Document Details Title. Early Warning Score Protocol for Community Hospitals and Prisons to detect the Deteriorating Patient

Transcription

1 Document Details Title Early warning Score Protocol for community Hospitals and Prisons to Detect the Deteriorating Patient Trust Ref No Local Ref (optional) Main points the document This protocol sets out standards for recording and scoring and covers responding to clinical observations for all patients within community hospitals and prisons in Shropshire Who is the document All nursing and medical staff who work within inpatient aimed at? community hospital wards and prison in Shropshire Owner Andrew Thomas, head of Nursing and Quality Who has been consulted in the development of this policy? Approved by (Committee/Director) Approval process Ward Managers, Clinical Service Managers, senior staff in prison healthcare Joint Delivery Group Extra Ordinary Policies Meeting Approval Date 2 nd March 2016 Initial Equality Impact Yes Screening Full Equality Impact N/A Assessment Lead Director Steve Gregory Category Clinical Sub Category Community hospitals and Prisons Review date 1 st March 2019 Distribution Who the policy will be distributed to All nursing and medical staff who work within inpatient community hospital wards and prison in Shropshire Method DATIX, Heads of Department Meetings, Team Meetings Keywords Observations, Early Warning Score Document Links Required by CQC No Other No Amendments History No Date Amendment 1 2 nd march Change of author and director

2 CONTENTS Page 3 Page 3 Page 4 Page 4 Page 5 Page 5 Page 5 Page 6 Page 6 Page 7 Page 7 Page 7 Page 7 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Introduction Purpose Duties Procedure Measurement of patient observation Calculation of the Early warning score Patient Intervention Equipment Use of the SBAR Tool (Situation, Background, Assessment, Recommendations) Training Monitoring Compliance Consultation References Associated Documents Appendix 1a Adult Early Warning Score Grid for Community Hospitals Appendix 1b Adult Early Warning Score Grid for Prisons Appendix 2a Early Warning Scoring Flow Chart for Community Hospitals Appendix 2b Early Warning Scoring Flow Chart for Prisons Appendix 3 SBAR Tool Appendix 4 Audit Tool Appendix 5 Monitoring Form 2

3 1.0 Introduction 1.1Community Hospitals The physical observation chart at the end of the bed is a familiar feature and its use can be critical in determining whether a patient is making a satisfactory recovery from illness or on the other hand deteriorating. The importance of the careful use of the observation chart to detect clinical deterioration is well known and the Early Warning Scoring (EWS) is an evidence based tool that flags these changes up at an earlier stage when they are easier to correct. The EWS is a system based on the allocation of points to clinical observations such as respiratory rate, pulse and blood pressure. These are recorded on the patient observation chart. The points for each observation are added to give a total score, an action protocol on the reverse side of the observation chart details the actions to be triggered at various scores. These actions include referral to more senior staff when certain scores are reached, referrals will then be made using the SBAR (Situation, Background, Assessment, Recommendation) Tool which assists staff to clarify what information should be communicated between team members (NHS Institute for Innovation and Improvement (2008) SBAR- Situation, Background, Assessment, Recommendation) Prisons A variety of patients present each day to nursing and medical staff within Shropshire prisons complaining of symptoms of illness. Although initial clinical assessment of patients is performed using the Manchester Triage System 1997 a small number of patients who were relatively well on their initial assessment will deteriorate, sometimes quickly, and require further interventions. The Manchester Triage System is an algorithm that is used to aid the triage process. It uses a series of flow charts and a five-point scale, which helps a triage nurse to categorize triage cases in a logical manner. The current qualified nurses employed at the two Shropshire prison sites are either Adult or Mental Health qualified, and may not have had experience in working in an acute or emergency care setting. 2.0 Purpose In order to mitigate potential risk it has become evident that the use of an early warning tool is required specifically for patients within Shropshire prisons. Critical illness is usually preceded by physiological deterioration and the EWS is a tool to measure these vital signs of deterioration. Previous guidance through the national Patient Safety Agency has identified that all acute nurses should be using early warning score systems to identify patients at risk of deterioration there is less evidence for their specific and adapted use in prison settings. As the Community Hospitals and Prisons in Shropshire are mainly nurse led, in that medical cover is a phone call away, except for a short period in the day when the GP visits the ward or unit, the EWS System is a way of detecting 3

