Last reviewed 23 July 2021
Older patients in residential care settings are at risk of physiological deterioration. Not all cases are easily predicted but failing to recognise early signs can mean poor outcomes for the individual. The effects of Covid-19 in particular can be very varied and not immediately obvious, especially in older people who often develop the “soft signs” of illness. Christine Grey investigates.
The Care Quality Commission (CQC) says emerging research has shown that more than half of patients who experienced a serious adverse event in their health could have been identified as high-risk earlier, and nurses are being reminded that measurement, observation and recording of vital signs are crucial in more timely detection.
To help care home staff detect and deal with deterioration among their residents, multi-disciplinary working and social and healthcare initiatives have emerged during the pandemic, including the roll out of the Framework for Enhanced Health in Care Homes across England between 2020 and 2024.
Innovative tools for remote deterioration monitoring and escalation have also been developed for use in care homes, and guidance and training for care providers on the use of monitoring devices such as pulse oximeters have evolved.
What is the EHCH programme?
The Framework for Enhanced Health in Care Homes (EHCH) ,here, was published by NHS England and NHS Improvement (NHSEI) on 31 March 2020 and creates a minimum standard for NHS support to people living in care homes.
The principles of the Framework should facilitate collaborative working to support care staff in physical monitoring and escalating, in order to enhance earlier detection of deterioration in care home residents.
Aspects of the EHCH programme were first established in England in May 2020 to offer NHS support to care home residents through the first wave of the Covid-19 pandemic. As this was an interim service, it transitioned to a more comprehensive one described in the Network Contract Directed Enhanced Service (DES) and the NHS Standard Contract from 1 October 2020.
The Framework aims to ensure health and care services are “wrapped around” the care home resident and their family and care staff, and that proactive, personalised care and support becomes the norm.
In practice, this means ensuring that residents have access to enhanced primary care and to specialist services, and that care home staff feel they are “at the heart of an integrated team spanning primary, community, mental health and specialist care, as well as social care services and the voluntary sector”.
It sets out how care homes should:
be aligned with a primary care network (PCN)
be given a named clinical lead
have a multidisciplinary team (MDT) in the PCN, formed by 30 September 2020
have weekly “care home rounds” or “check-ins” from the MDT.
Within seven days of admission or readmission to a care home, a resident should get a person-centred, holistic health assessment of need and a personalised care and support plan based upon their assessment.
The Framework says clinical teams can make use of technology to improve how they work with social care staff to make joint decisions about the care of individuals. For example, they may be able to assess some residents remotely, and sensors, apps and assistive technology can help to identify problems early. Monitoring technology can help reduce the prevalence of poor nutrition and can help alert care home staff and staff working in the wider health system “about the deteriorating health of an individual, before a crisis occurs”.
The Network Contract DES also requires PCNs to establish “protocols between the care home and with system partners for information sharing, shared care planning, uses of shared care records and clear clinical governance”.
The Care Provider Alliance’s guide on the EHCH programme, here, says the minimum service requirements described in the contracts are the building blocks on which the rest of the Framework can be developed, and that implementing the good practice EHCH model contained in the Framework will help support the important principles within it.
What are the physiological early warning systems in care and nursing homes?
The Royal College of Physicians (RCP) published the first National Early Warning Score (NEWS) in 2012 to standardise an approach to early identification of deterioration in healthcare. An updated version (NEWS2) launched in 2017, here, was based on a scoring system of six physiological parameters and was endorsed by NHSEI.
NEWS2 provided the basis for building subsequent resources to support staff and patients in care homes, nursing homes and domiciliary care settings.
Physiological measurements detect vital signs of deterioration and include measuring, questioning, and evaluating “or otherwise observing a patient or a specimen from a patient”. Some of the vital signs include oxygen saturation, pulse, respiratory rate, blood pressure and temperature, according to the CQC.
A resource called RESTORE2, here, was recently co-produced by West Hampshire Clinical Commissioning Group (CCG) and Wessex Patient Safety Collaborative to help care and nursing homes recognise physical deterioration in residents and measure the vital signs. It is based on nationally recognised methodologies including early recognition (“Soft Signs”), NEWS2 and structured communications (SBARD), and has the approval of the CQC.
The tool also supports a care home to act appropriately according to the resident’s care plan to protect and manage the resident; get 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; and provide a concise escalation history to health professionals to support their professional decision-making.
Care homes wanting to use a "soft signs" only approach can use the RESTORE2mini version as a pre-diagnostic indicator of concern, which is adapted for use in other care settings including domiciliary care.
Free training resources for those involved in implementing the tools are here. Online, video-based training for care home and community staff has been published on the Health Education England (HEE) YouTube website, here. It includes a Soft Signs of Being Unwell and Introduction to Sepsis and Serious Illness unit.
Using pulse oximeters in care homes
The Government guidance, Admission and Care of Residents in a Care Home During COVID-19, here, stated that the NHS will encourage care home professionals to use well evaluated tools such as RESTORE2 and NEWS2, “accompanied by support and access to specific equipment such as pulse oximeters, which can also help determine whether a resident is unwell and as a way of monitoring residents with symptoms”.
It was subsequently recommended, in November 2020, that CCGs put in place a “Covid Oximetry@home” model as rapidly as possible, further to NHSEI guidance on pulse oximetry, here.
Pulse oximeters help to monitor how fast an individual’s heart is beating and the level of oxygen in their blood. Many GP practices and community teams already use oximetry to support patients living in their own homes or care home to diagnose acute illness remotely and conduct longer-term monitoring. It can be used for patients at an early stage of disease who are sent home from A&E or discharged after short hospital admissions. Blood oxygen level is also the most accurate way of monitoring an individual’s progress with Covid-19.
The use of remote monitoring and pulse oximetry is normally overseen by the local CCG and is at the discretion of the clinician. The NHS’s Covid Oximetry@home Standard Operating Procedure, here, supports remote monitoring with pulse oximeters for residents in care homes with confirmed or possible Covid-19.
Care home staff and other supporting services are expected to facilitate the same standard of care as for someone in their own home, including full escalation or emergency admission or potential emergency home oxygen treatment and palliative treatments where appropriate.
Training and support for using pulse oximetry is available from the Care Provider Alliance, here, including a monitoring diary tailored for use in care homes. The healthcare clinician should confirm during “check-ins” that the oximeter and diary are being used correctly, and that readings are 95% or above.