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Showing results for tags 'Deterioration'.
Found 141 results
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News Article
Covid pressure forces cancellation of most operations
Patient Safety Learning posted a news article in News
Planned operations including ”priority two” procedures were postponed at short notice at one of England’s largest hospital trusts earlier this week due to rising covid compounding other operational pressures, HSJ understands. Several sources said Leeds Teaching Hospitals Trust cancelled the large majority of elective operations scheduled for Tuesday 2 November due to rising occupancy in intensive care and throughout the trust, particularly linked to increasing numbers of covid patients. The postponed operations included ‘priority two’ cases, which must be undertaken within one month to avoid further harm and deterioration, a well placed source told HSJ. The trust said it did not, however, cancel ‘priority one’ urgent operations, which must be performed within 72 hours. It said most elective operations resumed on Wednesday as pressure had “eased a little” since Tuesday. Some daycase surgery was also postponed, it said, as areas had to be repurposed for emergency care. One concerned family member of a Leeds patient whose operation was cancelled, who contacted HSJ, said: ”My relative is on the cardiology list and might not be fit enough for the op if there are further delays — that could be fatal.” Read full story (paywalled) Source: HSJ, 4 November 2021 -
Event
Deteriorating Patient Summit
Patient Safety Learning posted an event in Community Calendar
The 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 from the Royal College of Physicians 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 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 & covid-19, involving patients and families in recognising deterioration, and improving the communication and use of NEWS2 not only in an acute setting but also in the community 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 member receive a 20% discount. Email info@pslhub.org for the code. Follow on Twitter @HCUK_Clare #deterioratingpatient -
Content ArticleDespite the effectiveness of total knee arthroplasty (TKA; knee replacement surgery), patients often have lingering pain and dysfunction. Recent studies have raised concerns that preoperative mental health may negatively affect outcomes after TKA. The primary aim of this study from Melnic et al. investigates the relationship between patient-reported mental health and postoperative physical function following TKA. The study found that poor mental health should not be a contraindication for performing TKA. For patients with the lowest mental health scores, physicians should account for the possibility that physical function scores may deteriorate a year after surgery. Tighter follow-up guidelines, more frequent physical therapy visits, or treatment for mental health issues may be considered to counter such deterioration.
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Content Articlen the UK, while most primary care contacts are uncomplicated, safety incidents do occur and result in patient harm, for example, failure to recognise a patient’s deterioration in health. This study by Cecil et al. determined the patient and healthcare factors associated with potentially missed acute deterioration in health. Differentiating acute deterioration from self-limiting conditions can be difficult for clinicians, particularly in patients with sepsis, urinary tract infections, or long-term conditions. The findings of this study support the call for longer GP consultations and caution against reliance on telephone consultations in primary care; however, more research is needed to understand the underlying mechanisms.
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Content ArticleWest Midlands Ambulance Service has highlighted the death of a woman which it says was due to “being delayed on the back of an ambulance”, just two days after it warned that lives were ‘at risk’ from long handovers. Below is the full account from the organisation's board paper.
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Content ArticleThis video introduces England's 15 Patient Safety Collaboratives (hosted by Academic Health Science Networks) and how they support the NHS Patient Safety Strategy in areas such as COVID-19, managing deteriorating patients, maternal and neonatal safety, medicines safety, mental health and more. Download the slides here
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Content ArticlePleural effusions are the accumulation of fluid between the lung and chest wall, which may cause breathlessness, low oxygen saturation and can lead to collapsed lung(s). They are a common medical problem and have over 50 recognised causes and various treatments. Large effusions, such as those caused by pleural malignancy, may require insertion of a chest drain and controlled drainage of fluid to allow the lung to inflate. If large volumes of pleural fluid are drained too quickly, patients can rapidly deteriorate. Their blood pressure drops, and they can become increasingly breathless from the potentially life-threatening complication of re-expansion pulmonary oedema. T A review of the National Reporting and Learning System (NRLS) over a recent three-year period identified 16 incidents where patients experienced acute and significant deterioration after uncontrolled or unmonitored drainage of a pleural effusion; two of these patients died and a cardiac arrest call was made for one patient although the outcome was not reported.
