Andy Cook, chief nurse for Interserve Healthcare, talks below about the simple and cost effective soft signs system developed by the organisation to recognise signs of deterioration in people being cared for at home and reduce hospital admissions.
When we first set out to find a solution to detecting deterioration earlier we thought we’d probably come up with some form of algorithm or scoring system. We expected to create something along the lines of NEWS, or a training package to equip our care staff to spot signs and symptoms better.
However, we found that our Quality Improvement model, which we had learned through our work with the Wessex AHSN, was an ideal tool for ensuring early communication about changes in a client’s condition and this led to our soft signs system.
Unlike a hospital, it is important to avoid medicalising a person’s home environment. People live at home to feel independent and to lead lives that they determine. We aim to provide care as unobtrusively as we can make, whilst meeting their needs. Furthermore, it isn’t routine for many of us to get out of bed each morning and take our blood pressure, which is no different for people who have a disability or a long term condition, unless those conditions specifically require such close monitoring at home. Also, most of our clients are cared for by healthcare staff who do not have clinical assessment skills to interpret blood pressure or other test readings.
We set out to increase the likelihood that our care staff would identify and raise any concerns about subtle changes in the client’s condition early, all without the need for intrusive medical equipment. We could then intervene before a minor change potentially deteriorated into something more serious.
Being alert for soft signs will help to detect sepsis, but this system is not just about early detection of sepsis. Soft signs can be used to spot a whole range of medical or clinical conditions that could become serious and lead to harm.
At Interserve Healthcare, we carried out a retrospective review of a sample of care records and looked for subtle changes, which with hindsight could have been used as a pre-diagnostic indicator of concern. We realised that clients can often deteriorate slowly, but if care staff can flag simple changes sooner we take action and avoid unnecessary, and often distressing, transfers to hospital. This is particularly important for people with learning disabilities.
Our system works on the basis that everyone’s soft signs indicators are individual to them. What works for one person may not work for another. We put in place a selection of soft sign indicators for each individual client which were relevant to them and most likely to help us spot the beginnings of deterioration. They can be changes in sleeping patterns; feeding; toilet habits; an increased lack of interest in wanting to get out of bed or more fatigue than usual.
We now have 120 observable measures. These are not physiological measurements as they can be positive where people with learning disabilities struggle with having their blood pressure or temperature taken using medical equipment.
At Interserve Healthcare we use a combination of these indicators to create bespoke care plans for every patient. Each plan details a short list of super-stable indicators, taken from the list of 120 signs, which are specific for each patient. If they suddenly change that might indicate something of concern that warrants further investigation. Soft signs are not directly diagnostic in their own right, simply indicative of the need for more detailed clinical review or consideration.
Care plans are drawn up by a qualified nurse with care staff, the patient’s family and most importantly the patient, where they are able to engage in that process.
Our care staff are empowered to escalate when there is a sudden change in one of those pre-determined soft sign indicators. They alert one of our registered nurses, who will then review the patient and liaise with primary care or the relevant hospital team as needed.
The care plan ensures communication but not necessarily diagnostic intervention. Our soft signs system means that our care staff are more tuned into changes, which are often subtle. It also takes away the need for care staff to have to make a judgement about whether that change is serious enough to require medical attention, whether that be from a nurse, GP or a stay in hospital. This has reduced the human factors impact on the care process; the fear of concerns being considered too minor or irrelevant stopping carers from speaking up. Now all healthcare staff need to do is to follow the care plan.
This has led to early interventions. Since our system was first implemented we have avoided around 35 hospital admissions as a result of the use of early indicator soft signs.
However, we are on a journey with this. The soft signs system gives us a solid structure and framework for spotting the early signs of deterioration for people who we care for in their own homes. We need to continue getting better at communicating with the wider care team, be that GPs, paramedics or hospital teams. This means working with these colleagues to encourage the use of soft signs and to engage in conversations when people raise concerns based on changes to a person’s soft signs.
This article was first published in the University of Bristol LeDeR Learning into Action Bulletin