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So, hi, everybody. Um Welcome to our Scottish Intensive Care Society evening update. Um I'm just gonna give it a couple of minutes um for people to join, anyone needs to reset the password and then we'll get started. Okay. Okay. So welcome everyone. Um This is our April edition of uh six education evening updates. Um Thanks everybody for coming. Um We've got a really interesting talk for you tonight from Doctor Gregory mcneal about the deteriorating patient. So, Doctor mcneil is the National Clinical Lead for the Scottish Patient Safety Programme, Acute Adult within the healthcare improvement Scotland. And he's been a consultant in intensive care medicine at NHS Lothian since 2015. Um He moved up from Nottingham where he worked since 2012. Um and he was the clinical lead of critical care during the first COVID 19 pandemic at the Royal Infirmary of Edinburgh. He has a passionate for quality improvement and he is a Scottish Quality and Safety fellow. His main Q I interest is improving the care of deteriorating patient's prior to critical care admission. And as well as his sp sp work, he chaired the recent update to the sign Guidance on deteriorating patient. In addition to this, Doctor mcneil is the Scottish A CCP Training Network chair and the co chair of the A C C C C P subcommittee within thick. Um And he's here tonight to talk to us about the deteriorating patient and what's next for this watch critical care unit. So, thank you so much for coming tonight and I'll hand you over to doctor mcneil. Um Thank you very much Ellen and thank you to you and to Julie Fleming for the opportunity to speak to um uh I see s colleagues uh this evening. Um Okay. So uh the diet using patient, what next for Scottish Girl Care units? This is what I've been asked to talk about. It's a broad topic, but hopefully over the next hour, we can get into a bit more detail about it. Uh Gillian Helen of kindly give me some kind of framework to talk to you about and I'll try and kind of go through most of this over over the next hour. Um Thinking about identifying types of patient deterioration and early warning indicators for you as the attending cruel care person on the wards and understand what those uh early one indicators are and how we respond to them. Um is something we'll also talk about a lot of what I'm going to talk about is um the systems we use in healthcare to manage patient deviation. Thinking about what we're using now, what we've used in the past and what we might want to use in the future. I will try to explain to you um uh from my perspective, what the Scottish Patient Safety program is for the kid a little program, clearly other programs going on there. But, but what it means for you within critical care, I'll try and kind of unpack a bit for um uh effective management of patient situation is kind of what the ask is for our critical care units often feels that we, we are kind of a catchall for all the ills of the hospital. But I'll try and explain, you know, where I see that and how we can kind of share the resource to make sure our patient's stay safe. So, um the first thing to probably start is why is patient deterioration important. It's a broad topic, but it's important to, to think about the landscape in which we are right now. We are undoubtedly at historically challenging times for healthcare, not only in Scotland, but worldwide. Um I've just come today from the uh annual SP sp conference looking at patient deterioration in Glasgow and everyone from all 14 boards across Scotland who was there. We agree that our system is under pressure. It's maybe slackened off slightly in the past couple of weeks, but we've had her, we're coming out of a really tough winter and that undoubtedly in part is, is our recovery from the pandemic. It's important to realize that our hospital systems are not working as they were designed to work. Uh No one designed there A and E S to have patient sitting them for 40 hours, that's not how they're meant to work. So we have to respond to that and the way we respond to that, particularly if you think about deteriorating, patient's has to be, has addressed. The reality is we find it right now as part of my work with an SP sp we see a lot of the data, national data coming through. And it's clear since the pandemic, that patient's are getting sicker. So if we look our census mortality in Scotland right now, that census mortality is rising, there are less patients presenting with sepsis, but the ones who are presenting to our hospitals are sicker. You have more orien failure, they're going to be knocking on our doors, incredible care more. We're seeing more overdoses because of the mental health uh pandemic. But even if you look at things like acute coronary syndromes, I'm sure many of you are seeing patients present with uh delayed presentations and acute coronary syndrome. So they're coming to knock on our door with the sequela of other organ failure, courage and it shocked etcetera. Our patient's are sick right now and we have to try and manage that effectively. And if you think about quality improvement and patient safety, the time before the pandemic almost feels like the Wembley pitch. It's a green grass. It was predictable. We knew what the landscape was. We knew our patient's got sick where the, the, where the, the areas of high acuity were, uh, where we had to kind of focus on improvement. Now, the landscape is very unstable. It's more like a, a muddy muddy field. Patient's are deteriorating in random places. There's a lot of boarding patient's out there, there's patient's and corridors deteriorating in corridors. It's all a bit of a bloody mess. And that makes it more challenging for us when we identify patient's who are deteriorating, humane equal care when we go to, to, to our eighties, when we go to the wards and it makes more challenging for us to work out. When is that goldilocks time that we admit that patient to the ICU because not necessarily on a day to day basis? Anyway, just about how sick that patient is. Do I even have any critical care nursing staff to manage that patient's once they come to critical care, the whole system is under stress. And we see that and, and, and unfortunately, I, I get to speak to people coming really across the, um, the British Isles about what they're seeing with their admission acquittal care admission data. And, and it's, it's clear that many of us have been challenged by this. I wouldn't name the area, but I was speaking to uh colleagues in another area of um uh of the country recently and they were finding that from their ward admission's 25% of their war admission's to critical care were needing reno replacement therapy within 24 hours getting into critical care. Um, that's not what we're seeing locally in a, in a Scottish context, but that tells you these patient's are