The development and introduction of a national e-learning programme to support the dissemination of NEWS2.

Early detection, timeliness and competence of clinical response are a triad of determinants of clinical outcome in people with acute illness. In 2012, the Royal College of Physicians published the National Early Warning Score (NEWS) with the aim of standardising the response to, assessment of and monitoring of acutely ill patients. This was subsequently updated in December 2017 to become NEWS2. Alongside the development of NEWS/NEWS2, it was clear that a supportive educational package was going to be essential for dissemination, learning and national adoption of NEWS/NEWS2 across all healthcare settings. Another driver for the early development of an e-learning package to accompany the launch of NEWS in 2012 was the opportunity that it provided not only to standardise the early warning system across the NHS but also to use that standardised process to facilitate better and more consistent education and training across the entire healthcare system; building on the concept of NEWS providing a common language.

Quality metrics for the evaluation of Rapid Response Systems: Proceedings from the third international consensus conference on Rapid Response Systems.

BACKGROUND: Clinically significant deterioration of patients admitted to general wards is a recognized complication of hospital care. Rapid Response Systems (RRS) aim to reduce the number of avoidable adverse events. The authors aimed to develop a core quality metric for the evaluation of RRS. METHODS: We conducted an international consensus process. Participants included patients, carers, clinicians, research scientists, and members of the International Society for Rapid Response Systems with representatives from Europe, Australia, Africa, Asia and the US. Scoping reviews of the literature identified potential metrics. We used a modified Delphi methodology to arrive at a list of candidate indicators that were reviewed for feasibility and applicability across a broad range of healthcare systems including low and middle-income countries. The writing group refined recommendations and further characterized measurement tools. RESULTS: Consensus emerged that core outcomes for reporting for quality improvement should include ten metrics related to structure, process and outcome for RRS with outcomes following the domains of the quadruple aim. The conference recommended that hospitals should collect data on cardiac arrests and their potential predictability, timeliness of escalation, critical care interventions and presence of written treatment goals for patients remaining on general wards. Unit level reporting should include the presence of patient activated rapid response and metrics of organizational culture. We suggest two exploratory cost metrics to underpin urgently needed research in this area. CONCLUSION: A consensus process was used to develop ten metrics for better understanding the course and care of deteriorating ward patients. Others are proposed for further development.

Crisis checklists for in-hospital emergencies: expert consensus, simulation testing and recommendations for a template determined by a multi-institutional and multi-disciplinary learning collaborative.

BACKGROUND: 'Failure to rescue' of hospitalized patients with deteriorating physiology on general wards is caused by a complex array of organisational, technical and cultural failures including a lack of standardized team and individual expected responses and actions. The aim of this study using a learning collaborative method was to develop consensus recomendations on the utility and effectiveness of checklists as training and operational tools to assist in improving the skills of general ward staff on the effective rescue of patients with abnormal physiology. METHODS: A scoping study of the literature was followed by a multi-institutional and multi-disciplinary international learning collaborative. We sought to achieve a consensus on procedures and clinical simulation technology to determine the requirements, develop and test a safe using a checklist template that is rapidly accessible to assist in emergency management of common events for general ward use. RESULTS: Safety considerations about deteriorating patients were agreed upon and summarized. A consensus was achieved among an international group of experts on currently available checklist formats performing poorly in simulation testing as first responders in general ward clinical crises. The Crisis Checklist Collaborative ratified a consensus template for a general ward checklist that provides a list of issues for first responders to address (i.e. 'Check In'), a list of prompts regarding common omissions (i.e. 'Stop & Think'), and, a list of items required for the safe "handover" of patients that remain on the general ward (i.e. 'Check Out'). Simulation usability assessment of the template demonstrated feasibility for clinical management of deteriorating patients. CONCLUSIONS: Emergency checklists custom-designed for general ward patients have the potential to guide the treatment speed and reliability of responses for emergency management of patients with abnormal physiology while minimizing the risk of adverse events. Interventional trials are needed.

