Recent eLetters

Displaying 1-10 letters out of 72 published

  1. Moving Beyond Tokenism: a public health response on Researcher in Residence models

    Marshall et al's (2014) paper was highlighted as an exemplar of stakeholder participation by a speaker at a recent public health research conference, held in Newcastle. Participants gave useful feedback about many of the core issues raised, which we reflect here.

    Marshal et al's (2014) 'Researcher in Residence' models are suggested as a means of co-engaging academics and practitioners in the promotion of evidence-informed service improvement. But participants at our event raised questions about public involvement as key stakeholders from earlier on in the research process. In the experience of our presenters and participants, research that starts from questions derived from both academics and participants (i.e. that is co-produced) is more likely to address patient needs than questions driven by academics, funders or institutions.

    Important (though hardly novel) questions remain. Are academics open enough to co-produced research ideas? Is there sufficient willingness to see questions differently, to work differently, and to enable tacit knowledge and patient and public experience to be valued as a legitimate contribution to the research process? Public stakeholders at our event expressed hunger to know how to engage with academia, but felt the opportunities to do so were unclear. There is much to learn from Patient and Public Involvement (PPI) in research.

    As others have observed, effective patient and public involvement (PPI) requires difficult conversations about vested interests (Greenhalgh et al 2014) and power and status among stakeholders (Centre for Social Justice 2012). Discussions about paying research participants can present thorny issues for some, among wider concerns around how public views are sought/used/valued/acknowledged. PPI raises philosophical questions around 'independent research' and what this means, as well as similarly tricky issues around what expertise and experience 'counts' (for researchers and the public) and how to address institutional barriers and facilitators to its use.

    Public health, classically defined as 'organised community effort' to prevent disease, prolong life and promote health (Winslow 1920 cited in Lang and Raynor BMJ 2012), presents a unique set of challenges. The relocation of public health responsibilities to local government raises questions about the different cultures of research and evidence use, the place of public involvement and democratic accountability, and how to use opportunities to address the social determinants of health. The exemplars used by Marshall et al (2014) are all drawn from clinical settings, and models of PPI may need adapting for use in public health.

    Our event showcased pockets of good practice and highlighted different methods to involve patients and the public, including in public health (see Some of these have been published elsewhere (Centre for Social Justice 2012, Lewis and Russell 2014). Taken together with feedback from those with experience of PPI, we can discern some underlying principles to guide meaningful PPI in research (which may also support research use in practice). Though not comprehensive, these include the need to; clarify motives; reach out to marginalised groups; use existing networks; take account of context; be reflexive and adaptive; value different forms of knowledge and expertise; be committed to the possibilities of facilitating change.

    Neither in public health nor clinical settings have we 'cracked it' in terms of PPI. Our conference opened a black box of similarities and contrasts between PPI in public health and clinical settings - requiring different approaches. Learning opportunities can flow in both directions, recognising the complexity inherent in PPI in population health interventions (Best et al 2009).

    The researcher in residence model introduced by Marshall et al (2014) is one approach to co-production. However, we argue that early involvement in setting research agendas is more likely to meet the needs of the public. There are critical blocks to effective engagement, for example silo thinking, the "paradigm shift" (Hunter 2009) required in academia, and specific skills amongst researchers. New ways of doing research must have co-production at their core - they must be collaborative and engage stakeholders from the start of the research process, when questions are being formulated, through to dissemination.

    References Best, A., Terpstra, J.L., Moor, G. Riley, B., Norman, C.D., Glasgow, R.E. (2009) Building knowledge integration systems for evidence-informed decisions Journal of Health Organization and Management, Vol. 23, issue 6, pp 627 - 641.

    Centre for Social Justice and Community Action, Durham University and the National Co-ordinating Centre for Public Engagement (2012) Community- based participatory research. A guide to ethical principles and practice, available from

    Hunter, D. J. (2009) Leading for Health and Wellbeing: the need for a new paradigm Journal of Public Health, Volume 31, No. 2, pp 202-204

    Lang, T and Raynor, G (2012) Ecological public health: the 21st century's big idea? British Medical Journal 345: e5466. 21 August.