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Content Article
UCL Partners: Proactive care frameworks
Patient Safety Learning posted an article in Care pathways
UCL Partners have developed a series of proactive care frameworks to restore routine care by prioritising patients at highest risk of deterioration, with pathways that mobilise the wider workforce and digital/tech, to optimise remote care and self-care, while reducing GP workload. The frameworks include atrial fibrillation, high blood pressure, high cholesterol, type 2 diabetes, asthma and COPD. -
Content ArticleSpotting and acting on the signs of deterioration in a patient or care home resident is vital to ensuring patient safety. The objective of the national Managing Deterioration Safety Improvement Programme (known as ManDetSIP) is to create and embed the conditions for staff across the healthcare system to improve the safety and outcomes of patients by managing deterioration, and provide a high quality healthcare experience across England.
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Content ArticleRyan's Rule is a three step process to support patients of any age, their families and carers, to raise concerns if a patient’s health condition is getting worse or not improving as well as expected. Ryan’s Rule applies to all patients admitted to any Queensland Health public hospital including the emergency department, and in some Hospital in the Home (HITH) services.Ryan’s Rule has been developed in response to the tragic death of Ryan Saunders, who died in 2007 from an undiagnosed Streptococcal infection, which led to Toxic Shock Syndrome. When Ryan’s parents were worried he was getting worse they did not feel their concerns were acted on in time. In light of his death, the Department of Health made a commitment to introduce a patient, family, carer escalation process (Ryan’s Rule), to minimise the possibility of a similar event occurring.Follow the link below to the Queensland Government website to find out more about Ryan's Rule and how it works in practice.
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Event
Deteriorating Patient Summit
Patient Safety Learning posted an event in Community Calendar
The 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 from the Royal College of Physicians 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 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. Follow the conference on Twitter #deterioratingpatient Register -
Content ArticleThere is a lack of awareness regarding the pervasive influence of the built environment on caregiving activities, and how its design could reduce risks for patients and providers. This article from Joseph et al. presents a narrative review summarising key findings that link health care facility design to key targeted safety outcomes: health care–associated infections, falls, and medication errors. It describes how facility design should be considered in conjunction with quality improvement legislation; projects under way in health systems; and the work of guideline-setting organizations, funding agencies, industry, and educational institutions. The article also charts a path forward that consolidates existing challenges and suggests what can be done about them to create safe and high-quality healthcare environments.
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Content ArticleThis study from Harris et al. estimated the effect of prompt admission to critical care on mortality for deteriorating ward patients. They found that prompt admission to critical care leads to lower 90-day mortality for patients assessed and recommended to critical care.
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Content ArticleDelays in evaluation and escalation of needed care can compromise outcomes of the patient significantly and, in many cases, may lead to death. The assembly of a rapid response team would not only provide timely multidisciplinary evaluation of a potentially deteriorating patient, but it would also help reinforce the organization’s culture of collaboration and interprofessional support for safety. Patients often exhibit signs of deterioration before experiencing the adverse event. The rapid response team’s timeliness in evaluation, coupled with the recommendations from multiple, interprofessional individuals, instead of solely the bedside nurse, would significantly prevent a plethora of adverse events and save financial resources. Specifically, the implementation of rapid response teams has been associated with reductions in cardiac arrests, inpatient deaths, and number of days in the hospital. Many healthcare organisations have successfully implemented and sustained improvements with the advent of rapid response teams. These organizations have focused on projects that included establishing standardized calling criteria for both clinicians and patients and family members, and delineating roles and responsibilities for all upon rapid response team arrival. This Patient Safety Movement Actionable Patient Safety Solutions (APSS) provides a blueprint that outlines the actionable steps organisations should take to successfully implement and sustain rapid response teams and summarises the available evidence-based practice protocols.
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Content ArticleA rapid-learning report on the role of Patient Safety Collaboratives (PSCs) during the pandemic has been published by the AHSN Network. PSCs are just one part of the health and care system which responded quickly to the immediate crisis from COVID-19 in March. They reprioritised their day-to-day work and took on new programmes at speed, such as promoting safer tracheostomy care. The report has been published as part of the NHS Reset campaign and gives examples of how PSCs refocused their work ‘almost overnight’ to respond to the pandemic. It illustrates some of the creative ways AHSNs supported their local systems and how this experience will be built into future patient safety programmes.
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Community Post
Should patients be actively involved in following up their referrals?
