THE REAL TIME HEALTHCARE PODCAST · Jul 21 · 19:22 min

#39 - Clinical Deterioration with Bradford Teaching Hospitals NHS Foundation Trust’s Sepsis Nurse Specialist, Clare Nandha

In this Episode:

In the next installment of the Real Time Healthcare podcast, Becky Knee is joined by Clare Nandha, Lead Sepsis Nurse at Bradford Teaching Hospital. They’ll talk about the Patient Deterioration Tile and how it's being used at Bradford.

Becky Knee:
Hello and welcome to our next installment of our Real Time Healthcare podcast. I'm very excited to be joined by Clare Nandha today, who's a Lead Sepsis Nurse at Bradford Teaching Hospital, and we're going to be talking about the Patient Deterioration Tile and how that's being used at Bradford. So thank you very much, Clare, for joining us. We really appreciate your time.

Before we start the interview, I'm just going to explain a little bit about what a Deterioration Tile is. So the Deterioration Tile is pulling all the NEWS scores and the vital signs observations from the Bradford EPR that's in use there, and it's pulling it through into one central location. So we can really see who our most acutely unwell patients are at the moment. People who've got very high NEWS scores or people whose NEWS scores are getting higher and getting worse, and we can also see monitoring information as well, so who hasn't had their next set of vital signs done within the time period that we'd expect based on the Royal College of Physicians guidance.

So it's helping us helping or helping Bradford certainly to understand who needs to be seen quicker and we can prioritize those patients, and it also gives us some other really useful alerts around things like sepsis and escalations as well.

So that's the Deterioration Tile that is currently being used at Bradford. So Clare, I guess we'll kick off straight away. So who is it who's really using the Tile at Bradford and what are they using it for?

Clare Nandha:
So, yeah hi, thanks Becky for inviting me to do this. So here at Bradford, we were excited to get this title because we recognized that there's always improvements to be made with patient safety and the main purpose of this Tile is to help us recognize, escalate and respond to any deteriorating patients. The way that we have been using it is multifactorial, really. So nursing staff are using it to help recognize when patients' observations are due from the monitoring side. And what we've been able to move away from is having observations be part of just a task-orientated job. So patients are now getting observations as and when required, according to our national guidance, so they can identify when the patients are due and it allows for them to do continuous monitoring of the more poorly patients. And it's really useful on the severity side to help them use what parameters of the NEWSs are abnormal when they are looking to escalate a NEWSs S-bar as a tool to aid that communication, whether that be from a healthcare to a qualified nurse or qualified nurse onto a doctor to come and review that patient.

The other thing that we found has been really useful for the nursing staff as well is it actually has improved teamwork on the wards. So we have found and we can identify now really easily if there are some outstanding observations due in one team, then the recognition is there that that team might be really busy and do they need some help. So it's helped teamwork across lots of different areas to help them recognize when their colleagues are busy and they need some support.

From a doctor perspective, they obviously are more involved with the response to the recognition and escalation. So it helps them to identify on the wards that they're working on specifically as their home wards, are there any patients at the beginning or middle or end of the day that they need to be concerned about? And so it means that within some areas they're choosing to use the Tile to review those sickest patients first. Rather than not knowing where the sicker patients are across the ward and starting at bed number one, they could start a different patient now.

Identifying deterioration and prioritizing their workloads, so that's how they'd be doing that in hours. Within out of hours, actually having an overview of the whole trust and wards that they are covering out of hours also provides them with that reassurance that they're not missing any patients that are poorly across the trust. And it helps them to understand where their priorities should be at the beginning of their shifts, or if anything changes.

Critical care outreach are also using this Tile actively to again identify the sickest patients across the trust, which is really important, which was something we haven't been able to do before. And so as an overview of a trust, they are now able to respond earlier to patients who are deteriorating. And although we are still in the process of measuring the outcomes of those patients, we can hopefully say that we are reducing our intensive care admissions and therefore improving outcomes.

