Week 2

Context

When we looked at Deteriorating Patient Initiatives, one common theme was the need for Early Warning scores or track and trigger systems to identify deterioration early on. In the UK, over the past 8 years a number of early warning systems were developed in response to the guidelines, the most common being a Modified Early Warning system (MEWS). These varied in their application across the UK, with different healthcare providers using different systems, adapting existing ones and an overall lack of consistency and no standardisation from one organisation to another. This in turn led to a lack of familiarity when staff and patients move between clinical areas and hospitals when charts/scores held little relevance. . As a result of this, in 2012 the Royal College of Physicians, in the UK, released the National Early Warning Score (NEWS) with an aim to standardising the use of a single early warning system across the NHS.

NEWS

Since the release of NEWS, NHS hospitals have been slowly adopting the new system, replacing old EWS and observation charts.

What is NEWS?

The NEWS is a very simple scoring system. A score of 0-3 is allocated to each of the six physiological measurements used for patient monitoring. The six measurements are:

Respiratory rate
Oxygen saturations
Temperature
Systolic blood pressure
Pulse rate
Level of consciousness.

A score is allocated to each as they are measured, the magnitude of the score reflecting how extreme the parameter varies from the norm. The score is then aggregated. The score is adjusted for people requiring short or long term oxygen. A higher score denotes deterioration. Download the NEWS observation chart here.

When should NEWS be used?

The recommendations are that NEWS should be used for both initial and continuous monitoring of all adult patients. The RCP recommend that the NEWS is used to improve the following:

the assessment of acute illness
the detection of clinical deterioration, and
the initiation of a timely and competent clinical response.

Who is NEWS not suitable for?

NEWS is not suitable for children, or people under the age of 18 years, however alternative early warning scores are available such as PEWS. NEWS is also not suitable for women who are pregnant due the physiological changes in pregnancy and their impact on the parameters. Also, when undertaking NEWS the healthcare worker should be aware of the impact of the abnormal physiology of some patients with COPD on the sensitivity of the NEWS.

The scoring system

The RCP developed a clear scoring system. Scores vary from 0-3 for each parameter . Once the scoring is complete, the actions to be taken are clear, as follows:

A low score (NEWS score 1–4) should prompt assessment by a competent registered nurse who should decide if a change to frequency of clinical monitoring or an escalation of clinical care is required.
A medium score (ie NEWS score of 5–6 or a RED score) should prompt an urgent review by a clinician skilled with competencies in the assessment of acute illness – usually a ward-based doctor or acute team nurse, who should consider whether escalation of care to a team with critical-care skills is required (ie critical care outreach team).
A high score (NEWS score of 7 or more) should prompt emergency assessment by a clinical team/critical care outreach team with critical-care competencies and usually transfer of the patient to a higher dependency care area. Use this thresholds chart to review the scoring system Note: when using the scores, an additional 2 can be added for supplementary oxygen.

A free NEWS eLearning tool is available from the RCP, this will give you more information on completing the tool in practice.

Always use SBAR as a model to shape your escalation ensuring that you are giving sufficient and relevant information for the healthcare professional to make a judgement. Make it clear and be assertive as to how quickly the patient needs to be seen. If used appropriately NEWS can be a very powerful tool, just by reciting a high score, it signifies the urgency of the situation.

SBAR

'Situation, Background, Assessment, Recommendation' known as an 'SBAR' is a communications tool that is used to help frame conversations. The SBAR tool can also be used by members of the healthcare team as a focused way of transferring information about a patient's condition.

Why use SBAR?

To reduce the barrier to effective communication across different disciplines and levels of staff.
SBAR creates a shared mental model around all patient handoffs and situations requiring escalation, or critical exchange of information (handovers)
SBAR is memory prompt; easy to remember and encourages prior preparation for communication
SBAR reduces the incidence of missed communications

Background

"Michael Leonard, MD, Physician Leader for Patient Safety, along with colleagues Doug Bonacum and Suzanne Graham at Kaiser Permanente of Colorado (Evergreen, Colorado, USA) developed this technique. The SBAR technique has been implemented widely at health systems such as Kaiser Permanente" (Institute for Healthcare Improvement, 2014)

The tool consists of standardised prompt questions within four sections, to ensure that staff are sharing concise and focused information. It allows staff to communicate assertively and effectively, reducing the need for repetition. The tool helps staff anticipate the information needed by colleagues and encourages assessment skills. Using SBAR prompts staff to formulate information with the right level of detail.

The increasing review into patient safety generally, required health care workers to find ways of communicating effectively, but also to be able to pass information in a quick and accurate way, especially when under stress in a critical situation, or when work is very busy.

The World Health Organisation summarised these issues in 2007: "During an episode of disease or period of care, a patient can potentially be treated by a number of health-care practition- ers and specialists in multiple settings, including primary care, specialized outpatient care, emergency care, surgical care, intensive care, and rehabilitation. Additionally, patients will often move between areas of diagnosis, treatment, and care on a regular basis and may encounter three shifts of staff each day—introducing a safety risk to the patient at each interval. The hand-over (or hand-off) communication between units and between and amongst care teams might not include all the essential information, or information may be misunder- stood. These gaps in communication can cause serious break- downs in the continuity of care, inappropriate treatment, and potential harm to the patient" (WHO, 2007).

SBAR in Action

The following short video shows two members of the School of Health & Social Care demonstrating the SBAR Tool in a paediatric setting. You will see Matt trying to escalate his concerns about a patient, first without any tool, and then using the SBAR Report.

The SBAR form used in the video is a standard NHS Form.

References and Further Reading

Beckett, CD. & Kipnis, G. (2009) Collaborative Communication: Integrating SBAR to improve quality/ Patient Safety outcomes. Journal for Healthcare Quality Vol. 31, No. 5, pp. 19–28

Haig, KM.; Sutton, S; Whittington, J. (2006) SBAR: A Shared Mental Model for Improving Communication Between Clinicians. Joint Commission Journal on Quality and Patient Safety, Volume 32, Number 3, March 2006, pp. 167-175

Institute for Healthcare Improvement (2014) SBAR Technique for Communication: A Situational Briefing Model [WWW] http://www.ihi.org/resources/Pages/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.aspx

National Health Service Wales (2011) Improving Clinical Communication using SBAR. National Health Service Wales

World Health Organisation (WHO) (2007) Communication During Patient Hand-Overs. Patient Safety Solutions. 1(3) May 2007