Recognising &
Responding to
Deteriorating Data:
Embedding a RRCD program into Clinical
Practice in a Tertiary hospital set...
The Big Picture
Sandia Peak, Albuquerque, New Mexico, USA – August 2014
Acknowledgments
JUDY SEE – RPH RRCD PROJECT OFFICER
DR. WILHELM SMITHIES – RPH CLINICAL LEAD
RPH DIRECTOR OF CLINICAL SERV...
Standard 9:
Our RRCD journey
 The first two years of work
 Piloting charts, education and training,
monitoring data
 Es...
Royal Perth Hospital, WA
An organisation in transition
www.rph.gov.au
• Currently the largest Tertiary hospital in WA
• 18...
The Steering Committee
Having the right people in the room…
 Senior clinical leadership
 Executive sponsorship
 Suffici...
The importance of Clinical Audit
El Morro National Monument, New Mexico, USA – August 2014
 Evaluate the system
 Check p...
First Pilot & Escalation Mapping 2011
The trigger-happy rainbow
o Worked best in general
medicine and general
surgery
o Sp...
2012 – Enter the ADDS chart
 The Adult Deterioration
Detection System was
considered a better
alternative for our site
 ...
Clinical Audit Strategy
 Clearly defined standards
 Clinically relevant metrics
 Cognisant of clinical risk
 Congruent...
Key elements of success?
 Communication
 Planning
 Contingency
 Simplicity
 Pragmatism
 Consideration of
clinical lo...
Interesting findings:
On any given day…
 ~ 40% of our patients trigger an EOC
 90-95% of EOC's are ADDS score 1-3
 Trig...
Results & Reporting
Multiple levels of reporting:
• Ward level
• Survey Monkey PDF extract
• Service Level reports
• One a...
Reporting templates
Compliance Measure Audit Period Jan-13 Feb-13 Jun-13 Sep-13 Dec-13 Mar-14 Jun-14
Numerator 0 0 0 0 0 0...
Dashboard development
SERVICE RPH WARD
Total ADDS
charts audited
Full set of
observations
documented
(n)
% set of
observat...
Dashboard Development
3K
4F
5A
5B
6A
6G
9A
9B
9C
10A
10C
BMTU
CTUP
4A4B
2K
S09/HDU
ASU/AMU2
5G
5H
6H
7A
8A
AMU
BURNS
EMW
S...
Data Integration
 Shared audit tool
 MET call database
 Incident management
 Benchmarking between sites
 Informing cl...
Summary thoughts
• Heuristic track & trigger
charts are the way that
we do business
• Bringing together expert
clinicians,...
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Samanatha Rankin - Royal Perth Hospital - STANDARD 9| Recognising and Responding to Deteriorating Data: Embedding a RRCD Program into Clinical Practice at a Tertiary Hospital

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Samanatha Rankin delivered the presentation at the 2014 Clinical Audit Improvement Conference.

The Clinical Audit Improvement Conference explored the role of clinical audit in the new era of National Care Standards.

For more information about the event, please visit: http://bit.ly/clinicalaudit14

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Samanatha Rankin - Royal Perth Hospital - STANDARD 9| Recognising and Responding to Deteriorating Data: Embedding a RRCD Program into Clinical Practice at a Tertiary Hospital

