Staff shortages and time targets barriers to spotting deterioration

A report by the Healthcare Safety Investigation Board (HSIB) found a number of factors can get in the way of providing prompt care to critically ill patients and called for a stronger, nationwide approach along the lines of national efforts to reduce deaths from sepsis.

“On one occasion there was only one nurse to cover 12 patient cubicles”

HSIB report

It found staffing issues in emergency care meant hard-pressed nursing staff struggled to do regular observations, which were key in identifying if a patient’s condition was getting worse.

Meanwhile, the HSIB’s Recognising and Responding to Critically Ill Patients report suggested the four-hour A&E target risked putting pressure on staff to hit deadlines rather than prioritise patients according to clinical need.

It also cautioned against an over-reliance on Early Warning Scores to identify deteriorating patients and called for more staff training.

The national investigation into the way healthcare teams identify and respond to seriously unwell patients was sparked by a case at an unnamed hospital in which a woman died less than 24 hours after coming into A&E with a potentially treatable condition.

The 58-year-old was taken to hospital in an ambulance with severe abdominal pain about a fortnight after having undergone emergency surgery for a perforated duodenal ulcer.

“We felt it would be beneficial to bring together experts and leaders in the field, so that there is a more unified approach”

Stephen Drage

Her condition deteriorated in the seven hours she spent in the emergency department and got worse after she was referred to a surgical ward.

But the investigation found nurses and doctors did not spot or respond to warning signs, and the woman later died after receiving treatment in intensive care.

A post-mortem found scar tissue – probably from the perforated ulcer – was partially blocking her duodenum and the cause of death was “shock secondary to bowel obstruction as a result of adhesions”, said the report, which suggested she could have been referred to surgery sooner.

In examining the case in detail, investigators found a number of factors that influenced decision-making and “why the patient’s deterioration was not sufficiently recognised or responded to”.

These included issues around the availability of staff and how information about the patient was recorded and communicated at different stages including staff handovers.

“The information that was communicated across the patient’s care eroded at each stage, resulting in limited awareness of her clinical risk,” said the report.

The patient spent two hours and 20 minutes on the surgical ward where it appeared staff “did not recognise the severity of her condition”, the report stated.

The surgical ward nurse had not reviewed the patient’s emergency department notes “because she was busy with other tasks and so was not aware of the patient’s clinical risk”, said the report.

“The nursing staff on the surgical ward focused on caring for the patient’s individual needs as opposed to making a complete assessment of her overall clinical condition,” it added.

“The absence of sufficient staff numbers and the right skills mix is inevitably a contributing factor”

Suman Shrestha

The report also highlighted a tendency to rely on Early Warning Scores when “working in a busy and complex environment” and focus on the latest observations rather than looking at the overall trend, which could result in staff being “falsely reassured”.

The HSIB, which looks into around 30 individual cases each year to draw out wider safety lessons, also reviewed research evidence, consulted experts in the field and professional bodies and looked at tools and guidance on treating deteriorating patients.

As part of the research, investigators visited two emergency departments to observe work practices and foundthe number of patients per staff member could vary significantly throughout a shift”.

“On one occasion there was only one nurse to cover 12 patient cubicles because the other three nurses were transferring patients to other areas of the hospital,” said the report.

“The remaining nurse was experiencing observably increased workload and pressure as a result.”

During these periods “staff struggled to achieve all required tasks, including taking regular observations”.

“It was observed the nurse in charge would rapidly move from one task to the next and was provided with a lot of verbal information. The nurse in charge stated that she tried to remember everything she had been told, however, she would at times forget,” said the report.

“The manner in which she coped with the amount of information she was given was by making notes, however, this was not always possible.”

Evidence gathered during interviews with staff and through observing emergency departments in action also “revealed that staff feel under pressure to achieve discharge, or admit patients, in order to achieve the four-hour standard” said the report.

In the emergency department that cared for the woman who died investigators found “the patient management system displayed which patients were close to breaching the four-hour standard as the most prominent indicator”.

“How information is displayed can influence how staff prioritise tasks. For example, prioritising a patient who is close to breaching the four-hour standard may lead to prioritising patients for operational reasons rather than on clinical need,” said the report.

This finding follows the recent publication of plans to scrap the blanket four-hour target in favour of an approach that prioritises the most acutely unwell patients.

Other concerns raised by the HSIB include the wide range of different guidance and publications on managing deteriorating patients which can “make it difficult for trusts and staff”.

At the time, the trust in question was using a locally-modified Early Warning Score. However, the HSIB said concerns raised about the way this had been deployed were applicable to the National Early Warning Score (NEWS) system developed by the Royal College of Physicians and recommended by the National Institute for Health and Care Excellence.

One of the key benefits of NEWS and the latest version NEWS2 was the fact it offered “a common language to communicate the physiological condition of a patient between staff”, said the report, which recommended NHS trusts used updated NEWS2 observation charts and protocols.

However, the report stressed NEWS2 – currently used by all ambulance and most acute trusts – was never intended to be deployed as a “stand-alone tool”.

“It is intended to be combined with other relevant charts, clinical investigation results and notes together with clinical observations of the patient,” said the report.

“There may be benefits to staff being trained in this approach and systems being designed to support bring relevant information together,” it added.

It recommended ongoing monitoring of the use of NEWS2 in practice, its effectiveness in different care settings and the guidance and training available to staff.

Another key recommendation was for NHS England and NHS Improvement to extend the remit of the Cross-System Sepsis Programme to include the physical deterioration of patients.

“They have already had great success with their work, and there has been an increase in the identification and timely treatment of sepsis,” said Dr Stephen Drage, director of investigations at HSIB.

“We felt it would be beneficial to bring together experts and leaders in the field, so that there is a more unified approach taken in tackling the recognition and response to critically unwell patients.”

The Royal College of Nursing welcomed the call for a national approach to deteriorating patients.

It also highlighted the need to ensure patients received appropriate information on being discharged from hospital and to address staffing shortages that can make delivering optimal care much harder.

“The absence of sufficient staff numbers and the right skills mix is inevitably a contributing factor in failures to recognise and treat deteriorating patients. We need greater accountability for delivering this at the highest levels,” said Suman Shrestha, RCN professional lead for acute emergency and critical care.

However, he said the RCN was not convinced the four-hour A&E target had been a factor in specific case discussed in the report.

“We have seen no evidence that the four-hour target has been a contributing factor; we continue to engage with NHS England regarding the efficacy of this target and potential alternatives to ensure patients are treated quickly and safely,” he said.

“We will be taking these issues forward through our advisory group which is already in place to do this”

Andrew Goddard

The Royal College of Physicians said it would be taking forward the report’s recommendations on NEWS2.

“This HSIB investigation confirms the value of the RCP’s NEWS2 in identifying deteriorating patients,” said RCP president Andrew Goddard.

“The report identifies several areas where the RCP can review the training and implementation around NEWS2 and we will be taking these issues forward through our advisory group which is already in place to do this,” he said.

NEWS2 Development Group lead Professor Bryan Williams said the free NEWS resource had helped save “thousands of lives” in the UK and across the world.