Still failing to rescue what more can we do to keep patients safer? - - PowerPoint PPT Presentation

www.qgi.org.uk

Still failing to rescue

‐ what more can we do to keep patients safer?

www.qgi.org.uk

In 2006 we reviewed the NRLS and identified three themes:

• No observations made for a prolonged

period and therefore changes in a patient’s vital signs not detected.

• No recognition of the importance of the

deterioration and/or no action taken other than recording of observations.

• Delay in the patient receiving medical

attention, even when deterioration has been detected and recognised.

NPSA guidance

www.qgi.org.uk

Six years on, why is it so difficult to consistently and effectively do nursing observations?

www.qgi.org.uk

Lucien Leape on

patient safety culture

• Mistakes are caused by bad systems, not bad people
• Systems set people up to fail, or fall into ‘a trap’
• We must recognise that humans are error prone and

try to error‐proof our systems

• Remove hazards wherever possible

www.qgi.org.uk

‘We cannot change the human condition, but we can change the conditions under which humans work.’

Jim Reason (2000) If we accept human fallibility, we need to rely

• n well‐designed systems

to support us in the workplace. And remove error traps wherever possible.

www.qgi.org.uk

Observations continue to be largely taken at set times rather than in response to patient need Most observations are taken by untrained staff Reluctance to escalate EWS complex to calculate – particularly in sick patients

So what are the error traps in a deterioration incident?

www.qgi.org.uk

The sickest patients are the least likely to have their

• bservations taken on time

Observations continue to be frequently missed at night Multiple paper‐based records and charts kept in ring binders There’s no baseline and There’s no plan…

So what are the error traps in a deterioration incident?

www.qgi.org.uk

Embracing technology ‐ more consistent care delivery ...

• More legible charts
• 99% completeness observations
• 40% quicker to record
• bservations /escalate care
• 100% accuracy EWS
• More timely observations
• More observations through the

night

• Improved communication
• Earlier intervention by medical

teams

• Fewer cardiac arrests

www.qgi.org.uk

Fluid balance???

• What is the goal?
• What is the plan?
• Which patients need a

fluid chart?

• Which patients need a

catheter?

• What about yesterday?
• When do we add it up?
• What does OTT plus wet

++ equal?

www.qgi.org.uk ‘They are a broken tool that has

been expected to do too many different jobs, and they do none of these jobs well!’

‘We need to stop thinking about

charts and start thinking about what the

information is, that is needed by busy clinicians to make important decisions about patient care.’ ‘Currently fluid balance charts are an unhelpful distraction from clinical care. We have to think of both technological and practice based solutions to determine the information required, to make changes and stop be‐moaning the fact that nurses don’t fill in charts and start thinking differently.’

A broken tool?

www.qgi.org.uk

www.qgi.org.uk

Time to intervene?

‘Many patients had multiple reviews in the 48 hours prior to cardiac arrest, 160/391 had more than 5 reviews. There was no evidence of escalation to more senior staff in patients who had multiple reviews.’

NCEPOD 2012 Time to Intervene?

www.qgi.org.uk

The ‘no improvement’ cycle

• The patient has a ViEWS score of 6 at 3pm
• HCSW informs RN (as per escalation protocol) when she

finishes her obs at 4pm

• RN repeats obs at 4.30pm – patient again scores 6
• RN informs F1
• F1 sees patient at 5.30pm (as per escalation protocol) and

prescribes fluids

• RN gives fluids as prescribed over 2 hours

www.qgi.org.uk

The ‘no improvement’ cycle

• HCSW takes obs at 7.30pm – patient again scores 6
• HCSW informs RN (as per protocol)
• RN informs F1 at 8pm
• F1 sees patient at 9pm and requests ECG, Us and Es,

FBC and chest x‐ray

• HCSW repeats obs at 9.30pm and patient scores 7
• Patient has investigations and F1 visits again at 10pm

www.qgi.org.uk

A predictable cardiac arrest?

