Ann McDonnell (Sheffield Hallam University)Angela Tod (Sheffield Hallam University)

Debbie Shone (Sheffield Teaching Hospitals NHS Foundation Trust)Tracey Moore (Sheffield University)

Background

Four linked papers

Questions and discussion

Hospitalised patients may be at risk of clinical deterioration

Catastrophic events such as cardiopulmonary arrest are often preceded by abnormalities in vital signs

Deterioration may not recognised or acted upon by hospital staff resulting in adverse outcomes (NPSA, 2007)

Early warning scoring systems (EWS) aim to ensure timely recognition of deteriorating patients

NICE Guidance (2007) recommended that some form of EWS should be used to monitor all adult patients in acute hospital settings

EWS at least twice daily and a graded response strategy with 3 levels for patients who 'trigger'

A before and after study to evaluate the impact on nursing staff of a new model for detecting and managing deteriorating patients

A qualitative study to explore patients perceptions of the same model

A study to look at the impact of a new patient pathway on practice

A qualitative study of factors that influence the practice of nurses when patients 'trigger'

Ann McDonnell, Angela Tod (Sheffield Hallam University)

Derek Bainbridge, Kate Bray, Dawn Adsetts (Rotherham Hospital NHS Foundation Trust)

Old system - only patients at high risk of deterioration were monitored and scored using an EWS. Patient at Risk (PAR) chart - a detailed obs chart including fluid balance and EWS.

New system - modification of the existing EWS and response algorithm and the introduction the EWS as part of the clinical monitoring chart for all adult patients who are not monitored using PAR chart.

Thus the hospital moved from a single system to a two tier system involving two different observation charts.

The new system was introduced on all in-patient areas (12 wards) excluding care of the elderly, opthalmics and day surgery.

All nursing staff and support workers on the intervention wards attended a short training session prior to the introduction of the new charts.

Staff were given ongoing support by the Critical Care Outreach Team.

to evaluate the impact of a new hospital wide model for recognising and responding to early signs of deterioration in patients

to evaluate the impact on nurses knowledge and confidence in detecting patient deterioration

to gain an understanding of any observed change

to explore staff perceptions of the new system

to explore if the two tier system offers any benefits over a single system

A mixed method study which included:

Stage 1. A before and after survey'Before' questionnaires, based on existing instrument developed by Featherstone, Smith et al (2005) were given to staff before the start of the training session.

'After' questionnaires were sent to staff 6 weeks after the new charts were introduced on the wards.

Stage 2. A before and after qualitative consultation with nursing staffSemi-structured interviews were carried out with 15 staff purposively sampled to reflect different wards, grades and time since qualifying. Interviews were done before and 6 weeks after the intervention.

Our primary outcome was confidence to recognise a critically ill patient (on a 1 to 10 scale)

To have an 80% chance of detecting a 0.5 point change in this outcome at 5% significance level, 128 paired responses were needed

84% (n = 271) of eligible staff attended a training session and completed baseline questionnaires

The final number of paired responses was 213 (66%)

'rapid deterioration' (n = 139, 66.2%)

'lack of information about the patient' (n = 131, 61.5%)

Knowing your patient is essential

You can see colour, whether they‟re drowsy, whether they‟re awake, you know, what they‟re normally like. Especially if they‟ve been in a while you get used to

them. It‟s harder to tell somebody that‟s just come in. But it‟s just like the more you care for them the more you get used to them and know what they‟re like‟ (7)

'being unable to get help when needed' (n = 120, 57.4%)

'getting a timely response from more senior staff' (n = 113, 53.8%)

Staff felt the new charts and system for escalating care had helped make them more confident to seek help from medical colleagues because they enabled the clear delivery of objective information to doctors

„Nurses have something objective for talking to medical staff, and say this is what we do here to get help i.e. the

response algorithm‟ (2)

„You‟re telling the doctor over the phone all the information that they need, everything is there to tell

them‟ (12)

The intervention had a positive impact on the knowledge, skills and confidence of nursing staff to recognise and manage deteriorating patients e.g. confidence to recognise a critically ill patient (on a 1 to 10 scale) increased from 7.5 (SD 1.8) to 8.2 (SD 1.4), 95% CI 0.55 - 0.92, p < 0.01.

All staff valued the training and reported that using the EWS helped to identify patient deterioration earlier

We now use it on every single patient that we have on the ward, and obviously they all get a score at the end of it, so I think it just rings more alarm bells if you like if a patient is unwell or is deteriorating, whereas just

recording a patient‟s observations, you know, you might miss something‟ (15)

The time taken complete a score for every set of patient observations was seen as time well spent

Senior nurses described how the new scoring system supported inexperienced and junior staff:

I think it empowers the juniors because they‟ve got a tool to say this is the guideline and this needs

acting on. So I think it‟s given them the confidence to do that‟ (10)

The more detailed PAR chart for when a patient 'triggered' was useful. It highlighted patients at risk.

