Implementing the Emergency Department Safety Checklist

Introduction

Acknowledgements
This toolkit has been based on the ED Safety Checklist Adoption and spread
and Key Performance Indicators developed and tested by
University Hospitals Bristol NHS Foundation Trust (UH Bristol) The safety checklist has been adopted by all six hospital trusts and the ambulance service in the
and the West of England Patient Safety Collaborative. West of England, who comprise the Emergency Department Collaborative:

We would like to thank the team at UH Bristol for their • University Hospitals Bristol NHS Foundation Trust
work in the development of this project.
• North Bristol NHS Trust
The UH Bristol pilot scheme was funded by the Health
• Royal United Hospitals Bath NHS Foundation Trust
Foundation SHINE Innovation programme.
• Great Western Hospitals NHS Foundation Trust

• Gloucestershire Hospitals NHS Foundation Trust

• Weston Area Health NHS Trust

• South Western Ambulance Service NHS Foundation Trust

Roll out to these other Emergency Departments was financially supported by the West of England
Patient Safety Collaborative.

The ED Safety Checklist won Best Patient Safety

Initiative in A&E award at the 2017 Patient
Safety Awards.

NIHR CLAHRC West, now recommissioned as the NIHR The judges felt that this entry had a significant impact on
Applied Research Collaboration West (ARC West), have patient safety in period of crowding in ED. It has already
completed an independent evaluation of the ED checklist. spread across multiple organisations and using established
This toolkit has been updated in August 2019 to incorporate tools has potential for wider spread across the UK.
evidence-based recommendations from their evaluation.

2
Introduction

Aim
This toolkit supports the implementation of the Licence
ED Safety Checklist and gives advice and guidance
Training materials and supporting resources are © West of England Academic Health Science Network
on achieving a successful implementation in your
2017, and provided under licence for use under the following terms:
emergency department.
• Attribution — You must give appropriate credit, provide a link to the licence, and indicate if
This toolkit also provides information and links to
changes were made. You may do so in any reasonable manner, but not in any way that suggests
resources on change management methods.
the licensor endorses you or your use.
Supporting documents and resources are available at
• Non-commercial — You may not use the material for commercial purposes.
www.weahsn.net/ed-checklist
• Share alike — If you remix, transform, or build upon the material, you must distribute your
contributions under the same licence as the original.

• No additional restrictions — You may not apply legal terms or technological measures that
legally restrict others from doing anything the licence permits.

Who this document is for This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0
International Licence. To view a copy, visit http://creativecommons.org/licenses/by-nc/4.0/
This guide is for clinical teams in the emergency or send a letter to Creative Commons, PO Box 1866, Mountain View, CA 94042, USA.
department, consultants, nurses, quality and
safety leads and operational managers as well
as ambulance staff.

This document is version 5.1 September 2019

3
About the West of England Patient Safety Collaborative

England’s 15 Patient Safety Collaboratives play an

essential role in identifying and spreading safer
care initiatives from within the NHS and industry,
ensuring these are shared and implemented
throughout the system.

The Patient Safety Collaboratives are coordinated Cheltenham

by the 15 Academic Health Science Networks and
they are part of the national patient safety programme, Gloucester
with a mandate to create a culture of continuous
learning and improvement in the NHS.

Bristol Swindon

Weston-super-Mare Bath
The West of England Academic Health Science Network
(AHSN) is based in Bristol and is one of 15 AHSNs across
England, established by NHS England in 2013 to spread Salisbury
innovation at pace and scale. As the only bodies that
connect NHS and academic organisations, the third
sector and industry, AHSNs are catalysts that create
the right conditions to facilitate change across whole
health and social care economies, with a clear focus
on improving outcomes for citizens.

Find out about more about the work of the AHSN West of England Academic Health Science Network Map
Network at www.ahsnnetwork.com.
Bristol, North Somerset andSouth Gloucestershire STP (Healthier Together)
Find out more about the West of England AHSN at Bath and North East Somerset, Swindon and Wiltshire STP
www.weahsn.net and follow us on Twitter @WEAHSN. Gloucestershire ICS (One Gloucestershire)

4
About the Emergency Department Safety Checklist

The aims of the Emergency Department (ED) Safety Checklist are to standardise and improve the delivery of basic care in EDs, to improve resilience in EDs during periods of crowding,
to improve the safety and clinical outcomes for patients accessing the emergency care system, and to improve ED performance against Best Practice Tariffs.

