Improving care for deteriorating patients

Since 2014, UCLPartners has been working with NHS and social care organisations across our region to reduce avoidable harm and  improve the outcomes and experience of deteriorating patients,  through better recognition, response, and communication. The deteriorating patient is a patient that moves from one clinical state to a worse clinical state, increasing their risk of  disease, organ failure, prolonged hospital stay or death.

We have developed programmes to encourage and support the use of a single early warning score – the National Early Warning Score (NEWS2) as the ‘common language’ for communicating patient deterioration at all stages of a patient’s journey.

This work supports the priorities of NHS organisations within our region and is  in line with national efforts and the work of the Patient Safety Collaborative programme.

Improving deterioration in out of hospital setting

 Many individuals with complex needs receive care in the community: at home, in care homes or in assisted living accommodation. Identifying acute illness amongst older adults can be difficult and most of the ongoing care is delivered by non-clinically trained carers who do not always have the confidence and ability to recognise physical deterioration in people they care for. Studies have shown that health care assistants  could spot signs of illness 5 days before they were seen in clinical observations.  Therefore,  helping these staff / carers to develop  the skills and knowledge to recognise and escalate deterioration is key to preventing unnecessary hospital admissions, now more than ever.   

We have partnered with four lead organisations: North Central London Stainability and Transformation Partnership, London Borough of Newham, Southend Clinical Commissioning Group and Essex Partnership University NHS Foundation Trust, and East London NHS Foundation Trust to support them with identification of the deteriorating patient in the community setting.

We have worked across 26 care providers (spanning care homes, domiciliary care, learning disability services and informal carers) to  train non-clinical staff and carers to use standardised tools such as NEWS2 and SBAR (Situation, Background, Assessment, Recommendation – structured communication tool), as well as digital tools and regionally developed tools for detecting early signs of deterioration.

NEWS2 and digital technology

NEWS (National Early Warning Score) is a tool developed by the Royal College of Physicians which improves the detection and response to clinical deterioration in adult patients and is a key element of patient safety and improving patient outcomes.

We are supporting adoption of the latest version of  NEWS to standardise the assessment and response to acute illness in the community setting by piloting Whzan – a new digital tele-health solution.  

The Whzan Blue Box kit includes portable monitoring equipment and a tablet; it is used to measure body vital signs, record photos, perform multiple assessments and questionnaires including the NEWS2 score and allows access to patient results and analysis in real-time through a secure cloud-based portal. 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.  

Through this work, we are also providing support to primary care and community health services to set up care home virtual ward rounds and enable regular review of residents identified as a clinical priority.  We are also using our online toolkit  to deliver non face to face clinics.

Using lessons learned from this programme and in response to COVID-19, the use of the Whzan Blue Box is now being rolled out to 250 care homes across the Mid and South Essex STP.

Soft signs of deterioration

In situations when carers are not able to take the measurements required for a NEWS2, for example if they work in residential care homes or are supporting someone in their own home, they can be looking out for ‘soft signs’ of physical ‘unwellness’ to help them recognise deterioration and take the appropriate actions.

‘Soft signs’ of deterioration are the early indicators that someone might be becoming unwell. A video by Health Education England explains how soft signs of deterioration can be spotted early by a carer or health professional.

Significant 7+

We have been supporting spread of the Significant 7+, a paper-based tool and training package, developed and licenced by North East London Foundation Trust to enable care workers to spot the ‘soft signs’ of deterioration. The aims of Significant 7+ are to improve identification of early signs in residents, while  helping care home staff to recognize and manage deteriorating residents. 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.

We have trained a  group of trainers / champions who have since  delivered the training to 150 carers across 22 care homes and domiciliary care providers.

Knowledge and learning sharing sessions for both innovations, Significant 7+ and Whzan, were facilitated through our regional community of practice events. We continue to support engagement across a wider health and care system. 

Significant Care

Building on the above work and as part of our response to the COVID-19 pandemic, we have developed and launched a new ‘soft signs of deterioration’ tool  called Significant Care. Significant Care is a free paper-based tool aiming to help carers both at home and in care homes to identify the signs of deterioration specifically related to the patient’s skin, toilet habits, mobility and levels of confusion, and take prompt action. The tool was adapted from Significant 7+ and developed in partnership with North East London NHS Foundation Trust (NELFT), Care City, and NHS Basildon and Brentwood Clinical Commissioning Group.

You can download the tool here and watch video by Geraldine Rodgers, NELFT’s Significant 7 Clinical Lead, explaining the benefits and how to use the tool.  

You can also access other helpful resources that can be used by carers and care home staff to assess patient deterioration and work safely.

