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Content Article
Top picks: Six resources about sepsis
Patient Safety Learning posted an article in Deterioration and sepsis
According to the UK Sepsis Trust, sepsis affects 245,000 people every year in the UK alone, and 48,000 people die of sepsis-related illnesses. Sepsis arises when the body’s response to an infection injures its own tissues and organs. It may lead to shock, multi-organ failure, and death – especially if not recognised early and treated promptly. At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; to provide a space for people to come together and share their experiences, resources and good practice examples. We have pulled together six useful resources about sepsis that have been shared on the hub. They include advice on recognising and managing sepsis along with educational materials. -
Content Article
Health Education England: THINK SEPSIS
Patient Safety Learning posted an article in Deterioration and sepsis
“THINK SEPSIS” is a Health Education England programme aimed at improving the diagnosis and management of those with sepsis. A number of sepsis cases result in death every year. Some of the deaths are preventable. Prompt recognition of sepsis and rapid intervention will help reduce the number of deaths occurring annually. The learning materials that are available on this website support the early identification and management of sepsis. It includes a film and a wide range of learning materials for primary care, secondary care and paediatrics. -
Content ArticleA series of videos on managing deterioration, including: Introduction to sepsis and serious illness Preventing the spread of infection Soft signs of deterioration NEWS What is it Measuring the respiratory rate Measuring oxygen saturation Measuring blood pressure Measuring the heart rate Measuring the level of alertness How to measure temperature Calculating and recording a NEWS score Structured communications and escalation Treatment escalation plans and resuscitation Recognising deterioration in people with a learning disabilities How to use your pulse oximeter and Covid-19 diary.
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News ArticleThe mother of a seriously ill boy said she was "very alarmed" when a doctor at an under-fire children's ward admitted they were "out of their depth". In October, Carys's five-year-old son Charlie was discharged from Kettering General, but she returned him the next day in a "sort of lifeless" state. She said it seemed "quite chaotic" on Skylark ward before he was transferred to another hospital for further tests. Since the BBC's report in February that highlighted the concerns of parents with children who died or became seriously ill at the hospital, dozens more have come forward. In April, Care Quality Commission (CQC) inspectors rated the Northamptonshire hospital's children's and young people's services inadequate. Among the findings, inspectors said "staff did not always effectively identify and quickly act upon patients at risk of deterioration". Read full story Source: BBC News, 6 June 2023
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Content ArticleFailure to rescue is defined as mortality after complications during hospital care. Incidence ranges 10.9%–13.3% and several national reports such as National Confidential Enquiry into Patient Outcomes and Death and National Institute of Clinical Excellence CG 50 highlight failure to rescue as a significant problem for safe patient care. To avoid failure to rescue events, there must be successful escalation of care. Studies indicate that human factors such as situational awareness, team working, communication and a culture promoting safety contribute to avoidance of failure to rescue events. Understanding human factors is essential to developing work systems that mitigate barriers and facilitate prompt escalation of care. This qualitative evidence synthesis identifies and synthesise what is known about the human factors that affect escalation of care.
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Content ArticleMeasures exist to improve early recognition of and response to deteriorating patients in hospital. However, management of critical illness remains a problem globally; in the United Kingdom, 7% of the deaths reported to National Reporting and Learning System from acute hospitals in 2015 related to failure to recognise or respond to deterioration. The current study from Albutt et al. explored whether routinely recording patient-reported wellness is associated with objective measures of physiology to support early recognition of hospitalised deteriorating patients. The preliminary findings suggest that patient-reported wellness may predict subsequent improvement or decline in their condition as indicated by objective measurements of physiology (NEWS). Routinely recording patient-reported wellness during observation shows promise for supporting the early recognition of clinical deterioration in practice, although confirmation in larger-scale studies is required.
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Content ArticleWound care is rarely considered a strategic objective within health and care, but it has considerable impact on patients and on health service resources. In this blog, Ameneh Saatchi, Senior Partnerships and Policy Manager at Public Policy Projects looks at the growing burden of wound care on the health service and what can be done to tackle the problem.
