Action 8.10

The health service organisation has processes that support timely response by clinicians with the skills required to manage episodes of acute deterioration

Intent

Clinicians have the skills and knowledge to deal with deterioration, as appropriate for their role.

Reflective question

How does the health service organisation ensure that clinicians are competent in the skills required to respond to patients whose condition is acutely deteriorating?

Key task

Develop systems to ensure that clinicians are competent in the skills required to respond to patients whose condition is deteriorating.

Strategies for improvement

Hospitals

This action means different things for people in different roles and settings. It applies to both the workforce providing the initial response while awaiting help, and to the response team who bring extra skills to the patient. Take a risk assessment approach to identify and prioritise training needs.

Clinicians who provide clinical care need skills in providing essential emergency interventions for common causes and symptoms of life-threatening physiological deterioration while awaiting help. These include skills in essential emergency management of conditions such as airway obstruction, hypoxia, respiratory distress or suppression, arrhythmia, hypotension, fluid overload, seizures and sepsis.

Clinicians who provide clinical care need skills in responding to aggressive behaviour when attempts to de-escalate the situation have failed and there is potential harm to the patient or to others.

Clinicians working in specific specialties or settings may need training in extra skills to provide an immediate response while awaiting help. For example, clinicians working in a coronary care unit need cardiac resuscitation skills, while those working in maternity settings need skills in managing obstetric emergencies.

Clinicians who have particular roles also need training in other skills. For example, medical emergency team responders need advanced clinical assessment skills and competence in specialist procedures such as intubation.

Clinicians who respond to acute deterioration also require non-technical skills such as graded assertiveness, negotiating patient goals of care, communicating bad news and team leadership.1

Day Procedure Services

This action means different things for people in different roles and settings. It applies to both the workforce providing the initial response while awaiting help, and to the response team who bring extra skills to the patient. Take a risk assessment approach to identify and set priorities for training needs.

Clinicians who provide clinical care need skills in providing essential emergency interventions for common causes and symptoms of life-threatening physiological deterioration while awaiting help. These include skills in essential emergency management of conditions such as airway obstruction, hypoxia, respiratory distress or suppression, arrhythmia, hypotension, fluid overload and seizures.

If the response to acute deterioration is provided by clinicians within the day procedure service (rather than an external service such as an ambulance), ensure that responders are competent in the required skills. These include advanced clinical assessment skills and other, non-technical skills, such as graded assertiveness and team leadership.1

Examples of evidence

Select only examples currently in use:

  • Employment documents that describe roles and responsibilities in the event of episodes of acute deterioration
  • Training documents about emergency interventions in the event of acute deterioration, including specialist training for responders, such as members of medical emergency teams
  • Evidence of clinician competency assessment (for example, through simulation exercises, peer review or formal assessments)
  • Records indicating that clinicians have met the ongoing professional development requirements of a specialist college in relation to responding to acute deterioration (for example, through the College of Intensive Care Medicine).
MPS & Small Hospitals

MPSs and small hospitals should develop systems relevant to their service context to ensure that clinicians are competent in the skills required to respond to patients whose condition is deteriorating. This should be based on a risk assessment approach to identify and prioritise training needs.

Clinicians who provide clinical care need skills in providing essential emergency interventions for common causes and symptoms of life-threatening physiological deterioration while awaiting help. These include skills in essential emergency management of conditions such as airway obstruction, hypoxia, respiratory distress or suppression, arrhythmia, hypotension, fluid overload, seizures and sepsis.

Clinicians who provide clinical care need skills in responding to aggressive behaviour when attempts to de-escalate the situation have failed and there is potential harm to the patient or to others.

Clinicians working in specific specialties or settings may need training in extra skills to provide an immediate response while awaiting help. For example, clinicians working in maternity settings need skills in managing obstetric emergencies.

Clinicians who have particular roles also need training in other skills. For example, medical emergency team responders need advanced clinical assessment skills and competence in specialist procedures such as intubation.

Clinicians who respond to acute deterioration also require non-technical skills such as graded assertiveness, negotiating patient goals of care, communicating bad news and team leadership.1

If possible, use resources developed by the Local Hospital Network, state or territory health department or nearby larger hospital to support the education of clinicians working in an MPS or small hospital.

Action 8.11

The health service organisation has processes to ensure rapid access at all times to at least one clinician, either on site or in close proximity, who can deliver advanced life support

Intent

Expert input and assistance is available to manage acute physiological deterioration.

Reflective question

What processes are in place to ensure that clinicians who are competent in providing advanced life support are available to respond to patients who acutely deteriorate?

Key task

Provide a system to ensure rapid access to advanced life support for patients who acutely deteriorate.

