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Recognition and management of patients who are deterioratingSummary This document describes the standards and principles of the Deteriorating PatientSafety Net System for the recognition, response to and the appropriate managementof the physiological and mental state deterioration of patients.Document type Policy DirectiveDocument number PD2020_018Publication date 12 June 2020Author branch Clinical Excellence CommissionBranch contact (02) 9269 5500Replaces … Continue reading “standards and principles of the Deteriorating Patient | My Assignment Tutor”

Recognition and management of patients who are deterioratingSummary This document describes the standards and principles of the Deteriorating PatientSafety Net System for the recognition, response to and the appropriate managementof the physiological and mental state deterioration of patients.Document type Policy DirectiveDocument number PD2020_018Publication date 12 June 2020Author branch Clinical Excellence CommissionBranch contact (02) 9269 5500Replaces PD2020_015Review date 12 June 2025Policy manual Patient Matters Manual for Public Health OrganisationsFile number D20/16324Status ActiveFunctional group Clinical/Patient Services – Governance and Service Delivery, Medical Treatment,Mental Health, Nursing and MidwiferyPersonnel/Workforce – Learning and DevelopmentApplies to Ministry of Health, Public Health Units, Local Health Districts, Board GovernedStatutory Health Corporations, Chief Executive Governed Statutory HealthCorporations, Specialty Network Governed Statutory Health Corporations, AffiliatedHealth Organisations, NSW Health Pathology, Public Health System Support Division,Cancer Institute, Government Medical Officers, Community Health Centres, NSWAmbulance Service, Dental Schools and Clinics, Public Hospitals, EnvironmentalHealth Officers of Local Councils, Private Hospitals and day Procedure CentresDistributed to Ministry of Health, Public Health System, Divisions of General Practice, GovernmentMedical Officers, NSW Ambulance Service, Environmental Health Officers of LocalCouncils, Private Hospitals and Day Procedure CentresAudience All Staff and Executives of Public Health OrganisationsPolicy DirectiveSecretary, NSW HealthThis Policy Directive may be varied, withdrawn or replaced at any time. Compliance with this directive ismandatory for NSW Health and is a condition of subsidy for public health organisations.PD2020_018 Issue date: June-2020 Page 1 of 2NSW HEALTH POLICYRECOGNITION AND MANAGEMENT OF PATIENTSWHO ARE DETERIORATINGPOLICY STATEMENTAll NSW public health organisations are to have local systems, structures and processin place to support the recognition, response to and appropriate management of thephysiological and mental state deterioration of patients.In this policy, public health organisations include local health districts, statutory healthcorporations and affiliated health organisations (with respect to their recognisedservices) that provide direct patient care.SUMMARY OF POLICY REQUIREMENTSAll NSW public health organisations are to: Have a clearly defined governance system to oversee the management andcontinuous improvement of the local Deteriorating Patient Safety Net System.Use standard clinical tools and approved local clinical managementguidelines/pathways as part of the local Deteriorating Patient Safety Net System to assess and monitor patient deterioration, including the NSW Health standardobservation charts (paper or electronic) (unless an exemption from use of the chartshas been granted). Formalise and implement a local Clinical Emergency Response System (CERS) thatmeets the requirements outlined in section 5 of this Policy Directive.Engage all patients, carers and families in a culturally appropriate manner to informthem about processes to escalate their concerns about patient deterioration,including who to contact and how to contact them.Have a local education program to support the local Deteriorating Patient Safety NetSystem that aligns with the Deteriorating Patient Education Strategy.Ensure that all staff are made aware of the local Deteriorating Patient Safety Net System (including how to activate their local CERS), and their roles andresponsibilities under the system during orientation and/or ward induction. Ensure that all clinicians who provide direct patient care have completed themandatory BTF Tier one and Tier two education and training prior to or during theirinduction to the health service, as outlined in the Deteriorating Patient EducationStrategy. Implement a local measurement strategy that monitors the performance andeffectiveness of the Deteriorating Patient Safety Net System, including the collectionand reporting of mandatory quality improvement measures.Communicate data and information about the performance of the local Deteriorating Patient Safety Net System to key stakeholders, including patients, carers, familiesand clinicians/staff.PD2020_018 Issue date: June-2020 Page 2 of 2NSW HEALTH POLICYREVISION HISTORY VersionApproved byAmendment notesJune-2020(PD2020_018)Chief Executive,Clinical ExcellenceCommissionAmendment of period of time for acute alterations to callingcriteria from not longer than 12 hours to not longer than 8hours (page 16).May-2020(PD2020_010)Deputy Secretary,Patient Experienceand SystemPerformanceReplaces PD2013_049. Amended to streamline thedocument, support flexible implementation by a broader rangeof NSW health facilities/clinical services/clinical units and alignwith the NSQHS Recognising and Responding to AcuteDeterioration Standard (second edition).December2013(PD2013_049)Deputy DirectorGeneral,Governance,Workforce andCorporateReplaces PD2011_077. Additional guidance for paediatric,maternity and emergency department implementation.December2011(PD2011_077)Director-GeneralReplaces PD2010_026. Altered calling criteria section 5.2May 2010(PD2010_026)Director-GeneralNew Policy ATTACHMENTS1. Recognition and Management of Patients who are Deteriorating: ProceduresRecognition and management of patients who are deterioratingPD2020_018 Issue date: June-2020 Contents pageNSW HEALTH PROCEDURECONTENTS1 BACKGROUND………………………………………………………………………………………………………… 11.1 Roles and responsibilities……………………………………………………………………………………. 22 KEY TERMS …………………………………………………………………………………………………………….. 43 GOVERNANCE ………………………………………………………………………………………………………… 84 ASSESSMENT OF DETERIORATION………………………………………………………………………. 104.1 Assessment …………………………………………………………………………………………………….. 104.2 Standard clinical tools……………………………………………………………………………………….. 114.3 Minimum requirements for vital sign monitoring …………………………………………………… 124.4 Individualised monitoring and assessment plans………………………………………………….. 154.5 Alterations to calling criteria……………………………………………………………………………….. 154.6 Vital sign monitoring for patients in non-hospital/residential care settings……………….. 174.7 Palliative care and last days of life ……………………………………………………………………… 175 CLINICAL EMERGENCY RESPONSE SYSTEMS……………………………………………………… 185.1 CERS in specialty areas……………………………………………………………………………………. 195.2 Clinical review process ……………………………………………………………………………………… 205.3 Rapid response process……………………………………………………………………………………. 205.4 Patient transfer processes…………………………………………………………………………………. 225.4.1 Intra-hospital transfer processes ……………………………………………………………… 225.4.2 Inter-facility transfer processes………………………………………………………………… 225.4.3 Transferring patients from non-hospital/residential care settings …………………. 226 EDUCATION…………………………………………………………………………………………………………… 237 EVALUATION…………………………………………………………………………………………………………. 248 REFERENCES………………………………………………………………………………………………………… 269 RELATED DOCUMENTS…………………………………………………………………………………………. 279.1 National…………………………………………………………………………………………………………… 279.2 NSW Health …………………………………………………………………………………………………….. 2710 APPENDICES…………………………………………………………………………………………………………. 2910.1 Example roles and responsibilities for the Deteriorating Patient Safety Net System…. 2910.2 Response instructions on the standard observations charts for hospital settings …….. 3210.2.1 Blue zone response ……………………………………………………………………………….. 3210.2.2 Yellow zone response…………………………………………………………………………….. 3210.2.3 Red zone response………………………………………………………………………………… 33Recognition and management of patients who are deterioratingPD2020_018 Issue date: June-2020 Page 1 of 33NSW HEALTH PROCEDURE1 BACKGROUNDFailure to recognise and appropriately manage patient physiological and mental statedeterioration is a contributing factor in many adverse events in hospitals and health careorganisations around the world.(1-6) Evidence derived from clinical incident reporting inNSW has demonstrated the same problem exists in NSW health services.(3)Between the Flags was developed by the Clinical Excellence Commission incollaboration with clinical experts. It is based on research into patient clinical deteriorationinitiated in NSW and published in the international literature.(3, 6) Between the Flagsprovides the foundation for the NSW Deteriorating Patient Safety Net System, which isstrengthened by the integration of other programs and frameworks, such as: Sepsis KillsEnd of LifePatient, carer and family escalation, known as R.E.A.C.H, and  Take 2, Think, Do framework for diagnostic error.The Deteriorating Patient Safety Net System has five components:1. Governance: structures and processes to support implementation, managementand quality improvement at Local Health District (LHD)/Specialty Health Network(SHN), facility, clinical service and clinical unit level2. Standard Clinical Tools: including observation charts with standard callingcriteria for clinical review and rapid response, and approved local clinicalmanagement guidelines/pathways that outline the Clinical Emergency ResponseSystem (CERS) response and support documentation3. Clinical Emergency Response System (CERS): a local system for theescalation of care that is used by staff, patients, carers and families4. Education: tiered education for clinicians to develop and reinforce clinical andnon-technical skills in recognising and responding to patients who aredeteriorating5. Evaluation: evaluation strategy that includes a family of measures (outcome,process and balancing measures) for monitoring the performance and improvingthe effectiveness of the Deteriorating Patient Safety Net System.The Deteriorating Patient Safety Net System addresses criteria within the AustralianCommission on Safety and Quality in Health Care’s Recognising and Responding toAcute Deterioration Standard.Recognition and management of patients who are deterioratingPD2020_018 Issue date: June-2020 Page 2 of 33NSW HEALTH PROCEDURE1.1 Roles and responsibilitiesClinical Excellence Commission Identify and advise the NSW Ministry of Health and public health organisations(PHOs) on available strategies, standards and tools to support continuedimprovement of the NSW Health Deteriorating Patient Safety Net System.Support clinicians and relevant Executives/Directors of Clinical Governance (DCGs) to implement, monitor and improve the Deteriorating Patient Safety NetSystem across NSW. Monitor and evaluate the implementation of local Deteriorating Patient Safety NetSystems and provide advice to PHOs to make changes, as required. Health Education and Training Institute Work in