Standard 9: Recognising and Responding to Clinical Deterioration in Acute Health Care

National Safety and Quality Health Service Standards Guide for Use in Hospitals

Standard 9: Recognising and Responding to Clinical Deterioration in Acute Health Care

Health service organisations establish and maintain systems for recognising and responding to clinical deterioration. Clinicians and other members of the workforce use the recognition and response systems.

The intention of this Standard is to:

Ensure a patient’s deterioration is recognised promptly, and appropriate action is taken. #

Context

It is expected that this Standard will be applied in conjunction with Standard 1, ‘Governance for Safety and Quality in Health Service Organisations’ and ‘Standard 2 Partnering with Consumers’.

Criteria to achieve the Recognising and Responding to Clinical Deterioration in Acute Health Care Standard:

Establishing recognition and response systems

Recognising clinical deterioration and escalating care

Responding to clinical deterioration

Communicating with patients and carers

# This Standard does not apply to psychiatric deterioration associated with mental disorders.

Criterion: Establishing recognition and response systems

Organisation-wide systems consistent with the National Consensus Statement are used to support and promote recognition of, and response to, patients whose condition deteriorates in an acute health care facility.

C/D / This criterion will be achieved by: / Actions required: / Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the Standards / Self assessment /
C / 9.1 Developing, implementing and regularly reviewing the effectiveness of governance arrangements and the policies, procedures and/or protocols that are consistent with the requirements of the National Consensus Statement / 9.1.1 Governance arrangements are in place to support the development, implementation and maintenance of organisation-wide recognition and response systems / ·  Agendas, meeting minutes and/or reports of the relevant committees
·  Position descriptions, workforce duty statements and/or employment contracts for workforce with responsibility for developing, implementing, sustaining and monitoring recognition and response systems
·  Reports on actions arising from review and evaluation of recognition and response systems
·  Education resources and training of the workforce in relation to developing, implementing, sustaining and monitoring recognition and response systems
·  Records of attendance at training by the workforce / MM
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C / 9.1.2 Policies, procedures and/or protocols for the organisation are implemented in areas such as:
·  measurement and documentation of observations
·  escalation of care
·  establishment of a rapid response system
·  communication about clinical deterioration / ·  Policies, procedures and/or protocols that are consistent with the requirements of the National Consensus Statement and that address items listed in 9.1.2
·  Examples of actions taken to implement policies throughout the organisation.
·  Observational and documentation audit of compliance to policies, procedures and protocols / MM
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(i) The recognition and response policy framework should apply across the whole organisation. The policy should address:
o  governance arrangements for overseeing the performance of recognition and response systems
o  roles, responsibilities and accountabilities for key clinical and organisational support activities
o  resources for the recognition and response systems, such as equipment and staff
o  processes to support prompt and effective recognition of and response to clinical deterioration apply across the organisation, including identification of any areas where variations to these arrangements apply
o  evaluation, audit and feedback processes and tools
o  arrangements with external organisations that may be part of the rapid response system
Link with Standard 1.8.3
C / 9.2 Collecting information about the recognition and response systems, providing feedback to the clinical workforce, and tracking outcomes and changes in performance over time / 9.2.1 Feedback is actively sought from the clinical workforce on the responsiveness of the recognition and response systems / ·  Report on surveys of staff use and experience of the recognition and response systems
·  Feedback mechanisms for the clinical workforce using the recognising and responding systems such as debriefing on individual events and/or peer review processes
·  Agenda papers, meeting minutes and/or reports of relevant committees such as Medical Advisory Committee related to the recognising and response system and review of feedback from the clinical workforce / MM
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C / 9.2.2 Deaths or cardiac arrests for a patient without an agreed treatment-limiting order (such as not for resuscitation or do not resuscitate) are reviewed to identify the use of the recognition and response systems, and any failures in these systems / ·  Policies, procedures and/or protocols describe processes for mortality reviews
·  Records of death reviews and reviews of cardiac arrests
·  Mechanism for recording deaths, a mortality review process, and outcomes of reviews
·  Agenda papers, meeting minutes and/or reports of committee meetings on morbidity and mortality / MM
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C / 9.2.3 Data collected about recognition and response systems are provided to the clinical workforce as soon as practicable / ·  Performance data on the recognition and response systems provided to the clinical workforce
·  Reports or documents provided to the clinical workforce on the recognising and response system / MM
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(i) Data about the performance of recognition and response systems should be collected. This should be reviewed against the planned operation of the system and the effectiveness of the system in improving the recognition of and response to clinical deterioration (outcome measures). Data items that could be collected include:
·  Process measures:
o  existence of required policies and procedures, such as an escalation protocol
o  proportion of observation charts completed correctly
o  number of calls for emergency assistance
o  number of calls for emergency assistance within 24 hours of admission to the ward
o  number of calls for emergency assistance with 24 hours post surgery
o  details of each call for emergency assistance, including antecedents to the call, such as whether calling criteria were triggered with no action taken
·  Outcome measures:
o  number of cardiac arrests
o  number of deaths, including deaths where the patient does not have a treatment-limiting order
o  outcomes of calls for emergency assistance
o  number of unplanned admissions to intensive care
o  number of transfers to units or facilities with a higher level of care
Further information is available from the Recognition and response systems implementation guide found at: www.safetyandquality.gov.au
C / 9.2.4 Action is taken to improve the responsiveness and effectiveness of the recognition and response systems / ·  Risk register or log that includes actions to address identified risks
·  Agenda papers, meeting minutes and/or reports of relevant committees that detail improvement actions taken
·  Quality improvement plan includes actions to address issues identified
·  Examples of improvement activities that have been implemented and evaluated
·  Communication material developed for the workforce and/or patients
·  Education resources and ongoing training for the workforce in recognising and responding to clinical deterioration
·  Records of attendance at training by the workforce / MM
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Criterion: Recognising clinical deterioration and escalating care

