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Recognising and Responding to the Deteriorating Patient

Today's conference focuses on recognising and responding to the deteriorating patient through improving the reliability of patient observations and ensuring quality of care to reduce failure to rescue of acutely ill patients.

Chris Hancock Programme Manager 1000 Lives Improvement opens the morning by discussing 'Enabling clinical teams to improve the identification of acute deterioration and to effectively treat its causes including sepsis and AKI', covering:

  • ensuring a rapid response to the deteriorating patient: giving frontline staff permission to act 
  • the development of the Rapid Response Acute Illness Learning Set 
  • tackling acute deterioration at the front door 
  • our experience and learning from Wales: creating a National social movement

In his presentaton Chris commented:

  • NEWS, it’s our common language, we’ve had it set up for quite a long time.  It’s not because it’s a perfect tool, it’s because we are all using the same tool.  That’s the strength for us
  • Tools don’t have to be perfect, just good enough for what you want to achieve.  Does it empower you to make clinical judgements
  • Tackling Sepsis ‘DRIP by DRIP’: Data/Review the cases/Improvements/Plot the dots/Share & celebrate
  • Address sepsis at the ‘front door’
  • Our Multidisciplinary screening tool is about providing a safety net which our patients should not fall through
  • Importance of data: We need to see that our actions have meaning
  • Standard Operating Procedures give ‘permission to act’.  Anything you can do to allow people to do this has got to be a bonus
  • If you want to change people’s behavior you should make it easy for them to do the right thing

Full powerpoint presentation

Pre conference abstract:

Enabling clinical teams to improve the identification of acute deterioration and to effectively treat its causes including sepsis and AKI

In October 2015 the then Deputy Welsh Health Minister announced a significant reduction in the mortality associated with two ICD 10 codes for sepsis which had occurred whilst the national Rapid Response to Acute Illness Learning Set (RRAILS) had been active. Across Wales, a country of three million people, this equated to an estimated reduction of approximately 200 deaths per year since April 2013.

In this presentation Chris Hancock, RRAILS lead, will argue that the two themes that have been essential to this improvement have been a focus upon measurement and a deliberate attempt to build a nationwide social movement.

There have been several approaches to establishing the quantitative burden of causes of acute deterioration in NHS Wales including the ‘Size of Sepsis’ survey and the spread of Acute Kidney Injury (AKI) e-alerts. It is strongly suggested though that there can be no control of outcomes without control of process reliability and that it is essential to generate and feedback on these data rapidly and for it to be owned by the clinical team.

The role of the data collector will be discussed and the concept of the Critical Care Outreach Team (CCOT) as the ‘Patient Safety Engine of the Hospital’ will be promoted.

A new approach to improving outcomes for patients with sepsis in the Emergency Department using ‘DRIPS’ meetings will be detailed as will the early findings that tackling acute deterioration at the ‘Front Door’ has a positive knock on effect for the rest of the hospital.

Lastly, the implementation of the Behavioural Insights Team acronym ‘EAST’ in the development of a national social movement will be discussed. Various low tech tools, including the ‘Wee Wheel’, ‘NEWS card’, ‘Sepsis Box’ and ‘Kidney Safe bracelet’ have been developed specifically to make it easy and attractive to ‘do the right thing’.

Underpinning the entire approach are the twin principles ‘good enough now beats future perfection’ and giving frontline staff ‘permission to act’.

Chris Hancock's Biography

Chris Hancock is a patient safety advisor and improvement leader working in the Welsh NHS. He leads the Acute Deterioration Programme and manages the Rapid Response to Acute Illness Learning Set (RRAILS), initiatives that has enabled clinical teams throughout Wales to improve the identification of acute deterioration and to effectively treat its causes including sepsis and AKI.

During the time that RRAILS has been active, mortality associated with ICD 10 sepsis codes A40/41 across Wales has reduced by 20%.

As an important step in this project, Chris facilitated the implementation of the National Early Warning Score (NEWS) as the standard in all acute Welsh hospitals as of April 2013. Wales was the first large healthcare economy to introduce NEWS.

Prior to this he led the Welsh Critical Care Improvement Programme (WCCIP) showing that reliable implementation of care bundles in all Welsh ICUs was associated with sustained reductions in central line infections.