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News Article
Kettering hospital ward accused of failing children rated inadequate
Patient Safety Learning posted a news article in News
The safety of a ward accused of failing children has been rated as inadequate by inspectors. The care regulator warned Kettering General Hospital (KGH) in Northamptonshire over its children's and young people's services. Inspectors' worries include sepsis treatment, staff numbers, dirt levels and not having an "open culture" where concerns can be raised without fear. Since the BBC's first report in February highlighting the concerns of parents with children who died or became seriously ill at KGH, dozens more families have come forward, bringing the number to 50 to date. Inspectors found that "staff did not always effectively identify and quickly act upon patients at risk of deterioration". They said there were sometimes "delays in medical reviews being undertaken outside of normal working hours", highlighting one case where a seemingly deteriorating patient was not seen until three hours after being escalated to the on-call team. Read full story Source: BBC News, 20 April 2023 -
EventThis conference focuses on recognising and responding to the deteriorating patient and ensuring best practice in the use of NEWS2. The conference will include National Developments including the recommendations on NEWS2 and Covid-19, and implementing the recommendations from the Healthcare Safety Investigation Branch Report Investigation into recognising and responding to critically unwell patients. The day will include practical case study based sessions on identifying patients at risk of deterioration, improving practice in patient observations, the role of human factors in responding to the deteriorating patient, improving escalation and understanding success factors in escalation, sepsis and Covid-19, involving patients and families in recognising deterioration, using clinical judgement, and improving the communication and use of NEWS2 in the community, including care homes, and at the interface of care. The Recording of NEWS2 score, escalation time and response time for unplanned critical care admissions is now an NHS CQUIN goal. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/deteriorating-patient-summit or email kate@hc-uk.org.uk. hub members receive a 20% discount. Email: info@pslhub.org Follow on Twitter @HCUK_Clare #DeterioratingPatient
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Content Article
NSW Government: Between the Flags
Patient Safety Learning posted an article in International patient safety
The Between the Flags (BTF) system is a 'deteriorating patient safety net system' for patients who are cared for in New South Wales (NSW) public health facilities in Australia. It is designed to assist clinicians to recognise when patients are deteriorating and to respond appropriately when they do. -
News Article
Top doctor ‘desperate’ to keep parents out of ‘lobster trap’ hospitals
Patient Safety Learning posted a news article in News
One of the country’s most senior doctors has said he is “desperate” to keep his elderly parents out of hospital, which he said are like “lobster traps”. Dr Adrian Boyle, president of the Royal College of Emergency Medicine, said hospitals are easy to get into but hard to get out of. His comments come after figures showed the number of patients in hospital beds in England who no longer need to be there has reached a new monthly high. An average of 13,613 beds per day were occupied by people ready to be discharged from hospital in October. That was up from 13,305 in September and the highest monthly figure since comparable data began in December 2021, according to analysis by the PA news agency. In an interview with the Daily Mail, Dr Boyle said: “Hospitals are like lobster traps – they’re easy to get into and hard to get out of. “If social care was able to do its job in the way we want it to, these poor people wouldn’t be stranded in hospital. “I have elderly parents and I’m desperate to keep them out of hospital. “For someone who is frail, hospital is often a bad place for them. They’re being harmed by being in hospital.” Read full story Source: The Independent, 14 November 2022 -
News ArticleA Guardian analysis has found that as many as one in three hospital beds in parts of England are occupied by patients who are well enough to be discharged, with a chronic lack of social care meaning many do not have suitable places to go. Barry Long's 91-year-old mother has Alzheimer’s and was admitted to Worthing hospital on 30 May after a minor fall. She was a bit confused but otherwise unhurt, just a bit shaken. Whilst in hospital, she caught Covid and had to be isolated, which she found distressing, and became increasingly disoriented. She was declared medically fit to be discharged but no residential bed could be found for her. Then, in August, she was left unsupervised and fell over trying to get to the toilet and she fractured her hip, which required surgery. Her hip was just about healed when she caught her shin between the side bars and the frame of the bed, cutting her shin so badly that she is being reviewed by a plastic surgeon to see if it needs a skin graft. "Since the operation, my mum is pretty much bedbound and lives in a state of confusion and anxiety", says Barry. "Her physical health and mental wellbeing have deteriorated considerably in the almost five months she has spent in the care of the NHS. She spends all day practically trapped in bed, staring into space or with her eyes shut, just rocking to and fro. She has little mental stimulation." Read full story Source: The Guardian, 13 November 2022
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Content ArticleThis Australian study in Health Expectations aimed to evaluate the implementation of 'Calling for Help'(C4H), an intervention for parents to escalate care if they are concerned about their child's clinical condition. The study used a convenience sample of 75 parents from inpatient areas during the audit, and the authors held interviews with ten parents who had expressed concern about their child's clinical condition and five focus groups with 35 ward nurses. The authors found that there was an improvement in the level of parent awareness of C4H, which was viewed positively by both parents and nurses. To achieve a high level of parent awareness in a sustainable way, a multifaceted approach is required and further strategies will be required for parents to feel confident enough to use C4H and to address communication barriers.
