Deteriorating patients: the tools to help you know when to speak up
As a student you may feel unsure about raising concerns, but doing so could save a life
After a lecture highlighted the number of preventable deaths every year in the UK, it scared me to think I could be involved in the care of a patient whose deteriorating condition I could have spotted earlier.
I was in the second year of my adult nursing degree, and wanted to learn more about how nursing students can help identify and manage patient deterioration. As a result, I carried out some research on the subject, which I then presented at a Health Education England learner engagement event.
What the data reveals about avoidable deaths
As a student you may feel unsure about raising concerns, but doing so could save a life
After a lecture highlighted the number of preventable deaths every year in the UK, it scared me to think I could be involved in the care of a patient whose deteriorating condition I could have spotted earlier.
I was in the second year of my adult nursing degree, and wanted to learn more about how nursing students can help identify and manage patient deterioration. As a result, I carried out some research on the subject, which I then presented at a Health Education England learner engagement event.
What the data reveals about avoidable deaths
Data from the Office for National Statistics show that in 2018, around 22% of all deaths in the UK were considered avoidable. Research from the British Heart Foundation shows that around 30,000 people a year experience an out-of-hospital cardiac arrest in the UK, but just one in ten survive.
Equally alarming is a 2012 report from the National Confidential Enquiry into Patient Outcome and Death (NCEPOD), which found that 38% of in-hospital cardiac arrests in the UK could have been prevented. The report revealed that despite 75% of patients having clear warning signs before cardiac arrest, 56% of those cases were not adequately acted on.
More recently, the latest National Cardiac Arrest Audit shows that of the 12,682 people who had a cardiac arrest in hospital between April 2019 and March 2020 in the UK and Ireland, only 24% survived to discharge.
Students may be first to notice changes in a patient
The Nursing and Midwifery Council (NMC) Standards of Proficiency for registered nurses say that at the point of registration, nurses must be able to ‘demonstrate the knowledge and ability to respond proactively and promptly to signs of deterioration… and use this knowledge to make sound clinical decisions’.
‘Even if you lack the clinical experience to know exactly what is wrong with the patient, if you notice changes or feel that something isn’t right, speak up straight away’
Our supernumerary status as nursing students means we are able to spend more time with our patients. We may be the first to notice changes in a patient’s condition, which we can then flag up to registered nurses or other clinicians.
Even if you lack the clinical experience to know exactly what is wrong with the patient, if you notice changes or feel that something isn’t right, it is important to speak up straight away and report any concerns to a more senior member of staff.
We work in busy clinical areas that may be short-staffed, with nurses and other healthcare professionals also under immense pressure due to COVID-19. One way we can support nursing staff in identifying acutely ill patients is by carrying out vital observations and using the National Early Warning Score (NEWS) system.
How NEWS works
The National Early Warning Score (NEWS) is based on a simple aggregate scoring system.
A score is allocated to physiological measurements, which are recorded as part of routine practice, when patients present to or are being monitored in hospital.
Six simple physiological parameters form the basis of the scoring system:
- Respiration rate
- Oxygen saturation
- Systolic blood pressure
- Pulse rate
- Level of consciousness or new confusion*
- Temperature
*The patient has new-onset confusion, disorientation and/or agitation, where previously their mental state was normal. This may be subtle. The patient may respond to questions coherently, but have some confusion, disorientation and/or agitation. This would score 3 or 4 on the GCS (Glasgow Coma Scale), rather than the normal 5 for verbal response, and scores 3 on the NEWS system.
Source: Royal College of Physicians
Assessing the patient
Although NEWS is a useful tool in helping to identify deteriorating patients, it should not be relied on alone, but rather to support your clinical judgement.
The ABCDE approach is a well-established way to carry out patient assessments. It stands for:
- Airway.
- Breathing.
- Circulation.
- Disability.
- Exposure.
The ‘look, listen and feel’ approach relies on using your senses and clinical skills to assess the patient, for example, manually monitoring a patient’s pulse, measuring peripheral capillary refill time, and checking for signs of respiratory distress. Even when we are all extremely busy, a simple patient assessment can be carried out while you are helping patients with personal care, such as washing and dressing.
Establishing a good understanding of the patient’s baseline presentation will also help you detect small changes, and you should familiarise yourself with the patient’s history.
