Improvement aim
Specific, measurable, time-bound
To increase overall NEWS2 escalation compliance from 78% to ≥90%across acute medical wards and SDEC within 6 months, focusing on clinical review within target time, repeat observation reliability and structured documentation of delay reasons.
Improvement themes
Areas where local action is likely to help
Suggested local improvement actions
Editable — drawn from baseline dashboard signals
| Gap identified | Proposed action | Owner | Target date | Priority | Status |
|---|---|---|---|---|---|
| Clinical review within target time (58%) | Introduce a NEWS2 escalation clock on EPR with automated prompts at the local target time. | Digital / AMU Lead | 2026-08-31 | High | Planned |
| Reason for delay documented (47%) | Add a mandatory structured 'reason for delay' field to the escalation note template. | Nursing Lead / EPR Team | 2026-08-15 | High | Planned |
| NEWS2 calculated correctly (78%) | Targeted teaching at induction; laminated NEWS2 aide-mémoire on all obs trolleys. | Practice Development / Med Ed | 2026-09-30 | Medium | Not started |
| Ceiling of care reviewed (55%) | Add ceiling-of-care review prompt to the deteriorating patient bundle in EPR. | Consultant Body / Governance | 2026-10-15 | Medium | Not started |
| Repeat observations within target (61%) | Nurse-in-charge safety-huddle prompt for outstanding repeat NEWS2 observations at handover. | Nursing Lead | 2026-07-31 | High | In progress |
Suggested local implementation actions — not national guidance. Editable by the project team.
PDSA cycles
Plan → Do → Study → Act
- Plan
- Add mandatory 'reason for delay' field to escalation note template on AMU A and AMU B.
- Do
- Rolled out 12 May 2026 across AMU A/B with ward-round briefing.
- Study
- Compliance with 'reason for delay documented' rose from 41% to 63% over 4 weeks; no adverse events reported.
- Act
- Adopt across all inpatient wards; add to nursing induction.
Sustainability considerations
How the change is embedded
- Embed NEWS2 escalation prompts into EPR observation workflow.
- Add deteriorating patient module to nursing and medical induction.
- Include NEWS2 compliance in monthly ward governance dashboards.
- Nurse-in-charge safety huddle to include outstanding repeat observations.
- Quarterly re-audit with feedback to ward teams.
Learning points
For ARCP, supervision and governance
- NEWS2 documentation frequently strong for score capture, weaker for actions after the trigger.
- Escalation route inconsistency is a system issue — not an individual competence issue.
- EPR prompts significantly change behaviour when embedded in existing workflow.
- Ceiling-of-care conversations are a recurring gap in the deteriorating adult pathway.
Governance reminder
Lazomis QIP supports quality improvement planning and documentation. It does not replace clinical judgement, local deteriorating patient policy, professional responsibility or organisational governance processes.