    Lewis and Russell (2011) Being embedded: A way forward for ethnographic research Ethnography 2011 12: 398. DOI: 10.1177/1466138110393786

    Lomas, J (2007) the in-between world of knowledge brokering British Medical Journal, 334, (7585): 129.

    Conflict of Interest:

    All authors were members of the organising committee for Beyond tokenism: PPI with impact Enriching patient and public involvement in public health research, October 16th 2014. The event was sponsored by the Newcastle Institute of Social Renewal, Newcastle University Faculty of Medical Science, Fuse Centre for Translational Research in Public Health and Involve North East.

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  2. Ryan's Rule - consumer / family escalation.

    Dear Editor,

    We read with interest your Editorial re the role of families in preventing avoidable harm in children (1).

    Many public hospitals in Queensland Health in Australia have now implemented Ryan's Rule. When Ryan's parents were worried he was getting worse they didn't feel their concerns were acted upon in time. It was subsequently established that Ryan died from likely preventable causes. Ryan's Rule was developed to provide patients of any age, families and carers with another way to get help. Families and carers are educated by staff and with the prominent display in the wards of Ryan's Rule posters containing the following advice re escalation.

    There are three steps for families and carers to raise their concerns:

    [1] talk to a nurse or doctor about your concerns. If you are not satisfied with the response->

    [2] Talk to the nurse in charge of the shift. If you are not satisfied with the response ->

    [3] Phone 13 Health (13 43 25 84) or ask a nurse to call on your behalf. Request a Ryan's Rule Clinical Review and provide information about hospital name, patient's name. ward, bed number, your conduct number. A Ryan's Rule nurse or doctor will review the patient and assist.

    We await with interest the results of the prospective audit of this statewide process.

    Yours sincerely,

    Dr Mai-Ing Koh MBBS (JCU), Resident, Namboru Hospital

    Assoc Prof Tieh Hee Hai Guan Koh BA MA (Oxon) MBBChir(Cantab) MD (Cantab) FRCPCJ Director Neonatology The Townsville Hospital Queensland 4814 AUSTRALIA

    1) Roland, D. But I told you she was ill! The role of families in preventing avoidable harm in children BMJ Qual. Saf. 2015 24:186-187

    2) Ryan's Rule (accessed 11.3.15)

    Conflict of Interest:

    None declared

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  3. Response to letter regarding 'working smarter, not harder'

    We thank Dr. Iedema for highlighting that a gap exists in providers having the skillset to 'work smarter.' We agree that novel approaches to healthcare improvement are required that move beyond gadget-based solutions and that require a new set of skills of providers and provider organizations. The suggestion of video taping one's performance to review how the system (and its participants) currently operates and reflect on how to (re-) design their workflows is intriguing. It exemplifies the concept of 'exnovation' or 'innovation from within', meaning innovation arises from within established practice, and from within practitioners.

    However, our article did not aim to imply that it is providers who are responsible for, or required to gain the skills to work smarter. Our message is directed to all those seeking and driving healthcare system improvement. Although we agree that providers may benefit from the skillsets that Dr. Iedema proposed, we believe that those seeking change also need additional skillsets and perspectives. We can no longer presume that healthcare providers have the space to add new tasks, workflows, procedures etc. We have, as a system, to work on simplifying the current work environment, finding non-value added tasks and work with healthcare providers to design ways of achieving improved outcomes that don't add net new workload or complexity. Now some may argue that added work at one part of the system may have larger benefits downstream. This may be true but those charged with carrying the weight of the new tasks have to do so in a sustainable and reliable way. Otherwise subsequent change initiatives will disrupt this balance and its downstream benefits.

    Our message was also aimed at those adding new regulation, policies, performance measures and incentives or disincentives. Adding pressure on top of an environment that doesn't have the space nor the knowledge and skill to create it only adds to workplace burden, resistance and non- sustained improvement. We believe that there needs to be a system-wide look at the capabilities and investments required to create a 'working smarter' healthcare system. Providers will play their role but they need a commitment that a 'work harder' strategy is no longer acceptable.