Becky Knee:
I guess, for them as well, previously I know it used to be sort of who shouted loudest or "Please come and see this patient," which would determine quite a lot of their prioritization. I guess, with you're Tile they've got a less biased view. Obviously if you are worried, you can still call them, but they're getting that overview which is updating real time all the time, rather than starting with a list at 9:00 AM and working through it where obviously deterioration can happen quite quickly.

Clare Nandha:
Absolutely. Yeah. So yeah, the Tile's absolutely helping with that recognition of where the poorliest patients are and where they should, again, prioritize their time so that the right patients get seen at the right time. And lastly, we've also got obviously the command center, which is part of the big overview of all of the Tiles, but their use of specifically the deteriorating patient Tile is helping both patients and staff. So it's helping with staffing to understand acuity versus dependency and if staff are asking for more help, what would they need and what grade of nurse they may need, versus are we placing the patients in the right place. So are some wards having higher acuity patients that actually we need to think about moving a patient to a different area to ensure that the patients are being seen in the right places? So they are also using it. So across the board, right from healthcare up to the command center, there are lots of people using this Tile for lots of different reasons, but ultimately for patient safety and improvement of patient care.

Becky Knee:
I think that that's great because when we think about command centers, we think sometimes that it's a very centralized tool, but actually in the case of Deterioration Tile, although the command center are using it to help with especially out of hours staffing, what it's actually doing is the de-centralization actually giving empowerment back to the board that they are more in control and able to own their own patients because they've got more visibility of them.

Clare Nandha:
And I think that's key to this, Becky, is that this is absolutely owned by the wards. It is not owned centrally. It's the wards, because at the end of the day, it's about their patients and they are the best people to ensure that their patients are getting the best care. So the wards absolutely are essential and I don't think it would work as well if it were to be centralized. I think the best impact that you can see with this is because the wards are owning it and I've embraced it. Absolutely.

Becky Knee:
Yeah. And the tool isn't something that the ward system or the ward manager has to look at all day every day, is it? How would they actually use it, because it's not something that you're stuck with and can never use anything else or never get out behind the screen.

Clare Nandha:
So I think from having it now live for just about six months, I think what we've recognized is that it's that visual aid that's there, or it's on 24/7. And whilst there may be no physical interaction with it, the visualization of being able to be reassured that patients' observations are up to date and do they have any poorly patients or who is deteriorating, there's been quite an impact with that. So when we do the upgrades and we may have to turn the screen off for a short period of time, the response to that has been, "I don't know how I'm going to cope without it," because the interaction-

Becky Knee:
It's a fabulous testament, really, isn't it?

Clare Nandha:
Absolutely.

Becky Knee:
To say in six months as well, going from never seen it, never used it, don't know what it is to, "I don't know how to do my clinical practice without it." I mean, massive testament to all the work that you and Bradford have done with that.

Clare Nandha:
Yeah. And I think when you start seeing something regularly, you become used to it and it becomes part of your daily routine. It's obviously something new that we've never had in the trust before. We didn't know. Obviously we had visions of what we thought, how it might look and how it might be used. Some have come to fruition and some are completely different to what we thought, which is absolutely fine. And every ward is slightly different and the way that they work as well. So it's fitted in with everybody. We haven't found in any area that that is not for them, because it's always going to be for them because it's always about their patient and their patient base. It's not something that's an overview of the trust, which most people won't be interested in. You're interested in your own patients.

Becky Knee:
And that's very important, that the Tile is filtered for each individual ward or each individual department.

Clare Nandha:
Yes.

Becky Knee:
So you're not searching through this long list of people that you're not that interested in. It really is exactly who you need to see and only those people who are acutely ill. So you're really getting down to the individuals you can notice really, really quickly as well.

Clare Nandha:
Absolutely. Yep.