Clinical outcomes of patients seen by Rapid Response Teams: A template for benchmarking international teams.

AIM: The study was developed to characterize short-term outcomes of deteriorating ward patients triggering a Rapid Response Team (RRT), and describe variability between hospitals or groups thereof. METHODS: We performed an international prospective study of Rapid Response Team (RRT) activity over a 7-day period in February 2014. Investigators at 51 acute hospitals across Australia, Denmark, the Netherlands, USA and United Kingdom collected data on all patients triggering RRT review concerning the nature, trigger and immediate outcome of RRT review. Further follow-up at 24h following RRT review focused on patient orientated outcomes including need for admission to critical care, change in limitations of therapy and all cause mortality. RESULTS: We studied 1188 RRT activations. Derangement of vital signs as measured by the National Early Warning Score (NEWS) was more common in non-UK hospitals (p=0.03). Twenty four hour mortality after RRT review was 10.1% (120/1188). Urgent transfer to ICU or the operating theatre occurred in 24% (284/1188) and 3% (40/1188) of events, respectively. Patients in the UK were less likely to be admitted to ICU (31% vs. 22%; p=0.017) and their median (IQR) time to ICU admission was longer [4.4 (2.0-11.8) vs. 1.5 (0.8-4.4)h; p<0.001]. RRT involvement lead to new limitations in care in 28% of the patients not transferring to the ICU; in the UK such limitations were instituted in 21% of patients while this occurred in 40% of non-UK patients (p<0.001). CONCLUSION: Among patients triggering RRT review, 1 in 10 died within 24h; 1 in 4 required ICU admission, and 1 in 4 had new limitations in therapy implemented. We provide a template for an international comparison of outcomes at RRT level.

'Score to Door Time', a benchmarking tool for rapid response systems: a pilot multi-centre service evaluation.

INTRODUCTION: Rapid Response Systems were created to minimise delays in recognition and treatment of deteriorating patients on general wards. Physiological 'track and trigger' systems are used to alert a team with critical care skills to stabilise patients and expedite admission to intensive care units. No benchmarking tool exists to facilitate comparison for quality assurance. This study was designed to create and test a tool to analyse the efficiency of intensive care admission processes. METHODS: We conducted a pilot multicentre service evaluation of patients admitted to 17 intensive care units from the United Kingdom, Ireland, Denmark, United States of America and Australia. Physiological abnormalities were recorded via a standardised track and trigger score (VitalPAC™ Early Warning Score). The period between the time of initial physiological abnormality (Score) and admission to intensive care (Door) was recorded as 'Score to Door Time'. Participants subsequently suggested causes for admission delays. RESULTS: Score to Door Time for 177 admissions was a median of 4:10 hours (interquartile range (IQR) 1:49 to 9:10). Time from physiological trigger to activation of a Rapid Response System was a median 0:47 hours (IQR 0:00 to 2:15). Time from call-out to intensive care admission was a median of 2:45 hours (IQR 1:19 to 6:32). A total of 127 (71%) admissions were deemed to have been delayed. Stepwise linear regression analysis yielded three significant predictors of longer Score to Door Time: being treated in a British centre, higher Acute Physiology and Chronic Health Evaluation (APACHE) II score and increasing age. Binary regression analysis demonstrated a significant association (P < 0.045) of APACHE II scores >20 with Score to Door Times greater than the median 4:10 hours. CONCLUSIONS: Score to Door Time seemed to be largely independent of illness severity and, when combined with qualitative feedback from centres, suggests that admission delays could be due to organisational issues, rather than patient factors. Score to Door Time could act as a suitable benchmarking tool for Rapid Response Systems and helps to delineate avoidable organisational delays in the care of patients at risk of catastrophic deterioration.

Monitoring and recording patients' neurological observations.

This article provides a detailed account of how to monitor and record neurological observations. It outlines the importance of neurological observations in acutely ill patients and focuses on carrying out observations using the Glasgow Coma Scale.

