Clinical Outcome Modelling Saves Lives
Submitting InstitutionUniversity of Portsmouth
Unit of AssessmentComputer Science and Informatics
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Nursing, Public Health and Health Services
Summary of the impact
Practitioner/professional service impact. Our work on clinical
outcome modelling has
influenced the Royal College of Physicians' (RCP) new standard for the
assessment of the
severity of acute illness (known as the "National Early Warning Score"
or NEWS). The specific
recommendation is for adoption by NHS bodies, but is already being
Health impact. The chairman of the RCP working party estimated
that our work could result in
the saving of thousands of lives per year.
Economic impact. Our work is incorporated in the VitalPAC
system developed by The
Learning Clinic Ltd (TLC), and currently deployed to more than 20
Outline of research
The impact arises from the health informatics research carried out in
Portsmouth by Professor
David Prytherch and Dr Jim Briggs, supported by Bernie Higgins, Jeff Sirl
and others. Our
collaborators included Portsmouth Hospitals NHS Trust (PHT), Bournemouth
University and The
Learning Clinic. Our approach is extremely inter-disciplinary, but
embedded in all we do are the
fundamental principles that information must be acquired by reliable means
and reasoned about
rigorously; all applied in a clinical context.
We collect and use clinical data to model adverse patient outcome. The
models enable clinicians to
predict which patients are at risk of deterioration, and medically
intervene. Our research has built
on work done in the late 1990s and up to 2003 to develop models (P-POSSUM)
of outcomes in
surgery (1). P-POSSUM was a success and has been widely adopted, but is
only applicable to
surgical cases. This led us to investigate ways to model outcomes in
general medicine cases,
using pathology data. We have shown that biochemistry and haematology
(BHOM) can be used to identify patients at risk of mortality with very
high discrimination (2, 3).
Other monitoring and surveillance systems (e.g., Dr Foster,
CHKS and HES) require coded
administrative data only available after discharge. Our techniques add
clinical context to these, and
have obvious uses in clinical governance and clinical performance
management as well as direct
patient care. Our approach only uses data routinely collected and
available immediately after a
patient's admission to hospital.
We know that serious physiological abnormalities frequently precede
primary events (defined as in-hospital
deaths, cardiac arrests, and unanticipated intensive care unit admissions)
(4). The P-POSSUM / BHOM
work led to our collaboration with The Learning Clinic Ltd (TLC). In
provided a means to collect vital signs data quickly and accurately in an
electronic format. As a
result we have access to probably the biggest database of vital signs data
anywhere in the world.
Using that data we have shown that:
- innovative techniques can be used to join different databases in such
a way that clinical
significance is not lost or corrupted (unpublished work due to
- vital signs data can be used to devise an early warning score (EWS)
system that can both
identify patients whose condition is deteriorating and minimise
unnecessary false alarms (5)
- an EWS devised from vital signs data (ViEWS) performs better than any
of the 33 other
EWS systems in the literature (6)
- decision tree data mining techniques can be used to develop new early
systems (DT-EWS) quickly (Badriyah, Briggs, Prytherch, Smith, Schmidt,
Our EWS models can be applied to any patient under clinical care, but are
increasingly used to
allow nurses to determine which of their patients are deteriorating and
when to summon assistance
(e.g. a doctor), without causing too many false alarms (which would
BHOM and the VIEWS/DT-EWS/NEWS family of models are applicable to
virtually all hospital in-patients.
University of Portsmouth Researchers
- Prof David Prytherch (Visiting Senior Research Fellow seconded to UoP
Visiting Professor 2011-present).
- Drs Paul Schmidt and Peter Featherstone (Honorary Medical Senior
- Dr Jim Briggs (currently Principal Lecturer and Director of the Centre
Modelling and Informatics (CHMI), appointed 1995).
- Jeffrey Sirl (Research Associate 2002-2004).
- Bernard Higgins (Senior Lecturer in Mathematics; submitted in the
Professions, Dentistry, Nursing and Pharmacy UOA, appointed 1979).
References to the research
1. Prytherch DR, Whiteley MS, Higgins B, Weaver PC, Prout WG, Powell SJ.
POSSUM and Portsmouth POSSUM for predicting mortality. Physiological and
Score for the enUmeration of Mortality and morbidity. Br J Surg.
2. * Prytherch DR, Sirl JS, Schmidt P, Featherstone PI, Weaver PC, Smith
GB. (2005). The
use of routine laboratory data to predict in-hospital death in medical
3. Prytherch DR, Briggs JS, Weaver PC, Schmidt P, Smith GB. (2005).
performance using routinely collected clinical data. Med Inform Internet
4. Kause J, Smith G, Prytherch D, Parr M, Flabouris A, Hillman K, et al.
(2004). A comparison
of antecedents to cardiac arrests, deaths and emergency intensive care
admissions in Australia
and New Zealand, and the United Kingdom — the ACADEMIA study.
6. * Prytherch DR, Smith GB, Schmidt PE, Featherstone PI. (2010).
national early warning score for detecting adult inpatient deterioration.
* Papers that best indicate quality of underpinning research
Briggs, Knowledge Transfer Partnership with TigerTeam
Software Ltd (former name of TLC),
Technology Strategy Board, 2006-2008, £114,000.