    Conflict of Interest:

    None declared

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  4. Working smarter, not harder

    The Hayes, Batalden and Goldmann piece is an important contribution to the debate about what exactly is practice improvement. Most practice improvement thinking is anchored in the 'innovation' paradigm, and this paradigm is predominantly 'gadget thinking'. Others' solutions are to be adopted here because they produce great outcomes elsewhere. Except now we have to figure out how we can get the gadget to work. Few commentators have been game to shift towards acknowledging that care practices are now too complex for 'gadget thinking'. Hayes and colleagues are an exception. They propose that frontline professionals themselves need to become smarter at 'co-designing' solutions that suit their unique contexts and practices. Here, we are not talking about adopting new gadgets from elsewhere. We care talking about people who will - and who have the skill to - take inspiration from the smartness that may be invested in whatever gadget or improvement initiative, and apply this smartness to their own workpractices. Indeed, these professionals may not even need inspiration to come from elsewhere: they may well be motivated by issues arising in their own work, and decide to redesign their practices. But to date, we have not focused on what this ability to co-design care practices consists in. We expect frontline professionals to somehow know how to co-design practice, and know how to be smart about what they do and what they should do. And yet, their training has not skilled them in practice design. We nevertheless expect them to readily (re)design the organisational dimensions of their work. Usually, such designs fall prey to people's espoused ideas and pre-existing assumptions about how things work and should work. Often there are worrying gaps between what people know and what they (think they) do. Put differently, smartness, in the sense of learning about how to manage complex situations and improve complex practices, is rare. Smartness cannot be expected to exist or arise in situations where there are no resources available for professionals to learn about (or 'make explicit') the complexities of their own day-to-day work. Smartness must be nurtured. The way par excellence to achieve this is professionals, just as do top- end athletes, studying their own performances. In sport, video-ing one's game for transforming good performances into excellent ones is now not just common but also indispensable. This is about capitalising on and building on existing strengths. By analogy, video-ing in situ practice and using the resulting footage to reflect on the work is central to enhancing smartness at work. This is what Katherine Carroll and Jessica Mesman and colleagues have referred to as 'exnovation'. Of course, many excuses and objections are raised to auto-observation, the most common ones of which are privacy, the Hawthorne effect, and subpoenable evidence. But these concerns are over-stated, and they trade a real need and opportunity for improvement and smartness off against maintaining the status quo. Without auto-observation, existing habits and routines will go on unquestioned. Work can only become harder, as the only solutions to improvement will remain gadget-based. Smartness, by contrast, starts from where we are, and explores where we can go.

    Conflict of Interest:

    None declared

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  5. "Driven to distraction" and driving for excellence in ward round practice

