Transcript Adverse events – the scale of the problem

‘Count your calls’
Dr Alex Stone
&
Sarah Garrett
Thank you for joining this WebEx.
The presentation will begin in a few minutes time, please wait.
To hear this presentation you need to also call in by phone. If you have not called in by telephone,
go to COMMUNICATE on the menu bar above and select JOIN TELECONFERENCE,
then follow the onscreen instructions in the pop up window.
Reducing harm from deterioration
Why ‘Count your calls’?
“The aim should be to reduce the number of cardiac
arrests drastically. This can only be achieved if
organisations can really understand the specific local
conditions that led to the cardiac arrest.”
Marie-Noelle Orzel
Director of Nursing and Patient Care
The Royal Devon and Exeter NHS Foundation Trust,
Patient Safety First intervention lead for reducing harm from deterioration
Five steps to ‘Count your calls’
1. Where?
2. When?
3. Who?
4. What?
5. Why?
Where are your cardiac arrests calls or cardiac arrests
coming from?
When are your cardiac arrest calls occurring?
Who are the individual patients needing cardiac arrest calls?
Are there particular patient groups with high levels of calls
or deaths associated with cardiac arrests?
What happened? What type of cardiac arrest call was it?
What was the immediate outcome?
Why was a cardiac arrest call required?
Where?
Where are your cardiac arrest calls or cardiac arrests
coming from?
This will help to identify potential ‘hotspots’ within the hospital that need
targeted work.
While some calls might be expected from Coronary Care Units,
Resuscitation Rooms and Cardiac Catheterisation Suites, regular calls
or cardiac arrests within hospital wards should flag up concern.
When?
When are you cardiac arrests or cardiac arrests ocurring?
This will help to identify whether certain days or times are a specific
problem.
Calls and arrests at night or at weekends may indicate that deterioration
issues are not being dealt with adequately during normal working hours.
Who?
Who are the individual patients needing cardiac arrest calls?
Are there particular patient groups with high levels of calls or
deaths associated with cardiac arrest?
Identification of the patient, normally using the hospital unit number,
helps to collect key demographic data for individuals.
It also helps build up a picture of any patient groups which are
particularly associated with calls.
What?
What happened? What type of call or cardiac arrest was it?
What was the immediate outcome?
This enables identification of the type of cardiac arrest call (eg. periarrest / urgent call for assistance) or type of cardiac arrest (e.g. VT/VF
or Asystole/PEA).
It also provides data on the immediate outcome (e.g. patient died
immediately or there was return of spontaneous circulation (ROSC)).
Why?
Why was a cardiac arrest call required?
There are only three reasons why a patient requires a cardiac arrest call:
a) a sudden catastrophic event (a rarer occurrence than often believed)
b) failure to act on a patient’s deteriorating physiology in time
c) failure to recognise that a patient is near the end of life.
In other words, cardiac arrests or calls can be classified as potentially
predictable or unpredictable.
Potentially predictable calls can be further classified into preventable or
unpreventable.
Data collection tool example
DATE
TIME
DEPT
NAME
DOB
AGE HOSP NO CPR Defib TYPE OUTCOME
COMMENTS
O/A Dr decided NFR
form?