• And then the patient has a cardiac arrest and dies at

11pm – having triggered 8 hours earlier

• 64% of cardiac arrests in the NCEPOD study were

considered to be predictable

• 38% were thought to be predictable and avoidable

www.qgi.org.uk

www.qgi.org.uk

• Was there a clearly documented physiological

monitoring plan stating type and frequency of

• bservations in the 24 hours preceding the arrest (as per

NICE and NCEPOD Guidance) and were these undertaken as per request?

• What were the patient’s Early Warning Scores in the 12

hours preceding the arrest?

• If the patient’s scores at any time in that 12 hour period

were elevated to ‘trigger level’, as per the local escalation policy, was the correct escalation response enacted?

www.qgi.org.uk

• Did the patient receive appropriate treatment for

raised EWS in response to escalation?

• If the patient received appropriate treatment, did

his condition improve in response to that treatment?

• If he did not improve, was the patient escalated to a

more senior level in a timely manner?

• Did the patient have documented and discussed

ceilings of care/DNAR status/ ‘a dignified death?

www.qgi.org.uk

Depending on the response to these questions the incident should be subject to full RCA

www.qgi.org.uk

1960s Resuscitation

• It works in theory, so….
• Little or no structured

education

• Poor and variable in‐

hospital response systems

• 14% survival to

discharge *

* McGrath, 1987

www.qgi.org.uk

Resuscitation in 2012

• Extensive evidence base
• Extensive staff

education programmes

• Highly coordinated in‐

hospital response

• 17% survival to

discharge *

* Peberdy et al, 2003

www.qgi.org.uk

www.cddft.nhs.uk

How much does a resuscitation service cost?

£241 781 resus team costs £40 000 per annum in emergency drugs £733 000 for defibrillators £33 200 for consumables 13 374 hours to deliver training £211 809 pay to staff whilst attending training Thanks to Paul Fish, Associate Director of Nursing, CDDFT

www.qgi.org.uk

Is this really where we can make the biggest impact on practice?

www.qgi.org.uk

Philosophies around cardiac arrests

Dr Alex Stone

www.qgi.org.uk

The majority of cardiac arrests that occur on the general wards of

• ur acute hospitals are not sudden unpredictable and

unpreventable occurrences. Rather, they are the consequences of either unrecognised or untreated deterioration or the failure to recognise or deal appropriately with end of life circumstances or life limiting disease.

Unrecognised and untreated deterioration

www.qgi.org.uk

Any patient for whom resuscitation from cardio‐respiratory arrest is deemed appropriate should be for all possible therapeutic measures to prevent cardio‐respiratory arrest occurring in the first place.

Pull out all the stops before it happens, not after

www.qgi.org.uk

Whilst cardio‐pulmonary resuscitation (CPR) after a ward based cardiac arrest is perceived by both many lay members of society and medical practitioners as a signal of “everything being done” for a relative or patient, it is more often than not a red flag being waved indicating exactly the opposite.

Failing to rescue

www.qgi.org.uk

The concept and culture of cardiac arrest calls, cardiac arrest teams and cardiac arrest trolleys needs to be replaced with the concept and culture of emergency calls, emergency teams and emergency trolleys. The culture of disappointment, false alarm, nuisance call or even

• utright irritation amongst members of our current highly skilled

multi disciplinary cardiac arrest teams when they run to the bedside of a patient who is still alive needs to be dispelled. It should be replaced with the concept and culture that it is a far better use of resources and far more likely to produce a favourable outcome if we run to the bedsides of our patients whilst they are still alive and institute appropriate care.

Dispel the crash call culture

www.qgi.org.uk

www.qgi.org.uk

Questions?

Kate Beaumont

Director, QGi Quality Governance Intelligence www.qgi.org.uk Email: kate.beaumont@live.co.uk Nurse Director The Learning Clinic, 7 Lyric Square, London W6 0ED Web: www.thelearningclinic.co.uk Mobile: 07989 485669