Testing the Deterioration Early Warning System (DEWS) for residential aged care: a feasibility study

Trial: Type two hybrid feasibility testing study of 1) a newly developed tool (DEWS) designed to support staff to recognize and respond to acute deterioration of people living in residential aged care (RAC) and 2) the quality improvement processes designed to support tool implementation. Rationale: DEWS was developed using best available national and international evidence, It was co-designed to work in the RAC environment. Both DEWS and the implementation processes need small scale testing in the real-world environment before any recommendation for use can be made. Method: Adaptation of the quality improvement (QI) implementation processes used during the New Zealand (NZ) hospital based Deteriorating Patient program. We will recruit three to five RAC facilities from across NZ to implement DEWS. They will be supported to set up QI teams to implement and test DEWS in day-to-day practice. Researchers will be providing a standardized support package of a) all QI tools, project initiation document, data collection tools, education package, DEWS tools, DEWS tools guideline. b) initiation education workshop about DEWS tools and QI processes, c) site visits to establish baseline and support local QI teams to promote implementation and tackle roadblocks and progress visit at approx. 3 months d) regular (fortnightly) video conference support meetings to problem solve, collect data, continue impetus. Support Package details: The DEWS tools consist of three parts that reflect the existing RAC processes for recognizing and responding to acute deterioration. i) Quick DEWS for use by healthcare assistant is a nine-item clinical indicator check list of signs that are significantly associated with acute deterioration. It is for completion once per shift (3x a day). The clinical indicators are observable during routine care provision. The presence of one indicator triggers a nurse assessment ii) DEWS-RN is a chart including observable clinical indicators and vital signs. The chart is structure is based on Te Whare Tapa Wha holistic model of health. The chart has colors and numbers that indicate the degree of urgency associated with each measure. The chart is scored and triggers a mandatory clinical escalation pathway (same concept as hospital based early warning scores). iii) SBARR-DEWS is a handover and critical thinking tool that structures clinical communication, it includes the score from DEWS-RN and uses the well know situation, background, assessment, recommendation and response communication process. This supports RN handover to next responder. iv) The tools come with a user guide and standard presentation Wrapped around DEWS implementation is a quality improvement process i) Implementation guide and project charter, includes measurement suggestions, such as how often GP is call out of hours, hospital presentation, cost of implementation, staff time (to be refined with facilities as access to data varies across the different providers) Education package detail i) one full day face to face workshop for up to 5 members of each RAC quality team. First half of day includes DEWS tools (development process, train the trainer how to use DEWS in practice, small group familiarity with tools, copyright, IP and boundaries of use) Second half of day Quality improvement focus, Health and Disability Commission present on importance of recognizing acute deterioration in consumers in RAC. Then small group activities mapping current processes and where DEWS fits, Deciding from available data what can be measured. Setting task timeline to lead up to DEWS launch in practice. Teams will be provided with "train the trainer" materials to provide education about DEWS in their own facilities. Following this fortnightly zoom meetings 2 hours duration problem solve, support, assist processes need to launch DEWS. Then meetings will track DEWS use. One site visit by researchers during testing to support teams, check progress, talk to staff, provide data so far and celebrate. The research team includes a primary care provider, nurse practitioner, and quality improvement practitioners and data analyst and is supported by Te Taha Hauora Health Quality and Safety Commission New Zealand. The research team will be supported by an expert advisory group to help manage the wider implications of the project (for instance unintended impact on service providers external to RAC) and cultural (Maori indigenous New Zealanders) and consumer considerations. Recruited RAC facilities will have at least 50 bed capacity with a primary care provider with at least one year experience of working with that facility, they will need to agree to providing human resources necessary to complete project (including adequate release from clinical duties) and agree to abide by copyright rule for DEWS tools and processes. We aim to recruit a representative sample of RAC facilities, including all levels of care delivery. Feasibility phases: PLAN: (approx. 2 months) facilities supported to understand their current state, gather base line data, establish their implementation team. PREPARE (approx. 3 months) attend workshop, establish escalation processes, socialize DEWS with staff teams, confirm data collection mechanisms. TEST (approx. 5 months) Use the DEWS tools, collect data, audit use of tools, provide narrative examples of tool use, collect data. EVALUATE (approx. 1 month) participate in qualitative interviews and survey about the DEWS tools and QI processes and thier view of whether is it feasible and worthwhile implementing DEWS. Researchers will collate data from across the 3-5 test sites, including hospital presentation data, primary care use data and clinical care study narrative of DEWS use. Research outcomes will include recommendations for change to DEWS tools and QI implementation processes and a recommendation for further implementation.