REACH Patient and family activated escalation of care

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Emery Walsh
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1 REACH Patient and family activated escalation of care 12 MONTHS ON AND THE SKY DID NOT FALL Dr Karen Luxford, Alison Lee & Prof Cliff Hughes ISQua 2013 Patient Based Care Model If I would have been able to call a rapid response team, I believe Josie would be here today Sorrel King 1

The role of family in recognising deterioration Mr Bertoncini was admitted to hospital with severe

Family members became concerned that his condition was deteriorating and that he was suffering more pain

Coroner s report Following Mr Bertoncini s death, the coroner reported: In the context of this case in

regular observations, it would have been helpful if more regard had been paid by staff to the family s

The deceased s wife had been with him constantly...and was well placed to notice changes in his condition.

monitoring 2 nd most common RCA classification in NSW Patient & Family Escalation models: Lead to

2 The role of family in recognising deterioration Mr Bertoncini was admitted to hospital with severe abdominal pain (72yrs old). Family members became concerned that his condition was deteriorating and that he was suffering more pain than appeared to be recognised by the healthcare team. Coroner s report Following Mr Bertoncini s death, the coroner reported: In the context of this case in determining whether the condition of the deceased was deteriorating, in addition to the recording of regular observations, it would have been helpful if more regard had been paid by staff to the family s opinion that the condition of the deceased was deteriorating. The deceased s wife had been with him constantly...and was well placed to notice changes in his condition. (WA State Coroner 2005) Engagement - Patient & Family activated escalation Deficiencies in patient monitoring 2 nd most common RCA classification in NSW Patient & Family Escalation models: Lead to significant decrease in mortality Improved patient & family care experience Without an overload of false positive calls for a rapid response Gerdik et al 2010 Resus 81: Prevention Clinical Review Patient Condition Rapid Response The Slippery Slope ALS Source: Charles Pain CEC Time 2

Staff fears Vs The evidence about impact fear that implementing patient & family activation will result in increased non-urgent calls Range: average of 2 calls/yr to 2 calls/mth Family concern

over 50% of family activated cases require transfer to ICU The evidence After a record review: family concern about patient safety was identified as a potential predictor of deterioration and hence

3 Staff fears Vs The evidence about impact fear that implementing patient & family activation will result in increased non-urgent calls Range: average of 2 calls/yr to 2 calls/mth Family concern continues to be reason for activation of rapid response in 5-6% of total calls. reasons for calls mirror those identified by staff (e.g. shortness of breath). over 50% of family activated cases require transfer to ICU The evidence After a record review: family concern about patient safety was identified as a potential predictor of deterioration and hence included in 5 risk factors bundle. Bundle reduced transfers and serious events by 50%. We believe that assessment of risk as relayed by family...has substantial face validity in identifying and predicting deterioration. Brady P et al 2013 Pediatrics 131(1): e298-e308. Engagement - Patient & Family activated escalation Deficiencies in patient monitoring 2 nd most common RCA classification in NSW Patient & Family Escalation models: Lead to significant decrease in mortality Improved patient & family care experience Without an overload of false positive calls for a rapid response Gerdik et al 2010 Resus 81: Partnerships to improve quality in health care Alicia Wood Consumer Advisor CEC PWPAC Former Chair Patient and Family Activated Rapid Response Working Group Casting the safety net wider REACH -Patient & family activated escalation Toolkit - information & processes for patients & carers, clinicians & management Engaging local champions clinical & executive NSW Local Health District leads: 13 hospitals Flexible model Work with local teams Provide education and material 3

