6,000 patients die a year due to poor staff checks
Six thousand patients are dying every year because hospital staff are not properly monitoring vital signs.The health of patients is deteriorating and going unnoticed because important signs, such as blood oxygen levels which can predict heart and lung problems, are either not being recorded at all or often enough.
Bedside health charts are not designed to pick up subtle physiological changes which together can indicate if a patient’s condition is going downhill, according to the Royal College of Physicians.
Doctors would be able to intervene much more promptly and save thousands of lives every year if hospitals used a more comprehensive chart, the report states.
Hospital staff are also being left confused by the more than 100 different types of chart which are used across the country.
There should be just one system used for all staff who check on patients’ conditions – whether they are in care homes, hospitals or in ambulances, a working group set up by the college said.
It has developed a new chart which it is campaigning to have rolled out across all hospitals in the UK.
The chart is a ‘traffic light’ monitoring system of six vital signs such as pulse, temperature and blood pressure, in which each is given a risk score.
The healthcare worker then adds up the score for each sign to give an indication of the severity of illness and whether the patient needs more urgent care.
Bryan Williams, professor of medicine at University College London, chair of the working party which developed the new chart, said it would have a “major impact”.
“Most improvements we make are incremental, but we see this as transformational. It’s going to make a big difference,” he said. “Subtle changes identified together are often more significant than a single extreme change. That’s why deterioration is often missed.”
“If you go into hospitals, you will find very different systems in place. Sometimes staff are not taking all six measurements, but even where they are, they are not being scored in the same manner – sometimes even between wards. There is also tremendous variation between hospitals in frequency of monitoring.”
The National Early Warning Score will require nurses and healthcare assistants to monitor temperature, pulse, blood pressure, breathing rate, level of consciousness, and oxygen saturation.
The last is a measure of how much oxygen is in the blood, and has only recently been adopted by hospitals. A low score can indicate heart and lung problems.
The Patients Association welcomed the new chart system, saying it should be implemented “urgently”.
Katherine Murphy, chief executive of the association, said: “The public will be shocked to learn that the NHS has been operating such an ad hoc system of monitoring deterioration in a patient’s condition – with different approaches in each hospital.”
The Royal College of Nursing has been closely involved in the project.
Janet Davies, director of nursing and service delivery, said: “There is nothing nurses and doctors should prioritise more than patient safety, and this system, if implemented across the board, will be a great leap forward for patient care.”
The Society for Acute Medicine also welcomed it, saying the “lack of consistency” between hospitals “may be a contributory factor in the higher levels of mortality in early August when many junior doctors change jobs”.
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