collaboration with the CEC on the development of education programcontent.State wide education and training and management of the learning pathways forthe Deteriorating Patient Program.Provide advice on educational standards and governance of content in the statewide learning management system. Local Health Districts & Specialty Health Networks Assign responsibility, personnel and appropriate resources to implement all therequirements of this Policy.Ensure the requirements of this Policy are effectively implemented, includingsystem governance, standard clinical tools, CERS, education and evaluation.Work with NSW Ambulance in the development, implementation and monitoring oflocal CERS where the provision of CERS Assist is required. HealthShare NSW Incorporate the core principles of Deteriorating Patient Safety Net System andclinical handover into non-emergency transport clinical practice, whereappropriate.Support PHOs with the implementation of the Deteriorating Patient Safety Net System/s, where required.NSW Ambulance Incorporate the core principles of the Deteriorating Patient Safety Net System andclinical handover into Ambulance clinical practice, where appropriate.Support PHOs with the implementation of the Deteriorating Patient Safety NetSystem, including the provision of CERS Assist, where required. Recognition and management of patients who are deterioratingPD2020_018 Issue date: June-2020 Page 3 of 33NSW HEALTH PROCEDUREeHealth NSW Ensure that the design and build of electronic medical record functionality andclinical decision support tools align with the standards and principles outlined inthis document.Ensure that relevant electronic medical record functionality and clinical decisionsupport tools are maintained and continuously improved where required.Support PHOs, as required, to implement applicable electronic medical record functionality and clinical decision support tools that align with the standards andprinciples outlined in this document.Recognition and management of patients who are deterioratingPD2020_018 Issue date: June-2020 Page 4 of 33NSW HEALTH PROCEDURE2 KEY TERMS Acutealterations tocallingcriteriaAlterations made to calling criteria for a condition where the patient’sobservations will fall outside the standard parameters for a definedperiod of time, while treatment is taking effect. Acute alterations tocalling criteria are set for a defined period of time (not longer than 8hours), after which they revert back to standard calling criteria.Patients with acute alterations to calling criteria must have dailymedical reviews to ensure their clinical progress aligns with thepatient’s treatment plan.AdditionalcriteriaSigns or symptoms of deterioration depicted on the standardobservation chart that a patient may exhibit outside of, or in additionto, the standard calling criteria for vital sign observations.Agreed signsofdeteriorationSigns or symptoms of deterioration that a patient may exhibit outsideof, or in addition to, the standard calling criteria and additional criteriathat are agreed following engagement of the patient, carer and family,and tailored to the patient’s specific circumstances.AlteredcallingcriteriaChanges made to the standard calling criteria by the AMO/delegatedclinician responsible, to take account of a patient’s uniquephysiological circumstances and/or medical condition. Alterations maybe ‘acute’ or ‘chronic’.A-GsystematicAssessmentA structured approach to physical assessment that considers apatient’s Airway, Breathing, Circulation, Disability, Exposure, Fluids,Glucose.AttendingMedicalOfficer (AMO)/ DelegatedclinicianresponsibleSenior medical practitioner who has primary or delegatedresponsibility and accountability for a patient on a temporary orpermanent basis. For an inpatient, this is the named AttendingMedical Officer (AMO) or another consultant, staff specialist or visitingmedical officer with delegated responsibility. As defined in localguidelines and following a risk assessment, the delegated clinicianresponsible may also be a senior clinician such as a nursepractitioner.In the non-hospital/residential setting this may be the patient’s generalpractitioner.Balancingmeasure/sA unit of data that measures whether changes to one part of a systemhave an impact on another part of the system and the size of theeffect.BehaviourchangeChanges to the way a patient interacts with other people or theirenvironment that deviate from their baseline or their expectedresponse, based on developmental age. Changes may present asshifts in cognitive function, activity/tone, perception, or emotional Recognition and management of patients who are deterioratingPD2020_018 Issue date: June-2020 Page 5 of 33NSW HEALTH PROCEDURE state, such as abnormal thinking, irritability, agitation, inconsolabilityand/or delirium.Blue zoneA coloured zone on the standard clinical tools that requires anincrease in the frequency of observation. Staff are to consider callingfor an early clinical review.ClinicalEmergencyResponseSystem(CERS)A formalised system for staff, patients, carers and families to obtaintimely clinical assistance when a patient deteriorates (physiologicaland/or mental state). The CERS includes the facility-based andspecialty unit based responses (clinical review and rapid response),as well as the formalised referral and escalation steps to seek expertclinical assistance and/or request for transfer to other levels of carewithin the facility (intra-facility) or to another facility (inter-facility).CERS AssistA NSW Ambulance program whereby urgent additional clinicalassistance is provided in response to a rapidly deteriorating patient(red zone observations or additional criteria) in a public health carefacility.Chronicalteration tocallingcriteriaAlterations to calling criteria where a patient has a chronic (lasting >3months) health condition which causes their normal observations tofall outside standard parameters. Chronic alterations are set for theduration of the patient’s episode of care and are reviewed duringroutine medical review and assessment of the patient.ClinicalReviewA review of a deteriorating patient undertaken within 30 minutes bythe clinical team responsible for the patient’s care, or designatedresponder/s, as per the local CERS protocol.Clinical teamresponsiblefor thepatient’s careThe clinicians, led by the AMO/delegated clinician responsible, whoare involved in, and responsible for, the care of the patient on atemporary or permanent basis. In most cases this is the medical teamunless otherwise specified.ClinicalserviceA health professional or group of professionals who work in cooperation and share common facilities or resources to provideservices to patients for the assessment, diagnosis and treatment of aspecific set of health-related problems/conditions in a facility or in thecommunity.Clinical unitA subset of a facility or service with a special clinical function.Clinician/sMedical, nursing, midwifery and allied health professionals whoprovide direct patient care.Deteriorationin mentalstateA negative change in a person’s mood or thinking, marked by achange in behaviour, cognitive function, perception or emotional state.Changes can be gradual or acute; they can be observed by membersof the workforce, or reported by the person themselves, or their familyor carers. Deterioration in a person’s mental state can be related to Recognition and management of patients who are deterioratingPD2020_018 Issue date: June-2020 Page 6 of 33NSW HEALTH PROCEDURE several predisposing or precipitating factors, including mental illness,psychological or existential stress, physiological changes, cognitiveimpairment (including delirium), intoxication, withdrawal fromsubstances, and responses to social context and environment.(7)DeterioratingPatient SafetyNet SystemThe NSW Health Deteriorating Patient Safety Net System referscollectively to the various individual programs and frameworksimplemented by NSW Health facilities/clinical services or clinical unitsto support the recognition and appropriate management of patientswho deteriorate.End of lifeRefers to the timeframe an individual is clearly approaching the end oftheir life and is living with and/or impaired by a life-limiting illness. Thisincludes the patient’s last weeks or days of life, when deterioration isirreversible and when a patient is likely to die in the next 12months(10).FacilityA building or structure where healthcare is provided by a public healthorganisation, such as a hospital, multi-purpose centre or office-basedclinic.Family ofmeasuresA collection of outcome, process and balancing measures thatmonitor many facets of the system and provides a framework tounderstand the impact of changes.IndividualisedmonitoringandassessmentplanA plan for assessing and monitoring the patient’s clinical situation thatconsiders their diagnosis, clinical risks, goals of care and proposedtreatment, and specifies the vital signs and other relevantphysiological and behavioural observations to be monitored and thefrequency of monitoring(7, 8).ISBARAn acronym for Introduction, Situation, Background, Assessment,Recommendation, a structured communication tool.Last days oflifeRefers to the last 24-72 hours of life when treatment to cure or controlthe person’s disease has stopped and the focus is on physical andemotional comfort and social and spiritual support.New onsetconfusionA disturbance of consciousness, attention, cognition and perceptionthat develops over a short period of time (usually hours to a fewdays)(11).Outcomemeasure/sA unit of data that measures whether changes to the system have animpact on the intended recipient and the size of the effect.PalliativecareAn approach that aims to prevent and relieve suffering and improvethe quality of life of patients and their families who are facing theproblems associated with life-threatening illness through earlyidentification and assessment and treatment of pain and otherphysical, psychosocial and spiritual issues(10).ProcessA unit of data that measures whether the system is performing as it is Recognition and management of patients who are deterioratingPD2020_018 Issue date: June-2020 Page 7 of 33NSW HEALTH PROCEDURE measure/sintended to and that activities are occurring as planned, and theextent to which that is happening.Public healthorganisation(PHO)Local health districts, statutory health corporations and affiliatedhealth organisations (with respect to their recognised services) thatprovide direct patient care.RapidresponseAn urgent review of a deteriorating patient by a rapid response team(RRT), or designated responder/s, as defined in the local CERSprotocol.R.E.A.C.HAn acronym for Recognise, Engage, Act, Call, Help is on its way.R.E.A.C.H is a CEC program for patients, carers and families todirectly escalate concerns about deterioration through the localCERS.Red zoneColoured zone on the standard clinical tools that represent warningsigns of deterioration for which a rapid response call (as defined bythe local CERS protocol) is required.ResuscitationPlansA medically authorised order to use or withhold resuscitationmeasures (formerly called ‘No CPR Orders’). Resuscitation Plans canalso be used to document other time-critical clinical decisions relatedto end of life.A Resuscitation Plan is made:Resuscitation