Organisations standardise the pathway to manage rising GP workload and facilitate early identification of deterioration, resulting in a 8.4 per cent reduction in 999 calls

Synopsis

RESTORE2 is a project to support staff in care and nursing homes to proactively recognise and manage physical deterioration in order to improve resident experience and outcomes, reduce 999 calls and prevent admissions to hospital. RESTORE2 stands for Recognise Early Soft-Signs, Take Observations, Respond and Escalate and uses National Early Warning Scores as a common language across the healthcare system.The project was started by West Hampshire CCG in partnership with 66 care/nursing homes, local GPs, the ambulance service, secondary care clinicians and the Wessex AHSN. It has now been adopted by 16 CCGs nationally including Somerset and Cornwall.

Ambition

“The care home deterioration pathway redesign was undertaken against a 5% annual increase in emergency department attendances involving 1,987 residents, rising General Practice workload and serious incident investigations arising from poor outcomes for residents. Root causes for unmanaged deterioration were;

• The ability of care home staff to recognise deterioration early, often impeded by resident complexity, training and confidence;
• The timeliness of response to deterioration, dictated by the capability of care home staff to communicate critical information concisely and effectively to external healthcare professionals along with the system’s ability to respond quickly to clinical need; and
• The competency of clinical response provided by the system, often determined by competing clinical priorities and the quality of triage information.

A QI project was established with the AHSN Patient Safety Collaborative and the pathway for deterioration was mapped with stakeholders to identify potential weakness. The project outline and targets were identified by partners in the system on the basis that;

• The pathway solution must be co-produced, owned and accessible to the care home workforce and standardised across the system;
• It was important not to overly medicalise care home environments;
• Developing a skilled, supported and stable care home workforce was paramount to delivering more complex care in the community;
• Not all hospital admissions were inappropriate but that planning for deterioration with residents was as important as managing deterioration;
• Existing resource had to be utilised and targeted without increasing overall demand on General Practice/NHS111
• The quality of information exchange at all pathway interfaces required improvement.

The primary ambition of the project was zero deaths due to unrecognised or unmanaged physical deterioration by achieving right care at the right place in the right time for residents. Secondary qualitative outcomes were improving care home staff support, deteriorating knowledge and confidence with quantitative outcomes of reducing 999 calls, conveyances and attendances at Emergency Departments through targeted and earlier intervention.

Extensive review was undertaken around the safety and validity of utilising NEWS as a standardised assessment tool in community settings. General Practice supported a retrospective analysis of the correlation between patient NEWS and urgency of clinical review/mode of conveyance to inform the development of the escalation pathway. Most importantly, focus groups were held with care home workers to develop the concept of soft signs as an entry point to NEWS under the principle that the pathway redesign and tools had to work for all carers.”

Outcome

“Between 2016 and 2019, the CCG worked with all stakeholders to reach consensus and develop the required knowledge and tools to deliver the re-design. The re-design resulted in the development of the RESTORE2 tool for care/nursing homes and the adoption of NEWS across the system deterioration pathway. RESTORE2 includes core soft-signs of deterioration, co-designed by carers in homes to provide sensitive trigger points without over medicalising residents.

The addition of bespoke soft-signs places an emphasis on the involvement of residents and family members in identifying unique early warning indicators of deterioration. The re-design has introduced NEWS into both nursing and care homes; the former now using the complete six physiological parameters within NEWS for assessment compared with limited temperature, pulse and respiration with the latter trained to perform physiological observations with NEWS interpreting the outputs.

The CCG worked in collaboration with the Local Medical Committee and system stakeholders to formally engage GP’s in the use of NEWS which is now utilised as the standardised assessment for the system by GP’s, out of hours, the ambulance service and all acute providers.

Collaboration between the CCG, AHSN, and ambulance service and care homes has been highly effective. Many GP’s have advocated for RESTORE2 but the volume and dispersion of GP’s has been challenging. Learning includes recognition that all elements of General Practice require engagement and education, including reception staff and the challenge of influencing national algorithms for NHS111 and GP OOH.

Quantitative outcomes are currently focused on 999 call reduction.

In West Hampshire CCG, between July 2016-June 2017 (baseline period) and February 2018-January 2019 (redesign period) nursing homes using RESTORE2 saw an 8.4% reduction in 999 calls compared with a 1.5% increase for non-RESTORE2 homes, equating to 50 residents either not being seen and treated or attending the Emergency Department. Likewise, a 31.1% reduction was noted for RESTORE2 care homes compared with a 14.1% decrease for other homes. This equates to a further 33 residents not passing through 999 services.

Cost savings associated purely with reduced ambulance interactions are currently modest at between £15K and £19K per annum (based on see and treat costs £181 or conveyance £233) although if this programme was rolled out across the remaining care/nursing homes in the CCG the cumulative cost saving would be an additional £54-£70K per year.

The qualitative impact of RESTORE2 on staff and patients is described in the value section.

Spread

“RESTORE2 started as a pilot project within West Hampshire CCG in 2016 in three homes. Once proof of concept had been achieved, the CCG worked with the local AHSN to design a scale up project which has resulted in successful spread and adoption by 50 nursing homes and 16 care homes within the locally (77% and 22% of CCG total, respectively).

As well as independent homes and Hampshire County Council, larger chains such as BUPA, Barchester, Sunrise and Colten Care have all signed up to RESTORE2 locally. RESTORE2 has now been adopted as the care home deterioration tool of choice across the Hampshire and Isle of Wight Sustainability and Transformation Partnership (eight CCG’s covering a population of 2million) and is currently being rolled out in national areas including Dorset, Somerset, Cornwall, Lancashire, Sheffield, Leeds, Ipswich and Suffolk, Greater Manchester, Buckinghamshire and Frimley ICS.

