Recognising and Responding to Clinical Deterioration

Recognising and Responding to Clinical Deterioration 1

The Victorian Department of Health is making this document freely available on the internet for health services to use and adapt to meet the National Safety and Quality Health Service Standards of the Australian Commission on Safety and Quality in Health Care. Each health service is responsible for all decisions on how to use this document at its health service and for any changes to the document. Health services need to review this document with respect to the local regulatory framework, processes and training requirements

The author disclaims any warranties, whether expressed or implied, including any warranty as to the quality, accuracy, or suitability of this information for any particular purpose. The author and reviewers cannot be held responsible for the continued currency of the information, for any errors or omissions, and for any consequences arising there from.

Published by Sector Performance, Quality and Rural Health, Victorian Government, Department of Health

February 2014

Acknowledgements

The Department of Health Victoria acknowledges the contribution of medical and health specialists, Victorian health services, and members of the National Safety and Quality Health Service Standards: Educational Resources Project project team, Steering Group and Advisory Committee.

The Steering Group members comprised:

Associate Professor Leanne Boyd, Steering Group Chair; Director of Education, Cabrini Education and Research Precinct, Cabrini Health

Ms Madeleine Cosgrave, Project Manager

Ms Susan Biggar, Senior Manager, Consumer Partnerships, Health Issues Centre

Mr. David Brown, Consumer representative

Dr Jason Goh, Medical Administration Registrar - Cabrini Health

Mr Matthew Johnson, Simulation Manager, Cabrini Education and Research Precinct, Cabrini Health

Ms Tanya Warren, Educator, Cabrini Education and Research Precinct, Cabrini Health

Ms Marg Way, Director, Clinical Governance, Alfred Health

Mr Ben Witham, Senior Policy Officer, Quality and Safety, Department of Health Victoria

The Advisory Committee members comprised:

Associate Professor Leanne Boyd, Advisory Committee Chair; Director of Education, Cabrini Education and Research Precinct, Cabrini Health

Ms Madeleine Cosgrave, Project Manager

Ms Margaret Banks, Senior Program Director, Australian Commission on Safety and Quality in Health Care

Ms Marrianne Beaty, Oral Health National Standards Advisor, Dental Health Services Victoria)

Ms Susan Biggar, Senior Manager, Consumer Partnerships, Health Issues Centre

Mr David Brown, Consumer representative

Dr Jason Goh, Medical Administration Registrar, Cabrini Health

Ms Catherine Harmer, Manager,Consumer Partnerships and Quality Standards, Department of Health, Victoria

Ms Cindy Hawkins, Director, Monash Innovation and Quality, Monash Health

Ms Karen James, Quality and Safety Manager, Hepburn Health Service

Mr Matthew Johnson, Simulation Manager, Cabrini Health

Ms Annette Penney, Director ,Quality and Risk, Goulburn Valley Health

Ms Gayle Stone, Project Officer, Quality Programs, Commission for Hospital Improvement, Department of Health Victoria

Ms Deb Sudano, Senior Policy Officer, Quality and Safety, Department of Health Victoria

Ms Tanya Warren, Educator, Cabrini Health

Ms Marg Way, Director, Clinical Governance, Alfred Health

Mr Ben Witham, Senior Policy Officer, Quality and Safety, Department of Health Victoria

Recognising and Responding to Clinical Deterioration 1

Contents

Recognising and Responding to Clinical Deterioration

Introduction

Learning outcomes

National Standards

Aim of Standard 9

Policies and procedures

Background

Recognition and response systems

Measurement and documentation of observations

Escalation of care

Responding to clinical deterioration

Your role in recognising and responding to clinical deterioration

Education and further resources

Engaging with patients and carers

Reporting adverse events

Summary

Glossary of Terms

Test Yourself

References

Recognising and Responding to Clinical Deterioration 1

Recognising and Responding to Clinical Deterioration

Introduction

This module relates to The National Safety and Quality Health Service (NSQHS) Standard 9: Recognising and Responding to Clinical Deterioration in Acute Health Care.

Learning outcomes

On completion of this module, clinicians will be able to:

1. Discuss the importance of measurement and documentation of observations.
2. Discuss the use of track and trigger systems to assist clinicians to recognise clinical deterioration.
3. Outline the process for escalating care in your organisation.
4. Describe the requirements for responding to clinical deterioration.
5. Discuss the importance of engaging with patients and families.