Plans are intended for use for patients 29 days andolder in all NSW PHOs, including acute facilities; sub-acute facilities;ambulatory and community settings; and by NSW Ambulance (12).Special CareNurseryA clinical unit with space designated for the care of neonates whorequire additional support, or who need additional monitoring and/orobservation(13,18).StandardcallingcriteriaSigns and symptoms that a patient is deteriorating and may requirereview of their monitoring plan or escalation of care through theClinical Emergency Response System to appropriately manage thedeterioration. Standard calling criteria are depicted on standardobservation charts as blue, yellow and red zones.Standardclinical toolsA tool or resource that supports clinicians to recognise when a patientis deteriorating and outlines the appropriate response, such as thesepsis pathways; electronic fetal heart rate monitoring algorithm andlabels; Comfort Observation and Symptom Assessment chart; andResuscitation Plan, as well as the NSW Health standard observation  With reference to pre-planning by patients (such as AdvanceCare Directives or plans) In consultation with patients, carers and families Taking account of the patient’s current clinical status, as well astheir wishes and goals of care. Recognition and management of patients who are deterioratingPD2020_018 Issue date: June-2020 Page 8 of 33NSW HEALTH PROCEDURE charts.StandardobservationchartStandardised observation chart approved for use by the NSW Ministryof Health. These have been developed for a variety of clinical settings.Track andtrigger toolA tool, such as the standard observation chart, that records vital signobservations and allows them to be tracked over time to supportidentification of a change in the patient’s condition that requires areview and/or change in management or frequency of observation.Transfer ofcareThe transfer of professional responsibility and accountability for someor all aspects of care for a patient, or group of patients, to anotherperson or professional group on a temporary or permanent basis. Alsoknown as clinical handover.Yellow zoneColoured zone on the standard observation charts and standardclinical tools that represent warning signs of deterioration for which aclinical review or other CERS call may be required. 3 GOVERNANCEPublic health organisations (PHOs) need to have a clearly defined governance system inplace at LHD/SHN level and facility/clinical service/clinical unit level to oversee themanagement and continuous improvement of the local Deteriorating Patient Safety NetSystem.At the LHD/SHN level, the governance system needs to: Provide leadership to support the management and continuous improvement ofthe Deteriorating Patient Safety Net System locallyEstablish and articulate clear objectives and expectations for the DeterioratingPatient Safety Net System that align with the standards and principles outlined inthis policyProvide a framework, endorsed by the Director of Clinical Governance or other responsible senior executive, for determining exemptions for specialty clinical unitswhere patients are appropriately monitored and care is escalated as required,such as intensive care units, coronary care units and operating theatres, fromusing the NSW Health Standard Observation Charts Delegate clear roles, responsibilities and accountabilities to personnel atfacility/clinical service/clinical unit level to lead, manage and continuously improvethe Deteriorating Patient Safety Net SystemDetermine the education and training requirements for all staff involved in the management and continuous improvement of the Deteriorating Patient Safety NetSystem at a facility/clinical service/clinical unit level, including those with delegatedroles, responsibilities and accountabilities for managing the systemRecognition and management of patients who are deterioratingPD2020_018 Issue date: June-2020 Page 9 of 33NSW HEALTH PROCEDURE Review regular reports and monitor performance of the Deteriorating PatientSafety Net System across facilities, clinical services and clinical unitsCommunicate with stakeholders, including patients, carers, families, clinicians and the Clinical Excellence Commission, to provide feedback on the performance andeffectiveness of the Deteriorating Patient Safety Net System.At the facility/clinical service or clinical unit level, the governance system needs tosupport the following functions: Facilitate collaboration between patients, carers and families, clinicians andmanagers to design, implement, monitor and continuously improve theDeteriorating Patient Safety Net System consistent with the objectives andexpectations of the LHD/SHN, including a local CERS protocol that meets therequirements outlined in this Policy Support the development of organisational policies and procedures relevant to theDeteriorating Patient Safety Net System that reflect the role, capacity andcapability of the facility/clinical service or clinical unit in hospital and non-hospitalsettings Delegate clear roles, responsibilities and accountabilities to appropriately skilledand trained personnel for managing and improving the local Deteriorating PatientSafety Net SystemEnsure clinicians with delegated roles, responsibilities and accountabilities under the local Deteriorating Patient Safety Net System are oriented to the system anddemonstrate a clear understanding of their roles, responsibilities andaccountabilities, including contracted staff, locums and clinicians on rotatingrosters Provide opportunities for clinicians to complete the required education and trainingrelevant to their delegated role in the local Deteriorating Patient Safety Net Systemand maintain records of completionEnsure that clinicians with delegated responsibilities under the local DeterioratingPatient Safety Net System are appropriately credentialedSupport use of appropriate standard clinical tools/approved local clinical management guidelines or pathways as part of the local Deteriorating PatientSafety Net System, including approved NSW Health standard observation chartsunless exempt Ensure that adequate resources (personnel and equipment), are allocated,available and fit-for-purpose to support the delivery of high-quality care as part ofthe Deteriorating Patient Safety Net SystemCollect and report data and information on the performance and effectiveness of the Deteriorating Patient Safety Net system to the LHD/SHN, relevant localcommittees, clinicians, patients, carers and families to facilitate qualityimprovementRecognition and management of patients who are deterioratingPD2020_018 Issue date: June-2020 Page 10 of 33NSW HEALTH PROCEDURE Monitor variation in practice against expected outcomes and provide feedback toclinicians on variation in practice and health outcomes to inform improvements inthe Deteriorating Patient Safety Net SystemRegularly test the local Deteriorating Patient Safety Net System and/or processes through mock drills or simulated exercises where these events are infrequent orwhen there are significant changes to the context of service delivery.Clinicians using, and/or with delegated roles, responsibilities and accountabilities underthe Deteriorating Patient Safety Net System are to: Actively take part in the design, implementation, monitoring and improvement ofthe local Deteriorating Patient Safety Net SystemUnderstand and perform their delegated roles and responsibilities, as per theirlocal Deteriorating Patient Safety Net SystemParticipate in education and training related to the Deteriorating Patient Safety NetSystem, including education and training that focuses on culturally appropriateengagement of patients, carers and families and shared decision makingReview their clinical practice and performance of their roles, responsibilities and accountabilities under the Deteriorating Patient Safety Net System and use theinformation to implement improvements to the system and changes to practice.The allocation of roles, responsibilities and accountabilities under the DeterioratingPatient Safety Net System will vary depending on the health services’ local context,availability of resources and models of care. Some examples of the key roles,responsibilities and accountabilities that might be allocated to personnel as part of a localDeteriorating Patient Safety Net System are outlined in Appendix 10.1.4 ASSESSMENT OF DETERIORATION4.1 AssessmentAssessment of a patient needs to, at a minimum, include a systematic A-G assessmentand be documented in the patient’s health care record, as per the requirements outlinedin NSW Health Policy Health Care Records – Documentation and Management(PD2012_069). To establish the patient’s baseline and agree on other patient-specificsigns of deterioration initially, assessment needs to: Include a comprehensive systematic physical and mental state assessment Consider any pre-morbid conditions and where accessible, medical or clinicalhistory documented in health care records Engage patients, carers, families and where appropriate, the patient’s generalpractitioner, case manager or other clinicians familiar with their care.Ongoing assessment is to involve the patient, their carer/s and family in monitoringchanges in their physical and mental state and vital sign observations, as well asinterpretation of clinical information and trends.Recognition and management of patients who are deterioratingPD2020_018 Issue date: June-2020 Page 11 of 33NSW HEALTH PROCEDUREThe frequency of assessment is to be increased above the minimum requirementsoutlined in Table 2 when: The patient’s vital sign observations fall within a coloured zone on a standardobservation chart Assessment identifies other signs and symptoms of deterioration A CERS call has been made.Assessment is to be respectful of, and sensitive to, the cultural and religious needs of thepatient, including their personal preferences, cultural values, language and kinshipsystems. Patients and carers are also to be given information and education of theimportance of communicating concerns around signs of deterioration.4.2 Standard clinical toolsStandard clinical tools support clinicians to assess patients, recognise when they may bedeteriorating and outline the appropriate escalation of care.The standard observation charts approved by the NSW Ministry of Health arestandardised clinical tools designed using human factors principles. The chartsincorporate colour-coded calling criteria and a ‘track and trigger’ format to alert cliniciansto patients who are deteriorating, by graphically ‘tracking’ their vital sign observationsover time and ‘triggering’ an appropriate escalation of care based on the coloured callingcriteria. The charts also include a list of additional colour-coded escalation criteria thatinclude other standard signs and symptoms of deterioration.All NSW Health services are to use the approved standard observation charts as part oftheir Deteriorating Patient Safety Net System, unless they have an exemption issued bytheir LHD/SHN to use alternative charts. Specialty clinical units where patients areappropriately monitored and care is escalated as required, such as intensive care units,coronary care units and operating theatres, may be exempt from using the standardobservation charts, as per section 3.Where