THE REAL TIME HEALTHCARE PODCAST · Jun 3 · 16:11 min

#36 - Clinical Deterioration with Bradford Teaching Hospitals NHS Foundation Trust’s Chief Nurse, Karen Dawber

In this Episode:

In this podcast episode, Jeff Terry, along with Becky Knee from GE Healthcare will be speaking with Karen Dawber of Bradford Teaching Hospitals NHS Foundation Trust. They will be discussing the Clinical Deterioration Tile and how it's used at Bradford.

Jeff Terry:

Hello and welcome. I'm Jeff Terry. Delighted to be joined today by Karen Dawber of Bradford Teaching Hospitals NHS Foundation Trust and Becky Knee, my colleague at GE. We're going to speak today about the Clinical Deterioration Tile and how it's used at Bradford.

*Tiles present and aggregate information gathered from other systems to improve visibility and workflow efficiency, based on hospital defined standards. Tiles do not make clinical determinations and are not intended for patient monitoring.

So before we jump in, let me just make sure that the audience understands that the tile, of course, a real-time app in the Command Center software platform, you should see it on the screen there, what it does is pulls information in real time from different parts of the EMR and gives a common picture of each patient who's not in an ICU or in an HDU, and is at some critical level of risk as measured by an early warning score in the EMR. If you're looking at the screen, you see each of those rectangles is a patient that's at a high risk and out of protocol, the protocol that was determined by Bradford, in this case. You can see the vital signs there, labs, respiratory.

Then if I hover on any number, as you see, it tells me, hey, what were the recent measures of that vital sign. Along the bottom, we're getting census information, so how many patients in the medicine service, in the surgery service are at different levels. You see SP means single parameter or a score of five to six or a score of seven plus. And if I hover, I get the list of those patients so that we know where are my critically ill patients. Then above that, where are my critically ill patients who maybe aren't getting care according to the protocol that we would like.

Jeff Terry:

But, of course, most importantly is how it's used in practice. So maybe with that, Becky, I'll turn to you to start us off with a couple of questions.

Becky Knee:

Hi. Karen, what would be really interesting to know is what was the reason that Bradford Hospital chose the Patient Deterioration Tile start with?

Karen Dawber:

One of the biggest concerns as a Chief Nurse is not knowing what's going on or not knowing if your patients are sick, not knowing if people are being cared for properly. And what this helps is to have some checks and balances in the system, because actually I can't be everywhere all the time. My matrons can't be everywhere all the time, but this allows us to have technology that will allow us to flag where the areas of most risk are. And that's what was really, really exciting about it. It gives us eyes all the time in lots of different places.

Becky Knee:

What were the key things you were hoping to achieve? Obviously, you've talked about it's difficult for one person to know what's happening across the board, but what were the key areas of improvement or quality that you were hoping to get to with this?

Karen Dawber:

Inevitably, we wanted to prevent patients from deteriorating and dying. And we know that when you look back at hospitals or the NHS and look at the Patient Safety Agenda, there are often issues around care while somebody is in hospital. That there is opportunities when you look back where you could have intervened and you could have done something different that may have changed the outcome. I want to know that we've done everything we possibly could have to make sure that the outcome we got is the outcome that that family and that patient deserved or was expected.

We have had incidents in this hospital where patients have died unexpectedly on wards, and when we've looked back, there may have been opportunities to intervene. That's why this is so important. We want to prevent avoidable harms and avoidable death.

Becky Knee:

I think one of the interesting things about the tile here is that is the way it's used, not just by leadership, but by really owned by the wards themselves. If you could talk a bit about how you feel that works at Bradford?

Karen Dawber:

I mean, there's no point just doing something to people or inventing something that people just go, "Oh yeah, that's that thing on the desktop, but we don't really use it." We've all been down that route at some point or another and there's usually many reasons why people don't use new technology, either it doesn't work properly or they actually don't see the value of it.