03/12/2009
19.19
A&E
90
X
X
PEA
Died
06/12/2009
1.09
A&E
79
Yes
X
PEA
Died
No
06/12/2009
3.27
A&E
19
X
X
Trauma
Alive
07/12/2009
20.10
A&E
88
Yes
X
Asystole
Died
10/12/2009
6.44
A&E
82
X
X
Post Arrest
Alive
10/12/2009
17.15
A&E
Yes
X
PEA
Alive
12/12/2009
12.31
A&E
75
Yes
X
PEA
Died
13/12/2009
16.47
A&E
77
X
X
Peri-Arrest
Alive
16/12/2009
13.19
A&E
67
Yes
X
Asystole
Died
No
16/12/2009
18.31
A&E
89
Yes
X
PEA
Died
No
20/12/2009
13.37
A&E
61
Yes
X
Asystole
Died
23/12/2009
14.10
A&E
74
Yes
Yes
PEA
Died
25/12/2009
7.55
A&E
47
Yes
X
Asystole
Died
Yes
28/12/2009
9.14
A&E
76
Yes
X
PEA
Died
Yes
28/12/2009
19.13
A&E
29/12/2009
1.50
A&E
90
X
X
Peri-Arrest
Alive
LOC LVF
No
29/12/2010
20.28
A&E
87
X
X
Peri-Arrest
Alive
Post Resp Arest
No
13/12/2009
12.46
Bedwell
76
X
X
Peri-Arrest
Alive
Put on DNAR
Yes
25/12/2009
1.08
Castlepoint
83
X
X
Peri-Arrest
Alive
?vagal attack
Yes
29/12/2009
4.35
Castlepoint
73
X
X
Peri-Arrest
Alive
LOC, post total knee replacement, ?DVT GI bleed, Hb
5.1
No
15/12/2009
21.45
Chemotherapy Unit
65
X
X
Peri-Arrest
Alive
Hypotension
Yes
23/12/2009
9.53
Edmund Stone
76
X
X
Peri-Arrest
Alive
GI bleed, vital signs OK
Yes
07/12/2009
0.18
Eleanor Hobbs
83
X
X
Peri-Arrest
Alive
LOC, put on DNAR
Yes
No
RTC to SAU
No
No
PEA @ nursing home, put on DNAR
No
No
No
?AAA Ctscan to theatres
No
Yes
Diabetic, renal failure, K 9.7
Yes
No
Source: Southend University Hospital NHS Foundation Trust
Data analysis example
Outcome from Cardiac Arrest Calls Jan 1 – Dec 31 2008
220
Ward Cardiac
Arrest Calls
204
Patients
VF/VT*
29 Calls
19 Patients
PEA*/Asystole
117 Calls
116 Patients
ROSC*
13 Patients
ROSC*
30 Patients
5 Patients
Discharged from
Hospital
6 Patients
Discharged from
Hospital
‘Peri-Arrest’
56 Calls
55 Patients
‘Not recorded’
10 Calls
10 Patients
‘False Alarm’
8 Calls
8 Patients
No further
Information
18 Patients
Discharged from
hospital
1 Patient
Discharged From
Hospital
Source: Southend University Hospital NHS Foundation Trust
Data analysis example
January to April 2008 Cardiac Arrest Calls and Notes Review
75 patients
74
Sets of notes
reviewed
46 (61%)
Asystole/PEA
7 (9%)
VF/VT
18 (24%)
‘Peri-arrest’
4 (5%)
Not recorded
41 Died
5 Survived
(12%)
6 Died
1 Survived
(17%)
10 Died
8 Survived
(44%)
3 Died
1 Survived
(25%)
Source: Southend University Hospital NHS Foundation Trust
Data analysis example
January to April 2008 Cardiac Arrest Calls and Notes Review
79
Cardiac Arrest Calls
from the Wards
75 patients identified
74 sets of notes
reviewed
60 patients died in
Hospital (80%)
15 survived at least to
discharge from
Hospital (20%)
Source: Southend University Hospital NHS Foundation Trust
Data analysis example
January to April 2008 Cardiac Arrest Calls and Notes Review
74
Sets of notes
reviewed
51 patients identified as
Potentially predictable
and
preventable episodes
47 Died in hospital
4 Survived to discharge
36 occurred out of hours
11 occurred in hours
1 occurred out of hours
3 occurred in hours
Source: Southend University Hospital NHS Foundation Trust
(Out of hours = outside the hours of
0800 – 1800, Monday to Friday)
Building a CAFÉ culture
CAFÉ : Cardiac Arrest Free Environment
“Cardiac arrests are red flags being waved at missed
opportunities for us all to provide a
better standard of care.” (Dr Alex Stone)
Building a CAFÉ culture
No avoidable death
No avoidable harm
Take one new step: www.patientsafetyfirst.nhs.uk
‘Count your calls’
More information and resources
for ‘Count your calls’ are
available on the Patient Safety
First website:
http://www.patientsafetyfirst.nhs.uk/Co
ntent.aspx?path=/Campaignsupport/countyourcalls/