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Content ArticleREACH is a system that helps patients, carers and family members to escalate their concerns with staff about worrying changes in a patient's condition. It stands for Recognise, Engage, Act, Call, Help is on its way. REACH was developed by the New South Wales Government Clinical Excellence Commission in collaboration with local health districts and consumers. It builds on the surf life‐saving analogy for recognition and appropriate care of deteriorating patients by encouraging patients, carers and their families to 'put their hands in the air' to signal they need help.
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EventThe Deteriorating Patient Summit focuses on recognising and responding to the deteriorating patient through improving the reliability of patient observations and ensuring quality of care. The conference will include national developments, including the recent recommendations on NEWS2 and Covid-19, and implementing the recommendations from the HSIB Investigation into recognising and responding to critically unwell patients. The conference will include practical case study based sessions on identifying patients at risk of deterioration, improving practice in patient observations, responding to the deteriorating patient, improving escalation and understanding success factors in escalation, sepsis and Covid-19, involving patients and families in recognising deterioration, and improving the communication and use of NEWS2 in the community, including care homes, and at the interface of care. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/deteriorating-patient-summit or email kate@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code Follow on Twitter @HCUK_Clare #DeterioratingPatient
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Content ArticleRyan Saunders is a little boy who died in 2007 from an undiagnosed streptococcal infection, which led to Toxic Shock Syndrome. According to the Queensland Clinical Excellence Division, when Ryan’s parents were worried he was getting worse, they did not feel their concerns were acted on in time. This blog outlines Ryan's Rule, a process introduced by the Queensland Department of Health to try and prevent similar events happening in future. Ryan's Rule allows patients and their families and carers to escalate serious concerns about their own or a family member's condition.
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Content ArticleThis investigation by the Healthcare Safety Investigation Branch (HSIB) explores issues around patient handover to emergency care. Patients who wait in ambulances at an emergency department are at potential risk of coming to harm due to deterioration or not being able to access timely and appropriate treatment. This is the second interim bulletin published as part of this investigation, and findings so far emphasise that an effective response should consider the interactions of the whole system: an end-to-end approach that does not just focus on one area of healthcare and prioritises patient safety. The reference event in this investigation involves a patient who was found unconscious at home and taken to hospital by ambulance. They were then held in the ambulance at the emergency department for 3 hours and 20 minutes and during this time their condition did not improve. The patient was taken directly to the intensive care unit where they remained for nine days before being transferred to a specialist centre for further treatment.
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Content ArticleThis study in Health Expectations aimed to identify barriers and facilitators to implementing a parent escalation of care process: Calling for Help (C4H). Guided by the Theoretical Domains Framework, the authors carried out audits, semi-structured interviews and focus groups in an Australian paediatric hospital where a parent escalation of care process was introduced in the previous six months. The authors found that although there was a low level of awareness about C4H in practice, there was in-principle support for the concept. Initial strategies had primarily targeted policy change without taking into account the need for practice and organisational behaviour changes.