facilities or clinical services use electronic versions of the standard observationcharts, processes must be in place to ensure documentation of vital sign observationscan continue to be completed during system outages.The standard observation charts have three colour-coded zones:Blue zone: (where applicable) represents criteria for which increasing the frequencyof observations and/or increased vigilance is requiredYellow zone: represents early warning signs of deterioration and the criteria for whicha clinical review (or other CERS) call may be requiredRed zone: represents late warning signs of deterioration and criteria for which a rapidresponse call is required.Appendix 10.2 provides further details of required actions when each zone is triggered.Other standard clinical tools, such as the sepsis pathways, electronic fetal heart ratemonitoring algorithm and labels, Comfort Observation and Symptom Assessment Chart,Recognition and management of patients who are deterioratingPD2020_018 Issue date: June-2020 Page 12 of 33NSW HEALTH PROCEDUREand Resuscitation Plan, have been designed to align with the colour-coded calling criteriaused on the standard observation charts. The coloured zones on the standard clinicaltools outline the appropriate response and these are to be incorporated as part of thelocal CERS.Local clinical management guidelines or clinical pathways may be developed forspecialty areas or groups of patients with clinical indications for more or less frequentmonitoring. Local clinical management guidelines and clinical pathways need to outlinethe criteria for escalation of care (coloured zones); be approved using the localgovernance system; and incorporated into the local CERS.4.3 Minimum requirements for vital sign monitoringThe minimum set of vital signs and frequency of observations for different patient groupsare outlined in Table 2 below.In addition to the minimum requirements, a full set of vital sign observations must betaken and documented in the patient’s health care record: At the time of admission or initial assessment (this excludes the brief clinicalassessment conducted as part of the triage process on arrival to the EmergencyDepartment) Within one (1) hour prior to discharge from a facility, clinical service or clinical unit. Prior to and following transfer of care between a facility, clinical service or clinicalunit.A medical officer may only prescribe the frequency of vital sign observations below theminimum requirements following an assessment of the patient and with authorisationfrom the AMO/delegated clinician responsible for the patient’s care.Where a medical officer is not available onsite, a registered nurse/midwife or allied healthprofessional may vary the frequency of observations below the minimum frequencyoutlined in Table 2, with authorisation from the AMO/ delegated clinician responsible forthe patient. This must be arranged via phone order and follow agreed local procedures.Table 2: Minimum number and frequency for vital sign observations PatientgroupMinimum requiredfrequency ofassessmentMinimum set of vital signobservationsCommentsAdultinpatientsFour (4) times per dayat six (6) hourlyintervals.Respiratory rate, oxygensaturation, heart rate, bloodpressure, temperature, level ofconsciousness, new onsetconfusion or behaviourchange*, pain scoreIncluding pregnant womengreater than twenty (20) weeksgestation and less than six (6)week post-partum admitted fora condition unrelated topregnancy who are monitoredon the Standard MaternityObservation Chart (SMOC).Mental healthacute andThree (3) times perday at eight (8) hourlyRespiratory rate, oxygensaturation, heart rate, bloodMental state assessment ofpatients within a mental health Recognition and management of patients who are deterioratingPD2020_018 Issue date: June-2020 Page 13 of 33NSW HEALTH PROCEDURE PatientgroupMinimum requiredfrequency ofassessmentMinimum set of vital signobservationsCommentssubacuteintervals for aminimum of 48 hours.Then daily thereafter.pressure, temperature, level ofconsciousness, pain scoreinpatient unit are to becompleted in line withEngagement and Observationin Mental Health Inpatient UnitsPD2017_025.Mental healthnon-acuteThree (3) times perday at eight (8) hourlyintervals for aminimum of 48 hours.Then monthlythereafter.Respiratory rate, oxygensaturation, heart rate, bloodpressure, temperature, level ofconsciousness, pain scorePatients with active comorbidphysical health conditions oraged 65 years and over are tohave observations no less thanweekly and are to have acomprehensive systematicphysical assessmentcompleted at least monthly.Hospital inthe HomeAt least once duringeach consultation/visit(17)To be determined locallybased on the models of careand assessment of riskSpecial CareNurserySix (6) times per dayat four (4) hourlyintervalsRespiratory rate, respiratorydistress, oxygen saturation,heart rate, temperature,behaviour change*, pain scoreNewbornBefore leaving thebirthing environmentOne (1) full set of vitalsigns observations anda newborn riskassessment completedIf perinatal risk factorsare identified and/orobservations within theblue, yellow or redzone and/or additionalcriteria present, furtherobservations must berecorded on aStandard NewbornObservation Chart(SNOC) six (6) timesper day at four (4)hourly intervals.Respiratory rate, oxygensaturations, heart rate andtemperatureNewborns with low or noidentifiable risk factors are tobe monitored/assessed in-linewith local protocols.PaediatricinpatientsSix (6) times per dayat four (4) hourlyintervalsRespiratory rate, respiratorydistress, oxygen saturation,heart rate, temperature, levelof consciousness, new onsetconfusion or behaviourchange*, pain scoreBaseline blood pressure (BP) isrequired within 24 hours ofadmission. Additional BPs areto be taken as clinicallyindicated (PD2010_32) Recognition and management of patients who are deterioratingPD2020_018 Issue date: June-2020 Page 14 of 33NSW HEALTH PROCEDURE PatientgroupMinimum requiredfrequency ofassessmentMinimum set of vital signobservationsCommentsMaternity/antenatalinpatientFour (4) times per dayat six (6) hourlyintervals.Respiratory rate, oxygensaturation, heart rate, bloodpressure, temperature, level ofconsciousness, new onsetconfusion or behaviourchange*.For fetal heart rate monitoringrequirements refer to Maternity– Fetal heart rate monitoringGL2018_025SMOC is recommended forwomen greater than twenty(20) weeks gestation and lessthan six (6) week post-partum.Maternity/postnatalinpatient withno identifiedrisk factorsBefore leaving thebirth environmentOne (1) full set of vitalsigns observations anda maternity riskassessmentcompleted.Respiratory rate, oxygensaturation, heart rate, bloodpressure, temperature, level ofconsciousness, new onsetconfusion or behaviourchange*, accumulated bloodloss.If a woman has observations ina coloured zone or identifiedrisk factors, vital signobservations are to beperformed four times per day atsix hourly intervals.Women receiving midwiferycare in the home are to bemonitored according to localprotocol, refer to section 4.6.Maternity/postnatalinpatient withrisk factorsFour (4) times per dayat six (6) hourlyintervals.Respiratory rate, oxygensaturation, heart rate, bloodpressure, temperature, level ofconsciousness, new onsetconfusion or behaviourchange*, accumulated bloodloss.SMOC is recommended forwomen greater than twenty(20) weeks gestation and lessthan six (6) week post-partum.Inpatientsub-acute/long stay/rehabilitationTwice a day at amaximum interval of12 hours apartRespiratory rate, oxygensaturation, heart rate, bloodpressure, temperature, level ofconsciousness, new onsetconfusion or behaviourchange*, pain scoreIf a patient develops an acutemedical/ physiological problemthe required frequency ofobservations reverts to aminimum of four (4) times perday at six (6) hourly intervalsInpatientpalliativecareTwice a day at amaximum interval of12 hours apartRespiratory rate, oxygensaturation, heart rate, bloodpressure, temperature, level ofconsciousness, new onsetconfusion or behaviourchange*, pain scoreIf a patient develops acutemedical/physiological problemsare managed in line with theirgoals of care and ResuscitationPlanResidents inlong termcarefacilities,such as amultipurposeAt least once permonthRespiratory rate, oxygensaturation, heart rate, bloodpressure, temperature, level ofconsciousness, new onsetconfusion or behaviourThe frequency of observationsmay change depending on theresident’s condition and will bedetermined locally by theAMO/delegated clinicianresponsible for the resident’s Recognition and management of patients who are deterioratingPD2020_018 Issue date: June-2020 Page 15 of 33NSW HEALTH PROCEDURE PatientgroupMinimum requiredfrequency ofassessmentMinimum set of vital signobservationsCommentsservice(MPS)change*, pain scorecare.Additional vital signs may bedetermined as clinicallyappropriate for the patientcohort cared for in thesesettings, such as weight, andmonitored on a regular basis. * Includes an assessment of the patient’s behaviour in the context of their developmental age and/orbaseline assessment, noting changes in their cognitive function, activity/tone, perception, or emotionalstate such as abnormal thinking, irritability, agitation, inconsolability and/or delirium.4.4 Individualised monitoring and assessment plansIt is recommended that patients with clinical needs which differ from approved clinicalmanagement guidelines have an individualised monitoring and assessment plan in place.An individualised monitoring and assessment plan takes into account the patient’s clinicalsituation, including their diagnosis, clinical risks, goals of care and proposed treatment,and specifies the vital signs and other relevant physiological/mental state observations tobe monitored, and the frequency of monitoring.Individualised monitoring and assessment plans, along with the rationale for the plan, areto be documented in the patient’s health care record.Patients, carers and families need to be engaged in the development of an individualisedmonitoring and assessment plan to ensure that it meets the patient’s needs.An AMO/delegated clinician responsible must authorise any individualised monitoringand assessment plan which varies the vital signs or other observations to be monitoredbelow the minimum requirements outlined in section 4.3, Table 2. This includes when thedelegated clinician responsible is a senior medical officer not employed or contracted bythe PHO, such as the patient’s treating general practitioner.If a patient with an individualised monitoring and assessment plan has observationswithin the blue, yellow or red zone, care must be escalated according to the appropriatezone response unless an alternative response is stipulated in their Resuscitation Plan.Following the initiation of a CERS call, the individualised monitoring and assessment planneed to be reviewed and the frequency of observations increased.4.5 Alterations to calling criteriaStandard calling criteria (blue, yellow or red zone parameters) may be altered and/orother agreed signs of deterioration identified, based on assessment of the patient’scondition and with input from patients, carers and families.A medical officer may alter the standard calling criteria following assessment of thepatient and engagement