Becky Knee:
And what about, obviously we've been in the COVID wave for over a year now and we obviously added the COVID alert as well. How do you think the Tile has helped you during these difficult 12, 13 months now?

Clare Nandha:
So at the current time we, the Tile is live across every ward that we have apart from the two COVID wards. But part of the reason for that is because of the number of staff working on those wards actually was much higher and they had intensive care input straight from the beginning. So the recognition and early response on those wards was automatically improved. Our... not concern, but our focus needed to be on areas outside of COVID where we still had patients coming through the door who were still poorly and we wanted to ensure that we weren't missing any patients. And that's where it's worked the best is those areas that may not have been opened and changed to care for patients. The staff may not have cared for that cohort of patients before. We've had staff obviously being reallocated and redeployed from lots of different areas where they wouldn't normally work and so it's given them some confidence in what their day-to-day tasks are and making sure that their patients are safe as well. So it's absolutely helped with the confidence of those staff members.

Becky Knee:
Fantastic. And as you said, it's now live across almost every inpatient ward, adult ward that you have now. What has been the feedback from staff? Because that's a big change in quite a small period of time and as we know, change is always difficult across all organizations. So what's been the feedback from the staff in terms of its use?

Clare Nandha:
They've got used to seeing it very quickly and are now comfortable and confident that actually it is showing them how their patients are or how unwell their patients are. From a junior doctor perspective, we've had some fantastic engagement with lots of different doctors across lots of different specialties seeing the positives, especially out of hours. Giving junior doctors the reassurance that they are not missing patients has been massive for them because they know now that they've got this tool which is going to help aid them to respond to the patients in a timely way that they didn't have before. And because they can filter it, if they're covering four wards, they can filter it to all four awards. They don't have to go onto each ward individually, which we would have to do with our current EPR.

Then it's much quicker. Quicker view. It's easier. On the severity side where you've got the parameters that are broken down, you can easily see and you can see a 24 hour look back period so you can easily recognize when that patient has become unwell, and what changed. So is this something we need to be concerned about, when you've got patients who are scoring, potentially, if you've got, I don't know, you've got five patients all scoring the same NEWS score, who do you go and see first?

Becky Knee:
Yeah.

Clare Nandha:
This helps to identify your priorities and who should I be seeing first, this patient has deteriorated quicker, which parameters have changed will make a difference. And by being able to see that they absolutely can see they were able to prioritize their workloads.

Becky Knee:
That's fantastic. That's really great. I guess a final, final question. We've spoken to Karen Dawber, who's the chief nurse at Bradford about this, and we will be speaking to LeeAnne Elliot who's the deputy medical director about deterioration as well. But the question we're going to ask all three of you is what is the impact that you've really seen or that you're hoping to see shortly, so far? What are the really great stories or changes that you've seen?

Clare Nandha:
So I think the biggest things for me are a massive improvement in completion of NEWS scores in line with the national guidelines. A fantastic improvement in our documented evidence of escalation.

Becky Knee:
Yeah.

Clare Nandha:
The junior doctors, as I've just said, having the confidence to prioritize their workloads. Staff engagement has been fantastic and everyone's embraced it really well and I think in the future, and hopefully shortly, what we will be able to look at is what improvements have we made to patient outcomes. And essentially that's where we are and that's where we want to be. We want to ensure that our patients are cared for safely and in a timely manner. And absolutely this Tile is helping us to provide that care for our patients.

Becky Knee:
Fantastic. I mean, what a note to end on.

Becky Knee:
Thank you very much for joining our podcast today. Thank you so much to Clare for joining us and for talking through your experience of the Patient Deterioration Tile, and we really appreciate all your feedback and the effort you've been making at Bradford as well, so thank you so much.

Tiles present and aggregate information gathered from other systems to improve visibility and workflow efficiency, based on hospital defined standards. Tile users have the ability to filter information and organize information for their needs. Tiles do not make clinical determinations and are not intended for patient monitoring.

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