National Standards

The Australian Commission on Safety and Quality in Health Care (ACSQHC) developed the 10 NSQHS Standards to reduce the risk of patient harm and improve the quality of health service provision in Australia. The Standards focus on governance, consumer involvement and clinically related areas and provide a nationally consistent statement of the level of care consumers should be able to expect from health services.

Aim of Standard 9

The intention of Standard 9: Recognising and Responding to Clinical Deterioration in Acute Health Care is to ensure that patient deterioration is recognised promptly, and that appropriate action is taken. The Standard builds on The National Consensus Statement: Essential elements for Recognising and Responding to Clinical Deterioration (ACSQHC,2010). This Standard does not apply to deterioration in a patient’s mental state.

Standard 9 also relates to Standard 1: Governance for Safety and Quality in Health Service Organisations and Standard 2: Partnering with Consumers. The principles in these Standards are fundamental to all Standards andprovide a framework for their implementation.

ACSQHC, 2012

Table 1: Criteria to meet Standard 9 (ACSQHC, 2012)

Recognising and Responding to Clinical Deterioration 1

Policies and procedures

There are numerous policies, procedures and resources within health care services to assist you in recognising and responding to clinical deterioration. It is important to access, read and adhere to systems, policies and procedures within your organisation.

Background

Serious adverse events such as unexpected death or cardiac arrest are often preceded by observable physiological abnormalities. These signs are not always identified or acted upon.

A 2007 study from the United Kingdom’s National Patient Safety Agency (NPSA) identified that 11 % of reported deaths in a one-year period were as a result of deterioration not recognised or acted upon. Some of the factors which contribute to this are:

• poor or absent monitoring of the patient’s physiological observations
• lack of understanding of signs and symptoms of deterioration
• lack of formal systems for responding to deterioration
• inadequate skills to manage patient deterioration
• difficulty for clinicians in prioritising competing demands
• ineffective communication between clinical staff
• failure of clinicians to respond appropriately to clinical concerns

Early identification of deterioration, followed by prompt and effective action, can improve patient outcomes. It can also lessen the level of intervention required to stabilise patients whose condition deteriorates. Recognition and response systems need to address all of these factors, and be applied consistently across a health care facility.

ACSQHC, 2010; ACSQHC, 2012; NPSA, 2007

Recognition and response systems

Recognition and response systems aim to ensure that patient deterioration is recognised promptly and receives appropriate and timely treatment. The National Consensus Statement: Essential Elements for Recognising and Responding to Clinical Deterioration (ACSQHC, 2010) reflects the agreed views of experts in the field and the ACSQHC.

It describes the essential elements that are required for prompt and reliable recognition of, and response to, clinical deterioration. The Consensus Statement is supported by a comprehensive implementation guide.

These elements are:

1. measurement and documentation of observations
2. escalation of care
3. rapid response systems
4. clinical communication
5. organisational supports
6. education
7. evaluation audit and feedback
8. technological systems and solutions

ACSQHC, 2010; ACSQHC, 2012

Measurement and documentation of observations

There are often long periods during which patients lack appropriate measurement of observations. This can result in delays in the recognition and treatment of patient deterioration.

In a large proportion of patients, there are recognisable changes in routine observations during the twenty-four hours prior to cardiac arrest in hospital. This may include changes in vital signs, oxygenation levels and conscious state.

NPSA, 2007; ACSQHC, 2010; ACSQHC, 2012

Measurement of observations

A comprehensive patient assessment is required to compile information about the patient and their condition. Physiological observations are a component of this assessment and should include:

• respiratory rate
• oxygen saturation
• heart rate
• blood pressure
• temperature
• level of consciousness

Patient assessment should also include information about:

• fluid balance
• any pain and responses to analgesia
• respiratory distress
• skin colour e.g. flushing or pallor
• presence of sweating, rigors, nausea or vomiting
• results of tests e.g. blood, radiology
• other neurological signs such as pupil size and reactivity

Monitoring plan

A monitoring plan should be developed that specifies the frequency and nature of observations based on the patient’s diagnosis and clinical situation. Any modifications to the monitoring plan need to be documented.