Briggs, The Hospital of the Future, Oxford University (Prof
Tarassenko's group) — a sub-contract
on their EPSRC-funded project, 2012-2013, £10,036.
Details of the impact
Our research has had three types of impact during the period 2008-2013:
- economic impact by increasing the prosperity of TLC Ltd
- practitioner/professional service impact on the RCP (and its members)
in its development of
the National Early Warning Score (NEWS)
- health impact by the lives saved by the adoption of NEWS
Economic impact on TLC
TLC have incorporated our ViEWS (VitalPAC Early Warning Score) model (and
NEWS, see below) into their VitalPAC family of products. This work was
done as part of a KTP
(April 2006 — April 2008) to give them that capability. The KTP associate
was also involved in the
development of the doctor interface to the system. TLC became aware of us
because of our BHOM
work and our links with the Vascular Society of GB & Ireland.
VitalPAC replaces the typical paper chart at the foot of a hospital
patient's bed by recording
(electronically on a mobile device) the vital signs measurements,
typically taken by a nurse every
few hours. ViEWS/NEWS translates the vital sign measurements into a single
number known as
an early warning score (EWS). Depending on the value, the nurse is
instructed to take some
action, which (in increasing order of severity) involves taking further
observations more frequently,
calling a doctor to see the patient, or calling a doctor urgently. Our
recommended thresholds for these actions.
The economic benefits to TLC included increased turnover (13-fold over 3
years), created 15 new
jobs, and allowed them to attract over £1m from private investors (source
1). The VitalPAC product
generates 80% of their revenue.
Policy impact on RCP work
In 2012, the Royal College of Physicians (RCP) published a report
recommending adoption across
the NHS of a new National Early Warning Score (NEWS) for monitoring
patients in hospital (source
0, source 3). NEWS is (with only a couple of small changes) based on ViEWS
as published in our
2010 paper (research reference 6).
The background to this was that the RCP had set up a NEWS Development and
Group (NEWSDIG). One of the members of the group was Professor Gary Smith,
collaborator and a former Consultant Physician at PHT, now affiliated to
David Prytherch and Gary Smith undertook (on behalf of NEWSDIG) the
performance analysis that
confirmed the weightings, triggers and escalation criteria.
Health impact and the ultimate beneficiaries
Ultimately the research impacts everyone who is admitted to a hospital
that uses the system.
Portsmouth Hospitals Trust led the way — it served as the development site
for the VitalPAC
software. PHT began piloting the software in 2006 and by 2010 its use had
spread to the whole
hospital. Currently, ViEWS/NEWS is used in 20 hospitals via the VitalPAC
system, but it has also
been carefully designed to be used in hospitals still using paper records.
An ongoing survey of 116
UK hospitals by the National Outreach Forum (source 4) revealed that (as
of September 2013)
28% had already implemented NEWS, a further 31% planned to introduce it
within a year and a
further 9% had longer-term plans. Only 8% were not considering it. NEWS
has 100% adoption by
NHS Wales (source 5) and it has been adopted by the Health Service
Executive in the Republic of
Ireland (source 6).
Since introducing VitalPAC, initial findings are that hospitals have seen
intensive care unit admissions, shorter lengths of stay (source 7) and (in
one hospital) a 22%
decrease in seasonally-adjusted mortality (source 8). A paper evidencing
this is in preparation.
A 2012 study published in the journal BMJ Quality and Safety found there
were nearly 12,000
avoidable deaths of adults in English acute hospitals annually. In the
publicity surrounding the
RCP's publication of NEWS, the chairman of the Working Party (Professor
Bryan Williams from
UCL) estimated that up to half of those lives might be saved. Not only
does NEWS aid in
identifying deteriorating patients in need of additional clinical
intervention, but its adoption
nationally results in savings in the training of nurses. This attracted
much press attention, for
example by the BBC (source 9) and the Independent (source 10).
Finally, the collaboration between PHT and TLC for the development of the
VitalPAC system has
won three national awards (the NHS Connecting for Health Leadership in
Accolades Scheme 2006, the "Technology and IT to improve Patient Safety"
category in the 2010
Health Service Journal/Nursing Times Patient Safety Awards, and the Bupa
Safety Award 2010).
Sources to corroborate the impact
- Letter of support from the Chief Executive of TLC, on the economic
benefits to TLC, 16th
- Royal College of Physicians. National Early Warning Score (NEWS):
assessment of acute-illness severity in the NHS. Report of a working
party. London: RCP,
Report by the RCP recommending the adoption of NEWS in all NHS hospitals.
- New National Early Warning Score could save 6,000 lives, http://www.rcplondon.ac.uk/press-releases/new-national-early-warning-score-could-save-6000-lives.
RCP press release relating
to the publication of the report above.
Evidence from the National Outreach
Forum that NEWS is being adopted by 68% of NHS hospitals.
0page%20leaflet.pdf. Leaflet describing Wales as the first country
to adopt NEWS nationally.
ore/. Evidence of the adoption of NEWS in Ireland (as National
Clinical Guideline No. 1, and as
part of the national COMPASS education programme).
Open letter from the Medical Director of TLC relating to the RCP's report.
Preliminary results of a study showing reduced mortality from the introduction of VitalPAC, presented
BBC coverage of the RCP report.
An example of the extensive newspaper
coverage of the RCP report.