Qualified Unqualified

n mean SD n mean SD

mean

diff* 95% CI P-value Standardised

effect size

Level of experience

142 8.2. 1 71 6.2 1.8 2 2.4 - 1.5 <0.001 1.1

Level of knowledge

142 8.0 1 71 5.9 1.7 2.1 2.6 - 1.6 <0.001 1.2

Confidence to

recognise 141 8.2 1 70 6 1.7 2.1 2.6 - 1.7 <0.001 1.2

Confidence when

to contact 141 9.0 1 71 8.4 1.6 0.6 1.0 - 0.2 <0.001 0.4

Confidence who to

contact 141 9.0 1 71 8.8 1.5 0.2 0.6 - -0.2 0.332 0.1

Confidence to

report abnormal

obs

141 9.3 1 71

8.5 1.7 0.8 1.2 - 0.4 <0.001

0.5

Confidence to ask

senior staff to

come

141 9.4 1 71

9.2 1.1 0.2 0.5 - -0.1 0.288

0.2

Total no of

concerns 142 4.2 2.6 71 4.3 2.7 -0.1 0.5 - -0.1 0.814 -0.03

Qualified Unqualified Differences

n mean SD n mean SD mean

diff

95% CI P value Standardised

effect size

Change in level of

experience

141 0.4 1.0 71 1 1.7 -0.6 -0.2 - -1.0 0.008 -0.4

Change in level of

knowledge

141 0.5 1.0 71 1.2 2 -0.7 -0.2 - -1.2 0.008 -0.4

Change in

confidence to

recognise

141 0.5 0.9 70 1.2 1.9 -0.7 -0.2 - -1.2 0.006 -0.4

Change in

confidence when to

contact

141 0.3 1.1 71 0.2 1.7 0.1 0.5 - -0.3 0.622 0.1

Change in

confidence who to

contact

140 0.3 1.0 71 0.4 1.5 -0.1 -0.3 - 0.5 0.547 -0.1

Change in

confidence to

report abnormal

obs

141 0.2 0.8 71 0.4 1.5 -0.2 0.1 - -0.6 0.215 -0.1

Change in

confidence to ask

senior staff to

come

141 0.1 0.8 71 0 1 0.1 0.4 - -0.2 0.539 0.1

Change in total no

of concerns

142 -0.5 2.0 70 -0.7 3 0.2 1.0 - -0.6 0.668 0.1

Qualified staff use the information from EWS in a very different way – to augment rather than substitute for clinical judgement

„as an experienced nurse I certainly would take in to account past medical history‟ (10)

„Some one with COPD is not going to have a resp rate of 12 to 16, it‟s going to be more elevated generally, but that is normal for them. So

it‟s inappropriate to be phoning doctors all the time with a COPD patient who might have a resp rate of 24 when that might be perfectly normal for them. Using your clinical judgement to

determine what is normal for that patient‟....(9)

Unqualified staff may only do observations infrequently

The new model had a positive impact on the self-assessed knowledge and confidence of all grades of nursing staff

Although no strong message emerged that having a two tier system was better than a single system, some staff commented that having a different chart for acutely ill patients did highlight those most at risk

Differences between qualified and unqualified staff

Staff interviews showed that the charts themselves only represent part of a complex picture. The importance of having experienced staff with time in the specialty, good clinical judgement, knowledge of their patients and knowledge of the clinical area where they worked were important parts of the jigsaw

Dr Angela TodPrincipal Research Fellow

Centre for Health and Social CareSheffield Hallam University

Background

Aim

Methods

Sample

Selected findings

Key issues

What are patients aware of in terms of the monitoring of their condition?

What do patients want in terms of the monitoring of their condition?

Evidence is lacking on the understanding and acceptability of Early Warning Scoring Tools to patients (Goa, McDonnell et al 2007).

NPSA (2007) asked what priority patients set on observations?

What is the role of patients in improving patient monitoring?

National Patient Safety Agency (2007) recognising and responding appropriately to early signs of deterioration in hospitalised patients. London, NPSA.

To investigate the utility of the Rotherham Two Tier Warning System (RTTWS) in terms of ease of use and acceptability to patients.

We did this by asking: about their views and experiences of being

assessed and monitored on the ward? what this feels like your point of view? how you think your health is assessed? what you know and understand about this? what you think is important in terms of being

monitored and assessed?