Critical care outreach: the need for effective decision-making in clinical practice (Part 1).

Since the publication of 'Comprehensive Critical Care' (2000) critical care outreach (CCOR) services have been developed to meet the needs of patients through critical care provision 'without walls'. Now embedded nationally, CCOR is a central part of health care delivery in the National Health Service (NHS). To date, approximately 75% of hospitals in England have introduced and developed the service according, at least to some extent, to local needs and resources. While this has resulted in a somewhat inconsistent approach to the development and configuration of these services, a number of common elements remain. Arguably, effective clinical decision-making by CCOR practitioners is fundamental to efficient patient care management and the success of these services. In its examination of CCOR service provision this, the first of two papers, addresses the theoretical background of clinical decision making and the knowledge that underpins practice in CCOR. In the second paper, through collaborative reflection and analysis of a case study, the authors bring these together in a process that illuminates the realities of clinical decision making for CCOR practitioners. From this, recommendations are made about the future development of CCOR practitioners and services.

Critical care outreach: the need for effective decision-making in clinical practice (part 2).

As the extension of nursing into roles previously within the domain of medicine and the demand for evidence based practice continue to increase, the quality of decision making becomes imperative. Making accurate decisions is essential, both for the practitioner and for the patient, especially in the provision of critical care outreach (CCOR), to improve outcomes of care. With changes in health care delivery and increased accountability for practitioners' decisions, it is important to understand more about how clinical decisions are made and what factors influence them in order to inform practice. The previous paper outlined the theoretical background of clinical decision making and the knowledge that underpins practice in CCOR. In this paper, the authors, a Nurse Consultant in CCOR and a research fellow, examine the process of a practitioner's decision making in the practice of CCOR, through a collaborative reflective account of a case study. From this, recommendations are made about the future development of CCOR practitioners and services.

Critical care outreach 1: an exploration of fundamental philosophy and underpinning knowledge.

Critical care outreach (Outreach) is central to the effective management of critically ill patients. Its recent, expedited and somewhat uncoordinated introduction has, however, resulted in a lack of understanding about the fundamental philosophical theories and sources of knowledge that underpin it. Furthermore, there is a lack of understanding of the context in which these are applied. It is important that we understand and are able to provide sound rationale and guidance for current and future Outreach practice, for the education of practitioners and in order to evaluate and show the impact of Outreach on patient care. The need for this is heightened in the context of current changes in roles and role boundaries, in which there are significant pressures and expectations from organizations for Outreach teams to demonstrate their effectiveness. The authors argue that the complex situations encountered and managed by Outreach are not amenable to traditional forms of measurement and that its impact on patient care is, therefore, not readily acknowledged by those external to the service. This study explores the philosophical underpinnings and types of knowledge inherent in the practice of Outreach. In doing so, it illuminates how they apply and contribute to the practice and impact of Outreach.

Critical care outreach 2: uncovering the underpinning philosophy and knowledge through collaborative reflection.

Critical care outreach (Outreach) was introduced as part of a government strategy to address increasing demands on limited intensive care (level 3) and high-dependency (level 2) resources. The discipline of Outreach developed rapidly and, as a result, the fundamental philosophical theories and sources of knowledge that underpin its practice remain, at least to some extent, unexplored, and their contribution to practice overlooked. It is important that we understand these philosophical theories and sources of knowledge so that we are able to provide sound rationale and guidance for practice and address the increasing pressure to demonstrate effectiveness. The authors argue that the complex situations encountered and managed by Outreach are not entirely amenable to traditional forms of measurement, and that its impact on patient care is, therefore, not readily acknowledged. In applying a model of collaborative reflection, this study analyses the management of a clinical case by a nurse consultant in Outreach. In doing so, it explores the realities of practice by deconstructing the complexity of a particular situation and highlights the variety of knowledge that contributes to effective Outreach practice.