4 3.0 Duties physiological changes and requesting medical intervention before the patients condition starts to show actual visible signs of deterioration 3.1 The Chief Executive The Chief Executive Officer has overall responsible for maintaining staff and patient safety and is responsible for the governance and patient safety programmes within the organisation. 3.2 Directors Directors of Services are responsible for ensuring the safe and effective delivery of services they manage; this includes securing and directing resources to support the implementation of this policy. They are also responsible for ensuring a process is in place to effectively manage patient safety and that the organisation is compliant with the Care Quality Commission (CQC) and National Health Service Litigation Authority (NHSLA). 3.3 Ward Managers Ward Managers/Clinical Nurse Managers will ensure that all staff carry out patient observations using the EWS and SBAR tools, and that adequate staff training is undertaken within their area including annual mandatory resuscitation training. 3.4 Staff All staff members must ensure that they understand the EWS and SBAR and the implications of its use and are up to date with their mandatory resuscitation training. 4.0 Procedure This protocol must be used in conjunction with the EWS tool ( Appendix 1) and the EWS protocol flowchart (Appendix 2). It should be noted that the EWS is not a replacement for clinical judgement. Each Community Hospital and Prison Site has a named link nurse who is responsible for initial and ongoing education and training regarding the EWS, and for associated audits. The use of the EWS can be divided into three areas: Measurement of patient observations Calculation of the EWS Appropriate interventions utilising the protocol The Use of the EWS can also: Improve the quality of patient observation and monitoring. Improve communication within the Community Hospital multidisciplinary team Allow for timely transfer to the acute hospital Support good medical judgement Aid in securing appropriate assistance to sick patients Give a good indication of physiological trends Are a sensitive indicator of abnormal physiology 4

5 However the EWS is not: A predictor of outcome A comprehensive clinical assessment tool A replacement for clinical judgement The use of the EWS may be inappropriate in patients who are terminally ill, this should be discussed with the attending GP. 5.0 Measurement of patient observations A baseline set of observations must be taken on all patients upon arrival at the Community Hospital or Prison and this must be recorded in the patient s medical record and on the observation record chart. Patient observations must be measured by an appropriately trained and competent member of staff. All observations should be entered into the patient s clinical record and observation record chart with the time and date of observation clearly documented. A full set of observations should always be recorded to include blood pressure, heart rate, respiratory rate, temperature and consciousness level. If an observation is unrecordable or undetectable this must be escalated to the nurse in charge/senior general nurse to assess the patient. An unrecordable observation should always be given a score of 3 unless assessed otherwise by a doctor. The frequency of observations will be determined by the EWS flowchart. 5.1 Calculation of the Early Warning Score For Community Hospitals the EWS (Appendix 1a) must be calculated for every set of observations taken. The total EWS and individual observation scores must then be documented in the observation record chart. A EWS of more than 0 triggers the EWS flowchart which then highlights the steps to be taken. In Prisons the EWS (Appendix 1b) is triggered using clinical judgement when a patient complains of feeling unwell, following triage or on GP advice. 5.2 Patient Intervention When using the flowchart, (Appendix 2a Community Hospitals, Appendix 2b Prisons) to provide an appropriate intervention the following must be noted: If at any time there is cause for concern or a severe deterioration in the condition of the patient, immediate treatment of the patient as high risk should be considered. In Community Hospitals if the patient has a cardiac arrest then resuscitation must commence unless a Do Not Attempt Cardiopulmonary Resuscitation (DNAR Adult 1) form has been completed and signed by the patients attending GP as per Trust Cardiopulmonary resuscitation/ Do not attempt resuscitation policy Responsibility for a DNAR decision rests with the most senior healthcare professional responsible for the patient s care. When a DNAR decision is made it should be recorded clearly, together with the reasons for the change and the names and designation of those involved in the discussion and decision. If no discussion takes place either with the patient or with those 5