Strategies for improvement

Hospitals

Ensure that response systems include provision for rapid access to at least one clinician with advanced life support skills at all times. Develop and maintain rosters to enable rapid access to this clinician at all times. In most large health services, this clinician will be accessed through the rapid response system.

Establish clinicians’ competence in advanced life support with evidence of relevant qualifications (for example, advanced life support certification compliant with Australian Resuscitation Council guidelinesor medical qualifications in specialties such as anaesthesia and critical care). Establish competence in paediatric advanced life support for responders in services that provide care to children. More clinicians may require training so this level of care can be provided 24 hours a day and when key clinicians are absent.

Clinicians need regular opportunities to practise and maintain their skills so that they retain competence.4,5 Put systems in place to provide evidence of clinicians’ ongoing competence in advanced life support. This may require the organisation to provide access to formal advanced life support training for clinicians. Further benefits can be gained by providing opportunities for members of rapid response teams to train together, and practise using non-technical skills such as leadership, teamwork and communication while managing simulated scenarios of acute deterioration.

Day Procedure Services

Ensure that response systems include provision for rapid access to at least one clinician with advanced life support skills at all times. Depending on the size, location and type of day procedure service, options to provide this access include:

  • Supporting senior nurses to complete advanced life support training
  • Developing agreements with anaesthetists who provide services in the organisation
  • Accessing external ambulance services.

If advanced life support is to be provided by members of the workforce, establish clinicians’ competence in advanced life support with evidence of relevant qualifications (for example, advanced life support certification compliant with Australian Resuscitation Council guidelines6 or medical qualifications in specialities such as anaesthesia and critical care). Establish competence in paediatric advanced life support for responders in services that provide care to children. More clinicians may require training so that this level of care can be provided when key clinicians are absent.

Clinicians need regular opportunities to practise and maintain their skills so that they retain competence.4,5 Put systems in place to provide evidence of clinicians’ ongoing competence in advanced life support. This may require the organisation to provide access to formal advanced life support training for clinicians. Additional benefits can be gained by providing opportunities for members of rapid response teams to train together, and practise using non-technical skills such as leadership, teamwork and communication while managing simulated scenarios of acute deterioration.

Examples of evidence

Select only examples currently in use:

  • Rosters of clinicians who can provide advanced life support
  • Audit results of episodes requiring advanced life support, to determine whether members of the workforce who can provide advanced life support were available
  • Employment documents that describe advanced life support roles, responsibilities and accountabilities
  • Evidence of qualifications or up-to-date certification for the provision of advanced life support
  • Policy documents for rapidly gaining access to a clinician who can provide advanced life support
  • Records of ongoing competency assessments for advanced life support
  • Training documents about non-technical skills relating to advanced life support, such as teamwork, team leadership and communication.
MPS & Small Hospitals

MPSs and small hospitals should provide a system to ensure rapid access to advanced life support for patients who acutely deteriorate. This includes provision for rapid access to at least one clinician with advanced life support skills at all times. Develop and maintain mechanisms to enable rapid access to this clinician(s) at all times.

Mechanisms may include:

  • Providing extra training to some doctors and nurses to ensure the required level of care can be provided 24 hours a day and when clinicians are absent; external training programs can be used to provide training in advanced life support skills if this cannot be provided locally
  • Establishing competency in paediatric advanced life support for responders in services that provide care to children
  • Putting systems in place to provide evidence of clinicians’ ongoing competence in advanced life support – clinicians need regular opportunities to practise and maintain their skills so that they retain competency4,5
  • Ensuring that clinicians who respond to acute deterioration also have non-technical skills such as graded assertiveness, negotiating patient goals of care, communicating bad news and team leadership1
  • Scheduling training for registered nurses in a first-line emergency care course in health services without 24-hour medical coverage
  • Using external providers such as local general practitioners, visiting medical officers or ambulance services; in some situations, the use of retrieval services to provide an emergency response may also be required.

When clinicians with advanced life support skills are located off site, response times need to be rapid so that patient safety and care are not compromised. This may require the clinician to be contacted early during a patient’s episode of deterioration, or if response times are prolonged, the capacity to have the clinician on site.

Action 8.12

The health service organisation has processes to ensure rapid referral to mental health services to meet the needs of patients whose mental state has acutely deteriorated

Intent

Care for patients whose mental state is deteriorating is escalated safely and effectively.

Reflective questions

How does the health service organisation ensure that the workforce knows the local processes for escalating care to mental health specialists?

What partnerships are in place to help patients gain access to mental health services if they are not provided within the health service organisation?

How are patients, carers and families informed about rapid referral to mental health services?

Key tasks

  • Develop a protocol for escalating care when a person’s mental state is deteriorating, which includes designation of roles and responsibilities for members of the healthcare workforce and time frames for response
  • Develop partnerships with other relevant organisations if responding to acute deterioration in a person’s mental state is outside the scope of the health service organisation
  • Ensure that members of the workforce are aware of, and use, the escalation protocol.