What is the ED Safety Checklist? What is the evidence base for the
intervention?
An ED Safety Checklist is a time based framework of
tasks that is completed for every patient, other than At University Hospitals Bristol NHS Foundation
those with minor complaints. Trust (UH Bristol) the mean proportions in Key
Performance Indicators (KPI) taken before and after
The ED Checklist is a resource for all clinical staff in
the introduction of the ED Safety Checklist improved
the ED but will most likely be completed by nursing
in 5%-25% in most cases.
and nursing support staff, temporary/bank nursing
staff and nursing supervisors. Quality improvements the checklist
aims to achieve:
Best Practice Tariffs and early triggers to specific care
pathways such as sepsis are included. • Improved baseline clinical care
• Less clinical incidents
What is the problem we are trying • More efficient handover
to address? • More efficient documentation
Crowding has a profound impact on the ED’s ability • Improved performance against best practice tariff
to deliver safe care. • Decrease avoidable harm by recognising
deterioration
Delays in recognition and treatment of severe illness • Enhanced safety region-wide
are common, with associated poor outcomes. This is • Improved communication
particularly problematic for patients suffering from • Improved team morale
stroke, heart attack and sepsis. • Improved patient and staff feedback

A scarcity of staff in the ED workforce has resulted

in a reliance on agency and non ED-trained staff.

Human factors - as staff become overwhelmed by

the tasks they need to complete in a timely fashion
and with constant interruption.

5
Case study - University Hospitals Bristol NHS Foundation Trust

Overcrowding has an impact on the ability of staff in

the ED to deliver safe care. Delays in recognition and
The impact Since the introduction of the ED Safety Checklist at
treatment of severe illness are common, with associated UH Bristol there have been no clinical incidents related
poor outcomes. This is particularly problematic for UH Bristol’s performance was analysed against similar to failure to recognise deteriorating patients or delay
patients suffering from stroke, heart attack and sepsis. baseline data. After the introduction of the ED safety in care delivery. This can be compared with the winter
checklist, performance against baseline increased with prior to implementation when there were five serious
Staffing challenges in the ED workforce have resulted
a p-value of <0.0001 in most cases. incidents due to failure to recognise deterioration,
in a reliance on agency and non ED-trained staff. As
three of which were in the ambulance queue.
staff become overwhelmed by the tasks they need Quantitative improvements
to complete while faced with constant interruptions “International evidence, highlighted in the
• Improved management of time-critical conditions,
there is a risk of omissions in the delivery of basic care ‘Keogh Review’ of Urgent and Emergency
UH Bristol saw a mean increase of over 5% in CT
elements, which contributes to harm and difficulty in Care clearly demonstrates the risks that
scanning within one hour for suspected strokes.
identifying the deteriorating patient in a crowd. crowded EDs pose to patient safety and
• Earlier recognition and rescue of clinically
outcome.
Safety checklists have been shown to improve deteriorating patients. UH Bristol saw a mean
standardisation and demonstrate improvements increase of 25% in hourly observations and early “This intervention is designed to directly
in patient safety and care. The team at UH Bristol warning score calculations. address these challenges, and has
developed the ED Safety Checklist. • Ensuring patients are on the correct care already been shown to be effective: it is
pathways out of EDs. UH Bristol saw an 11% entirely consistent with national policy in
Following a period of development and testing,
increase in patients treated on the stroke emergency care.”
including input from public and patient representatives,
pathway.
the ED Safety Checklist was introduced to the UH Professor Jonathan Benger, National Clinical
Bristol adult ED in November 2014. Qualitative improvements Director for Urgent Care, NHS England
At UH Bristol the checklist is used for every ‘major end’ • Reduced length of hospital stay.
patient coming into the adult ED - a footfall of almost • Better supported staff, including those less Key contacts
14,000 patients every year. familiar with the ED and ambulance crews.
Dr Emma Redfern, Consultant in Emergency
• Improved quality of handover.
Medicine, University Hospitals Bristol NHS Foundation
• Appropriate continuity of care.
Trust, [email protected]

