Training HCAs to recognise patient deterioration
Healthcare assistants have a vital role in recognising patient deterioration, but may lack the relevant skills. A tailored training programme can provide these
In this article…
- Why recognising deterioration is important
- The content of training for healthcare assistants
- Follow-up assessment on wards
David Watson is senior charge nurse in emergency care/hospital emergency care team; Martin Carberry is consultant nurse critical care; both at NHS Lanarkshire.
Watson D, Carberry M (2014) Training HCAs to recognise patient deterioration. Nursing Times; 110: online issue.
The role of the healthcare assistant/support worker has developed in recent years to support the changing demands of healthcare, particularly in relation to the recording of vital signs and patient assessment. A Scottish health board has created a course to develop these workers’ patient assessment skills to improve the detection of deterioration in ward patients. To date, 280 have completed the course, the vast majority achieving follow-up clinical competency. The course has been well received, although its effect on patient safety has yet to be investigated.
Healthcare assistants (HCAs), known as healthcare support workers (HSWs) in Scotland, are now the primary presence at the patient bedside, which puts them in an ideal position to identify clinical deterioration early. However, they may lack the assessment skills needed to pick up the signs. NHS Lanarkshire therefore developed the Clinical Support Workers Assessment Support and Help (CRASH) course for its HSWs.
- This article has been double-blind peer reviewed
- Figures and tables can be seen in the attached print-friendly PDF file of the complete article in the ‘Files’ section of this page
5 key points
- The Scottish Patient Safety Programme aims to reduce inpatient cardiac arrests by 50% by the end of 2015
- National confidential enquiry data shows that clinical signs of deterioration are often missed, misinterpreted or mismanaged
- One study found that 71% of support workers had cared for critically ill patients in the previous month
- Checking respiratory rate and pulse for a minute is a highly sensitive way to detect deterioration
- The SBAR tool supports communication about deteriorating patients
Rationale for the course
The Scottish Patient Safety Programme has a deteriorating patient national workstream, which aims to reduce inpatient cardiac arrests by 50% by the end of December 2015 (Scottish Patient Safety Programme, 2013) by improving the recognition, communication and escalation of the deteriorating patient.
Evidence from the National Confidential Enquiry into Patient Outcome and Death revealed that clinical signs of deterioration are often missed, misinterpreted or mismanaged (NCEPOD, 2012). Its retrospective review of 462 inpatient cardiac arrests over a one-month period in England, Wales and Northern Ireland found that 75% showed signs of clinical deterioration before the event.
The Modified Early Warning Score (MEWS) was introduced in NHS Lanarkshire in 2002 (Carberry, 2002) to provide a physiological score that should trigger a response to clinical deterioration.
Traditionally, nurses have recorded vital signs and calculated MEWS; however, this has been devolved to HCAs/HSWs. James et al (2010), in their exploratory study of these workers, found that 71% of respondents had been involved in caring for critically ill patients within the previous month, and 45% reported that they had dealings with critically ill patients on a regular basis. Mosley et al (2007) identified that 82% of 96 HCAs/HSWs studied had never received training in acute illness.
This apparent gap highlighted in the literature, the clinical demand within our organisation, and the national safety agenda provided the impetus for the CRASH initiative.
The CRASH course was developed and led and is facilitated by nurses, as advocated in the Cavendish report (Department of Health, 2013), which recommended that the profession should take ownership of the HCA/HSW role. The hospital emergency care team (HECT), the health board’s hospital at night team, developed the course, which aims to:
- Provide evidence of ABCDE assessment and competence;
- Identify clinical deterioration early in ward-based patients;
- Carry out a simple, concise systematic ABCDE assessment;
- Recognise when there is a need to get help;
- Communicate concerns to nurses.
In NHS Lanarkshire, many HSWs have undertaken a “vital signs” course in recording patient observations. The CRASH course encourages them to carry out these observations within the context of an ABCDE assessment, which is a simple, effective method of identifying life-threatening events (Thim, 2012; Allen, 2004).
