CCOT Advanced Clinical Practice: Improving the Recognition and Escalation of Deteriorating Patients in Adult Acute In-patient Wards

In this case study, Horizon Fellowship Fellow Maria Lorena Pena, lead of the Critical Care Outreach Team (CCOT) and an advanced nurse practitioner in Chelsea and Westminster Hospital NHS Foundation Trust, shares how she is working to improve the management of deteriorating patients by preventing adverse outcomes as a result of sub-optimal care.

Project Summary

Failure to recognise and respond to deteriorating patients is a global challenge that can lead to adverse health outcomes (Burke et al.,2022). Within our Trust, inadequate monitoring of patients’ physiological observations resulted in delays in detecting acute deterioration, putting patients at risk. In response, the Critical Care Outreach Team (CCOT) spearheaded a quality improvement project, the Recognition and Escalation of Deteriorating Patients (REDP), aimed at enhancing the performance of ward staff in monitoring and escalating patients’ physiological observations and adherence to Trust National Early Warning Score (NEWS2) guidelines. This initiative facilitates the prompt recognition and escalation of acute deterioration, thereby increasing the chances of survival and improving the patient experience, leading to other positive health outcomes.

Driver Diagram and PDSA (plan-do-study-act) cycle were utilised to implement:

1. The ‘Observations Rounds’
2. The efficient utilisation of a digitalised real-time ‘Deteriorating Patient Dashboard’
3. Cultivating collaborative culture in developing effective strategies through CCOT partnerships with the senior and ward nursing staff.

The key metrics/performance indicators used were:

• Improved compliance with the Trust’s NEWS2 and Escalation Protocol
• Reduced cases of failure in recognising and escalating deteriorating patients

With the gaps in clinical practice identified and limited resources encountered by the team, thorough planning and employing CCOT’s advanced clinical practice were crucial to achieving the target outcomes. As a result, adherence to the Trust’s NEWS2 and Escalation protocol and clinical performance in recognising and escalating acute deteriorations improved from 55% to 89%. The electronic incident record also indicated a notable decrease in cases by 50%. The REDP delivered other positive outcomes, underscoring the project’s effectiveness in enhancing patient care.

The next phase focuses on sustaining a high standard of clinical practice in patient monitoring and developing innovative digitalised tools to support the nursing team in detecting and escalating patients’ deterioration.

Project Objectives

Instances of sub-optimal care resulting from failure to recognise and address deteriorating patients in adult in-patient wards threaten patient safety. It was determined that inconsistencies in monitoring physiological observations lead to substandard clinical performance. Dedicated to enhancing patient safety and improving care, the CCOT took steps to rectify this clinical sub-standard practice.

Identified gaps in practice include:

1. Lack of standardised practice or timing for patient observations
2. Overreliance of nurses on healthcare assistants for monitoring physiological observations
3. A high number of newly qualified and international nurses require training
4. Increased use of temporary staffing without proper knowledge of Trust policy/protocol.

To address these issues, several measures were implemented:

• ‘Observation Rounds’ (OR) to help nursing staff detect and promptly escalate acute deteriorations,
• Efficient use of the ‘Deteriorating Patient Dashboard’, a digitalised system that records all patients with high NEWS2 scores in real-time.
• CCOT partnership with the ward teams – ‘CCOT: Ward Buddies’

OR aims to standardise clinical practice and address inconsistencies in monitoring patients’ physiological observations. This involves setting specific times during the day and night when ward staff are required to check patients’ physiological observations, clinical needs, and concerns. The 2 AM observation rounds approach was redesigned to ensure stable patients have adequate rest and sleep.

Each observation round has specific tasks and responsibilities for ward staff, emphasising the early recognition and escalation of acutely ill patients. This improvement initiative promotes shared accountability within the multidisciplinary team, as all healthcare assistants, nurses, and clinicians can oversee patients’ observations through the real-time deteriorating patient dashboard. The observation rounds were initially piloted on nine wards at Chelsea and Westminster Hospital and, after proving highly effective, were implemented across both sites.