of patients, carers and families, and in consultation with theAMO/delegated clinician responsible.Recognition and management of patients who are deterioratingPD2020_018 Issue date: June-2020 Page 16 of 33NSW HEALTH PROCEDUREIf the AMO/delegated clinician responsible is not available onsite, a registerednurse/midwife or allied health professional responsible for vital sign observationmonitoring may alter calling criteria when prescribed by the AMO/delegated clinicianresponsible and following assessment of the patient. This process needs to be outlined inthe local CERS protocol, along with defined processes for altering calling criteria, aslisted in section 5, below.The local CERS protocol also needs to define processes for altering calling criteria,including: Documentation of the rationale for the new calling criteria in the patient’s healthcare recordAuthorisation of the alterations by the AMO/delegated clinician responsible,including when the delegated clinician responsible is a senior medical officer notemployed or contracted by the PHO, such as the patient’s treating generalpractitionerThe minimum timeframe for review of the altered calling criteria.Altered calling criteria are to only be used:To align the calling criteria with the patient’s baseline vital sign observationparameters when they are above or below the standard calling criteria. Establishment of the patient’s baseline is to be done in consultation with thepatient, carers and/or family and based on assessment of the patient If the course of the patient’s disease or condition, or recovery from a particularintervention, is expected to be above or below the standard calling criteriaIf the proposed changes to the standard calling criteria will improve detection ofpatient deterioration. A ‘chronic’ alteration may be set to align the calling criteria with the patient’s baseline vitalsign observation parameters. A chronic alteration may be set for the duration of thepatient’s episode of care and needs to be formally reviewed by the clinical teamresponsible for the patient’s care during routine assessments. A chronic alteration maybe set for patients treated in non-hospital or residential care settings, however time limitsfor the duration of the alteration must be set at the time the alteration is ordered anddocumented in the patient’s medical record.An ‘acute’ alteration may be set to align the calling criteria with the expected progressionof a patient’s disease or condition. Acute alterations are set for a defined period of time,not longer than 8 hours, before reverting back to the standard calling criteria on theappropriate standard observation chart. Acute alterations are not intended to be used forpatients who are cared for in a non-hospital or residential care setting.Special treatment plans, such as a Resuscitation Plan, which may also alter the responseto the red and yellow zone triggers, are to be documented in the patient’s health carerecord.Recognition and management of patients who are deterioratingPD2020_018 Issue date: June-2020 Page 17 of 33NSW HEALTH PROCEDURE4.6 Vital sign monitoring for patients in non-hospital/residential caresettingsIt is expected that patients who are receiving care outside of a hospital or in a residentialcare setting (such as outpatient clinics, community and primary health care services,midwifery care provided in the home or Hospital in the Home services) are monitored forsigns of deterioration and that protocols are in place to escalate care as required.For patients in these settings, monitoring of vital signs and other observations will dependon the: Patient’s clinical needs, risks and proposed treatmentEnvironment in which care is being deliveredScope of practice of the clinician providing careResources available to monitor and document vital signs and other observationsCapacity of the service to escalate care when required. Non-hospital and/or residential care settings need to develop local protocols thatestablish clear expectations for monitoring physiological or mental state deterioration,including the vital signs and other observations that will be monitored, how frequentlythey will be monitored and the criteria for escalation of care (coloured zones).Non-hospital and/or residential care facilities may implement a local clinical managementguideline or pathway for cohorts of patients who are frequently cared for or based on themodel of care that is provided. The minimum expectations for monitoring signs ofdeterioration need to consider clinical risks and be approved by the local governancesystem or relevant committee.Non-hospital and/or residential care settings may also consider using individualisedmonitoring and assessment plans for each patient. Where individualised monitoring andassessment plans are used in non-hospital/residential care settings, the requirementsoutlined in section 4.4 apply.4.7 Palliative care and last days of lifePatients admitted under palliative care services are to have an individualised monitoringand assessment plan and Resuscitation Plan that aligns with their goals of care. When itis identified that a patient under the care of any clinical service/clinical unit is dying or intheir last days of life, the use of standard observation charts is not appropriate. Thepatient’s individual monitoring and assessment plan and Resuscitation Plan are to bereviewed in consultation with the patient, carers and family to ensure comfort is observedand, where required, concerns escalated via the local CERS.Clinicians are to refer to the CEC Last Days of Life Toolkit for appropriate resources to: Ensure comfort is observed in patients whose death is expected, such as theComfort Observation and Symptom Assessment Chart; andFacilitate the accelerated transfer for the patient who wishes to die at home. Recognition and management of patients who are deterioratingPD2020_018 Issue date: June-2020 Page 18 of 33NSW HEALTH PROCEDURE5 CLINICAL EMERGENCY RESPONSE SYSTEMSA Clinical Emergency Response System (CERS) is a formalised system for obtainingprompt assistance from appropriately skilled and knowledgeable clinicians when a patienthas signs and symptoms of physiological or mental state deterioration.As the signs and symptoms of deterioration in mental state are often indicative of aphysiological/organic condition and not necessarily a sign of an acute mental healthcondition, the CERS response to these are to be same as for physiological deterioration.Organic causes of deterioration are to be considered prior to accessing specialtyexpertise from a mental health service.The CERS needs to: Operate 24 hours per day, 7 days per weekHave the capacity to manage multiple calls at any given time;Have contingency plans to account for known or unexpected absences of keypersonnel;Be known and understood by all clinicians.Be able to be activated by staff, patients, carers or families. NSW Health organisations are to develop and implement a local CERS across theirorganisation which includes: Procedures to enable patients, carers and families to directly escalate care within30 minutes to a clinician who is not routinely involved in the patient’s care. Theseprocedures must clearly identify how patients, carers and families may initiate theescalation and what the expected response is. Refer to the CEC’s R.E.A.C.Hprogram(22) Procedures to systematically and proactively identify patients at increased risk ofdeterioration, with appropriate mitigation strategiesProtocols that outline the actions to be taken to escalate care when a patient’sobservations breach a blue, yellow or red zone, including who will respond andhow they are to be contactedProcedures to review the provisional diagnosis and/or differential diagnosis by a second clinician following a CERS call, or when deterioration has not beenreversed Protocols for accessing secure clinical units or clinical services not physically colocated with an acute service that is responsible for responding to a CERS callwithin agreed timeframesProcedures for accessing specialty expertise in alignment with the facility, clinical service or clinical unit’s service capability framework or referral networkRecognition and management of patients who are deterioratingPD2020_018 Issue date: June-2020 Page 19 of 33NSW HEALTH PROCEDURE Protocols for intra- and inter-facility escalation that clearly identify who to refer to,how to contact them and how the transfer is to be conducted, consistent with theprinciples outlined in section 5.4 Defined skills, education and training requirements for clinicians with assignedresponsibilities as designated responders that align with the Deteriorating PatientEducation StrategyDefined roles and responsibilities for team leaders and members of the rapidresponse team (RRT)An agreed set of minimum core emergency equipment and medication consistent with best practice guidelines that is readily available throughout the facility, clinicalservice or clinical unit in accordance with the organisation-wide risk assessment,and approved by the governance system or relevant committee Procedures for orientation and training of staff on how to access and useequipment for advanced resuscitation, including specialist equipment forpaediatric, neonatal and maternity patientsA structured clinical handover tool, such as ISBAR, to communicate critical information, outcomes, alerts and risks during the escalation of care between theclinicians involved Requirements for documenting a CERS call, including the outcome of the call, thesubsequent medical management and monitoring plan, and a provisional and/ordifferential diagnosis in the patient’s health care recordPrompt communication with the patient, carers and families about the response to and outcome of any CERS calls.For facilities, clinical services or clinical units that have a formal arrangement with theNSW Ambulance or who use ‘CERS Assist’ as part of their escalation framework, thepoint at which escalation to NSW Ambulance is required must be outlined in the relevantprotocols and procedures.5.1 CERS in specialty areasSpecialty areas with the internal resources to manage clinical emergencies may use agraded and tailored response protocol for patient deterioration that uses a combination ofinternal specialty expertise and external support to escalate care. Areas that may requirea graded and tailored response protocol include emergency departments; maternitywards; neonatal intensive care or special care nurseries; and post-anaesthetic care units(recovery units).Where a facility, clinical service or clinical unit requires a graded and tailored responseprotocol, the organisation wide CERS must identify and include these specialty areaprotocols. A specialty area’s response protocol needs to:1. Identify the area to which the protocol applies2. Outline the types of deterioration that can be managed without external supportand the point at which external support needs to be calledRecognition and management of patients who are deterioratingPD2020_018 Issue date: June-2020 Page 20 of 33NSW HEALTH PROCEDURE3. Define the roles and responsibilities of both internal and external designatedresponders in managing, and reversing, patient deterioration4. Specify the minimum core emergency equipment and medication consistent withbest practice