Ignoring warning signs is 'criminal'

12 January 2010 | By Clare Lomas

Nurses who “actively choose” not to use early warning scores to spot deteriorating patients should face disciplinary action, the senior nurse lead for a new patient safety campaign has told Nursing Times.

Royal Devon and Exeter Foundation Trust director of nursing and patient care Marie-Noelle Orzel, who is the deterioration intervention lead for the campaign Patient Safety First, said the risk assessment tool should become a routine requirement in appropriate clinical settings.

Ms Orzel said trusts should make it clear in policies and guidance that the use of early warning scores - in which a patient’s vital signs are measured and given a score to reflect the stability of their condition - is not optional. Not using them is “almost criminal”, she said.

“Trusts should offer extra training and supervised practice, but this is a patient safety issue and nurses who actively choose not to use [early warning scores] should be held to account in the same way as if they choose not to check a drug properly,” she said.

A spokesperson for the NMC said it is not their place to admonish nurses who refuse to follow hospital policy, but in line with the NMC code of conduct nurses must “act without delay if they believe they or a colleague may be putting some one at risk”.

The Care Quality Commission said that if it suspected an NHS organization was not compliant with certain regulations it might ask how it was monitoring risk for individual patients. “Early warning scores may be one of a number of tools that might be used to help demonstrate compliance of the regulations.”

Ms Orzel was speaking to Nursing Times ahead of the launch of the “count your calls” initiative to encourage acute trusts to count the number of cardiac arrest calls and gather information to help reduce the number of in-hospital cardiac arrests and deaths (see box).

The National Patient Safety Agency’s head of NHS and patient engagement Kate Beaumont said the majority of in-hospital cardiac arrests are avoidable.

“A cardiac arrest is the last outcome we want when a patient deteriorates and there is no acceptable rate of preventable cardiac arrests,” she said. “Observing, recognising and responding to deterioration can all help prevent an arrest occurring.”

Ms Beaumont said the goal of the campaign is to get trusts to use the data from “count your calls” to look more closely at what is happening at their trust, and how it can be used to help target training, education and resources.

The five steps to ‘Count your calls’ are:
· Where are your cardiac arrest calls or cardiac arrests coming from? This helps to identify potential ‘hotspots’ within the hospital that need targeted work.
· When are your cardiac arrest calls or cardiac arrests occurring? This will help to identify if there are certain days or times that are a specific problem, for example at night or at the weekend.
· Who are the individual patients needing cardiac arrest calls?Are there particular patientgroups with high levels of calls or deaths associated with cardiac arrest? Identifying and collecting key demographic data helps build a picture of any particular patient groups that are associated with calls.
· What happened? What type of call or cardiac arrest was it? What was the immediateoutcome? This helps to identify the type of cardiac arrest call or type of cardiac arrest and provides data on the immediate outcome.
· Why was a cardiac arrest call required? This helps to determine whether a cardiac arrest call or cardiac arrest is predictable or unpredictable. Potentially predictable calls can be further classified as preventable or unpreventable.

Readers' comments (30)

Andrew Foster | 13-Jan-2010 9:14 am
Yes, yes, yes!!! Iagree with most of this stuff however we should keep in mind what is said-not all cardiac arrests will be prevented therefore there will always be those which are unheralded. There could be an accepted minimum for hospitals of a particular size as a measure to aim for BUT NOT another target to demonstrate to an SHA if NHS Trust are to be self governing.

Not using EWS "almost criminal"? Certainly negligent and a professional failing but not criminal surely. Certainly seems like an autocratuic statement to her nursing staff and an unwanted one within Nursing in my opinion...
Unsuitable or offensive?
Andrew Foster | 13-Jan-2010 9:34 am
I should add that we are already bombarded by assessment form after assessment form to reduce clinical risk so it is little suprise that overworked ward staff are reluctant to use yet another method of assessment.

We should put our nurses in the best position to learn, understand and embrace EWS rather than lambast them for being slow to use it as a worthwhile tool to help assess a patient. That means providing protected teaching (not piecemeal during handover where there are distractions) about these things on induction and in an ongoing basis. Such a supportive/facilitative method may help people feel valued rather than work in fear of litigation.

