Recognising and responding to physical deterioration of patients within a mental health and learning disability NHS Foundation Trust using a physiological track and trigger system

• Our aim was to improve the recognition and response to the physical deterioration of patients in line with NICE CG50: Acute illness in adults in hospital: recognising and responding to deterioration.   
• Our objective was to improve physical health provision and outcomes for our patients.

Geographically,  Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) is a large mental health and learning disability Trust spread over coastal, rural and industrial areas providing care to an estimated population of 1.9 million people. The government mental health strategy No Health without Mental Health states ‘more people with mental health problems will have good physical health. Fewer people with mental health problems will die prematurely’ (Department of Health, 2011). This was further reiterated by the Royal College of Psychiatrists' publication, Whole-Person Care: from rhetoric to reality achieving parity between mental and physical health (RCPsych, 2013).

As a response, TEWV identified physical healthcare as a priority in their 2014-17 Business Plan which resulted in the implementation of a new physical healthcare project to review and improve the Trust’s current approach to the physical healthcare of patients. One of the key aims of the project was to increase staff awareness and knowledge of recognising and responding to the physical deterioration of patients whilst in our care. Despite having an existing Early Warning Score (EWS) procedure, it was evident that from an initial baseline scoping exercise that the use of the EWS was not embedded across the organisation, resulting in disparity in the frequency of monitoring, documentation, and response to the deteriorating patient.

The Physical Healthcare Project Team held engagement events with clinical staff to gain an understanding of why there was variability in the use of the Early Warning Score (EWS) tool; and to gain an understanding of the staffs’ challenges in delivering physical healthcare in a mental health and learning disability setting. Feedback highlighted that staff were not confident in using the EWS, were unclear when to complete the EWS and that further awareness and support to embed the EWS was required.

A Physical Healthcare Project Steering Group was formed to include key stakeholders to debate and agree a new Procedure for Using the Early Warning Score for the Early Detection and Management of the Deteriorating Patient and standardise charts for both adult and young people for all services in the Trust. The new procedure reflected the National Early Warning Score (NEWS) and NICE CG50 whilst taking into consideration the needs of patients within a mental health and learning disability setting.

A training package was developed by the Physical Healthcare Project Clinical Educator for clinical staff to increase their knowledge and skills in the use of the EWS to promote the early detection, prevention and management of physical health deterioration. Training commenced in the localities and services that had been identified through the scoping exercise as inconsistently using the EWS in practice.

Due to the geography of the Trust and the difficulties of getting staff released for training, the training was delivered on site within each service area as a two hour session. The Project Team publicised the new procedure and EWS charts trust-wide, including a quick reference guide that was circulated to all inpatient areas to display within their clinical area/EWS folder. The guide offered clarity of when to record the EWS, frequency of monitoring and how to interpret and respond accordingly.

This information was shared at the training session, via a post training email and regularly in the Trust e-bulletin. A EWS audit tool to reflect the updated procedure and charts was developed with support from the Clinical Audit and Effectiveness Team. Once EWS training was complete, the Project Team visited each service specific area approximately one month following the training to conduct the audit to monitor compliance with the EWS procedure and identify any areas where staff needed further support.

Staff attending Early Warning Score (EWS) training were asked to complete a pre and post assessment of their knowledge, understanding, confidence and competence of EWS.  In the six months since the training commenced, a total of 386 staff have completed the EWS training. All staff reported either an increase in their understanding, confidence and competence or the same level following the training. Compliance of the EWS procedure was monitored through audit.

The audit results indicated that 100% of wards audited had completed an EWS on admission to an inpatient unit to provide a baseline assessment.  81% of EWS charts audited, highlighted that all EWS scores were calculated correctly, however this indicated further improvement could be made which was included in the audit action plans. 100% of wards audited had the quick reference guide on display in their clinic room/EWS folder.

The audit highlighted areas for improvement such as accurate calculation of EWS scores, documentation on the electronic patient record and response and actions to raised EWS scores. Audit action plans were disseminated to each area and progress against actions were monitored by the Physical Healthcare Project Clinical Educator. A survey was distributed to all staff who had attended the original engagement events. Results indicated that 100% of staff surveyed felt more confident in monitoring a patient’s physical health using the EWS tool and had observed a change in culture in how the Trust prioritises physical healthcare.

• EWS training to form part of the physiological observation training package in the future.
• All staff to record response and action to raised EWS scores on the patient’s electronic record.
• Annual EWS audit to monitor compliance.
• Engagement and consistent communication with clinical staff to disseminate learning points from the audit results.