guidelines that is to be readily available and the location of these (inaccordance with the organisation-wide risk assessment), and approved by thegovernance system or relevant committee5. Define the skills, education and training requirements for clinicians with assignedresponsibility as a designated responder for that specialty area that align with theDeteriorating Patient Education Strategy6. Include a structured clinical handover tool, such as ISBAR, to communicate criticalinformation, outcomes, alerts and risks during the escalation of care between theclinicians involved.5.2 Clinical review processPrompt and effective clinical review is essential in managing patients who aredeteriorating and is to be undertaken (or supervised) by experienced staff.If a patient’s observations enter the yellow zone (based on vital sign observations and/oradditional criteria), the yellow zone response instructions on the appropriate standardobservation chart, standard clinical tool or approved local clinical managementguideline/pathway are to be followed. Unless specified otherwise, the decision to call aclinical review (or other CERS call) is to be made in consultation with the nurse/midwifein-charge or relevant clinical supervisor. The decision to escalate (or not) is to bedocumented in the patient’s health care record.For patients in hospital settings, a clinical review is to be undertaken by the clinical teamresponsible for the patient’s care (or another designated responder) within 30 minutes.Depending on the local CERS protocol, the clinical review may be undertaken by amedical officer on call or an appropriately experienced registered nurse/midwife(RN/RM), preferably First Line Emergency Care Course (FLECC) accredited, or postgraduate qualifications in emergency/critical care nursing, or credentialed in theprocedures of the relevant specialty.For patients in non-hospital or residential care settings, initiation of a clinical review mustfollow local procedure. The timeframe for review, the clinician most appropriate toundertake the review and other related responses need to be locally determined in linewith the implemented model of care and based on clinical risks associated with thedelivery of care. In these settings, the decision to initiate a clinical review also needs tobe made in consultation with a clinical supervisor and documented in the patient’s healthcare record.5.3 Rapid response processIf a patient’s observations enter the red zone (based on vital sign observations and/oradditional criteria), the red zone response instructions on the appropriate standardobservation chart, standard clinical tool or approved clinical management guideline are tobe followed, and a rapid response is to be activated as per the local CERS protocol.Recognition and management of patients who are deterioratingPD2020_018 Issue date: June-2020 Page 21 of 33NSW HEALTH PROCEDUREFor patients in hospital settings, the nurse/midwife-in-charge or equivalent relevantclinical supervisor must be informed that a rapid response call has been made, and theinstructions outlined on the appropriate standard observation chart, standard clinical tooland/or approved local clinical management guideline/pathway need to be followed.Where a rapid response is called for a patient who is on an end-of-life pathway, and theappropriate level of escalation is unclear, the AMO/delegated clinician responsible is tobe called, as well as the patient’s carer and/or family.The RRT members or designated responder/s must urgently attend a rapid response call,assess the patient, treat the underlying cause of deterioration and/or provideinterventions to resuscitate the patient.In small or rural health services, the designated responder may be an appropriatelyexperienced registered nurse/midwife (RN/RM), preferably First Line Emergency CareCourse (FLECC) accredited or with post graduate qualifications in emergency/criticalcare nursing, or credentialed in the procedures of the relevant specialty, or a paramedicwho attends as a result of a CERS Assist call.When responding to the deterioration of a maternity, paediatric or neonatal patient, atleast one member of the RRT or designated responder needs to be credentialed in theadvanced resuscitation techniques and procedures of that specialty.A facility, clinical unit or clinical service may implement a graded rapid response processbased on the: Severity of the patient’s condition and the reason for the call. For example,patients with an immediately life threatening condition, such as cardio-respiratoryarrest, airway obstruction, stridor, or are unresponsive, are prioritised to a rapidresponse team, and patients with red zone observations or additional criteria thatare not immediately life threatening are attended by a senior registrar orequivalent in the first instance Skills required to support a tailored response to a specialty area. For example, amaternity emergency managed by obstetric and midwifery staff who requireadditional airway support for immediate management and ICU support postintervention.This graded response needs to be risk assessed and approved by the relevant localcommittee/senior management, and clearly defined in the local CERS protocol.For patients in non-hospital or residential care settings, the initiation of a rapid responsemust be in accordance with the local procedure. The actions to be taken when a red zoneresponse is triggered need to be locally determined in line with the implemented model ofcare and based on the clinical risks associated with the delivery of care. In most cases,this will usually mean calling triple zero (000) for NSW Ambulance.Recognition and management of patients who are deterioratingPD2020_018 Issue date: June-2020 Page 22 of 33NSW HEALTH PROCEDURE5.4 Patient transfer processes5.4.1 Intra-hospital transfer processesPatients with observations in the red or yellow zone can only be transferred betweenclinical units when:1. The transferring responsible clinician approves the transfer2. There is an individualised monitoring and assessment plan in place, which mayinclude altered calling criteria3. The receiving clinical team responsible for the patient’s care is advised of theindividualised monitoring and assessment plan4. They have appropriate clinical support during transportation.5.4.2 Inter-facility transfer processesFor patients requiring transfer for specialist care, the processes for requesting andarranging transfers are outlined in the following documents:PD2011_031 – Inter-facility Transfer Process for Adults Requiring Specialist CarePD2018_011 – Critical Care Tertiary Referral Networks & Transfer of Care (ADULTS)PD2019_024 – Adult Mental Health Intensive Care NetworksPD2019_020 – Clinical HandoverPD2019_053 – Tiered Networking Arrangements for Perinatal Care in NSWGL2017_010 – NSW Paediatric Service Capability FrameworkPD2010_030 – Critical Care Tertiary Referral Networks (Paediatrics)PD2010_031 – Children and Adolescents Inter-facility TransfersGL2016_018 – NSW Maternity and Neonatal Service Capability FrameworkPD2018_002 – Service Specifications for Transport Providers, Patient Transport Service5.4.3 Transferring patients from non-hospital/residential care settingsPatients in non-hospital or residential care settings who require escalation of care willusually be referred to their general practitioner or an acute health care facility; this mayinvolve transfer via ambulance or other patient transport service.Staff in non-hospital or residential care settings are to refer to and follow their locallydetermined procedure for escalating care. Staff must support the transfer process bycommunicating relevant clinical information to the receiving health care professional orfacility through written documentation provided to the patient, carer or family,documenting notes in the patient’s health care record or verbally during clinical handover.This does not include patients who are cared for in the community as an admitted patientof a Hospital in the Home (HITH) service. HITH patients who deteriorate are to bemanaged as per the requirements outlined in GL2018_020 Adult and Paediatric Hospitalin the Home.Recognition and management of patients who are deterioratingPD2020_018 Issue date: June-2020 Page 23 of 33NSW HEALTH PROCEDURE6 EDUCATIONThis section is to be read in conjunction with the CEC Deteriorating Patient EducationStrategy which outlines the minimum training requirements for clinicians who providedirect patient care.All facilities/clinical services/clinical units are to have a documented local educationprogram that: Incorporates patients, carers and families in the co-design and delivery of locallyprovided deteriorating patient education and trainingEnsures all staff are aware of and know how to activate the local CERS, includingcontracted staff, locums and clinicians on rotating rostersDescribes the skills, knowledge, education and training requirements for allclinicians to understand how to engage and partner with patients, carers and families in the recognition and management of deteriorating patients, includingcultural awareness and cultural competency training Identifies appropriate education and training programs for clinicians to completethat align with the Deteriorating Patient Education StrategyDescribes the minimum skills, knowledge, education and training requirements onthe recognition and management of the deteriorating patient for all clinicians providing direct patient care, including completion of basic life support training Describes the skills, experience, education, training and credentialingrequirements for clinicians who are members of the RRT or are designatedresponders, including advanced life support trainingDetails the resources allocated to support clinicians to complete the requirededucation and training, including protected time offIdentifies specialty units that require clinicians to respond to and manage clinical emergencies within their own clinical service/clinical unit, and describe the skills,experience, education and training and credentialing requirements for theseclinicians, including team training and the non-technical skills component of theBTF Tier Three Framework Outlines the system for ensuring regular educational updates are provided forexisting clinicians, and the orientation and training of new clinicians on therecognition and management of the deteriorating patientIncorporates the components of the BTF education into other educational activities/opportunities, including: signs of physiological and mental statedeterioration; systematic A-G assessment, synthesising assessment findings andobservations to guide clinical decision making; expected trajectory of illness;appropriate escalation of care and the appropriate management of thedeteriorating patient; structured communication, handover and team work Outlines processes to reinforce structured communication techniques andsystematic patient assessment in daily clinical practice Recognition and management of patients who are deterioratingPD2020_018 Issue date: June-2020 Page 24 of 33NSW HEALTH PROCEDURE Identifies appropriate performance measures for monitoring satisfactorycompletion of required education and trainingDescribes the roles and responsibilities for the governance of the local education