Qualitative

Individual semi-structured interviews

Framework analysis

Purposive sample of 11 patients

On ward areas which had changed to the new model of scoring

Range of patients included:◦ Those on a new observations chart◦ Those who has been on a new observation chart AND a

“patient at risk” (PAR) chart◦ Patients who had been “stepped up”

Patients recruited through ward staff

Range in terms of:

◦ Age

◦ Gender

◦ Clinical area

◦ Diagnosis

I.D Age M/F Diagnosis Category Elective/

Emergency

Speciality PAR Chart Clinical

Observation

Chart

1 57 M Lower Gastrointestinal Emergency Surgery Yes Yes

2 56 F Lower Gastrointestinal Elective Surgery Yes Yes

3 45 F Lower Gastrointestinal Emergency Surgery Yes Yes

4 40 F Upper Gastrointestinal Emergency Surgery Yes Yes

5 39 F Lower Gastrointestinal Emergency Surgery No Yes

6 71 M Vascular Emergency Medicine Yes Yes

7 67 M Orthopaedic Emergency Orthopaedic Yes Yes

8 81 F Orthopaedic Emergency Orthopaedic Yes Yes

9 80 M Orthopaedic Emergency Orthopaedic Yes Yes

10 27 M Neurological Emergency Orthopaedic Yes Yes

11 67 M Respiratory Emergency Orthopaedic Yes Yes

Semi-structured interviews.

Aim = utility of the RTTWS from patients perspectives

Challenge = what question do you ask? ◦ May not be aware of being monitored if ill

◦ May not have heard of the RTTWS

We asked about their views and experiences of being assessed and monitored on the ward e.g.

Do you know how nurses assess or monitor your condition / health on the ward? After they have undertaken these measurements what do they do then? Do you know what is written on your charts? Do you think it is important that you know what is written on your charts? Have the type or frequency of these assessments ever changed? How did you know this? If assessments weren't done would you be aware/notice? If you thought an assessment should have been done but wasn't, would you say

something? Do you have any worries or concerns about how your health has been monitored

or assessed since you have been on this ward? How could the way your health has been monitored and assessed on the ward be

improved? Are you aware of the critical care outreach team?

Awareness of observations

Frequency of observations

Nursing staff and communication of observation results

Changes in clinical condition

Self management and clinical observations

Ownership of information and charts

Worries and concerns

All aware that nursing staff monitored their condition by taking observations such as blood pressure, pulse, temperature.

Some patients mentioned oxygen saturation, heart rate, and fluids in and out.

Only one patient mentioned that respiratory rate was measured (relevant to this patient who self managed his medical condition).

All participants were aware that observations were taken during the day and sometimes at night.

They did not know the exact frequency.

Some patients knew that the frequency of observations changed e.g. when they had an operation or first admitted.

The majority noticed that the frequency reduced as they improved:

„Since I started getting better and the pain was less they don‟t come in and take my blood pressure as much‟ (4)

All reported that if their clinical observations had not been taken for some time they would ask the nursing staff why this was so, but were unsure how long they would wait before asking.

Communication variable: staff and patients

„Depends on which nurse, some will tell you straightaway without asking and some don‟t, you have to ask‟ (5)

Communication was generally reassuring

Don‟t always understand the detail

„If I asked them I don‟t understand blood pressure anyway, so it won‟t really mean anything to me‟ (4)

Some want to know anyway

Some were aware that if their condition changed this was communicated e.g. Doctor was informed and reviewed

„Doctors saw me as my oxygen saturation was worse, nurses took this half hourly, and my observations were taken regularly that night (11)

Some assumed that happened but hadn‟t experienced it

Patients who self managed at home (3):◦ They wanted staff to tell them their obs◦ Knew what normal parameters were◦ Wanted to be involved e.g. Read dynamap

They tell me what the reading is, because I do my own blood pressure at home, so I know what it should be‟ (6)

Patients concerned about current condition◦ Were motivated to know their obs e.g. Temperature◦ Asked nurses to check obs if they noticed a change e.g.