Patients whose condition is deteriorating are recognised and appropriate action is taken to escalate care.

C/D / This criterion will be achieved by: / Actions required: / Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the Standards / Self assessment /
D / 9.3 Implementing mechanism(s) for recording physiological observations that incorporates triggers to escalate care when deterioration occurs / 9.3.1 When using a general observation chart, ensure that it:
·  is designed according to human factors principles
·  includes the capacity to record information about respiratory rate, oxygen saturation, heart rate, blood pressure, temperature and level of consciousness graphically over time
·  includes thresholds for each physiological parameter or combination of parameters that indicate abnormality
·  specifies the physiological abnormalities and other factors that trigger the escalation of care
·  includes actions required when care is escalated / ·  Policies, procedures and/or protocols that describe the observation chart to be used and reference resources
·  Audit of patient clinical records shows the use of a general observation chart / MM
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(i) ‘Human factors’ is the study of the interactions among humans and other elements of a system, and the profession that applies theory, principles, data and methods to design in order to optimise human well-being and overall system performance. In this context, an observation and response chart that is designed according to human factors principles is designed to optimise the recognition of clinical deterioration, and to prompt an appropriate and timely response.
Key characteristics of observation and response charts that have been designed according to human factors principles include:
·  Having observations listed in order of importance in detecting deterioration and in logical groups. Because there is good evidence regarding respiratory rate as predictor for clinical deterioration, it should be listed as the first observation to be recorded.
·  Ensuring that when values for an observation are categorised into discrete ranges, that these categories are mutually exclusive.
·  Only including information in the main observation recording part of the chart that is critical for recognising clinical deterioration, and responding to it appropriately. Generally this will only include space for recording key observations graphically, the response to be taken when deterioration is identified, and whether there are any modifications to the normal physiological ranges for the patient.
·  Ensuring that the space on the chart for recording observations is close to the information about the responses that need to be made when deterioration is identified. This reduces the potential for cognitive and memory load and errors occurring.
·  Design elements that support ease of use of the chart. These include:
o  recording observations as separate graphs, rather than overlaying them on the same area of the chart
o  consistent use of abbreviations, labels, fonts and formatting
o  font sizes and spaces for recording observations and writing text sufficient to allow easy use
o  features to support accurate recording of observations such as dual scales within the table for recording observations, and appropriate use of thicker horizontal and vertical lines
·  Using colour in a meaningful way to support the recognition of deterioration. The density of colours should relate to the extent to which a patient’s observations are outside normal ranges. This supports of the charts by users who have red-green colour blindness.
For more information see the Recognition and Response Systems Implementation Guide
C / 9.3.2 Mechanisms for recording physiological observations are regularly audited to determine the proportion of patients that have complete sets of observations recorded in agreement with their monitoring plan / ·  Policies, procedures and/or protocols that describe the frequency and processes for auditing observations charts
·  Feedback to the clinical workforce on audit of observations charts
·  Results of audit of observation charts that may be included as part of routine documentation audit / MM
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C / 9.3.3 Action is taken to increase the proportion of patients with complete sets of recorded observations, as specified in the patient’s monitoring plan / ·  Orientation and ongoing education resources and records of attendance at training by the workforce on the importance of taking observations
·  Risk register or log that includes actions to address identified risks
·  Agenda papers, meeting minutes and/or reports of relevant committees that detail improvement actions taken
·  Quality improvement plan that includes actions to address issues identified
·  Examples of improvement activities that have been implemented and evaluated
·  Communication material developed for the workforce and/or patients / MM
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C / 9.4 Developing and implementing mechanisms to escalate care and call for emergency assistance where there are concerns that a patient’s condition is deteriorating
/ 9.4.1 Mechanisms are in place to escalate care and call for emergency assistance / ·  Policies, procedures and/or protocols that describe the process for escalation of care
·  Observation of mechanisms such as signs, posters or stickers on how to call for assistance
·  Orientation and ongoing education resources and records of attendance at training by the workforce
·  Record of operational and mechanical call device testing / MM
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C / 9.4.2 Use of escalation processes, including failure to act on triggers for seeking emergency assistance, are regularly audited / ·  Policies, procedures and/or protocols describe the frequency and processes for auditing escalation processes
·  Feedback to clinical workforce on audit of escalation processes
·  Results of audit of patient clinical records
·  Results of audit of observation charts / MM
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C / 9.4.3 Action is taken to maximise the appropriate use of escalation processes / ·  Data provided to relevant committees and the clinical workforce on the recognising and responding system
·  Reports or documentation from review of escalation processes
·  Reports on staff survey relating to escalation of care
·  Education resources and records of attendance at training by the workforce on escalation processes
·  Risk register or log that includes actions to address identified risks
·  Agenda papers, meeting minutes and/or reports of relevant committees that detail improvement actions taken
·  Quality improvement plan that includes actions to address issues identified
·  Examples of improvement activities that have been implemented and evaluated
·  Communication material developed for the workforce and/or patients / MM
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Criterion: Responding to clinical deterioration

