Still failing to rescue

Still failing to rescue ‐ what more can we do to keep patients safer?
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NPSA guidance
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. www.qgi.org.uk
Six years on, why is it so difficult to consistently and effectively do nursing observations?
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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
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‘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 on well‐designed systems to support us in the workplace.
And remove error traps wherever possible.
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So what are the error traps in a deterioration incident?
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
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So what are the error traps in a deterioration incident?
The sickest patients are the least likely to have their observations 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…
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Embracing technology ‐ more consistent care delivery ...
• More legible charts
• 99% completeness observations
• 40% quicker to record observations /escalate care
• 100% accuracy EWS
• More timely observations
• More observations through the night
• Improved communication
• Earlier intervention by medical teams
• Fewer cardiac arrests
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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?
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‘They are a broken tool that has A broken tool?
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.’
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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?
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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
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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
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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
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•Was there a clearly documented physiological monitoring plan stating type and frequency of observations 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?
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• 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?
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Depending on the response to these questions the incident should be subject to full RCA
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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
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Resuscitation in 2012
• Extensive evidence base
• Extensive staff education programmes
• Highly coordinated in‐
hospital response • 17% survival to discharge *
* Peberdy et al, 2003
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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.cddft.nhs.uk
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Iswww.qgi.org.uk
this really where we can make the biggest impact on practice?
Philosophies around cardiac arrests
Dr Alex Stone
www.qgi.org.uk
Unrecognised and untreated deterioration
The majority of cardiac arrests that occur on the general wards of our 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.
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Pull out all the stops before it happens, not after
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.
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Failing to rescue
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.
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Dispel the crash call culture
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 outright 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.
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Questions?
Kate Beaumont
Director, QGi
Quality Governance Intelligence
www.qgi.org.uk
Email: [email protected]
Nurse Director
The Learning Clinic, 7 Lyric Square, London W6 0ED
Web: www.thelearningclinic.co.uk
Mobile: 07989 485669
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