The Chief Nursing Information Officer (CNIO) at Imperial College Healthcare NHS Trust led the implementation of digitising the National Early Warning Score (NEWS) at the Trust, with support from nursing, midwifery and healthcare assistant colleagues. This has significantly improved patient safety and outcomes, improved staff experience, and streamlined and standardised handovers which has increased time spent caring for patients.
Where to look
NEWS is a tool developed by the Royal College of Physicians which supports practitioners to detect and respond to clinical deterioration in adult patients and is a key element of patient safety and improving patient outcomes.
The tool is based on a simple aggregate scoring system in which a score is allocated to physiological measurements already recorded in routine practice, when patients present to, or are being monitored in, hospital. Six physiological parameters form the basis of the scoring system:
- respiration rate;
- oxygen saturation;
- systolic blood pressure;
- pulse rate;
- level of consciousness or new confusion;
A score is allocated to each parameter as they are measured, with the magnitude of the score reflecting how the parameter varies from normal ranges. The score is then aggregated and guidance given to staff carrying out the assessment as to what actions are needed to support good patient outcomes. NHS England described how this standardised approach can reduce the number of patients whose conditions deteriorate whilst in hospital and potentially save over 1800 lives a year.
Since its initial launch in 2012, NEWS has seen widespread uptake across the NHS. At present around 70% of acute Trusts in England are using NEWS, with other Early Warning Scores in place in other areas.
The senior nursing team at Imperial College Healthcare NHS Trust identified that the existing paper-based approach to documentation of patient’s observations was varied across the Trust and a robust tool to identify deterioration which could contribute to patient safety incidents was not standardized practice – this was unwarranted variation.
What to change
Imperial College Healthcare NHS Trust provides acute and specialist healthcare in north west London. The senior nursing team completed an audit of current practice including patient case note reviews and gathering feedback from the Critical Care Outreach Team (CCOT). The results indicated that the practice of documenting patient information on paper often resulted in a fragmented approach to the recording, visibility and access of information, and ease of escalation of patients at risk of deterioration. There was a risk of transcription errors or incomplete records, paperwork was time consuming, and audits were resource intensive.
To address this unwarranted variation, the ‘Safer Care Project’ was initiated at the Trust with an aim of using digital technology to identify patients at risk of deterioration and provide optimal care to improve their outcomes and experience of care. The nurse leaders took this opportunity to implement a system that would make vital patient information more visible, support staff in decision making, establish and highlight trends and improve clinical judgements on risk and escalation.
How to change
The Chief Nursing Information Officer led an initial pilot to introduce 70 digital bedside vital signs monitors, supported by nurses and midwives providing leadership as local champions supporting decisions on areas for implementation.
Hand held devices were introduced to reduce documentation time with decision support at the bedside. Digital touch screen monitors now capture clinical observations such as blood pressure and temperature and automatically transfer it into the electronic patient record (EPR) by wireless connection. The EPR is supported by a handover page detailing a patient’s latest NEWS score that is automatically calculated, and any escalation instructions automatically on screen.
Face to face training to support staff to understand and use the equipment was rolled out across the Trust.
Following a successful two-month pilot, the digital NEWS system was further rolled out across the Trust, with 200 additional digital bedside vital signs monitors to support staff to implement the system.
Better outcomes – Patient assessment is now standardised and information goes directly into the patient record, increasing the accuracy of information. Patient safety has been improved through earlier and consistent referral to CCOT and medical colleagues. The technology provides decision-making support for staff and alerts teams when support is needed. There has been a positive impact on handovers, through streamlining and standardising the process; there is now a real-time digital list of patients for colleagues to review and investigate individual NEWS scores.
Better experience – The NEWS system has been well received by staff, with feedback including: “In the old system it took me at times an hour and a half to take all my patients’ vital signs, but with this system it just takes me 30 minutes.”
Better use of resources – The mean time to take and record vitals has reduced from 2 minutes 35 seconds to 1 minute 12 seconds now that there is a digital solution. This is a 53.5% reduction in the time it takes to document a full set of NEWS observations. By using bedside devices, 600 hours of nursing time has been released from routine documentation and that time can be used in direct patient care. A saving of 30 hours per month of audit time has also been achieved. Together, this is projected as 323,500 hours a year across the Trust.
Challenges and lessons learnt for implementation
It is important to ensure staff are educated, trained and supported correctly from the start and understand the potential benefits. Challenges included ensuring that each time a new patient was admitted, the appropriate electronic link was made through the electronic device and that the previous encounter was not continued. Having sufficient equipment is vital.
Technology was not seen as something new, but rather as something that can support improving patient care. To implement something similar, consider the conditions of change that are needed to affect and improve patient care, better experience for staff and better outcomes for patients. Think about the leadership and what you are trying to achieve; bring staff together and involve them in using technology.
Involve the patient and show them what you are doing with the technology – it’s their clinical information. Graphs are useful, especially to show improvements.
Imperial College Healthcare NHS Trust was selected as a Global Digital Exemplar (GDE), who are internationally recognised NHS providers exceptional care, efficiently, through the use of world-class digital technology and information.
Find out more
For more information contact:
- James Bird, Chief Nursing Information Officer, Imperial College Healthcare NHS Trust, James.firstname.lastname@example.org