Acute physical deterioration can happen at any point during a patient’s admission to hospital.
Many patients show signs and symptoms of physical deterioration before events such as cardiac arrest or unplanned admission to an intensive care unit (ICU). This means there are opportunities to intervene early and prevent these events from occurring. Hospitals worldwide, including our own, have developed systems such as rapid response teams, critical care outreach services and early warning systems to improve early recognition and response to patient deterioration, which have been shown to reduce rates of events such as cardiac arrests.
In New Zealand, there is currently considerable variation in early recognition and response systems including variation in vital sign charts and trigger systems hospitals use to escalate care, the types of response teams, and how organisation’s oversee and monitor care of the deteriorating patient.
There are also continued reports of failures to identify or act on patients adverse hospital events resulting in poor outcomes for patients.
The New Zealand Health Quality and Safety Commission is running a five year national patient deterioration programme (2016-2021) to improve the quality and safety of systems for recognising and responding to sign of deterioration among adult patients in New Zealand hospitals. Waitemata DHB has set up a Patient Deterioration Programme to support and participate in the improvement initiatives recommended by the HQSC and to coordinate an organisation wide strategic approach to the management of the deteriorating patient.
National HQSC Patient Deterioration programme
The National HQSC Patient Deterioration programme aim is to reduce harm from failures to recognise or respond to acute physical deterioration for all adult inpatients (excluding maternity) by July 2021.
The HQSC have identified the following priority areas for improvement, which are informing the Waitemata Patient Deterioration Programme:
Waitemata DHB Patient Deterioration Programme
The overall Waitemata Patient Deterioration Programme aim is to reduce harm from failures to recognise and respond to acute physical deterioration for all inpatients (including maternity and paediatrics) by July 2021.
In recognising these local and national opportunities for improvement, we have developed a local programme of improvement called the Patient Deterioration Programme.
We have set up the Waitemata DHB Patient Deterioration Programme to:
- develop and coordinate an organisation wide strategic approach to the management of patient deterioration,
- oversee our involvement in the national and regional patient deterioration programme,
- facilitate the development and introduction of new systems and processes to improve, monitor, and evaluate care of the clinically deteriorating patient
- Introduction of the national standardised vital signs chart with national early warning scores for all adult inpatient settings in 2018. This will replace our current system
- A revised localised escalation pathway to promote early recognition and response to patient deterioration
- A programme leadership group
- Education and training to support programme initiatives.
- A system for measuring patient care and programme improvement A system for patient, family and whānau to escalate concerns if they feel worried about any deterioration in a patient’s condition
- An agreed approach to shared goals of care, the decision making processes between the patient and clinical team for the overall direction for an episode of care
The HQSC have developed national health and safety markers for the patient deterioration programme that all hospitals are required to report on nationally starting in May 2018. We are also developing additional local and regional measures to monitor care of the deteriorating patient and evaluate programme improvement activity.
We will monitor the following:
- measures of Patient, whānau and staff experience
- measures of patient outcomes such as cardiac arrest rates, unplanned admission to ICU, unwanted treatments
- measures of our response systems such as escalations in care, response times, compliance with vital signs monitoring
The HQSC national quality and safety markers
- Percentage of eligible wards using the national vital signs chart (or electronic equivalent)
- Percentage of audited patients with an early warning score calculated correctly for the most recent set of vital signs (total and by ethnicity)
- Percentage of audited patients that triggered an escalation of care and received the appropriate response to that escalation as per the DHB’s agreed escalation pathway (total and by ethnicity)
- Number of in-hospital cardiopulmonary arrests in adult inpatient wards, units or departments (total and by ethnicity)
- Number of rapid response team escalations per hospital (total and by ethnicity)
- Patient Deterioration Programme Project Charter
- Waitemata DHB Patient Deterioration Programme 2016-2020
- Waitemata DHB NEWS Chart
- NZ National Vital Signs Chart
- Andrew Brant, Chief Medical Officer
- Jocelyn Peach, Director of Nursing + Midwifery
- Penny Andrew, Director of i3
- Jeanette Bell, i3 Innovation + Improvement Project Manager
Overall Programme and Shared Goals of Care
- Sue French, i3 Innovation + Improvement Project Manager
Workstream 1: Recognition + Response Systems
- Olivia Anstis, i3 Innovation + Improvement Project Manager
Workstream 2: Kōrero Mai, Patient + Whānau Escalation
- Jonathan Casement, Clinical Director ICU
- Gina Watkinson, Clinical Nurse Director, Specialist Medicine + Health of Older People