Transforming Acute Care - HAI Watch

Transforming the Acute Care 

Pathway in CMFT 

Dr Jane Eddleston

Background 

• No standardised way to perform clinical observations 

• No agreed monitoring policy 

• No assessment of workforce’s competency to 

undertake observations 

• EWS policy in place since 2000 but not embedded 

effectively in patient pathway of all in-patients 

• EWS policy which underpinned the pathway for acute 

illness recognition and response did not work 

• Late presentation of patients to critical care service 

• High cardiac arrest rate 

• Readmission rate to Critical Care >2%

NCEPOD 2005 

• All medical admissions to UK 

ICUs in June 2003 

• 21% of admissions to ICU 

were deemed avoidable 

• 40% were deemed not to have 

received prompt or 

appropriate treatment prior to 

admission 

• Suboptimal ward care 

contributed to 35% of ICU 

deaths

NPSA 2007 

• Review of “576 deaths 

that could be 

interpreted as 

avoidable” 

• “Clinical or 

physiological 

deterioration not 

recognised or not 

acted on”

Baseline data 

• 747 consecutive patients (MAU) 

• 20% of EWS were incorrectly calculated 

• 116/747 patients alerted: generated 567 alerts (EWS 3 

or more) 

• 47% EWS of 3 

• 30% EWS of 4 

• 23% EWS of 5 or above 

• 31% of patients with an EWS of 3 or above had a 

documented clinical response (16% for EWS 6 or 

more) 

• 65% of patients with an EWS of 3 or above continued 

to trigger

Transforming the Pathway 

• Monitoring Policy 

• Standards for the undertaking of observations 

• Documentation (electronic solution, accountability, paperless 

system) 

• Response (automated, response aligned to competency) 

• Skills and Knowledge of Workforce 

• Assurance of Competency 

• Accountability (Emergency Bleep meeting)





system) 









system) 





Observation Entry 

• Tabs for each data item to be 

entered 

• Designed for use by finger 

using intuitive “calculator” 

keypad 

• Data entered is validated 

against configurable EWS 

ranges

How does it work 

Ward View 

• Lists all patients on 

the ward 

• Current alerts 

highlighted 

• Overdue observations 

highlighted.

Ward Summary

Toughbook 

Not in use 

Power 

Camera 

Not in use 

Not in use 

Shortcut to Patientrack 

Shortcut to CWS 

To lock/ unlock device





system) 





Adult 

Patient 

Non-Clinical Staff 

Recorder 

Recogniser 

Primary Responder 

Communicationr 

Secondary Responder 

Tertiary Responder 

Critical care

-Developed to 

compliment NICE 

50 

- 75 Acute Care 

Competencies 

-Designed to 

include all members 

of the workforce

Competency Group Non clinical Staff "Recorder" "Recogniser" "Primary 

Responder“ 

Description of 

group role 

NICE Response 

Level 

call for help and 

recognition of illness 

recorder and 

interpretation within 

T&T protocol 

recognition and 

interpretation of 

observations 

primary response and 

intervention 

"Secondary 

responder" 

Secondary response 

and intervention 

Critical Care 

Tertiary 

response and 

Critical care 

Low Risk Low Risk Low Risk Medium Risk High Risk 

Patients themselves 

Relatives 

Ward Clerks 

Ward Domestics 

Porters/support staff 

Trainee clinical staff 

Band 2-4 HCAs 

Band 5-6 Ward Nurses 

Band 6-8 Ward Nurses 

Physiotherapists 

FY 1 Doctors 

FY 2 Doctors 

ST 1-2 Doctors 

ST 3 to Consultant Doctors 

Hospital at night team 

Critical care outreach 

Critical care advanced practitioners 

Critical care ST1-2 Doctors 

Critical care ST 3 to Consl

Using technology to enhance acute care

Implementation of Patientrack 

• All observation sets complete 

• No summation errors 

• EWS policy determines time for next set of 

observations 

• Alerts sent to inform staff of next set of observations 

• Where responses have occurred all are within 

appropriate timeframe 

• Length of hospital stay for acute medical patients 

maintained at 5 days 

• Introduced other electronic software to the bedside 

• Roll-out in progress (~80 wards to be included)

Implementation of Patientrack: June to October 2010 

• EWS profiles differ in Medicine and Surgery 

• Acute Medical admissions ~21% of all observations 0 

~ 72% EWS 1-3 

~ 6% EWS 4-6 

• Surgery (Hepato-bilary Surgery) 

Monthly increase in EWS of 0 

~12 to 39% (ward 11), 25 to 60% (ward 12) 

Corresponding reduction in EWS 1-3 with time 

~77 to 54% (ward 11), 68 to 34% (ward 12) 

EWS 4-6 ~5 to 4% (ward 11), 3 to 1.5% (ward 12)





system) 





Emergency Bleep meetings 

• 351 cases discussed 

• 100 cases brought back for review 

• 8 cases outstanding 

• Classify cardiac arrests as potentially avoidable or not 

• Include potentially avoidable cardiac arrests on patient 

safety dashboard 

• Divisional Clinical Governance teams to be responsible 

for completing and monitoring successful 

implementation of these action plans 

• As Patientrack rolls out the tracking of events prior to a 

clinical event will be traceable and accountability will be 

clearly defined

Themes of EBM 

Medical cover 5% 

Other 20% 

Fluid Balance 8% 

Oxygen Policy 8% 

Other refers to: 

*Consultant Ownership 

(1%) 

oNIV issues (2%) 

oInappropriate patient 

placement (2%) 

oTransfer of patients 

(3%) 

oCommunication / 

handover (3%) 

oABG delay (3%) 

oDelay in medical 

attendance (3%) 

oAgency staff 

competency (3%) 

EWS 19% 

Observation Policy 

11% 

Documentation 10% 

DNAR Issues 9% 

Sepsis recognition and 

management 10%

Next steps 

• Continue with implementation 

• Continue education programme and assessment of 

competency in acute care 

• Use Patientrack data as basis for H@N handovers 

• Assess response times and reasons for non-response as 

more surgical wards come on board 

• Amend Patient safety dashboard to include :avoidable 

cardiac arrests; response times for EWS 4+; duration 

from last cardiac arrest 

• Consider if H@D team required to assist in response 

and intervention

• Transformation of Acute Care requires a multistranded approach 

• Acute Care is core business for the NHS 

• All clinical staff need to be engaged in Acute Care 

• Identifiable Process Measures for the pathway need to be 

implemented 

• Responsibility for Clinical Care resides with senior medical and 

nursing staff 

• Organisations must ensure each individual clinician is accountable 

for their performance 

• Ultimate outcome measures for the pathway need to be published

Transforming Acute Care - HAI Watch

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