COMPASS

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 morbidity and mortality.

The project arose from evidence in the literature that there was a failure to recognise and manage deteriorating patients on the general ward. This was evidenced by delays in admission to the intensive care unit (ICU)(1,2,3), unexpected referrals to intensive care,  and unexpected deaths often preceded by significant physiological disturbances (4,5).

The ability to detect early deterioration in patients allows early and appropriate intervention. Early interventions can reduce unplanned admissions to ICU and unexpected deaths (6,7).

ACT Health sponsored the Early Recognition of the Deteriorating Patient project 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 Early Recognition of the Deteriorating Patient 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).

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

Publications:

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

H. McKay, I.A. Mitchell, K. Sinn, H. Mugridge, T. Lafferty, C. Van Leuvan, S. Mamootil, M.E. Abdel-Latif.  Effect of a multifaceted intervention on documentation of vital signs and staff communication regarding deteriorating paediatric patients.  Journal of Paediatrics and Child Health 49 (2013) 48-56

COMPASS® recognition

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

• National Lead Clinicians Group: Awards for Excellence in Innovative Implementation of Clinical Guidelines – 2013- Finalist

• 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:

• Criterion Conferences, Strengthening Clinical Handover, Sydney 2014
• IRR Conferences, Managing a deteriorating Patient, Melbourne 2014
• 10th Annual ACCCN Victorian Symposium on Critical Care Nursing 2013
• International Forum on Quality and Safety in Healthcare, London 2013
• 8th International Conference for rapid response Systems and Medical Emergency Teams, London 2013
• 7th International Safety, Quality, Audit & Outcomes, Research In Intensive Care, Sydney 2013
• IRR Conferences, Managing a Deteriorating Patient, Melbourne 2013
• Maternity Pilot at the WHA CHA Conference in November 2011 in Sydney
• 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

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Standalone COMPASS® education is available for the following areas:

• Adult
• Paediatric
• Maternity and Neonatal

The COMPASS® education package consists of:

• The COMPASS® manual
• COMPASS® Online Learning 
• A quiz to be completed before attending the face to face session
• A 3 hour face to face session that includes
  • PowerPoint presentation
  • Four interactive case studies

The option is available to have the ACT program manager and/or clinical lead travel to your facility to assist in the implementation of the program. A schedule of fees has been developed for this service.

ACT Health Early Recognition of the Deteriorating Patient Program  - Schedule of fees

Support for the introduction of ACT Health’s Early Recognition of the Deteriorating Patient Program is available. The following schedule of fees will apply for ACT Health staff to provide training support to facilities interested in rolling out the program. Educational materials are available free of charge from the website (www.compass.act.gov.au).

The program manager and the clinical lead for the ERDP program may travel to a facility to provide support. The fee is based on the time commitment required from each of these staff members.

• Program Manager- $500.00 per day
• Medical Lead - $2000.00 per day

Travel costs, including airfares, accommodation if required, and meals will be in addition to the above costs.

Support can be provided in the following areas:

• Presentation on the overview of the project
• Assistance with engagement of stakeholders
• Train the trainer sessions
• Assistance with project planning including:
  • Scoping of the project
  • Risk identification/risk register development
  • Stakeholder identification/stakeholder register development
  • Communication plans
  • Scheduling of the project
  • Identification of quality measures
  • Governance arrangements
  • Audits

Please note that attendance by ACT Health staff is on an availability basis.

Resources for all COMPASS® programs

The following documentation is available for your download:

• Vital Sign and Early Warning Score Policy
• COMPASS® Online Learning – COMPASS® Online Learning takes participants through the case of a deteriorating patient.  It explains why the vital signs change when the patient deteriorates. There is a strong focus on basic physiology and oxygen delivery. There is also voiceover so please ensure that you have the volume up on your computer.
• COMPASS® Manual – the COMPASS® education manual consists of approximately 100 pages in A5 format which you can download. It includes information on early warning scores, physiology, communication, teamwork and management plans.
• COMPASS® Adult/Paeds and Maternity Manual
• Some organisations like to use the education material but adapt the early warning score and escalations to suit the local environment. Download a physiology only manual so you can add a supplement for your local health service.
• Adult manual without MEWS
• Quiz questions - ten multiple choice questions which should be completed by participants before attending a COMPASS® training session
• COMPASS® Train the trainer PowerPoint
• COMPASS® Train the trainer manual
• COMPASS® Flowchart- this is used as a reference and reminder for staff when assessing patients
• Oxygen Delivery Poster

Changes may be made to each of the documents to reflect any differing escalation policy based on available medical coverage. You may need to remove reference to the Medical Emergency Team if you do not have this service at your institution.