6 close to them, the reasons for this should be recorded. The use of an easily identifiable, dedicated form to record DNAR decisions is recommended and must be communicated to all relevant health professionals, in Community Hospitals and Prisons this will be the DNAR Adult 1 form. It is also the responsibility of the senior healthcare professional responsible for the patients care, to enter the DNAR decision in the patient s medical records including the rationale for the decision and those who are involved. DNAR decisions should be reviewed whenever clinically appropriate, but particularly when there is a significant change in the patient s clinical condition or when the patient is transferred from one healthcare setting to another. An emergency ambulance must be requested for any patient scoring more than 7, unless otherwise documented in the patient s notes by the patients GP. To ensure that the resuscitation process is as effective as possible staff must ensure that the resuscitation trolley is checked as per local policy and should be recorded so that there is an audit trail, this will be undertaken through the monthly Quality review. All staff have a responsibility to familiarise themselves with the emergency equipment within their clinical environment. 6.0 Equipment Basic equipment required for basic life support should be available in all health care settings where staff carry out clinical procedures. It is the responsibility of the individual carrying out a clinical procedure to assure that resuscitation equipment is accessible and fit for use and recorded as such. There should be a local system for monitoring all resuscitation equipment, to ensure that it is available, has not passed its expiry date and that it is fit for purpose. For example each service should have an identified role responsible for checking and recording the state of readiness of all resuscitation drugs (expiry date) and equipment. These checks should be undertaken at least once a week and should be recorded so that they provide an audit trail. All staff however have a responsibility to familiarise themselves with the emergency equipment within their clinical environment. 7.0 Use of the Situation, Background, Assessment, Recommendation (SBAR) Tool This tool consists of standardised prompt questions within four sections, to ensure that staff are sharing concise and focused information. It allows staff to communicate assertively and effectively, reducing the need for repetition. SBAR is easy to remember and is used to ensure that communication is carried out in a structured way and that clinical problems that require immediate attention are escalated effectively. The SBAR tool (Appendix 3) will be used for all communication between team members and with external health professionals in order to maintain effective communication of status and risk. 6

7 Staff will be trained and assessed in the use of the SBAR tool by the EWS link nurse, and a programme of ongoing training for new staff will form part of the ward/prison induction programme. Laminated posters prompting staff in the use of SBAR will be displayed in all relevant areas and pocket-sized laminated cards will be made available for all nursing staff. 8.0 Dissemination and Implementation All nursing staff in Community Hospitals/Prisons will be trained in the recognition of the acutely unwell patient by attending mandatory Basic Life Support, defibrillator and anaphylaxis training on a not less than annual basis. This policy will be available to staff through the Trust website and discussed at local staff forums. Training in the use of the EWS tool and flowchart will be undertaken for all nursing staff by the EWS link nurse at each Community Hospital/Prison site, and will be included in the induction programme for new staff. This training will be recorded in each individual s personal file. All non-registered staff will receive ongoing advice in the recognition of their roles and responsibilities when undertaking patient observations, and this will be monitored through individual appraisal and personal development planning. 9.0 Monitoring Compliance Ward Managers/Clinical Nurse managers will be responsible for ensuring that there is a plan to Audit the use of the EWS in their area on an annual basis. Exceptions will be patients on the Liverpool Care Pathway Definitions Early Warning Score- the Early Warning Scoring (EWS) is an evidence based tool that detects clinical deterioration in a patient by allocation of points to clinical observations such as respiratory rate, pulse and blood pressure and an action protocol to guide triggers for total score obtained. Situation, Background, Assessment, Recommendation (SBAR) is a tool used to assist staff in clarifying communication with colleagues. Manchester Triage System- the Manchester Triage System is an algorithm that is used to aid the triage process. It uses a series of flow charts and a fivepoint scale, which helps a triage nurse to categorize triage cases in a logical manner. Liverpool Care Pathway- is a care pathway which a patient can expect in the final days and hours of life, which also becomes a structured record of the actions and outcomes that develop. It aims to help doctors and nurses provide end of life care 7

8 11.0 Monitoring Element to be monitored Requirement for a documented plan for vital signs monitoring that identifies which variables need to be measured, including the frequency of measurement. Lead Tool Frequency Reporting Arrangements Maggie Bayley Early Warning Score for Community Hospitals for the Deteriorating Patient Protocol Audit of Observations undertaken Annual The audit report will be submitted to the Quality and Safety Group. The group is expected to read and interrogate the report to identify deficiencies in the system and act upon them Action on Recommendations and Lead(s) Any changes to the process will be identified as part of the audit and allocated to a relevant person(s) within a specified timeframe Changes in practice and lessons to be shared Relevant clinical staff will be responsible for changes in the risk assessment. Lessons will be shared with all the relevant stakeholders. Use of an early warning system within the organisation to recognise patients at risk of deterioration. Maggie Bayley Audit Annually The audit report will be submitted to the Quality and Safety Group. The group is expected to read and interrogate the report to identify deficiencies in the system and act upon them Any changes to the process will be identified as part of the audit and allocated to a relevant person(s) within a specified timeframe Relevant clinical staff will be responsible for changes in the risk assessment. Lessons will be shared with all the relevant stakeholders. 8