He has sat on the Expert Advisory Groups for the NPSA Matching Michigan Study, the European Union IMPLEMENT Programme, the inaugural committee of the United Kingdom Sepsis Group (UKSG), the NCEPOD ‘Just Say Sepsis’ study advisory group and is a member of the National Outreach Forum (NOrF) Executive Board.

Chris has a background in critical care nursing and clinical education. He is particularly interested in patient safety, quality improvement, measurement, behaviour change and human factors principles.

He has been involved in the development of low tech tools and aide memoires such as the NEWS card, Wee Wheel, KidneySafe Bracelet and Sepsis Box and believes that achieving improvement often involves using ‘good enough’ tools to ‘give permission to act’ to all members of the clinical team.

He is a keen cyclist and has combined this interest with promoting Welsh Healthcare, firstly in the ‘Improvement Cycle’ in 2010 visiting all acute Welsh hospitals on a 450 mile round trip and in 2013, 2014 and 2015 on the ‘Cycle for Sepsis’ between Wales and the Houses of Parliament in London.

oncluding the morning sessions is John Welch Nurse Consultant - Critical Care University College London Hospitals NHS Foundation Trust & Member National Early Warning Score Development and Implementation Group (NEWSDIG). John delivers an important session on 'NEWS: Latest evidence and improving the effectiveness of NEWS in an NHS Trust ', and will discuss:

  • the new edition of NEWS: what has changed 
  • the latest evidence in the use of NEWS: ensuring NEWs is used properly 
  • improving the effectiveness of NEWS in an NHS Trust 
  • how to measure and improve the quality of the response to deterioration 
  • our experience of recognising and responding the deteriorating patient: what works? 

John stated:

  • The NEWS system has value in us all speaking the same language.  Unless you can prove your system is loads better I would recommend that we all use NEWS.
  • NEWS is a very efficient system.  John cited a 2016 comparison to the MET criteria
  • NEWS performed equally well, or better, in surgical patients
  • We all know that a new definition of sepsis came out last year
  • Hot off the press: We now have a new NEWS, NEWS 2
  • Now includes two scales for saturation, this may be a challenge
  • NEWS top tips: we were not sure whether we wanted to introduce it, but having decided to do it you have to work carefully and systematically with each ward to introduce it.  It has to be a progressive development.
  • John demonstrated the UCLH chart, highlighting that the ‘Patient’s report of wellness’ is just as important as something like hypertension
  • We need a plan in place for escalation of treatment, this often fails

Full powerpoint presentation

John Welch's Biography:

John has degrees in psychology and in nursing.  He worked as a Staff Nurse, Charge Nurse, Senior Nurse and Lecturer in critical care through the 1990s, was then appointed to one of the first Consultant Nurse posts in the UK, and set-up one of the first Critical Care Outreach services.

John is currently Consultant Nurse at University College London Hospitals and was previously Deteriorating Patient Lead and then Clinical Lead for sepsis across thirteen UCL Partners hospitals in a NHS England funded Patient Safety Programme Breakthrough Series Collaborative – as well as former Programme Lead for Critical Care Outreach at the Department of Health Modernisation Agency.

John was the first Chair of the UK National Outreach Forum, co-wrote the Department of Health Quality Critical Care: Beyond 'Comprehensive Critical Care' report and sat on the Royal College of Physicians National Early Warning Score Design & Implementation Group.  He has been a member of the All Party Parliamentary Group on Sepsis Clinical Advisory Group and is now President of the international Society for Rapid Response Systems

In 2013, John co-wrote, developed and delivered a novel Nurse Intensive Care Skills Training programme in Sri Lanka which is now a gold standard course in that country.  He is currently co-investigator on two National Institute for Health Research studies, evaluating i) the impact of interventions aimed at recognising and rescuing deteriorating patients across the NHS, and ii) nurse-led psychological interventions for at-risk patients.  John is also co-lead of a new European Union Horizon 2020 funded programme to develop a novel, integrated system for identifying and communicating deterioration - in and out of the hospital - which will facilitate patient and carer contributions and participation too.

Future conferences of interest:

Learning from Serious Incidents: Implementing the National Guidance on Learning from Deaths
Monday 5 February 
De Vere West One Conference Centre

Deteriorating Patient Summit
Friday 23 FebruaryThe Studio Conference Centre

16 October 2017


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