Strategies for improvement

Hospitals

Ensure that there is a clear process for escalating care when deterioration in a person’s mental state is recognised, which includes:

  • Designation of roles and responsibilities for members of the healthcare workforce
  • Time frames for response.

Tailor the escalation protocol to the specific health setting, taking into account:

  • The size, location and role of the setting
  • The available resources, including the clinical workforce skill mix
  • The capacity to engage specialist help.

Large tertiary hospitals typically have consultation liaison psychiatry services available internally. Ensure that all members of the workforce are aware of how to contact the service when they recognise deterioration in a patient’s mental state. Many consultation liaison services provide templates for referral that support effective communication and enable reviews to be prioritised across the hospital. Support consultation liaison processes with education for the workforce. Consultations can provide opportunities for further education and upskilling of the workforce.

For organisations that do not have consultation liaison services on site, develop and maintain local partnerships to enable rapid referral. This may involve linking with the local community mental health service, a general practitioner or on-call psychiatrists.

Provide access to essential psychiatric medications at all times.

Provide members of the clinical workforce with access to legal advice relating to delivery of treatment under mental health and other relevant legislation.

Support referral processes with systems to encourage appropriate documentation about the person’s mental state at transitions of care, and to reduce the burden of documentation and data collection when possible.

Day Procedure Services

Because of the short duration of stay in day procedure services and the use of pre-admission screening to determine that it is currently safe for a person to undergo a procedure, there is very low prevalence of acute deterioration in a person’s mental state in day procedure services.

Day procedure services do not typically have workforce members with mental health expertise on site. It is therefore recommended that services develop partnerships with local services that can provided emergency mental health assistance in the rare instances that it is needed. Maintain these partnerships, and ensure that all members of the workforce can escalate care appropriately.

Examples of evidence

Select only examples currently in use:

  • Policy documents about rapid referral to mental health services
  • Audit results of episodes when patients’ mental states have acutely deteriorated, to determine whether rapid referrals were made to mental health services
  • Document that identifies areas of the health service organisation where the risk of acute deterioration in mental state is highest.
MPS & Small Hospitals

MPSs and small hospitals should:

  • Develop a protocol for escalating care when a person’s mental state is deteriorating, which includes designation of roles and responsibilities for members of the healthcare workforce and time frames for response
  • Develop partnerships with other relevant organisations if responding to acute deterioration in a person’s mental state is outside the scope of the health service organisation
  • Ensure that members of the workforce are aware of, and use, the escalation protocol.

Tailor the escalation protocol to the specific health setting, taking into account:

  • The size, location and role of the setting
  • The available resources, including the clinical workforce skill mix
  • The capacity to engage specialist help.

Develop and maintain partnerships with other organisations if the MPS or small hospital is required to provide a safe and effective response to deterioration in a person’s mental state. This may involve linking with the local community mental health service, a general practitioner or on-call psychiatrists. Technological resources such as teleconferencing or videoconferencing facilities can also enable prompt mental health review when a person’s mental state deteriorates.

Provide access to essential psychiatric medicines at all times.

Provide members of the clinical workforce with access to legal advice relating to delivery of treatment under mental health and other relevant legislation.

Support referral processes with systems to encourage appropriate documentation about the person’s mental state at transitions of care, and to reduce the burden of documentation and data collection when possible.

Action 8.13

The health service organisation has processes for rapid referral to services that can provide definitive management of acute physical deterioration

Intent

Patients who need other services to resolve the cause of their acute deterioration are rapidly referred to these services.

Reflective questions

What services may be required by patients who acutely deteriorate but cannot be safely provided?

What referral mechanisms are in place to ensure that patients whose acute deterioration cannot be definitively managed within the health service organisation are rapidly referred to other organisations?

Key tasks

  • Map the causes of acute deterioration against the capacity of the health service organisation to provide for their definitive management
  • If the organisation is not able to provide definitive care, develop systems for rapid referral of patients with acute deterioration to other services.

Strategies for improvement

Hospitals

Definitive management means that the patient receives the best possible treatment for decisively resolving the cause of their acute deterioration. Acute deterioration may be the outcome of a disease process, medical intervention or condition that is not able to be effectively managed by the health service organisation where the patient is. This means that systems need to be developed to rapidly refer patients to other services.

Identify common causes of acute deterioration using data from the recognition and response systems. These may include common presentations and causes of acute physiological deterioration, such as8-11:

  • Airway obstruction and respiratory depression associated with issues such as neurological events or opioid overdose
  • Altered level of consciousness associated with issues such as neurological events, abnormal blood glucose or delirium
  • Respiratory distress associated with issues such as fluid overload, sepsis or exacerbations of existing lung disease
  • Arrhythmias
  • Hypotension associated with conditions such as
    • sepsis
    • dehydration
    • post-surgical bleeding
    • postpartum maternal haemorrhage
    • cardiac failure
  • Medicine side effects, interactions or related complications such as allergies or errors.

