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Beware the worried well – they might have a point !

We all worry at times. We worry about the weather, rising interest rates or arguments with colleagues. And we worry about health. Being worried is an unpleasant feeling but probably also quite important. Being worried about something that could protentially be dangerous or life threatening is an important protection mechanism to prevent harm. A lot of my time teaching doctors, nurses and students is around relating to them when it would be good to be worried: worried about hard numbers such as a lot blood pressure, a fever, an abnormal blood test result. But is it worth it to feel worried? Has it got a value for care?

A Dutch colleague of mine, Gooske Douw, has conducted a whole research program around this topic: she explored with nurses in her hospital what they might be worried about, categorised these items and devloped the ‘Dutch Early Nurse Worry Indicator Score’. She then went out to examine over 3500 patients, record things that featured on the Indicator Score and vital signs and observe what happened to her patients. Her study concluding that “Adding ‘worry’ and the Early Warning Score to the DENWIS-model resulted in higher areas under the receiver operating characteristics curves (0.87 and 0.91, respectively) compared with the Early Warning Score only based on vital signs.” In Gooske’s study being worried added significant value to the hard numbers of the vital signs.

There is some other circumstancial evidence for the theory that being worried really adds value. And it comes from a slightly unexpected corner. You might have read in the last couple of days about the rise in death from sepsis by nearly 40% in only two years from 2014/15 to 2016/17. The data is from hospitals in the United Kingdom and has been presented by Brian Jarman from Imperial College. Professor Jarman blames hospital overcrowding. While things have certainly gone worth over the last few years it would be plain shoking if this would lead to a 40% rise in complications from hospital stays. Possible? Yes. Likely? Not really. Without a good trend analysis it is difficult to see where this comes from. In Wales we have seen a rise in the diagnosis of sepsis coupled with a reduction in the number of death from sepsis. We know when the trend started: When we introduced a new system to detect whether patients in hospital were getting sick. The National Early Warning Score is a tool that quantifies how abnormal blood pressure, heart rate and other vital signs are. In 2012/13 we introduced this tool into all hospitals in Wales. We talked a lot about sepsis, we talked a lot about what to do if you are worried about a patient. As a result we saw an increase in the number of patients who were recognized with spesis and a reduction in the number of patients who died from it. Per year we have since been able to avoid 500 death across all hospitals in Wales.  We even got an award from the Global Sepsis Alliance. While we gave our teams tools that were based on hard numbers, we encouraged escalation whenever staff was worried: ‘Concern about a patient should lead to escalation, regardless of the score’.

Healthcare professionals can use their feeling of concern and worry to improve patient care. How about patients themselves? Patient concern has been evaluated in a number of studies: Patients who are concerned about skin cancer, are often right. Patients who express concern in hospital are often right to be concerned. And families who activate these sytems will have a positive impact on patient outcomes too. In a systematic review of the literature 10 studies were identified that looked at family activation. Calls of worried relatives seemed to be appropriate in all of the reported cases and led in some case even to admissions of patients to intensive care.

It might thus be worth to get the worried well involved!

Would you trust family members to highlight concern?

Should patient and family concern be systematically recorded in the same way as Gooske’s nurse concern?

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