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 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 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 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-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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Unresolved with no ABCDE
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Pathway 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
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, 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 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 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