Delivering a system-wide change in how healthcare providers recognise and respond to the deteriorating patient.

Background

Since 2015, all organisations within the West of England Patient Safety Collaborative (PSC) have been involved in a major programme to introduce the National Early Warning Score (NEWS) at all handovers of patient care – primary care, ambulance, hospital, community and mental health.

Building on the successful outcomes of this work in the West, the National Quality Board has endorsed the adoption of NEWS across all NHS acute care and this is now a clinical priority for NHS England.

Structured observations, or early warning scores (EWS) have been used for some time to recognise deterioration in the acute hospital setting.  In 2015, The Royal College of Physicians (RCP) introduced the National Early Warning Score (NEWS) to standardise the approach across England. The NHS alert NHS/PSA/RE/2016/005 requires all acute providers to standardise their approach to deterioration [1].  However, many organisations have been slow to adopt the National Early Warning Score (NEWS) and still use regional or non-standardised versions.

In 2015, approximately 7% of patient safety incidents reported to the National Reporting and Learning System (NRLS) as death or severe harm were related to a failure to recognise or act on deterioration [2]. Sepsis kills around 44,000 people per year in the UK [3] and NEWS has been recommended by National Confidential Enquiry into Patient Outcome and Death (NCEPOD) as a tool to enable early detection and treatment of sepsis [4].

The aim of this 3 year project which started in 2015 was to standardise to NEWS across all acute trusts in the West of England AHSN (WofE AHSN) and to move the use of NEWS scores into pre-hospital care.  By agreeing escalation triggers the aim was to facilitate early recognition of acute illness including sepsis. This also enabled standardised communication across the system so that acutely unwell patients could be seen at the right time in the right place by the right grade of clinician.

The Institute for Health Improvement’s Breakthrough Collaborative Approach was used to influence change across a whole system. This was supplemented by local health community meetings which met under existing NHS structures. This led to trusts and community providers using a standardised approach to recognising and responding appropriately to the deteriorating patient.

Highlights so far include:

  • All acute trusts in the West of England standardised to NEWS.
  • One tertiary referral centre developed NeuroNEWS for use in neurosurgical and neurology wards.
  • NEWS was introduced into the electronic patient record of South Western Ambulance Service Foundation Trust (SWAST)
  • Gloucestershire community services used NEWS, combined with care by the rapid response team to prevent 26 unnecessary hospital admissions in a 3 month pilot.
  • All community services, mental health providers and prisons in the West of England adopted NEWS.
  • GP single point of access teams altered the call handler script to ask for a NEWS score on referral.
  • Introduction of a primary care collaborative and an ED collaborative to enable implementation.
  • In conjunction with the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) evaluation of NEWS has been undertaken. This included:
    • A systematic review of EWS in both hospital and pre-hospital settings.
    • A qualitative analysis of the use of NEWS across the system.
    • A quantitative analysis demonstrating the distribution of NEWS scores across the healthcare system.

According to the new suspicion of Sepsis dataset the West of England is a positive outlier of mortality compared to the national average.

Aims, objective and scope

The aim was for NEWS to be used at the point of a referral of acutely unwell patients and throughout their entire journey into secondary care.  The use of NEWS is not recommended in children under the age of 16 and pregnant women and outside the scope of this project.

Using NEWS at each handover of care as a standardised communication tool enables the sickest patients to be seen at the right time, in the right place by the right grade of clinician.  The WofE Patient Safety Collaborative (PSC) wanted to show that NEWS could be successfully used to identify sick patients, both inside and outside of secondary care settings.

Method and approach

The Institute for Healthcare Improvement’s breakthrough collaborative model was used. It is designed to close the gap between what is known and what is done by creating a structure in which interested organisations can easily learn from each other and from recognised experts in topic areas where they want to make improvements.

Teams from across the healthcare system met every six months at collaborative events.  In addition, health community task groups met more frequently to lead the work where teams met under existing NHS structures. This was supported by the introduction of an emergency department collaborative and a primary care collaborative.

Summary of actions:

  • Collaborative events and shared learning.
  • A project manager was funded to standardise NEWS in two hospitals in Bristol and to develop a toolkit to aid introduction of NEWS into other settings.
  • The West of England AHSN provided some financial support to introduce NEWS into the electronic patient clinical record system in the Ambulance service. In addition funding was given to trusts to enable data collection in emergency departments and support a clinical lead and project manager for the programme.
  • The West of England AHSN developed and provided resources for member organisations, such as educational posters, prompt cards, patient stories and videos.
  • The West of England PSC Board has a representative from all member organisations (CCGs, acute and ambulance trust, mental health and community providers) as well as public contributors. A steering group was formed to oversee the design and delivery of the programme.
  • Three regional Health Community Task Groups were setup to work inter-organisationally within the Health Community geography to implement the project design and direct the work in partnership with the steering group.
  • Specialised primary care and Emergency Department (ED) collaboratives were established to enable implementation.

Measurement planNEWS scores

To measure the spread of NEWS, organisations share their interactions with other organisations in the area. A network map is in development which aims to show the changes from the start of the programme in 2015. An example of the map depicts the connections between each organisation in the region. Each segment represents an organisation and its size is driven by the number of connections it has, e.g. the more links the larger the segment.

