Podcast transcript

Laura: Hello, and a very warm welcome to all of our listeners. My name is Laura Hailes. I’m a nurse and I’m a senior improvement manager at NHS England, and I work in the National Patient Safety team.

Today we’re going to be talking about physical deterioration. In particular, we’re going to discover more about the acronym PIER, so that’s P.I.E.R., prevention, identification, escalation and response.

We’re going to delve a little deeper into how each of these little letters can have a big impact and help improve physical deterioration in health and social care.

Today, I’m joined by Dr Aidan Fowler, National Director of Patient Safety in England, who will be able to tell us much more about why physical deterioration needs addressing and how PIER can help.

Welcome Aidan

Aidan: Good morning, Laura.

Laura: Good morning. Before we talk about the P, I, E and R, can you give us a bit of a background as to why deterioration is such a priority for the NHS and why now?

Aidan: Certainly, and I know that people will be very focused on deterioration following a lot of news around the story of Martha Mills and Martha’s Rule.

And we’ll be aware that we have agreed in England that we are going to bring in Martha’s Rule, which allows families and patients, if needed, to call for help when they feel that they are deteriorating and that people aren’t responding appropriately. And the plan is to roll that out across England.

But in discussion with Martha’s family, it’s very clear that they, like me, feel no one should ever actually have to call this number if we get it right upstream.

And so, PIER came about as a way of describing in simple terms the actions we think we need to address deterioration, which we know is a continuing problem. That deterioration can be missed and that clearly impacts on people’s health. They can end up unnecessary on ITU. Sadly, some people die as a result of missed deterioration still. And of course it impacts on length of stay.

And so, if we can improve this, we potentially save lives, we improve health, we improve experience for people. But secondary to that, if we can reduce length of stay, if we can take people out of beds that could be used for other patients, we improve the lot of more patients by doing the work. So, I think it’s really important.

Laura: Thank you. It’s obvious that we need to address this huge and complex issue, and we’ve been working in this space for a few years now. We focused on the I, so the identification, for quite a while. Can you give us a bit of a flavour of some of the work already done and some of which I’m sure that the listeners will be familiar with.

Aidan: Certainly. So, I mean, there are 4 letters and the first is prevention. So how do we prevent people deteriorating in the first place by timely treatment, for example, timely identification of what’s going on. And there are many and various causes of deterioration. And at one point we talked a lot about sepsis. And sepsis is one cause of that deterioration. We still obviously talk about it, but there are other causes.

And so, I was really keen that we talked about work on deterioration in general, because when someone deteriorates, you don’t know what the underlying cause is and you have to have your mind open to all causes, including sepsis.

And we know from studies that deterioration, I mean, clearly everyone deteriorates before they die, but that failure to spot deterioration is a contributory factor in about 11% of patient deaths that we see reported on NRLS when we review it.  So NRLS being the old reporting system, we’re now obviously switching to the Learn from Patient Safety Events System. But same thing.

And actually, a study of 2,000 patient incident reports relating to, and showed that the mismanagement, difficult term I know, of deterioration was the most common category of harm caused to patients in hospital.

So, we know that this is a big issue. And if we can prevent that, that’s the best approach. But importantly, where deterioration occurs, we need to identify it. And so, people will be familiar with some of the physiological scoring that we’ve seen brought in. So NEWS2, has been rolled out across the system. Recently we launched PEWS the paediatric early warning score, the first of a sort of unified approach to that across the country and standardised approach. And we’re looking at maternity and neonatal. And there’s some work ongoing actually on foetal deterioration.

So, we need a suite of physiological scores where we record some things people will be familiar with and look for and deterioration in those. But we also know that it’s important that staff are aware of when a patient’s condition is deteriorating and there are softer signs that are non-physiological, in people’s behaviours and so on.

And often the families actually are those that notice that most. And we’ve got early work that suggests that families can spot deterioration before the physiological scores change. So, in identifying deterioration, we want to use physiology, we want to use staff concerns about changes in condition, and we want to use family and patient concerns and where possible, codify that into a scoring system to standardise that approach so that we identify issues.

Then we need to look at how they are escalated and what responses and part of the work we’re doing around Martha’s Rule, for example, is looking at what the right response system is. So, people will have heard of critical care outreach teams. That is one form of how we can respond to deterioration by sending skilled people in to support the treatment of that person at that time.

Laura: I think it’s really clear, isn’t it, that a tool is very, very useful, but having that in isolation isn’t going to help anybody. It’s all very well having a score there, but you’ve got to do something about it. So that’s why the whole of PIER viewing this as a P, I, E and R in its entirety is so important.

