The news on NEWS - and tips on using NEWS. John Welch (Consultant Nurse, ICU & Outreach)

Transcription

1 The news on NEWS - and tips on using NEWS John Welch (Consultant Nurse, ICU & Outreach)

2 Declaration of interest

3 H Precommercial Procurement Project Smart monitoring, safer care Help us save lives lost to unrecognised deterioration

4 First, the old news

5 Lee A, et al. Anaesth Intensive Care. 1995;23(2):183-6.

6 Background

7 PLoS Med. 2014;11(6): e

8 A patient story 91 year old male increasing confusion, worsening memory hypertension, atrial fibrillation; heart failure peripheral vascular disease gastritis bilateral knee replacements

9 Thursday Friday - fall, hip fracture ED Surgical Assessment Unit - Theatre (hemi-arthroplasty)

10 Prognosis 5% of hip fractures die within 30 days 18% probability male aged 91 will die before reaching 92 add in long term conditions, frailty

11 Thursday Friday Saturday Sunday Monday - fall, hip fracture ED Surgical Assessment Unit - Theatre (hemi-arthroplasty) ICU - ICU ward - on ward - on ward: cardiac arrest

12 Friday Surgery: straightforward 1L intravenous fluid given Operation began at 12.15, patient in ICU by at 15.00: Ur 11.8, Cr 129, K 4.1

13 Saturday on ICU 06.30: routine morning bloods - Ur 14.1 ( ), Cr 161( ), K 4.6( ) PLAN: ready for ward monitor for any signs of sepsis

14 Saturday on ICU 06.30: routine morning bloods - Ur 14.1 ( ), Cr 161( ), K 4.6( ) PLAN: ready for ward monitor for any signs of sepsis daughter he s more confused than usual physio unable to follow commands

15 Saturday afternoon, Sunday, Monday on ward Saturday - observations: Sunday - observations: (pulse 138*) (pulse 144*) Monday - observations: (pulse 135*) (pulse 144*) CARDIAC ARREST at 11:15 (bloods: Ur 24.5, Cr 258, K 7.2)

16 daughter he s more confused than usual physio unable to follow commands

17 NEWS: a common language In five years, ¾ of hospitals are using NEWS

18 Evidence: NEWS & risk of arrest, ICU, death Smith GB, et al. Resuscitation (4):

19 NEWS vs MET criteria Single centre study, 103,998 admissions - higher specificity, less workload Smith GB, et al. Crit Care Med (12):

20 NEWS in non-elective medical & surgical patients Single centre study, 65,896 admissions NEWS performed equally well, or better, in surgical patients Kovacs C, et al. Br J Surg (10):

21 NEWS at Emergency Department triage Single centre study, 500 patients; 27 (5.4%) with severe sepsis Area under the curve for NEWS to identify risk of severe sepsis = 0.89 Keep JW, et al. Emerg Med J. 2016;33(1):37-41.

22 Just one ED triage is predictive Multi centre study, 2003 patients with sepsis NEWS = outcomes (AUC 0.7) Initial NEWS & mortality Initial NEWS 30-day mortality % % % % Corfield AR, et al. Emerg Med J (6):482-7.

23 Talking of sepsis

24 Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection Most precisely, organ dysfunction is represented by an increase in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score of 2 points At the bedside, sepsis is likely with infection, and 2 of RR 22, SBP 100, altered mentation 24

25 25

26 NEWS and sepsis risk prediction Single centre study, 30,677 patients; 7,385 (24%) died / transferred to ICU Churpek MM, et al. Am J Respir Crit Care Med Sep 20.

27 Finally, the hot off the press NEWS

28 NEWS 2

29 NEWS 2 A-B-C-D-E ordering of chart Modified colour scheme Wider spread of respiration rate values (12-14, 15-17, 18-20) Space to record type of oxygen administration device New, separate scale for SpO 2 in chronic hypercapnic respiratory failures (New) confusion added to AVPU Scale 29

30 GCS value was converted to an AVPU equivalent using a protocol established within our hospital A V P U Scale A (91.7% of patients) Glasgow Coma Score 15 V (5.8%) 14 P (1.8%) 13-9 U (0.7%) 8

31 NEWS: top tips Tell and sell the concept - tailored to the audience Compare, contrast with existing track & trigger system Set it out as a progressive development Facilitate and support ward staff to input Try out good ideas, e.g., with PDSA cycles Challenge resistors: get data Measure processes and outcomes 31

32 How reliable is your system? 91% of referrals had all seven vital signs and NEWS scores completed. 32

33 How reliable is your system? 95% of referrals had accurate NEWS scores. There were two outliers. 33

34 NEWS: top tips Tell and sell the concept - tailored to the audience Compare, contrast with existing track & trigger system Set it out as a progressive development Facilitate and support ward staff to input Try out good ideas, e.g., with PDSA cycles Challenge resistors: get data Measure processes and outcomes Use an A3 chart! 34

35

36 Going forward 36

37 BMJ Qual Saf. 2015;24(1):

38 Subbe CP, et al. Crit Care. 2017; 21:52.

39 The bed side nurse Anyone at the ward board... The Outreach Team Subbe CP, et al. Crit Care. 2017; 21:52.

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41 But don t forget more soft data Call 4 Concern enables patients and families to call for immediate help and advice when they feel concerned that the health care team has not recognised their own or their loved one s changing condition. The Outreach team can be contacted directly if: 1. A noticeable change in the patient occurs and the health care team is not recognising your concern. Odell M, et al. Br J Nurs Dec Jan13;19(22): You feel there is confusion over what needs to be done for the patient.

42 more soft data 1 Douw G, et al. Int J Nurs Stud. 2016;59:

43 Summary: Factors in Failure to Rescue Patient-level factors Volatile aspects: physiology (vital signs, blood profile, bio-chemistry) Non-volatile aspects: age, co-morbidities, frailty Hospital-level factors Culture: reliability Physical resources, technology (monitoring, analytics, coms systems) Human resources: nursing, medical, AHPs, administration / leadership skill mix, permanent vs non-permanent staffing, turnover, training staff-patient ratios Multi-disciplinary team-working

44 Deteriorating Patients Care Bundle Review sample of referrals to Outreach / unplanned transfers to ICU / arrests / deaths

45 Any questions?