Authors: Dr Bashar Elwir , Dr Mei JINGHON , Aqsa Munir , Dr Thomas Selina

Abstract

Background

Emergency Departments (EDs) are increasingly affected by crowding, prolonged patient stays, and delayed transfer of care, increasing the risk of missed or delayed recognition of clinical deterioration. At Royal Derby Hospital ED, delays and inconsistencies in escalation following abnormal National Early Warning Score 2 (NEWS2) observations were identified as a patient safety concern. A sentinel event involving a patient with viral myocarditis, where delayed escalation and response contributed to a fatal outcome, triggered this quality improvement project (QIP). Although trust escalation guidance existed, adherence was inconsistent and did not reflect ED workflow.

Aim

To improve compliance with timely escalation and response for deteriorating adult patients in the ED from 56% to 80% within 6 months, by standardising escalation pathways and embedding reliable NEWS2-aligned escalation processes.

Methods

A multidisciplinary QI team was established including ED consultants, registrars, nursing staff, healthcare assistants (HCAs), junior doctors, and digital transformation colleagues. The project used a Plan–Do–Study–Act (PDSA) approach over multiple cycles, supported by structured QI tools and staff engagement. Interventions were co-designed with frontline staff to address practical barriers and reduce variation between “work-as-prescribed” and “work-as-done.”

Key interventions included: bedside digital entry of observations using Nervecentre devices; mandatory registered nurse (RN) sign-off for abnormal NEWS2; clearer identification of senior decision makers (registrar/consultant) via ED whiteboards; structured clinician documentation prompts; morbidity and mortality (M&M) teaching using a real ED case to promote shared learning; and development and implementation of a simplified ED-specific escalation flowchart aligned with departmental workflow.

Four process measures were tracked: (1) timely escalation following HCA observations; (2) RN response to escalations; (3) escalation to clinician/senior decision maker (SDM); and (4) clinician assessment and documentation following escalation.

Results

Measurable improvements were achieved across key escalation steps. Timely escalation following HCA observations improved from 56% to 68%. RN response to escalations improved from 61% to 74%. Escalation to a clinician/SDM improved from 52% to 70%. Clinician assessment and documentation improved modestly from 59% to 62%, remaining the most persistent challenge. Staff feedback suggested improved clarity of roles, increased confidence in escalation expectations, and better awareness of departmental escalation standards following implementation of the ED flowchart and teaching interventions.

Conclusion

An ED-specific NEWS2 escalation algorithm, supported by digital observation systems and multidisciplinary engagement, improved timely escalation and response to deterioration in a pressured ED environment. While improvements were seen across multiple escalation steps, clinician documentation remained inconsistent and requires further targeted work. Sustaining progress will depend on reinforcing a culture of shared responsibility, strengthening accountability across disciplines, and continuing iterative PDSA cycles.

Keywords: NEWS2, Emergency Department, deterioration, escalation, patient safety, quality improvement, PDSA, digital observations, Nervecentre, clinical governance.