Adult Observation Chart Policy

Transcription

1 Adult Observation Chart Policy (Inc. Modified Early Warning Score MEWS) Document Author Written By: Interim Head of Clinical Services Date: 17 th September 2014 Lead Director: Director for Nursing & Workforce Authorised Signature Authorised By: Chief Executive Date: 21 st October 2014 Effective Date: 21st October 2014 Review Date: 20 th October 2017 Approval at: Policy Management Group Date Approved: 21 st October 2014 Version No. 6 Page 1 of 32

2 DOCUMENT HISTOR (Procedural document version numbering convention will follow the following format. Whole numbers for approved versions, e.g. 1.0, 2.0, 3.0 etc. With decimals being used to represent the current working draft version, e.g. 1.1, 1.2, 1.3, 1.4 etc. For example, when writing a procedural document for the first time the initial draft will be version 0.1) Date of Issue Version No. Date Approved Director Responsible for Change Jun Jul 2013 Executive Director of Nursing & Workforce Jul 2013 Executive Director of Nursing & Workforce Sep 2013 Executive Director of Nursing & Workforce Nature of Change Ratification / Approval Ratified at Matrons Action Group Ratified at Clinical Standards Group Ratified at Nursing policy Sep 2013 Executive Director of Nursing & Workforce Sep 2013 Executive Director of Nursing & Workforce Minor Amendments Ratified at Policy Management Group Ratified at Physicians Committee 5 07 Oct 2013 Executive Director of Nursing & Workforce Aug Document Updated Sep 2014 Executive Director of Nursing & Workforce 6 21 Oct 2014 Executive Director of Nursing & Workforce Approved at Trust Executive Committee Ratified at Clinical Standards Group Approved at Policy Management Group NB This policy relates to the Isle of Wight NHS Trust hereafter referred to as the Trust. Version No. 6 Page 2 of 32

3 Contents Page 1. Executive Summary 4 2. Introduction 5 3. Scope 5 4. Purpose 6 5. Roles and Responsibilities 6 6. Policy detail / course of action 7 7. Consultation Training Dissemination Process Equality Analysis Review and Revision arrangements Monitoring Compliance and Effectiveness Links to Other Organisation Policies/Documents References Disclaimer 15 Appendices: A. Key definitions for documentation 16 B. Adult Observation Chart 17 C. Pain Scoring System 18 D. A, B, C, D, E Assessment 19 E. S.B.A.R Communication Tool 20 F. At Risk and Deteriorating Patient Care Pathway 21 G. Audit Tool for Monitoring AOC/MEWS Compliance 23 H. Checklist for the development and approval of controlled 24 Documentation I. Impact assessment forms on policy implementation (inc. checklist) 26 J. Equality analysis and action plan 29 Version No. 6 Page 3 of 32

4 1. EXECUTIVE SUMMAR: This policy outlines the process of monitoring, recording and responding to adult observations within the acute hospital environment within in the Isle of Wight NHS Trust (also covering in-patient mental health services). This policy outlines clearly members of staff roles and responsibilities in monitoring, recording and responding to Adult observations in the acute care environment. The adult observation chart incorporates a Modified Early Warning Scoring System (MEWS) as recommended by the National Institute of Health and Clinical Excellence 2007, incorporating best evidence from the national NEWS work undertaken by the royal College of Physicians and stakeholders (RCP 2012).The organisation has made an informed decision to only use aspects of the new NHS NEWS system and this reflects a national trend of other Trusts doing the same. The rationale for this decision is based upon we have a working and embedded system to recognise and respond to deteriorating patients and by introducing a whole new system would add risk to our patients. This policy clearly defines what should be monitored and recorded every time observations are undertaken on an adult in the acute care environment within the Trust. This policy clearly outlines the process for escalating support for the sick and deteriorating patient. Compliance with this policy will be monitored monthly. The impact of the Adult Observation Chart Policy will be monitored against defined key performance indicators on an annual basis identified within this policy. Version No. 6 Page 4 of 32

