Early Recognition of the Deteriorating Patient Project (ERDP)

Greater Western Area Health Service

Abstract

Thirteen clinical Severity Assessment Code (SAC) 1 & 2 incidents over a 12-month period were attributed to an inability of clinicians to recognise or communicate the acuity of ill patients at Dubbo Base Hospital (DBH). This six-month project was developed to enable health care professionals to recognise the deteriorating patient early and initiate appropriate and timely interventions. The project piloted the COMPASS ERDP research from ACT Health included data collection, the development and implementation of observation and communication systems and education that addressed the needs of clinical staff, but more importantly improved the safety and treatment of patients.

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Aim

The project aims to enable health care professionals to recognise the deteriorating patient and initiate appropriate and timely management interventions.

Nature of the Problem

The ERDP project resulted from a number of serious incidents at DBH, involving the management of the deteriorating patient.

Investigations highlighted that clinicians often were unable to identify a deteriorating patient, from vital sign observations and also observations were infrequent or incomplete.

When deteriorating patients were identified there was no clear process to assist clinicians prioritise and communicate their concerns to the appropriate people in a concise and timely manner. Often patients would await review by a very junior medical officer who, for various reasons, were unable to make decisions about the care required.

Extent of the Problem

The extent of the problem was analysed in four ways:

Strategic Importance

The project utilised a clinical redesign framework and was part of the inaugural Redesign course. It focused on the same priorities identified by the Clinical Excellence Commission (CEC) with the ‘Between the Flags’ project. The main function was to increase patient safety by providing a consistent approach to clinical care. The approach has meant that the patient receives appropriate and timely interventions, therefore decreasing the need for unplanned admissions to critical care areas. Timely and appropriate interventions have led to an increase in patient satisfaction through a safer, more positive patient journey.

Planning and Implementing Solutions

Implementation was assisted by the project being supported with an executive sponsor, governance and funding from the Clinical Governance Directorate and the support of the General Manager, Central Cluster. Key stakeholders were identified including the Manager of Nursing and Patient Services, Manager of Patient Safety and Clinical Quality and in the absence of a Director of Medical Services, the Area Director of Critical Care. These groups meet on a regular basis to support and guide the project.

At a local level two clinical champions were recruited from each clinical area, to give the project carriage on the ground. These clinical champions received extra training in trouble shooting any problems that may occur, and were identified as the resource person on the wards. Specialist input was also received from a selection of JMOs, physiotherapists and nurse educators. Staff where kept updated with a monthly newsletter, Mews News.

The clinical champions met to discuss the issues raised at the process mapping sessions, and worked to devise solutions for identified problems. These solutions were then prioritised into a matrix that identified the greatest impact and ease of implementation, to hardest, as demonstrated in the diagram below. 

Over a period of a month the entire team worked on providing extensive training across the whole organization, this included a four-hour education session, development and modification of the observation chart, and implementation of the communication strategy. Wards worked hard to release all staff to attend the training, with sessions being run at number of different times and in different places to capture everyone.

Outcomes and Evaluation

During the diagnostic stage a set of Key Performance Indicators (KPIs) were agreed , to assist with the measurement of success. Some KPIs were easily measurable through simple auditing, and some have been delayed awaiting data from the Department of Health for official statistics. Results include:

Most importantly the staff completed a post change survey. They identified they felt much more supported in caring for the deteriorating patient, were able to demonstrate that they could identify a deteriorating patient and what should occur for that patient.

Sustaining Change

Sustainability of the project is of paramount importance to DBH and is now well integrated into clinical practice. The observation chart is now an accepted part of the culture. Auditing and continual education is the key.  Nursing Unit Managers include monthly auditing as a monthly KPI. This auditing will also form part of the Quality Plans for accreditation.

Regular education with new medical officers occurs at orientation on each rotation. An explanation of the observation chart and the processes surrounding their responsibilities are clearly explained.

The Nurse Education team will maintain carriage of the 4-hour education. A condensed version of the training has been developed with mandatory education for all clinical staff to be provided on an annual basis.

Future Scope

The most important learning from this project was the need to be owned by the facility implementing change. The processes undertaken prior to implementing change meant that staff felt they had identified the need for change and that they sourced solutions that met their needs.

The project is flexible with its delivery modes and will require very little change to tailor it more widely to a variety of facility types or sizes. Implementation would initially require some facilitation on site, but could then be sustained by existing staff resources.

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