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Deteriorating Patient in the Emergency Departments

Overview

This procedure details the new identification, escalation, response and management framework for clinical deterioration in accordance with Western Health’s (WH) deteriorating patient and clinical code procedures.

Several processes are already in place and are unchanged, including:

  • Use of the track-and-trigger observation charts
  • Minimum frequency of observations within the ED
  • Importance of Advance Care Directive and/or Resuscitation Plan
  • ED staff as first responders for all patients within the ED footprint, regardless of admission status
  • Ability to call for additional support for particular skills or resources.

The NEW processes are:

  • Updated adult track-and-trigger observation charts to include modifiable observations, similar to the EMR
  • Escalation framework for both admitted and non-admitted patients in the ED, including
    1. Creation of an “ED MET Call” and “ED Code Blue”
    2. Requirement for the inpatient team to respond to UCR and MET calls for admitted patients within 30 minutes and 10 minutes respectively
    3. Ability to escalate to a Hospital MET Call for deteriorating inpatients where
      1. the inpatient team response does not occur, or
      2. more assistance is required

Applicability

This procedure applies to adult and paediatric patients within all areas of the ED, including the Short Stay Unit (SSU) at SHED.  It does not apply to

  • A maternal clinical emergency or imminent birth, which requires escalation via 2222 and calling the relevant maternal code
  • The remote SSU at Footscray, which is managed as per the usual ward processes.

Responsibility

It is the responsibility of the Directors and Nurse Unit Managers of the Emergency Departments of each site to ensure the relevant staff are familiar with this QRG, that it is implemented according to the guidelines as outlined within, and that there is compliance by all staff members.

Guideline Details

Observation Charts

All patients presenting to the ED will have their observations recorded on the current track and trigger observation charts below.  This includes patients who have been triaged and are awaiting assessment.

  • Emergency Department Adult Flow Chart (EDAFC) (AD 51.2a) for adult patients
  • Maternity Observation and Response Chart (MORC) (AD 333.1) for all pregnant women and up to six weeks postpartum
  • Age-group appropriate Victorian Children’s Tool for Observation and Response (ViCTOR) Charts for all paediatric patients

Frequency of Observations

Observation requirements are unchanged and outlined in the following table:

WHEN MINIMUM FREQUENCY MINIMUM VITAL SIGNS
On arrival at Triage Once
  • Respiratory rate (RR), heart rate (HR), level of consciousness
  • Additional as indicated: Blood pressure (BP), temperature, oxygen saturation, neurovascular
Waiting Room Per ATS max. wait times:

Cat 2: 10 min

Cat 3: 30min (half hourly)

Cat 4: 60min (hourly)

Cat 5: 120min (2 hourly)

  • RR, HR, BP, temperature, oxygen saturation,, level of consciousness, pain score, BOC
Cubicle awaiting assessment by a medical officer Half hourly (30/60)
Following review by a medical officer and remains stable Hourly (1/24)
Admitted to an inpatient unit and remains stable. This includes medically cleared psychiatric patients. 2 hourly (2/24)
On discharge from the ED (both to the community and prior to the transfer of care to another clinical environment) Confirm no change from most recent set of observations within half an hour of discharge

Modifiable Observations

ED by definition manages undifferentiated acute patients, including many with abnormal vital signs especially initially and before treatment.  In situations where abnormal vital signs are deemed appropriate for the patient’s clinical condition, modifications are to be documented in the nursing observation chart with the following details:

  • Date and time of modification
  • The criteria being modified (e.g. blood pressure, oxygen saturation)
  • New acceptable criteria range
  • Senior doctor approval (registrar or above) – name and signature
  • Date and time for modification to be reviewed

ALL patients with observations within UCR or MET call criteria who do NOT have modifications documented should be escalated as below.  Please note, these modifications are not valid on the ward; any patient requiring modified observations for transfer to the ward will require these to be documented in the EMR.

Escalation

Criteria for UCR or MET calls are found on the track-and-trigger nursing observations charts.

