Shared learning database

Type and Title of Submission


Evolving a comprehensive, integrated and effective Trust wide strategy in optimising the management of deteriorating patients


The Trust set up a steering group in direct response to the publication of "Acutely ill patients in hospital", (NICE CG50 2007) and "Recognising and Responding Appropriately to early signs of deterioration in hospitalised patients", (NPSA 2007). This group set up a range of comprehensive initiatives designed to improve early monitoring and management, including the use of educator teams to peripatetically introduce a range of trust wide competencies. Monitoring has shown that there has been marked improvement over the last four years and this work continues to be seamlessly integrated with other related patient safety initiatives .

Does the submission relate to the general implementation of all NICE guidance?


Does the submission relate to the implementation of a specific piece of NICE guidance?


Full title of NICE guidance:

CG50 - Acutely ill patients in hospital

Is the submission industry-sponsored in any way?


Description of submission

Aims and objectives

Local and national data strongly suggested a gap in the relevant skill set in dealing with acutely ill/deteriorating patients. The aim was to promote rapid and consistent recognition and treatment of the acutely ill/deteriorating adult patient through the delivery of a robust, supportive and comprehensive Trust strategy launched in May 2008. This required an integrated, concerted global approach utilising enhanced critical care outreach service provision, improved early warning systems, supportive policies and guidelines, delivery of specifically designed practical ward based competencies, SMART action plans, monthly ward based quality reviews and detailed large scale bi-annual audit.


Prior to NICE CG50 (2007) there was no Trust mechanism for co-ordinating strategy for acutely unwell patients. The Acutely Ill Steering Group (AISG) was set up consisting of a Clinical Lead, Director and representatives from all clinical areas. This group detailed an initial gap analysis and led on detailed within the NICE CG50 (2007) document. The group reports on progress to the Patient Safety & Quality Standards Committee which is then communicated to the Trust through the Audit & Clinical Excellence Committee. EWS was not embedded in every in every clinical area. An initial baseline NICE CG50 (2007) audit was carried out in a single day in March 2008 on 490 individual patients. 6 key parameters were audited. Only 71% of patient had an Early Warning Score (EWS) in place. Of these, only 52% had observations monitored at least 12 hourly with only 66% of parameters recorded (one parameter was as low as 11%). 90% of patients had no indication of the frequency for observations in their monitoring plans. The NICE CG50 recommendations were mapped according to risk. From this, it was clear that as a Trust we needed to take firm action to ensure the majority of these risks (most were not adequately met) were managed. A critical care outreach team was in place but did not cover 24 hours There was no policy or guidelines for monitoring and responding to acute illness. It was uncertain how much ward culture would need to adapt to meet the challenges for monitoring and responding to acute illness, not least of which was the issue of communicating and escalating concerns. There was no strategy for delivering training for staff on dealing with acute illness. No matter which model was in use, the trend for mortality within the Trust was generally high immediately prior to and in the introductory stages of the initiatives. For example, one model shows a relative risk of between 158 and 170 during April-August 2008 (see supplementary information "Nice CG50 4 years on")


The critical care outreach team was funded to a 24 hour service and Hospital at Night services within the Trust were fully reviewed A policy for Acute Illness was ratified by the AISG Mandatory AIM training was set up for all nursing & allied staff Trust grades 4+ caring for in patient adults The EWS Track and Trigger chart was adapted to include a robust monitoring plan, prescription of observations and more detailed parameters. It has since been modified to include oxygen prescription as per BTS (2008) Oxygen Therapy Guidelines and is accompanied by detailed clinical guidelines on its application. Modified versions of this chart and accompanying guidelines are in use within obstetrics and paediatrics. The educator team was part funded by the SHA for 2 years at 167, 055 for each year and embedded the competencies for acute illness within all in patient adult areas. They were adapted according to discipline, level of responsibility and area. Most competencies were facilitated through ward based training of key educational facilitators in each area. The educator team also led on related practice improvements such as fluid balance, SBAR, inclusive handovers, prioritisation of observations and support of new services (e.g. surgical close observation unit at North Tees). Debriefing to ward leads led to marked improvements that in some cases led to complete changes in ward organisation The educator teams developed a withdrawal strategy which provided the AISG with a means of developing focused directorate action plans Monthly Patient Safety & Quality Standards visits showed significant investment from Trust leadership and take place each month led by the Director of Nursing. Each clinical area is carefully audited with detailed feedback. Additional Trust mechanisms such as the weekly Serious Untoward Incident meeting (SUI), and Global Trigger Tool (GTT) are linked to the work already undertaken on the identification and management of acutely unwell patients.

Results and evaluation

Bi-annual Clinical Guideline 50 audit continues and won a local audit award in 2009. The May 2011 audit utilised 451 patients. 97% (26% more) of patient's have an Early Warning Score (EWS) in place. 88% have observations monitored at least 12 hourly - a rise of 26%. 96% compliance shows a 30% improvement. Monitoring plans are specified in 71% of patients compared to 10% at outset. EWS is utilised with every in patient adult.
Over 2 years, a team of educators, (consisting of 1 Trust Grade Band 6 and 4.5 Trust Grade Band 5's) were tasked to ensure 100% of the target staff were to be trained on the practical, ward based competencies. 74% (N=1070) target staff were trained of which 59% completed their competencies within just 2 years.
Areas not meeting the standard from monthly Patient Safety & Quality Standards is given detailed measures. All clinical areas have responded to the challenge and met the standard required Progress toward maintaining the standards within NICE CG50 is risk assessed as part of a Corporate Risk Assessment/Action plan. The Trust has fully met 68% of actions within this with the remainder requiring continued monitoring. This reduced the risk to the required target level. Directorates provide monthly reports to the AISG detailing how their action plans are being met. Some examples include; NICE audit, AIM/competency training and compliance over innovations relating to communication such as SBAR. Overall, the greatest problem is in maintaining competencies for acute illness due to problems with staff turnover.
When considered alongside other related Trust initiatives such as serious untoward incident analysis and the use of global trigger tools, mortality reduction may be relevant. At the outset, Trust mortality was very high with a relative risk of over 170 (August 2008). Over the year following, this dropped by more than 15%. Moreover, the trend has continued and our relative risk has reduced to just over 90 in July 2011.

Key learning points

The objective of training 100% of target staff within the first 2 years of the project was unrealistic. What was unanticipated was the degree to which this would be dependant on addressing ward culture. Significant practice development requires a proportional degree of change management to achieve ownership and successfully embed the underlying concepts for acute illness recognition and management. Without this investment the competencies would have been without value.

Every clinical area was given action plans at the outset for ensuring that the competencies were embedded into clinical practice. Although this incorporated many elements of the directorate action plans that would emerge later when the educator withdrew in 2010, they lacked the corporate responsibility and accountability which now exists. High profile and specific directorate action plans should have been in place at the outset. A minimum standard for achievement should be clearly highlighted within these action plans.

Aim training does include training on ABCDE assessment and SBAR communication which is inextricably linked to the use of EWS and how it is utilised. However, there is much work to do in order to ensure that this is being applied in clinical practice. In hindsight, once educator teams completed in 2010, a clear strategy for how this could be facilitated should have been implemented.

View the supporting material

Contact Details

Name:Tess Moore
Job Title:Senior Clinical Nurse
Organisation:North Tees & Hartlepool NHS Trust
Town:Stockton on Tees
Postcode:TS19 8PE
Phone:01429266654 Ext 3788


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This page was last updated: 31 January 2012

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Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.