Benefits and challenges

Table 2 presents data to illustrate how the themes map against the benefits and challenges of the two sites' safety systems. The EWS had been used at both sites for over 2 years. Hospital audit data suggested that early warning scores were used by HCAs and nurses as part of their daily monitoring practice (Eastward and Westward observation audit results, unpublished data, 2009). The EWS across both sites functioned as a risk assessment tool and structured attention to those observations which were included in calculation of the score. An added value of the IAT at Eastward, as opposed to the EWS in operation across the rest of the hospital, was the requirement that HCAs had to enter vital signs into a handheld device and respond to inbuilt safety prompts (when partial data or ‘unlikely observations’ were entered). This, together with the tracking of vital signs against named nurses or HCAs and the flagging of overdue observations, was perceived to have increased the completeness of recordings and improved compliance to protocol.

The IAT provided access to real-time electronic data and generated information about the quality of recording observations, for example, adherence to protocol. ‘Lateness’ values for 6 hourly observations included any recorded over 8 h while for 1 hourly observations, anything over 1.5 h was termed as a ‘breach’. Electronic data suggested that after implementation of the IAT, adherence to protocol generally improved, but remained variable, with late observations on the ward ranging from 30% to 70%. Despite this, the display of patients' risk scores provided at a glance by the IAT was reported by HCAs and nursing staff to enable sharing of understandings, planning and managing their workload. The IAT on the two pilot wards at Eastward enabled doctors to review observation data remotely alongside other information such as patient records, x-rays, and blood results, facilitating understanding of deterioration.

At both sites, the scores provided staff with the license to escalate care across hierarchical and occupational boundaries. Following the re-launch of the EWS and introduction of an escalation protocol at Westward, the scores were observed to be part of the verbal and written vernacular at an organisational level, routinely integrated into handovers and documentation. The scores and protocol were observed to structure discussions regarding acutely ill patients among HCAs, nurses, doctors and physiotherapists. Observation and interview data additionally illustrated how the CCOT at Westward helped to overcome delays due to occupational divisions and hierarchies.

In contrast, while HCAs and nursing staff from the pilot ward at Eastward demonstrated awareness of the scores incorporated within the IAT, observations of medical staff working across the directorate illustrated how scores were not routinely utilised on other wards as part of the assessment or handover practice. This was substantiated by interview data. Utilisation of different EWSs across the hospital and the absence of a Trust-wide escalation protocol appeared to contribute to problems with utilisation and application of these scores in practice.

Westward's escalation protocol included a recommendation to use a modified ‘situation-background-assessment-recommendation’ (SBAR) communication tool. The tool was not witnessed in action despite being perceived by nursing and medical staff as useful for formalising interprofessional commitment and responsibilities. However, in the interviews, some junior nurses reported that they had used the structured template and found it facilitated handover in emergency situations. Lack of adherence to this standard was confirmed by hospital audit data (Westward observation audit results, unpublished data, 2009) and appeared to reflect difficulties monitoring compliance and concerns among senior nurses regarding the unnecessary formality of the tool's script.

Both the escalation protocol and the CCOT at Westward promoted uniformity and standardisation with regards to response to the acutely ill patient. The CCOT enabled error recoveries and provided educational support, a resource for nursing and medical staff, and ‘an extra pair of hands’. The team additionally bridged the gap between ward staff and critical care, and mediated communication and decision making at the interface between the two.

At Eastward, hospital audit results of consecutive admissions from the wards to general intensive care between December 2007 and March 2008 had demonstrated variability of response to seriously ill patients across the hospital (Eastward audit of acute pre-ICU care, unpublished data, 2008). Observations across the directorate illustrated instances of delayed escalation of care across hierarchical and professional boundaries (nurse to doctor, junior to senior doctor). A number of nursing staff, medical staff and managers reported that the variance in response reflected the lack of a ‘planned’ hospital-wide pathway for acutely ill patients.

Unintended consequences

Table 3 provides quotations to illustrate mapping of the themes against unintended consequences of introduction of the tools and safety strategies. Managers, nursing and medical staff perceived that the EWS and IAT increased reliability of clinical practice by reducing variance in the recording of observations and addition of weighted values to form a risk score (the IAT additionally offered automatic scoring). This appeared to legitimise the delegation of taking observations to HCAs, despite the fact that this introduced further boundaries and a new division of labour.

Intuitive-experiential knowledge was acknowledged by a number of senior nursing and medical staff to be a valid element in detecting early deterioration. However, junior nurses and HCAs reported and were observed to base their view of what constituted a crisis event on markers such as blood pressure and respiratory rates, which were included in the aggregated score. Other important indicators, such as tacit signs (eg, increasing restlessness) and blood results which were not included in the score, and markers such as urine output which were not mandatory, were given less importance leading to observed and reported instances of delay in recognition and triggering.

