Shared learning database

Velindre NHS Trust
Published date:
February 2011

Implementing the NICE Acutely ill Patients in hospital guidelines (CG50) using a care bundle based approach has improved the care and management of the acutely ill patients within a regional oncology hospital.

Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

To Improve the Care and management of the Acutely unwell patient within a regional cancer centre. - Improve reliability of observations. - Improve recognition of the acutely unwell oncology patient. - Improve medical response to the acute patient. - Introduce a MEWS system. - Develop a Sepsis screening tool for use in oncology patients. - Standardise Care for Severe Sepsis.

Reasons for implementing your project

The oncology setting where I work has no critical care facilities on site. This means that when our patients become acutely ill and require step up to a higher level of care this has to be delivered at the local DGH which is 2.5 miles away (approx 5 minutes in ambulance). Baseline audits of observation recordings show that patients respirations were not being recorded and a standard daily chart was in use for observations to be recorded along with other risk assessments, interestingly the observations of Temperature, pulse and Blood pressure were the only observations that were being recoreded and these were placed right at the bottom of the chart. There was also evidence to suggest that patient transfers were sometimes inappropriate, should of happened sooner or potentially could even have been avoided. There is no need to point out the cost effectiveness in terms of finance in these cases, but also the psychological cost to the patient having to experience an acute 999 transfer and admission to the High dependancy or intensive care unit.

How did you implement the project

A Pilot ward was chosen which was the inpatient Chemotherapy ward. This ward is also the admission ward for all emergency chemotherapy triaged admissions. Training and education was provided as part of the ward's Mandatory and statuatory training, utilising real case examples from the ward. A MEWS chart and sepsis screening tool were adapted for use in the oncology setting and further training around their use was required. Also we developed guidelines for the response to the acutely ill patient which were implemented with the MEWS chart. We used a care bundle approach to implement these slowly, this meant adopting the admission bundle, the recognition bundle and the response bundle focusing on the elements of care suggested in the clinical guideline. There were many problems encountered with the MEWS chart itself, font size etc and this required many changes. Some staff have been reluctant to engage with the process and we have had to overcome this by using the champions and providing regular feedback of good practice to the ward. The collection of the quantative data has proved very difficult to maintain and this has been one of the main challenges encountered.

Key findings

The recording of observations was audited by using the NPSA chart checker and this showed >95% compliance with recording of all observations, use of MEWS scores and escalation of the deteriorating patient to the medical team for review. Early indications from an audit of the emergency transfers of patients from the ward, along with global trigger tool audits show improved practice in managing the acutely ill patient and also that the patients who required transfer were transferred appropriately and in a timely manner and transfers of care in some instances have been avoided.

Key learning points

Use a small step change approach, utilsing PDSA methodology. Ensure you have Senior Leadership engagement and full support. Communication is vital! Identify Clinical Champions and give ownership to the ward staff for the data collection which is more meaningful to them in order to measure how you are doing. Use real patient examples for teaching purposes as these have proved very powerful.

Contact details

Ceri Stubbs
Clinical Lead - Critical Care
Velindre NHS Trust

Secondary care
Is the example industry-sponsored in any way?