Between August 2016 and May 2017 Interserve Healthcare (IHC) worked on a project with the Wessex Academic Health Science Network (AHSN) to explore how homecare services could improve their ability to spot early signs of patient deterioration. Deterioration often leads to hospital admission, secondary complications and an increase in long term care needs. This project has been a significant part of our quality improvement for 2016 and 2017.
The Wessex AHSN, part of NHS England, is one of 15 collaborative partnerships that aim to develop and implement patient safety improvements. AHSNs were developed in response to recommendations by Sir David Nicholson (former Chief Executive of NHS England) to improve patient and population health outcomes; translate research into practice and build stronger scientific and academic relationships with health care. Interserve Healthcare have been working with the Wessex AHSN since August 2016 and was the first national Independent Healthcare organisation to do so.
The project used a validated quality improvement model called the Break Through Series (BTS) which can be applied to any quality improvement project, in this case develop IHC approach to better managing deteriorating patients. The objective was to increase the knowledge and awareness of our field based care staff to identify early, subtle, indicators of deterioration; so called “the soft signs”.
Whilst there are well-developed systems for identifying deterioration in hospital settings, these rely on physiological measurement whichare often not available in a homecare environment (for example blood pressure monitoring). Innovatively the ‘soft signs’ work as proxy measures for deterioration and include observed changes in patients’ normal behaviour, such as sleep, eating, drinking and mood. These observations avoid the need for complex measurement equipment, whilst proving to be good indicators of early negative changes in the patient’s well-being.
The team worked with two of Interserve Healthcare’s branches to develop the new model of care. Each branch identified a maximum of 10 patients to work with, and together agreed a common list of over 100 ‘soft signs’. From this list a small number of soft signs are selected for each patient, relevant to their condition and normal patterns of behaviour, allowing care staff to spot sudden and unusual changes and escalate them to one of IHC’s Registered Nurses.
These are chosen through assessment and discussion with IHC Registered Nurses, the care staff, the family and, most importantly, the patient. Care plans and escalation flow charts were also designed to enable all staff to understand the process for identifying, managing and escalating the soft signs.
The care plans also set out interventions in response to each selected soft sign, whether that to be to monitor the patient carefully, consult with the patient’s GP, or to call the emergency refined as part of the BTS methodology ensuring all care staff were familiar and confident to use them in practice.
For the project the team measured the number of calls between care staff and branch staff in relation to the soft signs, to measure whether there was an impact on improving identification of the soft signs and subsequent escalation to the Registered Nurses to ensure a review of the patient took place.
The teams found the quality improvement model to be a useful tool that improved client outcomes with a significant increase in the communication between the care staff in the patients’ homes and IHC branch staff. In addition identifying soft signs early, ensuring review and intervention took place sooner, IHC were able to either avoid patients’ hospital admission altogether or significantly reduce the length of stay and complexity of treatment. The projected hoped it would see a positive impact like this but the team were surprised at how well this worked and how quickly it began to happen.
Following the pilot, the soft signs system has been rolled out and embedded across Interserve Healthcare’s full network. The teams have had positive feedback and engagement from a number of sources including the Wessex AHSN; the Director of Patient Safety for NHS England; a number of other care providers who have asked for the work to be shared and; and they recently presented the project at the national Patient First Congress in London providing a platform to share this innovative work with health and social care professionals across the UK.
During 2017, through identifying the early signs of deterioration, at IHC 15 client’s avoided hospital admissions.