Appropriate and timely care is provided to patients whose condition is deteriorating.

C/D / This criterion will be achieved by: / Actions required: / Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the Standards / Self assessment /
C / 9.5 Using the system in place to ensure that specialised and timely care is available to patients whose condition is deteriorating
/ 9.5.1 Criteria for triggering a call for emergency assistance are included in the escalation policies, procedures and/or protocols / ·  Escalation policies, procedures and/or protocols that include criteria for escalating care
·  Data on the use of the rapid response system
·  Education resources and training records of attendance at training by the workforce on care for patients whose condition is deteriorating / MM
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C / 9.5.2 The circumstances and outcome of calls for emergency assistance are regularly reviewed / ·  Escalation policy that requires 24 hour access to at least one clinician who can practise advanced life support, that may include ambulance services
·  Records of audits, reviews and routine data collection about calls for emergency assistance
·  Agenda papers, meeting minutes and/or reports of relevant committees related to escalation policy reviews and recommended changes
·  Feedback to the clinical workforce on calls for emergency assistance
·  Records of trained of the workforce in advanced life support skills / MM
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(i) Information collected about each call for emergency assistance made to the rapid response system includes:
o  patient demographics
o  date and time of call, response time and stand down time
o  reason for the call
o  treatment outcomes or intervention provided to the call, including the disposition of the patient
C / 9.6 Having a clinical workforce that is able to respond appropriately when a patient’s condition is deteriorating
/ 9.6.1 The clinical workforce is trained and proficient in basic life support / ·  Policies, procedures and/or protocols that describe the requirements and processes for basic life support
·  Education resources and records of attendance at training by the workforce on competencies in basic life support for the workforce
·  Record of audits, reviews and routine data collection about calls for emergency assistance
·  Agenda papers, meeting minutes and/or reports of relevant committees relating to basic life support competency of the workforce / MM
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(i) More information about basic life support and basic life support is available from the Australian Resuscitation Council: www.resus.org.au
C / 9.6.2 A system is in place for ensuring access at all times to at least one clinician, either on-site or in close proximity, who can practise advanced life support / ·  Policies, procedures and/or protocols that require 24 hour access to a clinician or ambulance officer who can practise advanced life support
·  Delegation of roles and responsibilities to clinicians who can practise advanced life support
·  Position descriptions, staff duty statements and/or employment contracts that describe an individual clinician’s delegated safety and quality roles and responsibilities
·  Record of currency of advance life support skills
·  Rosters or evidence that demonstrates 24 hour access to at least one clinician or ambulance officer with advanced life support skills
·  Audit of compliance with policy, procedures and protocols
·  Agenda papers, meeting minutes and reports of relevant committees consider review findings and identify improvement actions / MM
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(i) Advance life support (ALS) clinicians may include ambulance officers or nurse practitioners in remote or rural areas

Criterion: Communicating with patients and carers