Each CCO practitioner was assigned specific wards to support and collaborate closely with the ward staff to enhance their performance. They scheduled meetings to assess and monitor the performance regularly. This collaborative work played a crucial role in fostering a culture of teamwork, overcoming barriers, and achieving desired outcomes.

As the CCOT struggled to embed the new change in practice, the CCOT Lead sought help from the Director of Nursing to get support and assistance in implementing the designed interventions. Senior management engagement and support from the Quality Improvement team and the CW+ charity made a significant difference in implementing the improvement initiatives.

Impact/Outcomes

The CCOT’s measures have improved the management of deteriorating patients, increased patient survival rates, and prevented adverse health outcomes. It has reached all adult patients in the in-patient ward across both sites of the Trust, including:

• A marked improvement in adherence to the Trust NEWS2 and Escalation Protocol and clinical performance in recognising and escalating acute deteriorations in the adult wards from 55% to 89%.
• Reduced cases of sub-optimal care due to failure to recognise and escalate deteriorating patients by 50%
• A new REDP analytic database clinical audit system was developed because of the team’s unwavering effort to find a more efficient way of monitoring ward performance. 
• Achieved a consistent high-performance result of > 90% in the Commissioning for Quality and Innovation (CQUIN) 7—Recording and Response to NEWS2 Score for Unplanned ICU admissions.
• Reduced unplanned ICU admissions from the wards.
• Patients now benefit from the early initiation of appropriate escalation and management, which leads to positive experiences, early recovery, and shorter hospital stays and promotes confidence in the healthcare system.
• Staff now benefit from a positive collaborative culture that motivates and empowers them to provide high-quality care, improving morale and confidence in providing the best care.
• The Trust benefits from more efficient resource utilisation concerning cost avoidance and reduction from reduced potential litigations, short hospital stays, and reduced unplanned ICU admissions. Moreover, the financial rewards from high performance in achieving Commissioning for Quality and Innovation (CQUIN7) Recording of and response to NEWS2 score for unplanned critical care admissions scheme target outcomes. Furthermore, the CCOT’s initiatives enhance the Trust’s reputation as one of the healthcare providers that prioritises high-quality care whilst promoting patient safety.

The CCOT’s measures have significantly benefited patients, staff, and the Trust, contributing to the organisation’s overall success in providing high-quality healthcare services.

Next Steps

The next phase of the project is focused on:

1. Working collaboratively with the senior management team to design a sustainability plan that would help maintain improved clinical performance in managing deteriorating patients
2. Developing new innovative digitalised technology  to support nursing staff in recognising and escalating deteriorating patients (i.e. integrate ALERTIVE system to Cerner to detect patients with high NEWS and directly notify clinicians and CCOT)
3. Involving of patients, carers, families, and members of the public in the evaluation of interventions and the design of sustainability plans

The REDP project ultimately aims to improve the recognition and response to deteriorating patients, a shared global mission of every acute health provider. All interventions were designed to enhance the monitoring of patients’ physiological observations that lead to timely recognition and response to acute deterioration, which is the routine clinical practice in any clinical area where every health institution aims to achieve a high-performance standard, as demonstrated by the ward staff. The measures implemented were directed at standardising the practice that guides and supports nursing staff to adhere to the NEWS2 and Escalation protocol and focused on embedding a practical approach and positive attitude to enhance clinical performance.

The REDP improvement initiatives also cover the health intervention transferability standard criteria within the primary and target context of environmental conditions, population characteristics, and the intervention’s transferrable core elements, including its need for adaptation. In line with the global trend of using innovative health technologies to take and record physiological observations, REDP improvement initiatives target the efficient use of a digitalised deteriorating patient dashboard, which other trusts may find helpful in their newly developed electronic systems. All initiatives have proven their value, practicality, and cost-efficiency, which other Trusts can adopt.

Applications for Cohort Two of the Horizon Fellowship are now open until Sunday 4 August, 2024. To apply, complete the application form or email horizon@cwplus.org.uk for more information.

For more information on the Horizon Fellowship, visit the CW+ website or check out our Innovation Directory to browse through the full list of Fellows.