National Patient SafetyImprovement Programmes

Managing Deterioration

Delivered by: Led by:

NHS England

NHS Improvement

@NatPatSIP / @MatNeoSIP www.improvement.nhs.uk

Using RESTORE2™mini App: Understanding Soft Signs and Getting Your Message AcrossTraining Slides

Using RESTORE2™mini : Learning Outcomes

Why RESTORE2™mini was developed and digitised

Understand the importance of Soft Signs of physical deterioration

How to identify Soft Signs of deterioration in your residents

Know how to get your message across effectively to healthcare professionals once you have

identified Soft Signs in your residents

Where you can find additional helpful resources about Soft Signs and deterioration

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By the end of the session:

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RESTORE2™mini Digital App

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Introducing the App

• New functionality added to purpose built CV-19 clinical tracker tool

• No changes to accessibility

• Helps carers to communicate their concerns about their residents showing Soft Signs of deterioration concisely to healthcare professional

• Evidence-based tool (SBARD)

• Digitised to be easy, intuitive, and quick to use

• Part of the RESTORE2™ toolkit where NEWS2 (vital signs and physical observations) is incorporated

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Understanding Soft Signs

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Soft Signs and Deterioration

• Early signs of physical “unwellness” can be recognised intuitively by physical healthcare practitioners as evidenced by staff saying

“I know something is wrong, I just don’t know what”

• Even people without training, but who are familiar with someone’s usual behaviour and habits, can often sense a problem resulting in them reporting that the relative, resident, or child in their care

“Just aren’t themselves”

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Examples of Soft Signs

• Soft signs can be related to many things including residents’:

• Physical presentation

• Mental state• Behaviour and ability

• Some soft signs are universal – e.g. new onset shortness of breath or decreased urine output.

• Others may be unique to that particular person, e.g. a sudden inability to participate in activities they enjoy like doing crossword, or a particular change in behaviour such as withdrawal, agitation, or hyperactivity.

• By getting to know your resident, speaking with their family, friends and carers, you can build up a picture of soft signs that are significant to each particular resident.

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Mental Physical Behaviour or Ability

Worse than normal lethargy Worsening shortness of breath (can’t

talk in sentences)

Tiredness / not wanting to get out of

bed

WithdrawnNew or increasing oxygen

requirement

Reduced inhibitions Reduced

awareness

Anxiety/agitation or not themselves Chestiness Increased risk taking behaviour

More argumentative or tearful Fast or unusually slow breathingMore restless / hyperactive Loud or

animated

Increasing (or new onset) confusionCold hands/feet Worsening skin

colour PuffinessReduced interest in personal care

Less alert than normalSkin mottling or rash Increased or

new onset pain

Reduced interest in activities of daily

living

Reduced levels of concentrationObservations significantly different

from normal, including blood sugarsAnger / frustration outbursts

Shivery, fever or feels very hot, cold

or clammy

Off food, reduced appetite Reduced

fluid intake

New offensive/smelly urine or can’t

pee / reduced pee

Reduced catheter output

Diarrhoea, vomiting or dehydration

(dry lips, mouth, sunken eyes,

decreased skin tone)

Can’t walk or ‘off legs’, less mobile/

coordinated

Index of Soft Sign Indicators of Deterioration

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How to Spot Soft Signs

• It is good practice to ask people you care for

“How are you feeling today?”

• Allow them time to answer the question in their own way and make a note of individual or unique Soft Signs in the resident’s record.

• Encourage friends and family to tell you if they notice any Soft Signs.

• Soft Signs are particularly useful for residents who have difficulty communicating or understanding information due to dementia or learning difficulty

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‘By learning about Soft Signs, you may

be able to recognise deterioration early

and act to protect your residents from

serious illness

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Recognising Normal

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Knowing Your Resident

• As a carer, you know your resident better than any other healthcare professional that comes in contact with them.

• You are ideally placed to recognise small changes in your residents.

• By getting to know your resident, speaking with their family, friends, and carers, you can build up a picture of Soft Signs that are significant to each particular resident.

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Knowing Your Resident

• It is important when the resident is admitted to your home you:

• Complete a set of vital signs (physical observations) if possible.

• Take time to learn about their usual behaviours.

• Understand their medical history, including any medicines they regularly take.

• Assume that they have the ability (capacity) to make decisions about what they want, including if they become unwell.