In that respect, the headline of this article is irresponsible reporting given that it mis represents what Marie-Noelle Orzel says in the body.
Unsuitable or offensive?
Anonymous | 13-Jan-2010 10:33 am
Whilst I agree that we are overwhelmed by paperwork I totally disagree with it being 'another assessment'.
Our EWS scoring is simply added to the bottom of our regular chart therefore it is very clear to see and ALL members of staff measure scoring as easily as breathing themselves!!!
This is now totally embedded in patient assessment
Unsuitable or offensive?
Anonymous | 13-Jan-2010 12:16 pm
And how would this worthy person rate allowing cuts which reduce numbers to a minimum which almost precludes completing such tasks?

That to me really is a crime - but managers kow-tow as they never want to upset someone senior to them.... I have been told I lack 'political awareness' for making this point to the chief exec's face. Actually fully aware that I was destroying my career - but believe someone has to stand up for patients [perhaps the NMC would like to do this?]
Unsuitable or offensive?
Mark Goodfellow | 13-Jan-2010 12:20 pm
Registered staff should be able to interpret basic observations (that include respiratory rate) to detect deterioration without the use of the early warning score. The key word here is basic.

Inability to do this should call their fitness to practice into question as these observations underpin everything else that a nurse may do.

The EWS is the most ridiculously simple score to use, and with practice you can do it automatically. It's a simple premise - if an observation is within normal limits a score of zero is given. Then a score is given depending on how far out of range the observation is. No qualitiative assessment, no variables, no concerns of different people scoring differently.

If nurses had demonstrated an ability to react on observations, this score would not be needed, however countless research points to the fact that it is.

One of the benefits to the EWS is that it gives power to the nurses to get something done when a patient is blatantly deteriorating and they are getting no response from junior doctors (or the junior doctor is failing to respond appropriately).
Unsuitable or offensive?
kathleen white | 13-Jan-2010 12:30 pm
Surely the best tool for patient care is effective training. Research shows that some, so called "Mentors" are not providing the teaching that undergraduate nursing students require. Recent correspondence shows that some qualified nurses are jealous of those who will graduate with a degree,and are prepared to do all in their power to obstruct progress. In other words, an abuse of power that should not be allowed to happen (what's new!!).If Marie-Noelle Orzel adressed corrupt management where it occurs, there would be no need for her autocratic threats. If our bureacratic NHS management structure could be transformed into a learning organization, with peer support and continuous professional development, nurses might be able to use effective tools.
The culture of fear in nursing at Mid Staffordshire NHS Foundation Jan 2005-March 2009,described by RCN G/Secretary,Dr Peter Carter, is not an isolated situation. Unfortunately, this culture is alive and thriving as I write. Perhaps Marie-Noelle Orzel will let readers know what (if anything) she intends to do about this. Join the professional world Marie-Noelle, please!!
Kathleen White Edinburgh.
Unsuitable or offensive?
kathleen white | 13-Jan-2010 2:26 pm
Further to my comment 12.30-13 Jan2009. the EWS is a very practical tool, and I cannot understand why a practitioner would not use it, apart from (all too common) training deficits. It's not rocket science.

Anything that helps with consistency and standardisation of patient care is to be welcomed.

I trained in the 70's. Although the workplace culture was not perfect, we could depend on our colleagues to be professional in providing the highest possible standard of care. And no, I don't have rose-tinted spectacles.

On return to practice after a 10 year child care break in the 90's, I found a professional jealously culture, where support had been replaced by obstruction and a stab in the back mentality.

Being good at one's work automatically invited bullying & intimidation from the top. Good nurses are courageous enough to ask for appropriate levels of staff and other resources. Corrupt Nurse Managers are very effective at "removing" courageous staff ( with the help of Human Resources and a powerful legal team). Their skill in lying & deceiving is breathtaking. Nurses who ask for appropriate tools for providing professional care are not liked in most of today's workplaces. Mediocre colleageus are only too willing to support corrupt managers and are then rewarded with promotion
(often into positions where the cycle can be continued).
When high profile malpractice is made public, professional bodies including the NMC are quick to (quite rightly) ask why practitioners did nothing about it. Well I did speak out in 1999, and was rapidly removed from my Specialist Practitioner post.
The Medical Director, Principle Nurse, Clinical Nurse Manager and HR staff did not want to supply resources that were needed. What did my Union do? The Professional Officer who claimed to be representing me, was in fact working for management ( I discovered this later).

