MODELS OF CARE CSIRO PUBLISHING
Australian Health Review, 2014, 38, 169–176 http://dx.doi.org/10.1071/AH13245
Medical emergency response in a sub-acute hospital: improving the model of care for deteriorating patients Philip Visser1,8 MBChB, FACEM, Emergency Physician Alison Dwyer2 MBBS, MBA, MHSM, FRACMA, FCHSE, GAICD, Medical Director Juli Moran3 MBBS, FRACP, FAChPM, Director Mary Britton4 BSc (Hons), MBChB, FRCP, FRACP, MD, Aged Care Physician Melodie Heland5 MN, GDip Hlth Adm, Crit Care Cert, GAICD, Director Filomena Ciavarella2 BAppSc, Director Sandy Schutte6 RN Mid, GDipBus(Mgt), GDip HRM, Site Manager Daryl Jones7 BSc(Hons), MBBS, FRACP, FCICM, MD, Consultant Intensive Care Specialist 1
Emergency Department, Austin Hospital, 145 Studley Road, Heidelberg, Vic. 3084, Australia. Quality Safety and Risk Management Unit, Austin Hospital, 145 Studley Road, Heidelberg, Vic., 3084, Australia. Email: [email protected]; fi[email protected] 3 Palliative Care Services, Heidelberg Repatriation Hospital, 300 Waterdale Road, Heidelberg West, Vic. 3081, Australia. Email: [email protected] 4 Aged Care And Residential Care Services, Heidelberg Repatriation Hospital, 300 Waterdale Road, Heidelberg West, Vic. 3081, Australia. Email: [email protected] 5 Surgical Clinical Service Unit, Austin Hospital, 145 Studley Road, Heidelberg, Vic. 3084, Australia. Email: [email protected] 6 Nursing Administration, Heidelberg Repatriation Hospital, 300 Waterdale Road, Heidelberg West, Vic. 3081, Australia. Email: [email protected] 7 Intensive Care Unit, Austin Hospital, 145 Studley Road, Heidelberg, Vic. 3084, Australia. Email: [email protected] 8 Corresponding author. Email: [email protected] 2
Abstract Objective. To assess the frequency, characteristics and outcomes of medical emergency response (MER) calls in a subacute hospital setting. Methods. The present study was a retrospective observational study in a sub-acute hospital providing aged care, palliative care, rehabilitation, veteran’s mental health and elective surgical services. We assessed annual MER call numbers between 2005 and 2011 in the context of contemporaneous changes to hospital services. We also assessed MER calls over a 12-month period in detail using standardised case report forms and the scanned medical record. Results. There were 2285 multiday admissions in the study period where 141 MER calls were triggered in 132 patients (61.7 calls per 1000 admissions). The median patient age was 83.0 years, and 55.3% of patients were men. Most calls occurred on weekdays and during the daytime, and were triggered by altered conscious state, low oxygen saturations and hypotension. Documentation of escalation of care before the MER call was not present in 99 of 141 (70.2%) calls. Following the call, in 70 of 141 (49.6%) cases, the patient was transferred to the acute campus, where 52 (74.2%) and 14 (20%) patients required ward and intensive care level treatment, respectively. Thirty-seven of 132 (28%) patients died. A palliative care physician adjudicated that most of these patients who died (24/37; 64.9%) were appropriate for a call, but that 19 (51.4%) should have received palliation at the time of the call. Compared with survivors, patients who died after the MER call were more likely originally admitted from supported accommodation. Conclusions. MER calls in our sub-acute hospital occurred in elderly patients and are associated with an in-hospital mortality of 28%. A small proportion of patients required intensive care level treatment. There is a need to improve processes involving escalation of care before MER call activation and to revise advance care directives.