6
Case study - West of England Emergency Department Collaborative

University Hospitals Bristol NHS Foundation Trust Learning from implementation: Challenges:
(UHB) was funded by the Health Foundation
Benefits: • Cost of colour printing or photocopying of the
SHINE innovation programme in 2014 to introduce
Checklist
a Safety Checklist in the Emergency Department • Proven to be a useful tool in answering complaints • Continued departmental pressures, as well as
(ED). Since April 2016, the West of England and providing a safety net for staff sometimes high use of agency staff and high staff
Academic Health Science Network (AHSN) has • Increased regular contact with patients and family turnover
worked to support all six Trusts across the West leading to improved patient satisfaction • Initialling of the Checklist by staff (this was overcome
of England region to introduce the ED Safety • Provides structure in times of overcrowding to allow by explaining the importance of the Checklist and
Checklist across seven ED’s. effective timely treatment its ability to enable patient safety)
• Faster transitions for some patients through ED
The Checklist was piloted in UHB on November 2014 Checklist:
• An objective tool to communicate concern using a
and achieved demonstrable success in improvement
standardised language • More successful when included in observation
in patient safety during periods of crowding. This
• Better recording of pain management and booklet/with original notes
included the support and cooperation from the South
reassessment • Clear guidance for escalation to doctors/other
Western Ambulance Service NHS Foundation Trust who
• Improved recognition of sepsis colleagues/services
provided a National Early Warning Score (NEWS) via
Culture: • Edit the Checklist as necessary to be in line with
their Electronic Patient Care Record System and initiated
latest hospital policies/guidance
the ED Safety Checklist if managing patients in queues
• Checklist is a tool to support patient care and • Standard of care and documentation is clearly set out
waiting to transfer to ED.
deterioration – it doesn’t take away decision • Some of the Trusts are noting on the Checklist if the
Following the Institute of Healthcare Improvement making or clinical judgement patient is being monitored in the queue/corridor
model, an implementation toolkit was developed using • Continuous feedback to staff on progress and areas by adding a Q to the Checklist
the lessons learnt from the pilot site to support Trusts for improvement
• Identify a Checklist champion to drive Auditing:
introduce the ED Safety Checklist in their department.
An inaugural regional ED Collaborative meeting implementation • Data analyst role is key to the implementation
took place in May 2016 with a primary focus of • Feedback to champion with regards to staff of the Checklist and evidence its success by being
implementing the ED Safety Checklist. These were held members for additional training able to monitor it regularly
monthly and were an opportunity to regularly share • Checklists need to be at least 50% completed
learning and discuss issues. to be audited
For more information and resources • Staff are to initial when completed, along with
to help support implementation, please time and ‘n/a’ if necessary
go to www.weahsn.net/ED-Checklist • Clear Key Performance Indicators (KPI) measured

7
About the Emergency Department Safety Checklist

The ED Safety Checklist is a simple time-based framework of nursing and medical tasks. The checklist systemises the observations, tests and treatments required by patients in a time-
based sequence. This makes it clear what has been done and what needs to be done next. The checklist serves as an aide-memoire for busy staff. Any doctor, nurse, bank or agency
staff can join the department and provide the right care. By providing this structure, the checklist results in improved outcomes for patients and a reduction in system risk.