    Dear Sir, It is with great interest that we read the recent publication by Thomas and colleagues investigating ward-based patient care.1 They describe a study in which 28 medical students were randomised to either control (no intervention) or intervention (performance feedback and error management training) groups, performing simulated ward rounds complicated by environmental distractors. Significant reductions in errors were seen in both groups from the first to the second ward round, with a significantly greater reduction seen in the intervention group. We thoroughly commend on their efforts to add to the body of literature for what is such a crucial, but until now has been a sparsely investigated, area of care. There can be no doubt that in current practice, the conduct of ward rounds may be hugely variable,2, 3 with significant implications for patient outcomes.2 In surgical literature, the phenomenon of "failure to rescue" describes failures in ward-based management of complications, which represent a major source of variability in surgical outcomes, emphasising the need to focus on ward rounds to improve outcomes.4 Future research in this area must be robust, evidence-based, and ideally tied to clinically relevant subjects and outcomes. With this in mind, we would like to raise several questions in reference to the study by Thomas et al. How were the "distractors" selected? Loud radio noises and upset relatives would appear to represent fairly arbitrary factors with unclear relevance to clinical care. Additionally, the authors appear to suggest that the intervention included very specific feedback on how to cope with these distractors - if part of the scoring is to assess whether the radio was turned off, and the intervention includes instruction to do so, can the result be truly deemed valid? Finally, was there a reason for selecting medical students rather than a more valid population of clinical staff such as house officers, or even residents, who are commonly responsible for the ward round? Recently, we have described the Surgical Ward-care Assessment Tool (SWAT), a checklist-based tool for technical skills, and the Ward-based Non-Technical Skills score (W-NOTECHS), a Likert-based tool for non-technical skills; together these represent objective, validated scoring scales for ward round performance.5 It is possible that the adaptation of such surgical rating scales to address other specialty populations may present an effective way forward. We are fully in agreement with Thomas and colleagues in their statement that to move ward round initiatives forward, we must in future focus on changing patient safety behaviours. Thus, future assessments of ward round performance must focus on objective assessment metrics which are generalisable across studies, contexts, and specialties. Only in this manner can reliable, reproducible interventions be developed to standardise and improve care and outcomes. References 1. Thomas I, Nicol L, Regan L, et al. Driven to distraction: a prospective controlled study of a simulated ward round experience to improve patient safety teaching for medical students. BMJ Qual Saf 2014. 2. Pucher PH, Aggarwal R, Darzi A. Surgical ward round quality and impact on variable patient outcomes. Ann Surg 2014; 259:222-6. 3. Blucher KM, Dal Pra SE, Hogan J, Wysocki AP. Ward safety checklist in the acute surgical unit. ANZ J Surg 2013. 4. Silber JH, Williams SV, Krakauer H, Schwartz JS. Hospital and patient characteristics associated with death after surgery. A study of adverse occurrence and failure to rescue. Med Care 1992; 30:615-29. 5. Pucher PH, Aggarwal R, Srisatkunam T, Darzi A. Validation of the Simulated Ward Environment for Assessment of Ward-Based Surgical Care. Ann Surg 2014; 259:215-21.

    Conflict of Interest:

    Rajesh Aggarwal is a consultant for Applied Medical. No other competing interests declared.

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  6. Real-time information on preventable death provided by email from front-line intensivists results in high response rates with useful information

    Dear Editor,

    Recently, Provenzano and colleagues found that an electronic tool collecting real-time clinical information directly from front-line providers was both feasible and useful to evaluate inpatient deaths [1]. These findings concur with our evaluation of the preventability of death using a simple electronic evaluation tool in our 46-bed adult Intensive Care Unit.

    From September 2010 to September 2011 an email was send to the attending intensivist each time a patient died in our intensive care including 2 questions: "Was this death preventable? If yes, what was the cause of preventability?". The definition of preventable mortality was provided using three criteria: the illness was survivable, care was suboptimal, and suboptimal care was related to death. No reminding emails were sent. In addition, the patient charts of all cases were retrospectively reviewed by two ICU nurses and a physician.

    A total of 306 patients (9.9%) died. APACHE IV Standardised Mortality Rate was 0.77. In 48 of these deceased patients the APACHE IV based mortality risk was below 20%. Response rate was 92% and 47 deaths (15%) were reported to be potentially preventable. Large inter-individual variations between the intensivists (n=24) were observed. Response varied between 65% and 100% and preventable death judgments varied from none to 66%. When using blinded chart review was by the nurses and physician judged death potentially preventable in 7%, 11%, and 18%, respectively. Alike Provenzano et al. we also found poor agreement between the preventability ratings from front-line intensivist reviews when compared to blinded chart review [2]. In 21 cases (45%) in which the intensivist scored a preventable death all three reviewers scored these non- preventable. This might partly be explained by additional information on each patient's individual circumstances that cannot easily be deduced from patients' charts. Using APACHE IV as selection criterion for in-depth evaluation is insufficient while analysis of patients with an APACHE IV based risk of mortality below 20% showed that only 4 of these deaths (8.3%) were considered potentially preventable [3].

    Preventability of death evaluation of all inpatient deaths is required either for quality improvement and/or by regulatory authorities. A quick and efficient method with high response rates from front-line providers is feasible and may provide useful information for quality improvement [4]. However, large inter-individual variations in response and judgment exist and, therefore, this method apparently is insufficient for benchmarking.

