Embedded Files
SMART in context
SMART in context
The aim of the SMART course is to equip you to be able to confidently recognise and respond to acutely ill or deteriorating patients in hospital. The course will teach you the ABCDE approach to common presentations of deterioration, for example low blood pressure, low urine output and breathing difficulties.
The way you approach observations, the way you communicate and lead your team can all make a difference to patients who deteriorate.
If you were admitted to hospital, you would assume that if your condition deteriorated that this would be spotted immediately by the staff caring for you, and that you would receive prompt medical review and appropriate treatment.
Sadly it is a reality that some patients in hospital who deteriorate go unnoticed, or experience delays in getting the urgent treatment they need. Some receive inappropriate treatment. This can result in preventable intensive care unit admissions, preventable cardiac arrests and some unnecessary deaths.
Physical health in people with Mental Illness or Learning Disabilities
People who have a Serious Mental Illness or a Learning Disability have a shorter life expectancy than the general public, often a physical illness can exacerbate their mental illness or in the case of a person with a Learning Disability a physical illness can be perceived as a behavioural problem or as being characteristic of the person’s learning disabilities. This can lead to Diagnostic Overshadowing, a term used to describe a situation when a physical illness is overlooked due to the misattribution of any physical symptoms shown to their mental illness or learning disability, often leading to a delay in, or, inadequate treatment.
People living with severe mental illness (SMI) have a life expectancy of 15–20 years lower than the general population partly due to physical health needs being overlooked. Individuals with SMI also have double the risk of obesity and diabetes, three times the risk of hypertension and metabolic syndrome, than the general population. In people with Learning Disabilities gastrointestinal cancers are approximately twice as prevalent, coronary heart disease is the second highest cause of death and approximately 70% of people with a learning disability experience gastrointestinal disorder.
It is important to understand that a change in a person’s normal presentation whatever that may be should trigger physical health checks alongside any checks that would be done for their mental health or Learning Disability. The ABCDE approach is, as you will read a systematic approach to gather information about your patient when their condition is deteriorating – when there has been a change no matter what that change may be, assessing their physical health will ensure that there is no delay to, or inadequate treatment given.
References and further reading
Death by indifference
Confidential Inquiry into premature deaths of people with learning disabilities (CIPOLD)
https://www.bristol.ac.uk/media-library/sites/cipold/migrated/documents/fullfinalreport.pdf
Improving physical healthcare for people living with severe mental illness (SMI) in primary care
Overshadowing and Other Challenges Involved in the Diagnostic Process of Patients with Mental Illness Who Present in Emergency Departments with Physical Symptoms – A Qualitative Study Shefer, G., Henderson, C., Howard, L., Murray, J., & Thornicroft, G. (2014).
https://doi.org/10.1371/journal.pone.0111682
Health inequalities and people with learning disabilities in the UK. Emerson, E., & Baines, S. (2011).
https://doi.org/10.5042/tldr.2011.0008
Improving the physical health of people with mental health problems
Clinical assessment of Black Asian and Minority Ethnic (BAME) skin
Recognising clinical signs such as cyanosis and pallor in BAME skin is not the same as recognising these signs in white skin, therefore creating issues when conducting a comprehensive ABCDE assessment. Although noted in many articles, the lack of examples and particularly pictures of black Asian and minority ethnic skin in clinical education has not been rectified until recently.
A recent example of this is discussed by Lynch 2020 whilst exploring the prevalence of Covid in the BAME community stating, there is a failure in clinical education to visually show a variety of presentations and clinical signs seen in all ethnicities. Concluding that If clinicians cannot identify these signs, unwell patients will not be appropriately treated leading to increased morbidity and mortality in the BAME population.
In August 2020 medical student Malone Mukwende concurred, stating “If the doctors of tomorrow are better equipped to deal with how signs and symptoms present on black and brown skin, this will improve patient care and reduce the healthcare disparities that exist today.” Wanting to rectify this he worked with, Senior Lecturer in Diversity and Medical Education, Margot Turner, and Clinical Lecturerin Clinical Skills, Dr Peter Tamony from St Georges University of London and developed the Mind the Gap handbook, which shows pictures of cyanosis, pallor, rashes etc on BAME skin. The handbook that will grow and develop over time as clinicians share their work and observations.