pretty sick. Uh So it's getting back to what we've often discussed in the past. We want to get these patient's in when they have some degree of organ failure, but not multi organ failure. And how do we do that? It's, it's tricky. So pulling back from that, that initial context a little bit, what, what is the role of health improvement, Scotland? Now, uh some of you will be very familiar with this apologies if you are, but for those of you are not his is, is his, doesn't have an exact comparator in other parts of the test across the UK. His does a lot of stuff whether it's regulation of health technologies, uh medicines regulation, antimicrobial stewardship, but the sp sp but Scottish patient safety program that I'm involved with, um that is really dealing with quality improvement. We are not part of the assurance part of his. So it's important to say that I do not go and inspect your hospitals. I visit your hospitals and chat about how you're hoping to improve care. I don't, I don't have a kind of an assurance hat on but that, that is also part of, of, of his his role. So his does a lot of stuff, everything about SP sp so Scottish patient safety program, we trump it a lot in Scotland and, and internationally and it's been going since 2008. It was launched by then Health Secretary Nicola Sturgeon. And it started out looking at really just patient deterioration, a few other things, but it's now grown to cover many areas and they're sp sp programs. If you look at primary care, mental health, maternity, pediatrics and and and other areas and clearly within topics like maternity and neonatal pediatrics will be a patient deteriorate aspect, deterioration aspect of the program. But the overall acute adult one dealing with metal in patient's, that's, that's, that's part of my role. And why did SP SP gain traction because it showed improvement. And the premise of SP SP is that we used data, reliable data to drive forward quality improvement, which will drive forward the quality of care. And SP SP was able to demonstrate over the first number of years, it was in, in play a significant reduction in mortality and within the code another program, there are, there are, there are two mains uh programs of work. One is false or as I like to call it uh deterioration from a standing height. And there's the overall deteriorating patient program. And over the years, we have tried to improve the lot of uh dictating patient, whether it's reliable, recognition of deterioration, reliable delivery of care, educational awareness, creating a culture of safety and uh working kind of inform patient's and, and families. How do we do that? Well, we have um a network of SP SP program manages in every board in Scotland and within deteriorating patient's, we have a clinical lead for that in every board that we liaise with to try and drive forward and quality improvement. We use a collaborative approach which means we have a target time sensitive program of work that usually lasts for between 18 months and two years. And this one is going to be run a bit longer because of issues with the pandemic, but it was launched in 2021. Unlike any quality improvement, we have a driver diagram and overall aim. And again, this program is now going to run until March 2020 for not September 2023. You see there is to reduce calica arrests in the hospital wards across Scotland ski that you understand that that is not all kinda caressed, it's not kinda caressed in critical care or even see, see us. It's in general wards, it doesn't cover M E D either. And before the pandemic, when we're doing this work, we covered about 17 hospitals in Scotland. We now cover every acute site in Scotland. So it's, it's, it's in some, in some ways, one of Europe's most comprehensive audits of kind of caressed and we're trying to drive that down. And that is challenging and if you look at the primary and secondary divers there, the bet that we are really particularly focused on with incredible care is our response to deterioration, which requires a number of things. And, and, and we have, we're not the sole um people involved with these things. But if you think about screening through deterioration, use of human escalation plans. A CPS, these are the kind of things that we get involved with when we couldn't see our patient's on on board clearly support war teams in making these things happen. And when we launched a program of work, we we also launched a package of measurement tools. So it's not just about that overall kind of caressed rate. Although that is key, we want to give uh boards other process measures. And one of the ones which is particularly pertinent criminal care, which is useful that I find to think about when we, when I see a patient on the board is measures like a score to door time, otherwise known as a trigger time. We look at the length of time, a patient's early warning score, whether it's uh they're news to score usually how long that that patient's been triggering for before they get into critical care. And there are published metrics on what, what good looks like in that regard, whether it's fours from decision to admit or four as a trigger time. Uh That's, that's a useful measure to think about because we know, delay is associated with worse in organ failure and, and harm. It's important to think about are balancing measure as well. And I think um this is often something that is uh is confusing, particular for hospital managers were not necessarily trying to reduce cruel care admission rate and that'd be nice if it happens. But really, we're wanting to facilitate timely admission, cruel care. If we give patient's effective care and wars, clearly, some will no longer require cruel care. But we're not as, as, as an overall aim trying to reduce the curable care admission. Wait, we're trying to aim for timely admission to critical care and um particularly if you look at a UK wide context, that's why it's important to think about what standards we have around this area. Now this talk, we don't have time to go into the differences between the standards has laid out in the in in G picks for UK wide or our quality indicators we have for Six Act. It's important to say particularly from a UK context. They have a large number of standards relate two time timeliness of admission, school care following initial assessment, but also what you're cruel care service looks like as it manages his patient's out on the wards and as a particular the NHS England context focus on outreach services. Um uh Six after looking at their quality degrees, now understand you could argue although clearly far fewer quality um indicators with the six AC document. We, we may need to look more closely at having some kind of metrics which looks at timely admission process to our critical cares within the six uh document. And what we're aiming to do, what we have uh have successfully