Early Warning Score

Implementing a Digital Deteriorating Patient Pathway to improve the safety and effectiveness of care of the adult deteriorating patient

Original Articles, Volume 23, Issue 1, Pages 1 – 52 (2024)

Identification, escalation and clinical review of the deteriorating patient is essential for a safe and effective hospital. We present a deteriorating patient pathway developed within our electronic patient record, including implementation of a digital escalation and senior review process, triggered from a logic algorithm and vital signs. The pathway is activated by an average 43 patients per day with median mortality of 13.3%. Our Trust has seen a significant improvement in escalation and senior review and increased use of treatment escalation plans. The pathway has facilitated a cultural shift in the Trust towards the deteriorating patient. The new pathway is transferrable to both other digital Trusts as well as maternity and paediatric practice.

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Using trends in electronic recordings of vital signs to identify patients stable for transfer from acute hospitals

Original Articles, Volume 18, Issue 4, Pages 205 – 264 (2019)

Patients who are stable might not be required to remain in hospital. We aimed to create objective criteria to indicate stability based on vital signs. An index based on NEWS (NBI) was compared to a Patient Stability Index (PSI) algorithm created by random forest analysis.

Data from the VITAL II study was used to train the algorithm and data from the VITAL III study to validate it. Failure rate of the algorithms was set close to the rate of readmission to UK hospitals at 15%. After a training period of two days the NBI identified stability with acceptable failure rates only after a further 96 hours with a subsequent release of 2143 bed days compared to the PSI which identified stability after only 12 hours leading to potential earlier release of 2652 bed days.

Vital sign-based algorithms might be able to predict safe transfer from hospital and inform management of flow.

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Continuous Monitoring of Respiratory Rate on General Wards What might the implications be for Clinical Practice?

Original Articles, Volume 17, Issue 1, Pages 1 – 56 (2018)

Abstract

A high respiratory rate is a significant predictor of deterioration. The accuracy of measurements has been questioned.

We performed a prospective observational study of automated electronic respiratory rate measurements and compared measurements with electronic counts obtained in the 10 minutes prior to the manual measurement.

For 182 patients 1331 matching measurements could be compared. The mean age of these patients was 68 (SD 14) years. 96 (53%) of patients were female.

While mean and median measurements were similar frequency distributions were significantly different. Manual measurements were markedly lower than electronic measurements in patients with higher respiratory rates.

While electronic measurements are likely to be more reliable clinical implications require further investigation to clarify whether existing algorithms including Early Warning Scores will need adjustment.

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The Team at Work – The Society for Acute Medicine’s Benchmarking Audit 2014 (SAMBA’14)

Research Audit and Clinical Practice, Volume 14, Issue 3, Pages 97 - 144 (2015)

Abstract

Background: The Society for Acute Medicine’s Benchmarking Audit (SAMBA) serves as a tool for Acute Medical Units to compare and improve their quality of care.

Aim: To audit the performance of Acute Medical Units against clinical quality indicators, standards by the Royal College of Physicians and Specialist Societies relevant to the practice of Acute Medicine.

Methods: An online survey of unit profiles and staffing levels on the audit day was followed by a 24-hour data collection on Thursday the 19th of June 2014 for all patients seen by the local Acute Medicine teams as part of the general medical take. Patients were followed-up for 72 hours. We reviewed the impact of staffing levels on performance indicators.

Results: 66 Acute Medical Units admitted 2333 patients during the 24-hour period. Compliance with the quality standards of SAM was as follows: 84% of patients had an early warning score recorded within 30 minutes of admission, 81% of patients had been seen by a competent decision maker within four hours and 73% of patients were seen by a consultant physician within the appropriate period of time. Only 56% of patients received a standard of care compatible with all three quality standards. We found no relation between unit characteristics, staffing and performance indicator.

Conclusion: There remains a gap between the standard described by the quality indicators and the performance of Acute Medical Units during a one-day audit.

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‘State of the Nation’ – The Society for Acute Medicine’s Benchmarking Audit 2013 (SAMBA ’13)

Research Audit and Clinical Practice, Volume 12, Issue 4, Pages 185 - 252 (2013)

Abstract

Background: Benchmarking is important to improve quality of care.

Aim: To audit the performance of Acute Medical Units (AMUs) against the clinical quality indicators published by the Society for Acute Medicine (SAM).

Methods: 24-hour data collection on the 20th of June 2013 with follow-up data at 72 hours.

Results: 43 units submitted data on 1425 patients. 76% of patients had early warning scores recorded within 30 minutes of admission, 95% of patients had been seen by a competent decision maker within four hours. 79% of patients were seen by a consultant physicians within the appropriate period of time.

Conclusion: The difference in compliance with quality standards between UK units opens opportunities for learning. The reasons why some units perform better than others require further investigation.

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A Day in the Life of the AMU– The Society for Acute Medicine’s Benchmarking Audit 2012 (SAMBA ‘12)

Research Audit and Clinical Practice, Volume 12, Issue 2, Pages 65 - 124 (2013)

Abstract

Background: The absence of published data for benchmarking serves as a disincentive for Acute Medical Units to improve care.

Aim: To test feasibility of a national audit in Acute Medicine for compliance with common standards

Methods: On line questionnaire with summary data for patients admitted to participating Acute Medicine Units over a 24-hour-period.

Results: 30 units submitted summary data. The mean number of admission was 36 (SD 14). Compliance with standards around timing of junior and senior review was highly variable. In almost all other standards only a small number of units achieved high reliability with compliance of more than 90%.

Conclusion: SAMBA provides a data set that can be used for local and national benchmarking and quality improvement work. Annual audit might be beneficial to track improvements.

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