Please click onto the links below that will take you to the handbook itself and the website linked to further versions.
https://ndownloader.figstatic.com/files/24163535
https://www.blackandbrownskin.co.uk/
References
Lynch, C. (2020). Diversifying medical school education to represent BAME backgrounds. BMJ, 370, m2745–. https://doi.org/10.1136/bmj.m2745
This chapter will discuss why and how this occurs and the important role that you can play in ensuring that patient deterioration is recognised and managed confidently and competently.
Patient safety
Patient safety
Our top priority should always be to ensure patient safety and that we do everything to prevent avoidable harm and death. It is estimated that through improving understanding and capability around patient safety, harm could be reduced by 2%, 200 lives and £20 million could be saved per year (NHS England and NHS Improvement, 2019). The Darzi report (Department of Health 2008a) set the direction of the NHS by recommending that quality and patient safety needed to be at the heart of patient care.
Patient safety has taken on a new sense of urgency post Francis Report (2013) and the more recent Keogh report (2013). Both of these reports highlight the lasting physical and emotional damage that healthcare providers can cause to patients and their families when mistakes are made and quality is compromised.
“The simplest definition of patient safety is the prevention of errors and adverse effects to patients associated with health care.” (World Health Organisation, 2020).
A failure to recognise patient deterioration or respond appropriately to a deteriorating is a patient safety issue. Patient deterioration is one of the areas in which the NHS is focussing efforts to improve safety and this is a complex and continuous process, as illustrated in the diagram below. Creating robust patient safety systems and a healthy patient safety culture will contribute to improving overall patient safety (NHS England and NHS Improvement, 2019).
The National Patient Safety Improvement Programme is a large-scale patient safety initiative set up to support two areas of work, one of which is the prevention of deterioration and sepsis (NHS Improvement 2020).
How effective are we at spotting patients who deteriorate?
How effective are we at spotting patients who deteriorate?
All patients in hospital are at risk of becoming acutely ill, and often it can be the patients we least expect. There is a wealth of evidence from the last two decades that nurses and doctors could do much better in trying to prevent deterioration.
The basic ABCDE of care that all acutely ill patients need such as airway management, high concentration oxygen, fluids has not always been managed well. If a patient receives suboptimal ABCDE management on the ward prior to ICU transfer, the patient has a much poorer chance of survival.
The reports below highlight the importance of effective observation and management in patients that are deteriorating. Take some time to click on the images below to open up and read the reports.
A report by National Confidential Enquiry into Patient Outcome and Death (2005) looks at medical admissions to intensive care. NCEPOD (2005) found that 21 % ICU admissions were thought to be avoidable. The report also found that respiratory rate (a sensitive indicator of deterioration) was not always recorded as part of the patients' observations. In 2007 NCEPOD published Emergency Admissions: A journey in the right direction, which reported that emergency admissions do not always receive adequate clinical observations, both in type and frequency.
A report by NCEPOD in 2012 reviewed the care of patients who underwent CPR as a result of an in-hospital cardiac arrest. This report demonstrated that, despite previous studies and reports highlighting a failure to recognise and respond to deteriorating ward patients, this problem remains a real issue. 75% of patients who experienced cardiac arrest displayed clear signs of deterioration which were either poorly recognised, acted on infrequently or not escalated to more senior doctors promptly. The report summarises that of the patients who experienced cardiac arrest, 64% were predictable due to clinical signs of deterioration being evident. In 38% of cases the cardiac arrest was considered avoidable. Clearly we still need to do much better.
In 2015 NCEPOD reviewed the different aspects of care received by patients with sepsis in and out of hospital. When sepsis is identified and treated early, lives can be saved and patients can have fewer longer-term health implications. Out of the 505 cases reviewed in this study, there was a delay in the identification of sepsis in 36% of patients. The report supports the use of Early Warning Scores which assist practitioners in identifying patients with sepsis earlier. Observations key to identifying sepsis were missed in 39% of cases and delayed in 38% of cases. There was room for improvement in the management and treatment of patients with sepsis in a number of cases.
Why and how do things go wrong...
Why and how do things go wrong...