done in the past is reduce our cardiac arrest rate. And this is data from pre pandemic, looking at the reduction of categorize across those odds of hospitals in Scotland. And you can see over time, there was a reduction. If you look, I'm going to tell you which board this is, but this is a single board which encompasses a pandemic period. You can again see our overall reduction in cardiac arrest and for many of our board to now uh kinda caressed is a rare event to the point that we are kind of looking at other metrics we can use as an overall outcome standard for this work because many of our acute sites uh well included, we may only be seeing about one kind of caressed um per weekend in an an acute site. So it is a rare event and then the smaller boards, it's often a rare event still and how we managed to improve uh or reduce narcotic arrests. Well, again, there are many things we've done there where it's appropriate use of tepes D N A C P R s, but it's certainly also been uh appropriate escalation and care and how we've actually kind of found out what is most effective to drive forward change in this area is looking at the cardiac arrest you do have and getting as much learning from each cardiac arrest as possible. And we've done that and these are documents from NHS Lothian where we really just audit the heck out of the cardiac arrest event and review the card a question, great detail with the war teams. So they can reflect about what they really done differently next time. And through that, we've seen a reduction in cardiac arrest of the time. Um but the data is shaky now and uh and that probably reflects a number of things. And uh one of the undoubtedly though is is acuity of the system, it's important to remember that reduction in cardiac arrest is not the necessary. The only thing you need to look at and particularly when you speak to interest board managers, it's important to think about other measures, particularly your overall hospital standardized mortality ratio. So if you have a high SMR but a very low cardiac arrests rate that suggests that's not really a logical situation you want to find yourself in. And that suggests from a, a board wide level that you, you know, why are people dying if you've got a very low category straight? Uh When I see that pattern, I always worry about, you know, are we doing is that board being kind of too liberal in the use of D N A C P R s, etcetera. Because that, that is one way that you can, you can game the system. And if you like in terms of reducing your cardiac arrest rates. So it's important to think about your category straighten the overall context of H S M R. The other thing I would say there in terms of the blue panel panel, the panel there. Um and this is most pertinent since this winter, we still only audit cardiac arrests in ward areas. I'm not so worried about cardiac arrest and in our critical cares, something from uh from a kind of local experience. That's not, not a huge issue. But what I'm worried about is we currently do not order a know and audits kinda caressed occur in our emergency departments and we simply don't know some smaller boards are able to get that data. But in my own board, we know our, our E D has been very pressured with very long ways. We know patient's have been having cardiac arrests and corridors, but we don't really know, we don't really have a robust data. And certainly as we move forward, if, if our systems remain as they are, we really want to try and capture that data. So getting into the nuts and bolts, how how do we effectively respond to deterioration? Well, again, we said we're going to talk about systems and this is kind of a rapid response system pared down to its most kind of basic level, uh, patient gets sick, there's an Afrin limb, uh in terms of response to deterioration and then the front limb. Now the Afrin limit is recognition of deterioration and largely, uh pretty much every, every board in Scotland easily are going to move shortly over to news to or use is new news to, to identify deterioration. Now, it's clear that we don't want to tell our words just to use news too. We wanted to be using their appropriately clinical concern as well. If they're worried, they should escalate. You do not want to put all your back, all your, all your eggs in the, in the basket of the news to score alone. But, but that, that lodges how you will escalate. Now, the different limb, it depends where you work in the UK. It may be an outreach team, it may be a met team, maybe a rapid response team as far as it may be your hospital 19. But it's largely in Scotland. Uh probably the exception of the borders where they do have outreach. It's going to be escalating medical seniority and clearly um cruel care will be part of that escalating medical seniority. And it depends on your board about where critical care is really called out. In terms of when they respond, when they get involved, you will be aware that the RCP guidance on news to suggest. Once your news is seven, you might want to think about critical care that's not necessarily mandated in all of our boards. But what we want our patient's to get is definitive care. And we can talk in a second about what definitive care is for any, um, any individual patient. And I suppose what we want is a clear structure of how we respond to deterioration. And, and, and again, uh this is varied a lot and, and maybe I would kind of challenge you to say that often, certainly, uh particularly when our, our hospitals are in crisis, that we maybe want a response to be well framed and have a clear structure. But unfortunately, at times of crisis, it can be more kind of jelly like. Um and, and jelly's like structure to your response deterioration is, is possibly a risk, it's possibly a risk even more if you're hospitals in crisis and hospitals effectively on fire. Um And that's, that's what we certainly saw this winter with very high levels of referrals. Patient's in unusual positions, deteriorating in a hospital in crisis with very little capacity within the hospital, very little capacity within the cruel care uh and huge staffing pressures. And that is not what you want to be added to that within the current Scottish system were affected. By the way, we, we work well working shift. I don't know what it is like in your corral care, but certainly we have a, we have a day shift for multiple consultants on our floor in Edinburgh. Uh and there's a nighttime consultant on, there's a nighttime team on and essentially no one is in the hospital apartment occasionally for, for more than that kind of 12 hour period. And unless you have a system in place to manage your referrals, you may be able to manage rereview a patient within that 12 hour shift period. But if the patient's deterioration episode is longer than that, there's always a risk unless you have a system to manage your referrals that