Managing serious clinical deterioration in a tertiary hospital in Hong Kong: from indicators development to multiple measures in reducing the rates.

RATIONALE, AIMS AND OBJECTIVES: Timely detection and management of acutely deteriorating patients can save lives. Tuen Mun Hospital (TMH), a 1800-bed acute tertiary hospital serving more than 1.06 million populations in Hong Kong, is exploring to quantitatively monitor serious clinical deterioration (SCD) and uses it to guide patient care improvement initiatives. METHODS: Literature review on definition and measurement of SCD was conducted. Monthly SCD rates of TMH were first calculated according to the published methodology and benchmarked against those of international centres. A refined composite clinical indicator good for local use was compiled. In the second phase, p-control charts of SCD have been plotted based on cumulative data. RESULTS: TMH's performance was comparable with that of international centres. SCD on p-control charts has been plotting since January 2013. There were peaks in all 4 SCD rates during the winter surge period in 2013-2014. In the third phase, multiple measures have been taking to reduce the SCD rates including targeting the 3 main factors of winter surge situation. We are delighted to observe that the pattern did not repeat in the rate of cardiac arrest without do not attempt cardiopulmonary resuscitation (DNACPR) and rate of death without DNACPR in the same period in 2014-2015. CONCLUSIONS: SCD becomes a clinical governance tool to monitor the performance of clinical teams in treating acutely deteriorating patients in TMH. Any abnormal patterns or indications of special cause variations in the control charts would alert leaders to look for root causes of special cause variations and manage accordingly. We hope that this project will extend to corporate level and become a sustainable clinical indicator to guide audits, quality improvement initiatives and strategic planning.

Improving clinical handover: Development of a web-based intensive care unit consultation system with structured reply generation.

Clinical handover is a process of transferring a patient's clinical information from one team to another. Poor quality of handover of critically ill patients associates with misunderstanding, delay in treatment, and adverse outcomes. Therefore, a high quality and standardized information flow process and documentation are definitely crucial. We have developed a web-based platform for generating printed ICU consultation reply and data collection. Baseline measurement was performed by randomly identified 50 case records among 220 ICU consultations in March 2015, before the implementation of the system. We found that there were only 16% of cases had printed ICU consultation reply, 42% had documented patient's premorbid activity of daily living, 30% had recorded patient's mobility, 74% had written down patient's past medical history, 72% had clearly stated the ICU admission decision, 18% had provided the reasons for rejecting ICU admission, and 32% had remarked the mechanism for contacting ICU senior to review the admission. After implementation of the ICU consultation reply platform, the percentage of using printed consultation reply has increased to more than 90%, documentation of patient's morbidity and mobility have raised to over 80% and patient's past medical history has been recorded in over 95% of cases. Standardised ICU admission decision tree has been designed to assist ICU doctor to clearly state the ICU admission decision and the reasons behind. Appeal mechanism for doctors in general ward to contact ICU seniors for case discussion is included in every consultation reply. In short, ICU consultation platform improves the quality of ICU consultation reply and enhances communication among ICU doctors and general ward staff. It also serves as a big data pool for audit cycles which in turns direct ICU consultation service improvement.

Poisoning necessitating pediatric ICU admissions: size of pupils does matter.

INTRODUCTION: Childhood poisonings are common, but usually trivial, and infrequently necessitate intensive care unit (ICU) admissions. METHODS: A retrospective record review was conducted to analyze the pattern of severe poisoning-associated ICU admissions at a teaching hospital between May 2002 and December 2007. RESULTS: Six cases (4 boys and 2 girls, aged 2 months to 11 years) of drug poisoning-associated ICU admissions were identified. Methadone was the culprit in 3 boys and 1 girl, resulting in respiratory failure, depressed conscious state and pinpoint pupils. As relevant exposure history was not immediately apparent, diagnosis at the emergency department was only made correctly in 2 patients. Phenobarbitone overdose occurred in 1 girl with past history of phenobarbitone overdose as a clue. She was also considered to have pinpoint pupils that were unresponsive to naloxone. Features consistent with cholinergic toxidrome, including small pupils, and increased secretion occurred in an infant fed with milk prepared with an herbal broth suspected to have been adulterated with a pesticide. Atropine as an antidote was used when the child was in the pediatric ICU. All children made an uneventful recovery following their short ICU stay. CONCLUSIONS: Life-threatening poisonings requiring ICU support can pose diagnostic difficulties and challenges to frontline medical officers at the emergency department. Children from all age groups can be affected. Prompt diagnosis is based on relevant history, careful clinical examination and a high index of suspicion in patients known to be at risk. The pupillary size and its reaction following treatment serves as an important diagnostic clue.