Background

The aim of the Early Recognition of the Deteriorating Patient Project was to implement a framework that ensured the early recognition of deteriorating patients, the initiation of appropriate medical review and the instigation of timely medical management to reduce the morbidity and mortality of patients.

The project arose from evidence in the existing literature that there is failure to recognise and manage deteriorating patients on the general ward. This is evidenced by delays in admission to the intensive care unit (ICU)(1,2,3), unexpected referrals to the intensive care and unexpected deaths often preceded by significant physiological disturbances (4,5). the ability to detect early deterioration in patients allows early appropriate intervention. Early interventions can reduce unplanned admissions to ICU and unexpected deaths (6,7).

An ACT Health sponsored project commenced to address this problem in 2006. Within the context of quality in healthcare, this project contains aspects of harm minimisation for patients and systems support for effective clinical care.

The project introduced three interventions:

  • colour coded observation charts
  • a track and trigger system (MEWS)
  • the COMPASS education package

Results from the pilot on 4 wards at 2 hospitals:

Reductions were seen in unplanned admissions to ICU (21/1157 [1.8%] vs. 5/985 [0.5%], p = 0.006) and unexpected hospital deaths (11/1157 [1.0%] vs. 2/985 [0.2%], p = 0.03) during the intervention period. Medical reviews for patients with significant clinical instability (58/133 [43.6%] vs. 55/79 [69.6%]p < 0.001) and number of patients receiving a MET review increased (25/1157 [2.2%] vs. 38/985 [3.9%]p = 0.03) during the intervention period. Mean daily frequency of documentation of all vital signs increased during the intervention period (3.4 [SE 0.22] vs. 4.5 [SE 0.17], p = 0.001).

Publication:

I.A. Mitchell, H. McKay, C. Van Leuvan, R. Berry, C. McCutcheon, B. Avard, N. Slater, T. Neeman, P. Lamberth. A prospective controlled trial of the effect of a multi-faceted intervention on early recognition and intervention in deteriorating hospital patients. Resuscitation 81 (2010) 658–666

Compass recognition

The project has been recognised both locally and nationally with the following awards:

  • Finalist in ACT Quality in Healthcare Awards 2010 for Paediatric Pilot
  • Team Excellence Award 2009 Canberra Hospital for Paediatric working group
  • National Australian Institute of Project Management Awards 2008: Community Service and/or Development Project of the Year
  • ACT Australian Institute of Project Management Awards 2008: Community Benefit Project of the Year
  • ACT Australian Institute of Project Management Awards 2008: Community Service and/or Development Project of the Year
  • Guan Chong Award for best oral presentation ASMR, Canberra Region ASM 2008
  • Research Excellence 2008, 2008 ACT Midwives and Nurses Awards
  • ACT Quality Awards 2007: Innovative models of Care
  • ACT Quality Awards 2007: Overall winner
  • Dubbo Base Hospital received the Judge’s Award for GWAHS Quality Awards for 2008 for their pilot of the program and was a finalist in the NSW Health Baxter Awards

The project has also been presented at the following conferences:

  • Recognising and Responding to Clinical Deterioration Conference in Adelaide in November 2010
  • Critical Care in the Vines April 2010
  • International Symposium of Intensive Care and Emergency Medicine in Brussels, Belgium in March 2010 (Poster by Morgan Edwards- ANU Medical Student)
  • Change Champions- Deteriorating Patients Conference in Sydney in March 2010
  • ACSQHC Paediatric Deteriorating Patient meeting in Sydney in February 2010
  • ACSQHC Deteriorating Patient Conference in Sydney in November 2009
  • Health Round Table SAFE program in the Gold Coast in October 2009
  • Australasian Quality and Safety in Healthcare Conference in Sydney in September 2009
  • International Forum for Quality and Safety in Healthcare in Berlin, Germany in March 2009
  • The Adverse Conference in Melbourne in April 2009
  • European Society of Intensive Care Medicine Sept 2008 Lisbon
  • Australasian Conference on Safety and Quality in Health Care Sept 2008 Christchurch
  • Australian Society for Medical Research: Canberra Region Annual Scientific Meeting May 2008 Canberra
  • Australian College of Critical Care Nurses : ICE May 2008 Brisbane
  • The Hospital After Hours Conference May 2008 Sydney
  • Nursing Leadership Conference April 2008 Sydney
  • ANZICS/ACCCN Intensive Care ASM Sept 2007 Rotorua

For more information contact us on compass@act.gov.au or (02) 6207 6827.

References

1. An acute problem. National Confidential Enquiry into Patient Outcome and Death. www.ncepod.org.uk

2. McQuillan P, Pilkington S, Allan A, Taylor B, Short A, Morgan G, Nielsen M, Barrett D, Smoth G. Confidential inquiry into quality of care before admission to intensive care. BMJ. 1998 June 20, 1998; 316(7148):1853-8. www.bmj.com/cgi/content/full/316/7148/1841

3. McGloin H, Adam SK, Singer M. Unexpected deaths and referrals to intensive care of patients on general wards. Are some cases potentially avoidable? J R Coll Physicians Lond 1999; 33: 255-9

4. Hillman KM, Bristow PJ, Chey T, et al. Antecedents to hospital deaths. Inter Med J 2001; 31: 343-48

5. Kause J, Smith G, Prytherch D, et al. A comparison of antecendents to cardiac arrests, deaths and emergency intensive care admissions in Australia and New Zealand, and the United Kingdom-the ACADEMIA study. Resuscitation 2004; 62: 275-82

6. Bristow P, Hillman KM, Chey T, et al. Rates of in-hospital deaths and intensive care admissions: the effect of a medical emergency team. Med J Aust 2000; 173: 236-40

7. Bellomo R, Goldsmith D, Uchino S, Buckmaster J, Hart G, Opdam H, Silvester W, Doolan L, Gutteridge G. Prospective controlled trial of medical emergency team on postoperative morbidity and mortality rates. Crit Care Med 2004; 32: 916-921