5 2. INTRODUCTION Any patient in hospital may become acutely unwell. Therefore the accurate recording, documentation, interpretation & communication of physiological vital signs, also called patient observations (i.e. respiratory rate, heart rate, blood pressure etc.) is key to the early recognition of clinical deterioration. However there currently exists variation in practice with regard to the recording, documentation, interpretation & communication of patient observations. This is known to lead to a delay in the recognition of acute illness, avoidable admissions to critical care, increase in cardiorespiratory arrests & unnecessary patient deaths, especially when the initial standard of care is suboptimal. The National Institute for Health and Clinical Excellence (NICE) clinical guideline Acutely ill patients in hospital Recognition of & response to acute illness in hospital recommends the use of physiological observation track & trigger systems such as the Modified Early Warning Score (MEWS) system to help clinical practitioners to identify patients demonstrating physiological deterioration. This recommendation plus a series of adverse clinical incidents has prompted the Trust to develop an Adult Observation Chart incorporating a MEWS score track & trigger system. This system will provide a robust & standardised interdisciplinary approach to bring about early recognition of the acutely ill patient & timely appropriate clinical response. The MEWS system is for use in adult patients & is thus different from the Paediatric Early Warning System known as COAST the latter is not featured in this policy. 3. SCOPE The adult observation chart (AOC) will be the sole observation chart (see also sections 6 & 8) for all adult patients (over 18 years of age) within in-patient areas at St Mary s Hospital, in-patient areas in Mental Health and Learning Disabilities, EXCEPT: 3.1 Emergency Department: The Emergency Department will enter the first set of observations on the electronic Symphony system, any subsequent observations while in the department apart from discharge observations from ED, observations will be recorded on the AOC. 3.2 Intensive Care Unit: The Intensive Care observation chart will be used until the patient is ready to be transferred to the ward, at which point the AOC will be started pre-discharge from ITU. 3.3 Operating Theatres & Recovery: Patients undergoing surgery will have their observations recorded on the Surgical Care Plan/Anaesthetic Chart, during their time in theatre and theatre recovery. The AOC must therefore be sent to theatres with the patient. The final set of recovery observations, will be documented on the AOC by the recovery staff, and following the transfer of the patient back to the ward, the AOC will be used. 3.4 Enhanced Recovery Patients and the AOC and MEWS: Patients on the Enhanced Recovery Programme (which will be clearly indicated on the patient medical notes) may have physiological parameters that lie outside the standard MEWS scoring. The limits that will be set differently are urine output and blood pressure. The tolerated levels of these parameters will be clearly documented on the patient's epidural chart. If urine output or blood pressure fall outside these specifically documented levels on the epidural chart then the ward based team should contact the nurse/surgical registrar Version No. 6 Page 5 of 32

6 responsible for ERAS via the dedicated ERAS phone ( ). This number is always manned in and out of hours. Once the epidural is removed observations should be recorded on the Adult Observation Chart that incorporates MEWS. 3.5 Maternity Unit: The Maternity Unit use their specific observation chart and trigger system called MEOWS. 3.6 Children s Ward: The Children s ward use their specific observation chart and trigger system called COAST. 3.7 End-of-Life Care Pathway: MEWS scoring is inappropriate for patients on the End-of-Life Care Pathway and the AOC and MEWS should be signed off by the patients consultant or Registrar. This policy applies to all clinical staff involved in the care of acutely ill adults at St Mary s Hospital. 4. PURPOSE The purpose of the policy is to support the correct monitoring of adult patients and support the early recognition and response to actual and potential critical illness 5. ROLES AND RESPONSIBILITIES 5.1 Executive Director of Nursing and workforce and Executive Medical Director Ensure there is an early warning track and trigger system in place for detecting, monitoring and responding to the deteriorating adult patient in line with NICE Guideline Matrons and Ward/Department Leaders Ensure all new staff are educated in using the Adult Observation Policy. Undertake monthly audit to ensure clinical area is compliant with AOC Policy, if not compliant put in place a local action plan to improved compliance. Performance manage staff as per the Capability and Disciplinary policy if staff do not work within the framework of the AOC Policy. Ensure all staff that use this policy have completed and passed the observation and deteriorating patient competency. 5.3 Registered Practitioners (i.e. Registered Nurses & Operating Department Practitioners) Responsible for determining the frequency of patient observations, accurate recording & documentation of patient observations, MEWS score, following MEWS graded response & initiating emergency assessment & treatment of airway, breathing, circulation, disability & exposure (ABCDE). The registered practitioner in-charge of the clinical area must ensure that staff recording patient observations report MEWS scores of 2 or greater to them. Before undertaking the role and task of observations will undertake and pass the competency for registered staff on the deteriorating and observation competency and remain up-to-date and work within the content of this policy. 5.4 Health Care/Nursing Assistants Responsible for accurate recording & documentation of patient observations, MEWS score & following MEWS graded response. They must also inform the registered practitioner of each individual patients MEWS score. Version No. 6 Page 6 of 32

