NEWS flash! Chelsea and Westminster Hospital prescribes mobile patient warnings
- Summary:
- London hospital works with software company ThinkVitals to create a mobile application for identifying and escalating critical health situations
At Chelsea and Westminster Hospital in London, Dr Gary Davies, a consultant in respiratory medicine and the hospital’s clinical lead for acute medicine, welcomed the proposal. In fact, he’s since worked with software company ThinkVitals to develop and roll out a mobile app based on NEWS in the Acute Admissions Unit (AAU) at Chelsea and Westminster. As he explains:
When you work in acute medicine, it’s often possible to look back at a particular case and, with the benefit of your ‘retrospectoscope’, you can see there were small signs of deterioration in a patient’s condition around 12 to 24 hours before the problem was actually spotted and picked up and treatment began. If you can pick them up earlier, before the patient gets very sick, you’ve got a much better chance of getting on top of the problem and treating that patient successfully.
NEWS, he explains, is a simple ‘track and trigger’ approach, which enables medical staff to score patients based on the results of regular observations: breathing rate, oxygen saturation, temperature, blood pressure, pulse rate and level of consciousness. A high score means that action should be taken: a doctor should be notified, antibiotics should be administered, further observations should be recorded in an hour’s time, and so on.
There’s nothing particularly new here: many hospitals worldwide have used some kind of early warning score for years. What the Royal College of Physicians proposed in 2012 was a standardised approach across the NHS, so that a patient with a score of 7 in an Edinburgh hospital would be considered to require same speed of medical response as a patient with a score of 7 in Epsom, for example.
According to Dr Davies, many NHS Trusts - including Chelsea and Westminster - have adopted NEWS already and many more are in the process of adopting it. He considers this to be a positive step for patient outcomes, but acknowledges that audits have shown some problems in implementation:
NEWS can go wrong - and investigations have shown that it tends to go wrong in three ways. First, someone puts the ‘dot’ on a paper chart in the wrong place, leading to the wrong score. Or, they make an error in mental arithmetic - again, leading to the wrong score. Or, they simply don’t know what to do with a given score: who they should tell, whether the consultant should be contacted and so on.
All of these things have been flagged up by NHS Trusts across the country as problems. And at Chelsea and Westminster, we’ve had problems just like everybody else - but we were determined to overcome these problems in order to get the benefits from NEWS.
That’s what prompted him to work with ThinkVitals to create a mobile app that could capture medical observations more accurately; automate the calculations to give individual patients a NEWS result; and prompt medical staff to take the correct ‘next steps’ in treating them. To him, it made “absolute sense” to use software and algorithms to achieve these goals, he says, but:
...there are a lot of systems out there that aim to tackle this, and I’ve personally taken a look at many of them, and I have to say that most of them seem to have been designed by people from computer companies, without a great deal of clinical input.
Others are just a part of much larger healthcare management packages, which also tackle patient records, staff rostering and bed management - but if there’s one lesson to be learned from NHS IT projects, is that implementation of these wide-ranging systems comes with a lot of risk. ThinkVitals solves a specific problem - replacing the charts that hang on the end of a patient’s bed - extremely neatly, without falling into the trap of trying to do more than that.
Dr Davies began working with ThinkVitals in March 2014 on developing the app. In return, ThinkVitals gets an app it can sell into other NHS Trusts. Live testing of the app began at Chelsea and Westminster in October of that year and went for around six months, as tweaks and improvements on the advice of nursing staff and junior doctors - the staff, in other words, responsible for taking patient obs and doing first assessments of the results.
This phase, he says, threw up some interesting findings:
Things in the app that I thought looked pretty good from a clinical perspective turned out to be wrong for the nurses. They’d tell me, ‘Actually, this is the wrong way round. This step needs to be completed before this one’ and so on. Testing was an awful lot longer than we’d anticipated. The more we used the app, the more we found things that needed changing. But over the last few months, we’ve found fewer and fewer things, and we’ve finally got to the point where staff are very happy with how the app is today.
Pocket-sized
Another striking finding: in order to encourage uptake, a mobile healthcare app should be rolled out to devices that fit easily in the pockets of medical staff - but different size uniforms, it turns out, often have different size pockets. Says Davies:
That was another intricacy we hadn’t anticipated - but it was a really important consideration in selecting which mobile device to distribute to staff in the AAU. We needed something they could carry in their pocket, because otherwise, the device would be left at the nurse’s station and the app just wouldn’t get used. And the device also needed to be large enough for viewing charts, not just recording obs.
The pocket-size issue ruled out Apple’s iPad Mini at the final shortlist stage, with Samsung’s Galaxy Tab Active ultimately winning out. Other advantages of this device include its ruggedized design, the fact that it’s shock-proof in drop tests up to 1.4 metres and waterproof for up to 30 minutes (so wiping it clean for infection-control purposes poses no issue).
The app has now been rolled out in the AAU and there are plans to extend its use to other wards at the hospital, where the potential benefits may be greater still, as Davies explains:The AAU tends to have the sickest patients outside of the Intensive Care Unit and a higher density of nurses and doctors than any other word - so acute admissions patients are typically observed more closely and more frequently. It’s elsewhere in the hospital where there’s a greater risk of deteriorating conditions coming to light rather later on than they should.
In particular, that should help in the identification and treatment of sepsis (a life-threatening inflammatory response to infection often seen in post-operative and elderly patients as well as those with compromised immune systems.) This a new national performance indicator in the NHS Standard Contract, by which all NHS Trusts are judged by NHS England commissioners. Says Davies:
With severe sepsis, mortality rates rise 7 percent for every hour beyond one hour that treatment is delayed. The mobile application will allow us to spot sepsis and intervene earlier.