Observations should be taken on all patients commencing at the time of admission or initial assessment. For most patients, measurement and documentation of observations should occur at least once per shift in an acute setting. The frequency of observations should be modified according to the patient’s condition.

ACSQHC, 2010; ACSQHC, 2011;ACSQHC, 2012

Observation charts

Track and trigger systems assist clinicians to understand when and how to respond to deterioration. These systems specify thresholds for each observation to prompt identification of abnormalities. These thresholds should be included on the observation chart.

Observation charts should display graphical information to allow clinicians to recognise and monitor changes over time.

Charts need to specify actions that are needed when deterioration is identified or when an observation threshold is reached.

The chart should also allow for modification of escalation factors for individual patients or specialist units such as day surgery or palliative care.

ACSQHC, 2010; ACSQHC, 2012;

National Institute for Health and Care Excellence (NICE) 2007

Escalation of care

Action taken during the early stages of deterioration can prevent further patient harm. It can also prevent progression of deterioration, admission to intensive care units, cardiac arrest and death.

Escalation protocols should provide timely assistance to patients when deterioration is recognised. They should support the bedside clinician to escalate care until he or she is satisfied that an effective response has occurred.

It is important to follow your organisation’s escalation policy and protocols. These should outline responses such as:

• increasing the frequency of observations
• possible nursing/midwifery and medical interventions at ward level
• review by the attending medical officer or team
• obtaining emergency assistance or advice
• transferring the patient to a higher level of care

ACSQHC, 2010; ACSQHC, 2012; NICE 2007; NPSA, 2008

Patient and family involvement

Escalation policies and protocols should enable patients and families to trigger escalation of care in response to clinical deterioration. This provides another layer of safety in the system.

Currently, treatment following deterioration is often delayed despite reports from patients or carers to the health care team. This may be due to lack of response by, or access to, clinicians.

Families and carers may recognise early deterioration sooner than clinicians, as they are familiar with the patient and spend more time at the patient’s bedside.

Information should be given to patients and carers regarding the importance of communicating these concerns and signs of deterioration. They should also be informed of the process for doing so, including ward rounds, handover and systems for escalating care.

This information should be provided on admission and be reinforced throughout a patient’s stay. At a minimum, this should allow escalation to occur:

• if there is a belief that the patient is not receiving adequate medical treatment
• if there is concern regarding the patient

ACSQHC, 2010; ACSQHC, 2012

Advance care plans

The escalation protocol should also consider advance care plans and treatment-limiting decisions. This ensures identification of patient preferences and reduces the likelihood of communication problems and inappropriate health care treatments. Treatment-limiting orders should be documented in the patient’s clinical record and include relevant state or territory legislation or policy requirements.

ACSQHC, 2012

Responding to clinical deterioration

When deterioration occurs, it is vital that clinicians are able to access appropriate emergency assistance or advice to prevent and adverse events.

Patients who meet criteria for a rapid response call should receive immediate and appropriate emergency assistance. The source of this assistance will differ between organisations depending on the size and nature of the health service.

All clinicians should know how to access emergency assistance within their organisations.

There needs to be a system in place to ensure that there is access to at least one clinician, either on-site or in close proximity, who can practice advanced life support.

Clinicians or teams providing emergency assistance need to respond within an agreed time frame and be able to:

• assess the patient, provide a provisional diagnosis and initiate treatment
• stabilise and maintain the patient
• make transfer decisions
• contact a senior staff member to make treatment-limiting decisions

All reasonable attempts should be made to include the patient and family in these decisions.

The cultural, religious and spiritual needs of the patient and carers should always be considered.

To ensure that patients who are deteriorating receive the care that they need until emergency assistance is available, all clinicians should be competent in the provision of basic life support.

