PAT I ENT MONI TORING
most appropriate care. “There is room for improvement,” Karen concluded. “We need to think about how we educate staff to develop the necessary knowledge and skills, so that they can recognise and respond to the deteriorating patient. We also need to think about how technology may help – we are going to see a lot of changes in the coming years.”
Sepsis, the deteriorating patient, and technology Dr. Ron Daniels, executive director, UK Sepsis Trust, described how he categorised different types of patient deterioration. This included: l Sudden deterioration or acute deterioration arising from an established underlying condition, which may result in sudden or unavoidable cardiac arrest or stroke.
l Gradual deterioration that is common, which an organisation should be able to detect.
“Deterioration may be impacted upon by our actions or inactions; medication error is one example. However, just as iatrogenic is the failure to apply proper attention to nutrition, hydration, as well as input and output – leading to a gradual deterioration, electrolyte disturbance and sequalae. Similarly, the attention given to infection prevention and hygiene practices can give rise to sepsis. Sepsis has been likened to fractured neck of femur in terms of being an organisational ‘thermometer’,” commented Dr. Daniels. He explained that fractured neck of femur pathways in acute Trusts are often used as an indicator of the efficacy of their urgent surgery pathways and sepsis is similar. The condition is estimated to affect 245,000 people per year in the UK, with 48,000 people tragically dying. “Although 80% of sepsis cases are community acquired, these patients often end up deteriorating in hospital, while 20% is hospital acquired. We need to consider both holistically in any improvement
programme in hospitals,” Dr. Daniels asserted.
No early warning score is perfect, he acknowledged: “It is illogical to apply the same blood pressure threshold to a 20-year- old athlete as an 88-year-old with cardio- respiratory disease. But the advantage of NEWS2 is that it is applicable, it is evidence- based, it is consistent, and it provides a common language with which to assess deterioration,” he commented. Nevertheless, if an experienced nurse believes a patient is critically unwell, even if their NEWS2 score is not reaching a trigger threshold, it is important to act. He added that NEWS2 should be viewed as “an adjunct” and used to empower staff to act. He pointed out that escalation is just as important as the measurement. Technology can help the process of accurately recording observations and accurately transmitting these to the actors in the system – i.e. the sepsis teams, AKI teams, critical care outreach teams, and medical emergency teams. “This action is extremely important, and technology can help. But it’s not just about
We typically expect a minimum set of observations to be recorded every 12 hours; a lot of deterioration can happen during that period. If we embrace technology (including the use of wearable technology in the future), we may be able to make observations continuous and palatable to the patient. This can only add to safety.” Dr. Ron Daniels, executive director, UK Sepsis Trust
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that. We typically expect a minimum set of observations to be recorded every 12 hours; a lot of deterioration can happen during that period. If we embrace technology (including the use of wearable technology in the future), we may be able to make observations continuous and palatable to the patient. This can only add to safety,” continued Dr. Daniels.
He pointed out that current technology already has the ability to reduce transcription errors and he further anticipated that hospitals will increasingly move towards the electronic recording and transmission of observations. He was aware of several organisations that now have a dashboard where NEWS2 scores could be remotely viewed across the entire organisation – enabling the identification of trends, the rate and pace of change to a patient’s condition and enabling the organisation to divert their resources to individuals appropriately. “There can be anxiety around the technology – any change can be scary,” Dr. Daniels acknowledged. “But it has got to be safer than focusing entirely on paper-based observations. It is important that we measure NEWS2 scores; that we communicate and escalate them reliably, but it is also important not to be evangelical and to understand that that NEWS2 has its limitations. “They will improve over time, but right now they are the best thing that we have – technology can be of huge value in reducing observation recording errors and observation communication errors, which is a key area of patient safety,” he concluded.
Organisational and human factors Siân Annakin, a sepsis nurse practitioner with the Dudley Group NHS Foundation Trust, went on to discuss the role of the nurse within the organisation in detecting and responding to deterioration.
MARCH 2021
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