• Document No.

  • Department

  • Conducted on

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  • Personnel

Establishing recognition and response systems

  • 9.1.1 Governance arrangements are in place to support the development, implementation and maintenance of organisation-wide recognition and response systems

  • 9.1.2 Policies, procedures and/or protocols for the organisation are implemented in areas such as: measurement and documentation of observations escalation of care establishment of a rapid response system communication about clinical deterioration

  • 9.2.2 Deaths or cardiac arrests for a patient without an agreed treatment-limiting order (such as not for resuscitation or do not resuscitate) are reviewed to identify the use of the recognition and response systems, and any failures in these systems

  • 9.2.3 Data collected about recognition and response systems are provided to the clinical workforce as soon as practicable

  • 9.2.4 Action is taken to improve the responsiveness and effectiveness of the recognition and response systems

Recognising clinical deterioration and escalating care

  • 9.3.1 (D) When using a general observation chart, ensure that it: is designed according to human factors principles includes the capacity to record information about respiratory rate, oxygen saturation, heart rate, blood pressure, temperature and level of consciousness graphically over time includes thresholds for each physiological parameter or combination of parameters that indicate abnormality specifies the physiological abnormalities and other factors that trigger the escalation of care includes actions required when care is escalated

  • 9.3.2 Mechanisms for recording physiological observations are regularly audited to determine the proportion of patients that have complete sets of observations recorded in agreement with their monitoring plan

  • 9.3.3 Action is taken to increase the proportion of patients with complete sets of recorded observations, as specified in the patient’s monitoring plan

  • 9.4.1 Mechanisms are in place to escalate care and call for emergency assistance

  • 9.4.2 Use of escalation processes, including failure to act on triggers for seeking emergency assistance, are regularly audited

  • 9.4.3 Action is taken to maximise the appropriate use of escalation processes

Responding to clinical deterioration

  • 9.5.1 Criteria for triggering a call for emergency assistance are included in the escalation policies, procedures and/or protocols

  • 9.5.2 The circumstances and outcome of calls for emergency assistance are regularly reviewed

  • 9.6.1 The clinical workforce is trained and proficient in basic life support

  • 9.6.2 A system is in place for ensuring access at all times to at least one clinician, either on-site or in close proximity, who can practice advanced life support

Communicating with patients and carers

  • 9.7.1 (D) Information is provided to patients, families and carers in a format that is understood and meaningful. The information should include: the importance of communicating concerns and signs/symptoms of deterioration, which are relevant to the patient’s condition, to the clinical workforce local systems for responding to clinical deterioration, including how they can raise concerns about potential deterioration

  • 9.8.1 (D) A system is in place for preparing and/or receiving advance care plans in partnership with patients, families and carers

  • 9.8.2 (D) Advance care plans and other treatment-limiting orders are documented in the patient clinical record

  • 9.9.1 (D) Mechanisms are in place for a patient, family member or carer to initiate an escalation of care response

  • 9.9.2 (D) Information about the system for family escalation of care is provided to patients, families and carers

  • 9.9.3 (D) The performance and effectiveness of the system for family escalation of care is periodically reviewed

  • 9.9.4 (D) Action is taken to improve the system performance for family escalation of care

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