you just lose track of that patient. And then they are at risk of delayed and harmed, harmed care. There are other systems out there. Now, if you look at the rest of the English speaking world, most of some form of structure or developing some form of structure and it varies a lot in terms of what healthcare system you look at. If you look at uh the HSC healthcare within the Republic of Ireland, they're very much recently adopted. Um Cruel Care Outreach is a model of care. Um If you look at Australasia, they have a usually a medically led Met team in many of their hospitals and NHS England largely since really, really passed over 20 years. Now, they've had cruel care outreach which is often a can be medically led, but it's often a nurse lead service that may or may not be 24 7. So there's a variety of ways to uh to manage uh deteriorating patient's from accrual care perspective. Across the world. And in Scotland, we've not traditionally adopted these models and we're really still relying on the news and announce of uh uh the responding trainees from war specialty point of view and then a probe then hoping that they appropriately call us at the right time. Uh, in terms of critical care, we do have guidelines and I'll talk about the, the guideline guideline update for detecting patient's towards the end of the talk. But they do help us frame what kind of good care uh looks like. But I suppose my personal bias is particularly having trained down south is I do worry that uh the way we responded to tuition in Scotland is very much like uh well, the analogy is driving a car. Well, I would say is um uh we have relatively good resource uh internationally with kind of uh staffing, etcetera. NHS Scotland by and large. Over the past couple of years, we had a nice car that was uh if we think of our patient deterioration response that has that nice car. But because we didn't have any other redundancy in the system, any uh rapid response to etcetera, it was a nice car. We were driving it without insurance and, and, and that is fine until you until you have a crash. So because we're only relying on ward based doctors to assess the patient's, if they spot the patient is sick, you know, they are the ones that manage patients' all day long who are deteriorating. There is no one else that does it on their award, then they can escalate care in a timely way. But if they make a mistake, if they don't spot patient's deteriorating, then the consequences can be disastrous. And maybe in other healthcare systems across British Isles, they may have a less swished car, they may be less well staff, but they have that redundancy in the system. They have an insurance policy, whether that's outreach or a rapid response team or a met team too. If that war doctor Mrs, a deterioration, the Irish team can come in and obviously, there's, there's um there are drawbacks from the outreach team, anyone who's working and it's a single will know that there's a tense it when the outreach team descends on the war, the war team skedaddle and you in in outreach terms are kind of left holding the baby. But, but, but certainly it's something that we probably need to think about, particularly as the acuity of referrals continues to increase post pandemic and, and to just leave at that point a bit more. And certainly through the work I've done and just loading, looking and speaking to teams who are uh responding to DTs on awards, even a simple thing like us doing a little care of you and asking the war team to get a CT can be really fraud. And, and even if you think about a surgical based patient. There are a number of steps that they have to go to, to get out of our CT, particularly on the weekend and, and, and, and, and even it's been to our, our own ncs loading colleagues that can be a huge problem for them. And if that is a problem that can lead to delay and delay an escalation, if that CT is, is crucial in terms of finding out what's going on with the patient and everything is difficult. And in in surgery, think of the steps involved in getting an out of our ct abdomen for a potential surgical issue on a medical ward. Uh The junior doctor will have to call the registrar. They may have to speak to a surgeon. They may have to speak to a radiologist, they may have to speak to a surgeon again. And then if the CT shows pathology, they may have to speak to a, to a theater coordinator, anesthetist, there are numbers of steps there. And certainly, although we may be able to order radiology very rapidly uh from a cruel care perspective, that may not be the case for the war teams. So we have to be careful, we ask for and understand the context of what is achievable that patient in a ward setting. And just kind of uh kind of this is not really based on data, but this is just on trends in terms of what we see in the S A S etcetera. War for, for those of you maybe less used to assessing patient's on the wars or the things we need to think about where the high risk areas when things often go wrong. Well, there's in broad terms, think about that surgical patient. All right. That, that, that surgical problem on the medical ward. It's really anything that war team is not used to dealing with. You may know how to deal with, it may be your bread and butter, but they may not know that patient who goes into fast, the f on the surgical ward ward, that is not a good place necessarily to have uh that particular medical complication and anything award team is not used to dealing with, gives added risk and think about that. But a problem they can't currently deal with. So the classic one there is, you may know, you may think that in on, on a normal summer's day when the E D is empty, they, that the E D can clearly give a patient a bit of fluids recheck their obs and, and, and call you back if there's an issue with the patient. But if this patient is lying in a corridor, that E D is in chaos, even that minimal intervention may just not be possible. And you really have to make a judgment, not on uh what, what, what should be done in the future, but what are you going to do for that patient right there? Right now, it may actually be better to escape that patient's critical care, accepting that your own resource may be pretty stretched. If you do that for every patient, you see, we also have good data that uh although Scotland, why we have pretty low V admission rates, too critical care when we are called to see a patient within 12 hours of step down, often, that can be a sign that um there there is deterioration ensuing. And the big one is a patient who Krill care of. It has already seen. We know from uh quite interesting data from Portsmouth that the number of times you see a patient from a cruel care referral point of view. Uh Every time you see that patient, the risk of cardiac arrest for the next 24 hours goes up. So always think about that if they keep calling