1. Storyboard Title Use of the proposed National Early Warning System (NEWS) scoring matrix in a community hospital setting

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1 Powys teaching Health Board Storyboard submission: Improving Patient Safety 1. Storyboard Title Use of the proposed National Early Warning System (NEWS) scoring matrix in a community hospital setting 2. Brief Outline of Context This work, undertaken by the Powys Safety and Quality Improvement Manager and staff working on the community hospitals, sought to evaluate and implement a nationally devised observation-based safety matrix for use in a community hospital setting. 3. Brief Outline of Problem Work from the National Patient Safety Agency has shown that 10% of hospital deaths result from the failure to recognise the deteriorating patient 1. Other studies 2 have shown that 60% of such cases showed clear physiological changes that had been documented in the notes prior to the final deterioration. This was also true of episodes where unplanned admission to intensive care was required. 4. Assessment of Problem and Analysis of its Causes To address this situation, a number of Early Warning Tools have been developed 3,4. These assign a numerical score to the values for blood pressure, pulse, temperature and respiration rate. Observations falling within normal range attract a score of zero with deviations from the expected range falling into bands that score progressively higher the further they deviate. A measure of the stability of the patient can then be gained by simple addition of the scores. Triggers can then be set, with particular actions, such as increased observations or a medical review, that are required when a given score is reached. The 1000 Lives plus programme has developed an all-wales observational safely tool, the National Early Warning System (NEWS). As well as serving as a robust evidence-based safety tool, NEWS will also provide a commonality of language when discussing a patient s status, which will reduce misunderstandings and inappropriate transfers.

2 5. Strategy for Change For the community hospital, however, the introduction of a national early warning system is not without concerns. The Powys team charged with introducing the new scoring system set out to describe, evaluate and then address the following questions: (i) What can be done to reduce the training burden of introducing a new observation-based scoring system? (ii) How appropriate is the NEWS scoring matrix to the patient demographics of a rural community hospital? In particular: a) Is the NEWS matrix generally over-sensitive in its scoring? b) Is the NEWS matrix too insensitive in specific areas? (iii) What should the appropriate action be to a given trigger given the nature of community hospital care? The new form was developed by a small working group. This task was made easier by the fact that Powys was already using an observation-based safety form known as Track and Trigger developed by staff during the original 1000 Lives Campaign 5. The development criteria were that the form should fit onto a single A4 sheet and that staff should find it easy and intuitive to use. Four different forms were developed, with Form 3 being the closest to the existing Track and Trigger form. (Figure 1). Ward staff were asked to evaluate the form for user-friendliness. Feedback from the consultation was encouraging, the colour coding of scoring values being particularly valued by staff. There was also strong support to free up space by not recording diastolic blood pressure as a graph. One issue thrown up by the exercise was the differing conventions present in the NEWS scoring system. For example the highest trigger score for temperature is 39.1 C rather than 39.0 C. However the highest trigger score for systolic blood pressure is 220mmHg rather than 221mmHg. Likewise the highest trigger score for pulse is 131bpm rather than 130bpm. Based on initial feedback, a further form (Form 5.1) was quickly developed and sent out for consultation.

3 Further Plan-Do-Study Act cycles were done to refine the form. 6. Measurement of Improvement Analysis of the potential use of NEWS in a community hospital setting. In order to determine what the effect of NEWS would have been if it had been in service, some 300 real-world patient observations were re-scored using the NEWS matrix. See Figure 2. and Table 1 for results of this study To explain these findings one needs to remember that NEWS was developed for relatively young, but acutely ill, patients. Patients in community hospitals are older and may have multiple chronic conditions but are not necessarily acutely ill. Specific factors such as blood pressure may have been artificially lowered by antihypertensive medication and body temperature may often be lower in these clients. This may lead an older patient to trigger on NEWS at their normal physiological state. 7. Effects of Changes In the next stage was to analyse existing data for guidance on appropriate actions at a given NEWS score. The data convinced us that a NEWS score of 3 has no significance for the typical older rehabilitation patient. No patient who scored 3 on NEWS had ever scored the equivalent score on Track and Trigger (Figure 3). However, it is clear that NEWS is the more sensitive system, and by following the patient journey we noted that NEWS picks up a potential deterioration one observation earlier than Track and Trigger (Figure 4). There was debate over the appropriate actions for a score of 4. Re-scoring old observation charts showed that only 1% of patients who would have scored 4 on NEWS scored the equivalent score on Track and Trigger. It was possible, however, that we had simply failed to identify deteriorating patients using Track and Trigger, so a review was undertaken to study the fate of patients who would have scored 4 had NEWS been in use during their admission. This review showed that only 4% of cases that would have scored 4 required medical review or intervention within 72 hours. None of these cases led to a serious or fatal deterioration.

