In this case study, Maria Lorena Pena, Horizon Fellowship, Critical Care Outreach Team (CCOT) Lead and Advanced Nurse Practitioner at Chelsea and Westminster Hospital NHS Foundation Trust, explains how she is working to improve care patients whose condition deteriorates by preventing adverse consequences due to suboptimal care.
Project summary
The failure to recognize and respond to deteriorating patients is a global challenge that can lead to adverse health consequences (Burke et al., 2022). Within our Trust, inadequate monitoring of patients’ physiological observations has led to delays in detecting acute deterioration, putting patients at risk. In response, the Critical Care Outreach Team (CCOT) led a quality improvement project, Recognition and Escalation of Deteriorating Patients (REDP), aimed at improving the performance of ward staff in monitoring and escalation of physiological observations of patients and compliance with the National Trust Early. Warning Scoring Guidelines (NEWS2). This initiative facilitates rapid recognition and escalation of acute deterioration, thereby increasing the chances of survival and improving the patient experience, leading to other positive health outcomes.
The pilot diagram and the PDSA (plan-do-study-act) cycle were used to implement:
- The “observation rounds”
- Effective use of a real-time, digitized “deteriorating patient dashboard”
- Cultivate a collaborative culture in the development of effective strategies through CCOT partnerships with senior and ward nursing staff.
The main parameters/performance indicators used were:
- Improved compliance with NEWS2 and the Trust escalation protocol
- Reduced failure to recognize and escalate significantly deteriorating patients
Given the identified gaps in clinical practice and limited resources encountered by the team, careful planning and use of advanced CCOT clinical practice was essential to achieve the targeted outcomes. As a result, adherence to the Trust’s NEWS2 and Escalation protocol and clinical performance in recognizing and escalating acute deterioration improved from 55% to 89%. The electronic incident log also indicated a notable decrease in cases of 50%. The REDP produced other positive results, highlighting the project’s effectiveness in improving patient care.
The next phase focuses on maintaining a high level of clinical practice in patient monitoring and developing innovative digitalized tools to help the nursing team detect and aggravate patient deterioration.
the project’s objectives
Suboptimal care resulting from failure to recognize and treat deteriorating patients in adult inpatient wards threatens patient safety. Inconsistencies in monitoring physiological observations have been determined to lead to substandard clinical performance. Dedicated to improving patient safety and care, CCOT has taken steps to rectify this substandard clinical practice.
Gaps identified in practice include:
- Lack of practice or standardized schedule for patient observations
- Overreliance of nurses on health assistants for monitoring physiological observations
- Large numbers of newly qualified and international nurses need training
- Increased use of temporary staff without proper knowledge of Trust policy/protocol.
To address these issues, several measures have been implemented:
- “Observation rounds” (OR) to help healthcare staff detect and quickly report acute deteriorations,
- Effective use of the “Deteriorating Patient Dashboard”, a digitized system that records all patients with high NEWS2 scores in real time.
- CCOT partnership with ward teams – “CCOT: Ward Buddies”
OR aims to standardize clinical practice and address inconsistencies in monitoring patients’ physiological observations. This involves setting specific times during the day and night when department staff should check on patients’ physiological observations, clinical needs, and concerns. The approach to 2 a.m. observation rounds has been redesigned to ensure stable patients receive adequate rest and sleep.
Each observation cycle has specific tasks and responsibilities for department staff, emphasizing early recognition and escalation of critically ill patients. This improvement initiative promotes shared responsibility within the multidisciplinary team, as all healthcare assistants, nurses and clinicians can monitor patient observations via the patient dashboard in real time in the event of deterioration. The observation rounds were initially trialled across nine wards at Chelsea and Westminster Hospitals and, after proving highly effective, were implemented across both sites.
Each CCO practitioner has been assigned specific services to support and collaborate closely with department staff to improve their performance. They scheduled meetings to regularly evaluate and monitor performance. This collaborative work played a crucial role in fostering a culture of teamwork, overcoming obstacles and achieving the desired results.
As CCOT struggled to integrate the new change into practice, the CCOT manager sought assistance from the Director of Nursing for support and assistance in implementing the designed interventions. Commitment from senior management and support from the quality improvement team and the CW+ charity has made a significant difference to the delivery of improvement initiatives.
Impact/Results
CCOT measures have improved the care of deteriorating patients, increased patient survival rates, and prevented health problems. It affected all adult patients in the inpatient department at both Trust sites, including:
- A marked improvement in adherence to the Trust NEWS2 and escalation protocol and clinical performance in recognizing and escalating acute deterioration in adult services from 55% to 89%.
- 50% reduction in suboptimal care cases due to failure to recognize and escalate deteriorating patients
- A new REDP analytical database clinical audit system was developed thanks to the team’s unwavering efforts to find a more effective way to monitor service performance.
- Achieved a consistent high performance score of >90% in Commissioning for Quality and Innovation (CQUIN) 7 – Recording and response to NEWS2 score for unplanned ICU admissions.
- Reduction of unplanned admissions to intensive care units.
- Patients now benefit from early initiation of appropriate escalation and management, leading to positive experiences, early recovery and shorter hospital stays and promoting trust in the healthcare system. health.
- Staff now benefit from a positive, collaborative culture that motivates and empowers them to deliver high quality care, improving their morale and confidence in delivering the best care.
- The Trust benefits from more efficient use of resources in terms of cost avoidance and reduction through reduction in potential litigation, short hospital stays and reduction in unplanned admissions to intensive care. Additionally, financial rewards linked to high performance in achieving Commissioning for Quality and Innovation (CQUIN7) Recording and responding to the NEWS2 score for unplanned intensive care admissions target outcomes. Additionally, CCOT initiatives enhance the Trust’s reputation as one of the healthcare providers that prioritize high-quality care while promoting patient safety.
CCOT’s measures have significantly benefited patients, staff and the Trust, contributing to the organisation’s overall success in delivering high quality health services.
Next steps
The next phase of the project focuses on:
- Work collaboratively with the leadership team to design a sustainability plan that would help maintain improved clinical performance in the management of deteriorating patients.
- Develop innovative new digital technology to help nurses recognize and flag deteriorating patients (i.e. integrate ALERTIVE system with Cerner to detect patients with high NEWS and directly notify clinicians and CCOT)
- Involve patients, caregivers, families and members of the public in evaluating interventions and designing sustainability plans
The REDP project ultimately aims to improve recognition and response to deteriorating patients, a global mission shared by all acute healthcare providers. All interventions were designed to improve monitoring of patients’ physiological observations that lead to rapid recognition and response in cases of acute deterioration, which is routine clinical practice in any clinical area where every healthcare facility aims to achieve a high level of performance, as demonstrated by the venue staff. The implemented measures aimed to standardize the practice that guides and supports nursing staff to adhere to the NEWS2 and Escalation protocol and focused on integrating a hands-on approach and positive attitude to improve clinical performance.
REDP improvement initiatives also cover the criteria for transferability of health interventions in the primary context and target environmental conditions, population characteristics and transferable core elements of the intervention, including its need for adaptation. In line with the global trend of using innovative healthcare technologies to take and record physiological observations, REDP improvement initiatives aim for the effective use of a digitized dashboard of deteriorating patients, which other institutions might find useful in their new electronic systems. All initiatives have proven their value, practicality and cost-effectiveness, which other establishments can adopt.
Applications for the second cohort of the Horizon Scholarship are now open until Sunday August 4, 2024. To apply, fill out the application form Or email to horizon@cwplus.org.uk for more information.
For more information about the Horizon scholarship, visit the CW+ website or see our Directory of innovations to browse the full list of Fellows.