7 Before undertaking the role and task of observations will undertake and pass the competency for unregistered staff on the deteriorating and observation competency. 5.5 Junior Medical Staff (F1 & F2) Responsible for regular review of patient observations (i.e. during ward rounds) & responding to calls by Registered Practitioner to review patient clinical condition according to MEWS graded response. 5.6 Senior Medical Staff (ST, Staff Grades, Associates Specialists & Consultants) Responsible for regular review of patient observations (i.e. during ward rounds), responding to calls by practitioners to review patients clinical condition according to MEWS graded response & (rarely, i.e. end of life situations) authorising the discontinuation of MEWS, making do not attempt cardiopulmonary resuscitation (DNACPR) decisions (if appropriate) & initiating end of life care pathway (if appropriate). 5.7 Critical Care Outreach Service/Hospital at Night Advanced Practitioners Implement the tracking element of the MEWS system and evaluate the effectiveness of the MEWS system. Send to the night Co-ordinators daily a completed MEWS tracking of at risk patients electronically. Handover at risk patients at the daily hospital at Night meeting to the oncoming night team. Monitor the performance of NHS IOW in managing adult deteriorating patients. Deliver formal and informal education to all clinical staff relating to deteriorating patients. Support clinical staff in caring and managing at risk patients. Undertake and complete nightly the MEWS tracking of at risk patients and return it to the day Critical Care Outreach Service each morning electronically. 5.8 Night Co-ordinator Undertake and complete nightly the MEWS tracking of at risk patients and return it to the Critical Care Outreach Service each morning electronically in the absence of the critical care outreach Advanced Practitioner. Work within this policy for managing deteriorating patients out of hours. Chair the Hospital at Night handover meeting. 5.9 Resuscitation Service The resuscitation service will support MEWS and AOC education via Immediate Life support training and the AIM course. 6. POLIC DETAIL / COURSE OF ACTION 6.1 Adult Observation Chart Format The Adult Observation Chart is a folded A3 document providing clear details for use on the front of the chart (see appendix B). On opening, the chart has grey shaded areas to assist in the early visual recognition of observations falling within MEWS parameters. The two solid black lines across the centre of the chart denote the upper & lower MEWS parameters for heart rate. The frequency of patient observations will depend upon the patient s condition. It is the responsibility of the practitioner in charge of the patients care to assess each individual patient and make an appropriate decision about the frequency of observations required. The chart number during the patient s admissions must be recorded to enable audit trail. Version No. 6 Page 7 of 32

