iSRRS Opening Address 2017

John Welch, iSRRS President

Financial Disclosures

Advisor …

•Philips GmbH

•PMD Solutions

www.nightingale-h2020.eu/

Developing the ‘ultimate patient monitoring system’

Just to recap …

1930

Learning points

• A reliable alerting system is essential

• People under stress forget the basics: was it safe to approach?

• A team is needed

• The second (third and fourth) victims need input too

1992

McQuillan P, et al. BMJ. 1998;316(7148):1853–1858.

1992

Lee A, et al. Anaesth Intensive Care. 1995;23(2):183-6.

Twenty five years later

89% of hospitals have a dedicated Outreach team- 49% have a 24/7 dedicated Outreach team

National Confidential Enquiry into Patient Outcome and Death ‘Just Say Sepsis!’. London, 2015.

Prytherch DR, et al.Resuscitation.

2010;81(8):932-7.

We now have more efficient Early Warning Scores

- Three quarters of hospitals in England use NEWS

Even the US Army are catching on!

Prytherch DR, et al.Resuscitation.

2010;81(8):932-7.

… and we’ve some ideas about more “soft” alerts

Call 4 Concern© enables patients and families

to call for immediate help and advice when

they feel concerned that the health care team

has not recognised their own or their loved

one’s changing condition. The Outreach team

can be contacted directly if:

1. A noticeable change in the patient occurs

and the health care team is not recognising

your concern.

2. You feel there is confusion over what needs

to be done for the patient.

… and we’ve more ideas about more “soft” alerts

Odell M, et al. Br J Nurs. 2010 Dec 9-2011 Jan 13;

19(22):1390-5.

We can measure processes and outcomes

‘Multi-disciplinary Audit EvaLuatingOutcomes of Rapid Response’ = MAELOR

Outcomes Positive Negative

Transfer to ICU, or Theatre

1. Timely transfer, e.g., < 4 hours after the first trigger

2. Delayed transfer, e.g., > 4 hours after first trigger

Alive on ward 3. No longer triggering 4. Still triggering

Deceased 5. On terminal care pathway / with DNAR order

6. Following cardio-pulmonary arrest

Others 7. Alive with documented treatment limits / DNAR order

8a) Trigger from new pathology unrelated to previous call-out

8b) Chronic condition …

8c) Discharged from hospital

9. Outcome unknown

Morris A, et al.Crit Care Resusc.2013;15(1):33-9.

Bannard-Smith J, et al.Resuscitation. 2016;107:7-12.

We might count and case-mix adjust deaths

Hogan H, et al. BMJ Qual Saf.2012;21(9):737-45.

Hogan H, et al. BMJ.

2015;351:h3239.

Count deaths … or, better, learn from them

PRISM 1 & PRISM 2 Studies: 3.6% deaths probably avoidable

- no statistically significant association between Hospital Standardised Mortality Ratios and proportion of avoidable deaths

Hogan H, et al. BMJ. 2015;351:h3239.

Treatment

escalation plan

in place - or

similar

Vital Signs

recorded as per

local policy in 6

hours before

event

Timely referral

as per local

policye.g., within 15 mins

of NEWS score ≥ 5

SBAR or similar

used in referral(not applicable in

cardiac arrest)

Timely response as

per local policye.g., in 30 mins with

NEWS score 5, or in 10

mins with NEWS score 7

Timely delivery of required

treatmente.g., Sepsis 6 in 60 mins

or Timely transfer to ICU e.g., in 60 mins

or Palliative Care

Example

patient

No Yes No N/a Yes No

Patient 1

Patient 2

Patient 3

Patient 4

Patient 5

Review five cases: new referrals to Outreach and/or unplanned admissions to ICUand/or cardiac arrests and/or patient deaths

Deteriorating Patients Care Bundle

Lawton R, et al. 369-80. BMJ Qual Saf. 2012;21(5):369-80.

Standardised, structured death reviews:framework of factors contributing to patient safety

It’s true, nothing is certain, except …

Clark D, et al. Palliat Med.2014;28(6):474-479.