Studies show that hospital staff may not always understand the changes in physiology that affect the sick patient. Unfortunately “doing the obs” has become a low priority task that is often delegated to more junior staff. Staff may for example accurately chart a low blood pressure and urine output but may not know how to interpret the clinical significance of such observations.
Below you will find a series of reports and guidelines that have been published in response to concerns about the detection and management of deteriorating patients in acute settings. Despite this being a national concern for over a decade, there is still work to be done to improve outcomes for patients (NHS England and NHS Improvement, 2019). We recommend you read the reports which contain valuable information.
This report focused on 107 patients who died in acute hospitals in (2005), where there were concerns about the safety of their care. 64 deaths related to patient deterioration not recognised or acted upon, and 43 deaths related to a problem with resuscitation of patients who had a cardiac arrest.
Deterioration not recognised group: in 30 cases, despite the recording of vital signs it was reported that there was no recognition of clinical deterioration and/or no action taken. In 17 cases deterioration was recognised and assistance sought but it was reported that there was a delay in the patient receiving medical attention. Below are some excerpts from real incident forms in these cases:
"BP 80/50 pulse 120, sats 74%... no further sats done, no action taken until noticed on transfer to ward X. Drs contacted to review. Transferred to ITU, died later same day."
"Patient transferred, handover given. Routine observations showed low oxygen saturations 80% - no oxygen prescribed. No urine output and no information at handover re oxygen or urine output."
Key recommendations
Better recognition of patients at risk of, or who have deteriorated
Appropriate monitoring of vital signs
Accurate interpretation of clinical findings
Calling for help early and ensuring it arrives
Training and skills development in recognition and response to acute illness
Key recommendations
Detecting and responding to patient deterioration is a complex issue and a series of points were identified where the process can sometimes fail:
Not taking observations (e.g. respiratory rate, blood pressure)
Not making basic visual observations (e.g. colour, consciousness level)
Calculating early warning scores incorrectly
Not recognising the early signs of deterioration
Not communicating observations causing concern (e.g. at staff handover, or at transfer between wards)
Not effectively communicating concern to other staff (e.g. medical staff)
Not responding appropriately to reports of deterioration (e.g. medical staff not responding with appropriate urgency)
There were a number of contributing and causal factors which the report identified:
Prioritising competing demands (meals, drug rounds, washes, ward rounds)
Poor verbal and written communication regarding acutely ill patients
Lack of effective team working and leadership
In 2016 NHS Improvement released a report highlighting that the detection and management of acutely ill patients was still a national concern. It is recognised that healthcare staff often fail to detect or act on signs of deterioration and that more work needed to be done at leadership level within organisations to promote positive culture change. 7% of death and severe harm incidents reported to the The National Reporting and Learning System (NRLS) throughout 2015 were linked to a poor recognition or response to deterioration. Organisations are advised to analyse their systems to identify the reasons for observations not being taken and recorded as they should be and to develop strategies at a local level to promote cultural change across all occupational groups.
In 2007 the National Institute for Health and Clinical Excellence (NICE) produced a guideline for the recognition and response to acutely ill adults in hospital. The key messages are listed below.
See Acutely Ill Patients in Hospital Overview (NICE 2020) for a pathway and flow chart based upon this guidance.
Key messages from acutely ill patients in hospital (NICE, 2007):
Routine monitoring use track and trigger systems to monitor patients.
Monitor physiological observations at least every 12 hours unless decided at a senior level to increase or decrease the frequency for an individual patient.
Use multiple parameter systems which use a graded response. The system should:
Define the parameters to be measured and the frequency of observations.
State the parameter which triggers a response
Monitor:
Heart rate
Respiratory rate
Systolic blood pressure
Level of consciousness
Oxygen saturation
Temperature
Consider monitoring:
Biochemistry (lactate, base deficit, blood glucose)
Hourly urine output
Pain
The guideline also recommended that a graded response be used when signs of deterioration are identified in patients. The graded response was initially developed by individual Trusts and varied between different hospitals. All individual track and trigger systems have since been replaced by a national Early Warning Scoring (EWS) system known as NEWS2 (see below for more information).
How can you make a difference?
How can you make a difference?
At its most simple level, monitoring patients (checking them and their health) regularly while they are in hospital, and taking action if they show signs of becoming worse can help avoid serious problems and will improve patient safety.
