Deteriorating residents: ensuring care home staff spot early signs and monitor conditions
Nurse helps develop simplified version of National Early Warning Score to support care in residential and nursing homes
- NEWSflash system uses daily observations of residents’ respiratory rate, oxygen saturation and temperature
- Team at GP practice worked with software developer, creating online system to assess observations input by care home staff
- System includes monitoring of long-term conditions and assessing reports to find early signs of deterioration
For all its devastating consequences, the COVID-19 pandemic has forced many nurses to think in innovative ways and accelerate the introduction of new practices.
When nurse consultant Suzie Southey took up her post at Saxmundham Health, a GP practice in Suffolk, her brief included looking at ways of enhancing care in residential and nursing homes.
‘Then COVID came along and we had to bring forward the agenda, including virtual visiting and “ward” rounds, much quicker than we thought,’ she says.
Need for an objective assessment of condition of residents
The practice strives to work in partnership with staff in homes to achieve the best care for residents. This includes monitoring long-term conditions and identifying early signs of deterioration.
But detecting those signs could sometimes be problematic. ‘We found that when residents were not well staff would ring us and say so-and-so is a bit confused,’ Ms Southey explains.
‘But it was a subjective assessment and we needed something more objective.’
Even a video link could be ineffective if the resident had dementia, for example, and was prone to wandering. ‘It was just not straightforward.’
NEWSflash allows observations to be relayed online and assessed
So the team at the surgery worked with a software designer to devise a means by which observations taken by care home staff could be relayed online to the practice, where any concerning signs would be assessed and investigated as required.
The result was NEWSflash, a stripped-back version of NEWS2, the National Early Warning Score system devised by the Royal College of Physicians.
Ms Southey says that although NEWS2 was devised for use in acute settings, some care homes have begun using it.
‘But when we started looking at it, we found it was too time-consuming for care assistants. Also, the parameters in older people with lots of comorbidities are skewed anyway, so they’re already scoring higher and the subtle changes may be missed.’
Data is fed into an iPad or tablet and results can be monitored at the surgery
A review of studies suggested that the most responsive of the NEWS2 measures were respiratory rate, oxygen saturation and temperature.
‘That’s how we developed NEWSflash, which uses those three measures,’ says Ms Southey.
NEWS2 and the three track and trigger parameters used by NEWSflash
NEWS2 is the second iteration of the National Early Warning Score, a ‘track and trigger’ system first produced by the Royal College of Physicians in 2012 and updated in 2017.
It aims to standardise assessment of and response to acute illness and is used mainly in hospitals and by paramedics.
Six physiological parameters are used as the basis of the scoring system:
- Respiration rate
- Oxygen saturation
- Systolic blood pressure
- Pulse rate
- Level of consciousness or new confusion
- Temperature
An aggregate score from the six measures indicates whether the patient is deteriorating and at risk, triggering an appropriate response.
A 2019 study in Age and Ageing concluded that use of NEWS2 in care homes was feasible. But it highlighted that low scores may offer false reassurance to staff, while high scores could generate ‘unnecessary clinical contacts’.
NEWSflash, devised by Saxmundham Health, uses just three of the NEWS2 parameters, respiration rate, oxygen saturation and temperature, with the aim of supporting care home staff, most of whom are not registered nurses, to undertake quick daily monitoring of residents, automatically alerting practice staff of deterioration.
The system means that all the residents in a home are checked every day. Their temperature is taken, and respiratory rate and saturation levels measured by a finger sensor. The data is fed into an iPad or tablet and the uploaded results can be monitored at the surgery.
- RELATED: National Early Warning Score update
But the system requires more than effective technology. Ms Southey stresses that implementing NEWSflash successfully means building relationships with those working and living in care homes. Considerable input is required, she says.
‘You need to understand how they work and what the residents are like, and you need to work with the staff to get it off the ground.’
Nurses get the demands on the care team
She suggests that some GPs may not necessarily see that this can be more complicated than it appears and says nurses’ skills come into play.
‘The implementation process is different from what some GPs think it is. But as a nurse, your head is in a different place. You get the demands on the care team.’
So far, the system is up and running in one local care home, Chantry House, and being streamlined in another. It is also being introduced in accommodation where older people live in their own flats but with supportive care.
Mihaela Sima is a registered nurse at Chantry House. She likes the system and says: ‘The surgery sees straight away all the observations in the system.
‘If something is wrong it comes up as a score and flashes red and you know you should take action.’
She adds that the surgery sometimes responds even before the care home has rung to discuss with the practice team a problem arising with a particular resident.
If NEWSflash indicates deterioration in a resident over a weekend, staff will contact NHS111 in the first instance.
Bringing care homes closer to local practices
Another element to this work is forging closer links between primary and residential care. Ms Southey refers to this sort of engagement as bringing care homes ‘under the wing’ of local practices. The residential care sector has been through an especially torrid time during the pandemic and ‘we need to look after them’, she says.
The data provided by the three physiological parameters measured by NEWSflash also provides a baseline for looking at other concerns. If a resident had a fall, for example, was it related to changes in those parameters?
And the system encourages homes to be more consistent in the way care staff monitor residents’ health, Ms Southey adds. That is particularly important given that frail older people can deteriorate rapidly. Detecting problems early may help avoid hospital admission.
An administrator can alert a clinician if parameters indicate deterioration
Daily monitoring of the numbers coming in from a care home may have resource implications for a practice. But as Ms Southey points out, checking the data is quick and does not need to be the responsibility of a nurse or doctor. An administrator can take on that role and alert a clinician if the parameters for any resident indicate deterioration.
She is keen to emphasise that the work undertaken so far does not constitute validation or evidence of effectiveness, so any potential wider rollout of NEWSflash is some way off.
‘This isn’t proven, nowhere near. But it could be huge if we can get some research investment into it.
‘At the moment we’re saying this is just an idea. We’re simply asking for these parameters to be measured at a very local level. But what we’re hoping to do is look at whether this is sustainable in care homes.’
Time and money well spent
She would like to see a qualitative aspect to any future research too. ‘We want to know what the carers feel about this. Has it made them feel more aligned to the surgery, more supported?’
The cost of the project so far includes £10,000 to develop the software and a proportion of Ms Southey’s time – ten hours a week officially.
And if NEWSflash can help prevent a single hospital admission of a care home resident that begins to look like time and money well spent.
‘We’ve funded it ourselves,’ she says. ‘I’ve spent a lot of time on it but I’m lucky because the surgery is supportive.’
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