Clinical Excellence Commission CEO Professor Cliff Hughes, AO, draws upon boyhood memories of dangerous rips and the iconic success of Australian Surf Lifesaving to develop a “Between the Flags” protocol for better patient observation to save lives.
Between the Flags protocol keeps patients safe.Standfirst:
ONE MINUTE we two 12-year olds were enjoying the surf at Sydney’s Harbord Beach, the next we were struggling for our lives! A “dumper” wave had stolen our sandbank and we were swept seawards in the strong rip. A nearby surfer gave me a ride back to the beach, but my mate was in trouble. Struggling much further out than I, he was thankfully spotted by the lifesavers, who went after him on their boards and saved him from a terrible fate. A happy ending – thanks to the vigilance of those professionals with the red and yellow caps.
Not surprisingly, this drama made an indelible impression on me about the strengths of good process. I knew first-hand that it could save lives.
No surprise then, that in my role at the Clinical Excellence Commission, it came to mind as I considered the issue of deteriorating patients in our hospitals. My deliberations also reverberated with comments made by the now retired NSW Deputy State Coroner, Magistrate Carl Milanovich, regarding the tragic 2005 death of Vanessa Anderson.
Vanessa Anderson, an apparently healthy 16-year-old, died at Sydney’s Royal North Shore Hospital, after being struck on the side of the head with a golf ball in November, 2005. It wasn’t the collision with the golf ball that claimed her, but accumulated shortfalls in her treatment process.
The Coroner’s summary, handed down at Sydney’s Westmead Coroner’s Court on 24/1/2008, stated that the, “death of Vanessa Anderson at the very young age of 16 years was a tragic and avoidable death”.
“Vanessa’s case should be used as a precedent to highlight how individual errors of judgment, failure to communicate, failure to record accurately and poor management of staff resources, cumulatively led to the worst possible outcome for Vanessa and her family... .
“...I have regrettably presided over many inquests involving deaths in hospitals. In many of those cases one error or omission, sometimes a serious one, led to death, however, I have never seen a case such as Vanessa’s in which almost every conceivable error or omission was detected and those errors continued to build one on top of the other,” Magistrate Milanovich said.
Obviously, improving hospital processes offered weighty critical outcomes such as saving lives, improving patient recovery, reducing hospital stays and reducing health system costs. The challenge was to conceive a process of sufficient strength, appeal and attractionfor the many disparate hospital and health practitioners and clinicians who would use it.
My mind returned to the surf and the lives saved by the surf life saving movement. Since Surf Life Saving Australia began collecting statistics in the late 1930s, there has only been one death from drowning between the flags on a patrolled beach.
Drownings outside the flags - yes. Deaths from other causes (heart attacks etc) - yes, but drowning under the watchful eye of the beach patrol - NO!
Vigilance is the key. Prompt action with the appropriate “rescue device” is important, but it’s secondary to recognising a swimmer is in trouble. If it is so simple on the beach, why not in our wards?
Of course, there is one obvious difference. Swimmers are usually healthy. Not so our patients. In fact, large numbers are just moments away from collapse and close observations can become life critical. The Clinical Excellence Commission researched NSW to identify problems facing hospital staff.
Our findings are not unique to NSW. Around the globe hospital staff are increasingly facing “waves” that threaten to engulf patients and staff alike.
The first wave is our patients themselves. The population is ageing rapidly and people present with many more complicated and injury-related diseases which, for the first time in history, can be treated. But the elderly have less tolerance for the disease and sometimes for the advanced treatments they require.
At the other extreme, we now also have advanced technologies for premature infant and neo-natal care.
The second wave is emerging technologies. Wonderful gadgets, medications and procedures each require time-consuming education, up-skilling and hands-on experience to use them effectively.
The third wave is the workforce itself.
We all know of the global shortage of nurses, doctors and allied health professionals. Increased university funding for medical graduates will provide many more interns for our hospitals, but we need staff and time to supervise, mentor and train them. After all, it is our junior staff, working in strange wards on night shifts, who are most exposed to rapidly deteriorating patients. Nurses became clerks, interns, and scribes. Junior staff indicated that they were uncertain about who and when to call. Other registrars and senior nurses were also frantically busy and often senior medical staff were not in the facility.
Strangely, technology, rather than helping, had confounded the problem. It’ s now possible to get most of the ‘vital signs’ for a patient just by looking at a monitor screen. Blood pressure, pulse, temperature and even the amount of oxygen in the blood, can be continuously displayed. So if a nurse or doctor is stretched to the limit, they do not even have to see the patient - until it is too late!
Research revealed that the breathing rate is the most sensitive indicator that something is wrong, but is the least often recorded. Why? Because it takes time and (at the moment) needs staff to stop and observe the patient for at least a minute.
The Coroner was right. The system needed fixing, but how? Staff and money are finite resources and technology is expensive.
Australia’s beaches are among the safest in the world, most of the time. Australian hospitals are also among the best in the world, most of the time. Peter Garling SC, in his landmark review of Acute Care Services in NSW in 2008 said: “I have formed a clear view that the level of healthcare provided in NSW and Australia is comparable with, if not better than, most of the first-world and developed countries”.
So what are the solutions when a patient begins to deteriorate?
The Clinical Excellence Commission, working with the Agency for Clinical Innovation (formerly GMCT) and senior intensive care staff across NSW, have recognised three key principles.
First, we have to make it easier for junior staff to recognise deteriorating patients. Second, we must ensure system-wide responses to support the patient and staff when deterioration starts. Third, we need to re-educate our staff on the early and subtle changes that may pre-empt sudden deterioration.
Between the Flags is built on these principles. Using iconic Aussie language and imagery, this program, for the first time anywhere in the world, embarks upon a major culture and practice change in every public hospital in the State. It consists of:
A Standard Adult General Observation chart, with simple yet profound track and trigger methodology.
A face-to-face education package and manual, custom-built in NSW for all clinical staff and supported by a mandatory e-learning tool.
Locally appropriate clinical emergency response systems in every facility.
Effective governance to ensure that junior staff will be heard when they call and rapid actions taken as a team.
Evaluation of the lessons learned.
This will work in concert with the “Essentials of Care” presently rolling-out under the direction of the Chief Nurse and the Clinical Handover project – a communication program under the auspices of the Clinical Services Redesign Program in NSW Health.
Can patients and their carers help? Of course, this program will demand that staff listen to concerns.
Why not before? Complexity confounds the simple and an unrealistic focus on technology can take us away from our patients. Imagine if all lifesavers spent most of their time writing reports or learning to fly a helicopter?
Autonomy has brought many good ideas, but also much variation that can confuse the busy and inexperienced. Between the Flags does not stop innovation or individual decision-making, but it does underpin all our care with the observations that first draw our attention to a patient potentially in trouble - wherever they are.
No matter which beach they are on, whether it’s Bondi or Torquay, Mermaid or Cottesloe, lifesavers begin saving lives by watching, keeping swimmers between the flags, and taking responsible actions when conditions change.
Then, when someone is caught in a rip, they apply the most appropriate response - for which I, for one, am grateful.
More than $40 million dollars is being invested upgrading the Emergency Department of Sydney’s St George Hospital. David Hutchins says facility executives are confident it will be business as usual throughout the project