What we've done here is with core designed this tile so that people really see the value. So if people can see something that so juicy and lovely and sumptious that you can't help but get involved with it, then you will want to do it and you will want to develop it further. You then combine that with the fact that it works and the technology works, it means it becomes a no-brainer then not to do it. So, you end up with a cohort of people that can sell this tile and sell the benefits of it to others.

What it will do is at any given point in time, for example, my sepsis lead nurse can look at the tile and see where the sickest patients are, where we might have patients that are at risk of sepsis or triggering for sepsis that we're not giving antibiotics to and it allows us to make quick clinical decisions and escalations.

Jeff Terry:

Brilliant. I know the last year has been crazy for a lot of reasons. We're recording this in April 2021, so what impact have you seen and what's been the reaction of the team?

Karen Dawber:

We started rolling out the tile pre-COVID and pre-the last year and we have very specific areas where we were targeting, areas that had high numbers of incidents in relation to observations of patients or where patients were of conditions that they were at more risk of developing sepsis and deteriorating quickly.

We started to roll out with those teams and it was all going extremely well, and then over the last 12 months, of course, everything has just been thrown up in the air. Those teams that were established in certain ways 12 months ago are no longer the same teams because we had to shut down the majority of elective surgery. We turned our patient nurses into mini-ITU nurses. So that sense of team got stronger as an organization actually, but that strength of individual ward teams didn't because we disbanded.

We're now starting to restart and rebuild and as part of that, we're saying, actually, we went on the journey with the deteriorating tile. We know it works. We know that people used it extremely effectively. What we now need to do is spread that so it's consistent throughout the organization. I think we would have been at that point probably six months ago if we hadn't have had COVID, because I think any change like this just, it takes about six, 12 months to get it embedded and being used robustly. And I would have thought by December this year, we'll be in a position where this is fully rolled out throughout the organization.

Becky Knee:

I think you've got it already rolled out in 19 inpatient wards, which is fantastic. But as you say, obviously, people have been moving around a lot and COVID has caused lots of uncertainty and movement in the trust. But it's really good time in the way that, regardless of what ward you're in, it looks exactly the same, so you can move between and that's helpful. How do you think the tile has supported you with COVID?

Karen Dawber:

Again, I can go into our Command Center and there's a number of tiles up there. There's some I look at more than others. The one I always look at is the Deteriorating Patient Tile, because that tells me where my sickest patients are, whether they're triggering for different things, whether they've got observations that are overdue and actually it might be a reason for that. But I also know that the clinical people that are sat in that room are focused on that tile and know to flag it to people to go and double and triple check those things.

We’ve been running hospitals at full tilt with very sick people, having very high levels of care with the same level of staff that we have to deliver very different care. So, we have not had the same amount of experience available to the needs of the patients, so therefore you need something to safety net that and the Deteriorating Patient Tile has been a huge safety net for that.

I think going forward, it will be more than a safety net, it will be a predictor. For example, in the future, what I would love to do is we have acuity staffing models where we look out for how we staff the wards. Wouldn't it be great to the Deteriorating Patient Tile speaking to that, to enable us to move workforce in accordance with where the sickest patients are.

Actually, wouldn't it be great when we've got lots of data and use this to be able to see before a patient deteriorates because we'll have the algorithms and understand what leads up to that, because you can guarantee that 80% of a patient's journey will probably be very similar and we could have probably get in there before somebody deteriorates to the point of requiring IV antibiotics, IV fluids, and other things. That's the exciting bit for me that you can really build on this now.

Jeff Terry:

Absolutely. The learning and playing it forward. Can I ask, so Bradford is really on the leading edge of digitization in the NHS, I think it's fair to say, both with the EMR and then now with the Command Center tiles and obviously digitization is a hot topic in the NHS. What would be your commentary on integrating these digital tools into the day-to-day practice of delivering patient care?

Karen Dawber:

I think the less handoffs you have in patient care, the better, and we know that there are many different systems throughout the NHS. Even in Bradford, when we look at the Bradford as a place, or as a system, there are many different organizations all using different digital platforms. And actually, if you have one tool that brings all of that together, so you can see the entirety of a problem to allow you to best target.

