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
staff
Semi-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 theyre drowsy, whether
theyre awake, you know, what theyre normally like.
Especially if theyve been in a while you get used to
them. Its harder to tell somebody thats just come in.
But its just like the more you care for them the more
you get used to them and know what theyre 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)
Youre 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 patients 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 theyve got
a tool to say this is the guideline and this needs
acting on. So I think its 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, its
going to be more elevated generally, but that is normal for them. So
its 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 Tod
Principal Research Fellow
Centre for Health and Social Care
Sheffield 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 dont 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 dont,
you have to ask (5)
Communication was generally reassuring
Dont always understand the detail
If I asked them I dont understand blood
pressure anyway, so it wont 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 hadnt
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 theyll 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
Dont understand what is on them
Dont think the information is for them
Did not think they had the authority to look at them
Put their faith in professionals
I dont really want to read me chart. I think thats for them
not me ..... I dont really think I should look at them either
so I dont look. I dont want to get into trouble (4)
Im not interested in seeing my charts, its not my
business (7)
I just put myself in their hands and I trust that theyre
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-ordinator
Sheffield 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 Smith BMJ 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 observations
Communication
Bleep escalation
Prompt medical response
ABCDE assessment and treatment as per SMART/ALERT
Clinical escalation
Consultant involvement
Delivery
Teaching
Resource packs, aids
Care pathway
Monitor
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Pre Pathway Data May June July Aug Sept Oct Nov Dec Jan Feb Mar Apr
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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 participants private
address
Telephone
interview
Consent
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, NVQs, untrained,
junior, bank staff
workload, high turnover, overstretched,
staffing, heavy, too busy
misunderstand, non-understanding, dont
understand
dont want to understand, cant be
bothered, feel they dont need it, dont and
wouldnt 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 Organisation
Ward Organisation
Management Strategies
Inter/Intra professional
relationships
Education
University
NHS
Programmes (ALERT)
One off study event
Skill
Knowledge
Awareness (not aware), noticing, recognition (lack of)
Confidence
Understanding
Inadequate
Less 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 somebodys 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
raftersyou havent always got time to get
back to them thats when things tend to
happen
we wouldnt 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
Cant 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 didnt have
enough staff for 28 patients
I was absolutely fuming that something
hasnt been done. It was 3.30 in the
afternoon and she scored five at 3 oclock
that morning and night staff didnt 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
problemthere is still a lot of inventive
documentationI 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 its, its very very rare that
there is not one filled in
our team dont 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