Trusts fail to use early warning systems to identify deteriorating patients
Hospitals are not using early warning systems to identify deteriorating patients, despite evidence they can help reduce hospital death rates.
The National Patient Safety Agency recommends the scoring systems - which are used alongside patient observations - are used for all patients on acute wards.
The early warning score is something that has made a massive difference
But only 52% of acute ward nurses taking part in Nursing Times’s patient observation survey said nurses on their ward “always” used the alert systems and 15% said they were used “rarely” or “never”.
That is despite growing evidence the scoring systems can help reduce hospital mortality rates.
Exclusive analysis by Nursing Times of data collected for the Dr Foster Hospital Guide suggests there is a link between hospitals’ use of early warning systems and the number of preventable deaths after surgery.
The new “deaths after surgery” measure in the 2010 guide is based on incidents where a patient has died after a “failure to rescue”.
It includes patients who died with a secondary diagnosis such as internal bleeding, pneumonia or a blood clot.
The measure is thought to be nurse sensitive as it highlights cases where patients have deteriorated while being cared for on wards.
Nursing Times’s analysis shows that hospital trusts where 100% of acute patients had warning systems in place had a failure to rescue rate 3% below the NHS England average.
But, in hospitals where fewer than six out of 10 patients had the systems in place, the death after surgery rate was 24% higher than average.
- 10 - Number of trusts in our sample of 140 that used early warning systems for fewer than 60% of acute patients
- 8% - Respondents who said procedures for acting on signs of deterioration were followed “rarely” or “never”
- 87 - Number of trusts where all acute patients had early warning systems in place
- 18% - Proportion of respondents who were not confident staff knew what to do when signs indicated a patient was deteriorating
Chelsea and Westminster Hospital Foundation Trust was one of two trusts that performed well on the failure to rescue measure.
Clinical nurse lead for surgery and medicine at the trust Holly Ashforth told Nursing Times that failure to rescue depended on a number of factors and that early warning systems gave ward staff confidence to flag up deterioration.
She said: “The early warning score is something that has made a massive difference.”
Head of the Florence Nightingale School of Nursing and Midwifery at King’s College Anne Marie Rafferty said the failure to rescue rate was “a good measure of the efficiency and effectiveness of a system to pull a patient back from a situation of danger”.
She said that it was a “very sensitive indicator for the quality of nursing observations” but “it is not just the individual nurse, it is the environment”.
Professor Rafferty said that the use of warning systems could indicate a ward that was concerned with safety in general and that the systems on their own would not necessarily make patients safe.
University Hospitals Birmingham Foundation Trust was one of four trusts with a “higher than expected” failure to rescue rate, according to Dr Foster.
Trust medical director Dave Rosser said: “The methodology for reaching their hypothetical figure is fundamentally flawed and misleading to the public.”
He said that certain patient groups had been wrongly included when the rate was calculated, which meant the trust scored worse than it otherwise would have.
Research by the National Nursing Research Unit says concerns that clinical coding skews the failure to rescue measure are unfounded. But warns against direct comparison between trusts.
The unit’s director Peter Griffiths, professor of health services research at the University of Southampton, said the traditional mortality rate metric primarily reflected the underlying conditions patients had when they were admitted.
He said the failure to rescue measure was an improvement on that measure because it focused specifically on conditions that were sensitive to the quality of hospital care.
His research found the failure to rescue metric reflected a number of factors, including levels of clinical staff.
“It is more about the culture, the systems that are in place and how teams work together,” he said.
Failure to rescue
Hospitals’ failure to rescue figures were published for the first time last year, by health analysis firm Dr Foster.
The indicator - also known as death after surgery, or death among patients with treatable complications - attempts to use routine hospital data to measure the quality of care for patients who are at a high risk of deterioration and death.
Deaths among this group of patients can, more often than among other patients, be avoided by good systems to identify and respond to deterioration following an operation - all linked to nursing.
The indicator is thought to be a better reflection of the quality of nursing care than many others, and is relatively easily produced by analysts.
It means the NHS is a step closer to routine measures that could be produced and used to either condemn or praise nurses about their skills and performance. Such measures could also be used by patients to decide which hospital to attend.
- View related practice articles from this issue: ‘Can adapted EWS improve response to deterioration?’, ‘Early warning scores: effective use’, and ‘Simulation: can it eliminate failure to rescue?’