Patients, both admitted and non-admitted, who are found to be in UCR or MET call criteria should be escalated according to the two flowcharts on the following pages (Figures 1 and 2).  The overarching principles are:

  1. ED is involved in the initial management of ALL patients, regardless of admission status
  2. The ED Resus Team is required to be nominated at the beginning of each shift. Please see the QRG ED Code Blue Teams for further information.
  3. Inpatient team response is required for ALL admitted patients.
  • An “Admitted Patient” is one who has been referred to an inpatient team for admission
  • Inpatient team “Response” requires either attendance in person, or over-the-phone consult and advice if unable to attend within the expected timeframe.
  • If no response is received within the 30 minutes (for UCR) or 10 minutes (for MET), a hospital MET call should be called by dialing 2222.
  • The inpatient unit must be involved in the process of transferring the patient from the ED to the Intensive Care Unit (ICU).

Figure 1: Clinical deterioration escalation for NON-ADMITTED patients in the ED

Figure 2: Clinical deterioration escalation for ADMITTED patients in the ED

Communication

Communication of deterioration should be managed as follows:

  • UCR and ED-MET call criteria:
    • Within ED (for all patients): via direct communication and overhead announcement intercom
    • With inpatient teams (for admitted patients): via phone, pager and switchboard
  • ED Code Blue: via emergency buzzer, with linked pagers at SHED
  • Hospital MET: via 2222

Clinical communication should follow the ISBAR format: identify, situation, background, assessment and request.

Medical Emergency / Code Blue Team and Responsibilities

Please refer to the QRG ED Code Blue Teams for team membership and responsibilities.

Documentation

Any UCR, MET Call or Code Blue should be documented both in medical clinical notes and in the nursing observation chart. Any episode should be communicated in nursing and medical handover.

Disposition

After ED Code Blue/medical emergency, stable patients may remain or return to their allocated cubicle or bed within the ED for ongoing care.

Unstable patients will continue to be cared for within a resuscitation cubicle/bed until they are either transferred to an ICU or high dependency unit (HDU) bed, or deemed stable enough to return to their cubicle within the ED or to be transferred to an acute inpatient bed for admission.

The exception to this is any patients in the SSU-3A at FH who requires ongoing critical care following clinical deterioration should be transferred directly to ICU/CCU/Recovery and NOT return to ED.

Quality Assurance

All MET and Code Blue activations require data collection as a requirement for Accreditation.  Hospital MET calls will be documented on the MET Call Register and reported monthly to the Deteriorating Patient Committee (DPC).  ED MET and ED Code Blue data is to be collected and reviewed as part of departmental multidisciplinary Morbidity and Mortality Reviews looking for trends and opportunities for proactive interventions. Processes will be audited during implementation to promote establishment.

Special Considerations

Special locations

  • The deteriorating patient in 3A-SSU at Footscray is managed using the hospital wide Met Call/Code Blue activation. If these patients require critical care following deterioration, they are NOT to return to the ED, and are to be transferred directly to a critical care space (ICU/CCU/Theatre Recovery).
  • The administrative areas of Level Two area of SHED is not equipped with resus buzzers or a first response trolley. A MET Call No Treating Team or an Adult Code Blue must be called for any person on this level who requires immediate medical attention

Special populations

  • Paediatrics: All three campuses have paediatric MET and Paediac Code Blue responses.
  • Pregnancy
    • Clinicians caring for pregnant women should be aware of the physiological adaptions of pregnancy, particularly in the setting of unwell women presenting with undifferentiated complaints.
    • To support early identification of clinical deterioration in pregnant and early post-partum women, the MORC will be used for all pregnant women and up to six weeks postpartum.
    • Escalation of clinical deterioration in pregnant women at the Sunshine Hospital precinct ONLY includes Maternal Code Blue, Code Pink (Obstetric Emergency) and Code Green (Emergency Caesarean Section). The relevant maternal code should be called as a priority to summon specialist obstetric and midwifery response team members.
    • These codes are NOT applicable at Footscray and Williamstown EDs.