Feel unwell

„I have always asked, and they‟ll do it for me, I like to know what they are, I always ask if every things fine‟ (3)

Know observations are recorded on charts Don‟t understand what is on them Don‟t think the information is for them Did not think they had the authority to look at them Put their faith in professionals

„I don‟t really want to read me chart. I think that‟s for them not me ..... I don‟t really think I should look at them either so I don‟t look. I don‟t want to get into trouble‟ (4) „I‟m not interested in seeing my charts, it‟s not my business‟ (7) I just put myself in their hands and I trust that they‟re doing the right job‟ (2)

Exception = patients who self manage

High reported levels of satisfaction

No worries or concerns regarding how they were monitored

RTTWS acceptability:◦ Frequency changed if condition changed◦ Change was reported on◦ Reassured by variation in frequency etc◦ Satisfied with the current monitoring system

NPSA recommendation supported by:◦ Indication that patients knew and were aware of much.◦ Self management in community may be changing patients

expectations of being involved in monitoring in hospital.

However:◦ Some patients are not interested in knowing and place faith in

professionals.◦ Do not think that observations and information on charts is for

them◦ Do not think they have the authority to look and be involved.

Just an initial exploration

Positive feedback on RTTWS

Indication that what the NPSA suggest has potential especially for those self managing long term conditions

Some patients preferred involvement is low.

Deteriorating Patient Care Pathway

Debbie Shone - Patient Safety Co-ordinatorSheffield Teaching Hospitals Trust

USA

2000 – Patient safety issues identified

UK

2001 – Building a safer NHS for patients: Implementing an organisation with a memory

2004 - Patient safety initiatives

2006 – Safety First report – Sir Liam Donaldson

2008 - Patient Safety First Campaign

12 million admissions to NHS acute trusts in 2006/07

One in ten patients in hospital experiences an incident which puts their safety at risk,

50% preventable

10% of incidents contributed to death

0%

10%

20%

30%

40%

50%

60%

ICU Mortality Hospital mortality

Good care

Sub-optimal care

The Effect of Sub-optimal Ward Care on Patient Outcome

Confidential inquiry into quality of care before admission to intensive care

Peter McQuillan, Sally Pilkington, Alison Allan, Bruce Taylor, Alasdair Short, Giles Morgan,

Mick Nielsen, David Barrett, Gary SmithBMJ 1998;316;1853-1858

Early recognition, treatment, escalation improves survival

Known policies in place: SHEWS / ABCDE Assessment

& Treatment

Known substandard compliance

Recognised & introduced improvement methodology

All patients with SHEW 3 or more

2 Surgical & 2 Medical wards; (Commenced March 2010)

Medical admissions, 3 Surgical & 1 Medical ward; (Commenced Sept 2010)

60% Patients had minimum of hourly observations commenced

<20% had documented evidence of communication to a Nurse in Charge

<40% had documented evidence of communication to a Medic

60% medics attended

20% attended in 30mins

30% documented ABCDE assessment

45% documented a management plan

Care Bundle/Pathway

Early recognition, hourly observationsCommunication Bleep escalation

Prompt medical responseABCDE assessment and treatment as per SMART/ALERTClinical escalationConsultant involvement

Delivery

TeachingResource packs, aidsCare pathway

Monitor

0.00

20.00

40.00

60.00

80.00

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140.00

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perc

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Hourly obs

mean

UCL

LCL

Pathw ay implemented

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mean

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Pathw ay Implemented

ABCDE assessment

-20.00

0.00

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Pre Pathway Data May June July Aug Sept Oct Nov Dec Jan Feb Mar Apr

audit

perc

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mean

UCL

LCL

Pathw ay Implemented

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Unresolved w ith no ABCDE

mean

UCL

LCL

Pathw ay Implemented

Compliance with the pathway!

Tracey Moore

Senior Lecturer

University of Sheffield

This investigation is the outcome of a proposal submitted in response to a call from the Yorkshire and The Humber SHA

Purpose – to investigate why, despite the fact that the problem of deterioration incidents is well recognised and quantified, the deterioration of some patients is still not recognised, appreciated or acted upon sufficiently quickly to prevent unpreventable harm

n

Estimates suggest that 1 in 10 patients in hospital experiences an incident that puts their safety at risk and that about half of these could have been prevented

1804 serious incidents resulting in death. 576 of these were interpreted as potentially avoidable. 425 of these were in acute trusts, 71 related to a diffuse range of diagnostic error (NPSA 2007)

433 surgical patient cohort, 59% experienced a peri-operative complication prior to death of which 24% were judged avoidable. In 91% of these cases the outcome was adverse (NCEPOD 2009)

Seriously ill patients are still receiving suboptimal care because their deterioration is not recognised, not appreciated or not acted upon sufficiently quickly (NPSA 2007, NICE 2007, NCEPOD 2009)

To gain a better understanding from staff why they still fail to prevent, recognise and effectively manage patient deterioration on the general wards despite the introduction of recommended systems of care

To discover and describe the reasons why staff feel they are unable to prevent, detect and manage deteriorating ward patients

