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Turning risk tools into life savers

According to the Royal College of Physicians, the updated National Early Warning Score tool could save 1,800 lives a year. Clinical adviser at the National Institute for Health Research Dissemination Centre Elaine Maxwell explores the possibilities.

In December, the Royal College of Physicians updated its 2012 National Early Warning Score (NEWS) tool for identifying deteriorating patients. It is estimated that standardising the use of the tool, known as NEWS2, could save 1,800 lives a year, and NHS England and NHS Improvement have announced their intention that by March 2019 all acute and ambulance settings will be using it. So far so good, but how does a risk scoring tool turn into a life saver?


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What history shows us

Quality improvement by national mandate is an attractive option, but history shows us there’s many a slip between cup and lip; how things are done is as important as what is done.

The use of the World Health Organization surgical safety checklist is a case in point. Haynes et al (2009) showed significant reductions in adverse events, including deaths, when the checklist was implemented, leading to its widespread international adoption.

In England, the National Patient Safety Agency promoted the checklist to eliminate surgical ‘never events’. However, between April and November 2017 there were 139 reports of wrong-site surgery, 46 reports of wrong implant or prosthesis and 88 retained foreign objects post-procedure in the NHS in England. Concerns about the failure of the checklist to deliver has led researchers to explore how it was introduced.

Findings demonstrate that there were many unspoken assumptions behind Haynes et al’s work and the written checklist was just the cherry on the top. Applying the checklist without understanding what lies behind it doesn’t deliver the goods.

Clinical judgement

The same is likely to be true of NEWS2. A review of evidence recently published by the National Institute of Health Research Dissemination Centre (2017) demonstrated there are also several implicit assumptions behind the success of early warning scores that need to be addressed in order to reap the benefits and save almost 2,000 lives year.

The review found strong evidence to support the use of scoring systems, but this was highly dependent on the context. Where there are sufficient, experienced registered nurses, who use early warning scores in combination with clinical judgement, huge benefits can be realised. However, the review also found that systems do not work as planned when organisations assume that the risk scoring replaces the need for clinical judgement.

Delegating the measurement of vital signs to healthcare assistants who rely on electronic equipment and who do not understand the significance of supplementary observations was found to reduce the reliability of the scoring. This raises real questions for nurse leaders about who should assess unstable patients.

The review also found relationships in multidisciplinary teams to be important. In hierarchical cultures where the focus is on communication of the score rather than clinical assessment, junior nurses often lacked confidence to share their concerns, which led to delays in senior review.

The development of NEWS2 is a valuable contribution to early identification of patient deterioration and certainly could improve safety; whether this potential is realised will depend in significant part on nurse leaders and managers understanding the assumptions behind it, so they can create the conditions for its success and ensure it is a dynamic decision aid rather than a simple checklist.

References


About the author

Elaine Maxwell is clinical adviser at the National Institute for Health Research Dissemination Centre

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