  1. 1. Recognising & Responding to Deteriorating Data: Embedding a RRCD program into Clinical Practice in a Tertiary hospital setting SAMANTHA RANKIN, RN, CHIA STAFF DEVELOPMENT EDUCATOR, CLINICAL AUDIT ROYAL PERTH HOSPITAL, WESTERN AUSTRALIA
  2. 2. The Big Picture Sandia Peak, Albuquerque, New Mexico, USA – August 2014
  3. 3. Acknowledgments JUDY SEE – RPH RRCD PROJECT OFFICER DR. WILHELM SMITHIES – RPH CLINICAL LEAD RPH DIRECTOR OF CLINICAL SERVICES RPH RRCD STEERING COMMITTEE RPH CLINICAL EDUCATORS, WARD LEADERS & AUDITORS
  4. 4. Standard 9: Our RRCD journey  The first two years of work  Piloting charts, education and training, monitoring data  Establishing governance and leadership  Changing the clinical culture toward early warning systems  Developing clinically meaningful metrics  Setting standards and attaching role-based accountability
  5. 5. Royal Perth Hospital, WA An organisation in transition www.rph.gov.au • Currently the largest Tertiary hospital in WA • 185 years as a public hospital • ~ 730 adult multi-day beds • Two campuses – City + State Rehab • State Trauma & Burns centre • Acute Mental Health service • ~ 250 ED presentations daily • Sees 2/3rds of rural aeromedical transfers We are in the midst of change: • Downsizing to a 450-bed specialist hospital • Services transitioning to Fiona Stanley Hospital • Reduction of units, teams and staff
  6. 6. The Steering Committee Having the right people in the room…  Senior clinical leadership  Executive sponsorship  Sufficient clinical expertise  Clinical Audit expertise  Strong links with:  Resuscitation committee  Clinical Safety & Quality  Senior Educators  Representation to area & state working groups  This evolved and changed over time
  7. 7. The importance of Clinical Audit El Morro National Monument, New Mexico, USA – August 2014  Evaluate the system  Check process adherence  Monitor outcomes  Flag areas requiring action…  Engage clinicians with their data  Establish variability in practice  Identify pockets of excellence  Create performance trends  Benchmark & drive improvement
  8. 8. First Pilot & Escalation Mapping 2011 The trigger-happy rainbow o Worked best in general medicine and general surgery o Specialty areas experienced challenges with over and under triggering of response o Clinician feedback was critical o 2180 observation events were prospectively analysed – results aligned with clinician and operational experience
  9. 9. 2012 – Enter the ADDS chart  The Adult Deterioration Detection System was considered a better alternative for our site  Implemented over a 4 week period with cascade training support  Audited at 6 & 12 weeks  50% sample size (~300 charts)  Documentation compliance  Charting accuracy  Process adherence  Escalation of Care  Modifications
  10. 10. Clinical Audit Strategy  Clearly defined standards  Clinically relevant metrics  Cognisant of clinical risk  Congruent with NSQHS Standard 9 requirements  Rapid reporting & feedback  Resource efficient  Retaining a pool of trained auditors  Refining a standardised audit tool
  11. 11. Key elements of success?  Communication  Planning  Contingency  Simplicity  Pragmatism  Consideration of clinical loads and competing demands  Communication
  12. 12. Interesting findings: On any given day…  ~ 40% of our patients trigger an EOC  90-95% of EOC's are ADDS score 1-3  Trigger rates double for patients on oxygen Key challenges involve:  Effective documentation of EOC  Safe practice for modification of care
  13. 13. Results & Reporting Multiple levels of reporting: • Ward level • Survey Monkey PDF extract • Service Level reports • One and two-page dashboards • High-level reports • Rolled up overall performance Reporting is modified to meet stakeholder needs and align with area- level reporting benchmarks
  14. 14. Reporting templates Compliance Measure Audit Period Jan-13 Feb-13 Jun-13 Sep-13 Dec-13 Mar-14 Jun-14 Numerator 0 0 0 0 0 0 0 Denominator 0 0 0 0 0 0 0 Compliance % #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Numerator 0 0 0 0 0 0 0 Denominator 0 0 0 0 0 0 0 Compliance % #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Numerator 0 0 0 0 0 0 0 Denominator 0 0 0 0 0 0 0 Compliance % #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Numerator 0 0 0 0 0 0 0 Denominator 0 0 0 0 0 0 0 Compliance % #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Numerator 0 0 0 0 0 0 0 Denominator 0 0 0 0 0 0 0 Compliance % #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Numerator 0 0 0 0 0 0 0 Denominator 0 0 0 0 0 0 0 Compliance % #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Numerator 0 0 0 0 0 0 0 Denominator 0 0 0 0 0 0 0 Compliance % #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Numerator 0 0 0 0 0 0 0 Denominator 0 0 0 0 0 0 0 Compliance % #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Numerator 0 0 0 0 0 0 0 Denominator 0 0 0 0 0 0 0 Compliance % #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! The monitoring plan is adhered to = number where observations adhere to monitoring plan --------------------------------------- number with a documented monitoring plan Escalation of Care (EoC) actioned as per protocol = number where EoC is actioned