ACSQHC, 2010; ACSQHC, 2012

Your role in recognising and responding to clinical deterioration

It is the responsibility of all clinicians to recognise and respond to clinical deterioration. You must ensure that you are familiar with the details of escalation protocols in your organisation which should include:

• measuring and documenting observations:

• with appropriate frequency
• on an observation chart incorporating track and trigger systems

• understanding the significance of physiological observations and assessments in identifying clinical deterioration

• processes for escalating care until the clinician is satisfied with the patient’s condition
• assisting patients and families to escalate care
• communicating effectively with other clinicians

Responsibilities for all rapid response providers and ward staff should also be outlined in policies and protocols. Roles and responsibilities include:

• directing and coordinating the response
• communicating with other clinicians
• organising treatment-limiting and patient transfer decisions
• communicating with the patient, family or carer
• documenting in the clinical record

ACSQHC, 2010; ACSQHC, 2012

Education and further resources

You need to ensure that you are trained and proficient in basic life support.

Clinicians with advanced life support skills must ensure they remain competent with the Australian Resuscitation Council Guidelines.

There are considerable education and training resources available to assist clinicians and patients with recognising and responding to clinical deterioration.

These are available from the following sites:

• Australian Commission for Safety and Quality in Health Care at:
• Victorian Department of Health at:

ACSQHC, 2012

Engaging with patients and carers

Patients and carers should be educated about the need for recognising and responding to clinical deterioration and their role in the process.

This collaboration enables an opportunity for patients, carers and clinicians to share information which may impact on the effectiveness of treatment and care and raise any concerns.

You should consider the following when discussing clinical deterioration with patients and carers:

• explaining their role in safe care, including their ability to raise concerns with the health care team
• enabling them to voice concerns about inadequate medical treatment
• providing relevant, easy to understand information
• enabling them to discuss their needs and preferences
• offering information in languages other than English and not assuming literacy
• providing an opportunity for patients and carers to ask questions and have them answered

You should ensure that the patient and carer understand the plan of care and have up to date information.

ACSQHC, 2012

Reporting adverse events

All adverse events should be reported in relation to:

• poor or absent recognition of clinical deterioration
• the use or non use of escalation processes
• poor or absent response to clinical deterioration

These should be reported to the nurse/midwife in charge, the attending medical officer (if necessary) and be documented in the clinical record.

They should also be reported in your organisation’s risk or incident management system.

Patients and carers should be fully informed of any adverse events and the organisation’s open disclosure processes implemented.

Information trends can then be used to inform quality improvement activities such as system, policy, protocol and equipment improvements and education and training activities.

ACSQHC, 2012

Summary

Recognising and responding to clinical deterioration in health care is the focus of standard 9 in the National Safety and Quality Health Service Standards.

The key messages are:

1. Serious adverse events such as unexpected death or cardiac arrest are often preceded by observable physiological abnormalities.
2. Early identification of deterioration, followed by prompt and effective action, can improve patient outcomes.
3. Recognition and response systems aim to ensure that patient deterioration is recognised promptly and receives appropriate and timely treatment.
4. There is considerable evidence that patients often go for long periods without appropriate measurement of physiological observations.
5. In a large proportion of patients, there are recognisable changes in routine observations during the twenty-four hours prior to cardiac arrest in hospital.
6. A comprehensive patient assessment is required to compile information about the patient and their condition. Physiological observations are a component of this assessment.
7. A monitoring plan should be developed that specifies the frequency and nature of observations based on the patient’s diagnosis and clinical situation.
8. Track and trigger systems assist clinicians to understand when and how to respond to deterioration.
9. Observation charts should display graphical information to allow clinicians to recognise and monitor changes over time.
10. Action taken during the early stages of deterioration can prevent further patient harm. It can also prevent progression of deterioration, admission to intensive care units, cardiac arrest and death.
11. Escalation protocols should provide timely assistance to patients when deterioration is recognised.
12. Escalation policies and protocols should enable patients and families to trigger escalation of care in response to clinical deterioration.
13. Patients and carers should be educated about the need for recognising and responding to clinical deterioration and their role in the process.
14. The escalation protocol should consider advance care plans and treatment-limiting decisions.
15. Patients who meet criteria for a rapid response call should receive immediate and appropriate emergency assistance.
16. Clinicians and teams providing emergency assistance need to respond within an agreed time frame.
17. All clinicians should be competent in the provision of basic life support.
18. All adverse events should be reported in your organisation’s risk or incident management system.

Advance care directive

A set of documents containing instructions that consent to, or refuse, specified medical treatments and that articulate care and lifestyle preferences in anticipating future events or scenarios which become effective in situations where the person is no longer able to make decisions.