(10,743 patients, 31/03/2010)

Rapid Response Systems In-hospital End of Life care

Observed problem Cardiac arrests, unplanned ICU

admissions, unexpected deaths

A third of RRS reviews have EoL care

issues

Adverse events Potentially avoidable morbidity &

mortality

Potential for poor provision of end of life

care

RecognitionWard staff did not reliably recognize

clinical deterioration

Ward staff did not reliably recognize the

dying patient

Potential benefits of

early interventionFewer adverse events

Improved quality of EoL & palliative care;

patient experience, staff satisfaction

Available

interventions

Critical Care Outreach / Rapid

Response Teams

Palliative care services & Amber care

bundle

Antecedents &

warning signs

Physiological deterioration - abnormal

vital signsNone validated

Jones D, et al. Curr Opin Crit Care. 2013;19(6): 616-23.

“Elderly people who are

dying need to be protected

from heroic but intrusive

live-saving hospital

interventions that often only

prolong suffering rather

than enhance quality of

remaining life.”

Cardona-Morrell M, Hillman K. BMJ Support Palliat Care. 2015;5(1):78-90.

29-point checklist …

Age ≥65 AND• admitted via ED

OR 2 or more of• decreased LoC• systolic BP <90 mm Hg• respirations <5 / >30• pulse <40 / >140• need for O2 / SpO2 <90%• hypoglycaemia• repeat / prolonged seizures• oliguria

OR MEW or SEWS score >4

AND other risk factors• advanced malignancy

• chronic kidney / heart / pulmonary disease

• new cerebrovascular disease

• Evidence of frailty……

……

……

Cardona-Morrell M, Hillman K. BMJ Support Palliat Care. 2015;5(1):78-90.

The following treatment plan should be used as clinical guidance and is not a substitute for ongoing consultation and shared decision-making wherever possible. The clinician should initial ONE of the patient’s priority boxes below, add relevant guidance in the large box and initial a CPR decision. The form must be signed, named and dated on the reverse.

Name:

Date of Birth: Hospital/NHS numbers:

Address:

1

This individual is FOR attempted CARDIOPULMONARY RESUSCITATION

Signature 6

This individual is NOT FOR attempted CARDIOPULMONARY RESUSCITATION Signature

If the patient dies in transit please take to: 6

Please provide clinical guidance on specific interventions that may or may not be wanted or clinically appropriate in community, hospital and critical care settings:

Provide details of other relevant care planning documents and/or documented wishes about organ/tissue donation (name and where held):

5

The priority is to get better. Please consider all treatment

to prolong life

Initials: .. . 4

The priority is to achieve a balance between getting better and ensuring good

quality of life. Please consider selected treatments

Initials: .. 4

The priority is comfort. Please consider all treatments aimed

at symptom control

Initials: .. 4

Turn over to complete this ECTP

Relevant information about the individual’s diagnosis, situation, ability to communicate, and reasons for the chosen plan.

3

Emergency Care & Treatment Plan

Date: __/__/____ 2

Clear planning: treatment escalation; and limitation

Designation - (Grade and specialty)

Print name & professional registration number

Signature Date and time

Senior Responsible Clinician

10

Plan review: If the individual’s condition changes (i.e. deterioration OR improvement) review the decisions on this ECTP. Document further conversations in box 8. If necessary, complete a new form, and write “CANCELLED” clearly across both sides of this form with signature and date. The decisions on this form should be reviewed specifically before any procedure during which abrupt deterioration or cardiac arrest may occur (e.g. endoscopy, cardiac pacing, angiography, surgery or anaesthesia). Make an agreed plan on whether or not to revoke temporarily the decisions on this form and, if so, on the treatments that will be considered if abrupt deterioration or cardiac arrest occurs. 11

Emergency contacts Name Telephone numbers Other relevant details

Welfare Attorney, Guardian etc.

Family/friend

GP

Lead Consultant

Specialist worker/key worker 12

Does the (adult) individual have capacity? (see guidance notes) YES NO

Do they have a valid advance directive or ADRT? YES NO

If so, record details in box 5

Do they have a representative with legal authority to make decisions? YES NO

(e.g. Welfare Attorney, Guardian, person with Lasting Power of Attorney for Health and Welfare)

If so, record their contact details and document details of discussion below. 7

The clinician signing this ECTP is confirming that these decisions: 1. have been discussed with and agreed with the individual; or 2. have been made in accordance with capacity law; or 3. in the case of a child, the person holding parental responsibility/court order. Date of discussion: __/__/____ Names of those present:

Full documentation of discussion can be found in:

Further conversations occurred on the following dates (state where details are recorded):

8

If there has been no shared decision-making with the individual, no shared decision-making with a

representative with legal authority to make decisions or no best-interests meeting for the individual who

lacks capacity, document a full explanation and a clear plan to address this in the clinical records.