Aidan: I think to pick up on that point, Laura, we know that in cases, including Martha’s, that sometimes the physiological scoring had deteriorated, the NEWS score was off, but the response to that wasn’t as it should have been.

And we need to understand that bit and how we make sure that people respond appropriately to the deterioration they see.

Laura: Exactly. This isn’t just the patients. This isn’t just the physiology, is it? This is about the culture. It’s about systems teams. This is the whole picture. And that’s why it’s such a complex, a complex issue.

So, it’s still important really to view the deterioration from the lens of the P, I, E and R. And we’re hoping to shortly release a suite of resources to help systems use PIER. So, we’re currently testing this in the Midlands region to make sure that this is user friendly and we’re getting feedback on how it can be used in practice, especially by integrated care board (ICBs). ICBs can potentially play a really important role here can’t they, they have that system view.

Aidan: I think it’s critical because of course, when we see, for example, we mentioned sepsis, we see people who develop sepsis in the community. And we’ve been very focused in the past when they are admitted to hospital on making sure they’re seen and treated within an hour. And the sepsis 6 and so on. But if you’ve been deteriorating in the community for several days from an infection, that’s a missed opportunity.

And so that overall pathway view, the ICB’s now give us where there’s greater connectivity between out of hospital and in hospital and out the other end again. I think that’s really important and gives us a chance to look at the whole pathway and again, get upstream of some of these conditions because some of the deterioration we see starts out of hospital, not all of it. So clearly there are conditions that arise when people are inpatients, but some of it starts out of hospital and we want to be able to address that where possible and shorten the time between people developing symptoms or signs and getting the treatment they need.

Laura: And I think that’s really key, and I think that’s why PIER is slightly different to how we viewed deterioration previously.

We used to talk about recognise and response, but actually you can do more before you get to the recognition, you can actually plan and you can prevent. And as you said at the top, you were talking about how before people die, they have a deterioration. We can actually plan and prevent aspects of that as well. So we’re going to talk about P,I,E and R in a bit more detail soon.

But that’s a really key point about the P and that this isn’t just about preventing, it’s about planning too. And that’s where you can bring in your planning for anticipatory care, for example.

Aidan:  Laura, you’re absolutely right. And we’ve had discussions about the P because there are those who say, well, actually it should be planning and I think it is both.

You’re right, it is both. Anticipatory care is important. One of the things we’ve been looking at recently, of course, is flow. We have a new renewed focus on flow, as you know. And looking at, for example, ambulance response times, I have concerns about category 2 as they’re called, ambulance response times. One of the things we’re seeing in amongst that is a lot of calls to people at end of life.

So, you may have somebody who’s elderly, who’s got a known cancer, for example, and is essentially at the end of life and someone picks up the phone and calls an ambulance, which is not what they need. It’s not in their best interest and it’s not what the system wants to be using resource for. So, end of life planning is part of P and it’s also sometimes the right part of R, the response is actually making sure people have a dignified end of life rather than escalation of care that may be totally inappropriate and not in the in the person’s best interest.

Laura: Absolutely. And we found that a lot, especially when we were doing some national work in care homes and we were doing that through the patient safety collaboratives over the last couple of years. We worked with over 11,000 care homes to support safer care, and we’ve actually prevented over 57,000 emergency admissions.

Some of that would have been appropriate. So, some of those escalations in response would have been managed in the community, but some of that would have been preventing inappropriate and not escalation, but inappropriate conveyance to hospital. Where that person’s wishes may not have been respected. So, I think it’s so key to make sure we’re viewing this as the whole acronym, the P, I, E and R.

Aidan: Yeah, and look, that was an incredible bit of work because, as you say, 11,000 care homes. That’s a staggering figure and that’s a proportion of our care homes. I think the figure is something like 15,000 care homes in England. And that’s a very complex world to work with. That’s the scale of what we’re trying to address, is working with those organisations to say, how can we do better for your residents and how can that benefit the wider health care system?

Laura: And I think that’s a really key part too. So, working with the care home sector to begin with there was some pushback and there was pushback from some people saying, this is NHS resource. Yes, but we would be short sighted not to see that they’re very much part of the health and social care system. And actually we can address UEC (urgent and emergency care) issues, flow issues, etcetera, by turning our attention to help our colleagues.

Aidan: And look, I get the point that we have a limited resource necessarily in the NHS and we have to manage that appropriately. But it saddens me to some extent to hear people say we shouldn’t be doing work in the care sector because we’re not funded to do so. If that work directly, well firstly, it benefits our population and their health, which is our remit as I see it.

