After World Sepsis Day on 13th September 2020, Dr Ron Daniels BEM, Chief Executive of the UK Sepsis Trust, provides his thoughts on the importance of standardising the national track and trigger systems across primary and secondary care to improve early detection in the deterioration of patients.
Standardising the process of monitoring patients to quickly and effectively detect deterioration, is a problem faced by healthcare professionals across the UK. With staffing issues, inter-observer discrepancies and transcription error there are many variables that impact on patient assessments which can subsequently lead to poor outcomes. Studies show that Respiratory Rate (RR) changes 6-8 hours before a major event, and by using a standardised track and trigger process such as NEWS2 to identify a change in accurate RR earlier, the patient data can be mapped and patient outcome could be improved.
The infrequent nature of observations due to staffing levels is a major problematic factor in the monitoring of patients. Typically taken by non-nursing staff, such as healthcare assistants, current guidelines recommend that patient observations are conducted every 12 hours as a minimum frequency. However, it is widely acknowledged that this ‘12-hour wait’ could be too long a period to effectively detect and manage patient deterioration. Inter-observer variability also impacts readings - successfully making note of an observation requires the close attention of the healthcare professional to the patient, however, this is rarely possible. Disruptions by the surrounding setting such as patient/family discussions and interruptions make taking an accurate reading very difficult. Even the background noises of a busy ward environment can impact on how successfully RR or heart rate is measured. In addition, it is also fairly common for observation numbers to be rounded up or down which obviously compromises accuracy. In fact, many Trusts report transcription error rates at between 2% and 5%, with some suggesting that the true figure may be as high as 18%.
Observing a change in Respiratory Rate can identify a patient at risk of deterioration before other parameters begin to show. RR is a very sensitive marker and tends to change before other markers indicating serious illness. Listed as one of the key red flags by NICE, if a patient with an infection develops a RR of over ‘25’, NICE recommends that the patient is treated as having sepsis. This early identification, before septic shock takes hold, is key and allows for a patient to be treated quickly on the ward using the ‘Sepsis Six’ which changed in 2019; request a senior clinician to attend, give oxygen if saturations are low, obtain access and take bloods (including cultures), give IV antibiotics, give IV fluid, and monitor including NEWS2 and urine output1.
If we allow patient deteriorations to progress, not only does it increase the risk of a more complicated, compromised and in many cases tragic patient outcome, it also increases NHS costs. From a clinical value perspective, if the deterioration of a patient isn’t acknowledged and treated with speed, their length of stay will increase and their care will in all likelihood need to be escalated to ICU. As an example, if a patient develops sepsis and needs to be moved to an intensive care bed, this treatment costs the NHS around £30,000, however if the deterioration is spotted earlier, patients can be treated using the ‘Sepsis Six’ on a ward.
Those healthcare professionals working and familiar with the acute sector understand that Respiratory Rate is the single most important factor in detecting patient deterioration. Those recently trained may not be as familiar with its importance, but much has been done and great progress has been made to highlight and raise awareness of this issue – these include initiatives and courses such as AIM and ALERT. However, more work needs to be done outside the acute care sector to reinforce the important RR message.
Sometimes those that require treatment on an AMU (Acute Medical Unit) are referred by their GP. Currently there isn’t a perfected track and trigger system to clarify the severity of the patient’s illness from primary to secondary care. However, it is vital that the same system is used across all areas of the NHS from community to hospital settings, using the National Early Warning Score or NEWS2.
A challenge that faces the current NEWS2 system is that there is a lack of evidence surrounding its effectiveness in a primary care setting. This isn’t because the system is wrong in itself, there just aren’t many studies that have sufficiently evaluated the impact of a track and trigger system at a primary care level. As we increasingly move towards community led care with more complex cases being managed within the community setting and patients being discharged earlier due to pressures on the system, it becomes increasingly important that the mechanisms in the community mirror those used in hospitals. It would be logical to standardise systems, such as NEWS2, to enable and facilitate observation data to be shared. This is already happening with the ambulance service and in some GP surgeries, but to ensure that these processes are fully optimised across both primary and secondary care they need to be made a national standard.
If these standardised processes are then automated to link to a patient’s EPR (Electronic Patient Record) a dashboard can be used to efficiently observe and give an accurate reading of a patient’s state. This can be easily seen by on-call doctors or Critical Care teams, allowing for an at-a-glance overview of a patient’s condition, which in turn allows for the healthcare team to prioritise treatments and any necessary interventions.
Finally, the automation and standardisation of observation data will also allow for the iteration of the NEWS2 process over time. If all patient data can be accumulated and mapped all the way to outcomes, we will have a far better understanding at a granular level, which areas of the observation process are working well, and which areas need improving. We may learn over time that a RR of 28 is more predictive than that of 25, however, we can only secure this insight and make strides and improvement in patient treatment through the standardisation of data collection. Mapping data across all care settings, both primary and secondary, will help improve patient outcomes.
Global medical technology leader Hillrom and The UK Sepsis Trust earlier this year announced a year-long partnership to raise greater awareness of sepsis. Together they are working together to provide training to hospitals on how they can use existing technology to help identify deteriorating patients more quickly. By using a fully connected vital signs patient monitor and an approved track & trigger System, such as NEWS2, clinicians can help deliver the Early Warning Score that aids rapid diagnosis and treatment.