you uh the risk to that patient is going up, so you might and just be aware then that we all suffer from this. I suffer from this a lot, the kind of diagnostic tunnel vision sometimes it's better to quit, put your head and think about escalating care for that patient or changing strategy. And and always think about that, that that system there, the Afrin limb and and the different limb uh of the rapid response system. And again, think about that does that doesn't, how do we get that redundancy in the system? And it may be some form of uh system to the way we manage coal care referrals, bills that redundancy in the system to make it safer. And in the same way that there's a chain of survival in L S Chris, somebody who's talking our local event today, consult in acute medicine and Krill care in North Wales, who's uh published a lot including initial paper on early warning scores. He talks about the the chain of survival in terms of deterioration and the chain of survival is only as strong as, as its weakest link. And if there, there there is a weak link there. So, okay, junior staff, uh you're relying on a very junior awards staff member to call you back. If there's an issue that might be your weakest link in the chain or it may be that you just do not have a robust way of handing over your referrals uh when you get them. So, so think about that, but certainly in terms of where we are in Scotland right now, we are uh certainly in the short term, at least we're focusing on improving our ward doctors response to the theory, patient and try and encourage them to do the right thing. And, and as we've done today in our sp sp event, we're trying to labor the point with the wards, wards to try and encourage them to have a structure in place so they can assess the decorating patient's work in whichever hospital they find themselves in, in May. Last year, we published a toolkit set of principles in terms of response to deterioration. And that had a lot of input from cruel care colleagues across Scotland, Stephen fear. And, and he says, Grampian and Graham Simpson who's talking today actually from HS fight. I'm the first thing we focus on with that tool is that recognition of deterioration. And again, I'm gonna labor this point too much. Other than to say that as many of us go to move to news to its key always, to ensure that we, we also use clinical concern. And NHS England right now are soon to launch a collaborative piece of work looking at patient and relative activation of concern. And it's clear from the pediatrics uh side that that is an area which can build reliability into your system. And many of us can reflect that our hospitals did feel different. At least we had no relatives at all in them during the pandemic. And it is interesting to reflect that whether patient's or relatives can um identify their deterioration earlier, uh particularly in the world of smartwatches, we're, we've all able to track our heart rate, etcetera, one for the future. But it's certainly something that we're looking at um uh increasingly and the other thing to say is that the way the OBS are done on, on, on your ward is, is changing. And if you, if you're in any of our boards, be aware that you're either already have electronic observations on your wards or they are coming. Um This is a screen grab of the current EOB system in track care and NHS Lothian, which is currently being uh rolled out other boards. NHS Lanarkshire, anything else Fife in particular have more well established York systems which clearly have some advantages in terms of reliability of collecting data, but maybe bring color challenges such as color fatigue if you're the junior doctor taking a pin where every time a patient and use was about five. And sadly compared to other parts of the world, we haven't got one national EOB system. Every board has brought their own system and there are various systems being introduced all across Scotland. Uh So it would have been nice. We had one but sadly, we don't. But the meat of any response to the tuition is the assessment by the uh by the team. When, when that news news to score, that clinical concern is raised. And when the document we published last year, we really trying to distill down the key things there and, and a bit here that uh there's a few things I would highlight one that we really want our teams to think early before they even maybe refer to little care about the context, whether it's the anticipated care plan or the treatment escalation plan because that's going to frame what you do. And clearly we should, we we want to encourage teams to assess patients' using the A B C D approach, but very much and this was very much informed about. Back Gavin Simpson was the idea that once you do that assessment, there are only really three triage outcomes. So you can have for that patient, you can either keep them in sit, you do some stuff and re review them to see if that stuff has worked. You might delegate that review to someone else but someone needs to re review you either you then maybe change the treatment goals, putting a DNA CPR being attempt stay there for ward level care or you get them into critical care or that whatever your higher level of care is, those are the only three triage options for any assessment of deterioration. And it's worth remembering that and that's something we can think about. That's only something I think about when I go and see referrals on the wards is, can I, can I make them better and sit you and look at them again? Can I do I, is it appropriate for me to change the treatment goals or do I just need to get them, get them into the? You know, I'm thinking about Tuman escalation plans. A CPS. We've seen a lot of these in acute care um over really since the start of the pandemic, there's no American sure that terms can be confusing. But when we talk about an anticipated care plan, we're really talking about a plan a clinician may make when the patient is in the outpatient clinic or in the in in the GPS practice when the patient comes in to hospital and their health status in flux. That's when we're really talking about the treatment escalation plan. There are many CPS out there. Respect is one of them. But Trumanesque clinician plans have been coming around around Scotland now and many of them have are now embedded in our track care systems and as certainly are, are very useful and sometimes that the complex we have to be involved. But often these are done by the war teams before, before we involved as a quick plug. I think I saw Stephen um on uh on the call here tonight. But uh my colleague Stephen Freer in N H S Grampian is organizing a webinar through medal that will run on the length of May looking at this particular topic with a number of invited speaker. So if you are interested to learn more about Trumanesque implant, escalation plans. A CPS, uh please register for