Aim
Preventing deterioration associated harm is a key aim of the NHS Patient Safety Strategy, focussing on implementation of Martha’s rule, a key component of the ‘PIER approach’.
Martha’s Rule
The purpose of Martha’s Rule is to provide a consistent and understandable way for patients and families to seek an urgent review if their or their loved one’s condition deteriorates, and they are concerned this is not being responded to.
Martha Mills died in 2021 after developing sepsis in hospital. Martha had been admitted with a pancreatic injury after falling off her bike whilst on holiday. Martha’s family concerns about her deteriorating condition were not responded to on several occasions and in 2023 a coroner ruled that Martha would probably have survived had she been moved to intensive care earlier.
In response to this and other cases related to the management of deterioration, the Secretary of State for Health and Social Care and NHS England committed to implement ‘Martha’s Rule’; to ensure the vitally important concerns of the patient and those who know the patient best are listened to and acted upon.
In April 2024, national implementation of Martha’s Rule began. Once NHS hospitals have fully implemented all components, patients, families, carers, and staff will have round-the-clock access to a rapid review from a separate care team if they are worried about someone’s condition.
Martha's Rule has three components:
- Patients will be asked, at least daily, about how they are feeling, and if they are getting better or worse, and this information will be acted on in a structured way.
- All staff will be able, at any time, to ask for a review from a different team if they are concerned that a patient is deteriorating, and they are not being responded to.
- This escalation route will also always be available to patients themselves, their families and carers and advertised across the hospital.
PIER
The ‘Prevention, Identification, Escalation, Response’ (PIER) approach.
The PIER approach facilitates safer and more effective management of acute physical deterioration in health and care. It applies to all clinical settings, specialities, and conditions, and views deterioration as a whole pathway supported by systems, as opposed to a single identification strategy.
PIER stands for:
- Prevention: planning ahead of any episode of deterioration to stop what is preventable, considering indicators of risk and patient choice.
- Identification: tools and methods to identify when deterioration is occurring in a standardised way.
- Escalation: timely escalation of care when deterioration has been identified using standardised communication tools.
- Response: timely, appropriate and effective response to escalation of the deteriorating patient/person.
The National Director of Patient Safety, Aiden Fowler, provides more information on PIER in a podcast recorded in early 2024. A transcript of the podcast is also available to read or download. You can listed to the podcast on Soundcloud here or in the featured video to the right of this page.
Previous programmes
The focus was be to establish consistent methods for deterioration management and supporting systems for monitoring and escalating the care of the acutely unwell.
NEWS2
NEWS2 is an approach to standardising the assessment of, and response to, acute illness. It consists of a scoring system based on a number of simple criteria which helps improve the detection of clinical deterioration in patients.
Locally, all acute hospitals and the ambulance trust in the North West Coast have adopted NEWS2.
The aim is for NEWS2 to become the ‘common language’ for communicating patient deterioration across the whole system and its use is now being explored in out-of-hospital settings as well, again with the support of the Patient Safety Collaborative.
RESTORE2
RESTORE2 is a physical deterioration and escalation tool for care and nursing homes.
It is designed to support homes and health professionals to:
- Recognise when a resident may be deteriorating or at risk of physical deterioration;
- Act appropriately according to the resident’s care plan to protect and manage the resident;
- Obtain 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 to get the right support;
- Provide a concise escalation history to health professionals to support their professional decision-making.
The Patient Safety Collaborative for the North West Coast is supporting the spread and adoption of deterioration management tools (namely Restore2/Mini) to Care Homes across the region.
Testing of the national Paediatric Early Warning System (nPEWS)
The focus is on improvement in deterioration management in the care of children.
Health Innovation North West Coast have supported the delivery of the NHS (National Health Service) System-wide Paediatric Observations Tracking (SPOT) programme between April 2021 to September 2022. This builds on our existing work around the National Early Warning Score (NEWS2), standardising the approach to acute deterioration in adults.
At present, there is no single nationally validated system for recognising and responding to deterioration for children and young people in England. The ambition in supporting the SPOT programme is to reduce deterioration associated harm in children and young people.
Between April 2021 to September 2022, the Patient Safety & Care Improvement Team have supported 5 pilot sites across the North West in implementing the new Paediatric Early Warning Score (PEWS). We have engaged with these acute trusts through regional learning events, 1:1 coaching sessions and our Coaching Academy offer of quality improvement, human factors, and coaching guidance to support adoption.
Information and resources to support this piece of work can be found here;
www.rcpch.ac.uk/
https://future.nhs.uk/
Resources for responding to COVID-19
The primary focus of responding to physical deterioration in relation to Covid-19 is support for the National Implementation of the NHS Covid Oximetry@Home and Covid Virtual Ward Models.
View our Patient Safety resources for COVID-19 >