Box 1.

Improving the identification and management of deteriorating patients

The mismanagement of deterioration is the most common area of systemic failure of avoidable patient death across the NHS, while poor communication is the leading root cause of adverse events in healthcare.7 In recent years, the regional Patient Safety Collaboratives (PSCs) have been working with acute and non-acute teams to support improvements in the identification and management of deteriorating patients. The work has been supported through a combination of locally-led activities, national coordinated work as well as a range of national policy levers to support change.
Supporting local implementation of national policy: embedding the use of the National Early Warning Score 2
The National Early Warning Score 2 (NEWS2) is the tool endorsed by NHS England and NHS Improvement to identify acutely ill patients, including those with sepsis, in hospitals in England. It originated out of a working party convened by the Royal College of Physicians (RCP), with the original NEWS tool released in 2012.8 It is a simple aggregate scoring system in which a score is allocated to six physiological measurements already recorded in routine practice (respiratory rate, oxygen saturation and so on), where the magnitude of the score reflects the degree to which the parameter varies from the norm.9
The regional PSCs have been supporting acute and ambulance trusts to implement NEWS2 so that it becomes standardised across the acute sector and creates a common language when quantifying patient deterioration in handovers of care. Support has typically been in the form of creating multidisciplinary and interorganisational networks, running regional NEWS2 events and working alongside individual hospitals to overcome specific implementation challenges, most commonly around integration with electronic systems, supporting the use of structured communication tools (such as Situation, Background, Assessment and Recommendation (SBAR)) to communicate critical information, and establishing escalation protocols to ensure the timely and appropriate medical response to deterioration.
Implementing a system-wide approach to NEWS2
The West of England PSC covers community and primary care, seven hospital sites, two mental health trusts, the ambulance service and, at the time of implementation, seven commissioners across the region. In 2015, the PSC began a programme of work to implement NEWS across the entire healthcare system, later supporting the system to transition to NEWS2 when it was released. The vision was that, regardless of the setting, an acutely unwell patient has a NEWS score calculated at the point of assessment and then at every handover of care to ensure that the action taken means that the patient is seen at the right time in the right place by the right grade of clinician.
The PSC used a quality improvement collaborative approach to bring together staff from across the health system every 6 months, while each area brought together local teams to meet more frequently to address specific challenges for their region. The PSC also facilitated the introduction of NEWS into the South Western Ambulance Service NHS Foundation Trust electronic patient care record and helped with implementation and spread. The work has resulted in all acute trusts, out of hours general practitioner services, mental health trusts, community service providers and clinical commissioning groups signing up to support the adoption and spread of NEWS2, and communicating the score at the interfaces of care across the system.10 Research found that, between April 2016 and November 2017, 63% of over 1 million attendances by the ambulance service in the region had a NEWS recorded.11
Reducing mortality from sepsis and acute kidney injury across London and the south-east of England
In 2014, UCLPartners – the Academic Health Science Network which serves the population of north-east and north-central London and parts of three connecting home counties – brought together senior clinicians and hospital leaders from its NHS trust partners to identify clinical areas for a quality improvement programme in patient care and safety. Causing around 80,000 deaths annually in England – and the focus of national campaigns and influential reports – acute kidney injury (AKI) and sepsis emerged as urgent priorities for improvement.
Two collaboratives were established, bringing together professionals to learn from and motivate each other to improve care. Teams from 12 NHS trusts formed the sepsis collaborative, and teams from nine trusts formed the AKI collaborative. Both completed three main programme phases – baseline, improvement and implementation – from September 2015 to June 2017. Throughout these phases, teams took part in a series of group learning sessions intersected with action periods during which they tested and measured improvements in practice in their own hospital settings. Interventions included redesigned care pathways, creation of dedicated roles and awareness campaigns.
In total, records from 950 AKI and almost 1,200 sepsis cases were included in the final analysis. Both collaboratives exceeded their initial aims for improving survival rates: AKI deaths reduced by 47%, and sepsis deaths fell by 24%. In sepsis, patients’ median length of stay in hospital was reduced by 20% and admissions to intensive care were cut by 52%. In AKI, rates of kidney function recovery were increased by 19.5%. Both collaboratives also demonstrated improvements in clinical processes, such as timely recognition of the conditions, improved documentation and best practice follow-up (see supplementary material S1).12