as per protocol --------------------------------------- number where EoC is triggered Modifications are authorised as per RPH guideline = number Modifications with authorisation --------------------------------------- number where Modifications are documented Embedding Use of the A-ORC = number with ADDS chart --------------------------------------- number audited Completeness of Observation Documentation (RPH - INCLUDES Pain & Urine Output observations) = number with a complete set of Observations --------------------------------------- number with A-ORC Completeness of Observation Documentation (SMHS - EXCLUDES Pain & Urine Output observations) = number with a complete set of Observations --------------------------------------- number with A-ORC Completion of ADDS score on last set of observations = number with an ADDS score documented --------------------------------------- number with A-ORC chart Accuracy of ADDS on last set of observations = number with ADDS scored correctly --------------------------------------- number with ADDS scored A monitoring plan is documented = number with a documented monitoring plan --------------------------------------- number of patients with an A-ORC
  15. 15. Dashboard development SERVICE RPH WARD Total ADDS charts audited Full set of observations documented (n) % set of observations documented ADDS score documented on last Obs (n) % ADDS score documented Monitoring Plan in Place (n) % Monitoring Plan in Place Number with Escalation of Care in last 24 hrs Care escalated according to escalation protocol (n) % Care escalated according to escalation protocol Number with Modifications % Modifications according to site policy 1 3K #DIV/0! #DIV/0! #DIV/0! #DIV/0! 1 4F #DIV/0! #DIV/0! #DIV/0! #DIV/0! 1 6A #DIV/0! #DIV/0! #DIV/0! #DIV/0! 1 6G #DIV/0! #DIV/0! #DIV/0! #DIV/0! 1 9A #DIV/0! #DIV/0! #DIV/0! #DIV/0! 1 9B #DIV/0! #DIV/0! #DIV/0! #DIV/0! 1 9C #DIV/0! #DIV/0! #DIV/0! #DIV/0! 1 10A #DIV/0! #DIV/0! #DIV/0! #DIV/0! 1 10C #DIV/0! #DIV/0! #DIV/0! #DIV/0! 1 BMTU #DIV/0! #DIV/0! #DIV/0! #DIV/0! 1 CTUP #DIV/0! #DIV/0! #DIV/0! #DIV/0! TOTAL SERVICE 1 0 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 0 #DIV/0! 0 2 4A4B #DIV/0! #DIV/0! #DIV/0! #DIV/0! TOTAL SERVICE 2 0 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 0 #DIV/0! 0 3 2K #DIV/0! #DIV/0! #DIV/0! #DIV/0! TOTAL SERVICE 3 0 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 0 #DIV/0! 0 4 S09/HDU #DIV/0! #DIV/0! #DIV/0! #DIV/0! 4 5A #DIV/0! #DIV/0! #DIV/0! #DIV/0! 4 5B #DIV/0! #DIV/0! #DIV/0! #DIV/0! 4 ASU/AMU2 #DIV/0! #DIV/0! #DIV/0! #DIV/0! 4 5G #DIV/0! #DIV/0! #DIV/0! #DIV/0! 4 5H #DIV/0! #DIV/0! #DIV/0! #DIV/0! 4 6H #DIV/0! #DIV/0! #DIV/0! #DIV/0! 4 7A #DIV/0! #DIV/0! #DIV/0! #DIV/0! 4 8A #DIV/0! #DIV/0! #DIV/0! #DIV/0! 4 AMU #DIV/0! #DIV/0! #DIV/0! #DIV/0! 4 BURNS #DIV/0! #DIV/0! #DIV/0! #DIV/0! 4 EMW #DIV/0! #DIV/0! #DIV/0! #DIV/0! 4 SMTU #DIV/0! #DIV/0! #DIV/0! #DIV/0! TOTAL SERVICE 4 0 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 0 #DIV/0! 0 5 S01 #DIV/0! #DIV/0! #DIV/0! #DIV/0! 5 S02 #DIV/0! #DIV/0! #DIV/0! #DIV/0! 5 S06/8 #DIV/0! #DIV/0! #DIV/0! #DIV/0! 5 S10 #DIV/0! #DIV/0! #DIV/0! #DIV/0! 5 S11 #DIV/0! #DIV/0! #DIV/0! #DIV/0! TOTAL SERVICE 5 0 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 0 #DIV/0! 0 TOTAL RPH 0 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 0 #DIV/0! 0 [xxx to xxx] Quarter 2014 - Summary of Performance Indicator Data Standard 9: Recognising and Responding to Clinical Deterioration
  16. 16. Dashboard Development 3K 4F 5A 5B 6A 6G 9A 9B 9C 10A 10C BMTU CTUP 4A4B 2K S09/HDU ASU/AMU2 5G 5H 6H 7A 8A AMU BURNS EMW SMTU S01 S02 S06/8 S10 S11 RPH 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Compliance% Clinical Area For last set of observations: Percentage of Complete Observations 3K 4F 5A 5B 6A 6G 9A 9B 9C 10A 10C BMTU CTUP 4A4B 2K S09/HDU ASU/AMU2 5G 5H 6H 7A 8A AMU BURNS EMW SMTU S01 S02 S06/8 S10 S11 RPH 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Compliance% Clinical Area Percentage of Patients with a Monitoring Plan3K 4F 5A 5B 6A 6G 9A 9B 9C 10A 10C BMTU CTUP 4A4B 2K S09/HDU ASU/AMU2 5G 5H 6H 7A 8A AMU BURNS EMW SMTU S01 S02 S06/8 S10 S11 RPH 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Compliance% Clinical Area For last set of observations: Percentage of ADDS Scores Documented 3K 4F 5A 5B 6A 6G 9A 9B 9C 10A 10C BMTU CTUP 4A4B 2K S09/HDU ASU/AMU2 5G 5H 6H 7A 8A AMU BURNS EMW SMTU S01 S02 S06/8 S10 S11 RPH 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Compliance% Clinical Area Compliance with Escalationof Care Protocol in the highest scoring ADDS in past 24 hours (Only in areas where EoC captured at audit)
  17. 17. Data Integration  Shared audit tool  MET call database  Incident management  Benchmarking between sites  Informing clinicians about local clinical risks  Involving patients & carers
  18. 18. Summary thoughts • Heuristic track & trigger charts are the way that we do business • Bringing together expert clinicians, clinical leaders and educators has driven cultural change • More change is on the horizon… so it’s a long road Salt River Canyon, Arizona-New Mexico border – July 2013

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