    References: 1. Provenzano A, Rohan S, Trevejo E, et al. Evaluating inpatient mortality: a new electronic review process that gathers information from front-line providers. BMJ Qual Saf 2015;24:31-37. 2. Hayward RA, Hofer TP. Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer. JAMA 2001;286:415-20. 3. Girling AJ, Hofer TP, Wu J, et al. Case-mix adjusted hospital mortality is a poor proxy for preventable mortality: a moddeling study. BMJ Qual Saf 2012;21:1052-1056. 4. Dijkema LM, Dieperink W, van Meurs M, et al. Preventable mortality evaluation in the ICU. Crit Care 2012;16:309.

    Conflict of Interest:

    None declared

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  7. Moving from Safety I to Safety II, but what about the media?

    To the Editor

    I have recently returned from the Association of Simulated Practice in Healthcare 2014 conference in Nottingham and whilst there was privileged to hear and meet Professor Erik Hollnagel. He presented eloquently on his work relating to “From Safety I to Safety II” [1] which provided an excellent opening for the conference’s theme of “Changing Behaviours.” His work sparked much debate and reflection, particularly by myself when presenting our simulation work related to the Duty of Candour. We opened with a discussion considering how the NHS was perceived by the general population of the UK. The conversation moved to the role of the media in driving the campaign for patient safety and openness.

    The media has embraced the reports of a small number of high profile failings in the NHS, with the now daily reporting of another “failure” or “cover-up”. It is therefore understandable why a large proportion of the population do not trust the NHS and feel there is a closed and dishonest culture [2]. The media focuses on the Safety I premise of failures [1]. This is driving the destruction of the NHS’s reputation and the wellbeing of staff and patients by focusing on the minority of outcomes which are negative. In November 2013, our local Trust was reported to be the second worst general hospital in England for avoidable deaths [3]. A review of the data and response from the Trust identified that the news report was misleading and the data inaccurate, causing unnecessary anxiety amongst patients and staff [4]. Such media reports place extra strain on the healthcare system with reputational damage and effects on morale which effect the ability of that organisation to sustain required operations.

    However, now 12 years later, the focus still remains on the serious errors, incidents and failures of the NHS. These events are still the minority of events, but the focus remains on what went wrong. As it is time for healthcare to focus on Safety II, should it not be the same for the media? By focussing on what goes right and the NHS's incredible ability to succeed under varying conditions, the media can celebrate the NHS and help to drive the next stage of safety improvement. It is time for the media to also move from Safety I to Safety II thinking.

    The discussion regarding media involvement in the NHS prompted me to consider this further and I read with great interest the 2002 paper published in BMJ Quality and Safety considering the role of the media in pushing patient safety forward as the priority [5]. There is no doubt that media involvement has benefitted the patient safety agenda, by acting as a “watchdog” to hold the medical profession accountable for improved safety and quality of care. This in turn has created a passionate group of healthcare professionals striving for excellence in care.

    12 years later, however, the focus still remains on the serious errors, incidents and failures of the NHS. These events are still the minority of events, but the focus remains on what went wrong. As it is time for healthcare to focus on Safety II, should it not be the same for the media? By focussing on what goes right and the NHS’s incredible ability to succeed under varying conditions [1], the media can celebrate the NHS and help to drive the next stage of safety improvement. It is time for the media to also move from Safety I to Safety II thinking.

    The difficulty will be in convincing the media of its role in the next stage of safety. It remains important for the NHS to be transparent, but a balance must be sought between the ongoing need for accurate reporting of serious problems and celebration of the NHS’s staff and its successes. In a recent well known report on health and healthcare service delivery [6], the UK ranked number one against ten other wealthy countries for overall healthcare (based on quality, access, efficiency and equity).

    Professor Hollnagel defined resilience as the ability of the healthcare system to adjust its functioning to sustain operations under both expected and unexpected conditions [1]. The media must understand the complexity of the NHS and be aware of the potential for their reporting to inadvertently remove those parts of the healthcare system that have contributed to its resilience.

    1) Hollnagel E. Safety I and Safety II: The Past and Future of Safety Management. Ashgate: Surrey, United Kingdom

    2) YouGov UK. One in two don’t trust the NHS. [Online] 2013. Available from: [Accessed 14th November 2014].

