M. TRAN, D. PIRES, K. AU IEONG, C. SNELL
Wagga Wagga Base Hospital
Murrumbidgee Local Health District
Introduction
The Clinical Emergency Response System (CERS), which involves clinical reviews (CRs) and rapid responses (RRs), is a process utilised within NSW public health organisations to facilitate and escalate management of deteriorating patients. Within the Murrumbidgee local health district (MLHD), medical and CERS staff are alerted to CRs and RRs via SPOK paging systems.
This retrospective study aims to identify errors in information sent through pages for CRs and RRs within Wagga Wagga Base Hospital (WWBH) when compared to MLHD local procedure standards. The second aim is to identify the number and frequency of CERS responses across the different shifts. This information may facilitate improvement of future pages to allow for CRs and RRs to be triaged and attended efficiently.
Method/Description
Paging information for CRs and RRs over a 1-week period were independently reviewed by authors to identify errors when compared to local procedure standards. The study design was discussed with a CERS nurse as a key stakeholder.
Results
A total of 315 CRs and 15 RRs were reviewed with 38% of the total CERS being paged correctly (38% of CRs; 40% of RRs). 3 categories of potential errors were identified in CERS pages: triage information error (36%), timestamp duplication (36%) and location errors (5%).
The average number of CERS responses ranges from 11 – 39 clinical reviews, and 0-4 rapid responses per shift. This is associated with a high frequency of CERS responses, 1.4-3.1 CERS events per hour. Of the CERS events, 66% occur within 30 minutes, and 21% occur with a frequency of less than 5 minutes.
Consclusions
This study provides insight of common errors of pages from CR and RR events, and frequency of CERS events, demonstrating a potential role for further standardisation and education regarding the CERS paging system.