The ‘How to Guide’ for

Improving Critical Care

Rapid Response

to Acute Illness

Main contacts for Rapid Response to Acute Illness

Campaign Director leading on the content area: Alan Willson

Faculty member for this content area: Dave Hope and Mark Smithies

Point person for the content area: Chris Hancock

IA/Senior IA: Mike Davidge

Other (as determined by Director):

Improving Critical Care

Table of Contents

Rapid response to Acute Illness Getting Started List

Goal: To reduce mortality and prevent harm to the hospital population through improving the recognition and response to acute illness.

Summary of NICE guidance (50)

Prevent harm from lack of recognition and treatment of the acutely ill

Processes

Implement NICE guidance (50) on recognition and treatment of the acutely ill including these interventions: -

Goal: Reduce complications and mortality from severe sepsis

Surviving Sepsis Campaign

Goal: Reduce complications and mortality from severe sepsis

Getting Started

Engage Senior Leadership Support

Leadership and Organisational Culture

Using the Model for Improvement

Forming a Team

Setting Aims

First Test of Change

Barriers That May Be Encountered

Establish Feedback Mechanisms

Track Measures over Time

Tips and Tricks

Rapid response to Acute Illness Getting Started List

Prior to testing and implementation of system for rapid response to acute Illness organisations may wish to consider the following:

  • Engage senior leadership support
  • Appoint a cross Trust multi-disciplinary implementation team to: -
  • Steer and co-ordinate the intervention
  • Review process and outcome data
  • Perform qualitative review of circumstances surrounding sudden deterioration in patient’s condition.
  • Link with critical incident reporting
  • Appoint individual or team as ‘process owner’.

This ‘rapid response co-ordinator’ will have extensive experience of both critical and acute care but should not be funded from critical care resources.

  • Establish single track and trigger system for the Trust
  • Determine the optimum structure for response based upon level of risk and clear lines of responsibility
  • Provide education and training
  • Establish quantitative and qualitative feedback mechanisms
  • Measure effectiveness

Goal: To reduce mortality and prevent harm to the hospital population through improving the recognition and response to acute illness.

The recently published literature from NICE and NPSA have highlighted that a significant risk to patient safety exists from the lack of recognition and treatment of acutely ill adults in Hospital.

Studies into this specific problem identify that about 40% of ITU admissions are preceded by error and that the mortality rate is much higher in the patients that experience error. Several other studies, including the National Confidential Enquiry into Peri-Operative Deaths have come to similar conclusions and these findings are entirely consistent with the experience of clinicians in the field.

In Wales as annual level 3 admissions number about 8000 and the 40% of admissions that receive poor care show a mortality increase of about 20% (35% vs. 56%) then the death toll is approximately 640 per year. This is a conservative estimate and does not include those patients who deteriorate and die prior to ICU admission.

This potentially avoidable mortality is due to systemic failures in all hospital areas and will be resolved only by adoption of the problem and co-ordination of the response at a Trust board level. Although hospital Critical Care departments are an enormous resource in the treatment of the acutely ill they are not funded to respond in isolation on behalf of the whole hospital.

This is why in evaluating the evidence supporting the interventions for the Saving 1000 Lives campaign the NPHS found little support for the effectiveness in isolation of Rapid Response Teams, Medical Emergency Teams or Critical Care Outreach.

Trusts will only respond effectively to this problem when medical, surgical and critical care areas collaborate in improving systems of care.

An effective system must

  • Operate hospital-wide
  • Work 24 hours a day
  • Facilitate rapid treatment
  • Facilitate escalation of care
  • Feedback to referring teams on process and outcome

In Welsh hospitals where this problem is being addressed the model for implementation depends upon an individual or group who co-ordinate activity, training and data collection. This individual or group must have experience in acute and critical care but can only work when independently funded.

It is the aim of the Saving 1000 Lives campaign to support Trusts in implementing the NICE guidance (50) on acutely ill patients in hospital and to therefore reduce harm for the entire hospital population.

