Deteriorating Patient Improvement Programme
The quality and safety of care for each patient are at the heart of the Irish healthcare system.
To ensure the implementation of quality health care for the recognition and response to a deteriorating patient, The National Deteriorating Patient Recognition and Response programme (DPIP) was established in May 2017 to ensure the implementation of quality health care for the recognition and response to a deteriorating patient.
The aims of the programme are:
- Better decisions - early warning systems provide a framework to assist with clinical judgement and decision-making in the care of acutely unwell hospital in-patients.
- Better care - the implementation of the EWS national clinical guidelines (INEWS, PEWS, IMEWS and EMEWS) are intended to lead to the improvement in quality and safety of care of this vulnerable group of patients
- Safer service - DPIP is a key patient safety initiative of the HSE.
Early warning systems
The first major outputs of the programme's work are INEWS (version 2), the supporting education programme and associated quality improvement tools.
INews National Clinical Guideline (Version 2)
You can view and download the guideline from this link.
When a patient is admitted to hospital acutely unwell, or deteriorates while in hospital and becomes acutely unwell, time is critical in the prevention of irreversible deterioration and death.
A system is necessary to assist clinicians in preventing irrevocable deterioration and death. This system must include:
- early recognition
- competent clinical response
- closed-loop governance
Early warning systems assist healthcare professionals in recognizing clinical deterioration. The National Early Warning System, that is, NEWS, based on the VitalPac EWS (ViEWS) is in use in Ireland since 2013.
In 2018 the Department of Health through the National Clinical Effectiveness Committee (NCEC) required that NEWS be updated by the HSE to reflect current evidence. A nationwide multi-disciplinary NEWS guideline development group (GDG) was established in early 2018; three patient representatives participated. The Health Research Board – Collaboration in Ireland for Clinical Effectiveness Reviews (HRB-CICER) was commissioned by NCEC to undertake the systematic review of the literature.
The GRADE process was used to translate evidence to recommendations. Other sources of evidence helped to inform the revised recommendations. Thee included focus groups with frontline doctors and nurses, audit data and critical incident analysis findings. The revised guideline was submitted to the NCEC on 30th January 2020, approved in March, endorsed by the Minister for Health in August and launched in September 2020.
There are a number of major changes in INEWS. 8 domains comprise forty-three recommendations which represent INEWS as a system rather than a score as in the previous version. The significance of INEWS as a system is that it comprises the complete cycle of care from the anticipation of deterioration, recognition and escalation of care, the response to the escalation, and evaluation at both clinical and organizational levels or ‘closed-loop governance’.
The individual elements of INEWS V2 include:
Anticipation: situation awareness, ‘cues for caution’, clinical judgment, clinical experience, safety huddles
Recognition: clinical judgment and the INEWS track and trigger tool i.e. the INEWS patient observation chart and patient’s INEWS score
Escalation: of care as per the Escalation and Response Protocol on the INEWS patient observation chart using ISBAR and ISBAR3
Response: appropriate bedside, urgent and/or emergency response as detailed on the Escalation and Response ProtocoEvaluation: after action review, audit, Mortality & Morbidity, Hospital Clinical Governance Committee
INews Recommended Changes
- Increased emphasis on clinical judgment and using the INEWS track and trigger tool as an aid to assist clinical judgment and decision-making rather than as a standalone tool.
- The addition of ‘healthcare worker/patient/family concern’ on the INEWS patient observation chart to capture, acknowledge and act on early concern.
- New ‘cues for caution’ included on the INEWS Escalation and Response Protocol to remind staff to think about the potential for patient deterioration.
- An increased emphasis on changes in respiratory rate as a key early indicator of deterioration.
- ‘New confusion’ – an early sign of deterioration – is captured as ‘C’ in ACVPU.
- The requirement for a minimum of 6 hourly observations for the first 24 hours following admission.
- A new recommendation stating that the adjustment of INEWS parameters or a patient’s INEWS score is NOT permitted.
- The option for a Consultant or Registrar to use a Modified INEWS Escalation and Response Protocol for patient’s whose baselines fall outside of INEWS parameter ranges.
- The facility for a Registered General Nurse to defer escalation for a brief period of time (max. 30 minutes).
- A three-tiered response model (bedside, urgent and emergency) evolving to an Advanced Nurse Practitioner response service.
- Closed-loop governance to drive improvement at clinical and organizational levels.
The national INEWS patient observation chart was redesigned to correspond with the revised clinical guideline. Human factors expertise was sought to ensure optimal chart design as were the views and experiences of frontline staff. Two sections were added to the back of the chart – one for Consultant or Registrar documentation of a Modified Escalation and Response Protocol and the second for the documentation by an RGN of the decision to defer escalation.
The Glasgow Coma Scale (GCS) is now included in the three-fold version of the chart. The chart is also available as a two-fold design without the GCS.
The INEWS V2 education programme aims to support clinical staff in the acute settings to use the Irish National Early Warning System to anticipate, recognise, escalate, respond and evaluate a non-pregnant patient (≥16 years) effectively in line with the INEWS V2 National Clinical Guideline.
INEWS V2 education resources include:
INEWS Service Improvement
DPIP has partnered with the national Quality Improvement team to develop tools and resources to support acute hospitals to audit, develop and sustain quality improvement initiatives. These will support the effectiveness and implementation of INEWS.
Deteriorating Patient Quality Improvement Partnership
Learning Set Day Bespoke Programme
DPIP Quality Improvement Resources
- National Quality Improvement Toolkit
- QI Toolkit – Practical tips on use of the toolkit and demo
- Deteriorating Patient QI Talktime with Chris Hancock, Acute Deterioration Programme Lead at 1000 lives Improvement, Public Health Wales
- Collaborative approach to reducing cardiac arrests in acute medical unit (McGregor et al 2017)
- Reducing Cardiac Arrests in Acute Admission Unit (Beckett et al)
Run Charts in Quality Improvement: Webinar 2
Paediatric Early Warning System (PEWS)
The Paediatric Early Warning System (PEWS) is a workstream of the National Clinical Programme for Paediatrics and Neonatology. PEWS provides a framework for care and empowers clinicians to act on behalf of a child with signs of deterioration or about whom they have clinical concerns. PEWS is designed to make hospital admissions safer for children and help staff care for deteriorating paediatric patients.
A National Clinical Guideline on the Irish Paediatric Early Warning System (PEWS) was published by the National Clinical Effectiveness Committee and Department of Health in November 2015 and updated in November 2016.
Emergency Medicine Early Warning System (EMEWS)
The Emergency Medicine Early Warning System (EMEWS) national clinical guideline was developed by the HSE National Clinical Programme for Emergency Medicine and was launched in 2018 by the Minister for Health.
It applies to adults patients (16 years and older) attending an Emergency Department (ED) in Ireland and is relevant to all healthcare professionals working in EDs. This guideline should be used in conjunction with other National Clinical Effectiveness Committee national clinical guidelines.
For further information visit the Emergency Medicine Programme website.
Irish Maternity Early Warning System (IMEWS)
The Irish Maternity Early Warning System (IMEWS) is a nationally agreed system developed for early detection of life-threatening illness in pregnancy and the postnatal period. IMEWS should be used for women who are clinically pregnant or who were delivered within the previous 42 days. An e-learning education programme was published in tandem and is available on HSELanD.
IMEWS should be used to complement clinical care and it is not designed to replace clinical judgement. Clinical concern about an individual woman should trigger a call to medical staff irrespective of the IMEWS.