Standard 9


Standard 9: Recognising and responding to clinical deterioration in acute health care


Ensure a patient’s deterioration is recognised promptly, and appropriate action is taken.

Hospital Standards


Epworth is accredited under the National Safety and Quality Health Service Standards. These national standards apply to all health services organisations and state the minimum level of care – the national benchmark – that consumers can expect. Hospitals must report their performance against the standards on a regular basis and are also subject to periodic reviews and assessments.

For further information, refer to the National Safety and Quality Health Service Standards Guide (PDF).


Epworth Standards


At Epworth we want to provide excellent patient care. For this reason, we set our own, stricter benchmarks against each of the standards, and we measure our performance against these. The table below provides details of the national benchmark, the Epworth internal benchmark and our average result against each of the items.

​Standard 9: Recognising and responding to clinical deterioration in acute health care
​National Benchmark
​Epworth HealthCare Internal Benchmark
​Epworth HealthCare Average 2014
​Epworth HealthCare Average 2015 ​Average FY 2015-16 † 
Rapid response call rate ​n/a*** ​26.70 ​28.20   25.60 # 27.80 #​
​MET* calls within 24 hrs of admission rate ​6.80 6.80 ​4.40 3.80 # 3.70 #​
​Cardiopulmonary arrest rate 0.52 ​0.52 ​0.23 0.36​ # 0.28 #​

Rate=per 1,000 bed days.

* Medical Emergency Team. 
** Not for resuscitation – documented plan based on patient choice in case of unplanned health deterioration.

*** n/a denotes that no national benchmark has been defined, so Epworth has set its own. 

# A lower number is better.
† Figures for year ending 30/6/2016.


  • Epworth has well established ‘Standard 9 groups’ at each of the hospitals, and a recently established Standard 9 committee for rehabilitation. These committees are active in ensuring we have robust systems and processes in place, and that these are well understood by the clinical staff caring for patients.
  • We utilise the Australian Commission on Safety and Quality in Health Care’s national Observation and Response Charts to monitor and document patient physiological observations. With patients under the age of 16, we have recently implemented the Victorian Children’s Tool for Observation and Response (ViCTOR), to help clinical staff recognize early deterioration in young patients.
  • These Observation charts clearly denote the physiological changes that require escalation of care.
  • Focus and increased education about the deteriorating patient and early escalation of care has resulted in documented actions in response to early identification of deterioration increasing from 35.4% in 2014 to 63.2% in 2015.

What we are working on


Epworth has established an End-of-Life-Care Subcommittee to ensure that our end-of-life-care is in line with the 10 guiding principles detailed in the National Consensus Statement.


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