Patient deterioration: how to identify those at imminent risk
Escalation and non-technical skills such as communication are vital in preventing serious harm, says a sepsis nurse expert with lived experience of the condition
Seven years ago, following what should have been a routine hospital procedure, Katie Dutton contracted sepsis. Now, she is using her experience to teach others how to spot and manage patients who are deteriorating.
‘Sepsis can happen to anyone at any age,’ says Ms Dutton. ‘Because I was a young girl in a side room, no one thought to recheck my observations until the morning after my procedure, by which time I’d gone into septic shock.’
So inspired was Ms Dutton by the nursing care she received during her long recovery, she began a distance learning nursing course from her hospital bed, eventually qualifying as an adult nurse at De Montfort University in Leicester in March 2020.
Secondment to recognise-and-rescue team
After spending the past two years working in intensive care, which included a role as sepsis link nurse, she has started a six-month secondment as a simulation educator in the recognise-and-rescue team at Nottingham University Hospitals NHS Trust.
A key aspect of her role is to devise and run simulation exercises with small groups of nurses, who must identify and manage a patient who is deteriorating, making decisions about what to do next. One of the three scenarios Ms Dutton has created is based on her own real-life experience.
The simulation involves a patient with an infected line in their arm. Penicillin given as treatment does not work and the patient is deteriorating. ‘This is what happened to me,’ says Ms Dutton, who at one point was given a 15% chance of survival.
Once the session is completed, she will play a video showing participants how ill she had become. ‘While it is simulation, we need to remember that things like this happen to patients,’ she says. ‘Staff will really benefit from it, as so often training can feel detached from reality.’
Read RCNi articles by Katie DuttonAs part of a pilot programme running in March and April, each scenario will take around 15 minutes and involve role play from two of the six nurses taking part in each training session. In practice, one nurse is with the patient and they must communicate with the second nurse when they become concerned.
Meanwhile, the other four nurses in the group are observing what happens, thinking about what they might do differently. ‘They are all learning from each other,’ says Ms Dutton.
Afterwards there is a debriefing session, taking around 45 minutes, exploring issues such as handover, escalation and communication. ‘It’s about how they think it went and anything they feel could be improved,’ explains Ms Dutton.
What is recognise and rescue?
Nottingham University Hospital’s recognise-and-rescue team started life as a multidisciplinary committee in 2013, in a bid to share knowledge and promote collaboration in the care of patients who were deteriorating.
‘We were one of the first trusts to set up something like this,’ says Sally Wood, matron for recognise-and-rescue and sepsis. ‘But now a lot of trusts have created their own “deteriorating patient” groups.’
Today, the team has 2.6 full-time-equivalent substantive nursing staff – including Ms Wood – plus a medical consultant. ‘Our role is in governance and oversight, knowing how well we are doing in our trust with unwell patients,’ she says. ‘A lot of what we do is spotting gaps where there is an opportunity for improvements, working with the clinical team to deliver them.’
Evaluation, and improving collaboration across complex systems
While it’s tricky to attribute advances in patient safety solely to the team’s interventions, many quality improvement projects they have been involved with have demonstrated benefits, says Ms Wood.
RCNiLearning: How to perform a respiratory assessmentMs Dutton’s secondment to the team came because she identified that while staff were adept at recognising deteriorating patients, challenges remained. ‘Education is a huge priority,’ says Ms Wood.
While staff had good knowledge and clinical skills, negotiating systems involving many different people can pose difficulties. ‘It’s those complexities that we’re exploring with clinical teams to better understand the particular challenges in their ward area,’ she says.
Simulation – a safe place to learn
Simulation offers a wealth of benefits for training and is widely appreciated by nursing staff, she says, adding: ‘It’s a safe space to learn and develop their skills. We stress that there is no such thing as a silly question.’
‘We’re bringing training to the ward, making it easier for staff to take the time to learn’
While nurses are clinically trained in what to do if a patient begins to deteriorate, they are not so aware of some of the other challenges in delivering care, Ms Dutton believes. ‘The aim is to focus on non-technical skills that may delay recognition and treatment of a patient who is deteriorating,’ she says.
‘In reality, often things don’t just fall into place and there can be barriers, so it’s about how we approach situations and learn from them.’
Escalation is among those key issues, including to the right person and in the right way, so its urgency is highlighted. Communication between everyone involved is another, including the confidence to challenge if concerns are initially dismissed or not taken seriously enough.
Career move into nurse education – a natural next step
Moving into education was always on Ms Dutton’s radar. In 2018, she won the nursing student category at the then RCNi Nurse Awards after organising a training day, attended by almost 200 students, to encourage them to become sepsis champions.
Enter the RCN Nursing Awards 2022 here‘The feedback I got was phenomenal,’ says Ms Dutton. ‘Students would come up to me afterwards and say they’d spotted sepsis in practice because of that day. I felt inspired to continue down the education route and knew it was something I really wanted to do.’
The other half of Ms Dutton’s new role involves working with clinical nurse educators based in different specialties in the trust, to identify areas where patient safety might be improved.
‘These initiatives feel especially important at the moment, when things are so busy’
She has already uncovered concerns about a rise in preventable adverse incidents during the transfer of patients between wards and is planning a simulated training session to help, covering issues such as who is most suitable to escort the patient, what equipment should staff take with them, and what should happen if there is an emergency.
She will also be working with clinical nurse educators to incorporate mandatory training on sepsis into induction, possibly using simulation, after discovering a low level of compliance with training delivered electronically.
RCNiLearning: Sepsis bitesize moduleHow to keep learning going during busy and challenging times
As the pandemic and staff shortages continue to take their toll, among the biggest challenges is trying to take staff away from their clinical practice to be able to provide them with education. ‘We’re finding ways to work around it,’ says Ms Dutton, who plans to take the training directly to staff and provide short simulations where they are working.
‘We’re bringing training to the ward, making it easier for staff to take the time to learn,’ she says.
Each of her initiatives are being evaluated, so progress can be analysed. ‘I hope it gives staff the opportunity to have some time invested in them and their learning, giving them confidence in their own practice,’ says Ms Dutton.
‘It feels especially important at the moment, when things are so busy. It can only be a positive for the staff and I hope it has a ripple effect on patients and their safety too.’
Related articles
- My dedicated nurses inspired me to join the profession
- What is the ABCDE approach and why is it so important?
- Simulated clinical placements: How to learn from mistakes in a risk-free environment
RCNiLearning modules