Journal compilation AHHA 2014
www.publish.csiro.au/journals/ahr
170
Australian Health Review
P. Visser et al.
What is known about this topic? Rapid response team (RRT) activation has been well described in the acute hospital setting. Although the impact on survival benefit to patients remains controversial, it has been widely adopted as a model of care to respond to deteriorating ward patients. This is particularly relevant in Australia at present with the implementation of the new National Safety and Quality Health Service Standards. What does this paper add? There have not been any previous papers published on rapid response systems in a sub-acute hospital. This paper describes some of the changes and challenges associated with increasing RRT activations in a sub-acute health care facility. What are the implications for practitioners? For clinicians in a sub-acute setting, the study reinforces the importance of pre-emptively documenting and communicating advance care directives. In addition, it is important to identify patients with reversible pathology likely to benefit from transfer and acute care, and to avoid the transfer of those who will not and, instead, provide appropriate palliation. For practitioners involved in models of care for deteriorating patients, the study provides information on where problems occurred in our system and the strategies used to address these issues. Received 23 September 2013, accepted 16 January 2014, published online 15 April 2014
Introduction The medical emergency team (MET) or rapid response team (RRT) has become a prevailing model of care in the management of deteriorating ward patients. Although its impact on patient outcomes remains controversial, it has been widely adopted in many acute care hospitals around the world, including Australia.1–5 Although the RRT and its functions have been extensively investigated in the setting of acute hospitals, reports of its role and effect on patient care and outcome in the sub-acute hospital setting are limited. The sub-acute hospital setting has traditionally been used for patients with lower medical acuity, for example psychiatry, rehabilitation, aged and palliative care wards. However, changing models of care in these areas have meant that there is an increased need to manage unwell patients. This has resulted in the development of individual emergency response systems for different precincts within our health service, using available local resources, with the option to transfer the patient to the acute care facility and critical care beds as required. The medical emergency response (MER) call is the afferent limb in our subacute hospital. Recent service changes at our subacute hospital have led to an increasing number of MER calls. Accordingly, we undertook a retrospective observational study of MER calls, to understand the nature of these RRT calls on our subacute campus. Specifically, we looked at the changes in MER calls over six financial years. In addition, we studied in detail the clinical triggers, characteristics and outcomes of patients subject to MER review over a 12-month period. Finally, we assessed aspects of limitations of medical treatment (LOMT) and appropriateness of escalation of care in the context of likely prognosis in these patients.
Methods The hospitals Austin Health is a major teaching and referral centre in the northeast of Melbourne and consists of three facilities: The Austin Hospital, Heidelberg Repatriation Hospital and Royal Talbot Rehabilitation Centre.
The acute campus The Austin Hospital is a 400-bed tertiary acute care hospital with a 20-bed intensive care unit (ICU) and a mental health precinct with acute psychiatric facilities for adults, children and adolescents. The hospital is also home to the Victorian Spinal Cord Service, Victorian Liver Transplant Unit and the Victorian Respiratory Support Service. It provides all major medical and surgical services, including cardiothoracic and neurosurgery. The sub-acute campus The Heidelberg Repatriation Hospital (HRH) is a sub-acute hospital 1.6 km from the Austin Hospital. It provides elective surgery, in-patient services (aged care, palliative care, mental health) and outpatient services (outpatient clinics, radiation oncology, dialysis, nuclear medicine and radiology). Over the 7-year period since implementation of a MER at the HRH, the following changes in patient mix and acuity have occurred. First, a 30-bed elective surgery centre was opened in the 2008–09 financial year that provides overnight care for 12 patients. There is also a 104-bed aged care service with beds across multiple wards providing rehabilitation, acute and interim care. This includes a 24-bed acute geriatric unit that opened in the 2009–10 financial year to admit patients from the emergency department (ED) and acute medical wards at the Austin. Finally, the site also contains a 17-bed palliative care unit (PCU) and a 20-bed psychiatric unit for war veterans. Clinical support services for deteriorating patients at the sub-acute campus Access to intensive care The HRH does not have an ICU or high dependency unit. Cardiac monitoring or non-invasive ventilation is also not available on this site. Accordingly, if patients experience significant clinical deterioration they need to be transferred to the acute care campus. Access to acute diagnostic services There is only limited access to diagnostic services, especially outside normal working hours. Pathology specimens are couriered to the Austin for analysis and there is only access to a blood