that webinar. And again, this is my my kind of 10 10 pence worth for, for, for this aspect when you go and see a patient, really just ask yourself a simple question. I ask myself if I'm retaining sick, but I need to come for the dying and I don't want to get the two mixed up and clearly sometimes I do, but that's always something to think about is this patient sick salvageable or are they just at the end of their life? And again, the other thing that we highlight when we respond to review is for the key metrics that may, may indicate severity and certainly particularly in our local data. And NHS Lothian, if you look at Lactic, lactic, lactic is a common theme in R S E R S when things go wrong and it's either a very raised lactate that was not appreciated or a very raised lactate that was never followed up again. And lactate is important in a number of syndromes, whether it's a cult ischemia sepsis or increasingly recognized as a marker of poor profusion and things like Kyra cardiogenic shock. We know from local data and NHS Lothian that if you're lactics over four, there were pretty much a 50% chance of either being dead or need incredible care. So respect the lactate and ensure when you see a patient does have a highlight, take, you have a robust way to make sure um that is uh has been cleared effectively. And again, think about the metrics when you see a patient about what, what constitutes improvement. And again, getting back to my colleague, Chris sub from NHS Wales who's published on this, his diagram here is quite useful and I hope it projects okay for you. Things are associated with good outcomes. What is a good outcome in deterioration? We'll timely admission to ICU HD you're theaters, whatever that defensive care is, is a good outcome. And again, G picks, it is really pushing us to admit these patient's get them in the grill care at least within four hours of the decision to admit. Um, if they're no longer triggering after you've done some stuff on the ward, then that's clearly a good outcome. But also satisfying outcome is an appropriate, uh Truman escalation plan that says there for ward care, if that's uh that's consistent with their wishes and their pathology, that is appropriate. But what a bad outcome is is the fact that they're still triggering after you saw them or that they did need in critical care. But there was unacceptable delay or that the worst case that you saw them, you said they're okay, you walked away and then they arrested and it would have been for escalation and, and, and the problem we have um you know, hospitals right now is because of the security of the system. We have a lot of those patient's in that, that latter category and we want trying to do that. And the other theme that comes out from S E R s and why the reason that it's in, it's in this document is the need to reassess. So you know, that patient, it's the patient where you do some stuff, but maybe it's not effective, maybe they start to trigger again. Maybe you say that I think the space and septic get a CT, but hey, the CT is normal, what do we do now? And particularly because we all know working 12 hour shifts that need to, to reassess by someone and it may be cruel care. Maybe someone else that's often where we find that things can fall down, particularly if the diagnosis is not clear. And maybe we have to be a bit better about accepting that diagnosis is not clear, but the physiology is bad that we need to get these patient's into a higher level of care. So really when we talk about reassessment, we're still really focusing on the same old things, but we're again focusing on what is the diagnosis? Have we got it right? Have we have got to reassess it? But the end of the day, the triage decision is the same, either stay where they are with some stuff done. You, you re evaluate the treatment goals or you get them up to a higher level of care. We've been trying to embed this approach to boards across Scotland and we've kind of nicked tools really from the oil industry where we map patient motivation. Um And we've done this now with uh seven boards in person across Scotland. It's quite useful. I've done this with both surgical and medical teams in NHS Lothian. We essentially get the team into a room, whether it's staff, nurses, nurse practitioners, junior doctors and a consultant. And you say to them, you know how we would you respond to this deteriorating patient? And it really is designed to define work as done as opposed to work as imagined. So, how you actually responding to deterioration? And it can really be very interesting to um we use the mapping tool to work out where the strengths in the system are, where the weaknesses are, whether targets for quality improvement and going back to CTS again, I was very struck when I did this with it and says losing colleagues that really, I did not realize that it's certainly an acute medicine at the weekend in our hospital, they cannot get CT scans at all. So it's just not going to happen if I suggest that to them in a, in a management plan. Unless I actually that myself with our current system, they're going to be waiting at least 24 hours for that, for that imaging. And clearly, it's the patient is a risk of the situation that may not be appropriate. And many boards across Scotland have um uh they're those specific ways about looking at deterioration and looking at what's or the key elements of an effective response to deterioration. And again, I don't know, I think Gavin is on the call as well. This is a slide that I've shamelessly nabbed from his slide set from today. This is our NHS Fife uh really display the key elements of their patient safety system when it comes to patient deterioration, looking early warning scores, learning, looking at Truman escalation plans are H A C P looking at search of response, but also drilling down on their DNA CPR data as well. So that's what we're trying to get our rewards to do. And again, we have a part to do when we respond in a structured way, hopefully to deterioration and in some ways, we really want to member what the wards are doing in terms of the way we assess are deteriorating. Patient from sp sp point of view, what else will be involved with? Well, traditionally Scottish government love us to kind of be involved with sepsis care. Um And, and, and we have a separate driver diagram that time to show you that that looks at sepsis. And many of you will know that the kind of guidance around sepsis is being tweaked internationally and nationally over the past couple of years. And, and our, our Q I work grounding sepsis tries to reflect that probably the biggest changes menu will be aware that is that we can't get away from the full antibiotics were in one hour for everyone. And we're trying to find a way in which we can down to my patient's who definitely need antibiotics within that time frame. But there are