Managing deterioration: Insights from the Sussex PIER workshop

Summary 

The PIER (Prevention, Identification, Escalation, Response) tool supports the effective management of acute physical deterioration across all health and care settings. A collaborative workshop hosted by Health Innovation KSS and Sussex ICS applied the PIER framework to emergency systems in Sussex to identify quality improvement opportunities in managing deteriorating patients. 

Challenge 

Avoidable deterioration accounts for an estimated 10% of overall harm in healthcare, contributing to approximately 1,000 preventable deaths and £100 million in additional treatment costs annually.¹ Sussex’s urgent and emergency care services are under increasing pressure, with rising demand across ambulance services, emergency departments, and urgent care pathways. There is a critical need to improve patient flow and reduce delays in care to enhance safety and outcomes. 

Approach 

Health Innovation KSS held an online workshop with 32 participants from 13 provider organisations across Sussex, including clinicians and system support teams. The PIER tool was used to guide discussions and identify areas for improvement across urgent care, primary care, care homes, community services, ambulance services, and hospital wards. Thematic analysis of the workshop data was conducted using an AI tool, following a structured framework to identify key themes. 

Impact 

The workshop successfully identified several themes for Quality Improvement (QI): 

• Escalation and referral processes 

• Information sharing challenges 

• Use of standardised tools (e.g., SBARD, NEWS2, UCR, Frailty Assessments) 

• Cross-system working and integrated care models 

• Admission avoidance and inappropriate placements 

• Workforce and training issues 

• Risk and patient safety concerns 

While patient-level outcomes are yet to be evaluated, the initiative aligns with national goals to reduce avoidable deterioration by 20%, potentially saving £20 million and 200 lives annually. 

Participants in the workshop itself said they felt heard and motivated that they could help to implement their improvement suggestions, which could save clinical hours and improve flow. 

Spread and scale 

The PIER tool provides a system-led approach to managing deterioration, applicable across all care settings. It supports ICSs in designing and implementing whole-pathway improvement plans. The workshop outputs are being used to inform the development of a Deteriorating Patient Quality Improvement Network within Sussex ICS, promoting shared learning and system-wide collaboration. 

Carol Hards, Quality & Learning Senior Manager, Sussex ICS:

‘We had a great opportunity to work collaboratively recently with Health Innovation Kent Surrey Sussex as part of a national NHSE project to identify themes for learning and improvements to improve the pathway for patients admitted through ED.  Together we facilitated a virtual workshop to help clinicians from across the ED system, including primary and community care, A&E and ambulance services to improve management of deteriorating patients using the PIER Framework (Prevention, Identification, Escalation, Response/Recommendations).

 

As an organisation we are planning on using the themes and trends from the analysis to identify key areas of focus for our Deteriorating Patient Quality Improvement Network. This will be a new of area of work which will encourage and enable system partners to share good practice and effectively and efficiently tackle challenges that affect the system to improve patient outcomes and experience.’ 

Key learnings 

Learnings from the workshop included:  

• Psychological safety fosters open dialogue: Not recording the session encouraged honest and insightful contributions from participants. 

• Representation matters: While a broad range of clinical specialties registered, the actual attendance skewed toward social and community care, which influenced the focus of discussions. 

• Data security is essential: The AI tool used for analysis required anonymisation of data due to security limitations. 

• Themes transcend framework categories: Overlapping themes across the PIER framework led to a thematic rather than framework-based organisation of findings. 

• Shared learning is a catalyst for improvement: The workshop highlighted the value of cross-system collaboration in identifying and addressing systemic challenges in patient care. 

To find out more about the workshop and the use of PIER, please contact Julie Smith, Programme Manager at Health Innovation KSS . 

Reference  

1. NHS England (2019) The NHS Patient Safety Strategy, https://www.england.nhs.uk/patient-safety/the-nhs-patient-safety-strategy/#patient-safety-strategy