Pathways and tools that can help you
NICE pathways cover a huge range of different conditions and are great learning tools for students. The pathways on acutely ill patients in hospital and sepsis can teach us how to recognise deteriorating patients and know when to call for assistance.
A patient’s condition can deteriorate for many reasons, including infection, so you must always ask yourself ‘could it be sepsis?’ The Sepsis Trust has developed a screening and management tool – the Sepsis Six – which sets out the six actions that should be taken within one hour in suspected sepsis cases (see box below).
The trust has adapted the screening tool for a variety of care settings, including general practice and community services, out-of-hours services and acute hospital inpatients.
The Sepsis Six
- Ensure senior clinician attends
- Oxygen if required
- Obtain intravenous (IV) access, take bloods
- Give IV antibiotics
- Give IV fluids
- Monitor using NEWS-2.
Source: Sepsis Trust
Putting what I’ve learned into practice
My research into deteriorating patients has helped improve my practice, increasing my confidence in identifying patients who are deteriorating and raising my concerns with more senior staff.
While on placement on a surgical ward, I was concerned about a patient who didn’t seem to be improving after abdominal surgery. He had spent an unusually extended time in recovery, and when he returned to the ward he didn't seem right – his skin was clammy, he was restless and his peripheral oxygen saturation level was 91%.
I reported this to a staff nurse on three separate occasions, but she told me he was being assessed using the chronic respiratory early warning score (CREWS) system – a variant of NEWS for patients with chronic hypoxaemia – and not to worry.
‘If you are having trouble being heard when raising concerns, talk to your practice supervisors or assessor, or another senior member of the nursing team’
However, I was becoming increasingly concerned, and when I spoke to a different nurse, she called the critical care outreach team, who immediately contacted the doctor. The patient’s observation recording system had been changed from NEWS to CREWS, but he didn’t have chronic respiratory disease, so should have stayed on NEWS.
Had I checked the patient’s history, I would have noticed this and been able to raise it as an issue from the start. This taught me a valuable lesson about checking patients’ histories and not just relying on what has been communicated in handover.
My checklist: Is my patient’s condition deteriorating?
If I am concerned about a patient, I have a checklist that I run through. Ask yourself the following:
- Does the patient look unwell?
- Does their skin appear clammy or sweaty?
- Is the patient’s family or carer concerned?
- Is the patient short of breath?
- How does their pulse feel, is it bounding or thready? What is the rate?
- What is their temperature?
- Do they appear confused or disorientated?
- Do they have a rash, or mottled, ashen or cyanotic skin?
- When did they last pass urine?
If you have any concerns, you must raise these straight away with a more senior member of staff.
Speaking up is scary – but saying nothing could put your patient at risk
The NMC code says we must make the care and safety of patients our main concern. Although it is not easy to speak out, it is important to be brave and prioritise the needs of your patient. Had I not ensured my concerns about the patient were listened to, his condition could have deteriorated further.
As nursing students, the hierarchy within healthcare organisations can feel intimidating and there is also the fear of retribution if we make a mistake. However, I would rather report concerns and be wrong than not tell anyone and put a patient at risk.
It is essential that nursing students have a voice and are able to contribute meaningfully to patient care. If you are having trouble being heard when raising concerns, talk to your practice supervisors or assessor, or another senior member of the nursing team. You can also contact your university lecturers for advice and support, and all NHS trusts now have Freedom to Speak up Guardians who you can talk to in confidence.
As students, we have broad experiences across a variety of acute and community settings, with more opportunities to learn about the latest evidence-based interventions across different specialty areas.
Evidence-based practice is the cornerstone of good nursing care, so always use the evidence – this is what gives us a voice.
Deteriorating patients: how to support nursing students to raise concerns
- Ensure that students are made to feel part of the team and that any concerns they raise will be listened to
- Regular SBAR – situation, background, assessment, recommendation – training and handover practice will help improve communication skills and increase students’ confidence
- Involving students when the clinical team are reviewing a patient whose condition has deteriorated will help improve skills in early detection
- Encourage students to use ABCDE assessments habitually, so that in an emergency situation it is a well-practised skill
- Enable students to develop therapeutic relationships with patients and those close to them, so they can detect any changes in a patient’s presentation and raise concerns
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