    3) Adams S. How 3,500 hospital patients lost their lives due to surgical errors or staff who were too busy to treat them... in just TWELVE months. The Mail on Sunday. [Online] November 09 2013. Available from: [Accessed 14th November 2014].

    4) Nottingham University Hospitals NHS Trust. Response to Mail On Sunday coverage (avoidable deaths). [Online: media response] 2013. Available from: [Accessed 14th November 2014].

    5) Millenson ML. Pushing the profession: how the news media turned patient safety into a priority. Qual Saf Health Care 2002; 11: 57–63.

    6) Davis K, Stremikis K, Schoen C, Squires D. Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally. The Commonwealth Fund. 2014.

    Conflict of Interest:

    None declared

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  8. Measuring the true impact of an electronic physiological surveillance system (EPSS)

    Dear Sir, We read with interest the article by Schmidt et al. We applaud the authors for undertaking this large and complex study and for highlighting the great potential of newer technologies to improve patient care. We hoped the authors could clarify some key issues. Firstly only one year's mortality data are used as a baseline comparator. Mortality fluctuates by year as this paper highlights, and can be affected by a large number of factors including how it is expressed (1). It is possible that the year chosen may have been an outlier that triggered the Trusts to actively invest in measures including EPSS. We would therefore be grateful if the authors could provide additional data on mortality in the years prior to the intervention. Were other strategies employed alongside EPSS? For example we understand University Hospital Coventry also called in Dr Foster Intelligence in 2007 to restructure practice (2). As the paper uses only a historical comparator it is possible that a proportion of the improvement reflects the general national improvement in hospital mortality seen over the last decade (3). Do the authors have any data comparing their improvements with other Trusts of a similar size, case-mix, and similarly average HSMR (4)? Interventions in healthcare are rarely without some adverse effects and as such we would be interested in any data collected on the potential negative aspects. These would include consequences of the increased workload for junior doctors and financial effect cost. Establishing that these were relatively minor would be very reassuring for other Trusts considering similar strategies. While we agree that randomised controlled trials are complex, we suggest there is a strong rationale for them to disaggregate the benefit of EPSS from many confounding factors, and to inform clear health economic analysis. Yours sincerely, Dominick Shaw, John Blakey and Jamie Rylance 1 2 3 4

    Conflict of Interest:

    None declared

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  9. WHO Safer Surgery Checklist not Immune to Human Errors

    We wish to congratulate Russ SJ et al. (1) for their excellent survey investigating patients' views of the WHO safer surgery checklist.

    The authors point out that the UK wide implementation of the checklist has encountered some difficulties. Specifically, barriers including checklist fatigue and difficulties in assembling the theatre team are mentioned. Whilst we certainly agree with this, we wish to amend the authors' catalogue of concerns by sharing our experience at Queen Alexandra Hospital (QAH).

    At QAH we operate a modified WHO safer surgery checklist to suit local practice. The checklist is applied to every patient passing through the theatre complex. During a routine audit we identified how an apparently minor communication error fundamentally undermined the checklist's safety function and placed our patients at risk.

    Our venous thromboembolism (VTE) prophylaxis checkpoint reads 'VTE prophylaxis considered?'. In practice however, this question is frequently altered to 'Flowtron's on?' (Flowtron refers to the intermittent pneumatic calf compression devices (IPCCD) used at QAH). The multiple meanings of the word 'on' (either interpreted as 'on the patient' or 'switched on') introduced ambiguity and a communication error. This incorrect use of the checklist resulted in multiple patients having IPCCDs applied to their calfs, yet the devices were never switched on and our patients were placed at risk.

    Our experience illustrates two important communication errors that may undermine the checklist's safety function. Firstly, accurate and unambiguous wording of each component of the checklist is essential. Words with homonymous meanings should be avoided where possible. Secondly, each checklist question must be verbalised accurately during the patient check to avoid introducing errors.

