National Early Warning Scoring System

Transcription

1 National Early Warning Scoring System A common language for health care The deteriorating patient Professor Derek Bell January 2013

2 Adult National Early Warning Score Background Overview of NEWS Next Steps Questions

3 Background Reports NICE NCEPOD Acute Medicine Task Force Report 2007 Publications Preventable death Excess weekend mortality Excess August mortality Excess ITU utilisation Increased LOS Patient experience?

4 Endorsed and developed RCPL RCN Critical outreach forum Multi-professional groups Patients Particular thanks Bryan Williams Lesley Durham Rachel Wicks

5 Drivers for National Early Warning Score NEWS International evidence sub-optimal care. Triad of failure of: Poor assessment Delayed interventions Lack of Senior Competent input 70 + different EWS / MEWS in UK Poor sensitivities Several 100 worldwide NB: Morgan et al 1997

6 Smith G et al Resuscitation 2008 Bakir ROC 0.78

7 Patterson C et al Clin Med 2011

8 Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study. Hogan et al, BMJ Qual Saf July 2012 Reviewers judged 5.2% (95% CI 3.8% to 6.6%) of deaths as a 50% chance of being preventable. The principal problems associated with preventable deaths were; poor clinical monitoring (31.3%; 95% CI 23.9 to 39.7), diagnostic errors (29.7%; 95% CI 22.5% to 38.1%), inadequate drug or fluid management (21.1%; 95% CI 14.9 to 29.0). Suggests (95% CI 8712 to ) adult preventable deaths in hospitals in England. Most preventable deaths (60%) occurred in elderly, frail patients with multiple comorbidities judged to have had less than 1 year of life left to live.

9 What does this mean? 500 excess deaths at weekends in London (NHS London Data) Excess weekend mortality England 3300 Aylin et al 2010 Estimated 5 excess paediatric deaths per day

10 Patterns of Illness behaviour time matters Unstable Point of Entry to Care Concerns Stable Assessment Hours Days

11 National Early Warning Score Design and Implementation Group NEWSDIG 2008 Key stakeholders ToR design a standardised EWS.. also an observation chart & web based e-leaning package Review existing systems Validation process (Prof Gary Smith) Primary outcome death within 24hrs of given set of observations. AUROC for the NEWS 0.89 (95% CI: )

12 National Early Warning Score (NEWS)

13 Prytherch D et Resuscitation 2010 NEWS ROC =0.89

14 The Chart National Early Warning Scoring System

15 Clinical Response to NEWS Triggers Minimum 12 hourly Continue routine NEWS monitoring with every set of observations Minimum 4-6 hourly -Inform registered nurse who must assess the patient: -Registered nurse to decide if increased frequency of monitoring and/or escalation of clinical care is required Increased frequency so a minimum of 1 hourly -Registered nurse to urgently inform the medical team caring for the patient -Urgent assessment a clinician with core competencies to assess acutely ill patients -Clinical care in an environment with monitoring facilities Continuous monitoring of vital signs -Registered nurse to immediately inform the medical team caring for the patient this should be at least at Specialist Registrar level: -Emergency assessment by a clinical team with critical care competencies which also includes a practitioner/s with advanced airway skills: -Consider transfer of clinical care to a level 2 or 3 care facility, i.e. higher dependency or ITU:

16

17 Considerations General: Potential for increased work load Define skills and competence of responders Clear Implementation plan Trust Board support Steering Group (NB membership) Operational Policy Charts: Can localise but not deviate Embed in Trust documentation / folder Education: Underpins all! Integrate e-learning package into Trust mandatory training / other

18 Discussion points? COPD and Type II Respiratory failure Urine output Acute Kidney Injury

19 Acute Kidney Injury Acute kidney injury is defined when one of the following criteria is met Serum creatinine rises by 26µmol/L within 48 hours or Serum creatinine rises 1.5 fold from the reference value, which is known or presumed to have occurred within one week or urine output is < 0.5ml/kg/hr for >6 consecutive hours The reference serum creatinine should be the lowest creatinine value recorded within 3 months of the event

20 Excess weekends mortality; exacerbations of COPD Barba et al Eur Respir J ,000 AECOPD in Spain deaths OR of weekend death 1.17 Similar to other conditions Small study from Portsmouth shows same results in Winter OR 1.65 = improved from 3.63 after introduction of acute medical unit Brims FJ et al n Med 2011

21 Observation 1 Observation 2 Observation 3 Observation 4 Heart rate Systolic BP Oxygen Saturation Temperature Supplemental oxygen Yes Yes Yes Yes AVPU A V A A Respiration rate COPD score COPD score BAP

22 Currently Free downloadable PDF s E learning package Unique opportunity - national and international National standardised documentation Patient safety Whole system (not just hospital) Staff training undergraduate postgraduate IMPACT ALS Commissioning framework (England) Improved audit and research

23 Where now? Listening exercise Royal College and RCN Review e learning site utilisation and utility Formal review of use and outcomes Probably pointless at unit level for outcomes = power of study How should we do it

24 adding in the decision from the north West London Critical Care Network Joint Clinical Forum about a consistent approach sought for Nort Aim of session is to share learning so far, pool intelligence, problem solve, group source ideas and to agree common areas, edu Where now? What we don t want Efforts to prove it doesn t work Local tinkering Colour New lines What we do want Effort to improve score Effort to improve design Use locally modifiable area of chart

25 C.M Roberts, et al. Acidosis, non-invasive ventilation and mortality in hospitalised COPD exacerbations. Thorax 2010

26 This patient has documented CO2 retention (Respiratory Failure) Score 3 on chart when SaO2 < 88% Maintain SaO2 between 88-92%

27 COPD Patients: The target oxygen saturation should be 88 92% in most cases or an individualised saturation range based on the patient s blood gas measurements during previous exacerbations. [Grade C] BTS guideline "Emergency Oxygen Use in Adult Patients"

28 Assessing responding and monitoring patients: a quality and patient safety Complex and at times imperfect system Excess variation exists in systems and process No common language No common training No monitoring static

29 Patient safety Complex and at times imperfect system Excess variation exists in process Simplification of existing systems Common language Common training Lead internationally Need to monitor