Stopping needless deaths in hospital

Every year, thousands of NHS patients suffer unintended harm from their treatment in hospital and many of them die needlessly from medical errors.

The National Confidential Enquiry into Patient Outcomes and Death has found that the patients who didn’t survive often showed signs that their condition was deteriorating long before they died. It has recommended that hospitals should pay more attention to physiological signs of decline, put in place ‘track and trigger systems’ for all patients and link this to a response team skilled in managing acute clinical problems.

Through its Safer Patients Initiative, The Health Foundation is supporting 24 hospitals across the UK to improve patient safety. The hospitals are aiming to reduce their number of adverse events by a minimum of 30 per cent. Their methods include putting in place track and trigger systems and rapid response teams, who will move in at the first signs of patient deterioration. One of the first sites to join the scheme, Luton and Dunstable Hospital NHS Foundation Trust, is now beginning to see the results from this work.

Saving lives

Luton and Dunstable has been a Safer Patient Initiative site since 2004. Reducing the hospital’s mortality rate was a priority for Chief Executive Stephen Ramsden, who believes that saving patient lives must be at the top of all chief executives’ agendas.

“As accountable officers we should be deeply concerned about the avoidable deaths happening weekly in our own hospital,” Stephen says. “There should be nothing more important to a CEO than saving lives and demonstrating their staff they are interested in this.”

To reduce avoidable deaths at Luton and Dunstable, the patient safety team brought three key elements together: an analysis of deaths through case note reviews using trigger tools, the development of an early warning scoring system and a rapid response team to attend failing patients.

The Luton and Dunstable team, led by medical director John Pickles, consultant anaesthetist Michael Carter, and patient safety mangers Jane Murkin and Anne Thomson, started off by examining patient records. The team examined patient records and reviewed 50 consecutive deceased patient records. The study highlighted a number of problems with patient observations – the respiratory rate was often missing and observations were often incomplete, absent or infrequent.

The accurate and timely measurement, recording and interpretation of patient observations is essential to identifying deterioration. A patient’s respiratory rate is the most sensitive observation and can give warning of deterioration long before other measures such as blood pressure and temperature begin to fluctuate.

“It was apparent that almost no respiratory observations were being done,” Michael Carter explains. “We concluded that the respiratory rate had lost emphasis in training, due to developments such as dinamaps and pulse oximeters. Because of this, wrong assumptions have crept into medical and nursing practice.”

The team set about reintroducing this ‘lost’ skill and delivered cascade training to nursing staff in respiratory rate skills. At the same time as observation skills were refreshed, an Early Warning Score system was introduced to record observations, highlight when these signaled that a patient’s condition was in decline and trigger a response.

Colour coded warnings

The Early Warning Score system used by Luton and Dunstable is a colour banded card that removes the need for a score to be calculated. The information is explicit – if the patient’s condition is in decline, scores fall into red or yellow boxes. If two yellow, or one red box, are filled, the nurse must take action and respond to the patient’s condition. 

Nurses can also call for assistance if they think the patient is showing signs of deterioration, even though they haven’t triggered a yellow or red score on the chart. “The first response can be informing the senior nurse on the ward,” Anne Thomson comments. “But if he or she can’t address the issues, the nurse must get a doctor to attend the patient within thirty minutes. If they can’t, then they call the outreach team.”

A communication tool has also been introduced to help nurses deliver information effectively to busy clinical staff who may not appreciate the importance of the call. The Situation – Background - Assessment – Recommendation (SBAR) tool was developed by Kaiser Permanente in the US. It acts as a reminder to the nurse to describe the situation, background, assessment and recommendation and give essential information. It also gives the nurses confidence in their judgment to call for medical assistance and helps them be more assertive in requesting an immediate response if one is needed.

The final part of the jigsaw was to put in place a rapid response team. At Luton and Dunstable, this is called a critical care outreach team. “We now have a team of three critical care nursing staff who can be paged and have a dedicated phone line. We can either call them to assist on the ward or to give support to ward staff in delivering the appropriate care,” Anne says.

The service also delivers education to staff, advice and a follow up service for patients who’ve been discharged from the Intensive Care Unit back to the wards. “‘Getting the team onto the wards to offer their services has helped win hearts and minds in getting the system accepted,” Anne continues. “The team has become so valued by clinical and nursing staff that the decision has been taken to provide the service 24 hours a day, 7 days a week.”

Small changes, big impact

Luton and Dunstable has seen a significant reduction in cardiac arrests since introducing the Early Warning Score system and critical care outreach. Cardiac arrests have fallen by 1.5 per week since baseline measures were taken and this change has remained steady. The fall in cardiac arrests has also had an impact on the site’s Hospital Standardised Mortality Ratio, which has shown a decline of 10 per cent since 2003.

“We’ve measured cardiac arrest calls weekly and plotted with statistical process control methodology,” John Pickles comments. “We found that the mean number of cardiac arrests fell after the introduction of the Early Warning Score system and outreach team, and then fell again when we extended the outreach service to 24 hours.”

By using the Early Warning Score system and outreach together, it’s possible to reduce avoidable deaths in hospital. New guidelines by the National Institute for Clinical Excellence, ‘Acutely ill patients in hospital’ were published last month. These outline a partial care pathway based on ‘track and trigger’ systems for patients showing signs of deterioration.

The National Patient Safety Agency has also analysed all incident reports resulting in death from the National Reporting and Learning System. Its report, ‘Safer care for the acutely ill patient’ confirms that “deterioration not recognised, not acted on” is the root cause for many needless deaths in acute care.

The NHS Institute for Innovation and Improvement estimates that if all hospitals took steps to reduce their mortality and achieved a reduction in mortality rates of 10 per cent, like Luton and Dunstable has done, then 10,000 patient lives would be saved every year in England alone.

“From our experience, the biggest gain has been the combination of critical care outreach with our improved early warning system and improved basic observations,” Stephen Ramsden says. “Together, we think these three things have reduced our mortality rates.”

“Luton and Dunstable hospital has shown that, using tools like the Early Warning Scorecard, we can save patients’ lives by making it easier for staff to assess when a patient's condition is getting worse and take action,” The Health Foundation’s Assistant Director Gill Hastings comments. “The 24 sites involved in our Safer Patients Initiative are all trialling approaches like this and we expect to see even more dramatic progress in the months and years to come.”