George Eliot Hospital Trust dramatically cut the number of in-hospital deaths after it brought in an intervention for deteriorating patients. This is how they did it.
Sharon Beamish, BA, is chief executive; Dawn Wardell, MBA, RGN, is deputy director of nursing; both at George Eliot Hospital Trust, Warwickshire.
Keywords: Patient safety, Deterioration, Early warning scores, Track and trigger
Back in 2005 George Eliot Hospital Trust had one of the worst patient safety records in England. Since then it has been changing the way staff of all levels work and has greatly reduced the number of adverse events. As part of its efforts, in 2008 the trust signed up to Patient Safety First, which consists of five interventions - four clinical and one on leadership.
While the trust signed up to implementing all five, it paid particular attention to the reducing harm from deterioration intervention. This aims to reduce in-hospital cardiac arrest and mortality rates through earlier recognition and treatment of deteriorating patients.
To help reduce in-hospital mortality rates, the trust’s associate medical director now monitors all cardiac arrest calls to establish any links between them. This is then fed back to the patient safety committee, and board when required. The committee discusses the results and, as a multidisciplinary team, agrees actions to be taken. The whole team takes ownership to monitor and make sure this happens.
Reducing harm from deterioration
This intervention involves six key areas:
- Physiological observations should be recorded for all adult patients in acute hospital settings;
- These observations should be recorded and acted on by staff trained to undertake these procedures and understand their clinical relevance;
- Physiological track and trigger systems should be used;
- There should be a graded response strategy;
- An escalation protocol should be in place;
- A communication tool should be used.
One of the key recommendations from Patient Safety First is to improve observations and, for this, the trust began to monitor initial observations on a much more reliable basis. We used the MEWS (modified early warning scores) track and trigger system. Such systems must be acted on promptly and appropriately.
However, it is important to note that by definition, a standardised track and trigger system is not patient specific, so an individual’s condition must be taken into account to ensure clinicians do not miss subtle changes, especially in those with atrial fibrillation and hypertension.
At George Eliot the MEWS system helps staff remain aware of patients’ needs by providing a visual reminder for the doctor and nurse on duty so they know when they need to take relevant action. A colour code is used on patient forms to reflect their current health:
- Red – abnormal;
- Yellow – leaving normal range;
- Green – normal range.
This in turn helps to reduce levels of deterioration as staff are more alert to patient changes.
New communication tool
Communication is also a key area. To ensure that information on deteriorating patients reaches relevant staff members quickly, the trust implemented the SBAR (situation-background-assessment-recommendation) tool in a number of wards. All staff are trained using ALERT (acute life-threatening events recognition and treatment) courses so they can use the tool correctly. Practitioners are taught to recognise early signs or indications of deterioration and identify whether action needs to be taken quickly.
Nurses can therefore fill in the relevant observation information or call a doctor or an outreach team if required.
The hospital 24/7 team
Another key component was the introduction of the hospital 24/7 team. This consists of experienced nurses who are competent in critical care and are able to attend deteriorating patients to prevent further worsening of their condition. This outreach team also audits patients’ care when they arrive in a clinical area so they can monitor whether the correct interventions were undertaken or if there were other ways in which staff could have helped to prevent patient deterioration.
Nurses have a key role in implementing Patient Safety First interventions, and particularly in the deterioration one. They are responsible for completing observations and MEWS forms, using the SBAR communication tool and encouraging others to get involved.
Since its poor hospital standardised mortality ratio (HSMR) was revealed in 2005-2006, George Eliot Hospital Trust has managed to reduce the number of in-hospital deaths from 126 in March 2006 to 76 in May 2009. Interestingly, 93% of staff employed by the trust in 2007 - when steps were first made to improve patient safety - are exactly the same as those employed today (this does not include doctors who have joined since). This shows the effectiveness of engaging staff.
Since improving the recording of observations, the number of correctly calculated MEWS scores has risen from 55% in October 2006 to 80% in May 2009.
- For more information on Patient Safety First, click here.
- George Eliot Hospital Trust won the patient safety category in the Nursing Times Awards 2009.
McQuillan P et al (1998) Confidential inquiry into quality of care before admission to intensive care. British Medical Journal; 316: 1853–8.
NICE (2007) Acutely Ill Patients in Hospital. Recognition of and Response to Acute Illness in Adults in Hospital. London: NICE.