4 REACH PROCESS FLOWCHART R REACH call activated by Patient or Family or Carer (RECOGNISE) E Concern raised with treating nurse or doctor or NUM. Rapid assessment of concerns raised (ENGAGE) Unable to identify clinical concern: - Thank patient/family - Address concern through other relevant avenue A Clinical Review requested and conducted within 30 minutes (Assess against BTF Review Criteria Yellow Zone) (ACT) Does not meet criteria: - Thank patient/family - Communicate care plan to patient/family - Follow up in 1 hour C Meets BTF Rapid Response Criteria (Red Zone) (CALL) H Initiate Rapid Response team (HELP is on its way) NB: if patients/family feel that their concerns about worrying changes are not addressed, they can independently escalate to a clinical review or rapid response REACH Toolkit Overview Guiding principles Research evidence summary Information brochure for patients & families + Poster Information sheet for managers and clinical leaders Information sheet for clinical staff Training tool for staff scripts (admissions & ward) Evaluation tools brief forms Evaluation Process, Impact & Acceptability Awareness of process Staff and Patient/family surveys Quantitative Data: impact on clinical reviews, rapid response calls, ICU transfers, number of deaths Lead Ethics Committee approval/ssa s First 12 months - Orange 4 REACH calls in lead rural hospital in 12 months (all were BTF white zone normal clinical ob s) Outcomes: treatment plans changed. Very positive feedback from patient & family about REACH and staff (100% strongly agreed staff addressed their needs ) 50% of REACH calls considered to have averted the need for a ICU transfer Clinicians found workload impact to be minor Continue doing REACH. There is benefit for everyone 1 st REACH call 77 year old woman laparoscopic cholecystectomy Blood vessel accidentally cut Daughter noticed increasing confusion and extensive abdominal bruise spreading JMO felt patient was OK /stable Family felt something just not right Family activated escalation of care 4

1 st REACH call Within 10 minutes Outreach Critical Care CNC came to review charts Within 30 minutes Registrar came to review patient, spoke to family & called specialist Issue: patient found to

with by all the staff, but now it s just part of normal business. All calls were genuine and for us we felt that REACH has provided another safety net for the patient.

Dubbo Base Hospital 1 August 2012 11 Months 1 Bathurst Base Hospital 5 November 2012 8 Months 0 The Children s Hospital Westmead 19 November 2012 8 Months 11 Total Number of REACH Calls Balmain

5 1 st REACH call Within 10 minutes Outreach Critical Care CNC came to review charts Within 30 minutes Registrar came to review patient, spoke to family & called specialist Issue: patient found to still be on anticoagulants; pneumonia also diagnosed & treated 12 day hospital stay REACH the results Testimonial Director of Nursing / Acting General Manager There was a lot of apprehension to start with by all the staff, but now it s just part of normal business. All calls were genuine and for us we felt that REACH has provided another safety net for the patient. Everyone was apprehensive at the start that we would get lots of nuisance calls and in reality that hasn t happened we have had exactly what the literature said and that s been really good. What we know so far... First REACH call in NSW Lead Site Start Date Months REACH has been Live since Implementation Orange Health Service 19 November Months 5 Calvary Mater Newcastle 30 July Months 0 Dubbo Base Hospital 1 August Months 1 Bathurst Base Hospital 5 November Months 0 The Children s Hospital Westmead 19 November Months 11 Total Number of REACH Calls Balmain Hospital 26 November Months 0 Hornsby Hospital 29 April Months 0 CEC Consumer Advisor Royal North Shore Hospital 8 April Months 2 What we know so far... In-line with international evidence Provides an important safety net Used appropriately Supported by staff and patients, family, carers Estimated cost savings (e.g. averted coronial case) Benefited patients, families and carers; the way care is delivered; and clinicians and staff 4. Implement process to support patient & family activated escalation of care 5

9.3: Performance and effectiveness of system periodically reviewed Questions?

6 REACH model & Standards National Safety & Quality Health Service Standards (ACSQHC) Supports Standard 9.9: PFAE 9.9.1: Mechanisms are in place for a patient, family member or carer to initiate an escalation of care response 9.9.2: Information provided to patient, family and carers 9.9.3: Performance and effectiveness of system periodically reviewed Questions? Acknowledgement: Alison Lee (PWP Project Coordinator) Karen.Luxford@cec.health.nsw.gov.au 6

Large scale health systems improvement to recognise and manage deteriorating patients Dr Harvey Lander and Malcolm Green

Large scale health systems improvement to recognise and manage deteriorating patients Dr Harvey Lander and Malcolm Green Australia? YOU ARE HERE NSW PRESENTATION NAME MONTH YYYY PRESENTER NAME 3 Clinical