This ‘How toguide’ has been adapted from the Safer Patient Initiative guidance on Rapid Response Teams and details service improvement methodology as well as tips and techniques learnt from the Safer Patients Initiative, Saving 100,000 Lives Campaign and Welsh Critical Care Improvement Programme.

References

P McQuillan et al. Confidential inquiry into quality of care before admission to intensive care. BMJ 1998;316:1853–1858

An acute problem? National Confidential Enquiry into Patient Outcome and Death 2005.

Summary of NICE guidance (50)

Adult patients in acute hospital settings, including patients in the emergency department forwhom a clinical decision to admit has been made, should have:

  • physiological observations recorded at the time of their admission or initial assessment
  • a clear written monitoring plan that specifies which physiological observations should berecorded and how often.

Physiological observations should be recorded and acted upon by staff who have been trained toundertake these procedures and understand their clinical relevance.

Physiological track and trigger systems should be used to monitor all adult patients in acutehospital settings.

Physiological observations should be monitored at least every 12 hours, unless a decision hasbeen made at a senior level to increase or decrease this frequency for an individual patient.

Staff caring for patients in acute hospital settings should have competencies in monitoring,measurement, interpretation and prompt response to the acutely ill patient appropriate to thelevel of care they are providing. Education and training should be provided to ensure staff havethese competencies, and they should be assessed to ensure they can demonstrate them.

A graded response strategy for patients identified as being at risk of clinical deterioration shouldbe agreed and delivered locally. It should consist of the following three levels.

– Low-score group:

– Medium-score group:

– High-score group:

If the team caring for the patient considers that admission to a critical care area is clinicallyindicated, then the decision to admit should involve both the consultant caring for the patient onthe ward and the consultant in critical care.

Prevent harm from lack of recognition and treatment of the acutely ill

Processes

Under Trust Board leadershipCritical Care departments to link with medical and surgical directorates in directing this work

  • Engage senior leadership support
  • Appoint a cross Trust multi-disciplinary implementation team to: -
  • Steer and co-ordinate the intervention
  • Review process and outcome data
  • Perform qualitative review of circumstances surrounding sudden deterioration in patient’s condition.
  • Link with critical incident reporting
  • Appoint individual or team as ‘process owner’.

This ‘rapid response co-ordinator’ will have extensive experience of both critical and acute care but should not be funded from critical care resources.

Implement NICE guidance (50) on recognition and treatment of the acutely ill including these interventions: -
  • Establish single track and trigger system for the Trust
  • Establish level of competence for training
  • Measure training uptake
  • Determine the optimum structure for response based upon level of risk and clear lines of responsibility
  • Establish criteria for initiating response
  • Establish a simple process for initiating the response
  • Provide education and training for responders
  • Use standardised tools
  • Establish qualitative feedback mechanisms

Measures:

Measure Name / Operational Definition / Data Collection Source
Number of cardiac arrest calls / Monthly calls for cardiac arrest team / Rapid response co-ordinator or hospital switchboard.
Number of calls for rapid response to medium and high risk acute illness / Monthly number of calls for a response to patients who have been assessed as being of medium or high risk illness. / Rapid response co-ordinator
Qualitative review and feedback on outcomes of cardiac arrest and rapid response calls. / Multidisciplinary evaluation of the processes and actions prior to the call being made and the outcome following the response.
Should be linked with critical incidence reporting and feedback mechanism in place to report to all stakeholders. / Rapid response co-ordinator
Number of do not attempt resuscitation (DNAR) orders / Monthly number of DNAR orders made. / Rapid response co-ordinator

Goal: Reduce complications and mortality from severe sepsis

Intervention level: All level 0, 1, 2, 3 and 3T units.