The ED Safety Checklist is structured into two parts:

Best practice
Part 1 - Provision of basic safe
clinical care The ED Safety Checklist needs to work for your ED
and be specifically structured to account for your
A time-based framework for vital sign measurement
Trust specialisms, your local demographic and other
and calculation of the National Early Warning Score
environmental factors. Each implementing ED will
(NEWS2), pain scoring, administration of drugs and
need to assess what should be included in their ED
front-loading investigations.
Safety Checklist. It is suggested that a comprehensive
Part 2 - Value added tasks review of ED clinical incidents should be carried out
to inform these decisions prior to PDSA testing of the
ED Safety Checklist.
Include referrals to drug and alcohol services, liaison
psychiatry and occupational therapy. However, the recommendations for best practice from
the Royal College of Emergency Medicine are:
Commencement of pathways that demonstrably
improve outcomes (e.g. fractured neck of femur, • Vital signs taken and NEWS2 calculated regularly.
stroke and diabetic ketoacidosis). • Front loading of investigations i.e. imaging,
bloods etc.
Our experience has shown that the Phase 2 value
• Pain relief
added tasks only improved after Phase 1 (basic clinical
care) was well embedded. Therefore, it is our strong recommendation that these
elements are included as mandatory fields. KPI data
will be driven by the fields in the checklist and will be
unique to each ED.

8
Implementing the ED Safety Checklist in your organisation

In order to implement the ED Safety Checklist in a

sustainable way in your organisation, and to be able to
measure the impact of this intervention, we recommend The IHI Model for Improvement What are we trying to
a structured Quality Improvement framework for accomplish?
There are three questions to ask when developing
implementation.
implementation projects shown to the right.

Quality Improvement science is the application of These are then followed by rapid cycle
a systematic approach using specific methods and improvement using PDSA. How will we know if a change
techniques in order to deliver measurable improvements is an improvement?
Plan, Do, Study, Act is an effective method
in quality, care and safety.
that helps teams plan the actions for their
model, test it on a small scale, and review before
The processes we describe can be adapted to meet the
deciding how to continue.
needs of your staff, service users and organisational
context. Our approach uses the methodology developed What changes can we make that
Using PDSA cycles are a fantastic way of taking
by the Institute of Health called the IHI Model of will result in an improvement?
ideas, trying them in practice, learning what
Improvement. works, and what doesn’t to help you achieve
success.
You can find out more about the Model for
improvement through the MINDSet quality You can then broaden the scale of the test, or

PL
adjust your ideas through more than one PDSA

T
improvement toolkit. Although aimed at people

AN
AC
involved in providing and commissioning services for cycle ­— it make take a few before the idea starts
people with mental health projects, it is an excellent to work reliably.
resource for practical quality improvement guidance.

ST
For a fun way to introduce a team to quality

DO
UD
Available at http://mindsetqi.net/ as a PDF to download.
improvement, check out this blog post

Y
www.weahsn.net/2016/01/anyone-for-tennis/
For an introduction to PDSA cycles watch this video
https://youtu.be/xzAp6ZV5ml4

9
Project logic model in the West of England Patient Safety Collaborative

Overcrowding in emergency departments is widespread and is associated with clinically significant delays to diagnosis, recognising deterioration and treatment.
Omissions in basic clinical care are common during crowding. Checklists have been shown to improve standardisation and reliability in the delivery of healthcare.

Inputs Activities Outputs Outcomes Impact

Existing UH Bristol Safety Develop and refine generic Team dashboards Improved baseline clinical care Decrease avoidable harm by
Checklist implementation toolkit - recognising deterioration
Team risk and issues registers Fewer clinical incidents
including educational material,
Checklist implementation Enhanced safety in all adapting
data collection and dashboard Regional dashboard (Life More efficient handover
toolkit EDs
System)
Recruit local implementation More efficient documentation
Learning from West of England Improved communication
teams. Regional risk and issues register
Collaborative Improved performance against
Improved team morale
Implement ED Safety Checklist Communication Strategy best practice tariff
SWAST (Ambulance Service)
in all regional EDs and - including programme Improved patient and staff
perspective and expertise
ambulance service. communication networks, feedback
Central clinical team tools, and Learning Set events
Host masterclass for national
Programme faculty support interested parties. Evaluation data and analyses

West of England Patient Safety Make toolkit and all resources Project reports and published
Collaborative support available via West of England outputs You may find it helpful to adapt this logic model
Academic Health Science
to your local implementation of the ED checklist.
National Institute for Health Network website. Disseminiation activities
Research Collaboration for
Leadership in Applied Health
Research and Care West
evaluation

Royal College of Emergency

Medicine support

10
Role descriptions

Each ED will need to appoint individuals to specific roles within each Local Implementation Team. It is a strongly suggested that these roles are fulfilled by staff already in post working
in the EDs, not staff brought in for the specific functions/roles outlined in this Toolkit. In order to release people to complete the roles specified in this Toolkits, a commitment must be
given by the Trust to backfill the individuals undertaken them.

