Urgent Clinical Review – The step before MET
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Urgent Clinical Review
- The Step before MET
Presented by: Melodie Heland
Director, Surgical Clinical Service Unit
Chair, Austin Health Deteriorating Patient Committee
September 2013
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Overview
• Background
• Why UCR is necessary?
• The triggers, calling and documentation processes
• The challenges encountered during introduction
• Audit and data collected to inform improvement
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Background – Deteriorating Patient Committee
The Deteriorating Patient Committee (DPC) will
- provide leadership and coordination to improve detection,
recognition and escalation of care for patients who
deteriorate across Austin Health.
- through compliance with relevant national documents,
including the National Consensus Statement Essential
elements for recognising and responding to clinical
deterioration and Standard 9 of the National Safety and
Quality Health Service Standards.
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Escalation policy
In our establishment of an ‘Escalation policy for care of
deteriorating patients’ we queried if MET was providing the
best method of early recognition and response.
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Is MET the solution?
Hospital
inpatient Abnormal
vital signs
MET
call
Cardiac
arrest
Mortality 2% Mortality 25% Mortality 80%
Old paradigm Current
paradigm Urgent Clinical
Review
ICU intervention Parent Unit intervention
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Urgent Clinical Review
• Gradual development of processes, audit, education and
systems to introduce this new response
• The experiences of the MET, feedback by ward staff and
recent data have confirmed the need for earlier intervention
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Review of 14 months MET calls 1/4/12 – 31/5/13
• 2,756 MET calls = 197 per month
• Top five reasons for call: tachycardia, hypotension, Low SpO2,
high respiratory rate, change in conscious state
• Notable: 37.5% of calls with a limitation of medical therapy
• Austin rate higher than published studies (30.7%)
• Notable: 31.5% were repeat calls
• This was higher than our 2006 rate of 25.6% repeat calls
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More MET calls per year than ICU admissions
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Patient outcome 2,756 MET calls (14 mths.)
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LOMT % by Unit
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Urgent Clinical Review (UCR)
• Introduced to alert parent unit earlier to patient deterioration
• Built into Observation and response chart and Escalation policy
• Part of education process and auditing
• We are in the process of developing our UCR policy further and
improving documentation of UCR
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Suite of documents agreed and developed
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Vital signs policy and
flowchart developed
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Flowchart:
Escalating response to
patient deterioration
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Early snapshot audit of UCR showed:
• Of 22 UCR calls audited, 77% required clinical intervention
• Majority of calls on surgical wards
• Documentation of call time was high, but documentation of the time to
medical response was poor
• When time was documented, 86% of pts were seen within 30 mins
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Early snapshot audit of UCR showed:
• Doctor documented their review and its outcome less than 50% of the
time
• Sometimes the Dr reviewed in person, sometimes by phone
• Nursing usually completed documentation
• The designation of the doctor who responded was poorly documented
• The completion of modified UCR and / or MET criteria was patchy
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Feedback from Junior medical staff
• JMOs ring the ward when a UCR is called and have trouble
getting on to the person who called it
• The message that a UCR is needed is lost in other pages
and information they receive on the page is variable
________________________________________________
ACTIONS………….
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Urgent Clinical Review policy drafted
Purpose
Early patient assessment and management of patient deterioration by the parent unit and ward staff, and a process for escalation of patient care will reduce the chance of life threatening complications.
Austin Health has a Parent Unit response to early deterioration called an Urgent Clinical Review. This system responds to early physiological instability (i.e. pre-MET) in any patient at Austin Health using vital sign measurements on the track and trigger Observation & Response chart
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Urgent Clinical Review policy (cont)
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UCR medical record
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Other supportive changes
• Dedicated cordless phone introduced
• Specific script for paging UCR
“Ext 5436 – URGENT REVIEW – Hypoxia – Jones – 326589 - 8E –Bed 5”
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Other
supportive
changes
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Provision of MET data to Units
Organisational audit policy developed.
If units are to get involved in UCR, they
need to know what is happening
regarding patient deterioration.
Riskman enables us to report MET calls
by unit, by day and by patient.
Example: 104 MET calls in the ortho unit
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Subacute campus emergency responses
0
5
10
15
20
25
30
35
Mar-12 Mar-13 Apr-12 Apr-13 May-12 May-13 TOT '12 TOT'13
Subacute
TSC
Outpatients
RDU
56% reduction
March-May 2013
vs
March-May 2012
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0
5
10
15
20
25
30
Dec 09-May 10 Dec 11-May12 Dec12-May13
Nu
mb
er
of
Eve
nts
Mental Health Outcomes emergency responses
Total Calls
Transferred
ROW
UNK
• Empowered / educated staff early identification & management deterioration
(ORC, COMPASS, ACCESS).
• Promotion UCR response in MHP
(Parent unit response to manage patient deterioration).
2012 = 27
2013 = 5
81% calls
87% transfers
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Continuing development
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Continuing development
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Summary
A patient who has a MET call has a 25% likelihood of mortality.
Higher if they have multiple calls
The response process is owned by ICU and not the parent unit
Urgent clinical review provides an earlier warning of deterioration
and place the onus on the unit to manage the situation
Robust processes and continuous improvement are required to
implement this new response