Organisations collected data on number and accuracy of NEWS scores as process measures. Data is presented using run charts both at individual trust and aggregate level. Emergency departments have monthly audits on whether NEWS is recorded on triage.

Results and evaluation

  • Year 1 – all acute hospitals standardised to NEWS and NEWS was introduced to pre-hospital settings.
  • Year 2 – focused on NEWS at handover of care.
  • Year 3 – focusing on data measurement, evaluation and sustainability.
  • All acute trusts, community services, mental health and ambulance services have now implemented NEWS.
  • NEWS has been introduced to GP practices and some care homes.
  • The use of NEWS can be demonstrated at handover of care.
  • A national survey has recently shown that the WEAHSN is one of only 2 AHSNs in the country where all acute trusts have standardised to NEWS.
  • The ambulance service have recorded NEWS scores for over 700,000 patients since April 2016.
  • All emergency departments now measure NEWS on arrival.
  • A rapid response team has used NEWS to avoid admission for patients in care homes.
  • Patient contributors continue to be involved and a patient video story has been shared.
  • We have performed qualitative and quantitative analysis of the programme which has been submitted for publication.
  • Early data using suspicion of sepsis codes suggests that WofE AHSN is a positive outlier for mortality from suspicion of sepsis and this has reduced since the start of the project in 2015.

Learning points

There was significant enthusiasm for the project as evidenced by the positive feedback forms received following each event. This enthusiasm was harnessed by the collaborative to push forward the project as most people understood the case for change and were keen to make it happen.

Many of the clinical leaders already had experience of quality improvement and the breakthrough collaborative approach. Acute and community trusts had been involved in a region wide safer care collaborative 2009-2014.

Some parts of the pathway were less familiar and less confident to standardise their approaches as their perception was that their own system/approach had worked to date and questioned the need to standardise. The response to this was to emphasise the clinical evidence, focus on the value of addressing human factors in designing safe systems of care, exploring at all time differences of opinion and creating a coaching culture so ‘all learn, all teach’.

Implementing change in a very complex system is difficult and organisations were at different starting points in terms of Quality Improvement (QI) experience and knowledge of NEWS.  The breakthrough model alone was not enough and this was supplemented with meetings using traditional NHS structures, meetings and project planning.  The QI Academy at the WofE AHSN was also utilised to support QI training.

There was some reluctance to use NEWS at handover in the emergency department. An Emergency Department (ED) collaborative was set up to spread use of an ED checklist which included NEWS. By allowing EDs to modify the checklist and discuss the issues related to ED, this also engaged this group of clinical staff.

There was also a big advantage in having a single ambulance trust covering the region.  This is because any handover between the ambulance service and another provider would use NEWS, meaning others began to adopt in order to share a common language.

Evidence from the qualitative analysis suggests digital enablers made NEWS easier to adopt. NEWS templates were put into GP IT systems such as EMIS and Adastra and SystmOne.

The project drew support from all areas. There was collaboration between the NIHR CLAHRC West, University of Bristol and Cardiff for evaluation. In addition the WofE AHSN provided support to develop innovative solutions to the problem. Innovative devices able to record observations and support the automatic calculation of NEWS are being explored.

What would we do differently? 

Despite trying very hard to stress the importance of baseline measurement and although measures were defined and agreed, not all organisations measured their processes.  It was hard to prospectively get baseline measurement as teams were enthusiastic to start implementing change.  Organisations that were more mature in terms of QI and patient safety were more focused on measurement.

Plans for spreading learning and encouraging adoption

Building on the work of the Patient Safety Collaborative in the West of England, in June 2017 the National Quality Board endorsed the adoption of NEWS across all NHS acute care and this is now a clinical priority for NHS England.

NEWS2 was released by RCP in December 2017. NHS England have updated their CQUIN planning guidance to require acute trusts to adopt NEWS2 by March 2019.

The WofE AHSN has supported all organisations moving to NEWS. We are scoping the support required to move to NEWS2. A key action will be agreeing a common communication strategy during transition when organisations might be using different versions of NEWS.

The project is now looking at patients who are acutely unwell where escalation would not be appropriate, for example those receiving end of life care. The next step is to standardise the use of the ReSPECT form and our communication and approach to end of life care. This has been agreed by all our member organisations and is due to start in June 2018.  This may form the basis of focused work within the care home sector.

Start and end dates

March 2015 – ongoing

Contact us for help and advice

Joanna Garrett, Patient Safety Improvement Lead, West of England Academic Health Science Network
E: joanna.garrett@weahsn.net

References

[1] The Royal College of Physicians. 2015. https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news (accessed 05 Sep 2017)
[2] NHS Improvement. 2014. https://improvement.nhs.uk/resources/learning-from-patient-safety-incidents/ (accessed 05 Sep 2017)
[3] The UK Sepsis Trust. 2014. https://sepsistrust.org/
[4] The National Confidential Enquiry into Patient Outcome and Death 2015. http://www.ncepod.org.uk/2015report2/downloads/JustSaySepsis_FullReport.pdf