Shared learning database

Dartford & Gravesham NHS Trust
Published date:
January 2013

A program, which started in 2007 (launch of NICE CG 50), improved the Trust's mortality, reduced cardiac arrest rates and reduced proportionally level 3 and increased level 2 admission to ITU. This means deteriorating patients are picked up earlier, treated earlier and have better outcomes. Between 2007 and 2012 the Trust's crude mortality for all admissions and for non-elective admission fell by 39% and its cardiac arrest rate fell by 73%.

Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

The Trust traditionally had a higher than average mortality rate. When CG50 was published in 2007, it was decided to apply CG50 and to continuously test it to see what further improvements could be made. Over the years this approach has been successful and the Trust's crude mortality rate fell by 39% and its cardiac arrest calls / 1000 admission fell by 73% in the period 2007-2012.

Reasons for implementing your project

The Trust's mortality rate had been higher than average for years, sometimes causing alerts, at other times coming within the statistical spread, however, never being better than average. The Trust serves an area with pockets of severe deprivation, has higher than average obesity rates and an ONS mortality which is worse than any inner London borough. 'Deteriorating patients' was a project that continuously was evaluated, refined and amended to allow the Trust to achieve these excellent results. The main novelty in our approach was the introduction of a Medical Emergency Team (MET). There was no real financial investment, no extra staffing and the resuscitation officer and the ITU audit nurse took it upon themselves to continuously audit, teach and promote this program, which was overseen by the clinical director for anaesthetics supported by the medical director.

How did you implement the project

In 2007 PAR scoring was introduced and ALERT courses run for all clinical ward-based staff. Escalation of deteriorating patients was not as swift as desirable, so in 2008 the concept of Medical Emergency Team (MET Team) was developed and launched in November 2008. The MET team is called via the same mechanism as a cardiac arrest team (linked pagers) and has to see the patient within 15 minutes of being called. It is composed of the Medical Registrar on call, the Anaesthetic Registrar on call and the ITU Outreach team. There were still delays in calling the MET team, so the MET audit forms were changed to allow tracking of delays to MET calls. These new forms were introduced on 1.1.2011. Since then the delayed calls have reduced from 8.7% (Q1 2011) to 4.5% (year 2012) with only 1.9% of MET calls delayed over 4 hours. This means that there are no longer significant delays between patients showing signs of deterioration and an appropriate team reviewing their care.

The ITU data show level 3 bed days to be stable with increasing numbers of admission and increasing level 2 bed days. This demonstrates that patients are admitted to ITU less sick, i.e. more timely. ITU mortality has halved in the time covered by this project and ITU's LOS has reduced.

In parallel, the Trust also developed Treatment Escalation Forms' (TEP), which are kept in the same book as the 'Do Not Resuscitate' forms. Each time a MET team is called to review a patient, discussions take place about treatment escalation, which can range from Liverpool Care Pathway to full ITU care. This prevents inappropriate resuscitations and allows dying patients a more digified death. It is a team discussion together with the patient / carers and has contributed to reducing the CPR rate independently (not qualtifiable).

Key findings

2007 2012
Crude Mortality
all admissions 2.55% 1.55%
NEl admissions 4.30% 2.61%

Cardiac arrest calls per 1000 admissions
6.27 1.71

ITU bed days
(collected in financial years, hence 2012 only 9 months)
Level 3 1475 1088
Level 2 794 1008

Key learning points

Timely intervention for deteriorating patients works and improves outcomes. The following were found to be essential:
- clear guidance when to escalate a patient to the MET team(escalation flow chart printed on the back of each observation chart)
- clear guidance on the expectation that the MET team is available within 15 minutes of being called. - logging of all MET calls via switchboard and continuous audit of performance
- continuous teaching and reminding of all staff of the need to do PAR scores properly and to escalate according to guidance
- continuous supervision by senior staff (CD and MD) to further refine process and prevent achieved standards from slipping.

Contact details

Annette Schreiner
Medical Director
Dartford & Gravesham NHS Trust

Secondary care
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