program, including responsibility for developing, implementing and monitoring theprogram.7 EVALUATIONAll PHOs need to have a measurement strategy in place to monitor the performance andeffectiveness of local Deteriorating Patient Safety Net Systems. The measurementstrategy is to outline a selection of outcome, process and balancing measures, includingthe collection and reporting of mandatory quality improvement measures: Rapid response call rate per 1,000 acute separations Cardio-respiratory arrest rate per 1,000 acute separations.Advice on collection and reporting of mandatory quality improvement measures, includingdefinitions and methods for collection, is provided by the NSW Ministry of Health as partof the LHD/SHN service agreements. Mandatory quality improvement measures areavailable on the CEC Quality Improvement Data System (QIDS).The outcome, process and balancing measures selected as part of the PHO’smeasurement strategy are to facilitate continuous quality improvement of localDeteriorating Patient Safety Net Systems. Details on developing a measurement strategyare provided in the Deteriorating Patient Measurement Strategy Guide.A list of example measures that could be used as part of a measurement strategy areprovided below. However, these are not exhaustive and facilities/clinical services/clinicalunits are to select the most meaningful measures for their context.Outcome measures: In-hospital mortality ratesPercentage of patients surveyed who report a positive experience Process measures: Rates/count/number of clinical review (yellow zone) callsRates/count/number of rapid response (red zone) callsRates/count/number for patient, carer and family (REACH) escalation callsPercentage of patients, carers and family members surveyed that know how toraise their concerns and if required make a patient, carer and family escalation(REACH) callPercentage of patients with a full set of observations completed at the requiredminimum frequency Recognition and management of patients who are deterioratingPD2020_018 Issue date: June-2020 Page 25 of 33NSW HEALTH PROCEDURE Percentage of patients with a full set of observations completed at initialassessment and prior to departure from a facility, clinical service or clinical unitPercentage of patients that have an increase in their observation frequencyfollowing triggering of a coloured zone and/or a CERS callPercentage of red zone triggers escalated to a rapid response callPercentage of yellow zone triggers escalated to a clinical review (or other CERS)callPercentage of patients with a Resuscitation PlanPercentage of patients transferred to a higher level of care following a CERS callPercentage of patients with alterations to calling criteriaPercentage of clinical staff that provide direct patient care who have completedtheir Deteriorating Patient mandatory training Balancing measure: In-hospital length of stayICU length of stayICU admission rates/occupancy ratesRe-presentation rates.When selecting measures to form their measurement strategy, PHOs are to:Consider the care provided by the facility, clinical service or clinical unit, the usualpatient cohort/s and the patients goals of careEnsure measures align with the aims and objectives of the system and anychanges/improvements made to itEngage with patients, carers and families to consider what factors are meaningfulto measure from a patient’s perspective. Performance reports are to be communicated to the LHD/SHN; clinicians and managers;patients, carers and families; and other key stakeholders and include an analysis of thedata identifying improvement opportunities and the impact of any improvementsimplemented by the facility, clinical service or clinical unit/s.Recognition and management of patients who are deterioratingPD2020_018 Issue date: June-2020 Page 26 of 33NSW HEALTH PROCEDURE8 REFERENCES1. Hillman KM, Chen J, Jones D. Rapid Response systems. The Medical journal of Australia.2014;201(9):519-21. Epub 2014/11/02.2. Jones DA, DeVita MA, Bellomo R. Rapid-response teams. The New England journal of medicine.2011;365(2):139-46. Epub 2011/07/15.3. Pain C, Green M, Duff C, Hyland D, Pantle A, Fitzpatrick K, et al. Between the flags: implementinga safety-net system at scale to recognise and manage deteriorating patients in the New South WalesPublic Health System. International Journal for Quality in Health Care. 2016:1-7.4. Chen J, Ou L, Flabouris A, Hillman K, Bellomo R, Parr M. Impact of a standardized RapidResponse system on outcomes in a large healthcare jurisdiction. Resuscitation. 2016;107:47-56. Epub2016/08/11.5. Jones D, Bhasale A, Bailey M, Pilcher M, Anstey MH. Effect of a National Standard forDeteriorating Patients on Intensive Care Admissions Due to Cardiac Arrest in Australia. Critical CareMedicine. 2018;46(4):586-93. Epub 2018/01/03.6. Green M, Lander H, Snyder A, Hudson P, Churpek M and Edelson D. Comparison of the Betweenthe Flags calling criteria to the MEWS, NEWS and the electronic Cardiac Arrest Risk Triage (eCART) scorefor the identification of deteriorating ward patients. Resuscitation. 2018;123:86-91.7. Australian Commission on Safety and Quality in Health Care (2017) National Safety and QualityHealth Service Standards In. Second edition ed, Sydney: ACSQHC. www.safetyandquality.gov.au/wpcontent/uploads/2017/12/National-Safety-and-Quality-Health-Service-Standards-second-edition.pdf8. Australian Commission on Safety and Quality in Health Care (2017) National consensusstatement: essential elements for recognising and responding to acute physiological deterioration In.Second edition ed, Sydney: ACSQHC. www.safetyandquality.gov.au/sites/default/files/migrated/NationalConsensus-Statement-clinical-deterioration_2017.pdf9. Australian Commission on Safety and Quality in Health Care (2017) National ConsensusStatement: Essential elements for recognising and responding to deterioration in a person’s mental state,Sydney: ACSQHC. www.safetyandquality.gov.au/sites/default/files/2019-06/national-consensus-statementessential-elements-for-recognising-and-responding-to-deterioration-in-a-persons-mental-state-july-2017.pdf10. NSW Health – Primary and Community Care (2019) End of Life and Palliative care framework2019-2024. www.health.nsw.gov.au/palliativecare/Pages/eol-pc-framework.aspx11. Australian Commission on Safety and Quality in Health Care (2016) Delirium Clinial CareStandard, Sydney: ACSQHC. www.safetyandquality.gov.au/sites/default/files/migrated/Delirium-ClinicalCare-Standard-Web-PDF.pdf12. Williams B. The National Early Warning Score and the acutely confused patient. Clin Med (Lond).2019;19(2):190-1. Epub 2019/03/16.13. Mohammed M. A., M. Faisal, D. Richardson, A. Scally, R. Howes, K. Beatson, et al. The inclusionof delirium in version 2 of the National Early Warning Score will substantially increase the alerts forescalating levels of care: findings from a retrospective database study of emergency medical admissions intwo hospitals. Clin Med (Lond). 2019;19(2):104-8. Epub 2019/03/16.14. Clinical Excellence Commission (2017) R.E.A.C.H Toolkit, Sydney: CEC.www.cec.health.nsw.gov.au/__data/assets/pdf_file/0007/362608/REACH-Toolkit-Updated-version-May-2017.pdfRecognition and management of patients who are deterioratingPD2020_018 Issue date: June-2020 Page 27 of 33NSW HEALTH PROCEDURE9 RELATED DOCUMENTS9.1 NationalAustralian Commission on Safety and Quality in Health CareNational Safety and Quality Health Service (NSQHS) Standards (second edition)National Consensus Statement: Essential elements for recognising and responding to acutephysiological deterioration (second edition)Recognising and Responding to Deterioration in Mental State: A Scoping ReviewNational Consensus Statement: essential elements for safe high quality end of life careNational Consensus Statement: Essential elements for safe high quality paediatric end-of-lifecareDelirium Clinical Care StandardNSQHS Standards User guide for health service organisations providing care for patients withcognitive impairment or at risk of deliriumNSQHS Standards User Guide for Aboriginal and Torres Strait Islander HealthNSQHS Standards User Guide for Health Service Providing Care for People with Mental HealthIssuesNSQHS Standards User Guide for Measuring and Evaluating Partnering with ConsumersNSQHS Standards (second edition) User Guide for Governing Bodies9.2 NSW HealthClinical Excellence Commission – Between the Flags Project: The Way ForwardClinical Excellence Commission – R.E.A.C.H ToolkitPD2012_069 Health Care Records – Documentation and ManagementGL2016_018 NSW Maternity and Neonatal Service Capability FrameworkGL2018_025 Maternity Fetal Heart MonitoringGL2018_016 Maternity – Resuscitation of the Newborn InfantGL2017_018 Maternity – Prevention, Detection, Escalation and Management of PostpartumHaemorrhage (PPH)IB2008_002 Fetal Welfare, Obstetric Emergency, Neonatal Resuscitation TrainingPD2019_053 Tiered Networking Arrangements for Perinatal Care in NSWPD2017_025 Engagement and Observation in Mental Health Inpatient UnitsPD2019_045 Discharge Planning and Transfer of Care for Consumers of NSW Health MentalHealth ServicesPD2015_004 Principles for Safe Management of Disturbed and/or Aggressive Behaviour andthe Use of RestraintGL2017_010 NSW Paediatric Service Capability FrameworkRecognition and management of patients who are deterioratingPD2020_018 Issue date: June-2020 Page 28 of 33NSW HEALTH PROCEDUREPD2010_034 Children and Adolescents: Guidelines for Care in Acute Care SettingsPD2010_032 Children and Adolescents – Admission to Services Designated Level 1-3Paediatric Medicine and SurgeryPD2010_031 Children and Adolescents – Inter-Facility TransfersGL2014_007 NSW Rural Paediatric Emergency Clinical Guidelines Second EditionPD2010_030 Critical Care Tertiary Networks (Paediatrics)PD2011_038 Children and Infants – Recognition of a Sick Baby or Child in the EmergencyDepartmentPD2018_011 Critical Care Tertiary Referral Networks and Transfer of Care (ADULTS)PD2011_031 Inter-Facility Transfer Process for Adults Requiring Specialist CareGL2020_004 Rural Adult Emergency Clinical GuidelinesPD2014_030 Using Resuscitation Plans in End of Life DecisionsGL2005_057 End-of-Life Care and Decision-MakingGL2005_056 Advance Care Directives (NSW) – UsingGL2018_020 Adult and Paediatric Hospital in the Home GuidelinePD2018_002 Service Specifications for Transport Providers, Patient Transport ServicePD2019_020 Clinical HandoverIB2018_048 2018-19 KPI and Improvement Measure Data SupplementGL2018_025 Maternity – Fetal Heart Rate MonitoringPD2018_010 Emergency Department Patients Awaiting CarePD2014_025 Departure of Emergency Department PatientsRecognition and management of patients who are deterioratingPD2020_018 Issue date: June-2020 Page 29 of 33NSW HEALTH PROCEDURE10 APPENDICES10.1 Example roles and responsibilities for the Deteriorating Patient SafetyNet SystemAMO/delegated clinician responsible (i.e. consultant / staff specialist / VMO) are to: Provide leadership to the clinical team responsible for the patient’s care, to ensurethey respond as per the local CERSSupport processes for, and awareness of, patient, carer and family escalationEnsure every patient, taking their diagnosis and proposed treatment into account,has an individualised assessment and monitoring plan specifying the