The core content of the course is outlined in Table 1; the course takes a blended learning approach, mixing theoretical and practical methods. This approach was implemented effectively by Colfar et al (2013) in their skills development pathway for HCAs, which incorporated scenario-based interactive learning to help deliver key messages.
During the ABCDE lecture, HSWs are required to count a colleague’s respiratory rate and feel a manual pulse for a full minute, as these observations are highly sensitive in identifying the sick patient (Jansen and Cuthbertson, 2010). The relatively small numbers attending each course (15-20) encourages interaction within the lecture and, more importantly, incorporates the core principles of the ABCDE assessment in a hands-on approach.
After the ABCDE assessment lecture, participants are split into small groups for MEWS workshops. They are required to identify errors or inconsistencies in a number of MEWS charts anonymised from real-life scenarios; relating the process to the real clinical situations is intended to improve knowledge retention. To further promote accuracy and competence, participants are then required to complete the MEWS charts for each scenario to demonstrate good practice.
The communication workshop explores barriers to effective communication, drawing on HSWs’ own experiences. These lived experiences are vital to achieving the objectives of the workshop and are used to facilitate discussion of how to overcome these obstacles in everyday situations. The participants are introduced to the Situation, Background, Assessment and Recommendation (SBAR) communication tool as a means to facilitate effective communication (NHS Institute for Innovation and Improvement, 2008). Christie and Robinson (2009) champion the use of a tool such as SBAR to help improve patient outcomes.
The course includes a video showing an accurate ABCDE assessment and summarising the SBAR technique. This is used to demonstrate what is expected of participants in the simulated scenarios that follow. All CRASH participants have access to the video after the course to consolidate their learning.
Participants are required to rotate through five scenarios, undertaking patient assessments, calculating and documenting MEWS, and communicating using the SBAR approach. During these scenarios, a “look, listen and feel” approach is emphasised, rather than the use of machines to record clinical observations. James et al (2010) identified that 54% of HCAs/HSWs identified the use of touch as important in patient assessment. The simulated scenarios give participants the opportunity to assess for clinical signs of deterioration such as changes in posture, consciousness level and capillary refill time in a safe environment (Akers, 2014).
Participants are continuously assessed throughout the course in relation to competency, contribution to discussions during the workshops and scenario participation - a practice advocated by the Resuscitation Council UK (2011). Their competence is further assessed in their workplace; a competency checklist is used to guide and support them when carrying out ABCDE assessments at the patient’s bedside.
This follow-up assessment is key to the fundamental rationale of the CRASH course, which is to improve and sustain the quality and consistency of clinical assessment in the ward area. IT is used to support the HSWs in their own clinical areas and provide an opportunity to clarify any points covered on the course that participants may not have understood.
A member of the HECT skilled in the ABCDE approach conducts this assessment; to date, only three HSWs have failed to achieve clinical competency. The HECT nurse provides a structured support mechanism to enable senior charge nurses to facilitate the HSWs’ continued learning and ongoing assessment; the senior charge nurse is responsible for continuing assessment of the HSWs’ clinical competency on a yearly basis.
To support ongoing competence and continuing assessment, the HECT has developed a CRASH course booklet. This booklet is given to all CRASH course participants and acts as a point of reference and study guide, reinforcing best clinical practice by outlining the observational policy in the form of a schematic diagram. The booklet is available in hard copy and on the organisation’s intranet. It is also applicable to nurses and student nurses.
Participant course evaluation
The CRASH course is one of a number of clinical initiatives that contribute to wider efforts to improve safety led by the Scottish Patient Safety Programme - in this case, the national deteriorating patient workstream (SPSP, 2013).
Outcome measures for this workstream include a 50% reduction in cardiopulmonary resuscitation attempts in general wards in NHS Scotland by December 2015 (SPSP, 2013). NHS Lanarkshire reports a number of process measures that contribute to the reduction in cardiac arrests; these include the reliability of MEWS recording, and the continued clinical assessment of HSWs after taking the CRASH course. The cardiac arrest count has shown a downward trend since 2012.