It starts with the basics of observations. All staff should use physiological track and trigger systems (EWS) whenever a set of observations are carried out and EWS scores should inform decisions if a patient's condition deteriorates.
Ensure that you and all other staff are aware of the graded response to deterioration in use in that particular hospital. This will include agency staff.
If you delegate this task (observations) then make sure that the staff who do the 'obs' have had appropriate training in how to interpret them.
NEWS2
NEWS2
A National Early Warning Scoring (NEWS) system was identified as essential as variation in the local approaches led to inconsistencies in response, particularly when staff move between different hospitals. In 2012 the Royal College of Physicians, with support from the Royal College of Nursing and the National Outreach Forum, developed a single standardised National Early Warning Scoring System (NEWS). NEWS2 superseded the original scoring system in 2017 and has been formally endorsed by NHS England and NHS Improvement leading to adoption of the system by all NHS trusts (Royal College of Physicians, 2017).
Remembering your ABC…
Remembering your ABC…
The goals with all acutely ill patients are the same. Maintaining a clear airway, ensuring optimal oxygenation and maintaining adequate blood pressure so that vital organs are perfused. All acutely ill patients require oxygen, IV fluids, monitoring of observations and NEWS2, and senior medical review. The Airway, Breathing, Circulation, Disability, Exposure approach will ensure that you do the right things for the patient in the correct sequence. The use of this approach forms the core of the SMART and other acute care and life support courses such as ALERT™ (Acute Life Threatening Events Recognition and Treatment) or ILS (Immediate Life Support).
Who can you call upon to help?
Who can you call upon to help?
Nearly all hospitals in the UK now have some kind of Critical Care Outreach Team that offer help and support to staff on general wards caring for acutely ill patients. The NEWS2 system will instruct you to call the critical care outreach team if the patient "triggers‟. As well as the Outreach and Hospital at Night (H@N) or Hospital Out Of Hours (HOOH) teams, however, there are others you can call upon if you are concerned about a patient and there is a delay in a doctor attending: bleep a more senior doctor, even if this means bleeping the Consultant.
If you can't contact the patient's own team bleep the on call SpR for Medicine or Surgery to ask for their help and advice. Bleep your Matron or senior manager if there are delays in getting the patient reviewed and they are deteriorating further. If all else fails and the patient is deteriorating rapidly and you feel the patient may be about to have a cardiac arrest call 2222. You don't have to wait until the patient has actually arrested to make the call!
Sometimes you may be concerned about a patient but they are not triggering the NEWS2. This may be more of a gut instinct or intuition you have that something isn't right with that patient. It may be a subtle sign that the patient is quieter or sleepier than usual.
Don't ignore your gut instincts or concerns, report them to the nurse in charge, call the Outreach Team or H@N or HOOH team and increase the frequency of the patients observations as well as remembering to pass your concerns on to the next shift when you go off duty.
Hospital at Night
Hospital at Night
Many hospitals have H@N or HOOH teams. One of the aims of H@N is to improve the handover of patients from the day team to the night team and back again to the day team. With the old system of handover, sick or at risk patients were not always identified or handed over when the day team went home. H@N brings all the night team together (doctors, Night Nurse Practitioners) to a comprehensive handover about all sick patients throughout the hospital site. Night Nurse Practitioners or Night Matrons filter bleeps to medical staff to avoid inappropriate calls. Many of the Night Nurse Practitioners take on elements of the Outreach Nurse role, advising ward staff about deteriorating patients and coordinating a prompt medical review.
Human factors
Human factors
Managing an acutely unwell patient requires a host of skills. As well as being able to interpret observations and clinical signs of deterioration and implement an ABCDE approach, you will also need to use non technical skills. These include communication, team working and situational awareness to optimise your performance and ensure your patients receive high quality care. You will also need to learn how to delegate tasks and roles to your team, to ask for help from senior colleagues (the Matron or bleep holder for your clinical area who can send staff from another ward to help you whilst you have a very sick patient). The SMART course will address these issues. There are also some useful links to training and resources at the end of this chapter that can help you develop team working and leadership skills (see Further Reading section below).