8 6.2 On Admission to hospital All charts will be labelled correctly with the patient s details, including name, date of birth, age, Isle of Wight number and/or NHS number, chart number during current admission, clinical area, and consultant in charge of the patients care. All patients will have a complete set of patient observations (temperature, blood pressure, pulse, respiratory rate, level of consciousness using AVPU or Glasgow Coma Score, inspired oxygen concentration and Oxygen saturations (SpO2%) recorded on their Adult Observation Chart upon admission to hospital and a MEWS score calculated and documented Emergency admissions via: Emergency Department (ED): The Emergency Department will enter the first set of observations on the electronic Symphony system. Any subsequent observations while in the department (apart from discharge observations from ED) will be recorded on the AOC. Medical Assessment Unit (MAU): If the patient enters hospital via the MAU, the AOC will be used to record initial & all ongoing observations / MEWS Scores. The AOC will then accompany the patient to the ward once a decision is made to admit to hospital. Direct Admissions from GPs: If the patient enters hospital directly from a GP surgery to a Ward area, the patient will have a full set of observation taken and recorded on the AOC Elective admissions via: General Surgical, Orthopaedic & Medical Wards: If the patient is admitted directly to the ward, the AOC will be used to record initial & all ongoing observations / MEWS scores. Initial patient observations on admission will be: Temperature Blood pressure Pulse rate (Should be taken manually and not via the pulse oximetery) Respiratory rate, (respirations/minute) Level of consciousness (using AVPU or Glasgow Coma Score) Urine output (mls per Hour) Oxygen saturations (SpO2%) Target Saturations should be recorded by the medical team responsible for the patient Percentage (%) inspired oxygen being administered (if none then write AIR ) Urinalysis Note last bowel action. Pain score on 0-3 scale (see appendix C) Blood Glucose level if indicated On completing recording the observations, the practitioner will calculate the MEWS score (see section 6.3), then date, time and initial the chart. The practitioner responsible for the patient will determine the frequency of observations according to the clinical needs of the patient and the MEWS score. The practitioner will then document this on to the AOC, for example 4 hourly = 4. Version No. 6 Page 8 of 32

9 6.3 Documenting Ongoing Observations & Calculating MEWS Scores Each time clinical observations are performed, a complete set of observations MUST be recorded on the adult observation chart. This will then enable a MEWS score to be calculated. A complete (MEWS) set of observations will consist of: Temperature Blood pressure Pulse Respiratory rate Level of consciousness using AVPU or Glasgow coma Score Any Supplemental Oxygen SpO2%Oxygen saturations A MEWS score MUST be calculated each time observations are recorded. To calculate a MEWS score, a complete set of patient observations must be recorded & for each of these six physiological parameters a score is allocated according to the MEWS observation parameters (see below): 6.4 Modified Early Warning System (MEWS) Observation Score Parameters Respiratory Rate Oxygen Saturations Any Supplemental Oxygen Pulse Systolic (BP) AVPU GCS Temp < >30 < >94 es < < New Alert Agitation/conf usion < < No > 200 > 131 Voice Pain Unrespon sive > 38.6 The individual scores for each of the six physiological parameters are then recorded in the appropriate boxes within the MEWS Scores section at the bottom of the chart. The 7 scores are then added together to produce a final MEWS score which is then recorded in the total box. IMPORTANT NOTE: Spo2 Monitoring: If a patients oxygen saturations generate a score of 1 (90-94%) OR 2 (86-89%) but remain within the target Spo2 level set by the responsible medical team, the score should be circled on the chart BUT NOT COUNTED within the MEWS Score. The practitioner recording the observations must then sign their initials & document their clinical grade at the bottom of the observation column. Version No. 6 Page 9 of 32

10 6.5 Use of concurrent treatment specific observation charts Where other treatment specific observation charts are in use such as: Epidural Chart Non Invasive Ventilation (BIPAP) Chart Only observations that are not already recorded on the treatment specific chart should be recorded on the Adult Observation Chart. Neurological Observations: Patients requiring neurological observations should be monitored using the Adult Observations Chart that incorporates MEWS and Neurological observations. Indications for neurological Observation Monitoring: Head injury Altered state of Consciousness Acute Stroke patients as per the stroke care pathway Medical instruction to monitor patients neurological condition Unwitnessed patient fall 6.6 Clinical Response to MEWS Scores Once the total MEWS score has been calculated, the practitioner will respond according to the MEWS graded response system on the front of the AOC (see below): MEWS Score Graded Response or More Stable Potential for Deteriorating Critically ill deterioration Normal observations Extra vigilance Assess & alert Inform Nurse in charge Observation Inform Nurse in Inform Nurse in charge Assess & treat A.B.C.D.E frequency will charge Assess & treat depend upon Repeat A.B.C.D.E Inform ward F2/SPR patients observations within Call ward F1-F2 Medical Team & CCOS condition 1 hour medical staff and NOTE: Critical Care Outreach Dial 2222 for the Minimum 12 Team to review within Adult Emergency Team hourly 15 minutes if U on the AVPU observations Minimum 30 min observations Perform observations using normal equipment for temperature, pulse, respirations, blood pressure and pulse oximetry. Monitoring Equipment Attach the patient to continuous monitoring which includes ECG (lead 2), pulse oximetry, and non-invasive blood pressure MEWS score Observations are stable: The frequency of further observations will be decided by the practitioner in charge of the patients care & will depend upon their clinical condition The minimum observation frequency for all patients will be 12 hourly unless they have been signed-off MEWS (see section 12) Version No. 6 Page 10 of 32