• Have a conversation with the resident’s GP about when and in what circumstances the GP might want you to call them with a concern.

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Getting Your Message Across

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Raising the Alert

• Follow your organisation’s reporting procedure

• Some occasions when the early signs of deterioration may be a medical emergency (999) such as:

• Chest pain or a suspected heart attack

• Displaying signs consistent with having a Stroke

• Prolonged seizure where a patient does not have a care plan in place to manage it

• Breathing is compromised

• Sustained a significant injury such as head injury or a fall

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to adjust the

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SBARD: What is it?

• Situation, Background, Assessment, Recommendation, Decision

• Standardised way to structure your conversation and getting your message across

• Proven to work effectively in hospitals and other healthcare settings

• Brilliant when used in busy environments to ensure important information is not missed

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• Introduce yourself

• Where you are calling from

• Key information about resident

• Explain what you are concerned about

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Getting Your Message Across

• Provide resident’s relevant medical history

• Could include medical conditions, relevant test results, medicines, or end of life care plans

• Summarise actions you have taken so far

• Suggest what you think might be happening

• Could include signs of diarrhoea, pain, medication you have given, actions like repositioning the resident

• Think about what you would like to happen next

• Use phrases such as “please could you”, or “I need you to”

• “what do I need to do next”, or “is there anything I need to do in the meantime”

• Write down the agreed actions and management plan so you are both clear on what each of you will do

• “we have agreed that you will” and “I will do”

• “If there is no improvement within xx I will take yyactions”

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Using the app

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RESTORE2™mini

report(s) outstanding

Number of

RESTORE2™mini

report(s) completed

Select

resident

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Select tab

23

Click to start

report

Number of Soft Signs

identified in previous

report

Information on starting a

report and what will

happen next

Return back to residents

home page

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Click if Soft Signs

present

Enter other

relevant notes

Click to continue

to SBARD

Colour coded for ease of

identification of Soft

Signs

Progress automatically

saved

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Complete SBAR

Click to continue

to summary

Can go back to add/

change Soft Signs

Summary of identified

Soft Signs

Prompts to help you

structure your message

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Click to continue

to summary

Can go back to add/

change Soft Signs and

SBAR

Summary of identified

Soft Signs

Summary of SBAR

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Call T&G Digital

Health ServiceDigital Health Service will

have access to the report to

talk you through it

Use your SBAR

report to talk with

the health

professional about

your concerns

when your call is

put through Use your SBAR

report to talk to the

health professional

when your call is

put through

Once completed

click submit to end

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RESTORE2™mini

report(s) updated

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Next steps

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Next steps

• Start using RESTORE2™mini

• Today: supporting information email

• Day 5 – follow-up support and feedback call

• Dedicated helpdesk

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CV19CareHomeResponse@healthinnovationmanchester.com

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Additional Resources

Managing Deterioration Training Videos From Health Education England (HEE)

1. Introduction to sepsis and serious illness2. Preventing the spread of infections3. The soft signs of deterioration4. NEWS What is it?5. Measuring the respiratory rate6. Measuring oxygen saturation7. Measuring blood pressure8. Measuring the heart rate9. Measuring the level of alertness10. How to measure temperature11. Calculating and recording a NEWS score12. Structured communications and escalation13. Treatment escalation plans and resuscitation14. Recognising deterioration in people with a learning disabilities

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Recommended viewing

RESTORE2™mini Paper CopyFrom West Hampshire CCG

1. RESTORE2mini2. RESTORE2mini A4 (with patient ID)3. RESTORE2mini A5 (with patient ID)

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Further Reading1. NEWS2 overview (NHS England)2. Managing the COVID19 pandemic in care homes for older people (British Geriatrics Society)3. Learning disabilities mortality review (LeDeR) programme (University of Bristol)4. Spotting serious illness and sepsis (AHSN network)5. Resource to support care homes and staff to monitor and manage deterioration (Health Innovation Manchester)

RESTORE2™ VideosFrom West Hampshire CCG

1. Introduction to RESTORE22. RESTORE2: Why use it?

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RESTORE2™ ResourcesFrom West Hampshire CCG

1. Official RESTORE2 website2. Training and resource3. Case studies

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Acknowledgements

Acknowledgements

Training slides adapted from Wessex AHSN and Hampshire CCG’s original format for Health

Innovation Manchester

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