The new PIER approach will enable the effective management of acute physical deterioration in health and care and will apply to all conditions, clinical settings and specialities.

The new PIER approach views deterioration as a whole pathway which is supported by systems rather than only advocating a single strategy for identification.

Acute physical deterioration is the rapid worsening of a patient’s condition. It can be identified from changes in physiology, such as respiratory rate, blood pressure or consciousness, or more subtle signs, such as not eating and a patient or their family’s concerns and observations around wellness, mental status or behaviour.

Deterioration can occur in any health and care setting and is the common pathway in all emergency admissions, prolonged illnesses and deaths.

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.

In Summer 2024, following a variety of testing with colleagues, we will produce a PIER toolkit, containing a range of resources to support integrated care boards (ICBs) to introduce the PIER approach across their local systems.

The toolkit will support and guide ICBs with pathway/system thinking for deterioration management that is system led. This suite of resources will help ICBs to use an improvement approach to design and implement a deterioration improvement plan that follows 7 key phases:

1. set up
2. building the ICB vision
3. mapping the ICB
4. improvement planning
5. operationalising
6. improvement action
7. evaluation and sustainability.

The three components of Martha’s Rule are:

• 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.

These components aim to empower patients, families, carers and staff to ensure the vitally important concerns of the patient and those who know the patient best are listened to and acted upon.

They will also empower staff to have the ability to raise concerns outside of official escalation channels, and to ask for additional support if they think it is required.

Since May 2024 143 pilot sites across England have been testing and implementing the three components of Martha’s Rule, identifying models that could be scaled up across the remaining providers. The pilot phase is running until at least March 2025.

The pilots are helping NHS England to understand what areas of implementation are working well and what areas could be improved, ahead of wider rollout.

Martha’s Rule allows hospital inpatients and their families to seek an urgent review if their condition, or the condition of a family member or friend, is deteriorating.

A second opinion is an already established process where patients, families or carers can ask to see another consultant to discuss any diagnosis or treatment.

Better identification and management of deterioration is one of NHS England’s key priorities in improving patient safety. NHS England » Managing acute physical deterioration through the ‘prevention, identification, escalation, response’ (PIER) approach

The introduction of Martha’s Rule comes alongside other measures to improve the identification and response to deteriorating patients in a healthcare environment, including the National Early Warning Score (NEWS) and the new early warning system for staff treating children, launched in November 2023.

To ensure that Martha’s Rule is effective, it will be implemented alongside an integrated programme to improve the management of deterioration, using resources which help systems to prevent, identify, escalate and respond (PIER) to physical deterioration:

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

In Greater Manchester  (GM) there are 6 hospital sites participating in the national first phase Martha’s Rule pilot. HInM are supporting the identified phase one sites to implement Martha’s Rule. Working collaboratively with the local Paediatric Critical Care Operational Delivery Networks (PCC ODNs) and Adult Critical Care Operational Delivery Networks (ACC ODNs), the PSC will support provider teams using a systematic approach to test and scale up Martha’s Rule.

HInM is working collaboratively with all 6 GM sites through a tried and tested collaborative model known as a Breakthrough Series (BTS) Collaborative. This model creates a structure for organizations to easily learn from each other and from recognized experts in topic areas where they want to make improvements.” The Breakthrough series are scheduled quarterly with additional coaching sessions for individual sites.

Through this model, HInM are working to bring together phase one sites and all relevant system stakeholders to:

• facilitate and nurture learning
• provide expertise and coaching in Quality Improvement (QI) methods
• provide a safe space to think, acting as a critical friend and mentor
• support site teams to use methodologies for sustaining change and improvement
• support teams to identify and understand the impact of Martha’s Rule using measurement methods.

For the PIER element of this work, HInM are engaging with the wider GM system through the now GM Deterioration Sub-Group and support the group to map deterioration pathways and work through the PIER toolkit, focusing on improving the pathway(s) identified as being amenable to improvement.