Development of Ryan’s Rule

The formative development of Ryan’s Rule began in 2011 led by the Patient Safety and Quality Improvement Service (PSQIS) in consultation with hospital and health services (HHSs).

Ryan’s Rule consists of a series of steps that a patient, their family member or carer can take to raise their concerns when the patient in hospital is getting worse or not doing as well as expected. These steps facilitate a clinical review of the patient. The patient, family member or carer can continue to escalate through the series of steps if they are not satisfied with the outcome after each step.

The Ryan’s Rule model and guidelines were launched in July 2013, enabling each HHS to develop a plan for local implementation. PSQIS provided training and ongoing support to the local HHS Ryan's Rule coordinators, who were key to the incremental roll out across the state and remain vital in ensuring the continued support for this process.

Each HHS and/or facility self-selected a start date based on their self-assessed readiness and successfully passing unscheduled, fictitious test calls and emails to all contacts. The first facility went live on 2 December 2013 and Ryan’s Rule was implemented in the final Queensland Health facility 17 months later, on 19 May 2015.

Ryan’s Rule continues as a core system for patient, family carer escalation. Queensland Health’s Health Contact Centre and Department of Science, Information, Technology and Innovation’s Smart Services Queensland (SSQ) were engaged and contracted to enable the use of 13 HEALTH as a single point of contact for all callers in Queensland Health.

Background

Ryan’s Rule was developed in response to the tragic death of Ryan Saunders, who died from an undiagnosed Streptococcal infection, which led to Toxic Shock Syndrome. Staff did not know Ryan as well as his Mum and Dad. When Ryan’s parents were worried he was getting worse they did not feel their concerns were acted on in time. The Department of Health made a commitment to introduce a patient, family, carer escalation process, Ryan’s Rule, to minimise the possibility of a similar event occurring.

Ryan’s Rule applies to all patients admitted in HHS acute health care facilities including those receiving care under Hospital in the Home and encourages patients or their family and carers to escalate their concerns regarding the patient’s deteriorating physical condition.

Improving the identification and management of the deteriorating patient can save lives, reduce unnecessary morbidity, reduce unexpected Intensive Care Unit admissions and reduce length of stay. Studies carried out on patients who have suffered cardiac arrests, unplanned admissions to Intensive Care Units (ICU) and unexpected deaths indicate that there are clear, observable signs of deterioration in 50 per cent - 84 per cent of all cases in the 24 to 48 hours prior to an event (Barbetti & Lee, 2008; ACSQHC 2010). However, research indicates that changes in the patient’s clinical signs are often missed, misinterpreted or not acted upon in a timely manner.

Solutions implemented

Queensland was the first state or territory in Australia to implement a statewide approach using one phone number (13 HEALTH) for the patients, families and carers to escalate concerns in the public hospital system.

The first point of contact to raise concerns is to speak with a nurse or doctor. The last escalation point of Ryan’s Rule is to contact the centralised call centre (13 HEALTH) who will contact a Senior Clinician at the hospital to coordinate a clinical review by a nurse or doctor and review the patient. The individual review process varies from facility to facility but in the majority of cases the clinical review takes place in person by a senior clinician not directly involved in the care of the patient. If the Ryan’s Rule request comes from a smaller / remote facility the review may take place using Telehealth services (video or phone) depending on the available equipment. Ryan’s Rule is activated an average of approximately 2 times per day across the state.

All Queensland public hospitals are required to be accredited using the National Safety and Quality Health Service Standards, specifically Ryan’s Rule helps Queensland Public Hospitals to meet Standard 9.9 Enabling patients, families and carers to initiate an escalation of care response.

Adoption

All 114 (100 per cent) acute public hospitals in Queensland had implemented Ryan’s Rule by 19th May 2015.

Clinical Evaluation and patient feedback

The evaluation consists of a clinical evaluation form and caller feedback questionnaire. The completion of these evaluations (required within 72 hours) is monitored and tracked by online customer relationship management systems and all data is transferred to a data warehouse, where hospital and health services can access their own data.

Average number of calls

Ryan’s Rule is activated an average of approximately 2 times per day across the state.

Lessons learned

Ryan's Rule was developed in collaboration with individual HHSs and was made possible by the following factors.

  • A willingness of the Hospital and Health Services to voluntarily participate in the project;
  • The pre-existence of a statewide Health Contact Centre with trained non-clinical customer service advisors to receive incoming calls; and
  • The pre-existence of a suitable single dial-in number that patients, family members or carers could call which could then be relayed to an independent senior clinician in a local facility to coordinate a clinical review.

The lessons learned from this project included:

  • engage executive support
  • engage clinical workforce
  • undertake an incremental rollout
  • test the readiness of the service implement the process before the launch of the patient family career escalation process in each service. To ensure that
    • the ability to provide a 24-hour response, seven days per week
    • oversight provided by a local governance committee
    • development of a localised, internal procedure based on the guidelines
    • three nominated staff/roles able to receive a ‘warm transfer’ of the caller from 13 HEALTH and to initiate a clinical review of the patient.

At least 80 per cent of staff had completed training to raise awareness and increase knowledge of Ryan’s Rule.

Partnerships

Queensland Health’s Health Contact Centre and Department of Science, Information, Technology and Innovation’s Smart Services Queensland (SSQ).

Implementation Sites

All Queensland Health Hospital and Health Services supporting their public hospitals, all acute public hospitals in Queensland, some primary healthcare facilities.

Last updated: 25 July 2019