Critical Care Transfers
Critical Care Transfers
One group of hospital patients that are at particularly high risk of deterioration are patients who have been transferred from ICU to the general ward. The NICE (2007) guideline makes some specific recommendations about this group of patients.
Discharge of patients from critical care should be avoided between the hours of 22:00 – 07:00 as transfers during this time have been shown to put patients at increased risk.
A comprehensive handover should take place between critical care and the ward team who will be taking over the patients care.
The handover of care should include:
A summary of the critical care stay including diagnosis and treatment.
A monitoring and investigation plan.
A plan for ongoing treatment including drugs and therapies, nutrition plan, infection status, and any agreed limitations of treatment.
Physical and rehabilitation needs.
Psychological and emotional needs.
Specific communication or language needs.
Staff should offer patients information about their condition and encourage them to participate in decisions that relate to their recovery.
The healthtalk.org website has short films of 'real' patients talking about their experiences of being transferred from ICU to a general ward. Remember this group of patients are at high risk of deterioration and it is often very stressful for them moving from an area where they had one nurse caring for them to a very busy ward where the nurse looking after them may also be caring for another eight patients. Click on these links to listen to some patient experiences:
healthtalk.org - Patient Experience - High Dependency Units
healthtalk.org - Patient Experience - The General Ward - Care and Environment
Summary
Summary
The way you approach observations, the way you communicate and lead your team can all make a difference to patients who deteriorate.
Learning should be life-long and hopefully in the future you will build on the knowledge and skills you will gain on the SMART course by attending other relevant courses, ILS or Care of the Sick Ward Patient courses that are ran by many critical care outreach teams.
References
References
Department of Health (2008a) Darzi Report - Next stage review. The Stationary Office, London.
Department of Health (2008b) Competencies for Recognising and Responding to Acutely ill Patients in Hospital. Retrieved from https://www.norf.org.uk/Resources/Documents/Resources%20documents/competencies%20AIP%20doh.pdf
Francis, R (2013) Report of the Mid-Staffordshire NHS foundation Trust Public Enquiry. Executive summary. The Stationary Office, London.
Keogh, B (2013) Review into the quality of care and treatment provided by 14 hospital trusts in England. Overview report. NHS England, London.
National Confidential Enquiry into Patient Outcome and Death (2015) Just Say Sepsis! NCEPOD, London.
National Confidential Enquiry into Patient Outcome and Death (2012) A Time to Intervene? NCEPOD, London.
National Confidential Enquiry into Patient Outcome and Death (2007) Emergency Admissions: A journey in the right direction? NCEPOD, London.
National Confidential Enquiry into Patient Outcome and Death (2005) An Acute Problem. NCEPOD, London.
National Institute for Health and Clinical Excellence (2020) Acutely ill patients in hospital overview. Retrieved from https://pathways.nice.org.uk/pathways/acutely-ill-patients-in-hospital
National Institute for Health and Clinical Excellence (2007) Recognition and response to acute illness in adults in hospital. NICE Quality Standard No. CG50. Retrieved from https://www.nice.org.uk/Guidance/CG50
NHS England and NHS Improvement (2019) The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients. NHS Improvement Publication Code: CG43/19. Publication approval reference: 000717. Retrieved from https://improvement.nhs.uk/documents/5472/190708_Patient_Safety_Strategy_for_website_v4.pdf
NHS Improvement (2020) The National Patient Safety Improvement Programmes. Retrieved from https://improvement.nhs.uk/resources/patient-safety-improvement-programmes/#h2-national-patient-safety-improvement-programme
NHS Improvement (2016) The adult patient who is deteriorating: sharing learning from literature, incident reports and root cause analysis investigations. IG 17/16. London, NHS Improvement.
National Patient Safety Agency (2007a) Safer care for the acutely ill patient. London, NPSA.
National Patient Safety Agency (2007b) Recognising and responding appropriately to early signs of deterioration in hospitalised patients. London, NPSA.
Royal College of Physicians (2017) National Early Warning Score (NEWS) 2. Retrieved from https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2
World Health Organisation (2020) Patient safety. Retrieved from http://www.euro.who.int/en/health-topics/Health-systems/patient-safety/patient-safety
Further reading
Further reading
Page updated
Report abuse