9 Do not attempt resuscitation orders How the organisation documents that resuscitation equipment is checked, stocked and fit for use Maggie Bayley Maggie Bayley Do Not Attempt Resuscitation Audit Equipment check record sheet Audit Annually Automatic Electronic Defibrillator checked and recorded daily Resuscitation Trolley weekly Audit through Monthly Quality Review The audit report will be submitted to the Quality and Safety Group. The group is expected to read and interrogate the report to identify deficiencies in the system and act upon them Quality Review Summary sent to the Director of Service and quality and the Enhanced care managers Any changes to the process will be identified as part of the audit and allocated to a relevant person(s) within a specified timeframe Any changes to the process will be identified as part of the audit and allocated to a relevant person(s) within a specified timeframe Relevant clinical staff will be responsible for changes in the risk assessment. Lessons will be shared with all the relevant stakeholders. Relevant clinical staff will be responsible for changes in the risk assessment. Lessons will be shared with all the relevant stakeholders. 9

10 12.0 Consultation Maggie Bayley Director of Quality & Nursing SCHT Ward Managers Community Hospitals Andrew Thomas Enhanced Care Manager Whitchurch Community Hospital Kate Clay Deputy Head of Health and Clinical Lead Prisons and CSMT Wendy Sweeney Clinical Nurse Manager HMP YOI Stoke Heath Tina Scott Clinical Nurse Manager HMP Shrewsbury Jeff Parker Staff Nurse HMP YOI Stoke Heath Senior Management Teams Prisons Prison Clinical Governance Groups 13.0 References Mann, S., Bowler, M. (2008) Using an early warning score tool in community nursing Nursing Times;104:20,30-31 NHS Institute for Innovation and Improvement (2008) SBAR- Situation, Background, Assessment, Recommendation NICE clinical guidance 50, Acutely ill patient in hospital July 2007 Track and trigger system for use in community hospitals. J Wolfenden. Llandrindod Wells Hospital. Wales Physiological Early Warning Scores. Northern Health & Social Care Trust Guideline for the Use of the Modified Early Warning Scores. Outer East London Community Services Consent to Examination and Treatment Policy 14.0 Associated Documents Early Warning Score Protocol Prisons. Shropshire Community Health Trust Advanced Decisions Policy Shropshire Community Health NHS Trust 2010 Information Sharing Protocol Shropshire Community Health Trust CPR- DNAR Policy Shropshire Community Health Trust Consent to Examination and Treatment Policy Shropshire Community health NHS Trust 10

11 Appendix 1a (b) Adult Early Warning Scoring System Shropshire Community Hospitals Score the patients observations using the grid below. Observations Temperature < > Respiratory < >29 rate. Breaths/min Pulse < > Systolic BP < > Conscious level Unresponsive/fits New agitation Alert Voice Pain Unresponsive The assessment of a patient s condition should be undertaken using clinical judgment and the Early Warning Score (EWS) For each vital sign, a score should be given and the total added up. This information should be recorded and acted upon based on the EWS flow chart The EWS provides an objective score based on the vital signs of the patients condition. However in some circumstances where a patient s condition is giving cause for concern, even though their total score has not triggered an action, the practitioner can make a subjective clinical decision. If patient scores > 7- immediate call needed. Unless otherwise documented by the attending GP in the patient records 11

12 Appendix 1b (b) Adult Early Warning Scoring System- Shropshire Prisons. Score the patients observations using the grid below. Observations Systolic BP < > Heart rate < > Respiratory rate. < >30 Breaths/min 20 Temperature < > Conscious level Unresponsive Pain Voice Alert Voice Pain Unresponsive The assessment of a patient s condition should be undertaken using clinical judgment and the Early Warning Score (EWS) For each vital sign, a score should be given and the total added up. This information should be recorded and acted upon based on the EWS flow chart The EWS provides an objective score based on the vital signs of the patients condition. However in some circumstances where a patients condition is giving cause for concern, even though their total score has not triggered an action, the practitioner can make a subjective clinical decision. If patient scores > 7- immediate 999 call needed. 12

