Lancashire Teaching Hospitals NHS Foundation Trust is one of the first hospitals to have used digital technology to implement a new national standard designed to help improve patient safety.
The National Early Warning Score (NEWS) – first documented by the Royal College of Physicians in 2012 and later revised in 2017, in the form of NEWS2 – is based around a simple scoring system focussed on six physiological parameters: respiratory rate, temperature, oxygen saturations, systolic blood pressure, pulse rate, and level of consciousness. This score adjusted for people requiring oxygen and also patients with hypercapnic respiratory failure (usually due to COPD).
Over 76% of NHS hospitals have now implemented NEWS2, with many still recording it manually on paper. The protocol was developed to provide all NHS caregivers with a common language and a consistent set of measures to diagnose patients and recognise deterioration. This standardisation of a common tool aims to eliminate variations in care; potentially saving lives.
However, one study highlighted that up to 34.5% of all manual observation sets were incomplete or had an incorrectly aggregated early warning score. To help mitigate this risk Lancashire Teaching Hospitals has taken the NEWS2 tool one step further by incorporating it into over 350 Mindray vital signs monitors – helping remove the need for manual transcription, ultimately reducing errors and improving calculation accuracy.
The fully electronic system is now being used on all Mindray monitoring devices across Royal Preston Hospital and Chorley District Hospital, ensuring that patient observations are immediately available in the hospital IT records. This makes them one of the first to have fully compliant, integrated NEWS2 e-vital signs devices in the country.
Lancashire Teaching Hospitals NHS Foundation Trust. (Source: National Health Executive)
Sourcing a solution
The Lancashire Teaching Hospitals NHS Foundation Trust first started working with Mindray on implementing an electronic version of the National Early Warning Score, alongside digital recording of vital signs, in 2015. The Trust successfully secured funding through the “Nursing Technology Fund” – an initiative introduced by the UK Government in 2012 to support investment in digital technology designed to help nursing staff work more “flexibly and effectively”, while increasing patient safety and reducing paperwork.
The Lancashire Teaching Hospitals NHS Foundation Trust issued a tender to replace all of its vital signs monitors and to provide digital, paperless reporting for NEWS. During trials of Mindray’s VS-900 devices, the hospital was impressed by the ease in which staff could visualise basic observations alongside the early waring score, a significant factor in the award of the contract. In addition, the VS-900 vital signs monitor can be easily connected to the electronic patient records system via Mindray’s eGateway, both through WiFi or wired connections.
For the Lancashire Teaching Hospitals NHS Foundation Trust, the Mindray system was configured so that the NEWS and vital signs values could be sent directly from the bedside patient monitor to the hospital’s EPR system. This approach enables e-vital signs to be viewed from any ward or department by the multi-disciplinary team.
Most critical events, such as cardiac arrests, are preceded by warning signs 6 to 8 hours prior to the event, making the early detection of these signs essential. By using an electronic system, the patient results are calculated automatically and saved directly into the hospital IT system, reducing errors and delay. Scanning of a QR code on the patient’s wristband displays the patient’s demographics for efficient validation and reducing risk of errors.
A collaborative approach
While the Royal College of Physicians stipulates that set parameters are incorporated for NEWS calculation, the hospitals wanted their own parameters to be added for a complete picture of the patient’s status and clinical care. Mindray was able to configure the screen to provide a bespoke solution to meet the customer’s exact requirements. This included the facility to input information on how oxygen was delivered – i.e. via face mask or nasal cannula; as well as the provision of alert messages specific to the Trust – such as who should be called, and on what number, in the case of an emergency.
A feature of the system also included colour coded alerts (green, amber and red) to provide clinical staff with a rapid visual indication of the patient’s status and the appropriate action required, as per the warning score.
Vicky Burton, Clinical Lead and Critical Care Outreach Practitioner and Janet Young, Head of Digital Programme Delivery at Lancashire Teaching Hospitals
“We have been extremely well supported by the Mindray team throughout this work. Mindray has listened to our suggestions and incorporated our ideas into the software to provide a complete NEWS2 setup with all the needs required the Trust.”