11 6.6.2 MEWS score Observations indicate potential for clinical deterioration: Extra vigilance is required. The person recording the observations must inform the practitioner in charge. A systematic A.B.C.D.E assessment (airway, breathing, circulation, disability & exposure). Observations MUST be repeated within a minimum of 1 hour. The use of professional judgment may be used by the Registered Practitioner for patients with a MEWS score of 3-4 and it may be deemed safe to repeat the observations in another 2 or 3 hours, rather then 1 hour. If this is the case this decision making must be documented in the patients care plan to evidence how and when the decision and judgement was made MEWS score 5 - Observations are deteriorating: The person recording the observations must inform the practitioner in charge. A systematic A.B.C.D.E assessment (airway, breathing, circulation, disability & exposure) must be performed and life threatening problems treated as they are identified. (See Appendix D) The ward F1 or F2 doctor must be called immediately & asked to review the patient within 15 minutes. (See Section 6.8) Call the Critical Care Outreach Service Bleep 006 ( 7 days,24/7) Complete the documentation on the back of the AOC. The call for help must be documented on the back of the AOC and in the medical and nursing notes. Observations MUST be repeated a minimum of 30 minutes If the practitioner is concerned about the clinical condition of the patient who has a MEWS score less than 5, they should still seek medical assistance. This policy does not override or negate the need to use professional experience and judgement. IF OU ARE CONCERNED ABOUT A PATIENT CALL FOR HELP e.g. Seizures Choking Respiratory distress MEWS score 6 - Observations indicate critical illness: The person recording the observations must inform the practitioner in charge. Another registered practitioner should attend the patient and a systematic A.B.C.D.E assessment (Airway, breathing, circulation, disability and exposure) must be performed and life threatening problems treated as they are identified. While the above is happening another registered practitioner should call for help: The ward F2 or SpR doctor must be informed (via fast bleep) of the 2222 call immediately & asked to attend. Call the Critical Care Outreach Service (7 days a week, 24/7). Dial 2222 for the Adult Emergency Team if the patient is a U on their AVPU score. The S.B.A.R communication tool should be used to clearly communicate and then document the call for help in the patient's medical notes and on the back of the AOC (See Appendix E) The practitioner completing the A.B.C.D.E assessment & emergency treatment of life threatening problems must give a clear succinct handover (using SBAR Appendix E) to Version No. 6 Page 11 of 32

12 the Adult Emergency Team leader when they arrive and document actions on the back of the AOC. The call for help must be documented in the medical and nursing notes, including the actions and treatment given to the patient by the ward nurse. The consultant responsible for the patient should make decisions with regard to the appropriate treatment, referral for expert advice for example an Intensive Care Opinion or make a decision not to escalate care/treatment and consider a Do Not Attempt Resuscitation Order MEWS Score response in the Emergency Department: Because the ED has an immediate access to senior medical and nursing staff the ED will use MEWS BUT their response to MEWS scores will differ to the Ward Areas. The response to MEWS in ED is outlined below and this information is displayed within the ED department on posters for clinical staff to access. MEWS Action Score 1-2 Repeat patient observations within 1 Hour 3 Repeat patient observations within 30 minutes 4 Request urgent medical review and consider move to Resus 5+ Move to Resus and call doctor immediately All adult patients in ED should have a MEWS score calculated following primary assessment and throughout their stay, each time their core observations are performed. 6.7 Calling for medical assistance When medical staff are called to review the patient with a MEWS of 5 it is expected that: The doctor will give the practitioner an expected time for his/her arrival on the ward/dept. The expectation is it MUST be within 15 minutes (see also section 5.8). The doctor must give advice where possible to assist the practitioner in the interim period. The practitioner should ensure that the patient s medical notes, x-rays, current treatment charts and recent haematology/pathology results ready for the doctors arrival. When the Adult Emergency Team are called to attend the patient with MEWS of 6 or above AND unresponsive, it is expected that: The Adult Emergency Team will attend immediately. The ward F2 or SpR will be called (via fast-bleep) to attend immediately. The practitioner should ensure that the patient s medical notes, x-rays, current treatment charts and recent haematology/pathology results ready for teams arrival. 6.8 Escalation of call for medical assistance When medical staff are called to review the patient with MEWS of 5, the doctor is expected to attend the patient within 15 minutes. If the doctor is already dealing with a critical situation & is unable to attend the patient within 15 minutes, he/she must advise the practitioner to contact the next grade of medical staff. Where possible the doctor must offer advice to assist the practitioner in managing the patient in the interim period. If the doctor called does not review the patient within 15 minutes, the practitioner must call the next level of medical staff, escalating (if required) to consultant level (F1 F2 Registrar Consultant). The Consultant has ultimate responsibility for the patients management. Version No. 6 Page 12 of 32

