Nurses Day! - Birmingham Children's Hospital

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Providing the Safest Possible Care: Acute Life-Threatening Events (ALTEs),
Cardiac Arrests and Respiratory Arrests
Good monitoring on wards means that we will
pick up deteriorating patients more quickly and
avoid preventable emergency and life- threatening
events.
Figure 23: Emergency Events 2012/13
GOAL:
reduce the number
of life threatening
events which
were preventable
and could have
been predicted by
monitoring to zero
Providing the Safest Possible Care: Mortality
Thankfully, the number of deaths at BCH is very
low relative to the number of patients we treat and
the seriousness and complexity of their illnesses.
We review every individual death to see if there
is anything we can learn, and to ensure that no
death is avoidable.
GOAL:
zero avaiodable
deaths
Figure 24: Deaths and deaths per 1,000 admissions 2011/12 - 2012/13
11
10
MEASURE:
number of cardiac arrests
on PICU and those
that were preventable
MEASURE:
absolute number
of deaths
14
12
9
10
8
7
6
MEASURE:
number of cardiac arrests
on wards, ED and theatres
and those
that were preventable
MEASURE:
number of deaths
per 1,000 admissions
8
6
4
5
4
3
MEASURE:
number of
respiratory arrests
and those
that were preventable
MEASURE:
number of deaths
that were avoidable
2
0
A M J J A S O N D J F M A M J J A S O N D J F M
2011 2012 2013
2
Deaths
Deaths per 1,000 admissions
1
0
MEASURE:
number of ALTEs
and those
that were preventable
M A M J J A S O N D J F M
No of Cardiac Arrests (ex PIC)
No of Respiratory Arrests
How have we done?
During 2012/13 there have been no preventable
acute life-threatening events (ALTEs), cardiac
arrests or respiratory arrests. We have therefore
reached our goal this year.
No of Cardiac Arrests (PICU)
No of ALTEs
What are we doing to improve?
We will continue to review each event to identify
any learning that could prevent or help predict
events in the future.
We are developing a pre-transfer checklist for
Extracorporeal Life Support (ECLS) to ensure all
monitoring functioning is checked.
How have we done?
There were more deaths in 2012/13 than in the
previous year but the number of deaths per 1,000
admissions has remained at a very similar level,
which suggests this reflects the increased number
of patients that we treated. We also, however, look
at a wide range of other information, including
details of every individual death to identify any care
failings that may have contributed to the death.
Our reviews have found that no deaths during
2012/13 were avoidable.
What are we doing to improve?
We will continue to monitor mortality rates in
a number of different ways to ensure that any
concerns are identified and that we learn from
every death in case there was anything we could
have done differently.
In 2013/14 we will also commission independent
reviews of our mortality review processes to ensure
they are of the highest quality and to identify any
ways that they can be improved.
More information about the way we review mortality
can be found at page 131.
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