The term sepsis covers a number of infectious diseases that result in a common picture of multiple organ failure. It is a condition with high prevalence – about 2.3% of hospital patients and about 27% of intensive care patients 1, 2. Mortality rates are very high – around 30 – 50%. In Wales this equates to the deaths of between 700-1100 people in ICU annually. Globally, sepsis kills about half a million people a year: as many as myocardial infarction.

Until recently sepsis has had a low public profile. Reporting of cause of death on death certificates often omits the term sepsis so its prevalence has been under-reported. Effective treatments have been hard to come by. Times are changing though and there is a growing international consensus both on the scale of the challenge and the practical ways to bring down mortality rates 3.

The good news is that the most effective treatments are simple interventions such as giving oxygen, large volumes of intravenous fluids and antibiotics 4. The main challenge is that these treatments must be given early in the disease process to be effective. The main focus then has to be on the early identification of patients with sepsis and in delivery of a package of treatments within a few hours of the onset of the disease. These simple targets are hard to achieve and require us to redesign how patients are monitored and treated throughout the hospital.

1. Angus DC et al. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome and associated costs of care. Critical Care Medicine 2001; 29; 1303-10

2. Padkin AM et al. Epidemiology of severe sepsis occurring in the first 24 hours in intensive care units in England, Wales and Northern Ireland. Critical Care Medicine 2003: 31; 2332–8

3. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock 2008. Crit Care Med. 2008; 36(1): 296-327

4. Rivers E et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345: 1368-1377

Surviving Sepsis Campaign

The Surviving Sepsis Campaign is an International campaign to reduce mortality and morbidity from sepsis by 25% over a 5 year period through the introduction of Sepsis Care Bundles. These bundles consist of interventions that have solid evidence in improving mortality.

These consist of 2 elements; the first 6 hours from the diagnosis of Severe Sepsis or Septic Shock (time zero) known as the Resuscitation Bundle and the first 24 hours from diagnosis known as the Management Bundle.

Early experience with the bundles at The University Hospital of Wales (UHW) and Nevill Hall Hospital (NHH) highlighted the following difficulties:

  • Inconsistency in the early diagnosis of severe sepsis and septic shock
  • Frequent inadequate volume resuscitation
  • Late or inadequate use of antibiotics
  • Frequent failure to support the cardiac output when depressed
  • Frequent failure to control hyperglycemia adequately
  • Frequent failure to use low tidal volumes and pressures in acute lung injury
  • Frequent failure to treat adrenal inadequacy in refractory shock

To overcome these difficulties the SSC care bundles have, in some areas, been operationalised into a care pathway with achievement of the so called ‘sepsis six’ within 1 hour of diagnosis as the primary intervention. As the characteristics of these ‘sepsis six’ are similar to the initial response to acute illness, it is recommended that sepsis bundles are incorporated into the recognition and response to acute illness system.

The Survive Sepsis Resuscitation Pathway can be obtained from:

Further information can be obtained from the following links:

The evidence base behind the implementation of Sepsis Care Bundles/Pathway:

Early recognition of severe sepsis and septic shock, with early aggressive resuscitation aimed at meeting defined goals [Rivers E, et al. Early recognition of severe sepsis and septic shock, with early aggressive resuscitation aimed at meeting defined goals. New England Journal of Medicine. 2001;345(19):1368-1377.]

Early use of appropriate antibiotics [Iregui M, et al. Clinical importance of delays in the initiation of appropriate antibiotic treatment for ventilator-associated pneumonia. Chest. 2002;122(1): 262-268.]

Tight control of blood glucose [van den Berghe G, et al. Intensive insulin therapy in critically ill patients. New England Journal of Medicine. 2001;345(19):1359-1367.]

Low volume and low pressure ventilation for acute lung injury patients [The NIH-ARDS Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. New England Journal of Medicine. 2000;342(18):1301-1308.]

Use of activated protein C for severe sepsis [Bernard GR, et al. Efficacy and safety of recombinant human activated protein C for severe sepsis. New England Journal of Medicine. 2001;344(10): 699-709.]