My point is that there is a lot to be adressed before tools like the EWS are used effectively. Nurses will have to learn how to trust & support one another in a professional way.
Kathleen White Edinburgh
Unsuitable or offensive?
Anonymous | 13-Jan-2010 3:10 pm
Education. Education. Education is so important to teach the nurses the warning signs to look for in a deteriorating patient. This should be taught in basic training. These are basics of CPR-the ABC's- Airway, Breathing and Circulation. Nursing is not rocket science. Those nurses that are not using the tool should be taught how to use it. Ignoring it is criminal.
Unsuitable or offensive?
Anonymous | 13-Jan-2010 3:32 pm
criminal? then take issue with the doctor who described a par 5 on the new assessment forms as a zero. It is there to assist in assessment but I can think of a large number of patients who scored a consistently mid-score PAR who didn't go on to have a cardiac arrest.
Unsuitable or offensive?
Anonymous | 13-Jan-2010 4:14 pm
Criminal-what bullying language ,this person ought to be ashamed of herself.
I cannot agree that anyone deliberatly refuses to use the EWS .
Most of us go a little bit extra and use our experiential judgement as well,adding an extra safe guard in monitoring patients stability.
The problems arise when nurses do not use or do not have the required extra dimension.
The criminality lies in th area of too little staff to monitor patients properly and the ineffectiveness of those who are supposed to support staff .
It is all well and good for those not at to sit in judgement of others but they lack a true awarenwss of the situation.
How do they square all this righteous indignation that they have when very often it is left to one trained nurse on a shift to ensure the safety and care of all the patients under her care, a situation that is known and ignored by managment.
A management that is more interested in impressing the regulayors with their buisness acumen (and achieving big bonus' for themselves) than they are in safeguarding patients and their staff.
Unsuitable or offensive?
Anonymous | 13-Jan-2010 4:55 pm
I am just completing a back to nursing course after many years working in a commercial environment outside of nursing. Whilst working in the private sector there was a constant pressure to deliver with reduced resources, to the detriment of our customers and the staff. However, the difference was people's lives were not at stake. I completely agree with the above comment from my experience so far. My studies are telling me what we should be doing as did the health trust induction; what I can actually achieve on the ward is a very different thing. Yes, early warning scores are quick to fill in, and should be used, it would just be nice to have time to see the patient rather than relying on a HCA to tell me their concerns. With so many priorities and directives, what is a nurse supposed to do first? I am equally dismayed by the impact that the media has obviously had on the public, who appear to be focused on complaining about the care their relatives receive; perhaps they should also focus their energies on complaining to the powers that be that the issue is staff shortages not poor quality of staff.
Unsuitable or offensive?
James Fenwick | 13-Jan-2010 7:19 pm
If the qualified / registered nurse was not abstracted completing forms all shift for other people who are clearly too important to fill their own forms the "task" of completing the clinical observations round would not fall to the health care assistant to complete. Conditional changes would then more thn likely be identified sooner. But HCAs cost less don't they.

I don't need a score to tell me if a pt is deteriorating, I find it rather unhelpful. I also work in an environment where the scores are allways high because of the patient group and our interventions. these scores are not helpful in specialist areas.

When does a director of nursing take obs anyhow. These people are dumbing the profession down with these kind of statements I feel.
Unsuitable or offensive?
judith willis | 13-Jan-2010 8:29 pm
Ignoring signs of deterioration in a patient is negligence, no more and no less.

If nurses require early warning scores tools to identify a deteriorating patient then, as previously stated , I would call into question fitness to practice.

Ms Marie-Noelle Orzell HOW did you reach director of nursing level??? You should be supporting your nursing staff and ensuring nurses within your remit receive the necessary training/education they clearly so sadly lack.

