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Showing results for tags 'Deterioration'.
Found 137 results
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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 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 ArticleFailure to rescue (FTR) denotes mortality from post-operative complications after surgery with curative intent. High-volume, low-mortality units have similar complication rates to others, but have lower FTR rates. Effective response to the deteriorating post-operative patient is therefore critical to reducing surgical mortality. Resilience Engineering might afford a useful perspective for studying how the management of deterioration usually succeeds and how resilience can be strengthened.
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Content ArticleJane Bruce was discharged from hospital on 24 March 2020 and was receiving wound care from the community nursing team twice a week, after surgery on a fracture following a fall in November 2019. She initially appeared to be recovering until 29 April when her pain increased significantly, rendering her bed-bound, with the exudate from the wound significantly increased. She continued to deteriorate and presented to Leicester Royal Infirmary on 1 May with features consistent with sepsis, and subsequently died the following day. In her report, the Coroner highlights concerns about an absence of continuity in Ms Bruce’s wound care. She notes that she had been seen by several different nurses but due to lack of photographic evidence/accessible electronic records they did not have the relevant information to recognise the change in her condition.
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Content ArticleCase study looking at how a Covid patient on a ventilator deteriorated due to their heat and moisture exchanger filter (HMEF) being flooded with secretions. The identified incident highlighted a possible under-recognised patient safety risk of the need to replace such filters.
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Content ArticleThis report looks at how when face-to-face midwife visits were replaced by virtual appointments during the Covid-19 pandemic, the health of the some babies deteriorated. Guidance has been amended to state that initial visits should be face-to-face.
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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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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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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 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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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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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 -
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 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 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 the discount code Follow the conference on Twitter @HCUK_Clare #DeterioratingPatient
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Event
Deteriorating patient safety network
Patient-Safety-Learning posted an event in Community Calendar
untilWould you like to collaborate across the South West to identify, learn and share best practice for managing deterioration? Join us at our next Deteriorating Patient Safety Network (DPSN) Workshop on 4 March 2022. Be inspired – come and listen to our inspirational speakers! Make connections and build new relationships – get to know others in the Deteriorating Patient Safety Network in our ‘chat over a coffee’ sessions. Learn more about our work to improve patient safety – find out more about the focus of the regional patient safety collaborative run by the South West Academic Health Science Network, our focus and our principles Network co-production – have the opportunity to co-design our DPSN in a targeted brainstorming session. Let’s work together to build a network which focuses on our collective priorities, which builds and harnesses our skills and experiences and improves patient safety In our DPSN sessions throughout 2021 we had identified the challenges in managing deterioration that you are facing within your settings and determined priorities for future work. The following are key themes that have come out of these sessions. Why not join us to continue exploring these themes? Improving staff confidence and skills to prevent, identify and escalate deterioration Improving response times so that the patient/person receives the right care in the right place at the right time Having sufficient staffing levels in all settings to maximize patient safety Reducing inequalities – access to care no matter who you are Communicating effectively so you are heard Who is invited? Our DPSN workshops are open to those who work in integrated care system organisations across Somerset, Devon and Cornwall, who are involved in patient deterioration in non-care home settings: Commissioners County Council Leads Domiciliary care providers – care @ home including care for people with a learning disability Mental health settings Prisons Primary care Ambulance Services Informal carers Acute Trusts Community Hospitals and nursing teams delivering care in community settings Register to attend About the Deteriorating Patient Safety Network The Deteriorating Patient Safety Network (DPSN) is hosted by the South West AHSN and supports its members to plan, deliver and monitor deteriorating patient and resident projects. Projects in the region have a variety of settings and support patient pathway collaboration between partners from acute and community hospitals, community services in the home, primary care services, care homes, clinical commissioning groups, councils and other partners across the region. Quarterly DPSN events bring teams together to collectively learn from good practice, share resources and support each other on their improvement journey. Bespoke quality improvement methodology and culture training assist the teams to collectively sculpt solutions to common problems and create a thriving and active regional support network. Find out more on our webpage. -
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 Follow on Twitter @HCUK_Clare #deterioratingpatient hub members can receive a 20% discount. Email info@pslhub.org discount code. -
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 ArticleThis report by researchers at the University of Birmingham is the first granular analysis of the known and hidden waiting lists for elective procedures in England. There has been previous analysis of the NHS waiting list, but it has been based on the overall waiting list and has included patients waiting for all types of consultant-led care, including outpatient clinic visits and non-surgical treatments. The authors of this report have used procedure-level data to produce estimates for the need for elective procedures.
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Content ArticleThis report examines the impact of the Covid-19 pandemic on people living with long-term conditions and highlights that many have deteriorated faster than usual due to being unable to access rehabilitation services. It makes recommendations to the government aimed at restoring rehabilitation support services. The report was produced collaboratively by The Alzheimer's Society, The Stroke Association, Macmillan Cancer Support, The Centre for Mental Health, Age UK, The College of Podiatry, The Royal College of Speech and Language Therapists, The Royal College of Occupational Therapists, The Chartered Society of Physiotherapy and The British Dietetic Association.
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation 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. HSIB has published an interim report outlining early investigation findings, and recommends a national response to tackle this urgent issue. 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. For its reference case, the investigation looks at the case of a patient who was found unconscious at home and taken to hospital by ambulance. The patient was then held in the ambulance at the emergency department for 3 hours and 20 minutes, and during this wait their condition did not improve. They were 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 ArticleA Treatment Escalation Plan (TEP) is a communication tool designed to improve quality of care in hospital, particularly if patients deteriorate. TEPs aim to reduce variation caused by discontinuity of care, avoid harms caused by inappropriate treatment and promote patients’ priorities and preferences. This article in the Journal of the Royal College of Physicians of Edinburgh examines the key components of a TEP, how and why TEPs should be implemented and the outcome-related evidence to support their use.
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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 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 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 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.