Emergency response in a subacute hospital
Australian Health Review
gas machine while the operating theatre is open. After-hours radiology is available on an on-call basis. Details of emergency response systems At the acute campus of Austin Health there is a MET to respond to calls for urgent care to all in-patients admitted to the Austin Hospital who meet predefined criteria. The system is activated by ward staff and announced on the overhead intercom and
171
pager systems to notify the MET and the treating unit of the call. The MET consists of an ICU registrar and nurse, a registrar from the parent unit, the nursing coordinator and nursing and medical staff on the ward. It has been described in detail elsewhere.3 At the sub-acute HRH, the RRT is called the MER team. The calling criteria are displayed on posters around the campus (Fig. 1). The call is announced using the overhead intercom and
Obstructed airway Noisy breathing or stridor Problem with a tracheostomy tube
Any difficulty breathing Breathing 25 breaths a minute SpO2≤90%, or requiring 8L/min oxygen
Pulse 110 bpm Low blood pressure (systolic
Australian Health Review, 2014, 38, 169–176 http://dx.doi.org/10.1071/AH13245
Medical emergency response in a sub-acute hospital: improving the model of care for deteriorating patients Philip Visser1,8 MBChB, FACEM, Emergency Physician Alison Dwyer2 MBBS, MBA, MHSM, FRACMA, FCHSE, GAICD, Medical Director Juli Moran3 MBBS, FRACP, FAChPM, Director Mary Britton4 BSc (Hons), MBChB, FRCP, FRACP, MD, Aged Care Physician Melodie Heland5 MN, GDip Hlth Adm, Crit Care Cert, GAICD, Director Filomena Ciavarella2 BAppSc, Director Sandy Schutte6 RN Mid, GDipBus(Mgt), GDip HRM, Site Manager Daryl Jones7 BSc(Hons), MBBS, FRACP, FCICM, MD, Consultant Intensive Care Specialist 1
Emergency Department, Austin Hospital, 145 Studley Road, Heidelberg, Vic. 3084, Australia. Quality Safety and Risk Management Unit, Austin Hospital, 145 Studley Road, Heidelberg, Vic., 3084, Australia. Email: [email protected]; fi[email protected] 3 Palliative Care Services, Heidelberg Repatriation Hospital, 300 Waterdale Road, Heidelberg West, Vic. 3081, Australia. Email: [email protected] 4 Aged Care And Residential Care Services, Heidelberg Repatriation Hospital, 300 Waterdale Road, Heidelberg West, Vic. 3081, Australia. Email: [email protected] 5 Surgical Clinical Service Unit, Austin Hospital, 145 Studley Road, Heidelberg, Vic. 3084, Australia. Email: [email protected] 6 Nursing Administration, Heidelberg Repatriation Hospital, 300 Waterdale Road, Heidelberg West, Vic. 3081, Australia. Email: [email protected] 7 Intensive Care Unit, Austin Hospital, 145 Studley Road, Heidelberg, Vic. 3084, Australia. Email: [email protected] 8 Corresponding author. Email: [email protected] 2
Abstract Objective. To assess the frequency, characteristics and outcomes of medical emergency response (MER) calls in a subacute hospital setting. Methods. The present study was a retrospective observational study in a sub-acute hospital providing aged care, palliative care, rehabilitation, veteran’s mental health and elective surgical services. We assessed annual MER call numbers between 2005 and 2011 in the context of contemporaneous changes to hospital services. We also assessed MER calls over a 12-month period in detail using standardised case report forms and the scanned medical record. Results. There were 2285 multiday admissions in the study period where 141 MER calls were triggered in 132 patients (61.7 calls per 1000 admissions). The median patient age was 83.0 years, and 55.3% of patients were men. Most calls occurred on weekdays and during the daytime, and were triggered by altered conscious state, low oxygen saturations and hypotension. Documentation of escalation of care before the MER call was not present in 99 of 141 (70.2%) calls. Following the call, in 70 of 141 (49.6%) cases, the patient was transferred to the acute campus, where 52 (74.2%) and 14 (20%) patients required ward and intensive care level treatment, respectively. Thirty-seven of 132 (28%) patients died. A palliative care physician adjudicated that most of these patients who died (24/37; 64.9%) were appropriate for a call, but that 19 (51.4%) should have received palliation at the time of the call. Compared with survivors, patients who died after the MER call were more likely originally admitted from supported accommodation. Conclusions. MER calls in our sub-acute hospital occurred in elderly patients and are associated with an in-hospital mortality of 28%. A small proportion of patients required intensive care level treatment. There is a need to improve processes involving escalation of care before MER call activation and to revise advance care directives.