others who may be less sick where we can wait while we do some investigations. And that's based on the um rock paper that was published in May last year. Many of us have concerns about that, particularly given the way R E D s are right now that the ability to effectively re review after investigations may not be there. So again, this is not something that's fully embedded in our systems yet, but it's certainly the direction of travel. We do regular webinars. And again, we try and cover topics which uh which cover a broad swathe of, of stuff, you know, webinars on sepsis, number of webinars on sepsis, eob's, etcetera. And our last one which may be particular interest to those uh covering Crittle cares was with Alison Proudfoot, who's a uh consultant, incredible care from Barts Health Center. Really talking about the recently published by CS report on shock to survival on the management of cara cardiogenic shock. Really stressing that first patient's in this group. Early identification of cardiogenic shock is key, early access to echo is key. And then once you've done that you may, you may need to escalate the patient not even to your I see you but to some other tertiary or Cortin every center ICU entirely. So and all these webinars are available on our SP SP youtube tell if you're interested. The last thing I really want to speak to you about is our update of the sign of 13 line, 139 guidelines. So um that's the guideline on care of deteriorating patient. And hopefully the content of that will make sense to you particularly after this. Um this talk tonight, it was first published in May 2014. And as you, as you can tell, there's been a lot that's changed since then. Um I chaired the update group and it was great to have uh input in the guideline process from for many people across various specialties include including good representation from those of you in critical care. One of the major changes to the updated guideline is that it's not just gonna be covering patient deterioration in the hospital setting, but also in in the pre hospital setting as well because clearly it doesn't really matter to patients where they deteriorate, they want to have uh effective evidence based care. Uh The guideline update has gone to consultation which has recently closed. It's not been fully launched yet. So I can't tell you exactly what it says, but I can give you the headlines in terms of the bits we're looking at which really hopefully reflects what we've talked about tonight. We talked about your jobs and what components of the OBS are important for an effective system. We talk about the use of tech, these ACP really getting away from just that red form to ensure that any patient you even think about having a red DNA CPR inform you ensure that that is fleshed out to the full, more effective TEP which really addresses what we're going to do for that patient in life. It's supposed to just talk about what we do want to die. We will be will be general recommendations around sepsis, particularly in light of the recent rock paper. And there will be recommendations about how we responded to, to Asian, whether we use the term kill, get outreach, a rapid response teams. So that will be part of the guideline. And again, we know particularly from uh various pieces of evidence that handover and communication is key. And uh we probably uh we probably all reflect that sometimes, particularly as I know, my own practices are critical care gets bigger. The number of consultants on the floor, anyone time gets bigger, the ability to hand over and communicate care between teams and within a team is more challenging. So there's some of the stuff about handover and communication within the guideline update. So in answer to the question that Julie posed me when she asked me to talk, what, what next for Scottish Carol Care units? What, what do I think management of patient deterioration is going to look like in the coming year as well? I think it's pretty clear that we will be living in an Yobs system in a world of e health record. So I can imagine myself sitting in my, my, I see you logging onto the wards and seeing where all those triggering patient's are obviously until the system crashes. But that, that I think will be affecting all of us. I think there will be less emphasis on just that red form DNA CPR and we will talk more about TEP or A C P. And I do wonder whether um particularly as, as the acuity of in our system continues, we will need to have some form of increased structure around how we respond to uh situation kill care. It is highly unlikely we're going to develop outreach uh services in the, in the way that they have been developed for over 20 years and other parts of the UK that resources just took too big and possibly too, too expensive for us. But some way of building more structure into the way that we manage our referrals is probably what we need in our own systems. And again, it should be bespoke for each individual hospital and Krill care scenario. So I hope over the past 50 minutes, we've touched on the types of patient deterioration and, and some of those early warning indicators. Um I hope I've kind of touched on how you respond and what your triage decision is. We've talked a lot about systems. I've given you a bit on what the Scottish patient safety program looks like and also hopefully give you a sense of uh the impact patient deterioration, particularly war deterioration has on cruel care facilities. Thanks again for the opportunity to talk to you and I'm very happy to take questions. Thank you so much, Doctor mcneal for that talk, um such a multifaceted topic, but you find that in a really clear and concise way. Um, so anyone's got any questions, um, please just write them in the chat. Um, I've got a couple of questions if that's all right. Um, so I suppose starting with, you have worked in England, trained in England and worked a consultant in England and now like in Scotland. Um, do you think it's ideally, I think it's time that we brought critical care outreach teams up to Scotland. Uh That's an interesting question, Helm. I mean, I think my, my own list answer is I thought having only worked in the service that had um I reached during my training and my first consultant job, but I moved up to Scotland, I thought, you know, how is this going to be? And actually, I was very much struck that if you do have an outreach service, um it suddenly becomes the management of the medication is no longer principally the responsibility of that war team. And when I moved up, Scotland's very clear that because there is no one else that war team has to manage and absolutely own that motivation until Krill care arrived. And as a real strength of the Scottish system, and I think that's served as well for many years. But I think uh particularly post pandemic patient's are so sick now. I don't think we need to dial up