Lead Nurse Lead Consultant Audit Coordination Nurse / Data Analyst

• Providing day to day nursing leadership to the • Providing day to day medical leadership to the • Collecting and collating agreed metrics
Project Project • Review retrospective data to enable comparison
• Agree quality metrics for measurement (clinical and • Agree quality metrics for measurement (clinical of current results
operational) to assess impact of project with Lead and operational) to assess impact of project with • Managing supporting staff involved in auditing
Consultant Lead Nurse • Liaise with trust data analysts to present data
• Educating ED staff on the project aims, • Provide education support in all aspects of the effectively and professionally
methodology and anticipated patient safety impact, project, but with specific emphasis on medical staff • Contribute and present data results to project group
by a full range of communication methods and at all levels and consultant colleagues. and wider audience
briefing sessions. • Champions of the project on the shop floor
• Delivering appropriate training and staff briefing • Presenting project information and results in
Other key stakeholders
sessions. a variety of formats
• Champions of the project on the shop floor • Target specific staff groups according to their Senior Medical & Nursing Team – need to entrust
• Ensuring regular feedback results to all staff groups involvement in the project (CSMs) commitment to project and be a champion on shop
• Presenting information in a variety of formats • Write and present reports as required floor
• Coordinate regular meetings with Project Team
to discuss project progression and action plan/ Data Analyst needs to be on board and prepared to
delegation of responsibilities assist project with data production and presentation
• Target specific staff groups according to their
Receptionist/Patient Flow Coordinators needs to
involvement in the project (ED admin staff, clinical
be on board and understand their contribution as per
site managers)
local procedures
• Liaise with trust data analysts to present data
effectively and professionally
• Write and present reports as required

11
Form your local implementation team

We recommend that each team makes time for fortnightly meetings to discuss the progress of the ED Safety Checklist implementation, to ensure the practicalities of the project
are being addressed, staff are being supported, messages are being appropriately disseminated and to review site data to track progress. We have provided a generic agenda,
which you may find helpful to facilitate these fortnightly meetings. Please feel free to tailor this to your specific team.

Project documentation Timing of implementation

LIT fortnightly meeting agenda It is recommended that each team maintain a We recommend that you consider the timing of the
Housekeeping Risk & Issue Log for the duration of the project. implementation of the ED Safety Checklist.

Review of the practicalities required to Once you have your aim agreed, as a team, consider In most EDs, winter crowding puts significant
introduce the ED Safety Checklist, such as what risks and issues may prevent you from achieving operational pressures on staff at all levels. Therefore,
printing etc your aim. it would be sensible to commence the implementation
project during periods when crowding is not as
Data An issue is something that is happening. A risk
prevalent and staff have capacity to be released
is something that might happen. Please use your
from their shop floor responsibilities.
Review of current data own organisational risk management scoring for
likelihood and impact of risks occurring.
Dashboard
The status of a risk can be open (action required),
Measurement strategy
accepted (all mitigation in place, no action required),
Staff closed (risk or issue has been closed).

Nursing and medical staff

Pioneers and laggards

Peer support

Risk & issue log

Communications & education

12
Organise your Emergency Department

Consider how you will print, store and restock the ED Safety Checklist. Each team will need to consider how this works for their local operational procedures.

Photocopy the ED Safety Checklist Interface with the ambulance trust

If printing in black and white, check the resolutions Patients queuing to offload from ambulance into
on all the fields. ED is common. The risk of patients deteriorating
in this queue is a significant patient safety issue.
Consider what you will do with the ED Safety
Checklist once a patient has been discharged Teams should consider engaging with their
out of ED. Ambulance Trust to agree a Standard Operating
Procedure (SOP) for paramedics to commence their
Sites in the West of England Patient Safety
ED Safety Checklist in the queue and as a tool at
Collaborative found that incorporating the ED Safety
handover of care.
Checklist into the ED notes ‘booklet’ saw an increase
in reliability of use of the checklist for all patients.
In some departments, this whole booklet gets
scanned when the patient is discharged out of the
department prior to being filed and/or taken with the
patient to the ward, which helped with monitoring
implementation.

