Table 1

Description of the safety strategies and utilisation at the two study sites

Safety strategyDescriptionDetails of particular safety strategies at study sites
Early warning score (EWS)Scores are generated from regular measurement of vital signs, such as breathing, heart rate, blood pressure and level of consciousness. When a certain threshold is reached the score triggers a warning and alerts staff to the possibility of patient deterioration.10Westward
An EWS had been in operation across the Trust since 2001, but was re-launched with the escalation protocol in 2008. A score was manually calculated from each set of observations and recorded on the observation chart
An EWS was introduced to the hospital 2 years previously. In addition, two of the medical wards were piloting an intelligent assessment technology (IAT) which utilised a different scoring system from the EWS already in use within the Trust (see below)
Intelligent assessment technology (IAT)Handheld personal digital assistants (PDAs) and hospital intranets replace traditional paper observation charts with real-time data and electronic charting. Vital sign data are taken and entered into the PDA, whereupon an early warning score is electronically generated on the PDA screen. The score prompts the time interval for the next set of observations and additional calls for help (eg, ‘involve senior doctor from the patient’s team immediately'). The vital signs data, EWS and observation charts are visible to the hospital staff via the hospital intranet.11Eastward
The IAT was introduced to two pilot wards 6 months previously. There were no paper-based observation charts on these two wards. Healthcare assistants (HCAs) and nurses recorded vital signs and then manually entered the data onto the PDA. Observation charts, trends and scores were displayed electronically via ward-based computers on wheels.
Escalation protocolAn escalation protocol details minimum standards for monitoring and recording vital signs and competencies of the ward staff. It also sets out a response strategy to high early warning scores.Westward
A Trust-wide escalation protocol was introduced across the Trust in 2008
There was no Trust-wide escalation protocol. However, for the two pilot wards, the IAT included an inbuilt algorithm which detailed a response strategy to high scores.
Communication toolCommunication tools aim to overcome hierarchical and occupational boundaries. They provide a structured template and direct nursing staff to handover specific information, ‘packaging’ details about deteriorationWestward
The Trust's escalation protocol included a recommendation to use a modified ‘situation-background-assessment-recommendation’ process (SBAR).12
Critical care outreach team (CCOT)A multidisciplinary critical care team who assist with identification and management of acutely ill patients on general wards, share critical care skills with ward staff and provide follow-up care of patients discharged from intensive care. It is usually nurse led, but composition of the team and availability of the team (5 days/week or 24/7) varies.13Westward
A CCOT was established in 2001 staffed by critical care nurses and physiotherapists. The team operated from Monday to Friday, 08:00 to 20:00, reviewing patients on the wards that scored above a trigger point of 4 and transfers from critical care. The team referred to a medical emergency team, covered by intensive care physicians, if they were concerned.