1. Information for Primary Care
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A common language across healthcare: using RESTORE2 & NEWS2 to identify the physically deteriorating patient in Care/Nursing Homes
Information for Primary Care

2. What is

3. RESTORE2 is a physical deterioration and escalation tool for care/nursing homes
It is designed to support homes to:
Recognise when a resident may be deteriorating or at risk of physical deterioration
Act appropriately according to the residents care plan
Obtain a complete set of physical observations to inform escalation and conversations with health professionals
Speak with the most appropriate health professional in a timely way
Provide a concise escalation history to health professionals to support their professional decision making

4. National Early Warning Scores (NEWS)
RESTORE2 uses NEWS as part of the tool
NEWS is a validated tool widely used in acute care and pre-hospital settings comprising six biological measurements:
Respiration Rate
Oxygen Saturations
Temperature
Systolic Blood Pressure
Heart Rate
Level of Consciousness (defined by ACVPU)
Mention in print NICE guidance
GP NEWS tools apps
Sepsis screening – lack of SIRs sensitivity and application to Primary Care

5. National Early Warning Score 2
Mention in print NICE guidance
GP NEWS tools apps
Sepsis screening – lack of SIRs sensitivity and application to Primary Care

6. National Early Warning Score (NEWS)
NEWS can be used for both initial assessment of acute-illness severity and as a track-and-trigger to identify acute clinical deterioration and response
Graded scoring system (0-20)
Based on aggregated scores and extreme variation in single parameters
NEWS is shown to be good at discriminating risk of acute mortality and is more sensitive than most existing systems
Small changes in parameters can be detected earlier using NEWS than waiting for obvious changes in individual parameters
NEWS is not a replacement for clinical judgement
Estimated could save 6,000 lives per year if everyone used NEWS
Mention in print NICE guidance
GP NEWS tools apps
Sepsis screening – lack of SIRs sensitivity and application to Primary Care

7. Triad of Clinical Outcomes
Supports Primary Care to prioritise response
Supports homes to recognise the early and soft signs
timeliness of response
early detection
competency of clinical response
Supports primary Care to know how to respond and allocate staff

8. Escalate using Escalation Tool Communicate using SBARD
Recognise Soft Signs
Take observations
Calculate NEWS
Escalate using Escalation Tool
Communicate using SBARD
Recognise the Soft Signs of resident deterioration
Use the SBARD tool to concisely communicate the message
Take a complete set of physical observations
NEWS is not accessible to care/nursing homes in its current RCP format
RESTORE2 combines soft signs with NEWS2, a clear escalation pathway designed around care homes and an SBARD communication tool
Designed to achieve the triad of good clinical outcomes
Works in care homes where staff are trained to take observations because the tool is colour coded and the escalation is prescribed
Escalate to the right health professional for clinical support
Calculate NEWS2 score

9. How does this support Primary Care?

10. Supporting Primary Care
Much of the care in care/residential/nursing homes is provided by untrained carers
The lack of available standardised assessment tools across homes and between homes and Primary Care
RESTORE2 supports carers to identify the soft signs of deterioration early so GP’s are informed in a timely way
RESTORE2 uses NEWS2 – a standardised deterioration tool accessible to GP’s and care homes – a common language across healthcare
(NEWS is available as templates on EMIS & SystmOne)

11. Supporting Primary Care
The complexity of recognising physical deterioration in residents with underlying health problems
The difficulty in achieving concise, effect communication and escalation
RESTORE2 supports GP’s and care homes to document what is normal for the resident and detect deterioration using a validated tool
RESTORE2 means that GP’s get a full set of observations and a NEWS score communicated in a structured and concise way using the SBARD tool

12. Supporting Primary Care
The number of calls from care/nursing homes to Primary Care can be overwhelming
RESTORE2 supports care homes to assess who needs escalating and who can be monitored locally – it also provides more information for GP’s to prioritise caseload

13. Questions

14. Questions
Who decides whether RESTORE2 is introduced into the care/nursing home I cover?
Ideally, the home, community care team, primary care practice and CCG will all be on board and support the introduction of RESTORE2. However, ultimately it is the decision of the care home as an independent business or council establishment how they keep their residents safe
Will RESTORE2 increase the number of calls from care/nursing homes?
No – this has not been the experience of using RESTORE2. Care/nursing homes will call their GP when worried about a resident anyway – RESTORE2 at worst means that when they call the practice will get a full set of observations and a concise history. At best, RESTORE2 often gives homes the confidence to monitor residents without escalating to the GP

15. Questions
Don’t all care home/nursing residents have high NEWS2 scores?
No. Data from residents in care and nursing homes show that most (more than 90%) have a NEWS2 score of 0 or 1. Some residents will have elevated scores as part of their normal underlying pathology but this is the exception to the rule

16. Questions
Can care or residential (non nursing) home staff do physical observations?
Qualified nurses through their professional registration are expected to be competent to undertake and interpret physiological observations. Care/residential home (non nursing) staff can take physiological observations if they are appropriately trained. Care/residential home staff are not expected to interpret the observations – this is the role of a suitably qualified healthcare professional. In RESTORE2, the interpretation of the observations is done by NEWS
How does RESTORE2 and NEWS2 link with other local services?
NEWS2 is being advocated for use in pre-hospital settings. Depending on your location, many GP’s, the ambulance service and certainly acute providers will be using NEWS2 as contained in the RESTORE2 tool

17. Questions When should I use the hypercapnic respiratory failure scale?
The new Sp02 scoring Scale 2 is for patients with a prescribed oxygen saturation requirement of 88-92% (e.g. in patients with hypercapnic respiratory failure). This should only be used in patients confirmed to have hypercapnic respiratory failure on blood gas analysis on either a prior, or their current hospital admission.
The decision to use the new Sp02 scoring Scale 2 should only be made by a competent clinical decision maker. We do not expect GP’s to be making this decision unless clearly instructed to do so by a suitably competent respiratory practitioner who has undertaken the necessary tests and assessment. This is supported by the RCGP.

18. Questions
What if we can’t meet the recommended timeframes for response in RESTORE2?
The timeframes in RESTORE2 are to support care/nursing homes to understand what response they should be asking for. This is to support timely communication. Practices are not bound by these timeframes. Practices remain responsible for their own clinical decision making, based on the information given to them

19. Questions
What if I don’t think the recommended / suggested action on a NEWS score is the right thing to do for the resident?
The escalation pathway is for care/nursing homes and not specifically for primary care. NEWS2 does not replace clinical judgement but can be used as an adjunct to patient assessment in general practice. Clinicians have latitude to decide the most appropriate course of action and should clearly document their decision making process and communicate any changes to plans or pathways to care/nursing home staff.

20. Questions Can you use RESTORE2 for residents with an End of Life plan?
Yes – feedback from homes has been that RESTORE2 is helpful in identifying when a resident is becoming end of life. The tool and observations can support appropriate conversations with relatives. Once a resident has been identified as being end of life, the RESTORE2 tool should be discontinued to avoid unnecessary distress or discomfort to the resident. It is important that the end of life care plan clearly documents where the resident wishes to die and how they want to be managed.

21. Questions
What conversations should I be having with residents and the care/nursing home before deterioration occurs?
Residents should have a clear end of life plan. This is not just about DNACPR but about where they wish to die and under what circumstances would they want to be treated in the community or admitted to hospital. This should be clearly documented and accessible. Residents without capacity should have a documented Best Interests Decision made in conjunction with family and professionals. Care/nursing home staff should be clear about the difference between DNACPR and other ceiling of care limitations. A good tool to support and document these conversations is the (Recommended Summary Plan for Emergency Care and Treatment) tool