Each team needs to consider how they will

incorporate the ED Safety Checklist into their ED
notes and what procedures will put in place for
filing and access for audit.

13
Communication and training

It is recommended that teams ensure information about the checklist programme, ‘go live’ dates and the wider patient safety benefits of the checklist are communicated not only to
ED but across the Trust in order to encourage a culture of support and participation in the programme. Teams should consider a communications strategy in advance of ‘go live’ dates
via planned bulletins or within regular communications to both ED and Trust wide staff.

ED Safety Checklist training Real-time feedback National Early Warning Score training
This Toolkit recognises that each team will have their To ensure ongoing compliance with the checklist A suggested field of the ED Safety Checklist is that vital
own training methods and structures for training their once implemented and embedded, UH Bristol gave signs and the National Early Warning Scores (NEWS2)
staff in the ED Safety Checklist. the Nurse Shift Leaders the responsibility to check are regularly calculated.
and monitor that the ED Safety Checklist was
For the pilot implementation at UH Bristol the ED Safety The NEWS2 is routinely used in inpatient wards but
being completed for all (appropriate) patients and
Checklist was introduced during the Bite size Teaching often not calculated or tracked in ED or in ambulance
provide ‘real-time’ feedback and support for those
Sessions that occur daily at 8am. The emphasis during queues. The use of a track and trigger system in the
staff who were failing to consistently complete the
these sessions was on: UH Bristol pilot showed demonstrable improvements
ED Safety Checklist.
to patient safety and quality of care. If teams do not
• Culture – ensuring organisational buy-in, especially
It is our strong recommendation that each adopting ED routinely use NEWS2 it may be worth considering an
senior nursing and medical staff.
identify on-shift resource to fulfil this role and provide ED training programme to familiarise staff with the
• Testing – Are the fields in the ED Safety Checklist
shop-floor support and feedback to staff. accurate calculation of the score.
right for your ED? Do additional fields need adding?
• Successes and challenges – review of the
testing cycles, the successes and challenges to
implementation.
• Staff feedback.

Feedback during testing

During your testing of the ED Safety Checklist, you may
find it helpful to carry out an anonymised staff survey
to see how well the checklist has been received and to
gather opinion on sections that work and those that
need improvement. A SurveyMonkey questionnaire may
be good format for this during your study period of a
PDSA cycle.

14
Case study - evidence informed recommendations

NIHR CLAHRC West, now recommissioned as the NIHR Applied Research Collaboration West (ARC West), evaluated the
implementation and use of the ED Checklist during 2017. The full findings will be available soon in a journal paper but
here are some of their key recommendations for implementation. The evaluation used qualitative and quantitative data.

The research interviews and observations conducted by NIHR CLAHRC West identified the value of emphasising the
primary purpose of the tool, involvement and endorsement from senior ED staff, dedicated training time and full
integration with existing clinical documentation improved its implementation.

1. Promoting the clinical purpose 2. Obtaining senior staff support 4. Tailoring & integrating the
ED checklist
The research found that the checklist was sometimes Obtaining senior ED management support
seen as an administrative rather than a clinical from doctors, managers and senior nurses To successfully integrate the ED checklist, two
document which contributed to it being overlooked is crucial to ensuring the ED Checklist becomes adaptations are necessary:
when busy. integral to the department’s usual workflow.
a) The ED Checklist needs to be tailored to your
Promoting the ED Checklist to be clear about its Our research found there was better recognition department’s specialisms/clinical priorities and
purpose and rationale for its introduction can help to and ‘buy in’ to the checklist when it was associated
b) the ED Checklist needs to be formatted and
implement it effectively. Taking a clear approach to with the Department and an implementation team
integrated into the ED paperwork and not just
its purpose is better and it should be promoted as: rather than an individual.
clipped or stapled to it
• A patient safety tool aimed at avoiding 3. Training time
Our research indicates these adaptations will reduce
undetected patient deterioration
Planning dedicated staff training sessions and the potential for the ED Checklist to be viewed as
• A framework to support staff in monitoring allowing staff time to train, ask questions and ‘just another form’ and will encourage smoother
patient care and patient safety in busy and reflect on the checklist was more effective implementation.
demanding ED environments for implementation purposes that ad-hoc
One trust who has implemented the ED Checklist
‘on the job’ training.
took several attempts and trial runs to get to the
This allowed a greater scope for communicating checklist they wanted and to get it integrated into
the purpose of the ED Checklist, how it can their clinical workbook.
support patient safety and be integrated into the
department’s work processes more effectively.

