: • respiratory rate • heart rate • systolic blood pressure • level of consciousness • oxygen saturation • temperature

  11. Issues • Evidence that MEWS/T&T not always completed properly (eg not timely, inaccurate categorisation) • Leading to late recognition of deterioration • Failure to act when MEWS/NEWS ‘triggers’ • End of life care not appropriately identified • Some patients’ conditions automatically ‘trigger’ eg COPD

  12. Innovations • Intermittent v continuous monitoring • Digital recording with automated ‘triggers’

  13. International perspective Australia: ACSQHC (standard 9), BTF (NSW: 2010) Safety net, designed to protect patients from unnoticed deteriorating, and ensure correct care if they do deteriorate

  14. Comparable important factors (Australia v UK) • ‘the slippery slope’ of deterioration • Training • Urgent clinical review • Patient and family involvement in instigating MET • Out of hours (night) team

  15. Combination of leadership, skills, knowledge and confidence to act appear to be key facets for reducing incidence of undetected deterioration

More Related