As an example, NHS Kernow CCG has run a pilot demonstrating successful adoption and compliance across a number of care and nursing homes with positive feedback from staff. NHS Somerset CCG trialled RESTORE2 in three homes linked to GP practices with qualitative data showing improved staff confidence.

To further support spread, RESTORE2 has been made freely available to CCG’s and West Hampshire lead the RESTORE2 Project Advisory Board, a quarterly meeting with national representation from deterioration leads, CCG’s and AHSN’s that monitors and supports adoption, updates stakeholders on developments, collates evidence and collectively shapes future development. The objective of the Board is to ensure a single unified tool is maintained and developed to promote standardisation and national spread.

For areas not using NEWS across the pathway, the CCG has developed RESTORE2 ‘mini’, a soft-signs and structured communication tool that acts as a bridge between having no deterioration tool and being fully trained in the measurement of physiology and NEWS. The CCG has also collaborated with West of England and Wessex AHSN’s and Health Education England to produce 14 short training videos specifically for care home workers on sepsis and deterioration based on RESTORE2 to support training and spread.

Further developments including a standardised training package and workbook are planned for January 2020. The next ambition is to digitise RESTORE2 on a compliant platform (ISO 13606, HL7) to allow push/pull of data to GP and health records, as well as supporting place based escalation pathways that make use of bespoke wrap-around local services for care homes.”

Value

“The impact of RESTORE2 can be summarised as:

• Improved confidence of care home staff to escalate concerns
• More constructive communication and relationships between healthcare professionals and safer hand-offs
• Increased ability of healthcare professionals to monitor unwell residents rather than admit
• Reduced 999 calls and conveyances.

Care home staff:

West Hampshire / Somerset

• 68% RESTORE2 supported decision making and helped identify an individual’s deterioration
• 100% RESTORE2 helped assessment and achieving earlier escalation of concerns
• 100% RESTORE2 helped to achieve earlier intervention from GP’s, Out of Hours or Ambulance Service
• 93% RESTORE2 gives confidence when communicating with other healthcare professionals

RESTORE2 has increased care home confidence and empowered staff to have timely conversations. RESTORE2 has decreased variation, both in the assessment of residents, the timescales for escalation and response and the communication of concerns through use of SBARD.

“definitely gives me confidence, I am able in short words say what is concerning me, my reporting is clear and in order”. –Care Home

“the paramedics were grateful for having information ready and provided. Personally feel we have a better response and working relationship with paramedics especially” -Care Home

GP’s, Ambulance and Acute Care:

The reduction in 999 calls has previously been described. For paramedics, GP’s, OOH and acute care, the ability to have normal and deterioration physiology to assess to extent and rate of deterioration has supported improved clinical decision-making. Case studies indicate avoided hospital admissions or reduced length of hospital stay.

“we are really grateful when RESTORE2 charts follow patients into the hospital, as they provide excellent background and baseline information” - Consultant Acute Physician

“I’ve seen the staff using RESTORE2, they have been far more prepared when we have gone to visit a patient who is unwell, with observations ready etc.”-GP

GP’s have started to use NEWS as a triage system for the urgency of home visits. Data indicates no overall increase in demand but more targeted use of current resources for residents most at risk.

“Where before GP’s would come and do observations and may say that the resident is ok to monitor, we can now monitor them using RESTORE2, which has decreased the GP visits.” – Care Home.

Residents:

Since the introduction of RESTORE2, there have been no Serious Incidents involving unmanaged deterioration in West Hampshire indicating improved safety. The ability to avoid or shorten hospital admissions and care for people in their own residence positively impacts patient experience.”

Involvement

“RESTORE2 has been a complex project and pathway re-design, undertaken by CCG’s in collaboration with AHSN’s and involving a minimum of six different healthcare organisation types (care/nursing home sector, GP’s, ambulance, NHS111, GP out of hours, acute providers). The original concept originated from the Patient Safety Collaborative and the re-design has evolved to create a strong partnership of subject-matter experts and experts by experience who now comprise the RESTORE2 PAG.

RESTORE2 was co-produced with care home staff using their language on the premise that any deterioration tool and pathway had to work for everyone and not just deterioration experts – the success of this collaboration can be evidenced by staff from West Hampshire and Cornwall stating that RESTORE2 raises confidence (100%, 90%) provides clear guidance (100%, 90%) and is easy to record on (100%, 98%). RESTORE2 was adopted by the Local Authority in West Hampshire and supported by the CCG with education and audit to support system adoption. West Hampshire has also support Somerset and Cornwall to roll-out with advice and resources.

The CCG engaged with local GP’s to look at the feasibility of NEWS in general practice, providing education to GP’s and practice nurses and supporting the addition of NEWS to GP templates. The escalation pathway of RESTORE2 was co-designed with GP’s to ensure that the route and timescales of escalation was clinically safe and manageable. The CCG also worked with a local practice and home to monitor the effect of first placing NEWS into a care homes and then the full RESTORE2 tool to ensure that demand and workload did not become unmanageable.

This demonstrated over time that the number of 999 calls decreased from an average of 2.8 per month to 1.2 per month and that GP home visits, if triaged using the NEWS tool could be returned to baseline following an initially increase in visits post NEWS implementation.

The local acute provider supported both the use of NEWS as a common language across the system and RESTORE2 in care/nursing homes by mandating a NEWS or all six physiological parameters during GP referral which created a push/pull effect on GP’s and subsequently care homes to provide a NEWS.

Residents have been involved in the re-design via care home staff although in this case, the purpose of the re-design was to avoid residents going onto the emergency pathway, rather than create a new pathway for them.”