But secondly, the benefit to us of avoiding conveyance and avoiding admissions is so significant that actually I think the return on that investment, if we want to look in financial terms rather than human terms and I think we have to look at both ways, is so great, that it’s absolute worth doing that work. And you know, we talk a lot about quality improvement, being able to share our quality improvement knowledge that we’ve developed over a number of years with the social sector who perhaps haven’t had as much experience of it, I think is a really important part of what we do.

Laura: The acronym PIER has been a long time in the making. We’ve been working with stakeholders from a variety of backgrounds and especially the work that we’ve been doing through the Acute Deterioration Design group. We spent many months developing and finalising each aspect of the P,I,E and R and as we’ve already alluded to, so that it fits the wide range of health and care settings.

So we’ve already spoken about care homes, but this needs to fit community. This needs to fit acute specialties in hospital, this needs to fit maternity, neonates. And so can we talk a little bit more about PIER, so the P, I, E and R.

Aidan: It’s one of those things where I still remember where I was when I coined it. And it was in a meeting where I was trying to get a point across and suddenly realised as I was saying it, it spelt something that perhaps was memorable. And, and I actually used the term just to demonstrate that point of 4 elements I could see in how we responded to deterioration, never thinking it would actually stick.

And just trying to illustrate the point and said, you know, this is a PIER approach because it spells PIER and it was sitting in a meeting talking about deterioration. The development of the tools that come out of that, yes, have taken some time. And I’m amazed that it stuck. But actually it’s a useful handle to remind us that there are these different steps in our approach to deterioration. And then thinking about the tools we need.

And it and it’s a logical order and I guess it’s a bit like ABC in resuscitation. It’s logical and hard to argue with. We should prevent first, when we can’t prevent, we should identify quickly. And once we’ve identified, we need to think of the appropriate escalation, not always appropriate as we talked about. And making sure that response is right.

And of course, sometimes we go straight from identification to response and skip the E. So, you know, but it was a convenient way of describing a point that seemed to resonate with people and seemed to help them think through the various steps.

Laura: We’re now developing a range of resources for systems to use so that they can view their system through that PIER lens. And in particular, we’re testing at the moment the PIER document, which probably is more akin to a toolkit. So, it’s something that coaches systems to follow a 7 step guidance.

So, this is about guidance. This isn’t about a must do, but it’s pretty much a no brainer. It’s a way of organising already the priorities that you have in the system.

So, I think if you are an ICB, you already have to do lots of things. You have to improve your urgent and emergency care, your UEC. You have to improve flow. You’re having to look at ways of improving the health of your population. And actually, if we look at things through a view of a deterioration or a PIER lens, you can actually hit a lot of those nails on the head.

Aidan: I think there is a really important point in there. As you’re talking through, I’m thinking about the amount we’re asking of our colleagues. And I think that’s a really important point. And Laura, you know, we talk a lot about phases of patient safety culture, and we talk about the sort of pathological reactive, the bureaucratic, the proactive, the generative as maturity in patient safety.

And there is a risk that we land in the bureaucratic phase and stick there, and create work for people. Now, a lot of that work is important and a lot of it rises for good reason. But one of the things that’s really important in developing this toolkit is that it is, A, useful to people, that they can use it when they need it and that it’s not just a top down directive, you must do these things.

It’s something they can pick up and use and that they feel is helpful and not just additional burden in a busy world. And so, I think getting that right is really important. And, you know, because you’ve worked with us for a while, we’re not in the business of producing documents to a grateful audience and saying, lucky you, look at this.

We like to test them out, we like to evaluate stuff. We like to talk to people. That’s why the work with the Midlands is important to say what of this is useful and what could we do to make it better. Actually practicing what we preach around quality improvement, testing and changing and responding and learning, to produce something that actually helps people when they need it.

Then they need to be aware it’s there and be ready to use it when it’s helpful to them.

Laura: Absolutely. And the PIER toolkit, the resources that we’re referring to, especially that for the ICB’s is based on the model of improvement. So, it’s based on that quality improvement methodology and it outlines that the 7 step guidance really. So that first being set up. Second, building a shared vision, so getting your team together, making sure everybody is on the same page. Third step being mapping the pathway across the system. Now that sounds that’s very easy to say, and quite difficult to do, but so worthwhile doing because once you have that system level view, I think it’s easier to diagnose the problems and to start, well, to diagnose where you might want to focus first.