At Eastward the handheld device which directed HCAs to follow a routine every time they recorded their observations at times appeared to promote inattention to other significant signs of deterioration (eg, a report of chest tightness was ignored). Although recordings of respiratory rates were reported to have increased at Westward and on the pilot ward at Eastward, concerns regarding the accuracy of some of the recorded respiratory rates were reported by senior nursing and medical staff at both hospitals.

At Westward, it was acknowledged formally (via the protocol) and informally by nursing and medical staff that the scores were an adjunct to clinical judgement. Despite this, without the ‘objective’ authority of either the score itself or a worsening trend in scoring, when junior nursing staff tried to escalate care using alternative indicators such as a tacit sign, a patient's or family member's concern, or an ‘intuitive’ sense that the patient's condition was deteriorating, they struggled at times to summon a response.

At Westward, concerns were also expressed by a number of nursing and medical staff that the CCOT reduced exposure of ward nurses and doctors to the trajectory of deterioration and had introduced further compartmentalisation and fragmentation of care.

At Eastward, replacement of paper records with electronic charting meant that vital signs, electronic flags and scores were not accessible until staff logged in and retrieved the charts. Access to the data was contingent on availability of computers on wheels, a problem during ward rounds and busy times (during the study period, two to three were in operation on a ward for 28 patients). The paper charts were also removed from the patient so markers from visual cues of potential deterioration were separated from the patient.

Factors influencing implementation

Table 4 maps the theme of contextual influences to those factors influencing implementation.

One of the key facilitating factors was senior-level commitment to patient safety. At Westward, patient safety leads championed a policy of zero tolerance for hospital cardiac arrests. The hospital had invested resources in establishing a comprehensive, hospital-wide RRS supported by an interprofessional training programme focusing on utilisation of the tools and the CCOT. With mandatory regulation and audit, compliance rates improved. A 6-monthly hospital audit of ward observations, use of the EWS and adherence to protocol was reported to a central safety committee. Data included cardiac arrest data, CCOT activity, review of escalations and the hospital standardised mortality ratio. Data demonstrated where cardiac arrests were occurring, triggers prior to the arrest and patient outcomes. Rapid cycle reviews of care pathways of those patients admitted to critical care generated additional insight into other risk factors, for example, lack of fluid balance. Regular review of these data by the safety committee was observed to generate new local knowledge about the management of the acutely ill patient and to drive clinical behaviour change. Audit data were fed back to the wards regularly, prompting the development of action plans.

At Eastward, the IAT enabled collection of ward data for benchmarking purposes for the two wards involved in the pilot. Data regarding observations and workload (eg, total number of observations taken including score), compliance (eg, completeness of observations, number of late observations) and escalations (eg, compliance to escalation protocol) were initially reviewed by the directorate team and fed back to the individual two wards for performance purposes. However, over time, managerial priorities shifted and interest in utilisation of the data for quality improvement purposes tailed off.

Gaps in the pathway

Lastly, we mapped the safety strategies onto a pathway of care for the acutely ill patient (see figure 1).

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Figure 1

Mapping strategies to an acute care pathway.

Although the pathway is displayed as a linear trajectory, in reality it took the form more of a recursive cycle since at various points, effective recognition and rescue involved continuous monitoring, review and response. The mapping showed that the majority of the strategies are designed to facilitate processes at the start of the pathway, suggesting a need for additional data and understanding about response behaviour, particularly team decisions downstream. Observation and interview data revealed that difficulties with referral (both routinely and during emergency situations) across medical boundaries occurred frequently at both hospitals (eg, poor handover practices, delayed response). While the CCOT helped facilitate escalation across hierarchical boundaries during emergency situations, junior doctors from both hospitals reported problems accessing specialist advice (eg, referrals to cardiology, surgery): ‘there was a delay to treatment onset because a registrar's mindset was antagonistic and negative … boundaries can make a huge difference (consultant, 9, Westward); ‘When we weren't so clued up on making referrals there were some really horrible ones, people would shout at you, tell you they were busy’ (junior doctor, 9, Eastward).

Observations of out of hours work also demonstrated instances of poor continuity of medical care, with reviews of ‘Do not attempt resuscitation’ status delegated to on-call teams and confusion regarding plans for escalation of care:

‘out of hours it's hard to get a decision because the doctors feel they don't know the patient and the full situation, and some of the more junior ones are quite worried about making a decision. A gentleman over the weekend became unwell and the doctors were confused about which bleep they should contact, it was difficult to get the person we needed. We ended up with a medical registrar for someone who needed palliative care; she made the decision to make him not for resuscitation’ (nurse, 5, Westward).

A further concern was that performance management of detection of and initiation of escalation of care (where the EWS, escalation policy and IAT strategies were principally directed) focused scrutiny largely on nursing care and opened up opportunities for selective blame of particular professional groups rather than fostering a culture of team responsibility for problems with rescue. While data on completeness of observations and scoring provided proxy measures of quality, few data were captured illustrating subsequent decision making and outcomes, particularly when patients were noted to have scored highly over a number of days. The ‘everyday’ process of ward medical team response to early stages of deterioration and follow-up reviews largely escaped scrutiny, both in terms of capturing rates of response and outcomes.