———— Vicky Burton
Clinical Lead and Critical Care Outreach Practitioner
Lancashire Teaching Hospitals NHS Foundation Trust
Clinical staff are also able to enter additional information such as respiration rate, urine output, temperature, and whether the patient is alert and in pain. This means that staff no longer have to enter all of these observations onto a paper chart and leave the clinical area to manually enter this data into a separate PC to calculate the warning score. All of this information can be quickly entered and analysed at the bedside via the monitor.
By removing manual, time-consuming steps, such as writing down results on paper and typing them in to a computer, the Trust is helping to release nursing time back to care – helping caregivers to spend more quality time with their patients. Some studies have shown that capturing patient’s vital signs electronically can halve the time it takes, when compared to the manual process.
Mindray worked closely with the Trust to avoid any potential issues around integration with other equipment and the Trust’s own IT networks, as well as the training of end users, to ensure everyone felt confident with the new protocol and technology, and that the installation was a smooth as possible. Helping the Trusts to manage change was also an important aspect of this and Mindray helped ensure staff fully understood exactly how “going paperless” could improve efficiency and patient safety.
Having successfully managed the transition to digital recording of vital signs and the roll-out of the NEWS protocol, Mindray was invited to work with the Trust, once again, with the implementation of NEWS2.
In 2017, the Royal College of Physicians (RCP) announced that the NEWS2 protocol would feature a number of changes, including:
Lancashire Teaching Hospitals NHS Foundation Trust was determined to begin NEWS2 before the target date of 31st March 2019. Therefore, the Trust upgraded around 350 monitors with the updated protocol, in a very challenging timescale, in order to achieve its target as part of CQUIN funding.
Qualifying for CQUIN
CQUIN, or Commissioning for Quality and Innovation, is a system introduced in the UK in 2009 to make a proportion of healthcare providers' income conditional on demonstrating improvements in quality and innovation in specified areas of care. Mindray helped the Trust achieve this target – achieving the upgrade of all 350 monitoring devices over a period of just 7 days.
“To qualify for the full CQUIN payment, we were able to highlight the system’s ability to provide timely detection of deterioration in patients, particularly around sepsis, using NEWS2 scoring,” said the Trust’s project manager, Susan Birch.
“We can now state for certain that all observations have a correctly calculated NEWS2 score,” adds Vicky Burton. “The accurate calculation of NEWS2 scores is enabling our staff to follow the NEWS2 action plan and escalate care as required within the advised time frame.”
“This is a digital solution supporting patient safety at its best.”
Clinical users have welcomed the move to automated NEWS2 scoring and have noted the ability of the Mindray system to improve efficiency and enhance patient safety:
“Having the ability to report e-vital signs directly to our electronic patient records (EPR), in real-time, is a huge advantage,” commented Eleanor Leadbeater, clinical change agent at the Lancashire Teaching Hospitals NHS Foundation Trust. “If the patient triggers the NEWS2 score, they will follow the escalation route visible on the bedside monitor, and warning messages will appear – the system will prompt the user on what they should do, based on the patient’s physiological factors.”
For Leadbeater, having a national, standardised early warning score is invaluable: “If a patient is transferred from another healthcare provider with a completed warning score, you know exactly what it means – we are all talking the same language.”
“This is a digital solution supporting patient safety at its best,” adds Janet Young, head of digital programme delivery at Lancashire Teaching Hospitals, pointing out that the automated system takes out a number of steps that can introduce risk. Data collected by the Mindray technology is also helping the Trust identify areas for training, thereby driving improvements in care quality.
Furthermore, the interaction between the dashboard and the EPR is also helping to prioritise patients requiring escalation, which ultimately enables the Trust to channel its resources more efficiently.
“This is particularly valuable for on-call doctors, who may be located anywhere within the Trust and responsible for the care of large numbers of patients,” Birch observed.
