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Purpose

The National Clinical Effectiveness Committee (NCEC) requires consideration of evidence on both the clinical and cost-effectiveness of health technologies in the development of all National Clinical Guidelines (NCG) in Ireland. In addition, the completion of a budget impact analysis (BIA) based on the implementation of a National Clinical Guideline is required. The role of the HRB-CICER team is to independently review the evidence and provide scientific and methodological support in the development, by the Guideline Development Group (GDG), of these evidence-based NCGs.

The Irish National Early Warning System (INEWS), launched in February 2013, was the first NCG to be published. It clearly sets out how to recognise and respond to patients whose condition is deteriorating. This guideline was designed for adults in acute hospitals and was based on international evidence of what is known to work best. As part of updating the INEWS NCG, the HRB-CICER team conducted systematic reviews of the clinical effectiveness and cost-effectiveness literature so that changes in the evidence on early warning systems (EWSs) for use in acute patient care could inform the NCG update. This involved:

  1. An update of the previous systematic review of clinical effectiveness and cost-effectiveness conducted to support the development of the INEWS guideline (four review questions)
  2. Two new systematic reviews were also completed. The first to identify the effectiveness of modified EWSs compared to the INEWS in two sub-populations (frail elderly adults and adults with acute respiratory conditions) and the second to assess why health care professionals fail to escalate the EWS as per the protocol?

A BIA was conducted to quantify the resource implications to the Health Service Executive following implementation of the guideline recommendations. The main cost and resource implications of the INEWS guideline update included the introduction of an advanced nurse practitioner responder model; an eLearning module; and protected time for Deteriorating Patient Consultant champions.

Background

Many cases of adverse patient outcomes (for example cardiac arrest or death) in the acute hospital setting may be preventable; therefore, early recognition of clinically deteriorating acute adults is a priority for improving health services and saving lives.

The Irish National Early Warning System (INEWS) incorporates a bedside tool that is used for monitoring the condition of acute adult inpatients to facilitate early detection and management of physiological clinical deterioration by the rapid response team. The INEWS chart is completed at the bedside. Vital signs (respiration rate, oxygen saturation, temperature, heart rate, blood pressure, urine and neurological response) are recorded on charts and colour-coded according to their value using pre-defined thresholds for abnormalities. If a patient exceeds these thresholds, an escalation of care should be initiated by the healthcare professional.

Methodology

The systematic review of the literature to support the update of the INEWS NCG No. 1 was carried out in accordance with agreed HRB-CICER quality assurance framework processes and following the HIQA guidelines for the retrieval and interpretation of economic literature  and for evaluating the clinical effectiveness of health technologies in Ireland .

The BIA was conducted in accordance with the HIQA guidelines for BIAs and economic evaluation in Ireland.