15
About the National Early Warning Score (NEWS2)

NEWS2 has been produced as a way of making sure that

where a patient is at risk of acute deterioration, then vital
signs are recorded at a frequency suitable to the clinical
scenario, and that escalation of treatment is timely and
appropriate where it is needed. Since then it has become
promoted as a communication device providing a summary
of a patient’s condition and a prompt for intervention,
escalation of care or referral as required.

Calculating NEWS2
Vital signs are recorded as a way of finding out if there
has been a positive response to treatment, or whether
a patient needs a change to an ongoing treatment plan.
Whilst it is recognised that serious complications may
happen to patients without any warning, in the majority
of situations there are warning signs that if acted on
are likely to be associated with better outcomes.

NEWS2 is an inherently simple device but its

implementation may involve considerable complexity
depending on the organisation in which it is being used.
There are two areas that require concentrated efforts;
these are ensuring that NEWS2 is recorded accurately, and The Royal College of Physicians (RCP) has led the development of the National Early Warning Score which
ensuring that NEW Scores are well linked to escalation advocated standardising the use of a NEWS system across the NHS in order to drive the ‘step change’ required
of treatment where this is required. There are significant in the assessment and response to acute illness.
training implications in any NEWS2 implementation. Following feedback a second iteration of NEWS was published by the RCP. We recommend use of NEWS2
To access free resources developed by the West of England as an early warning score as part of the ED safety checklist.
Patient Safety Collaborative to support the implementation Find out more at
of NEWS2 visit www.weahsn.net/dp https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news

16
Monitoring progress

Once you have started using the ED Checklist, it’s important to gather evidence to establish how successful its implementation has been.

Collecting data to establish how often the ED Checklist is getting used, which tasks are being completed and looking for trends or problems using this data can be very valuable.
Data collection can serve as evidence of care and its quality for each patient both internally and externally.

How to do this? How to audit? The audit process

A standardised approach needs to be followed. We Complete the audit spreadsheet for all patients
Each month, obtain a random set (eg 5%) of
recommend our audit template which has a column in your sample:
ED notes from all majors and resuscitation patients
for each patient and a row for each component of the
ED Checklist. The template includes core fields and • For each component of a checklist which has been
additional example fields such as ‘refreshments provided completed, fill in a “Yes” on the audit spreadsheet.
within 2 hours of admission.’ You will need to add • If n/a or a note has been filled out for a component
additional fields depending on how you have tailored of the checklist to say it was not required, a “Yes” For ALL sets of sampled notes, complete the audit
your checklist. should also be filled in on the audit spreadsheet spreadsheet with data on whether or not ED Checklist
(because this is still correct use of the checklist). fields have been completed
How often? • If a component has not been completed on the
(If a checklist is absent or blank, all fields on the
Decide how often you are going to audit the checklists. checklist, a “No” should be filled in on the audit
audit spreadsheet should be completed as ‘no’)
We recommend this is done monthly to accurately spreadsheet.
assess progress and observe how checklist completion • For the hourly repeated measures, a “Yes” should
is affected by factors such as winter pressures as well as only be completed on the audit spreadsheet if the
improvements over time. field has been completed for every hour up until
ED discharge Collate the data anonymously and store. The dashboard
Who to audit? • If no checklist is present in the notes, or a checklist within the audit spreadsheet will summarise the
Each month (or however often you choose) randomly is present but blank, all fields on the audit checklist data by calculating the percentage of each field
select a sample of majors/resus patients who came should be recorded as “No.” completed across all sampled patients each month
into your ED the previous month. You may want to • If a patient is discharged within an hour, we would
ask your IT team to help you with this. Sample size will not expect anything to be recorded for hour 4.
depend on the size of your ED and should be the same So, if a patient were in the ED for 3.5 hours,
proportion each month, for example, this could be 5 or NEWS should be recorded on arrival, at 1 hour,
Follow the same process and update the audit
10 per cent of patients. 2 hours and 3 hours.
spreadsheet each month so you can compare your data

