Failures in recognising deteriorating condition of patients, HSE audit finds
Doctors and nurses are failing to recognise the deteriorating condition of patients in many cases because of the limited application of a pioneering early-warning system used in Irish hospitals, a HSE audit has found.
The audit on the use of the National Early Warning Score (NEWS) system in nine hospitals could only provide “limited assurance” that guidelines were being followed.
“The lack of compliance with the recording and totalling of the NEWS made it difficult for nursing and medical staff to recognise patient deterioration and the need for timely intervention. It also impacted on both the minimum frequency of observations and decisions taken to escalate care,” the audit noted.
It found 26% of cases examined – 19 patients across eight different hospitals – suffered a cardiac arrest at a time when a check on their condition was overdue. The audit established there was a failure to comply with the minimum observation frequency prior to the cardiac arrest in 13 cases.
The audit, which was carried out between August 2017 and November 2018, also established that scores were not calculated in 30% of all patient records examined, while the correct score was only calculated in 55% of cases.
Ireland was the first country in the world to introduce the initiative for a standard approach to detecting the deterioration of a patient’s condition when the NEWS was launched in 2013.
Nursing staff are required to document and score seven different vital signs of a patient including respiratory rate, blood-oxygen levels, heart rate, temperature, blood pressure and level of consciousness in a structured observation chart.
They are meant to seek a medical review at specific trigger points which can result in either increased monitoring, a review by an “on call” team or activating an emergency response system.
“Recognising and responding to the early signs of deterioration in hospitalised patients remains a high priority as patients continue to experience preventable adverse events because their deterioration is not identified or properly managed,” the audit observed.
It added: “Avoidance of cardio-respiratory arrest is one of the key outcomes that the NEWS seeks to address through early identification of clinical deterioration,”
The nine hospitals surveyed were Naas General Hospital, Tallaght Hospital, Bantry General Hospital, Mercy University Hospital - Cork, Cork University Hospital, Regional Hospital Mullingar, St Michael’s Hospital - Dún Laoghaire, St Vincent’s University Hospital and St Columcille’s Hospital, Loughlinstown.
The audit examined the medical records, including the NEWS charts, of up to ten patients in general wards in each hospital who had experienced a cardiac arrest during their in-patient stay.
It found the scores were only calculated in 70% of cases across the nine hospitals including just 25% of cases at Bantry General Hospital.
The score was incorrectly calculated in all cases examined at Naas General Hospital.
The hospitals in Naas, Mullingar and Bantry were found to be non-compliant in relation to the recording, scoring and totalling of vital signs on NEWS charts. Only CUH, the Mercy and Tallaght were compliant with the guideline.
Across all hospitals an average compliance rate of 38% was found in following the minimum observation frequency of patients– ranging from 20% in Tallaght Hospital to 68% in the Regional Hospital Mullingar.
It showed that the requirement to alert a nurse in charge or on-call doctor when a patient’s NEWS score was above a certain level was followed in 54% of cases – ranging from 20% in St Michael’s to 100% in Regional Hospital Mullingar.
Medical care had been escalated in 86% of cases where the patient’s score warranted an immediate review of their condition by a doctor.
Seven of the nine hospitals were unable to provide information on the number of its current staff who had completed a standardised training course in NEWS.
The audit said the HSE should seek reassurance from hospitals that measures were being put in place to ensure compliance with NEWS guidelines.
The HSE said implementation of the NEWS guidelines was “complex and evolving”. It added that measures to increase compliance required ongoing support at local, hospital group and HSE corporate level.
“The HSE has established an improvement programme to update the current NEWS guidelines and promote the quality improvement around early warning systems,” a HSE spokesperson said.