To generate recommendations for improving early detection of deteriorating ward based patients

Qualitative study with an element of quantitative analysis

Telephone interviewing using a semi-structured interview technique

Content analysis in the form of conceptual analysis was used to analyse the data

Snowball sampling was adopted

Stage 1 sampling -PI contacts

NOrF EBM as potential

participant(s) and provides

consent form and information

sheet

Stage 2 sampling – NOrF EBM

identify a potential participant

telephone

interview

NOrF EBM makes initial

contact with potential

participant

NOrF EBM provides the PI

with contact name and

address of potential

participant

PI posts consent, stamped addressed

envelope and participant information

sheet to potential participant’s private

address

Telephone

interviewConsent

No further

contact made

No consent

PI = Principle

Investigator

NOrF = National

Outreach Forum for

Critical Care

EBM = Executive

board member

Semi-structured telephone interview

Possible obstacles;

participants may not be aware of current drive for improved patient safety

participants may feel their clinical practice is being questioned

Understanding of the national concern regarding patient deterioration on general wards

Experience of the problem of patient deterioration on general wards and that deterioration not being picked up

Thoughts regarding the number of unidentified deteriorating patients on general wards

Why identifying deteriorating patients on general wards is a problem?

Usefulness of track and trigger scoring systems Why track and trigger scores are not always

completed? Why escalation procedures are not always followed

? What do you think could be done to improve the

situation

:

time confidence ownership empowerment knowledge acuity training audit policing workforce inadequate judgement

sicker, acuity, co-morbidities, seriously ill less experienced, unqualified, students,

health care assistants, NVQ‟s, untrained, junior, bank staff

workload, high turnover, overstretched, staffing, heavy, too busy

misunderstand, non-understanding, don‟t understand

don‟t want to understand, can‟t be bothered, feel they don‟t need it, don‟t and wouldn‟t use it

nervous, shy, silly, bad, stupid, dismissive devalue, undermining

Translation rules give the coding process a crucial level of consistency and coherence

Training and education Trust OrganisationWard Organisation Management Strategies Inter/Intra professional relationships

Education –

University

NHS

Programmes (ALERT)

One off study event

SkillKnowledgeAwareness (not aware), noticing, recognition (lack of)ConfidenceUnderstandingInadequateLess supervision

“You could do with more senior staff guiding younger staff in what to look for…”

(younger doctors)

“…they are kind of left on their own and they may also make inappropriate choices for a patient that is deteriorating which will then deteriorate further”

“...they are not looking at like patterns over like a few days, like sometimes there may be a pattern of somebody‟s observations and that and you can see the decline like in the blood pressure and respiration and that”

Not enough doctors Hospital at night service 24/7 Critical Care Outreach (or not) Continuity of care Staffing levels Chronic shortage of staff Throughput Hospital beds

“...not able to access doctors quick enough”

“…its down to staffing levels ..the wards or the area you work in being absolutely full to the rafters…you haven‟t always got time to get back to them that‟s when things tend to happen”

“…we wouldn‟t necessarily get in touch with the doctor even though our early warning score says we should do….we have corrected it ourselves by the prescription and we know that the doctor has got enough to do…”

High turnover of patients Staffing levels Junior doctors No where to go Can‟t get people to see them Time Workload Sick/patient acuity Continuity of care Busy Older patients Freedom Fire fighting Flexibility

“…we only did observations on patients who were poorly because we just didn‟t have enough staff for 28 patients”

“…I was absolutely fuming that something hasn‟t been done. It was 3.30 in the afternoon and she scored five at 3 o‟clock that morning and night staff didn‟t do anything and neither did morning staff I was really mad …you know it should have been done”

Communication

Ownership

Good working relationships

Judgement

“Sometimes when you raise concerns to doctors they may ignore you and just pass it off”

“…a more senior nurse may raise it to a doctor and a doctor may take more notice than a newly qualified”

“…we know the patient, we see the patient day in and day out. We see when there is a slight change in their condition and they may ignore ..our opinions”

“… incomplete observations are a real problem…there is still a lot of inventive documentation…I have frequently found a whole bay of patients with, you know, a recorded temperature of 36.2…”

Patrol

Police

Outreach services

Audit

“…we monitor it, and police it, and it‟s, it‟s very very rare that there is not one filled in”

“…our team don‟t just respond to a call, if, you know we patrol the wards”

Further data collection

Further conceptual analysis

In depth relational analysis – explores strength of relationship between concepts, positive or negative relationships between concepts and the direction of the relationship

Knowing the patient

Looking at trends in observations

Interpersonal communication

Who does the observations?

Education and training