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Forster, Sarah (2024) Recognition of the deteriorating patient. PhD thesis, University of Nottingham.

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Abstract

Background

The discrimination between which hospital inpatients are stable, and which are at risk of clinical deterioration, has been the focus of significant research over the last 32 years since the concept of using vital sign derangement to alert a specialised team of people was first mooted. In the NHS, the National Early Warning Score has been mandated since 2017 across all adult patients outside obstetrics. However there have been concerns that it may not be equally predictive in all patient groups and may negatively impact hospital systems due to the demand generated by scores above set escalation thresholds.

Aim

To investigate the impact of NEWS2 on patients and hospital systems.

Methods

An initial literature review was performed in order to describe the current evidence base and define the research questions. A large outcomes-linked vital signs database was then analysed to determine the impact of introducing NEWS2 into a large teaching hospital with a mature electronic observations and task escalation system, before examining the predictive accuracy of NEWS2 in different population groups and investigating the possibility of improvements based on pattern of scoring. To complement this a qualitative study of the role of nursing concern in recognition and escalation of deteriorating patients was performed.

Results

The first study demonstrated an increase in demand following introduction of NEWS2, with a heterogeneity in accuracy of predicting risk of outcome of death within 24 hours between medical and surgical inpatients. This variation in prognostic ability was further demonstrated in a respiratory population and across cohorts defined by primary diagnosis and age. It was also demonstrated that improvements in risk prediction could be made in all cohorts through the addition of simple pattern values, with maximum score in the preceding 24 hours providing the most additional information of the values. The qualitative study demonstrated that nursing staff employ several factors independently of NEWS2 when assessing a patient’s clinical status and making a decision of whether to escalate for medical review.

Conclusions

This thesis has identified a variation in how different cohorts within a hospital population behave and the subsequent impact on predictive ability of NEWS2. The identification of pattern factors that could be incorporated into all systems, including those still using paper, is important as it could easily be integrated into future iterations. The clarification of the role of nurse concern in escalating patients at risk of deterioration should also be considered in future systems to improve risk prediction.

Item Type:	Thesis (University of Nottingham only) (PhD)
Supervisors:	Shaw, Dominick E. McKeever, Tricia M. Sharples, Sarah
Keywords:	Patient monitoring, risk analysis, nurse worry, early warning scores
Subjects:	W Medicine and related subjects (NLM Classification) > WB Practice of medicine
Faculties/Schools:	UK Campuses > Faculty of Medicine and Health Sciences > School of Medicine
Item ID:	78348
Depositing User:	Forster, Sarah
Date Deposited:	11 Dec 2024 04:40
Last Modified:	11 Dec 2024 04:40
URI:	https://eprints.nottingham.ac.uk/id/eprint/78348

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