Counties Manukau Health (CM Health) is piloting Call for Concern, a resource for patients and their families to call for immediate help if they become concerned about changes in a patient’s medical condition.
Internationally, patient- and family-initiated escalation services have been developed in response to avoidable patient deaths, and studies have shown that families notice subtle changes in a patient’s condition that can provide early warning of deterioration.[1-5] Moreover, such services improve confidence in care and help to identify system errors without increasing overall bed calls.[6,7]
In New Zealand, this type of service is part of the Health Quality & Safety Commission’s five-year quality improvement programme to improve recognition and response to clinical deterioration.
The Patient At Risk (PAR) team wanted to implement patient- and family-initiated escalation in CM Health.
The first step was to study patient and family experiences of deterioration and how they would prefer to learn about and use a Call for Concern service. The team interviewed 32 patients and nine family members across two adult inpatient wards. The interviewees represented a diverse mix of ethnicity, age and gender. Of these, 28 had experienced deterioration through either a medical emergency call or referral to the PAR team.
A thematic analysis of the interviews revealed five themes:
1. It was clear that patients understood their illness and recognised if their condition was deteriorating.
2. Aside from recovery, what mattered most to patients was the impact of hospitalisation on themselves and their loved ones.
3. Cultural and spiritual wellbeing and personal beliefs were important.
4. Patients and their families felt relieved and reassured once treatment had been escalated.
5. There was overwhelming support for a Call for Concern service, and phone or text were the preferred ways to contact the service.
Next, the PAR project team needed to know what nurses thought about Call for Concern. They worked with nurses on the two wards to identify the perceived pros and cons. Nurses felt positive about the potential of the service to improve communication, involve patients and their families in their own healthcare, and reduce delays in response to deterioration. However, they were concerned about patients and families using the service inappropriately, raising false alarms, and bypassing their general practitioner. They were also concerned about whether there would be enough nurses to cope with patient demand.
The project team developed posters and pamphlets to educate patients about Call for Concern. To ensure these were appropriate and effective, the team worked with a patient and whānau care advisor and the CM Health Consumer Council.
They ran the pilot in two adult inpatient wards. To prepare the wards, the project team developed a staff education and training package and identified ward champions to lead the education sessions. They also ran a focus week and a launch.
To date, the Call for Concern pilot service has received nine calls. All were appropriate. Reasons for the calls included communication issues, concerns about nursing or medical management, delays in treatment, and dissatisfaction or psychosocial issues. Three patients required escalation of treatment, and the PAR team requested house officer or registrar review for those patients. A quality co-ordinator follows up all calls, interviews patients and their families, and provides feedback.
The Call for Concern service has received positive feedback from patients and their families, including a letter thanking the PAR team for their care:
To the PAR team,
Thank you all for your care and support for me and my son Sean. This has been one of the hardest times in my life and having the extra support throughout my son’s recovery has been so valuable to me. Just brought me comfort having the extra support and care. I’m very grateful to you all. Such a terrific service for ppl like ourselves.
The PAR team plans to roll Call for Concern out across the adult inpatient wards at Middlemore Hospital.
1. Dean BS, Decker MJ, Hupp D, Urbach AH, Lewis E, Bennes-Stickle J. Condition HELP: a pediatric rapid response team triggered by patients and parents. J Healthc Qual. 2008 May-Jun;30(3):28-31.
2. Gerdick C, Vallish R, Miles K, Godwin S, Wludyka P, Panni M. Successful implementation of a family and patient activated rapid response team in and adult level 1 trauma center. Resuscitation. 2010 Dec;81(12):1676-81. doi: 10.1016/j.resuscitation.2010.06.020
3. Odell M, Gerber K, Gager M. Call 4 Concern: patient and relative activated critical care outreach. Br J Nurs. 2010 Dec 9-2011 Jan 13;19(22):1390-5.
4. Rainey H, Ehrich K, Mackintosh N, Sandall J. The role of patients and their relatives in ‘speaking up’ about their own safety – a qualitative study of acute illness. Health Expect. 2015 Jun;18(3):392-405. doi: 10.1111/hex.12044
5. Vorwerk J, King L. Consumer participation in early detection of the deteriorating patient and call activation to rapid response systems: a literature review. J Clin Nurs. 2016 Jan;25(1-2):38-52. doi: 10.1111/jocn.12977
6. Berger Z, Flickinger T, Pfoh E, Martinez K, Dy S. Promoting engagement by patients and families to reduce adverse events in acute care settings: a systematic review. BMJ Qual Saf. 2014 Jul;23(7):548-55. doi: 10.1136/bmjqs-2012-001769
7. Brady P, Zix J, Brilli R, Wheeler D, Griffith K, Giaccone M, et al. Developing and evaluating the success of a family activated medical emergency team: a quality improvement report. BMJ Qual Saf. 2015 Mar;24(3):203-11. doi: 10.1136/bmjqs-2014-003001
This case study is based on a Nursing Grand Round presentation by PAR team members Eve Christophers and Susan Takerei, as part of Patient Experience Week at CM Health.