• COMPASS® adult PowerPoint – this is used during the three hour education session
• Observation chart - This chart is a tool to be used to document vital signs and calculate a modified early warning score
• Case studies - these files contain the four case studies used in the face to face session of the COMPASS® education. There are also four mental health case studies.
  • Case Study 1 ADULT
  • Case Study 2 ADULT
  • Case Study 3 ADULT
  • Case Study 4 ADULT
  • Case Study 1 MENTAL HEALTH
  • Case Study 2 MENTAL HEALTH
  • Case Study 3 MENTAL HEALTH
  • Case Study 4 MENTAL HEALTH

The Paediatric COMPASS® program

• Paediatric early warning scores age specific observation charts
• Paediatric COMPASS® education including manual, lecture and case studies

A four month trial of Paediatric Early Warning Scores (PEWS) finished in November 2009. There was a significant improvement in the documentation of vital signs and in communication and medical review where deterioration was documented.

Paediatric COMPASS® PowerPoint presentation

Paediatric Case Studies

• Case Study 1 - PAEDIATRICS
• Case Study 2 - PAEDIATRICS
• Case Study 3 - PAEDIATRICS
• Case Study 4 - PAEDIATRICS

Paediatric observation charts

• Paediatric_General Observation Chart 0-3 Months 
• Paediatric_General Observation Chart_3-12 Months
• Paediatric_General Observation Chart 1-4 Yrs
• Paediatric_General Observation Chart 5-11 Yrs 
• Paediatric_General Observation Chart Paediatric 12-17 Yrs

The Maternity MEWS Program consists of:

• Maternity MEWS Early Warning Score charts
• Maternity MEWS COMPASS® education including manual, lecture and case studies

A five month trial of Maternity Early Warning Scores (Maternity MEWS) finished in January 2011. There was a significant improvement in the documentation of most vital signs, and in communication and medical review where deterioration was documented. In 2016 the Maternity MEWS chart was reviewed and redesigned as two separate charts - antenatal and postnatal.

Maternity COMPASS® PowerPoint presentation

Maternity MEWS Observation Chart

• Maternity MEWS Antenatal observation chart
• Maternity MEWS Postnatal observation chart

Maternity Case Studies

• Case Study 1 - MATERNITY
• Case Study 2 - MATERNITY
• Case Study 3 - MATERNITY
• Case Study 4 - MATERNITY

Neonatal NEWS

• Neonatal NEWS  Early Warning Score chart
• Neonatal NEWS COMPASS® education including NEWS manual insert, lecture and case studies

Please note that Neonatal NEWS COMPASS® education is incorporated into the Maternity COMPASS® Program at Canberra Hospital. 

In July 2013 a Neonatal Early Warning Score (NEWS) observation chart and risk assessment tool was trialled at the Centenary Hospital for Woman and Children (CHWC) in Canberra. 

As there was no Early Warning System in place for neonates at CHWC, a risk assessment tool was developed from a review of data collected on babies admitted to the Neonatal Department.

With the introduction of the NEWS chart every newborn at CHWC was required to have a risk assessment and complete set of vital signs recorded within one hour of birth.   The risk assessment tool stipulates the frequency of observations required, depending on the risk identified.

After the trial in 2013 the NEWS chart was rolled out for use in Birthing Suite, Birth Centre, Postnatal and Antenatal wards. 

