In 2005 the National Patient Safety Agency (NPSA) undertook a detailed analysis of 1804 reported serious incidents which resulted in death and made key recommendations from 64 incidents involving unrecognised patient deterioration and they were:
- Better recognition of patients at risk who had deteriorated.
- Appropriate monitoring of vital signs.
- Accurate interpretation of clinical findings.
- Calling for help early and ensuring it arrives.
- Training and skills development.
- Ensuring appropriate drugs and equipment are available.
Prior to this, in 2001 Hillman et al found there was evidence that acute illness is exacerbated by “failure to act” on recognised changes. This was consistent with the findings from the NPSA analysis and recommendations. Also, in the acute hospitals the monitoring of patients was done using different early warning scores which was recommended by the NICE guidelines CG50.
The early warning scores were related to all aspects of treatment and care of adults for acutely ill or at risk of physical deterioration in acute hospitals. This was strengthened by a national early warning score to be adopted by all acute trusts in the United Kingdom.
The early warning scores was very much acute hospital focused and the monitoring of patients involved access to nurse, doctor and when triggered an intensive care team review.
In the Intermediate Care Team (ICT), patients were being admitted to the service for admission avoidance from referrals to the service by the patient’s GPs and also from the acute hospitals in Northamptonshire. Patients were also taken on by the ICT to facilitate early discharge form the two acute hospitals in Northamptonshire.
The majority of the patients admitted to the Intermediate Care Team were older people with 80% aged over 65 years. The patients were reviewed by Advanced Nurse Practitioners and management plans including nurse monitoring, therapy intervention and care provision to maintain the patient’s independence in their activity of daily living were produced.
To monitor these patients it was impossible to adopt the early warning score from acute hospitals and it was felt necessary to devise a community early warning score/system, which was fit for purpose in the Intermediate Care Team for patients in their own home.
NICE guidance CG50 recommended physiological observations to be recorded at the time of initial assessment or admission. The physiological observations also should be recorded and acted upon by staff, who have been trained to undertake these procedures and understand their clinical relevance.
As a minimum, heart rate, respiratory, systolic blood pressure, level of consciousness, oxygen saturation and temperature should be recorded at the initial assessment and as a part of routine monitoring. The physiological observations needed to be monitored every 12 hours, unless a decision has been made at a senior level to decrease the frequency for an individual patient.
The NICE guidance is for acute hospitals and is good clinical practice. In the Intermediate Care Team, this guidance could not be adopted as patients were in their own home with nursing, therapy, care and physician visits carried out according to the needs of the patient. When caseload of patients in the Intermediate Care Team was reviewed on a regular basis, we found staff in the ICT sometimes were not recording observations, not recognising early signs of deterioration, not communicating observations causing concern and not responding according to concerns appropriately. This resulted in Dr Bharath Lakkappa (Clinical Director for Community Rehabilitation and Elderly Care – NHFT) along with Paula Love (Clinical Lead Unplanned care – NHFT) developing the Community Early Warning System (CEWS) for intermediate care team patients.
The CEWS needed to be fit for purpose for patients at home with the ICT. The early warning scores of acute hospitals were of narrow range and also showed deterioration of patient further to what can be managed safely in the community. With more than half of the patients with the ICT having a history of falls, a physiological measure which would help monitor patients with a history of falls needed to be added to make it more suitable in the community.
Orthostatic blood pressure measurement was added to the physiological observations as recommended by NICE CG50 and the parameters were adjusted to make it more suitable for monitoring and to action in the community. The increased risk of falls in patients who are frail, being treated for an infection or undergoing rehabilitation in their own home prompted us to review orthostatic hypotension monitoring. We developed the monitoring parameters to be in line with, the treatment possible at home for a patient who was diagnosed with postural hypotension.
Monitoring of blood sugars and level of consciousness was also incorporated into the CEWS. Delirium secondary to infection, fall or medication needed to be monitored, when the patients were with the ICT at home , this resulted in the incorporation of the AVPU into the CEWS, to give the staff a prompt for action based on the trigger.
Hypoglycaemia being an immediate threat to the elderly patient, discharged recently from the acute hospitals was not an uncommon theme seen with ICT patients. Furthermore, when slow progress of rehabilitation was reviewed among ICT patients , new diagnosis of diabetes and poorly controlled diabetes was a common theme. Hence to complete patient monitoring during their rehabilitation The Nice Guidelines for monitoring blood sugars was incorporated into the CEWS triggers.
This track and trigger system uses multiple parameters and also allows for a graded response. It has clear and explicit cut off points that trigger a response and was implemented in 2010. Since 2010 the Intermediate Care Team has been using the community early warning system.
The aggregated score used in NEWS was trialled in the CEWS before 2010 and on review before full implementation; the score had become a priority, than the parameters triggering the change reflected in the patient condition. When SBAR communication was used, the staff did not focus on the triggering parameters and focused only on the score. This prompted a to change the scoring system into a traffic light system more focused on the physiological parameters, thus helping to plan an action based on each individual parameters in the patient’s home.
The traffic light system consists of white, green, yellow and red with clear and explicit cut off points, triggering a response. In line with NICE recommendations the physiological observations were recorded and acted upon by staff. All staff, who come in contact with the patients of Northamptonshire ICT were trained to undertake these clinical observations and understood their clinical relevance.
A paper based chart similar to the NEWS was developed and incorporated into the clinical records in the patient’s home for staff to use.
Similar to the NEWS, CEWS has got the ability to record variance to each parameter, if it has been approved after discussion in an MDT, with a speciality team or GP who has been aware of this variance as a normal for that patient.
The monitoring need for patients in ICT is discussed with a senior member of the team/matron/doctor, through the live handover process. The Live handover process is a telephone advice service developed by the team, where senior members of the team are available to advice staff after every visit and also action urgent visits if needed after discussion. This was developed in view of the high acuity of the patients on the ICT caseload.
The triggers have a specific response of monitoring:
Green: a minimum of one daily nursing visit for 3 days is suggested. The necessary clinical monitoring or treatment is discussed and action through live handover.
Yellow: A minimum of 2 daily nursing visits is suggested. Also screening for infection, including blood investigations is suggested. If the patient is appropriate to stay at home, and the yellow trigger is persistent for 48hrs, senior review is suggested.
Red: Admission is suggested. If not admitted reasoning to be clearly stated. Mental capacity and rationale to be documented clearly. If palliative, DNAR and other documentation should be reviewed and palliative services informed.
The CEWS has greatly helped in patient monitoring and appropriate use of senior resource to monitor patients who trigger a need for response, in NHFT unplanned care (ICT) service. It has recently been adopted by all adult community services in NHFT when they are reviewing patients.
Dr Bharath Lakkappa (Consultant Geriatrician) – [email protected] @drgeriatrics