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Deteriorating Patient Summit

Chair’s Welcome and Introduction
Dr Mark Holland
, Immediate past President, The Society for Acute Medicine

Recognising and responding to the Deteriorating Patient
Dr Matt Inada-Kim
, National Clinical Advisor Deterioration, NHS Improvement, National Clinical Advisor Sepsis, NHS England, Consultant Acute Physician & Sepsis Lead, Hampshire Hospitals NHS Foundation Trust, Clinical Lead for Deterioration & Sepsis, Wessex Patient Safety Collaborative

Dr Indada-Kim gave examples of recording detioration inucluding; using alert stickers and a check list approach to ensure it is acted on.  He said the number one cause of avoidable death is communication and there is a need for a more aligned, standardised process.  He also suggested a combined, aligned Deterioration and Sepsis pathway. He said it is important that; "clinical judgement is allowed to flourish".
Full power point presentation

Improving the communication of NEWS at the interface of care, Learning from a patient safety collaborative
Anne Pullyblank
, Consultant Colorectal Surgeon & Clinical Director for Patient Safety, West of England AHSN
Dr Alison Tavaré, GP Clinical Lead, West of England AHSN
Pre-event abstract
Failure to recognise the deteriorating patient is a common cause of serious adverse events. In 2015 7% of patient safety incidents reported to the National Reporting and Learning System as death or severe harm were related to failure to recognise or act on deterioration.  Sepsis kills approximately 44,000 people per year in the UK and the Sepsis Trust estimates that earlier detection and recognition of sepsis could save up to 13,500 lives. Early warning scores or physiological ‘track and trigger’ systems are designed to support healthcare professionals to identify and respond to patients at risk of clinical deterioration. In 2012, The Royal College of Physicians developed a National Early Warning Score but this has not been adopted consistently by acute hospitals across the UK.
While the main focus of the RCP report was on using NEWS in acute hospital care, they also proposed using the tool in pre-hospital settings.  Since then, NEWS has been recommended by NICE and NCEPOD to aid early identification of sepsis. The aim of this project was to implement NEWS across the healthcare system from the community into acute care for acutely unwell patients to standardise communication and improve recognition and response to the deteriorating patient.
As clinical leads for patient safety at the West of England AHSN we used the Institute for Healthcare Improvement breakthrough collaborative model.  Starting in March 2015, teams from across the healthcare system met regularly to share and test ideas, define outcomes, identify learning and develop educational materials which standardised approach to the measurement of acute illness severity in new clinical environments.  A whole system collaborative was complimented by emergency department and primary care collaboratives lead by clinicians supplemented by coaching in QI methodologies.
Full power point presentation

The Recognise and Rescue programme: improving patient safety
Dr Nick Woodier
, Patient Safety Improvement Lead, Honorary Assistant Professor (Patient Safety), Nottingham University Hospital NHS Foundation Trust
Pre-event abstract
The “Recognise and Rescue of the Deteriorating Patient” (R&R) programme at Nottingham University Hospitals (NUH) NHS Trust has been active since March 2012. It was developed with the primary aim of improving the recognition of and response to clinical deterioration to improve the safety of NUH’s sickest patients. The programme pulled together independent work streams under one umbrella: Early Warning Scores, Sepsis, Acute Kidney Injury and Emergency Laparotomy. From these beginnings the programme has developed into a successfully integrated patient safety programme with additions of other work streams including electronic observations, electronic handover, Critical Care Outreach, improving fluid balance, human factors analysis and acute care education.
NUH is proud of its R&R programme. It is innovative, multidisciplinary, fully integrated, engage with and has been successful. The programme has supported improvements in management of sepsis, overdue observations, nursing and medical escalations, automated AKI electronic alerting, and rapid management of high-risk laparotomy patients with reduced mortality.
The programme has driven culture change at NUH, management of the acutely unwell patient is a priority and behaviour change of staff has been successful. This change has been brought about through an extensive analysis of the problems faced using human factors approaches, with staff and patient engagement to truly understand why the problems exist.
This session will introduce and explore the work of the R&R programme at NUH. It will share progress to date with local data to highlight learning and challenges. Alongside this the models and methods NUH uses to explore failure to rescue will be presented, including the use of a new code set for the Human Factors Analysis and Classification System developed collaboratively with National experts.
HFACS is an incident analysis tool that provides a taxonomy of contributory factors to error causation. Originating in aviation it uses the same components of the Swiss Cheese Model to systematically identify active and latent influencing factors within an organisation. It has been extensively used outside of healthcare, but has also started to show evidence of potential benefits in healthcare. HFACS can be used retrospectively to theme contributory factors in incidents and prospectively as part of incident investigation or risk management.
Above all this session is about sharing of local learning with the methodologies behind what NUH does to build knowledge. Not all change has been successful, but the learning that can be shared from these examples are valuable. The hope is that this session will lead to audience reflection about what NUH can offer other, similar, R&R programmes elsewhere.

Related Events

Sepsis Summit: Ensuring Adherence to the National Quality Standard
Friday 13 July 
De Vere West One Conference Centre, London

Investigation and Learning from Deaths in NHS Trusts
Monday 1 October 
De Vere West One Conference Centre, London

Download: Sepsis conference brochure

11 June 2018


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