Robert Barker GP partner, Corbridge Medical Group NIHR In-practice fellowship, Newcastle University robert.barker@newcastle.ac.uk Good NEWS for care home residents? A mixed-methods study exploring the impact of the National Early Warning Score in care homes. Barker R, Russell S, Stocker R, Liddle J, Adamson J, Hanratty B

NEWS intervention ‘Common language’ ‘TRACK’ & ‘TRIGGER’ ‘Blue box’ 47 care homes in Sunderland CCG from August 2015

Methods Quantitative Qualitative Nomad survey Every reading from Sept 2016 – Aug 2018 De-identified at patient and care home level Qualitative Purposive sampling to achieve variation, and convenience sampling. Semi-structured individual face-to-face interviews Thematic analysis Nomad survey 4 copies to each care home Impact on care home staff/whether it could form a routine part of their work, identify areas for improvement

RESULTS 18,015 NEWS scores were produced over 24 months for residents aged ≥65. Mean age = 84 Clinical context Count % Baseline 3930 62 Clinical concern 1255 20 Not recorded 1160 19   18015 100.0 On 787 (4%) of occasions, one or more of the components of the NEWS was not entered at the time of generating the score.

Patterns of use across different sites

RESULTS Care Home staff Senior carer/ Carer 8 Nurse 1 Deputy Manager 3   Senior carer/ Carer 8 Nurse 1 Deputy Manager 3 Manager Healthcare Professionals Older Persons Specialist Nurse Urgent Care General Practice Manager Family Members CCG Employees Total 24

Apparent simplicity of intervention vs. actual complexity “…I think that is a common problem, they sometimes get the sats, the oxygen saturations and heart rate, around the wrong way” Recovery at home team “If you could use a mobile phone, then you can use this kit… But, going onto the interpretation and the understanding of what you’re actually doing is a completely different question which would lead me to a different answer..” Specialist Nurse When asked about the quality of the training… “Very low, very low … if they [fellow care home staff had additional training or more quality of training, they may feel more amenable to actually engaging with it.” Carer

Complex setting “I thought it was going to be playing chess and helping people up and down but the amount of work actually involved, is ridiculous. I think it’s underestimated and it’s certainly undervalued.” Carer “…staff who are in the homes on minimum wage and we are expecting them to do more within their role and within a short space of time” Recovery at home team “One of my homes has had a different manager every year. The turnaround can be very rapid … so there can be a lot of unsettlement…” Specialist Nurse “The residents we have now coming to us are much more complex, much more dependent than even ten years ago.” Care Home manager

A ‘common language’ & ‘shared understanding’ “…when I finally spoke to the manager, she said, “Oh, it’s because we’ve had paramedics out who told us that it’s useless and we shouldn’t be using it anyway because it gives such wrong readings…” Specialist Nurse “We’ve done the NEWS and sometimes they’ll say “what’s the NEWS?”… it frustrates the paramedics when they come out and we say we’ve tried to explain things … And I think receptionists at GPs … you would ring and say “we’ve done a NEWS score” and they’d be like “what does that mean?” Dyadic interview with deputy managers “[it is] a useful resource … you can look at a resident and think “they’re not quite right, but I don’t know why”. It seems silly phoning a doctor to say … “they’re just not themselves”. But if you’ve done their NEWS and their NEWS is indicating, you can obviously relay that information to the GP and say “their score is normally this, but it’s gone up to this so there is obviously something going on somewhere”. Care home manager “It is reassuring to know that they have the equipment, and they have used it on my mam … it can’t be anything but a good thing…” Daughter of female resident with dementia

Technological issues “We’ve got homes that say they’ve got issues with WiFi … WiFi access, broken equipment, faulty equipment…” Specialist Nurse “We’ve had quite a few issues and we’ve reported them several times, where some of the kit doesn’t work. We were told, originally, that the thermometer went behind the ear and we were having issues, it wasn’t recording accurately… So, we’ve reported it a few times now and we’ve been told to use it in the ear. “ Care home manager

NoMAD survey 42 surveys were returned across 22 care homes General views: 67% (28) - intervention was worthwhile 88% (37) - could see the potential value of the intervention Fit with current work: 83% (35) - a normal part of their work & a legitimate part of their role 76% (32) - staff had a shared understanding of the purpose 88% (37) - would continue to support use of the tablets 24% (10) - disrupts working relationships Support and training 86% (36) - management adequately supported the intervention 81% (34) - sufficient training provided 86% (36) - work is allocated to people with the skills to use the equipment 67% (28) - had confidence in other people’s ability to use the tablet

DISCUSSION Mismatch between perceived and actual complexity VERSUS Mismatch between perceived and actual complexity Constraints on care home staff Use increasing but variability remains A challenge to roles Survey respondents were generally positive about the intervention

CONCLUSION Complex setting + complex intervention = very complex implementation Requiring context-specific training and implementation Some evidence to support the wider implementation of NEWS measurement in care homes