Managing deterioration in out of hospital settings

Overview

Improving the identification and management of deteriorating patients is a major patient safety priority for the NHS. Early identification of deterioration is important to improve patient outcomes, quality of care and reduce mortality and health and social care costs.

We worked with four partner organisations to improve the experience and outcomes for people cared for in the community who were at risk or already experiencing physical deterioration, by testing and implementing two innovative approaches: Significant 7+ a paper-based guide to enable care workers to detect the early signs of deterioration), and Whzan (a monitoring kit and NEWS2 based digital tele-health solution). 

The challenge

A significant number of people with complex needs receive care in the community: at home, in care homes or assisted living accommodation. This population often has high support needs and adverse safety events can quickly escalate.

The majority of ongoing care is delivered by non-clinically trained carers who do not always have the confidence and skills to recognise physical deterioration in people they care for, often resulting in inappropriate escalation and unnecessary hospital admissions. Studies have shown that carers in care homes can spot signs of illness before they were seen in clinical observations, and potentially avoid a hospital transfer.

What we did

One of UCLPartners’ roles is to improve patient safety across various care settings and build the skills of staff to enable them to improve the safety of services. As part of the AHSN Network, UCLPartners hosts a Patient Safety Collaborative, supporting the delivery of national patient safety improvement programmes and accelerating innovation.

In 2019, we initiated a programme to improve the ability of non-clinically trained staff to recognise, escalate and communicate the early signs of deterioration using two complementary innovations.

• Significant 7+ – a paper-based tool and training package, developed by North East London Foundation Trust, to enable care workers to spot the “soft”, or visible, signs of deterioration. Use of the tool has been associated with reduction in hospital admissions, reduction in episodes of pressure ulcers and falls and an increase in the confidence of carers in their role.
• The Whzan Blue Box – a digital telehealth solution that includes portable monitoring equipment and tablet to measure vital signs, calculate a NEWS2 score (the latest version of the National Early Warning Score to standardise the assessment and response to acute illness) and facilitate appropriate escalation. Its use in care homes is associated with a  49% reduction in hospital bed days, significant cost saving in A&E attendances and ambulance services; and increased staff engagement and satisfaction.

We partnered with four lead organisations: North Central London STP, London Borough of Newham, Southend CCG and Essex Partnership University NHS Foundation Trust, and East London NHS Foundation Trust and worked across 26 care providers, spanning care homes, domiciliary care, learning disability services and informal carers.

We trained a cohort of facilitators / champions for each intervention and held two regional community of practice events. Whzan boxes were introduced into care homes and senior staff were trained to use the equipment and provide NEWS2 scores. Site visits were conducted to support implementation and engagement across a wider health and care system. 

Outcome and impact

To date, 14 care homes are using the Whzan Blue Box and the Significant 7+ facilitators have trained a further 150 carers across 22 care homes and domiciliary care providers.

Formal impact assessment has been delayed due to the COVID-19 pandemic and is ongoing. However, early findings suggest that care homes that have consistently used both innovations have had a reduction in 999/111 call outs. In care homes, participation in our community of practice events have increased awareness of hydration and resulted in a number of hydration projects; and more junior staff are reporting increased confidence in their role.

Louise Keane, Education and Development Nurse and Project Lead at North Central London STP, said:

“At UCLPartners events, we have people coming together across the region and from different parts of the system to learn and share good practice. We come away with a lot of interesting ideas that we can implement in our own care homes or services, which is a massive benefit. At the last session, we spoke about importance of hydration and how to encourage residents to drink more liquid by being creative and engaging them in a social activity around it – making jellies, smoothies etc. Hopefully this will result in reductions in admissions to hospital from urine infections further down the line.”

In response to COVID-19 and using lessons learned from this programme, the use of the Whzan Blue Box is now being rolled out to 250 care homes across the Mid and South Essex STP. We have also developed a new soft signs of deterioration tool, Significant Care, in partnership with NELFT and Care City. The tool is based on Significant 7+, includes guidance on how to recognise and escalate if COVID-19 is suspected and is free to use. 

In these unprecedented times, spotting deterioration and acting quickly has become more important than ever. We are now striving to ensure that the dialogue we have started with this programme and the transformational changes we introduced in response to COVID-19 become part of the normal process of care for everyone involved in delivering community health and social care services.