This Future Hospital Programme case study describes how Nottingham University Hospitals (NUH) NHS Trust transformed hospital communication and patient safety by introducing innovative mobile technology. Dr Mark Simmonds introduces an integrated, mobile and electronic ‘eObservations and eHandover’ task management system.Key recommendations
• Deploy an integrated mobile electronic system to aid with observations, handover and task management. This system should allow clinicians on wards to enter observations on patients directly into a mobile device, which will calculate and automatically escalate any concerns to more senior clinicians.
• Additionally this electronic system should be used to gather, manage and interpret key handover details. This means more patients receive the right care at the right time, by the right clinician.
• Real-time access to patient information and automatic escalation systems can support faster decision making and reduce the need for multiple phone calls, thereby releasing time to care and reducing the risk of data degradation.
• Automated calculations, observation frequency setting and user prompts can help to improve compliance with early warning score (EWS) policy.
• Real-time data collection across the Trust allows for more effective workforce deployment and operational activity planning. Retrospective data also offers significant potential for research purposes.
• Involving clinical staff in designing and deploying large ICT systems is crucial to making sure the technology works for staff and in overcoming the challenges of training staff in new systems.
• ICT teams must be given time and resources to allow them to develop new systems that will support the rollout of new technology.
The challenge
At NUH ‘failure to rescue’ had been identified as a high clinical risk. While improvement work was being performed in silos there was a consistent lack of benefitting from shared learning or goals. We also identified that non-adherence to the Trust’s EWS policy and poor handover were common themes in patient safety incidents.
Local context
NUH is situated in the heart of Nottingham and has three major sites:
• Queen’s Medical Centre (QMC)
• City Hospital
• Ropewalk House.
We provide services for ~2.5 million residents of Nottingham and its surrounding communities.
We currently facilitate ~1,900 beds.
We have national and international recognition for many of our specialist services including: stroke, renal, neurosciences, cancer services and trauma. Additionally, as a teaching hospital Trust, we play a vital role in the education and training of doctors, nurses and other healthcare professionals.
Our solution
NUH Trust became the first UK trust to deploy an integrated, mobile and electronic eObservations, eHandover and task management system. The system allows clinicians on wards across our Trust to enter observations on patients directly into a mobile device, which will calculate and automatically escalate any concerns to more senior clinicians and offer them handover information instantly. The data collected through this medium now includes all physiological observations, neuro-observations, critical patient information (eg diagnosis, background, resuscitation status) as well as discharge planning information. Training and a personal mobile device were delivered to 4,500 staff.
The project was clinically led and designed with close liaison with our Recognise and Rescue programme. This process led to improved user experience whilst allowing flexibility within the system that allowed it to be rolled out across all departments at our Trust.
Outcomes
By June 2015, the new technology was fully in use on more than 65 wards covering more than 1,800 beds and connecting more than 4,000 staff. Over 2.5 million observations have been taken (manually) with more than 2 million electronic handover notes and over 200,000 automated escalations. Paperless handover across live wards has resulted in reduced data degradation and improved information governance.
Thanks to the new electronic system:
- observation collection takes less time
- decisions can be made and communicated at the bedside, therefore releasing time to care
- time-motion studies suggest that in the observation process alone, over 150 hours of nursing time per day are being saved at NUH
- clinicians are given vital information instantly due to the automation of escalating and negating the need for multiple telephone calls.
Through remote access on mobile and desktop devices, we have achieved real-time visibility of patient data across the whole Trust, allowing effective task prioritisation.
Audit results show that compliance with EWS policy has improved thanks to automated calculations, observation frequency setting and user prompts, helping us to meet four local EWS Commissioning for Quality and Innovation (CQUIN) targets.
Methods
The project was coordinated by a team of frontline clinicians working closely with ICT and our development partners at Nervecentre, using an inclusive and multi-disciplinary approach.
We rolled out the new approach ward by ward to begin with and ensured that lessons learned were quickly adopted both in adapting to the technology and in establishing new procedures. Particular challenges around staff lists and nuances of escalation pathways in different wards needed to be tackled. Only then did we accelerate to three wards a week. We continued to ensure we learned and improved as we went.
Barriers and levers
The logistics of procuring, preparing and distributing thousands of devices was demanding. Building a strong relationship with suppliers helped us overcome this demand. Likewise the relationship with a dedicated information and communication technology (ICT) team helped us with distribution facilitation. The project also required significant financial investment: it was funded by a matched grant from the national Safer Wards, Safer Hospitals programme, which provided £1.6 million for software, devices, project management and implementation. Key to the success of this bid was a reputation as a Trust for completing large scale ICT projects bolstered by strong clinical input to the written and verbal bid process.
Involving patients and the public
We have liaised with existing NUH patient involvement groups to ensure that we delivered a solution that was acceptable for patients. Whilst the introduction of widespread mobile technology may be seen as a negative by patients, we have actually had a positive response with the realisation that the ‘NHS is finally entering the 21st Century’. By marketing the project as a safety initiative we have been able to reassure patients why staff are on their phones!
Right care, right time
The new approach to gathering, managing and interpreting patient observations and key handover details means more patients receive the right care at the right time, by the right clinician. In addition, automated escalation negates the need for multiple phone calls, giving clinicians vital information instantly. Through remote access on mobile and desktop devices, we have achieved real-time visibility of whole systems, allowing effective prioritisation.
Staff responses
Over 80% find the system ‘saves time’ and ‘makes communication quicker and easier’ with over 80% of ‘patients feeling comfortable’ with mobile healthcare technology. Paperless handover across live wards has resulted in reduced data degradation and improved information governance.
An initial staff survey found over 90% of clinicians feel ‘the system helps in their work’.
Next steps
Patients whose observations suggest deterioration are much more quickly and effectively identified and their details are available to all clinicians, anywhere, instantly. Frontline clinicians are getting more time to care for patients and the potential for data mining and improving communication further are truly exciting.
• The impact of the new system will continue to be measured through audit of our EWS performance and analysis of patient safety incidents. We know we are only beginning to realise the potential of this solution clinically, operationally and managerially.
• By combining live acuity, location, diagnosis, handover and task allocation in one universally accessible place, we are able to harness the power of information that was previously impossible to draw together.
• The clinician-driven bedside data collection model means that we are now in a position to use both real-time and retrospective data to influence operational activity in the trust, with proactive bed management enhanced greatly by the improvement in information flow.
• Retrospective data analysis for research purposes is a potential gold-mine for understanding more about how to make patients safer.
• The Trust is determined to share our learning with others as we believe this solution could have universal applicability and scalability.
• To date, the Trust has hosted a seminar, involving 70 people from 11 trusts, and delivered a national webinar hosted by Patient Safety First in December 2014.
This case study is not an endorsement of any individual or organisation. The material within is promotional only and we do not necessarily reflect the views of the author and the organisation they represent.
Who’s involved?
Nottingham University Hospitals (NUH) NHS Trust
Dr Mark Simmonds qualified in 2001 from the University of Nottingham and trained in acute medicine and intensive care. He now works as a consultant, mainly in critical care with sessions in acute medicine, at Nottingham University Hospitals (NUH) NHS Trust
He chairs the NUH ‘Recognise and Rescue’ Programme, having worked as a trainee on improving the treatment of severe sepsis. More recently he has been the clinical lead for the ambitious ‘eObservations and eHandover’ project. He also sits on the NICE Sepsis Guideline Development Group. Mark was highly commended in the HSJ Clinical Leader of the Year Award 2015.
Email: [email protected]