    The original WHO safer surgery checklist (2009) (2) limits such potential error, as most questions are yes/no answerable. Any local checklist modifications should aim to maintain this format. Introducing words with homonymous meanings may lead to communication errors; undermine the checklist's safety function and place patients at risk.


    1. BMJ Qual Saf. 2014 Jul 18. The WHO surgical safety checklist: survey of patients' views. Russ SJ, Rout S, Caris J, Moorthy K, Mayer E, Darzi A, Sevdalis N, Vincent C.

    2. (accessed 18/08/14)

    Conflict of Interest:

    None declared

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  10. 'Between the flags': implementing a rapid response system at scale - A reply

    The authors (1) have raised a very important issue relating to recognition and management of a deteriorating patient. Over the years, cases have been reported where outcome may have been better if deterioration was recognized in time. Once recognized, an urgent response by a qualified team could instigate immediate investigations and management as warranted, possibly averting a poor outcome.

    Code blue calls or cardiac arrest teams (2) were first introduced in 1970, with the motive of initiating an urgent response to a deteriorating patient. By definition, activation of this system occurred after an arrest had occurred, so patient had no recordable pulse, blood pressure, respiration and did not respond to noxious stimuli.

    However, more gains were to be made by initiating this response before the patient had reached a terminal stage. Based on research showing that cardiac arrest usually follows a series of events, attempts were made to identify these events so as to preempt an arrest before it actually occurred. Medical emergency teams (MET) were a culmination of these efforts.

    MET responses, introduced circa 2000 include a critical care registrar and nurse, among others. Any clinician caring for a deteriorating patient is encouraged to activate the response though a rapid response system and can expect help within minutes. Whilst the concept of MET response is similar to that of cardiac arrest teams, a fundamental difference is in the timing of initiating the response.

    However, the MET response is also activated after a level of deterioration has occurred. The quest continued to find alarm signs or signals that indicate deterioration is likely to occur. Once again, the presumption is that an earlier response, before deterioration has occurred, should result in a better outcome.

    Analysis of hospital admissions suggests an adverse outcome is likely in about 10% of admitted patients (3). Improving the outcome further, particularly for these 10%, has triggered a nationally coordinated approach that is being overseen by the Australian Commission on Safety and Quality in Health Care (ACSQHC).

    A new paradigm as suggested by Jones et al (4) would be required to drive this further improvement. The focus is now on early detection and prediction of clinical deterioration, so urgent help can be sought even before the situation actually worsens. Eight essential elements have been identified and compiled into a package that is the effort of ACSQHC. Despite differences, it was encouraging that this consensus statement was ratified by all state health ministers in Australia (5). The package, widely distributed throughout Australian hospitals, is hoped to improve outcomes by encouraging early detection of deterioration, and calling for help early.

    These strategies, in addition to the "swimming between the flags" observation chart and rapid response systems include many other initiatives with focus on education as one of the essential elements. Different educational programs and packages such as COMPASS and DETECT (5) have been developed in Australia specifically to improve practice regarding the recognition and response to clinical deterioration amongst all staff.


    1. Hughes C, Pain C, Braithwaite J, Hillman K. 'Between the flags': implementing a rapid response system at scale. BMJ Qual Saf 2014;23:714- 717

    2. McGrath RB. In-hospital cardiopulmonary resuscitation -- after a quarter of a century. Ann Emerg Med 1987; 16: 1365-1368.

    3. Runciman W and Moller J. Iatrogenic Injury in Australia, A Report prepared by the Australian Patient Safety Foundation for the National Health Priorities and Quality Branch of the Department of Health and Aged Care of the Commonwealth of Australia (2001) available from: (accessed September 2014)

    4. Jones AD, Dunbar NJ and Bellomo R. Clinical deterioration in hospital inpatients: the need for another paradigm shift. Med J Aust 2012; 196 (2): 97-100

    5. Australian Commission on Safety and Quality in Health Care. National consensus statement: essential elements for recognising and responding to clinical deterioration. Sydney: ACSQHC, 2010. Available from: Consensus-Statement-PDF-Complete-Guide.pdf (accessed Sept 2014)

    Conflict of Interest:

    None declared

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