vital signobservations and other relevant observations to be recorded and the frequency oftheseInvolve patients, families and carers in the development and review of documented individualised assessment and monitoring plans, medicalmanagement plans and resuscitation plans, to ensure they align with the patient’sgoals of care Ensure any alterations to calling criteria are reviewed for appropriateness, formallyauthorised, and documented in the patient’s health recordEnsure that a medical management plan (including the monitoring plan) is reviewed and documented for all patients following a CERS call (clinical review orrapid response).Members of the clinical team responsible for the patient’s care are to: Inform patients, carers and families of processes available to escalate theirconcerns about deteriorationInvolve patients, carers and families in the establishment of baseline observationparameters for patients to inform individualised assessment and monitoring plansand potential alterations to calling criteriaInvolve patients, carers and families in the establishment of their communicationpreferences and needsIn consultation with the AMO/delegated clinician responsible, document a clear individualised assessment and monitoring plan that specifies the vital signs andother relevant observations to be recorded and the frequency of the observations Identifies patients at increased risk of deterioration and deploys strategies tomitigate the risksDiscuss with, and seek authorisation from, the AMO/delegated clinicianresponsible for any alterations to calling criteria and document the rationale for these alterations in the patient’s health care recordRecognition and management of patients who are deterioratingPD2020_018 Issue date: June-2020 Page 30 of 33NSW HEALTH PROCEDURE Review and confirm the provisional diagnosis and/or proposed differentialdiagnosis and medical management plan, including an individualised assessmentand monitoring plan, for all patients following a clinical review or other CERS call,and communicate critical information about a patient’s care to the AMO/delegatedclinician responsible and other clinicians, as appropriate Communicate critical information, outcomes, alerts and risks to patients, carersand families following a clinical review and/or rapid response in a timely mannerEscalate care as per the local CERS. Nursing/Midwifery Unit Manager/supervisor or delegate (i.e. nurse/midwife-in-charge) isto: Support processes for, and awareness of patient, family and carer escalationProvide leadership in monitoring compliance with the minimum requirements ofthe Deteriorating Patient Safety Net System, such as completion of vital signobservations at the required frequencyDetermine the need for a clinical review for patients whose vital sign observationsare in the yellow zone, when additional yellow zone criteria is present or when clinicians, patients, carers or family are concerned about a patient’s deterioration,and call for a clinical review or other CERS call as required Continue to escalate care as per the local CERS in the event that a clinical reviewis not attended by the clinical team responsible for the patient’s care, ordesignated responder, within 30 minutesWork in partnership with, and communicate critical information to, the RRT duringa rapid response callSupport staff to complete relevant deteriorating patient education programs,including the allocation of protected time to attend required trainingIdentify opportunities to reinforce structured communication techniques and systematic patient assessment as covered in the BTF education program duringroutine clinical practice Provide feedback to the local Deteriorating Patient governing committee(s)regarding implementation of the five elements of the Deteriorating Patient SafetyNet System.Nursing/midwifery/allied health staff (within the related scope of practice) are to: Be aware of, and know how to activate, the local CERSInform patients, carers and families about how to escalate their concerns aboutdeteriorationConduct a systematic patient assessment, including documenting a full set of vitalsigns observations on an approved standard observation chart, at the frequencyspecified in their individual monitoring plan. In the absence of an individual Recognition and management of patients who are deterioratingPD2020_018 Issue date: June-2020 Page 31 of 33NSW HEALTH PROCEDUREmonitoring plan, refer to the appropriate approved local clinical managementguideline/pathway, or the minimum requirements outlined in Table 2 of this policy. When a coloured zone is triggered, follow the relevant coloured zone responseinstructions on the standard observation chart, standard clinical tool or approvedlocal clinical management guideline/pathway.Increase the frequency of observations and initiate appropriate clinical care when a patient’s systematic assessment triggers a blue zone response on the standardobservation chart, standard clinical tool or approved local clinical managementguideline/pathway. Promptly notify the Nursing/Midwifery Unit Manager or delegated nurse/midwife-incharge when a patient’s systematic assessment triggers a yellow zone responseon the standard observation chart, standard clinical tool or approved local clinicalmanagement guideline/pathway. Initiate a rapid response call and notify the Nursing/Midwifery Unit Manager ordelegated nurse/midwife-in-charge when a patient’s systematic assessmenttriggers a red zone response on the standard observation chart, standard clinicaltool or approved local clinical management guideline/pathway, or serious concernexists about a patient’s deterioration Document actions taken in relation to recognition, and management ofdeterioration in the patient’s health care recordWork in partnership with, and communicate critical information to, the RRT duringa rapid response callCommunicate critical information, outcomes, alerts and risks of any clinical review or rapid response calls to the Nursing/Midwifery Unit Manager or delegatednurse/midwife-in-charge, and the clinical team responsible for the patient’s care,if/when they are not involved in the process.Rapid response teams are to: Ensure patients are attended to urgently when required as part of the local CERSWork in partnership with, and communicate critical information to the clinical teamresponsible for the patient’s care during a rapid response callEnsure all rapid response calls are documented in the patient’s health care recordand outcomes are handed over to the clinician and the clinical team responsiblefor the patient’s careCommunicate critical information, outcomes, alerts and risks to patients, carersand families following a rapid response in a timely mannerHave a process to challenge or confirm the provisional diagnosis and/or proposed differential diagnosis, medical management and monitoring plan for all patientsfollowing a rapid response.Recognition and management of patients who are deterioratingPD2020_018 Issue date: June-2020 Page 32 of 33NSW HEALTH PROCEDURE10.2 Response instructions on the standard observations charts for hospitalsettings10.2.1 Blue zone responseIf a patient has any observations which breach the blue zone on a standard observationchart, standard clinical tool or approved local clinical management guideline/pathway,clinicians are to: Initiate appropriate clinical careIncrease the frequency of observations, as indicated by the patient’s condition.If a clinician is worried or unsure whether to initiate a CERS call, consult with the nurse-/midwife-in-charge or relevant clinical supervisor to decide whether a CERS call is to bemade, considering the following:What is usual for the patient and are there documented alterations to callingcriteria?Does the abnormal observation reflect deterioration in the patient?Is there an adverse trend in observations? 10.2.2 Yellow zone responseIf a patient has any observations or additional criteria which breach the yellow zoneobservations or additional criteria on a standard observation chart, standard clinical toolor approved local clinical management guideline/pathway, clinicians are to: Initiate appropriate clinical careRepeat and increase the frequency of vital sign observations, as indicated by thepatient’s conditionConsult promptly with the nurse /midwife-in-charge or relevant clinical supervisorto decide whether a clinical review (or other CERS) call is to be made.Together with the nurse/midwife-in-charge or relevant clinical supervisor, consider thefollowing:What is usual for the patient and are there documented alterations to callingcriteria?Does the trend in observations suggest deterioration?Is there more than one yellow zone observation or additional criterion?Are you concerned about your patient?If a clinical review is called:Reassess the patient and escalate according to the local CERS if the call is notattended within 30 minutes or there is increasing concernDocument a systematic A-G assessment, reason for escalation, treatment andoutcome in the patient’s health care record Recognition and management of patients who are deterioratingPD2020_018 Issue date: June-2020 Page 33 of 33NSW HEALTH PROCEDURE Inform the AMO/delegated clinician responsible that a call was made as soon as itis practicable. Where required, outcomes of the clinical review are to be documented into any relevantNSW Health, LHD/SHN or local database for capturing key performance indicators.A structured communication tool, such as ISBAR, is to be used when providing clinicalhandover to the AMO/delegated clinician responsible and/or the designatedresponder(s).The patient, carer and family are to be informed that a clinical review was activated andthe outcome of this review.10.2.3 Red zone responseIf a patient has any red zone observations or additional criteria on a standard observationchart, standard clinical tool or approved local clinical management guideline/pathway, arapid response call needs to be made. In addition, the clinicians are to: Initiate appropriate clinical careInform the nurse/midwife-in-charge or relevant clinical supervisor that a rapidresponse call has been initiatedRepeat and increase the frequency of vital sign observations, as indicated by thepatient’s conditionDocument a systematic A-G assessment, reason for escalation, treatment andoutcome in the patient’s health care recordInform the AMO/delegated clinician responsible that a call was made as soon as itis practicable. Members of the RRT or designated responder(s) are to attend urgently (as per the localCERS protocol) to assess the patient; treat the underlying cause of deterioration and/orprovide interventions to resuscitate the patient.The RRT leader is responsible for ensuring the outcome of the rapid response and theresultant medical management plan is entered into the patient’s health care record.Where required, outcomes of the rapid response call are also to be entered into anyrelevant NSW Health, LHD/SHN or local database for capturing key performanceindicators.A structured communication tool, such as ISBAR, is to be used when providing clinicalhandover to the AMO/delegated clinician responsible and/or the designatedresponder(s).The patient, carer and family are to be informed that a rapid response was activated andthe outcome of this response.