13 Appendix 2a (a) Early Warning Scoring Flow Chart Community Hospitals Score < 3 but causing concern Score of 3. Score of 4 or more Score of 8 or more Hourly observations Inform nurse in charge If score increases or remains 2 and still concerned after 2hrs Call Doctor to visit Hourly observations Inform Nurse in charge If still scores 3 after 1 hour Call Doctor to visit Repeat observations after 5 10mins Call Doctor to visit within 1 hour Repeat after 3-5 mins Have urgent conversation with Doctor to decide if urgent transfer required 13

14 Appendix 2b Early Warning Scoring Flow Chart Prisons Score of 3. Score of 3 or 4 Score of Remain on wing location. 2. Review in 1 hour. 1. Contact senior nurse for assessment. 2. Repeat observations and reassess EWS. 3. Remain on wing location. 4. Review in 1 hour. Has the patients EWS improved? Yes NO 1. Treat possible cause. 2. Continue to monitor as clinically indicated. 3. Advise patient how to excess Healthcare if needed further. Is there a Doctor on Site? Yes No 1. Inform of current situation. 2. Is there anymore action required? Remain on current location. Monitor as clinically indicated. Book an appointment with Dr at next available clinic. Yes 1. Remain on wing location. 2. Agree management plan with Senior Nurse. 3. Treat possible cause. 4. Review by Dr within 24 hrs. 5. Continue with observations as per plan. Review with Senior Nurse. Has the EWS improved? Yes Is there a Dr on site? No No Review by Dr either wing based or in Healthcare. 1. Increase observations to 30minutes for 2 hours. Has the EWS improved? Is there a Doctor on site? Urgent review needed. Yes. No 1. Increase observations to 15 minutes for 1 hour (if possible attach to cardiac monitor.) 2. Were possible treat any symptoms (e.g. pyrexia). 3. Inform DPSM of potential bedwatch/escort. 4. Review with senior nurse in 1 hour. Has the EWS improved? Contact 1. Agree management plan with Shrodoc for No Yes MDT. 1. Refer to A&E via advice. 2. Review 2 hourly Continue to treat symptoms PRN. 2. Inform duty Continue as per plan. manager. 4. Review by Dr with 12 hours. Review by Dr within 12 hours. 3. Complete Datix. 14 Yes. No EWS >7?

15 Appendix 3 Situation, Background, Assessment, Recommendation (SBAR)Tool for Community Hospitals and Shropshire Prisons Situation State your name and unit I am calling about patient s name The reason I am calling is Background State the admission diagnosis and date of admission Relevant medical history A brief summary of treatment to date Assessment State your assessment of patient e.g. vital signs, EWS score, mental state, mobility, medicines Recommendation I would like (state what you would like to see done) Determine timescale Is there anything else I should do? Record name and contact number of contact SBAR Reporting Attention all team members Don t forget to document the call For good communication about patients between all health professionals, use the SBAR tool before calling: Assess the patient Know the admitting diagnosis Read the most recent progress notes and assessment from the prior shifts Have appropriate documents available e.g. Nursing and Medical Records, EWS (early warning score) charts, allergies, resuscitation status. 15

16 Appendix 4 Date... Community Hospital/Prison Audit Tool for Early Warning Scoring 1 Is the patient clearly identified on observation scoring chart? 2 Are consecutive dates and times recorded on chart? 3 Are all parameters completed for each set of observations? 4 Was Total score completed for each set of observations? 5 Was Total score correctly calculated for each set of observations? 6 Was time for next observation appropriate for the score? 7 Was any Total score 4 or higher? 8 Was any single parameter score3? Only complete questions 9 11 if total score 4 or more or single parameter 3 9 If any Total score or higher or single parameter score 3, is there a record of who contacted, and at what time? Yes No Comments 16

17 10 If medical staff were contacted is there a record of when they assessed the patient? 11 Was the patient medically assessed within the time set? 17