David Wastell is a Registered Nurse and Service Improvement Manager within the Acute Deterioration team in 1000 Lives Improvement.
We spoke to him about the ongoing roll out of Community NEWS in Wales – a key part of the *1000 Lives Improvement response to the challenge included in the ‘A Healthier Wales’ plan to improve management of acute illness across the whole system pathway.
Tell us a bit about your background
I qualified in Sydney Australia 21 years ago. My background has predominately been working in Intensive Care Units, I was fortunate to be involved in the ‘Between the Flags’ Programme in New South Wales and the implementation of colour coded charts in the health board in Northern Sydney. This was my first exposure to a chart that aided staff at the front line in identifying Acute Deterioration (AD).
How are charts being used in Wales?
I returned to Wales in 2014 and was amazed to find that colour coded, scoring observation charts were being widely used in the acute care sector and were a key element in identifying patients with Sepsis. NHS Wales has since been internationally recognised through the ‘Global Alliance Award’ (2016) for embedding a standardised approach to identifying Sepsis in acute settings through NEWS.
Until 2017, the primary focus for the Acute Deterioration team was working within acute settings. However, the emphasis has recently shifted in line with the ‘Healthier Wales’ agenda, and we are now focussed on working with staff in community settings to embed NEWS in practice. This is with the aim of making NEWS the single language for identifying patients at risk of acute deterioration across all parts of the health and social care system together. Through the implementation of NEWS and the early warning scoring system for Acute Deterioration, discussions around ceiling of treatment, escalation of care and Advanced Care Planning can be at the forefront of the individuals needs thus potentially providing care closer to home.
What’s the scale of this work in the community?
It’s huge – there are over 170 teams across Wales and together that totals over 1500 district nurses alone. We are also working with GPs, and Acute Response Teams across every health board as well as First Responders (Welsh Ambulance Services Ambulance and St John’s Wales). My role is to assist individuals and teams to look at their systems and processes in relation to acute deterioration and implement standardised improvement measures and tools across their teams to improve the identification of patients at risk of acute deterioration (including Sepsis).
What improvement measures and tools do you mean?
Working within the new Improvement framework we have supported community teams with the Model for Improvement, stakeholder engagement and forcefield analysis and using data collection and analysis tools. Utilising interactive maps of Wales we are able to plot the progress of the teams with a traffic light system. As the various teams have become NEWS Ready (Amber) to NEWS Active (Green), it is a visual representation of the improvements teams and health are making. Vitally important has been the monthly Programme Leads days, it has provided the opportunity for shared learning, in a supportive and non-judgemental environment. We have also developed tools such as NEWS charts, sepsis screening tools and Acute Kidney Injury bundles. You can download these from the 1000 Lives Improvement website or request copies from any members of our national team.
Why did the focus shift to community settings?
The success of NEWS in acute settings shows that it provided the basis for a unified and systematic approach to the first assessment and triage of acutely ill patients. It is a simple track-and-trigger system for monitoring clinical progress for all patients – reflected by its use today in 60 hospitals in Wales, as well as by the Welsh Ambulance Service (WAST).
However, there appeared to be a gap between what was happening in the Acute Care Sector and that of the Community. I had the opportunity in 2017 to undertake some work with Eve Lightfoot (RCN Nurse of the year 2018), to get involved with District Nurse training around Sepsis awareness and acute deterioration. I quickly realised that teams had obvious enthusiasm and desire to utilise NEWS but appropriate education around AD and Sepsis recognition was missing. At the same time, teams had limited resources yet their workload and complexity of patients’ needs was increasing dramatically.
I spent a lot of initial time shadowing District Nursing Leads and teams across Wales where I observed varied cases; from daily visits to check blood ketones and catheter flushes, to complex leg dressings and abdominal wound packing.
The focus was to observe the number of patients having a full set of observations and from that having a baseline NEWS score. This was not happening regularly.
The need to provide care closer to home for the people of Wales was fully supported by the Welsh Government and in particular the “Healthier Wales” strategy document made it a priority. In March 2019 the Chief Nursing Officer (CNO) mandated that NEWS should be rolled out and be implemented by all district nursing teams across Wales.
What difference would NEWS have made to changing outcomes in the cases observed?
If NEWS had been available in many of the cases that I observed, it would have provided a subjective measure of any deterioration and perhaps trigger the question around possible Sepsis. It also became very evident that staff did not have all the necessary equipment to provide a NEWS assessment. Training was needed to be provided around the recognition and response to Acute Deterioration in the community, and at an-all-Wales level. That became our programme focus.
How do you think improvement knowledge and training will make a difference to staff and patients?
Personally, I have seen in two continents the impact of embedding a systematic approach in identifying an unwell patient, underpinned by an improvement mind- set and desire to change. NEWS in the Community Sector in Wales will have a massive impact on how we communicate to patients and families. I believe NEWS will greatly improve the care we give, putting the person at the centre of everything we do.
For professionals, in particular more junior staff members, it will offer them the skills, tools and training resources they need to make changes that give them a greater sense of personal and team achievement. On that level, NEWS is an empowering tool.
For the first time we now have a common sickness language that connects all parts of the health and social care system together in Wales. Through NEWS, everyone is speaking the same language for identifying Acute Deterioration and sepsis, and at the earliest point in time which we know makes a huge difference. This is exciting for everyone, most of all our patients!
*1000 Lives Improvement is re-launching as Improvement Cymru – the new all-Wales improvement service for health and social care. Join us at the launch In November. Read about it and sign up here http://www.1000livesplus.wales.nhs.uk/news/51535