Map the common causes of acute deterioration against the capacity of the service to provide definitive management for each of them. For example, psychosis may be a relatively common cause of acute deterioration in mental state in the emergency department, but may be unable to be effectively managed in another service; a system for rapid referral to specialist mental health services would be required. Similarly, presentations of multi-organ failure associated with sepsis may be a relatively common cause of acute physiological deterioration and require a system for rapid referral to a tertiary intensive care service.

Develop processes for rapid referral between services within the health service organisation (for example, mental health services, palliative care, intensive care) and for rapid referral to external acute healthcare services. Include processes for the safe transport of patients in the referral systems. Referral to external services for definitive treatment of acute deterioration may also require referral to emergency transport services.

Day Procedure Services

Definitive management means that the patient receives the best possible treatment for decisively resolving the cause of their acute deterioration. Acute deterioration may be the outcome of a disease process, medical intervention or condition that is not able to be effectively managed by the day procedure service. This means that systems need to be developed to rapidly refer patients to other services.

Identify common causes of acute deterioration using data from the recognition and response systems. These may include common presentations and causes of acute physiological deterioration, such as8-11:

  • Post-anaesthetic airway obstruction and respiratory depression
  • Altered level of consciousness associated with issues such as neurological events or abnormal blood glucose
  • Respiratory distress associated with issues such as fluid overload or exacerbations of existing lung disease
  • Arrhythmias
  • Hypotension associated with conditions such as
    • dehydration
    • post-surgical bleeding
    • cardiac failure
  • Medicine side effects or interactions, or related complications such as allergies or errors.

Map the most likely causes of acute deterioration in the day procedure service against the capacity of the service to provide definitive management for each of them. For example, post-anaesthetic airway obstruction may be a routine scenario that is easily managed in the recovery room. However, fluid overload associated with cardiac failure may indicate serious deterioration that cannot be safely managed in the service. For these cases, develop a system for rapid referral to acute care services.

If the day procedure service is attached to an acute hospital, the system may involve referral and transfer to the affiliated emergency department. If the service is a standalone facility, an option is to rely on referral for ongoing care through emergency ambulance services.

Examples of evidence

Select only examples currently in use:

  • Audit results of the common causes of deterioration from the recognition and response systems mapped to organisational capacity
  • Policy documents about referral to other services for definitive management
  • Memorandums of understanding with external services that enable rapid referral for definitive management
  • Documented processes for safe transport to other services for definitive management
  • Evaluation of referral processes and patient outcomes, and evidence of associated quality improvement projects.
MPS & Small Hospitals

MPSs and small hospitals should:

  • Map the causes of acute deterioration against the capacity of the health service organisation to provide for their definitive management
  • If the organisation is not able to provide definitive care, develop systems for rapid referral of patients with acute deterioration to other services.

Definitive management means that the patient receives the best possible treatment for decisively resolving the cause of their acute deterioration. Acute deterioration may be the outcome of a disease process, medical intervention or condition that is not able to be effectively managed by the health service organisation where the patient is. This means that systems need to be developed to rapidly refer patients to other services.

Identify common causes of acute deterioration using data from the recognition and response systems. These may include common presentations and causes of acute physiological deterioration, such as8-11:

  • Airway obstruction and respiratory depression associated with issues such as neurological events or opioid overdose
  • Altered level of consciousness associated with issues such as neurological events, abnormal blood glucose or delirium
  • Respiratory distress associated with issues such as fluid overload, sepsis or exacerbations of existing lung disease
  • Arrhythmias
  • Hypotension associated with conditions such as
    • sepsis
    • dehydration
    • post-surgical bleeding
    • postpartum maternal haemorrhage
    • cardiac failure
  • Medication side effects, interactions, or related complications such as allergies or errors.

Map the common causes of acute deterioration against the capacity of the service to provide definitive management for each of them. For example, psychosis may be a relatively common cause of acute deterioration in mental state in the emergency department, but may be unable to be effectively managed in another service; a system for rapid referral to specialist mental health services would be required. Similarly, presentations of multi-organ failure associated with sepsis may be a relatively common cause of acute physiological deterioration and require a system for rapid referral to a tertiary intensive care service.

Develop processes for rapid referral between services within the health service organisation (for example, mental health services, palliative care, aged care, intensive care) and for rapid referral to external acute healthcare services. Include processes for the safe transport of patients in the referral systems. Referral to external services for definitive treatment of acute deterioration may also require referral to emergency transport services.

Last updated 30th May, 2018 at 01:48am
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