“Prior to the observations being made available via the EPR system, the on-call doctor would have to call the ward,” explains Dr Omar Ali, clinical informatics fellow. “This could be quite stressful at times, as the nurses were often busy dealing with patients, so the phone would not be answered straight-away. Retrieving the data took longer prior to the installation of the Mindray system. By having instant access to the observations, on-call doctors are now better able to prioritise and focus their time.”
A truly collaborative implementation
As the devices were being used by staff on patients, the upgrade required careful project planning and communication to all of the wards, to ensure patient safety and continuation of service, throughout the process. In fact, Mindray went “the extra mile” by conducting all the clinical testing, configuration and upgrading of the monitors in just one week.
“Working in partnership with the Trust – from 8am in the morning to 8pm at night – we physically walked the wards with the clinical team and the project team, to find and upgrade each individual monitor,” said Dr Omar Ali. “Normally, this process would be rolled out over a period of months, but we pulled out all of the stops to ensure we met the Trust’s extremely challenging deadline.”
In a short time-frame, Mindray had to rewrite the interface messages to accommodate NEWS2, which had significant changes, as well as upgrade three eGateway servers. The R&D team’s ability to produce such a significant software change, accommodating NEWS2 on the VS-900, in record time, was an impressive achievement – a fact that was recognised by the Trust.
Mindray’s involvement went much further than upgrading the monitoring equipment, however. Every effort was taken to ensure a smooth transition to the new protocol for end users: “For clinical staff, it has been an easy transition to NEWS2. It went live across the whole of the Trust and was very well received, with no complaints or concerns,” noted Birch.
While posters and emails were circulated by the hospital management, Mindray worked in partnership with the Trust to ensure that clinical staff were made aware of the changes.
Mindray worked alongside ward managers, demonstrating how the software would look and explaining the differences to staff, so they would feel confident and ready for the transition. This also avoided any confusion or potential clinical risk.
“We have been extremely well supported by the Mindray team throughout this work,” comments Burton. “Mindray have listened to our suggestions and incorporated our ideas into the software to provide a complete NEWS2 setup with all the needs required by Lancashire Teaching Hospitals NHS Foundation Trust. The team have been engaged and committed to providing a product to an extremely high standard.”
“In particular, we explained how users would now have to select whether a patient was categorised as ‘scale one’ or ‘scale two’. Scale one is a ‘normal’ patient and scale two is categorised as a patient with respiratory failure or COPD. This presented the main challenge around training and we needed to ensure staff were fully aware of this subtle change, both throughout the implementation period and beyond. Updating staff in a short space of time required a very hands-on approach,” said James Swarbrick, territory account manager at Mindray UK.
“The service we received was very professional and responsive,” Young confirms. “The project was delivered at both pace and at scale. Ahead of the system going live, Mindray did everything they could to ensure we were ready for the implementation, by demonstrating a beta release at meetings with board managers and matrons, so they could familiarise themselves with the look and feel of the interface.”
Looking to the future
The Trust has evolved from purchasing just a few devices, on an ad hoc basis, to implementing a large quantity of monitoring devices; working closely with Mindray to develop a bespoke solution.
Vicky Burton, revealed that future work has already begun with the Mindray team to incorporate Paediatric Early Warning Scores (PEWS) into the Mindray monitors.
“Helping to improve patient outcomes and nursing efficiency are key goals of any vital signs monitoring system,” Young concluded.
“Our system has now been live since March and we have some very positive statistics to show its usage and the benefits it is already giving to supporting patient safety and care. This project has been a great collaboration between the Lancashire Teaching Hospitals and the team at Mindray. We really couldn’t have made this happen without this full team effort.”
———— Janet Young
Head of Digital Programme Delivery
Lancashire Teaching Hospitals NHS Foundation Trust
 Clifton, D A, et al, ‘Errors’ and omissions in paperbased early warning scores: the association with changes in vital signs – a database analysis, BMJ Open, (2015)