Neonatal COMPASS® PowerPoint presentation

Neonatal NEWS Observation Chart

Neonatal Case Studies

• Case Study 1 - NEONATAL
• Case Study 2 - NEONATAL
• Case Study 3 - NEONATAL

The Australian Commission on Safety and Quality in Health Care (ACSQHC) National Safety and Quality Health Service Standards (second edition, 2017) outlines standards for health service provision to protect the public from harm and improve health care delivery.

Standard 8 – ‘Recognising and Responding to Acute Deterioration’ - requires that health service organisations have a process in place for patients, carers and families to directly escalate care (8.7). 

Family Escalation for ACT Health

Canberra Hospital has the Call And Respond Early (CARE) for Patient Safety process available in all inpatient areas.   

If a patient, carer or family member is concerned that they are “getting sicker” they can follow a simple 3 – step process:

Step 1 - Nurse/Midwife/Doctor

Press your buzzer

Tell to your nurse/midwife or doctor why you are worried.

Step 2 - Nurse/Midwife in Charge

If you are still worried

Ask to speak to the nurse/midwife in charge

Step 3 - CARE call

If after this you feel you require urgent assistance

Call XXXXXXXX. A senior nurse will review and assist as required.

The Response:

The CARE call goes directly to the switchboard and is then transferred to the CARE phone.  The senior nurse carrying the phone is trained to assess the situation and escalate as required.

Evaluation:

All calls are recorded and reviewed and feedback is provided to local and responding staff at the time of the event.

Family Escalation Poster

CARE for patient safety poster Paediatric

CARE for patient safety poster Adult

The following resources are available for your use and guidance for the implementation of an Early Recognition of the Deteriorating Patient Program.

Implementation guide- a quick guide for how to introduce the program

COMPASS® implementation guide

Implementation steps - this flowchart takes you step by step through the stages of introducing the program

Implementation flowchart 

Vital sign policy at top of website under resources

Project plan - The project plan flowchart will provide the necessary steps to be taken at your local institution from planning phases to evaluation. The project plan template provides a guide to assist you.

Project Schedule Template

Job description for project officer - an example of a duty statement and selection criteria is available

Duty statement job description

How to engage clinicians - tips and tricks

Engaging clinicians - tips and tricks

Audit tools- This audit tool is used to evaluate compliance with the observation chart and MEWS policy once introduced.

Paediatric PEWS Audit Tool

Maternity MEWS Audit Tool

Adult MEWS Audit Tool

Neonatal NEWS audit tool

Examples of governance and key positions

Project governance example

ISBAR poster - ISBAR is the communication strategy that we have used as part of the program.

Ireland launches COMPASS® nationally

• The Irish National Early Warning Score (ViEWS) and associated Education Program (COMPASS®) was launched by Dr. Barry White, National Director, Clinical Strategy and Programmes, Health Service Executive at the National Acute Medicine Programme Conference on March 27th 2012 in the Royal College of Physicians of Ireland. The Minister for Health, Dr. James Reilly was present to offer his support to the program

• The Irish program has won a 2012 Taoiseach's Public Service Excellence Award, for ‘the National Early Warning Score and COMPASS® Education Programme’, a project that improves the safety record in their health services per.gov.ie/taoiseach%e2%80%99s-public-service-excellence-awards-2012/

COMPASS® education is being used in facilities in Ireland, England, Oman and New Zealand and parts of the manual have been translated into Swedish.

Can we use the COMPASS® materials at our hospital?

Yes, the materials are available for use at your facility. We request you acknowledge the source of the work.

Are there any fees involved?

No, the materials are free to use.

If you would like us to provide a Train the Trainer program at your hospital then there is a schedule of fees for this support outlined in the COMPASS® Education tab above.

Can we change the educational materials to suit our facility?

Not all facilities will introduce modified early warning scores (MEWS) in conjunction with education. The COMPASS® program is designed to be able to be altered based on your local policy and resources. If you are not using a MEWS, then references to this can be removed from the manual and case studies, and your own form of escalation can be added. If you would like to make changes around the other content (physiology etc) please contact us.

Where can I find out more information?

To speak to our team for more information you can contact us on compass@act.gov.au or +61 2 6207 6827

• Australian Commission on Safety and Quality in Health Care website