Journal compilation AHHA 2014
www.publish.csiro.au/journals/ahr
170
Australian Health Review
P. Visser et al.
What is known about this topic? Rapid response team (RRT) activation has been well described in the acute hospital setting. Although the impact on survival benefit to patients remains controversial, it has been widely adopted as a model of care to respond to deteriorating ward patients. This is particularly relevant in Australia at present with the implementation of the new National Safety and Quality Health Service Standards. What does this paper add? There have not been any previous papers published on rapid response systems in a sub-acute hospital. This paper describes some of the changes and challenges associated with increasing RRT activations in a sub-acute health care facility. What are the implications for practitioners? For clinicians in a sub-acute setting, the study reinforces the importance of pre-emptively documenting and communicating advance care directives. In addition, it is important to identify patients with reversible pathology likely to benefit from transfer and acute care, and to avoid the transfer of those who will not and, instead, provide appropriate palliation. For practitioners involved in models of care for deteriorating patients, the study provides information on where problems occurred in our system and the strategies used to address these issues. Received 23 September 2013, accepted 16 January 2014, published online 15 April 2014
Introduction The medical emergency team (MET) or rapid response team (RRT) has become a prevailing model of care in the management of deteriorating ward patients. Although its impact on patient outcomes remains controversial, it has been widely adopted in many acute care hospitals around the world, including Australia.1–5 Although the RRT and its functions have been extensively investigated in the setting of acute hospitals, reports of its role and effect on patient care and outcome in the sub-acute hospital setting are limited. The sub-acute hospital setting has traditionally been used for patients with lower medical acuity, for example psychiatry, rehabilitation, aged and palliative care wards. However, changing models of care in these areas have meant that there is an increased need to manage unwell patients. This has resulted in the development of individual emergency response systems for different precincts within our health service, using available local resources, with the option to transfer the patient to the acute care facility and critical care beds as required. The medical emergency response (MER) call is the afferent limb in our subacute hospital. Recent service changes at our subacute hospital have led to an increasing number of MER calls. Accordingly, we undertook a retrospective observational study of MER calls, to understand the nature of these RRT calls on our subacute campus. Specifically, we looked at the changes in MER calls over six financial years. In addition, we studied in detail the clinical triggers, characteristics and outcomes of patients subject to MER review over a 12-month period. Finally, we assessed aspects of limitations of medical treatment (LOMT) and appropriateness of escalation of care in the context of likely prognosis in these patients.
Methods The hospitals Austin Health is a major teaching and referral centre in the northeast of Melbourne and consists of three facilities: The Austin Hospital, Heidelberg Repatriation Hospital and Royal Talbot Rehabilitation Centre.
The acute campus The Austin Hospital is a 400-bed tertiary acute care hospital with a 20-bed intensive care unit (ICU) and a mental health precinct with acute psychiatric facilities for adults, children and adolescents. The hospital is also home to the Victorian Spinal Cord Service, Victorian Liver Transplant Unit and the Victorian Respiratory Support Service. It provides all major medical and surgical services, including cardiothoracic and neurosurgery. The sub-acute campus The Heidelberg Repatriation Hospital (HRH) is a sub-acute hospital 1.6 km from the Austin Hospital. It provides elective surgery, in-patient services (aged care, palliative care, mental health) and outpatient services (outpatient clinics, radiation oncology, dialysis, nuclear medicine and radiology). Over the 7-year period since implementation of a MER at the HRH, the following changes in patient mix and acuity have occurred. First, a 30-bed elective surgery centre was opened in the 2008–09 financial year that provides overnight care for 12 patients. There is also a 104-bed aged care service with beds across multiple wards providing rehabilitation, acute and interim care. This includes a 24-bed acute geriatric unit that opened in the 2009–10 financial year to admit patients from the emergency department (ED) and acute medical wards at the Austin. Finally, the site also contains a 17-bed palliative care unit (PCU) and a 20-bed psychiatric unit for war veterans. Clinical support services for deteriorating patients at the sub-acute campus Access to intensive care The HRH does not have an ICU or high dependency unit. Cardiac monitoring or non-invasive ventilation is also not available on this site. Accordingly, if patients experience significant clinical deterioration they need to be transferred to the acute care campus. Access to acute diagnostic services There is only limited access to diagnostic services, especially outside normal working hours. Pathology specimens are couriered to the Austin for analysis and there is only access to a blood
Emergency response in a subacute hospital
Australian Health Review
gas machine while the operating theatre is open. After-hours radiology is available on an on-call basis. Details of emergency response systems At the acute campus of Austin Health there is a MET to respond to calls for urgent care to all in-patients admitted to the Austin Hospital who meet predefined criteria. The system is activated by ward staff and announced on the overhead intercom and
171
pager systems to notify the MET and the treating unit of the call. The MET consists of an ICU registrar and nurse, a registrar from the parent unit, the nursing coordinator and nursing and medical staff on the ward. It has been described in detail elsewhere.3 At the sub-acute HRH, the RRT is called the MER team. The calling criteria are displayed on posters around the campus (Fig. 1). The call is announced using the overhead intercom and
Obstructed airway Noisy breathing or stridor Problem with a tracheostomy tube
Any difficulty breathing Breathing 25 breaths a minute SpO2≤90%, or requiring 8L/min oxygen
Pulse 110 bpm Low blood pressure (systolic
