Detecting the Deteriorating Patient

In keeping with national and international trends, Hunter New England Local Health Network (HNE Health) is part of a state-wide clinical practice improvement program called Between the Flags, which focuses on strategies for early detection and management of the deteriorating patient.

Evidence from incidents, clinical review and patient feedback has demonstrated the need to improve recognition and appropriate management of patients where their condition either progressively or suddenly deteriorates. Inadequate recognition and/or management of deteriorating patients are contributing factors in many adverse events in hospitals and health care organisations across the world. This was further highlighted in the Report of the Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals (The Garling Report).

NSW Health has adopted the Clinical Excellence Commission’s Between the Flags program, which is designed to address systems errors that are recurrently associated with care of the deteriorating patient. HNE Health had already progressed implementation of several initiatives in this area, including the establishment of a Clinical Working Party on the subject, as part of the HNE Health Caring Together response.  In November 2010 this working party transitioned into the Deteriorating Patient Strategy Steering Committee.

These web-pages are designed to provide easy access to relevant resources and references about Between the Flags for clinical teams and health care professionals. They also contain links to useful guidelines and other information.

Implementing Between the Flags

Implementation of the NSW Health and the Clinical Excellence Commission’s “Between the Flags” program commenced in HNE Health in late 2009. The key elements of this program include:

• Standardised Observation Charts, including adult paediatric, 'at risk' maternity and emergency department
• Clinical Emergency response Systems (CERS) for clinical review and rapid response
• Education and Training, including a  training program, known as DETECT
• Evaluation and Monitoring, including Key Performance Indicators
• Governance, including a NSW Health Policy Directive 2010 _026 Recognition and Management of a Patient who is Clincially Deteriorating, and associated local Policy Policy Complaince Procedure

The Standard Adult General Observation (SAGO) Chart was implemented across HNE Health in January 2010. It replaced other observation charts used for adults in NSW public hospitals and multipurpose facilities, except those used in specialised areas such as operating theatres, intensive care units and emergency departments where specialised charts are currently used.  The SPOCs comprise a set of five age-related charts for:

• Neonatal / under 1 month (corrected)
• 1 - 12 months
• 1 - 4 years
• 5 - 11 years
• 12 years and over

Standardised charts for Maternity and Emergency Departments charts are being developed and will be available later in 2011. Where specialised charts are currently used in these areas, they will continue to be used in the interim.

The standardised observation charts incorporate indicators of deterioration, known as a "track and trigger" system. The Yellow Zones represent criteria which require a Clinical Review, and the Red Zones represent the criteria which require a Rapid Response. The paediatric charts have an additional Blue Zone which alerts nursing staff increase the frequency of observations.

For the two-tiered clinical/rapid response, an escalation plan is required for each inpatient service so there is a clearly delineated medical officer or an appropriately experienced registered nurse designated as responsible for timely review of a patient whose observations are recorded in the Yellow Zone.  If a patient’s observations fall into the Red Zone, this is escalated to the Rapid Response Team, for assessment and provision of interventions to resuscitate the patient or treat the underlying causes of deterioration.  

An important component of the chart is on the front page of each chart, where there is a box that records a treating doctor's decision to identify 'altered calling criteria' make a 'variation' to the frequency of observations. This is to meet the needs of patients such as those with chronic illness (e.g. respiratory disease), or who may have altered but acceptable observations for a specific reason (e.g. during the postoperative period).

An important part of the "Between the Flags" initiative is staff awareness and appropriate levels of knowledge and training of all front line clnical staff.

To address this need there are three levels of education/training in the Between the Flags education program:

1. Awareness training: for all staff and students, with the intention that all are aware of the key aspects of the Program
2. DETECT: for all front line clinicians, who will undergo DETECT e-learning and face-to-face practical sessions to use this knowledge to provide appropriate care for patients in clinical deterioration.
3. Advanced clinical and resuscitation skills: for Rapid Response Teams

The DETECT training program is an education program, specifically designed for front line clinical staff to improve detecting and managing a patient in clinical deterioration. The acronym stands for: Detecting, deterioration, Evaluation, Treatment, Escalation and Communicating in Teams.

All HNE Health staff are expected to have completed the Awareness on-line program to ensure that all staff working in HNE Health are aware of the key aspects of the Between the Flags initiative. Both the Between the Flags Awareness progarm and the eDetect program modules are available on the HNELHN Intranet MyLink Site at: http://mylink.hnehealth.nsw.gov.au/course/view.php?id=506 or by clicking on the above logo. By using individual staff login passwords, completion of each program by an individual staff member will be automatically recorded in the HNE Health Pathlore database for professional development.

DETECT Training Courses for all clinical staff commenced in 2010 with sites now conducting monthly courses in 2011.  The DETECT course includes presentations and case scenario based skills training to re-enforce learning from on-line eDETECT in relation to management of the deteriorating patient.  eDETECT is a pre-requisite for the face-to-face training course.  For information on courses at local sites, the contact is the local Manager or Education Unit.

The DETECT training also includes communication training using the HNELHN communication framework, ISBAR (which stands for Introduction, Situation, Background, Assessment and Recommendation). 

Between the Flags is a priority for improving safety and quality. The HNE Health Deteriorating Patient Strategy Steering Committee members, staff from Clinical Operations and Clinical Governance staff have been working with site executive sponsors and clinical leads, to promote its effective and sustainable implementation at each site across the local health network.

It is recommended that HNE Health staff:

1. Support this implementation and take every opportunity to familiarise themselves with the observation charts, their local rapid response system and the key elements of the “Between the Flags Program”.
2. Find 20 minutes to access and view the Awareness package.
3. Complete the DETECT on-line education and face-to-face training if they are a front line clinician.
4. Contact their line manager if they are interested in taking an active role in local implementation and education.
5. Keep informed of further updates and information on this initiative.
6. Keep in mind that primary responsibility for the care of the patient remains with the attending clinical team. Regular patient assessment and review of the plan of care with appropriate interventions can often prevent deterioration.

Further Information

This HNE Health Deteriorating Patient Fact Sheet, accompanying "Frequently Asked Questions Guide" and Paediatric Fact Sheet are available as a reference for use in HNE Health.

For more information contact Helen Byrnes, Project Manager - Deteriorating Patient Strategy, Clinical Governance on (02) 4921 4168:

Other members of the Deteriorating Patient Strategy Steering Committee are:

• Professor Anne Duggan (Project Team Leader)
• Dr Chris Trethewy (Clinical Lead) 
• Ian Nicholas, Nurse Consultant, Lower Hunter Cluster
• Marianne Gaul, Rural Critical Care CNC
• Sharon Nash, Theatre Manager Moree Hosptial
• Fiona Ellicott, Acute Care Registered Nurse
• Dr Martin Rowley
• Dr Keith Howard, Paediatrician Northern Child Health Network and The Maitland Hospital
• Ms Leanne Crittenden, Coordinator Northern Child Health Network
• Dr Bruce Whitehead, Staff Specialist John Hunter Children's Hospital
• Ms Louise Bright, Clincial Risk Manager Maternity Services

The Executive Sponsors for the Detection of the Deteriorating Patient program are Dr Kim Hill, Director Clinical Governance and Mr Scott McLachlan, Director Operations - Primary and Community Networks.