Week 1

Context

"Patients who are admitted to hospital believe that they are entering a place of safety, and they, and their families and carers, have a right to believe that they will receive the best possible care there". They feel confident that should their condition deteriorate, they are in the best place for prompt and effective treatment.

However, some patients who are, or become, acutely unwell in hospital may receive sub-optimal care because their deterioration is not recognised, not appreciated or not acted upon sufficiently quickly. Communication and documentation are sometimes poor, experience might be lacking and provision of critical care expertise, including admission to critical care areas, can be delayed" (The National Patient Safety Agency (NPSA) (2007).

Content

Failure to recognise and appropriately manage deteriorating patients is a contributing factor in many adverse events in hospitals and health care organisations around the world (Brennan et al, 1991; Wilson et al, 1995; Davis etal, 2002; Baker et al, 2004). Since the The National Patient Safety Agency publication in 2007 there has been continuing debate about the management of the deteriorating patient in the UK. The key documents are summarised below:

National Institute for Health and Care Excellence (NICE) Guidelines CG50

The key points from these guidelines in the context of this course are, the need for:

Recognition of and response to acute illness in adults in hospital
Physiological observations and action plan at point of admission
Physiological track and trigger systems
Healthcare staff competency
A graded response strategy

National Patient Safety Agency (NPSA) Recommendations

The NPSA conducted a review of incidents reported to them. The key points raised in their publication were:

The production of a ‘How to Guide’ for Reducing Harm from Deterioration
An analysis of 576 deaths reported to the National Patient Safety Agency over a one year period (2005) identified that 11 % were as a result of deterioration not recognised or acted upon
Six key areas identified:

Physiological observations should be recorded for all adult patients in acute hospital settings
Physiological observations should be recorded and acted upon by staﬀ who have been trained to undertake these procedures and understand their clinical relevance
Physiological track and trigger systems should be used
There should be a graded response strategy
An escalation protocol should be in place
A communication tool should be used.

Resuscitation Council UK 2015

The Resuscitation Council recommend that:

Every patient should have a documented plan for vital signs monitoring
A systematic approach for assessment should be used
EWS (Early warning signs), calling-criteria and rapid response systems can increase the completeness of vital sign monitoring.

National Confidential Enquiry into Patient Outcome and Death (NCEPOD)

The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) produced a report 'Time to Intervene? which looked at the outcome of cardiopulmonary resuscitation. They highlighted:

Lack of escalation
In-hospital cardiac arrests are predictable
Cardiac arrest follows a period of slow and progressive physiological derangement that is often poorly recognised and treated

The Francis Report

The Francis Report into the role of the commissioning, supervisory and regulatory bodies in the monitoring of Mid Staffordshire Foundation NHS Trust, also contains some key points relevant to our review of the management of the deteriorating patient. In particular the report highlights:

Failure of staff to recognise deterioration
Communication breakdown
Failure to escalate

NICE GUIDELINES ACUTELY ILL ADULTS IN HOSPITAL: recognising and responding to deterioration 2016

The guidance describes how patients in acute hospitals should be monitored to help identify those whose health becomes worse and how they should be cared for if this happens. Follow this link

The guidance gives clear directives as how a patient on admission should have a clear monitoring plan specifying physiological observations to be recorded and how often these should be performed.

They recommend that

heart rate
respiratory rate
systolic blood pressure
level of consciousness
oxygen saturation
temperature

Guidance is also offered regarding routine monitoring and scoring should continue using multi parameter or aggregate scoring track and trigger systems. Recommendations are given as to how to respond if the patients clinical condition is deteriorating or at risk of deteriorating.

Summary

What these debates highlight is:

That early signs of deterioration are not recognised
A lack of consistency in the taking and recording of vital signs
Concerns are not being appropriately escalated
There are challenges in prioritising competing demands
Verbal and written communication breakdown
Insufficient training to understand the relevance of observations
A lack of successful implementation of relevant policies and procedures
A lack of strong and effective ward leadership.

Michael Surkitt-Parr

Since the reports published in 2005 and 2006 The National Patient Safety Agency (NPSA) has looked to continue and build on the research in the area of managing the deteriorating patient. In this short (6 minutes) interview, Michael Surkitt-Parr from the NPSA, NHS England looks at how the NPSA is building on the work we have looked at in this week's materials. He explains what is next for the NPSA, including the creation of 'communities of interest', for example, around deterioration in children, and around sepsis.

The Vimeo video stream should be clever enough to detect the type of video stream you need for your device. If you do have difficulties with watching the video please leave us a message on the General Questions discussion board.

When you watch this video, think back to the materials we have used so far in this course. In particular think about what has changed (if anything) over the last 8-9 years since the early reports were produced. Has the Francis Report highlighted a lack of progress, or is there a steady move towards a more structured approach to the assessment, recognition and management of the deteriorating patient?

Transcript of the interview with Michael Surkitt-Parr

Michael Surkitt- Parr is one of the heads of The Patient Safety Agency for NHS England. Michael leads on several work streams such as the Deteriorating Patient and Sepsis. Michael is a surgical nurse by background and he has also worked as a theatre manager. In 2003, Michael moved to the National Patients Safety Agency to a regional role as one in thirty two patient safety managers. In 2010, Michael then moved to the Clinical View and Response Team latterly becoming a joint head of that team.

References and Further Reading

Baker, GR; Norton, PG; Flintoft, V; teal. (2004) The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. Canadian Medical Association Journal 2004; 170: 1678–86.

Brennan,TA; Leape, LL;Laird, NM; teal (1991) Incidence of adverse events and negligence in hospitalised patients: results of the Harvard Medical Practice Study I. New England Journal of Medicine 1991; 324: 370–77.

Davis, P; Lay-Yee, R; Briant, R; etal. (2002) Adverse events in New Zealand public hospitals I: occurrence and impact New Zealand Medical Journal 2002; 115: 271.

Francis, R. (Chair) (2013) The Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office

National Confidential Enquiry into Patient Outcome and Death (2012) Time to Intervene? A review of patients who underwent cardiopulmonary resuscitation as a result of an in-hospital cardiorespiratory arrest. London: National Confidential Enquiry into Patient Outcome and Death

The National Patient Safety Agency (NPSA) (2007) Recognising and responding appropriately to early signs of deterioration in hospitalised patients. London: The National Patient Safety Agency

The National Patient Safety Agency (NPSA) (2007) Safer care for the acutely ill patient: learning from serious incidents. London: The National Patient Safety Agency

Wilson, RM; Runciman, WB; Gibberd, RW; etal. (1995) The quality in Australian HealthCare Study. Medical Journal of Australia 1995; 163: 458–76.