Use of low-dose steroids in refractory septic shock [Annane D, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. Journal of the American Medical Association. 2002;288(7):862-887.]

Goal: Reduce complications and mortality from severe sepsis

Intervention level: All level 0, 1, 2, 3 and 3T units.

Processes:

Elements of the Surviving Sepsis Campaign Resuscitation Bundle

  • Serum lactate measured
  • Blood cultures obtained prior to antibiotic administration
  • From the time of presentation, broad-spectrum antibiotics to be given within 3 hours for ED admissions and 1 hour for non-ED ICU admissions
  • In the event of hypotension and/or lactate >4mmol/L (36mg/dL):
  • Deliver an initial minimum of 20 ml/kg of crystalloid (or colloid equivalent)
  • Give vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) 65 mm Hg.
  • In the event of persistent arterial hypotension despite volume resuscitation (septic shock) and/or initial lactate >4 mmol/L (36 mg/dl):

Achieve central venous pressure (CVP) of 8 mm Hg

Achieve central venous oxygen saturation (ScvO2) 70%

Elements of the Sepsis Six

  • Give 100% oxygen via non-rebreathe bag
  • Take blood cultures
  • Give IV antibiotics
  • Start IV fluid resuscitation with Hartmann’s or equivalent
  • Check haemoglobin and lactate
  • Place and monitor urinary catheter unless fully mobile (monitor UO)

Measures

Measure / Operational Definition / Data Collection Source
Percentage compliance with sepsis resuscitation bundle / 1. Determine the numerator: the number of patients fully compliant within 6 hours with the sepsis resuscitation bundle in one month.
2. Determine the denominator: all patients identified as having severe sepsis requiring a response in one month.
3.Calculate the care bundle compliance as a percentage by dividing the numerator by the denominator and multiplying the result by 100 / A report on this
measure is currently
generated by the
WCCIP database.
Percentage compliance with ‘sepsis six’ / 1. Determine the numerator: the number of patients fully compliant within 1 hour with the ‘sepsis six’ in one month.
2. Determine the denominator: all patients identified as having sepsis requiring a response in one month.
3.Calculate the care bundle compliance as a percentage by dividing the numerator by the denominator and multiplying the result by 100 / A report on this
measure is currently
generated by the
WCCIP database.
Severe sepsis mortality

Getting Started

Hospitals will not successfully implement these interventions overnight. If you do, chances are that you are doing something sub-optimally. A successful program involves careful planning, testing to determine if the process is successful, making modifications as needed, re-testing, and careful implementation.

  • Engage Leadership Support
  • Select the team and the venue.
  • Assess where you stand presently. Is there a process in place? If so, work with staff to begin preparing for changes.
  • Organize an educational program. Teaching the core principles to staff will open many people’s minds to the process of change.
  • Introduce the interventions to the staff.
Engage Senior Leadership Support
  • Engage senior leadership (executive and physician) support and buy-in, i.e., “We are going to do this; this is important and the right thing to do for our patients.”
  • Make an explicit organizational commitment to establishing the Rapid Response system.
  • Craft a very clear and widely disseminated communication message from senior leadership.
Leadership and Organisational Culture

Changing practice requires a change in organizational culture and attitudes about what is acceptable. The organisational culture within an individual organisation, or even at the local level of a department or patient care unit, develops based on overt and subtle messages employees receive. Leadership actions strongly influence employee beliefs as to what leaders consider important, even more so than what is actually said. This includes not only what leaders do, but also what they do not do.

Teamwork is essential in health care today, and communication within the team is indicative of the organisational culture. Everyone must be considered as an equally important member of the team, regardless of their role, and not only encouraged to speak up, but required to do so. If non-clinical or non-professional (i.e., non-licensed or certified) staff are not treated as equal members of the team, they will be less likely to point out an unsafe condition or take action.

What changes can we make that will result in improvement?

Understanding how organizational culture develops is important to changing it, and practical tools are available to effect change: