Acutely ill patients in hospital

1. Acutely ill patients in hospital Implementing NICE guidance July 2007 NICE clinical guideline 50

2. Changing clinical practice • NICE guidelines are based on the best available evidence. • The Department of Health asks NHS organisations to work towards implementing NICE guidelines. • Compliance with developmental standards will be monitored by the Healthcare Commission.

3. What this presentation covers • Background • Key recommendations • Implementation advice • Costs and savings • Resources from NICE

4. Background: • Any patient in hospital may become acutely ill. • This guideline covers recognition of • and response to acute illness • in adults in hospital.

5. Background:why this guideline matters • To improve patient safety by addressing shortcomings identified in the NCEPOD report (2005) that acutely ill patients in hospital receive suboptimal care. • To ensure early identification of the acutely ill patient and prevent deterioration of clinical condition. • To reduce patient mortality, morbidity and length of stay. • To reduce ICU admissions and re-admission.

6. Key recommendations • Assessment and Monitoring • Response • Critical care • Staff competencies

7. Assessment and monitoring • Adult patients in acute hospital settings, including patients in the emergency department for whom a clinical decision to admit has been made, should have: • physiological observations recorded • a clear written monitoring plan • Physiological observations should be recorded and acted upon by staff who have been trained and are competent.

8. Assessment and monitoring: physiological observations • Initial assessment should include at least: • heart rate • respiratory rate • systolic blood pressure • level of consciousness • oxygen saturation • temperature.

9. Assessment and monitoring: track and trigger systems • Physiological track and trigger systems should be used to monitor all adult patients in acute hospital settings. • Observations should be monitored at least every 12 hours. • Senior-level decision to increase or decrease the frequency of observations. • Increase (graded response) if abnormal physiology is detected.

10. Response • A graded response strategy for patients identified at risk should be agreed and delivered locally. It should consist of three levels. • Low-score group. • Medium-score group. • High-score group.

11. Graded response strategy

12. Response • Decision to admit patient to a critical care area should involve both the consultant caring for the patient on the ward and in critical care.

13. Critical care • Transfer patients from critical care to general ward as early as possible during the day. • Avoid transfers between 2200 and 0700. • Document as an adverse incident if they occur. • The critical care transferring team and receiving ward team should jointly ensure: • structured handover of care with written plan • receiving ward can deliver the agreed plan.

14. Critical care • The formal structured handover of care should include: • a summary of critical care stay • a monitoring and investigation plan • a plan for ongoing treatment • physical and rehabilitation needs • psychological and emotional needs • specific communication or language needs.

15. Staff competencies • Staff caring for patients should have competencies in monitoring, measurement, interpretation and prompt response appropriate to level of care they are providing. • Education and training should be provided and staff should be assessed to ensure that they can demonstrate competence.

16. Implementation advice • Feedback to NICE suggests that there are likely to be three key areas for successful implementation of the NICE guideline to improve patient safety: • appropriate care settings and transfer • training and competencies • communication

17. Appropriate care settings and transfer • Ensure your graded response strategy underpins the provision of care in the appropriate setting to improve patient safety. • Raise awareness. • Agree a local graded response strategy. • Communicate this to all staff. • Regularly review thresholds of graded response strategy. • Review policies and protocols for transfer. • Use NICE tools to underpin this work.

18. Training and competencies • Staff need to be competent in using the locally agreed 'track and trigger' system. • Use baseline assessment to check use of track and trigger systems. • Use existing team and network meetings to communicate agreed response strategy. • Use Department of Health competencies and training matrix to implement training plan for staff.

19. Communication • Effective communication between staff working in critical care and general ward areas and with patients and their carers is at the core of implementing this guideline. • Develop a process for effective handover with written care plan. • Make it clear who has responsibility. • Include psychological and emotional needs.

20. Costs

21. Savings • Potential benefits and savings • Reduced admissions to critical care • Lower length of stay in critical care and on general wards • Reduced negligence claims

22. Resources from NICE • Costing tools • costing report • costing template • Implementation advice • Audit criteria • www.nice.org.uk/CG050

23. Access the guideline online • Quick reference guide – a summary • Full guideline – all of the recommendations, the evidence and rationale • ‘Understanding NICE guidance’ – a version for patients and carers • www.nice.org.uk/CG050