the full out re service that many large hospitals from my contents. And, and we have down in NHS England I think that would be too much but some form of structure where we have uh some form of structure in terms of managing referrals, re review our referrals. I think, I think we do need that. And I think, I think it's something we should probably look at. But again, it will be, may be appropriate for me in a larger teaching hospital. There may be a different solution if you're in a much smaller critical care in a, in a different different setting with fewer calls. So I I what I was um thinking about, you've mentioned a few times about consultant so of handover, consult between consultants, but also between everyone else and shift changes. Is there anything that you do in your hospital in terms of patients that are out and about on the wards just to keep an eye on, you know how they're doing and make sure they don't fall off the radar of critical care. Um The, the short answer is no, we don't, we don't have a reliable system. We occasionally have a, have a white board in our office that we write the details of someone that we want to be re reviewed and we do have a handover between shifts, but we all know that that information can get degraded over time. So we don't have a reliable system, my colleagues at the Western General and then we do have more reliable system, but maybe that they're, they're dealing with with your referrals. So, and I think in my own local context and it became that we develop something a more robust way our, our own uh major trauma team within and it's just slowly and have a way that they can map all their referrals in their hospital. And then maybe we need to look at something similar for our own cruel care service just as a number of referrals and the complexity referrals increases. Yeah, I know it would be interesting to hear if anybody had um kind of a system up and running for, for managing those referrals. We've got a couple of questions in the chat here. So um from Lindsey Ford, got just a comment. We have an outreach service in the pediatric hospital in Edinburgh and it works very well. Uh My colleagues have some good data on early recognition deterioration and also reducing unplanned admission's too pediatric critical care. So yeah, from a children's point of view as well. Yeah, and I see when I was, I'm not because I do the role within SP sp and his right now, I don't do the local stuff in excess sodium. But when I did, I did have conversations with pediatric colleagues and it was really impressive. Uh the level of support their outreach team gives two sick Children within the, within that context. Um And another question from in Keith, um we often hear that being admitted to ICU critical care would be a good outcome. What is your thoughts and what a good outcome is with frailty common and at times simple level two interventions, um level three care can make a good outcome for them. Um So I think we're talking kind of on the lines of um TEPP and the outcomes that they had in the, was it mailer the Wrexham ones? Yeah. Yeah. And I think I would probably take that for you. I, I think a senior decision maker, whether they're cruel care or specialty, you know, defining appropriate limitations of care involving the patient family, etcetera, with no admission atrial care at all. It, for some patient is a, is a perfect outcome. And I think that's very much in our green box of good. Also having the time to clearly flesh out that the patient may only be suitable for level two cares was level three. Um again, that that is a good outcome. I suppose what we all want is we want the time to make that decision and if we're called too late, sometimes we don't have the luxury of time. We don't have the ability to aspiration what they one and, and the whole thing becomes out of control. So, absolutely agree. Um an effective rapid response system involving the wards and Kriel care would mean that for, for many patient's good is, is not coming to critical care. And I think it's interesting the conversation we're having today is that they're clear a lot of angst about the work in the NHS England and NHS Wales on relative um and patient activation of their outreach systems. But actually sometimes those people, whether it's the patient relative may spot that deviation earlier. So that potential will buy you time to make appropriate decision making. The real problem is if we're called when the news is 12 and the patient's pair arrest, then all bets are off and we don't have that much of time and sometimes we end up getting a patient who is never gonna benefit and uh that's, that's obviously harm. So we want to avoid that. Um And you had mentioned about the difference between of Tepes and A CPS. Do you? One of the things I've found is often you can see that a patient has an A C P but not see what it is. Has that been kind of any part of your work with healthcare improvement Scotland in terms of liaising with primary care on that kind of front? Yeah, so I mean many of us will be familiar with, I think G C uses portal portal system, but many of us use E kits. And if there is a the key information summary, there may be an A C P there that we can access through the key information summary, but in a number of boards is glitches in that system. Um NHS Forth Valley have um particularly around the use of the respect tool which has some evidence behind the uh they worked with Nez last year to develop an electronic respect tool. I think they're trialling at the moment and hoping to spread out to any chest Tayside which tries to get into, tries to use technology to make sure that people um can get access to that ACP when they need it. And I think what we're really looking about is ensuring that the A C P is owned by the patient. Is there A C P? They've had uh input into it and they should kind of carry it with them whether it's that physical or an electronic copy. So I think that's what, so they forcefully looking at it. It's only a weakness in our system right now and there's nothing worse than knowing that something's been discussed, but you don't know what it is. Exactly. Well, just, yeah, it would save so much time as well. Um I'm not seeing any other questions in the chat. Um And I probably grilled you enough. So I just wanted to say thank you so much, um Gregor for doing the talk for us tonight. Um I just want to quickly mention our next month talk and so we have this on the 25th of May. Doctor Allison Smith who is cardiologist, but snaps to the Scottish National um Heart Failure Service. Um It's going to talk to us about um the management of advanced heart failure and updates in that. Um So we'll send out the sign up link to put that in your diaries and hopefully see you there. And yes, thank you so much, Doctor mcneal for that talk and thanks everyone for coming see you all next month by.