At present 160 HSWs have completed the course. Their evaluations are ascertained by means of a structured questionnaire completed immediately after the course. All evaluations have been favourable and are summarised in Fig 1.
Ninety-seven per cent of attendees (n=155) reported that the course was useful while 89% (n=142) thought that it covered appropriate topics. The group work used throughout the course was well reviewed by 93% (n=149). Participants reported in the free text section of the questionnaire that the simulated scenarios were of considerable benefit, with many saying these were a new experience for them. In summary, the CRASH course to date has been well received and evaluations suggest attendees would recommend it to their hospital colleagues.
While the evaluations are encouraging, a more robust evaluation in the form of a mixed methods research study is under way. The purpose of this is to identify if attendance at the CRASH course actually improves the HSW’s perception of their role in the recognition and communication of the deteriorating patient.
The CRASH course can be used as a potential means of improving safety in wards, specifically in the assessment, documentation and escalation of the deteriorating patient.
The teaching methods used, including group work and simulation, appear to be appropriate and well received as was the course length of one half day. These are important considerations when staff have to be released from clinical areas.
CRASH could be used to support a wider multidisciplinary group of staff such as allied health professionals, student nurses and newly qualified staff. It is
worth noting and exploring the value of CRASH in promoting interdisciplinary working and integration and teamworking in wards.
For participants who excel on the course, the organisation now needs to look at how to develop their ability further to help in the recognition and management of the acutely unwell adult. The development of a course for both HSWs and nurses is being reviewed within the organisation.
Although training courses and follow-up after the courses are in place, the importance of the role of the senior charge nurse in each area cannot be overemphasised. The senior charge nurse is pivotal to improving the detection of clinical deterioration within their ward area and, importantly, in the supervision and the long-term support of staff after they have taken the CRASH course.
HSWs at NHS Lanarkshire play a key role in the early identification of the deteriorating patient and the timely communication of that deterioration to facilitate early interventions.
To help them to fulfil this role, the CRASH course uses a variety of teaching techniques to train them in ABCDE assessment, accurate MEWS recording and communication of patient deterioration. The course appears to have been well received by the HSWs; however, more in-depth evaluation is needed and its effect on patient safety has yet to be investigated. Following independent review from other health boards, CRASH has since been adopted by one Scottish and one English Health board, with others expressing interest.
Akers E (2014) Simulation learning in nurse education. in: Blended Learning in Practice. University of Hertfordshire.
Allen K (2004) Recognising and managing adult patients who are critically sick. Nursing Times; 100: 35, 34-37.
Carberry M (2002) Implementing the modified early warning system: our experiences. Nursing in Critical Care; 7: 5, 220-226.
Christie P, Robinson H (2009) Using a communication framework at handover to boost patient outcomes. Nursing Times; 105: 47, 13-15.
Colfar S et al (2013) A skills development pathway for HCAs. Nursing Times; 109: 21, 20-21.
Department of Health (2013) The Cavendish Review. An Independent Review into Healthcare Assistants and Support Workers in the NHS and Social Care Settings.
James J et al (2010) Vital signs for vital people: an exploratory study into the role of the healthcare assistant in recognising, recording and responding to the acutely ill patient in the general ward setting. Journal of Nursing Management; 18: 5, 548-555.
Jansen J, Cuthbertson B (2010) Detecting critical illness outside the ICU: the role of track and trigger systems. Current Opinion in Critical Care; 16: 3, 184-190.
National Confidential Enquiry into Patient Outcome and Death (2012) Cardiac Arrest Procedures: Time to Intervene? www.ncepod.org.uk/2012cap.htm
NHS Institute for Innovation and Improvement (2008) Quality and Service Improvement Tools, SBAR: Situation-Background-Assessment-Recommendation.
Resuscitation Council UK (2011) Advanced Life Support Course. Fact Sheet.
Scottish Patient Safety Programme (2013) Deteriorating Patient.
Thim T et al (2012) Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. International Journal of General Medicine; 5: 117-121.