But no, you have taken the easy route, just threaten them and accuse them of criminal behaviour.How incredibly negative you are. Not to mention, short sighted.
Unsuitable or offensive?
Anonymous | 13-Jan-2010 9:06 pm
I personally think that the EWS is a really useful tool..where I work you have to inform the nurse in charge if the score goes above 3, I informed the nurse in charge that my patient was deteriating this evening and she basically ignored me..patient continued to deteriate I went straight to SHO who came and reviewed my patient. Fed up over stretched nurse.
Unsuitable or offensive?
Anna Lincoln | 14-Jan-2010 0:12 am
I still don't understand how one nurse to 20 patients with constant interruptions (constant!!) and total chaos can possibly record any kind of observations or scores?

Tell me how to do it. You know damn well that we cannot get 10 seconds into any task without being pulled away for multiple things by multiple people. And none of those people give a crap about what the nurse is trying to accomplish. They don't care that she has a deteriorating patient. They want her to drop what she is doing and drop it this minute so they can have what they want. I am not talking about patients here. I am talking about visitors and other health care workers. They don't give these nurses 5 seconds to observe vital signs.

This and short staffing is what is totally criminal.
Unsuitable or offensive?
Anna Lincoln | 14-Jan-2010 0:15 am
I have way more patients than I can possibly see, assess, or nurse in a shift. It is physically impossible. And the hca's are not that much help. They don't have the knowledge.

It is disgusting that the powers that be have deskilled the nursing profession but increasing the ratio of untrained to trained staff. It's bloody sick and it is criminal.

America destroyed it's nursing care and it's nurses and killed countless patients by employing these exact same tactics that the NHS is now implementing.
Unsuitable or offensive?
Anna Lincoln | 14-Jan-2010 0:18 am
Kathleen,

It is absolutely insane to think that an RN with 15 patients could mentor a nursing student properly. Even if the RN is dedicated to mentoring and very good at her job she will still not be able to give her student the best experience. This situation is truly sick. They are balancing their budgets off the backs of nurses, making it impossible for the nurses to do their jobs, and then blaming the nurses. What a joke.
Unsuitable or offensive?
peter murphy | 14-Jan-2010 4:25 pm
Stop describing vital signs as clinical observations. They are vital signs. They are the difference between life and death for patients. Why are these observations not seen as a priority task? Anybody who thinks differently must sort it out. I didn't think the comments made in the article are offensive but make complete sense - they are a little sensational - journalistic spin?
Reading between the lines with this article it says to me that cardiac arrests are unacceptable - I agree with this, they are an end pint and for all but a small group are system failure. Equate this to the airline – thousands of cardiac arrests – thousands of plan crashes – is this acceptable? The Patient Safety First Campaign has rightly called this out as a real issue for patients and I applaud them and the comments made by Marie- Noelle in this article.
Unsuitable or offensive?
kathleen white | 14-Jan-2010 8:11 pm
Peter, I think you are missing the point. None of the comments see the vital signs as anything less than life and death. I hear commentators saying that they would like to see Ms Orzel doing more to ensure that mentors have appropriate time to mentor the undergraduates who will be the practitioners of the future, and provide resources that will allow them to practice with competence and DIGNITY.
What other profession would ask their members to practice without essential resources?
I have friends in medical, legal, pharmaceutical and other organizations, all doing great jobs. One of them is my daughter whose recent annual increment was £8000. What did she do to get this reward? a lot less than the average frontline NHS nurse. but then she works within a LEARNING ORGANIZATION with competent managers.
Many of our managers do not know how to support nurses, or indeed what nurses do. But then it is difficult for them to understand, when their bonuses, promotion and fat pensions depend on them not understanding such basics. Are you part of this clique Marie -Noelle? If not,please have your say and tell us what you intend to do to change the culture of fear,intimidation and disrespect that pervades our profession.
This ivitation is not extended in a disrespectful way. It's just that if you don't tell us,we will never know just how much you understand about he appalling conditions that frontline staff face on a daily basis.What Dr Peter Carter RCN general secretary, has to say about Mid Staffs NHS Trust is a typical snapshot of our daily workplaces (i.e.cultures of fear). Most of the above comments say the same thing.
Would it not be better to address the basics before criticizing those who are not being appropriately trained and resourced? Start by transforming our NHS into a learning organization where frontline staffare listened to.
Kathleen White (Edinburgh)
Unsuitable or offensive?
Anonymous | 14-Jan-2010 8:38 pm
Ithink the real criminality here is the nurse filling in paper whilst the patient deteriorates.........
Unsuitable or offensive?