That goes into step 4, talking then about your improvement plan. Step 5, into how you’re going to operationalise that. Step 6, actually do it, so actioning those improvements. And 7, as you’ve already spoken about, evaluation.  So, making sure that what you’ve done has worked and sustaining it, making sure that all of that hard work can be kept and can be sustained for a long time.

Aidan: I think that sustainability is really important. One of the things that we’ve been trying to do with the patient safety strategy is create structure, if you like, to help things sustain. So, you may have come across the Palestinian physician, Avedis Donabedian. He talked about structure and process equals outcome. And I think that’s really important because I think we have a habit of changing process and not the structure around it, and then it reverts to the me.

So, if we want this to stick and it is one of my worries about some of our historical quality improvement endeavour, big collaboratives that achieve great things. And then there is drift backwards. People feel we’ve done that work now and it doesn’t sustain. And I think you have to build it into the structures and processes together of your system to make them sustain.

It’s got to be what becomes normal. And if it’s just a new thing that you try out for a while, it will tend to fade backwards. And of course, we’ve constantly got to review things which can be quite resource intensive to keep going back to things and changing them.

So, for example, it’s time we started looking again at VTE. We feel we’ve done a lot of work on it in the past, but we know that there are still issues with it. The world has moved on. We have different anticoagulant treatments available. The population has changed, aged, size has changed, risk has changed. So, something like that. We need to be going back at it and saying, what do we do next and what are the next steps.

And that will be the case with deterioration. One of the things we haven’t talked about today is actually some of the technical side, so some of the testing that can go with it. So, biomarkers of inflammation and infection, for example. And in the future there will be point of care testing around that. Pathological testing, so if someone has got an infection, being able to identify the organism will be possible at the bedside.

So, point of care testing and using testing and monitoring of blood parameters and so on will change. And we need to adapt with that and make sure that is part of our identification resource.

Laura: And as with all these things, that then has a knock-on effect and impacts into other priorities, doesn’t it, that will then help address antimicrobial resistance if we know exactly what we’re treating, if it has to be broad spectrum antibiotics.

Aidan: So, there’s a tension there isn’t there Laura, between treatment of sepsis in a timely fashion and AMR, as you say. And we have this tension where we’re trying to measure our impact on sepsis. But the more cases we identify, the more we dilute the cases, which sadly, people die. And so, it can look like the mortality has changed when actually it’s an ascertainment bias.

And we have this issue of we encourage blood cultures for people with potential infections. So we identify more infections and we say our E.coli rate has gone up when actually it’s just identification and it makes this world more complex and confusing. So, we just have to be aware of that complexity and manage it.

Laura: And change with it. Absolutely.

So, this is probably quite a tricky question, but what are your aspirations for this work?

Aidan: Look, I think if I were going to put it in simple terms that it’s helpful to people and that it helps be part of, I’m not expressing this well, but helps to reduce the level of, well, I’d like to reduce the level of deterioration, but I’d also like to reduce the level of missed deterioration, and I’d like to see it identified earlier where it’s not prevented and treated appropriately.

That will be difficult to measure over time, but I think that’s the endeavour. This has to be helpful to people, we’re having a lot of success with the patient safety incident response framework, where people are saying this is helpful to us, this is a positive change.

I’d like PIER to be seen in that frame where people say this has been helpful to us in our work, this has made our work easier. It has made the world safer for our patients. That’s the aspiration, I guess.

Laura: Absolutely agreed.

Is there anything else that you’d like our audience to consider? Any parting words of wisdom?

Aidan: So that’s always a difficult one to put me on the spot.

No, I think the previous comments were what, I mean, we welcome feedback on these sorts of things.

We genuinely do and we genuinely change. And in response to that feedback, and as you were discussing earlier, a few words from a few people can change your thinking. You get so embedded in this work that sometimes it needs somebody else to come in and say, actually, I would do this instead of that, and that’s really helpful.

So, I would encourage people to engage with this, not as another task, but as something that is meant to be helpful, genuinely helpful to them, and give us feedback so we can improve the tools over time.

Laura: Thank you so much.

I think there’s been a really useful discussion. I’ve really enjoyed it and I hope our listeners have too. I think it’s been really interesting to see why we need this. This is a complex issue in a complex system. We need something actually, sometimes you need something simple to be able to view the complexity through.

And so having those 4 elements, that P, I, E and R, prevention, identification, escalation and response, really can help you break it down, take it bit by bit, see what you can improve and start that.

We’ll be keeping people posted on the development of the PIER resources, we’re doing that through our website, but also through our Twitter or X account, and that is @ptsafetyNHS.

Thank you Aidan for your time, and thank you to our listeners.

Publication reference: PRN01011