17
Measurement for improvement

Different types of measures

There are different types of measures:
Reasons for measuring: 9.0

• Process measures, e.g. the number of sessions

• Measurement for judgement: where 8.0

delivered each month, number of staff trained 7.0

measures are used to judge us against
in each session, number of public contributors 6.0
performance targets, other Trusts, etc.
involved in training sessions. 5.0
Improvement is not about judgement,

Values
4.0
• Outcome measures, e.g. staff attitude survey of however, you can use measures to judge and
3.0
perception of communication within the team and manage your own progress
2.0
safety attitudes, and confidence with using SBAR • Measurement for diagnosis: where data is
1.0
before and after the intervention gathered to understand the process, to see
0.0
if there is a problem and how big it is. This Jan Apr Jul Oct Jan Apr Jul Point 22 Point 25

• Balancing measures, e.g. number of 999 is a useful technique, especially early in your
Subgroups

call outs from residential homes before and after work, for example, to really understand the Infection Rate % Infection Rate % Run Alert Mean of Infection Rate %

training delivered, staff sickness and turnover rates. demand and capacity at a bottleneck in the
process
What can you measure? • Measurement for improvement: where Run charts
a few specific measures, linked to the your
We can count something, e.g. the number of patients objectives and aims, demonstrate whether A run chart is a tool for improvement which shows
who have diabetes in a given population, or the number the changes are making improvements how your project is going.
of serious adverse events in a given time period. • Measurement for sustainability: to ensure
To show that things have improved you need to show
We can use ratios which consider of two numbers, a the changes and the improved outcomes are
the things that have changed, and that the change
numerator and a denominator. Sometimes this number maintained and are part of everyday practice.
is not a one off. You must consider whether the
is expressed as a percentage. For example if there are These are long term measures linked to
change has been sustained. Run or control charts
5 adverse events each year in a 250 population, that is organisational aims
allow you to see if this has happened.
0.02 adverse events per person (ratio) or a 2% adverse • Measurement for spread: specific measures
event rate (percentage). to demonstrate the extent to which learning For more information on measuring visit
and change principles for improvement have Making Data Count https://improvement.nhs.uk/
been adopted. resources/making-data-count/

18
Appendixes

Supporting resources Research papers Image sources

This toolkit and supporting resources are available http://www.nhs.uk/NHSEngland/keogh-review/ Photo on front cover and p14 from NHS Photo
online at www.weahsn.net/ed-checklist Documents/UECR.Ph1Report.Appendix%201. Library.
EvBase.FV.pdf
The ED Safety Checklist is available online in All other images have been developed by the
editable format and as a PDF for printing. https://www.rcplondon.ac.uk/resources/national- West of England Patient Safety Collaborative
early-warning-score-news for this toolkit.
You can watch a short video here about the ED
Safety Checklist pilot at UH Bristol. https://www.england.nhs.uk/wp-content/
uploads/2015/08/Sepsis-Action-Plan-23.12.15-v1.
SHINE 2014 Final report at http://www.weahsn. pdf
net/wp-content/uploads/EDCL2016_A7_01.docx
http://www.nice.org.uk/guidance/indevelopment/
GID-CGWAVE0686/consultation/html-content

http://www.ncepod.org.uk/2015report2/
downloads/JustSaySepsis_FullReport.pdf

19
Version 5.1 September 2019
The most recent version of this toolkit and supporting
resources are available at www.weahsn.net/ed-checklist