Steve Turner posted a topic in Improving patient safety
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I've been posting advice to patients advising them to personally follow up on referrals. Good advice I believe, which could save lives. I'm interested in people's views on this. This is the message I'm sharing: **Important message for patients relating to clinical referrals in England** We need a specific effort to ensure ALL referrals are followed up. Some are getting 'lost'. I urge all patients to check your referral has been received, ensure your GP and the clinical team you have been referred to have the referral. Make sure you have a copy yourself too. Things are difficult and we accept there are waits. Having information on the progress of your referral, and an assurance that is is being clinically prioritised is vital. If patients are fully informed and assured of the progress of their referrals in real-time it could save time and effort in fielding enquiries and prevent them going missing or 'falling into a black hole', which is a reality for some people. It would also prevent clinical priorities being missed. Maybe this is happening, and patients are being kept fully informed in real-time of the progress of their referrals. It would be good to hear examples of best practice. -
Content ArticleResponding to abnormalities in patients’ vital signs is a fundamental aspect of nursing. However, failure to respond to patient deterioration is common and often leads to adverse patient outcomes. This study from Smith et al., in the journal Resuscitation, aimed to determine the association between registered nurse (RN) and nursing assistant (NA) staffing levels and the failure to respond promptly to patients’ abnormal physiology. The authors found that RN, but not NA, staffing levels influence the rates of failure to respond for patients with the most abnormal vital signs (NEWS values ≥ 7). These findings offer a possible explanation for the increasingly reported association between low RN staffing and an increased risk of patient death during a hospital admission.
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Content ArticleThis alert, from the National Institute for Health Research, provides a synopsis of a new study which suggests that many early warning scores are based on flawed research. It looks at the issue and the next steps in terms of patient safety.
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Content ArticleThe aim of this systematic review in the Journal of Patient Safety was to determine the impact of automated patient monitoring systems (PMSs) on sepsis recognition and outcomes. Authors Gale and Hall found that automated sepsis PMSs have the potential to improve sepsis recognition and outcomes, but current evidence is mixed on their effectiveness. More high-quality studies are needed to understand the effects of PMSs on important sepsis-related process and outcome measures in different hospital units.
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Content Article
FIRST: Family Initiated Rapid Safety Team
Claire Cox posted an article in Keeping patients safe
Despite the introduction of rapid response systems and early warning scores, clinical deterioration that is not recognised or responded to early enough prevails in acute care areas. One intervention that aims to address this issue and that is gaining increased attention is patient- and family-initiated escalation of care schemes. This short video by the University of Michigan Health System explains more. -
Content ArticleDespite the introduction of rapid response systems and early warning scores, clinical deterioration that is not recognised or responded to early enough prevails in acute care areas. One intervention that aims to address this issue and that is gaining increased attention is patient-and family-initiated escalation of care schemes. Existing systematic review evidence to date has tended to focus on identifying the impact or effectiveness of these schemes in practice. However, they have not tended to focus on qualitative evidence to consider the experience of deterioration and the factors that may promote or hinder engagement with these schemes in the practice setting. The aim of this review, published in Systemic Reviews, is to explore patients’, relatives’ and healthcare professionals’ experiences of deterioration and their perceptions of the barriers or facilitators to patient and family-initiated escalation of care in acute adult hospital wards.
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Content ArticleThis animation has been made to help patients stay safe while they are in hospital. It has been developed by Haelo, an innovation and improvement centre in Salford, in partnership with Guy’s and St Thomas’, and is based on the airline-style safety card developed by Guy’s and St Thomas’. Designed as part of their award-winning Welcome Pack, the safety card supports our commitment to patient safety and enables patients to play an active role in their care.
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Content ArticleThis report, from the Healthcare Safety Investigation Branch (HSIB), provides insight into a current safety risk that was identified on a referral. The referral was about difficulties in identifying clinical deterioration in patients with COVID-19 on general wards. The Royal College of Physicians (RCP) highlighted the issue of rapid deterioration in oxygenation in patients with COVID-19 and how this might relate to the use of early warning scores.
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Content Article
Scottish Patient Safety Programme: Acute Adult
Claire Cox posted an article in Resources for staff
This web page includes the four work streams that Health Improvement Scotland are undertaking. These include: Falls Deteriorating patient Catheter induced infections Pressure ulcers. -
Content Article
Escalation of deteriorating adults
PatientSafetyLearning Team posted an article in Deterioration and sepsis
This short film, produced by Homerton University Hospital, tells you how to manage a deteriorating patient on your ward. Dr Letty Dormandy, Chief Registrar, talks about the importance of early escalation and how to get help quickly.
