Leading change

Nursing leaders from Sunderland Clinical Commissioning Group (CCG) led a collaborative, multidisciplinary project team in designing and implementing a digital system to identify care home residents with deteriorating health. The multidisciplinary team (MDT) developed and applied an electronic system to support the monitoring of residents’ health. The electronic system, based on an adaptation of the National Early Warning Score (NEWS) tool, has improved resident outcomes and experience and has led to better use of resources across healthcare services within the CCG.

Where to look

As a nation, we are living longer than ever. With longevity comes challenge, particularly with regard to increasing frailty which can result in falls, disability and admission to hospital (NHS Improvement, NHS England, the Ambulatory Emergency Care Network and the Acute Frailty Network, June 2018). The nurse leaders identified unwarranted variation in the way Care Homes identified, responded to and supported their residents’ physical health needs. The CCG senior nurse leaders identified an opportunity to empower and enhance the skillset of Care Home staff to provide high quality care; enabling the identification of a resident who becomes unwell and responding to the situation completely and confidently.

What to change

NEWS is a tool developed by the Royal College of Physicians (RCP), to improve the detection and response to clinical deterioration in adult patients and is a key element of patient safety and improving patient outcomes. The tool is widely used across NHS services as it is an evidence-based approach to treat clinical deterioration and support clinical decision making. The CCG nursing team identified the opportunity for Care Homes to adopt the NEWS tool as well as embrace a new IT system, to improve outcomes for residents.

This move towards practical, clinical support for residents, especially shifting to a more proactive rather than reactive resident-centred care model was identified as good practice, improving resident experience, notably by supporting residents to stay at home rather than needing to be admitted to hospital. With the introduction of training, equipment and a digital platform for recording the medical examination results, the CCG enabled residential homes to provide holistic and effective care.

How to change

Nurse leaders used local data available from primary care, acute hospital Trusts and community-based services to identify opportunities within the homes and collaborated with key stakeholders to agree next steps. This team comprised of Care Home staff, the community older persons’ nurses, Sunderland City Council, the community geriatrician nurses, Sunderland CCG, GPs and a technology provider; all committed to improving outcomes for residents locally.

A project plan was agreed, which included education, resources, design of an intelligent informatics system and an offer of support for the local Care Homes. Once these elements were agreed, the MDT identified several pilot sites across the CCG, to test the effectiveness of the new system.

Following the initial pilot and testing phases, the programme team rolled out the bespoke NEWS tool embedded in a digital tablet, across 40 Care Homes in the CCG area. A comprehensive training and education package was developed to support the utilisation of the tool, along with technical support. A standard operating procedure was developed in collaboration with the MDT and Care Homes.

Adding value

Better outcomes – Residential care staff have adopted new skills and feel more empowered and confident in their care of residents. Residents’ illnesses are identified, responded to and supported more effectively than before and the use of wider healthcare services are more efficient and timely.

Better experience – The adoption of a common NEWS tool across local health and care services has supported better communication which is enhancing staff experience. For instance, when they transfer residents from a home to other service provision in the area. Some qualitative evidence of success from residents and their carers includes:

• “It’s great to see my mum’s care home using technology to monitor mum’s blood pressure.”
• “My Dad’s carer rang to say they had monitored his vital signs and they were a little high and had arranged for a nurse to visit. The nurse gave him some antibiotics and he started to feel better.  He has Chronic Obstructive Pulmonary Disease (COPD) so previously he had ended up in hospital.  This was so much better for my Dad.”
• “All care homes should have this technology. It’s fabulous and really provides good care to all of the residents.”

Staff feedback includes:

• “We had just walked a lady to the sitting room that has COPD. She was very out of breath and before this, I probably would have called for an ambulance. But because I had the equipment to take her oxygen levels I was able to see after some rest her oxygen levels came back to her baseline”
• “I love using this, residents and families feel reassured and better cared for because of it”

Better use of resources – This re-design of patient monitoring and care has demonstrated:

• 35% reduction of visits to a GP;
• 71% reduction in hospital admissions;
• 33% reduction in emergency admissions;
• 46% reduction in non-elective excess bed days from 26 down to 14.

These savings cannot be causally associated directly to the technology programme, but the evidence certainly demonstrates a positive shift in use of resources – crucially, providing care closer to home. The CCG has seen new ways of working, which includes MDTs as well as the technology, reduce the overall emergency admissions by 5.7%.

Challenges and lessons learnt for implementation

Establishing a MDT can inform real change with everyone involved and empowered. The investment of key partners is critical to support the changes needed and the implementation of the project. Some challenges that were experienced include:

• Sticking to the scope and not letting the project creep outside of this, despite several other ideas;
• A great deal of time is needed to develop a plan that everyone is happy with before starting to implement an innovation;
• Development of interoperability is ongoing and complex but a worthy priority;
• Care home staff turnover and embedding the use of the technology within the care homes.

As a Vanguard site, Sunderland CCG have shared their good practice with other CCG’s across the country. The system has now been adopted by 20 different areas across the country and over 10,000 care home residents have benefited from this technology.

For more information contact

Rachael Forbister
TECS Programme Manager; NHS Sunderland CCG
Rachael.forbister@nhs.net