I think the more joined up you can get as a system, the better. Because what I see is multiple handoffs of care between different organizations. Our top version is called a badge-less system because actually my badge says Bradford Teaching Hospitals, patients coming into our hospital see it as the NHS or The Health Service, they don't see me as an individual organization. But actually when you see the frustrations is when you get the individual organization [crosstalk 00:12:48]-

Jeff Terry:

The seams between the organizations.

Karen Dawber:

... from general practice to community nursing, to an acute trust, to a mental health trust, to a tertiary trust. It's all those handoffs that people just don't understand. And actually, why should they? We would never have designed the system that had all those handoffs in it, would we? And I'm sure back in 1948 when the NHS was designed, it was never meant to do that either.

Jeff Terry:

Can I play that back to you? What I hear in that is at Bradford with the Command Center, and the culture, and the technology, and all that, you have a common operational picture within the Bradford Teaching Hospital, but now it makes it more clear to where the boundaries are that, when you go beyond that, you lose that. And obviously, it makes sense to extend that and then to learn on top of all that knowledge. Brilliant. Thank you.

Karen Dawber:

Well, I'll tell you what that noise is. That noise never does that normally.

Absolutely. Like I said, we know what's happening here, actually, you don't know what's happening in wider and wouldn't it be good if everybody could see what was going on everywhere? Because I'm sure it would make more seamless and more efficient healthcare for patients.

Jeff Terry:

Absolutely.

Becky Knee:

Absolutely.

Jeff Terry:

Perfect. Last question from me, and then Becky, I don't know if you want to close with a question as well, but last question for me. A lot of work's been done, a lot of impact. One way to go forward is to extend, but what else is on your mind with the Deterioration Tile and that concept? As what does the future hold? What's the next step with that?

Karen Dawber:

I think the next step is we need to fully roll it out and fully integrate it. We're really keen to look at virtual healthcare more and a virtual hospital or a hospital without walls. I think the Deterioration Patient Tile also has something to do with that. We've rolled out, for example, pulse oximetry for COVID patients, either pre, before they would escalate to hospital level, and post to get them out of hospital sooner. Wouldn't it be great if those people in virtual healthcare were also picked up on the Deterioration Patient Tile?

Wouldn't it be even better if that pulse oximetry that was on that person's finger in the community didn't rely on them putting those fingers in actually, wirelessly pinged onto the interweb somewhere and then pinged up on the deterioration platform. Then you start to be able to manage risk really in real time.

Because I think, at the moment, we are still a bit dependent on people doing and putting the results into something. To me, the future is I would like it to go beyond the boundaries of the hospital, but also to learn how we use smart technology to do that real time inputting as well to make sure it's absolutely in real time, because there'll be thousands of nurses listening to this hopefully that'll all be giggling now, because everybody knows that we use paper towels and the back of gloves to write things on and not necessarily directly into the computer.

Sometimes those minutes matter, don't they?

Becky Knee:

Absolutely.

Karen, in your role as a Chief Nurse you've been involved in the full Command Center program and specifically in the Patient Deterioration Tile. If you had one top tip or piece of advice for other people in your role who are considering this or embarking on these sorts of projects, what would be your number one piece of advice?

Karen Dawber:

Bring people with you. Make sure you speak to the right person. Make sure when you describe what you're trying to do, that you really believe in what you're trying to do and you can describe it, and you can make it juicy and compelling. Because actually, if you can't sell it to people, then you're losing already.

Back to that what I was saying about, when things go wrong it's because either it's not useful or it doesn't work. If you've got something that works and you can describe its use, you're on a winning trajectory and then it's just stay with it and getting it so that it becomes part of everybody's day.

Jeff Terry:

Here, here. Becky, thank you very much. Karen, thank you very much, and thank you also just for letting us work for you and be on this journey with you, so here's to the next phase. With that, I think I'll close the podcast.

Karen Dawber:

Thank you very much.

Becky Knee:

Thanks.

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