PowerPoint Presentation · Title: PowerPoint Presentation Author: kingb Created Date: 12/13/2018 8:10:06 AM

NSW Medical Leadership Forum

23rd November 2018

David Storey

Debbie Draybi

Surgical Deterioration and Escalation


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Supervision of Clinical Care

In the public hospital system, supervision of clinical care plays a critical role in the care of every patient. Supervision of clinical care takes two forms -

Delegation Escalation

MORE EXPERIENCED, MORE EXPERIENCED,HIGHER RESPONSIBILITY HIGHER RESPONSIBILITY

LESS EXPERIENCED LESS EXPERIENCED


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Multiple elements

• Recognition of deterioration

• Escalation protocols at multiple levels

• Mutual understanding between trainee and senior• Assessment of the competencies of trainees

• Clinical leadership that engenders a culture of common purpose

• Monitoring of all of above


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What can we measure ?

• Surveys of ward based escalation (eg Darzi)• Surgical episodes (CERS, ICU assist, arrest)• Intraoperative escalation• Major failures of escalation (RCA)• Monetary costs of failed escalation (lawsuits)


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What can we measure ?Systematic survey of ward based escalation – 42 hrs in 6 surgical wards in 4 NW London hospitals

Johnston M, Darzi A et al Annals of Surgery 2014 1-8


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Systematic survey of ward based escalation – 42 hrs in 6 surgical wards in 4 NW London hospitals – 2 observers

28 deterioration events observed, many hazardous points, no redundancy

Nursing staff level – understaffing main hazard

Junior doctor level – inadequate history and/or examinationfailure to check chartsfailure to initiate correct treatmentfailure to inform senior doctor

Senior doctor level - failure to arrange definitive management

Johnston M, Darzi A et al Annals of Surgery 2014 1-8


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Local measures of the problem

• RCAs with supervision / escalation failure

• CERS / ICU Assist / Arrest calls

• Legal claims against LHDs with supervision elements

Supervision RCA Data 2016-17

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Since 2016, RCA’s have been coded to indicate if they were considered by the original RCA Committee to have demonstrated failure of delegation or escalation, or inadequate support.

Between June 2016 and June 2017, out of 712 RCAs

Category Number

RCAs with supervision issues 94

(non preventable outcome) 2

Supervision - delegation 10

Supervision - escalation 63

Supervision – support inadequate 53

Total no of issues identified 126


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RPAH Escalation

Three levels

1. CERS – response by the “home” team

2. ICU Assist

3. Arrest / prearrest


10


11


12


13

428

11431412

16671841

16281784

2989

3919

3202

0

500

1000

1500

2000

2500

3000

3500

4000

4500

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Number of Clinical review calls for surgical patients 2009-2018

Clinical Emergency


14

64

160208

254

371 366407

440

751

578

2556

27 53 76 75 83 89141 118

0

100

200

300

400

500

600

700

800

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Number of ICU Assist & Pre Arrest calls for Surgical patients 2009-2018

ICU Assist

Pre-Arrest


15

7

17

7

10 10

24

14

9

16

12

0

5

10

15

20

25

30

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Number of Cardiac Arrest calls for surgical patients/ year 2009-2018

Cardiac Arrest


16

0 100 200 300 400 500 600 700

Colorectal Surgery

UGIT Surgery

Orthopaedics

Cardiothoracic Surgery

Vascular

Urology

Neurosurgery

Liver Transplant

Renal Transplant

Melanoma

Transplant

Head & Neck

Plastics

ENT

Breast & Surgical

Total number of ICU Assist & Pre arrest calls per specialty 2009-2018

Pre-Arrest

ICU Assist


17

0 5 10 15 20 25 30 35

Cardiothoracic Surgery

UGIT Surgery

Orthopaedics

Vascular

Colorectal Surgery

Liver Transplant

Neurosurgery

Urology

Renal Transplant

Breast & Surgical

ENT

Plastics

Transplant

Total number of Cardiac Arrest calls/specialty from 2009-2018

Cardiac Arrest


18

0

20

40

60

80

100

120

140

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Number of ICU Assist & Pre Arrest Calls per year for Cardiothoracic patients (2009-2018)

ICU Assist

Pre-Arrest


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Σ CERS ICU Assist / Prearrest

Arrest

2010 1376 1143 83% 216 16% 17 1.2%

2017 4827 3919 81% 892 18% 16 0.3%

RPAH Surgical Patients


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TMF / iCare / GIO data

Is there evidence that failed supervision in general has been a part of successful medicolegal actions against LHDs ?

• How much are claims that include alleged supervision failure costing NSW Treasury Managed Fund ?

• What are the patterns of failure of supervision in the successful claims ?

(Data presented at the meeting, but not for distribution)

Delegation and Escalation of Clinical Care

Information provided by L McManus and K South GIO

Out of the 57 claims with supervision issues -

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It costs blood and treasure – what can we do about it ?

• Simulation based education

• Improve mutual understanding by

– Better assessment of trainee competencies

– Education in communication

– Ensuring that escalation is accepted gracefully

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“They have to learn to fly by themselves”“I can get a pretty good idea with a few questions at the scrub sink and watching them tie a knot”


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How to get there ?

1. Policy Directive

The proposed model asks each clinical discipline / division / department to assure the CE in writing that the group has met to discuss their practices of delegation and escalation, and have agreed upona. The principles under which they will delegate care b. The processes that they will use to assess their trainees’

competency to perform delegated tasks with safetyc. The circumstances in which they expect concerns to be

escalatedd. The ways that they will monitor their members’ adherence

to their own agreed principles

The Directive does NOT ask for details of these agreed practices.


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Department of Cardiothoracic Surgery RPAH


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How to get there ? - tools

Mobile app based competency assessments

• Provide a practical way of recording competency assessments• Assessments available immediately to authorised supervisors• Can provide individual or grouped dashboards of competencies• Current systems – Oslertechnology and Australian Orthopaedic

Association• Pilot planned for NSW Surgical Skills Network (SRMO level)

Oslertechnology AOA


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Potential benefits of more structured delegation / escalation

1. Patients are not harmed by being subject to treatment that is beyond a trainee’s competence

2. There is more efficient use of resources eg operating theatres

3. Trainees are under less pressure to inflate their competence

4. Escalation can take place with mutual understanding

5. Medicolegal claims based on poor supervision can be defended on the basis that delegation followed agreed principles

Documents

PowerPoint Presentation · Title: PowerPoint Presentation Author: kingb Created Date: 12/13/2018 8:10:06 AM