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Content ArticleThis document outlines the standard operating procedure (SOP) adopted by University Hospitals Bristol NHS Foundation Trust, relating to parental involvement in escalation of clinical care for acutely ill children. It aims to clarify the process of empowering parents to escalate concerns if they are worried about the clinical condition and care being delivered to their child, or themselves if they are a patient. It also aims to ensure accurate and appropriate information is provided to parents on admission (elective and acute) regarding how they should escalate concerns about the care their child is receiving.
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Content ArticleThe REACH Toolkit provides information, resources and quality improvement (QI) tools for managers and clinicians to improve patient, carer and family recognition and escalation of clinical deterioration in NSW health services. The resources can be adapted to suit local needs including initial program implementation, to review and improve current practices or to support current practice.
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Content ArticleThis framework produced by the Royal College of Paediatrics and Child Health (RCPCH) aims to improve how healthcare organisations recognise and respond to children at risk of deterioration. A safer system can work in partnership with families and patients, develop a patient safety culture and support ongoing learning. The framework covers: Patient safety culture Partnership with families Recognising deterioration Responding to deterioriation Open and consistent learning Education and training
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Content ArticleThe aim of this study in Australian Critical Care was to develop an evidence-based paediatric early warning system for infants and children, that takes into consideration a variety of paediatric healthcare contexts and addresses barriers to escalation of care. The development process resulted in an agreed uniform ESCALATION system incorporating a whole-system approach to promote critical thinking, situational awareness for the early recognition of paediatric clinical deterioration as well as timely and effective escalation of care. Incorporating family involvement was an important and new component of the system.
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Content ArticleThis document outlines the Escalation Policy for Leicester Children’s Emergency Department. It identifies five particular factors that lead to difficulty within the department. Acknowledging that these issues can be closely interlinked and may not occur in isolation, it provides practical way to deal with these factors to try and prevent secondary events. Staffing Overcrowding Inflow Outflow Acuity
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Content ArticleThis opinion piece by GP educator and writer John Launer looks at the current delays and cancellations to routine appointments facing patients with long term conditions. He describes his personal experience of waiting three years with no face-to-face of phone appointment to review his condition, when this should happen every six months. John outlines the fact that routine outpatient care in some hospitals is unravelling, but with no monitoring of the situation and without publicity. He highlights the risks for patients who are not receiving the regular contact with healthcare professionals that they need, including medical complications, emergency admissions and even preventable deaths. There is particularly risk to patients who do not feel able to contact their consultant or specialist. When speaking to the hospital department about how the risks were being mitigated, John was concerned to discover that there were no screening procedures in place for clinicians to determine which patients were at highest risk; no prioritisation as going on and there was no system in place to monitor the consequences of this.
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News Article
Cancer patients in England and Wales facing ‘unacceptable’ wait for support
Patient Safety Learning posted a news article in News
The physical and mental health of tens of thousands of cancer patients in England and Wales is deteriorating because they are having to wait months for financial support from the government, a charity has warned. Macmillan Cancer Support said many are waiting as long as five months to receive their personal independence payment (PIP), which is paid to people with long-term physical and mental health conditions or disability, and who have difficulty doing certain everyday tasks or getting around. Health leaders said the “unacceptable” situation had now become critical, with thousands of cancer patients increasingly desperate for help. Research for the charity found that among people with cancer who receive PIP, more than one in four (29%) have reported a deterioration in physical or mental health while they wait to receive it. This rises to almost half (46%) among those who wait more than 11 weeks to receive their first payment. Macmillan is launching a “Pay PIP Now” campaign, saying it is hearing from patients going into debt, skipping meals and cancelling medical appointments due to travel costs, all because of delays to PIP. It wants ministers to cut the average wait times for PIP from 18 weeks at the moment to 12. Research suggests most people with cancer suffer a financial impact from their diagnosis, including from being unable to work while having treatment, increased heating bills to stay warm and the cost of attending appointments. Read full story Source: The Guardian, 6 October 2022