Summarise the reason (e.g. describe any potential to cause harm) here:

9

What else?

Many of our patients are at high riskof psychological morbidity (e.g., post-ICU)

acute psychological reactions in critical illness are risk factors for mental illness in the future

55% of critically ill patients had psychological morbidity:

anxiety, depression, PTSDWade DM, et al. Crit Care. 2012;16(5):R192.

RRT / MET / Outreach staff could deliverpsychological support

POPPI trial: randomised controlled trial in 24 hospitals

a) Creation of calm, therapeutic environment

b) Detection of psychological distress

c) Delivery of three stress support sessions to identified patients

Technology

Seasonally adjusted mortality rates at Queen Alexandra Hospital (top) and University Hospital Coventry (bottom).

Schmidt PE, et al. BMJ Qual Saf 2015;24:10-20.

Subbe CP, et al. Crit Care. 2017; 21:52.

Technological aids in crises

Subbe CP, et al. BMC Health Serv Res.2017;17:334.

and also data and analytics …

Laboratory data to predict deterioration(Ur, Cr, Bili, pH, Alb, WCC, Bic, Hct, Hb)

Cohort AUC-ROC (CI) p-value

Computer 0.801 (0.668 0.910) -

Humans: All 18 participants 0.772 (0.650 0.879) 0.669

Humans: 6 Consultants only 0.608 (0.490 0.731) 0.016Loekito E, et al. Resuscitation. 2013;84(3):280-5.

- derived from analysis of 5 million patient encounters in a wide range of hospitals Singer M, et al. JAMA. 2016;315(8):801-10.

Artificial Intelligence 4, Human Champion 1

Cautionary note

Next…

The key questions

• Do you know how good (or bad) you are?

• Do you know where you stand relative to the best?

• Do you know about variation in your system?

• Do you know how things change over time?

After Maureen Bisognano, IHI President/CEO.

“Every system is perfectly designed to achieve exactly the results it gets.”

Thinking about the staff

Thinking about BARRIERS

Knowledge: Confusion over how to treat complicated patients

(fluid balance, long term in-patients)

Social Influences: Lack of communication: ‘Is this patient on the pathway or not?’, conflict between Drs

and Nurses

Beliefs about consequences: Fear of harming patients with Sepsis Six,

lack of confidence in the evidence

Steinmo S, et al. Implement Sci. 2015;10:111.

and LEVERS

Memory and Attention:Sepsis Six ‘branding and marketing’,

plus prompts and reminders

Environment: Materials and resources immediately available

Social influences: Superiors’ commitment; reciprocal feedback ‘It’s our pathway and

we’re being listened to’.

Beliefs about consequences:seeing health improve immediately,

following-up specific patients

Steinmo S, et al. Implement Sci. 2015;10:111.

Thinking about the whole system

Thirteen acute hospitals: 6m people

Breakthrough Series Collaborative

Aim

• to improve recognition & response to sepsis across participating trusts

• thereby improving patient care processes and outcomes

An improvement method thatrelies on spread andadaptation of existingknowledge to multiple settingsto accomplish a common aim.

Within

15 min

Prompt identification of sepsis

- All six vital signs recorded in 15 mins of arrival

(RR, SpO2, HR, BP, AVPU/GCS, To)

Within

1 hour

Immediate referral to doctor/nurse able to deliver tx

- The word ‘sepsis’ written/highlighted/ticked in patient

record in 1 hour of arrival

Timely care delivery

- Documented IVABs in 1 hour of arrival, & BCs in hour

- ≥500 mL iv fluid given in 1 hour of arrival

(unless clear contra-indication)

Within

3 hours

Follow-up review

- Documented review at 3 hours after arrival (+/- 30 mins)

- Evidence of escalation if not improved

(e.g., if NEWS ≥5)

At 48

hours

- Documented review of antimicrobial therapy in 48 hours

of arrival (if still in-patient)

Agreed processes across 13 acute hospitals

Emergency admissions with ‘SoS’ in 1o or 2o diagnosis fields

5.5

5.7

5.9

6.1

6.3

6.5

6.7

6.9

2013-14 2014-15 2015-16 2016-17

‘Suspicion of Sepsis’ Patient Mortality (%): UCLP Trusts

UCLP With thanks to Matt Inada-Kim.

Thinking about the whole system !!!