4 8. Lessons Learnt Therefore, current thinking for the care of Powys community inpatients is that scores of 0-4 on NEWS should warrant 12-hourly observations with the caveat that staff should be aware of sudden swings or variations to a settled pattern. Patients who would have scored 5 were also studied. It was noted that 96% of these patients did not trigger on Track and Trigger. However, a third of the patients who scored 5 were genuinely deteriorating and NEWS would have helped identify them sooner. Therefore, 5 will be kept as the trigger point for increased observations in our community hospitals. The next stage (ongoing) is the final polishing of the NEWS tool (Figure 5) and its piloting as the live observation form, before roll out of the remaining wards by April Message for Others Community hospital staff can still use the All-Wales NEWS tool but may have to set appropriate local actions for the lower trigger scores.

5 References 1. National Patient Safety Agency. Safer care for the acutely ill patient: learning from serious incidents National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Report An acute problem? 3. McArthur-Rouse F. Critical care outreach services and early warning scoring systems. J. Adv. Nurs Dec;36(5): Ridley S. The recognition and early management of critical illness. Ann. R. Coll. Surg. Engl Sep;87(5): Wolfenden J, Dunn A, Holmes A, Davies C, Buchan J. Track and trigger system for use in community hospitals. Nurs. Stand Jul 14-20;24(45):35-9.

6 Figures and Tables Form 1.0 Form 2.0 Form 3.0 Form 4.0 Figure 1. An early design decision was that the form should be usable without the need to refer to a reference table for the scores. This was achieved by means of colour coding the scoring bands to make obvious the fact that a particular observed value attracted a score. This figure shows the four designs of observation forms which were circulated to staff for comment during the developmental stage of the project. Form 1 rejected as there was not a positive no indicator for patients not receiving oxygen Form 2 The most simplified form - rejected as the abolition of both temperature and systolic blood pressure graphs was thought too radical Form 3 most like the existing form included graphical area for diastolic blood pressure rejected as staff felt was too cramped to use easily. Form 4 most popular layout but staff rejected simplified patient demographics box in favour of keeping the space for a printed sticker. This form was used as the basis for version 5.

7 Score on NEWS Score on Track and Trigger Figure 2. Graph showing the same patient observation data calculated both using the Track and trigger tool (x axis) and NEWS (y axis). The size of the circle indicates the number of examples. Overall good agreement was seen between the two scoring systems when the patient was sick, i.e. 4 in Track and Trigger and 6 in NEWS. top right quadrant.

8 Table 1. Trigger Category NEWS T n T No trigger Increased Obs Sick Urgent 11 0 Total Note that following the standard NEWS guidance for the action at NEWS values of 3, 4 and 5 would lead to a 15-fold increase in the number of observations required - a significant extra nursing burden.

9 Figure 3. This patient is very much a typical representative of our demographics - an older patent, requiring rehabilitation, but fundamentally quite well. Note that increased observations would have been suggested using the original NEWS protocol (scores of 3 with one score of 6) but not considered as requiring intervention using Track and Trigger. In practice, the patient was soon well enough for discharge Figure 4. Here is a frailer patient who had suffered a chest infection. Note that NEWS identified deterioration one observation before Track and Trigger, a finding that was noted for several patients.

10 Front of form Back of form Figure 5. Version 5.5 of the NEWS tool after several rounds of PDSA development. Changes include new colour scheme, action prompt box on front of sheet, scoring colour guide, repositioning of main part of document to the right to facilitate binding into notes, introduction of a raised temperature prompt (as older clients may not develop very high fevers in response to infection), inclusion of a sepsis awareness table on the back and inclusion of a worked example for staff to follow.

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