Care of deteriorating patients

Staff at Salford have already put a number of changes into practice as they endeavour to reduce in-hospital cardiac arrest and mortality rates through earlier recognition and treatment of the deteriorating patient.

One of the key things Salford did before making any significant changes was investigate the trust’s rate of unexpected cardiac arrests. An expert multidisciplinary steering group found the rate was within the national average, but the trust wanted to learn how to do better. 

One of the required changes was to improve the standard of recording and responding to acutely unwell patients. The solution the trust chose was to move away from electronic clinical observations and return to using the manual blood pressure machine.

Installing an old-fashioned sphygmomanometer beside every hospital bed may seem at odds with 21st century quality healthcare, but recalling this key cornerstone in nursing provision from the past has already contributed to the 30 per cent reduction in unexpected cardiac arrest outside critical care that Salford Royal Foundation Trust has achieved since signing up to Patient Safety First in 2008.

Peter Murphy, assistant director of nursing for quality improvement, says: “At first the idea that taking blood pressure manually could be the more accurate option seemed crazy, but in fact it makes good sense.

“When you take blood pressure manually, you also check the pulse and touch the patient’s skin and look at their face, all very important clinical observations. Having a nurse on hand to explain what’s happening, especially if there is a problem, is a better experience for the patient.”

The sphygmomanometer’s reappearance, however, will be a gradual process with the pace dictated at ward level - an essential characteristic of Patient Safety First’s philosophy of small steps to achieve sustained change. 

Ward to board

“Our success is due to executive support, with our trust board signed up to the whole programme,” says Mr Murphy, who has been closely involved from the outset in his previous role as nurse consultant in critical care. “But that support is very different from target-setting.”

Change, he explains, is decided at ward level. “It is a continuing opportunity for healthcare teams to redefine their roles and redesign their own working practice. I’m merely a spokesperson for the work that is being done by my colleagues.”

During the first year of Patient Safety First, the deterioration interventions have been tested in 12 wards at Salford with the highest rates of unexpected cardiac arrest, implementing the Institute for Healthcare Improvement’s Breakthrough Series Collaborative Model.  A driver diagram, now part of Patient Safety First’s suggested guidance, was constructed during a focused half day by the expert group that included all key stakeholders from consultants to porters.  This democratic approach to patient safety is reflected in the change package.

A code red alert has been introduced to ensure that every member of staff on the ward, from housekeeper to visiting consultant, is aware that a patient has suddenly become unwell.  Identified by a red spot beside the patient’s name on the board by the nurses’ desk, the alert is also communicated verbally so that everybody is watching out for that person, says Mr Murphy.

A nurse-led response to acute illness initiative means that, when appropriate, in response to an elevated early warning score, nurses are encouraged to first sit the patient up, put oxygen on the face and make sure medication is up to date. 

A reliable ward round checklist, identifying the essential components of the regular consultant ward round, has proved popular throughout the hospital. The checklist ensures that every component of the ward round is covered reliably for every patient.

Underpinning these life-saving initiatives is a decision-making tool around the escalation of care, based on a ceiling of care document. It provides clarity for staff to reliably identify in advance (and discuss in a “ward safety huddle”) whether a seriously ill patient will benefit from resuscitation in the event that they suffer a cardiac arrest.

After 18 months, the view is that there is still a long way to go. The good news, says Mr Murphy, is that safer care for patients appears to bring greater job satisfaction for nurses. In the first year the organisation had a 32 per cent reduction in the number of cardiac arrests.

The second wave of wards that have applied the change package are continuing to demonstrate further significant reductions. There is a definite suggestion that these issues are linked: “The staff involved in the Patient Safety First campaign come to work every single day to provide improved care to patients”, he says.