Almost every hospital in the UK uses the National Early Warning Score (NEWS) to record patients' vital signs (blood pressure, temperature, heart rate, breathing rate and oxygen levels). The NEWS system applies a new score every time a patient's vital signs are checked. Patients with higher scores are more unwell. All patients should have their vital signs checked at least every 12 hours. The early warning score system recommends patients with higher scores have their vital signs measured more often. This is so that patients can be treated quickly if they show signs of becoming more unwell. There are no formal guidelines for how long gaps should be between measurements of vital signs. Most hospitals have local policies that range between every half an hour for those at highest risk to every 4-6 hours for patients with a score that suggests they are at low risk of getting worse unexpectedly.
The Universities of Portsmouth, Southampton, and Oxford are working with the local NHS Trusts in Portsmouth and Oxford to look at ideal intervals for monitoring patients' vital signs when they are in hospital. The full title is "safer and more efficient vital signs monitoring to identify the deteriorating patient: An observational study towards deriving evidence-based protocols for patient surveillance on the general hospital ward" project. We call it 'Frequency of Observations' - "FOBS" for short. The project is funded by the Health Services and Delivery Research stream of the NIHR. You can read the project summary here but briefly we are looking for the best evidence to support how often patients should be monitored when they are in hospital.
The FOBS project team is using anonymised hospital records to create a timeline of early warning scores for individual patients. We will link these data to treatments and diagnoses, and will show when it was first possible to recognise that their health was getting worse. We will use this information to identify common trends for different types of patients and will propose the most efficient ways to pick up new problems that need urgent treatment.
We have spoken to patients, their relatives and carers, and staff working on hospital wards to find out how much people know about the NEWS system, and to understand their experiences. From these discussions we have learned that patients are surprised that there isn't much evidence behind the decisions made by healthcare staff when they decide how often vital signs are measured. We have also learned that although healthcare staff understand that the intent of the NEWS system is to offer individualised monitoring, and that they want to provide this level of care for their patients, they usually take vital signs measures during pre-planned 'observations rounds' that occur at set times each day. Patients and staff have also told us that other things happen when vital signs are checked. We know that some patients will ‘save up’ requests for things like a cup of tea, or will use the time to ask questions about their care. Both patients and staff told us that they value these ad-hoc opportunities to talk to each other. Almost everyone we spoke to was worried that these opportunities would be lost as part of changes to how often vital signs are recorded.
This understanding highlights two problems that are relevant to the processes behind the NEWS system of taking vital signs measurements in hospital. The first is practical. There are only so many hours in each day, and only so many nurses and healthcare assistants available. Everyone is constantly juggling several ongoing tasks and on a busy ward there are always urgent interruptions that need to be dealt with. Even on a small ward of just half a dozen patients, if each patient needed their next measurements to be taken at a different time this could lead to confusion very quickly and it is possible that someone would be forgotten. There is much that a standardised process can offer by way of efficiency and safety. The second point is that patients believe that everything that happens to them in hospital is "necessary". This means that they are willing to be woken up several times overnight, even though they would much rather be allowed to sleep, because they believe it is needed. Any conversation about timing of their next observation will be guided by the implicit understanding that the recommendation is correct. It is unlikely that the majority of patients, in the UK at least, will refuse what they believe to be 'advised care'.
The FOBS project could therefore also begin to address a wider point that relates to healthcare provision, that is the concept of shared decision making and the degree to which patients can be active in their own care. Most of the patients, relatives, and carers who we have spoken to said they were keen to be involved in decisions about their care. They said they wanted to be included in the conversation about when they would next have their vital signs checked, especially if the NEWS system recommendation would disturb their sleep. The nurses and allied health professionals we have spoken to were also keen to include their patients in these discussions, and were enthusiastic about using their own clinical judgment when advising patients. However, both groups also told us that these discussions are difficult to have at the moment because the evidence is lacking.
The aim of the FOBS project is to provide robust evidence to support decisions about frequency of monitoring. The team will use the information gathered from patients, relatives, carers, and healthcare staff to test shorter and longer intervals between measurements on the anonymous patient records to see which offer the best options for efficiency and safety. We will include views from patients and healthcare staff to help develop different schedules that could be used in hospitals with different groups of patients, depending on their risk of deterioration. This will make sure that those who will be affected by changes to vital signs collection are happy with the new schedules, and think they could be used in hospital.
Julie Darbyshire
January 2021