Improving deterioration in acute settings

In 2018, we  brought together the Deteriorating Patient Network  of around 50 representatives from partner organisations, to explore the challenges, opportunities and learning from work to improve the identification and management of deteriorating patients in acute settings. A particular focus for the network so far has been on supporting the implementation of NEWS2, as well as other ideas and innovations to improve outcomes for deteriorating patients.  All acute trusts in our region are now using the updated NEWS2, as recommended by the Royal College of Physicians.

Find out about the tools available to help staff recognise physical deterioration and take the appropriate actions in the resource section below.

If you would like to know more about this work, please email Valentina Karas, Patient Safety Programme Manager, at valentina.karas@uclpartners.com

Resources

Patient Stories

• Paul’s story about how he made a quick and full recovery from sepsis as a result of NEWS being communicated at every handover of care. (from West of England AHSN)
• Geoff’s story – watch the experience of a patient at Oxford University Hospitals who was treated for life-threatening sepsis told from the point of view of both the patient and his family.
• Julie’s story  about her treatment following a road traffic accident following which she experienced two further emergency admissions to hospital due to acute cellulitis and sepsis. (from patientstories.org.uk) 

Deterioration in COVID-19

• Assessing COVID-19 patients in primary care – watch a recent webinar from the RCGP and The AHSN Network talking about the assessment of patients who are unwell with COVID-19 or other causes which presents a significant challenge for GPs and clinicians working in Primary Care.
• British Geriatrics Society: Managing the COVID-19 pandemic in care homes for older people. This guidance aims to help care home staff – and NHS staff who work with care staff – to support residents through the pandemic.
• NEWS2 and deterioration in COVID-19 (RCP – 14 April 2020) – in patients with COVID-19 infection, respiratory function can rapidly deteriorate and the oxygen requirement might increase rapidly but this may not result in any significant increase in the NEWS2 score. ANY increase in oxygen requirements should trigger an escalation call to a competent clinical decision maker. NEWS2 should supplement clinical judgement in assessing the patient’s condition.
• NICE COVID-19 rapid guideline NG163 (6 April 2020) -provides recommendations for managing COVID‑19 symptoms for patients in the community, including at the end of life.
• Read more about how the AHSN and Patient Safety Collaboratives are supporting the response to COVID-19 (NHS National Patient Safety Improvement Programmes)

NEWS2

• A video clip introducing NEWS2 from NHS England featuring Professor Bryan Williams (University College London Hospitals) discussing the development of NEWS2, the benefits of a standardised system, and how it can be used to identify acute deterioration in adult patients. 
• The National Deterioration Forum on the NHS Future Collaboration Platform is a dedicated space to access and exchange knowledge and information about Deterioration across all care sectors nationally. You can request access by registering here.
• National Early Warning Score (NEWS2) is a tool developed by the Royal College of Physicians (April 2018) and endorsed by NHS England (NHSE) and NHS Improvement (NHSI) for use in acute and ambulance settings. Read more about this on the NHSE website.
• Online video based NEWS2 and Deterioration training for community and care home staff by Health Education England. The short videos describe how to take measurements from residents correctly (such as blood pressure and oxygen saturation), spot the signs of deterioration, and prevent the spread of infection.
• Access resources for health and care staff in residential care home settings (May 2020) on Health Education England’s E-Learning for Healthcare hub (e-Lfh) – an educational web-based platform that provides quality assured online training content for the UK’s health and care workforce.
• NEWS2 e-learning resource from OCB Media includes online training with certificate of completion and NEWS2 downloadable forms. Licenses are free for staff with an nhs.net email address. UCLPartners based Care Homes can get free access as well by contacting valentina.karas@uclpartners.com
• NEWS2 Calculation App – access the official and free NEWS2 Calculation App for both the iOS and Android as a joint development between the Royal College of Physicians (RCP) and the North West London Collaboration for Leadership in Applied Heath Research and Care (NWL CLAHRC). 
• Recognising and responding to critically unwell patients – a safety recommendation report from a national investigation (Healthcare Safety Investigation Branch – May 2019)

Soft Signs of Deterioration

• Significant Care – download a free paper-based tool helping carers spot soft signs of deterioration
• Significant 7+ – find out more about licensed training package to support early recognition of deterioration
• More tools available on AHSN Network’s website helping to spot the early ‘soft signs’ of deterioration and sepsis and take the appropriate actions.
• UCLPartners Care Home helpful resources that can be used by care home staff to assess patient deterioration and work safely.

Structured communication tools

• SBAR communication tool (Situation, Background, Assessment, Recommendation) an easy to use, structured form of communication that enables information to be transferred accurately between individuals.
• SBAR Training Guide developed by the NHS Institute for Innovation and Improvement in conjunction with clinicians and other frontline staff in the NHS.
• Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review (OpenBMJ)
• Using SBAR Communications in Efforts to Prevent Patient Rehospitalizations journal article