Since our inception, the Healthcare Safety Investigation Branch (HSIB) has sought to identify, analyse, and investigate some of the most common patient safety risks facing the NHS.

Throughout the coronavirus (COVID-19) pandemic we have been using this approach to rapidly identify specific safety risks for COVID-19 and other patients, then escalating those risks to the bodies and organisations that can respond to those concerns.

“The virus meant that we had to completely reorganise the way we worked in a short space of time. This brought new risks to the fore”, says Dr Kevin Stewart, HSIB’s Medical Director and Consultant Physician at Hampshire Hospitals NHS Foundation Trust.

“Many staff found themselves working in unfamiliar environments with unfamiliar equipment, looking after patients for whom they would not normally care, with colleagues with whom they would not normally work. They did a fantastic job in the circumstances but this sort of working can introduce new risks, especially when dealing with a new disease.

“At HSIB we wanted to use our expertise to highlight emerging risks and help in the ongoing effort to tackle COVID-19 through the publication of National Intelligence Reports.”

An early warning to save lives

One of the reports, published today (30 July 2020), focuses on the use of the early warning scores in detecting deterioration in COVID-19 patients.

The standard national early warning score (NEWS2) is in widespread use across the NHS. NEWS2 gives a numerical aggregate score gathered from certain physiological parameters (respiration rate, oxygen saturation, systolic blood pressure, pulse rate, level of consciousness or new confusion, temperature). NEWS2 has been shown to be valuable in detecting deterioration when used in conjunction with clinical judgement.

The report sets out the key risks identified by HSIB:

  • Failure of escalation in COVID-19 patients – a unique feature of COVID-19 appears to be a sudden increase in oxygen requirements without significant changes to other parameters. This means that increasing oxygen requirements alone should trigger escalation in patients with COVID-19. This element may not be detected by a change in NEWS2 score.
  • False reassurance from early warning scores – Non-specialist staff working in unfamiliar environments caring for COVID-19 patients may not have the necessary clinical experience to recognise deterioration if there is no change in the NEWS2 score.

“In one report that we received, a patient’s oxygen saturation significantly reduced within a period of half an hour, but this did not change their score and escalation didn’t happen in a timely way”, says Dr Kevin Stewart.

“Every day, NEWS2 helps to successfully identify deterioration in severely ill patients across the NHS. When undertaking these reviews of safety risks we seek to highlight where slight adjustments or additions could enhance established systems and tools to meet the needs of a very specific and rapidly evolving situation.”

Collaboration during COVID-19

As HSIB works rapidly to identify the risks, we also work closely with the national bodies that can respond to those risks. With the early warning systems findings, we collaborated with the Royal College of Physicians (RCP), providing further evidence for the experiences of the RCP’s network in relation to the deterioration of COVID-19 patients.

In early April, the College issued revised guidance for the use of NEWS2, recommending that all staff should be aware that any increase in oxygen requirements should trigger an escalation call to a clinical decision maker, as the patient’s NEWS2 score might not significantly change.

Dr John D Dean, RCP Clinical Director for Quality Improvement and Patient Safety, said: “The RCP issued additional guidance for the use of NEWS2 in patients with COVID-19 as soon as clinicians alerted us to the need for extra clarification.

“However, it is important to note that clinical teams should not solely rely on NEWS2 in decision making. As part of standard patient management, clinical teams should act swiftly if they observe a patient’s oxygen dependency increasing, other signs of deterioration, or a rise above agreed thresholds in NEWS2 score.”

Read the report

For more information, download and read the early warning scores national intelligence report.