This document summarizes strategies to improve management of deteriorating hospital patients. It discusses (1) establishing governance committees to oversee policies, (2) classifying rapid response team (RRT) calls to identify patterns and improve care, and (3) implementing programs to detect and manage deterioration earlier such as teaching junior doctors to conduct urgent clinical reviews, referring patients to palliative care, and placing an ICU fellow on high-risk surgical wards. The goals are to reduce RRT calls and prevent cardiac arrests by taking a more proactive approach to managing deterioration.

1. The future:
Integration of acute care in hospitals
A/Prof Daryl Jones

2. Overview
• Summary national standard 9
• Changes in RRT review
• Governance and deteriorating patients
• Classification of RRT syndromes
• Moving deterioration upstream
– SMS leadership EOLC / palliative care referral Reg
– Urgent clinical review
– Surgical ICU fellow

3. One size does not fit all
• Mostly experience Austin Hospital
• Described as “National leader” by ACHS
• May not be applicable / appropriate for your
hospital
Your hospital

4. Summary National Standard 9

5. Changes RRT reviews

6. Acute campus
Rehab campus

7. ICUMental health

8. Governance and deteriorating patients
• Deteriorating patient committee = Steering committee
• Broad representation ≈ 40 members (2 consumers)
– 3 campuses = Sub-acute / acute / mental health
– QSR / clinical staff / SMS / executive sponsor
• Working committees
– Escalation policy/UCR/ORC (Melodie Heland)
– End of life care (Juli Moran)
– Sub-acute care / surgical centre (Sandy Schutte)
– Mental Health precinct (Michelle Snell)
– Education collaborative (Robert Lopresti)
– Resuscitation committee (Sam Radford, Karen Mardegan)

9. • Overall principles
– Move detection & response to deterioration “upstream”
– Avoid using RRT as an alternative to “routine care”
– Audit RRT calls to find patterns  improve process care
– Re-engage parent unit / JMOs
» Attending own METs / UCRs
» Developing local strategies
– Parent unit audit of own emergency calls

10. Overall aims and philosophy
• Pre-emptive & pro-active strategies
Hospital
inpatient
Abnormal
vital signs
MET
call
Cardiac
arrest
Mort ≅ 2% Mort ≅ 25% Mort ≅ 80%
Old paradigmCurrent
paradigm
Future
paradigm

11. Improved audit of Emergency calls
• Risk-Man / VHIMS
• Entered at time of call
• Hard-copy printout in notes
• pdf of call emailed to quality
coordinators

15. Classification of RRT calls
• Quality data permits audit of RRT calls
• EOLC MET calls
≈ 1/3 calls
• Critically ill MET call
≈ 1/10 – 1/5 calls
• Remain on ward
≈ 2/3 calls

17. • Earlier deterioration
– Likely to be more of them  Contrast
– Spread over larger number units  with RRT
– Longer to respond (30 min) 
• ACCESS = “teach JMOs how to manage UCR”
• COMPASS = clinical education unit
• Standardised paging script
• Standardised documentation tool
• Dedicated phone on each ward
Urgent clinical review

18. • New UCR form
• Expected fields for
documentation
• Permits audit
Urgent clinical review

19. Deskilling ward staff

20. “Deskilling” vs ? “increasing gap”
• Older / sicker patients
• Surgical complexity
• NEAT & “drive through ED”
• HITH
• Surgical centres for low risk patients
• Better surgical & anaesthetic technique
• Societal expectations
• DOSA / ↓ length of stay
• ↑ administrative tasks
• Shorter working hr
• Consultants often VMOs
• ICU bed shortage

21. ACCESS
• Medical lead Sam Radford
– Faculty = ICU SMS, fellows and registrars
• Interns, HMO 2-3.
• After evening handover Tues night
• ICU lecture theatre
• CEO endorsed & sponsored

22. ACCESS – session topics
1. Approach to the unwell patient
- Introduction to ACCESS
2. Airway and altered
consciousness
3. Shortness of Breath and
Hypoxia
4. Chest Pain and arrhythmias
5. End of life care issues and
having discussions
6. Hypotension and Shock
7. Sepsis
8. Acute Kidney Injury and Oliguria
9. Electrolyte and Endocrine
Disturbances
10. Surgical Emergencies, bleeding
and transfusions

23. Reducing EOLC RRT calls
• Palliative care referral registrar
– Gen Med / renal / ortho over-represented in EOLC MET calls
– Collaborative project with ICU / PCU
– Pall care referral reg attends MET calls in these units during
working hours
– “De-escalation of care”
– Piloted late 2013. Project 2nd
half 2014
– ? Data available ANZICS-ASM

24. • CLEARx decisions (Consultant Leadership in EOLC
ACP and Rx decisions) programme
– Approx 50 SMS – endorsed by SMS exec
– Limited number projects
» ESLF/HCC (gastro) and CCF (cardiology)
» SMS leadership in ACP and EOLC decisions
 Trigger / response  discussion & documentation
» Communication workshop – SMS / registrars
» Standardised language definitions ACP / EOLC planning
» Guidelines for symptom control
» Educational material for JMOs
» Promoting timely referrals to palliative care referral reg.

25. Surgical ICU fellow
• In the past ≈ 30% all MET calls on two wards (8EW)
– Major surgical procedures
– Increasing age / unplanned admissions
• Projects to improve
– POST
– General medical registrar
• In 2014 = ICU fellow located on ward = co-management

26. • Part of comprehensive programme
– Expected roles / behaviours
– Face-face handover Dr-RNs
– Daily care plan
– ICU fellow oversight
– Streamlined referral to GenMed = consult reg
– Formal intern 2nd
round - ↓ paging numbers
Surgical ICU fellow

28. Outcomes
• RRT calls Acute campus
– 9.2% reduction April  Dec 2013 cf 2012
• RRT calls mental health precinct
– 81% reduction in calls
– 87% reduction in ambulance transfers
• RRT calls rehabilitation facility
– 56% reduction in calls
• 37% increase admission to PCU

29. Conclusions
• Mature RRT
– Increasing calls
– Detailed audit can permit identification of patterns
• Moving deterioration upstream
– SMS leadership ACP/EOLC planning + palliative care referral registrar
= “De-escalation of care”
– Teaching JMOs how to manage early deterioration (Urgent Clinical
Review)
– Surgical ICU fellow located on at-risk surgical wards