13 Practitioners can also call the Critical Care Outreach Service for immediate support if needed. (7 days a week, 24/7). Practitioners should contact the ward/dept Leader or Matron (in-hours) or Site Coordinator (out-of-hours) if experiencing difficulty accessing medical assistance. Whilst awaiting medical assistance, a member of clinical staff should stay with the patient. 6.9 Discontinuation of MEWS scoring Occasionally, MEWS scoring will be inappropriate (i.e. end of life situations) but patient observations may need to be continued. Authorising the discontinuation of MEWS is a SENIOR MEDICAL STAFF DECISION ONL & can only be made by the Consultant (or Registrar) in charge of the patients care. MEWS scoring is inappropriate for patients on the End-of-Life Care Pathway, although certain clinical observations (i.e. respiratory rate) may still be required. If the senior medical practitioner makes the decision that certain observations should be continued this should be clearly documented on the front of the observation chart and in the patient s medical notes. Please also refer to the DNACPR Policy to support decision making. 7. CONSULTATION This policy has been consulted and shared with both Medical and Nursing professionals who are using and implementing this policy. Changes within the policy are based on local audit and performance in relation to this policy. 8. TRAINING This AOC and MEWS Policy does not have a mandatory training requirement but the following non mandatory training is recommended:- Registered nurses and junior doctors working on general wards can access the Acute Illness Management (AIM) course as part of their continuing professional development. Registered nurses and junior doctors working on general wards will also be educated in the correct use of the AOC via: All Registered non medical staff who perform observations will complete the work based competency for observations and the deteriorating patient Unregistered staff who perform observations under this policy will complete a work based assessment of competency undertaken by a relevantly experienced and trained Registered member of staff Immediate Life Support (ILS) course delivered by the Resuscitation Officers Ward based training delivered by Ward Matrons & Sisters/Charge Nurses Care of the deteriorating ward patient study days Informal and formal education from the Critical Care Outreach Service Junior doctors will receive an introduction to this policy and process on their induction days Version No. 6 Page 13 of 32

14 9. DISSEMINATION 9.1 When approved this document will be available on the Intranet and will be subject to document control procedures. Approved documents will be placed on the Intranet within 5 working days of date of approval once received by the Risk Management Team. 9.2 When submitted to the Risk Management Team for inclusion on the Intranet this document will have fully completed document details including version control. Keywords and description for the Intranet search engine will be supplied by the author at the time of submission. 9.3 Notification of new and revised documentation will be issued on the Front page of the Intranet, through e-bulletin, and on staff notice boards where appropriate. Any controlled documents noted at the Trust Executive Committee will be notified through the e-bulletin. 9.4 Staff using the Trust s intranet can access all procedural documents. It is the responsibility of managers to ensure that all staff are aware of where, and how, documents can be accessed within their areas of work. 9.5 It is the responsibility of each individual who prints a hard copy of any document to ensure that the printed hardcopy is the current version. Current versions are maintained on the Intranet. 10 EQUALIT ANALSIS This procedure has undergone an equality analysis please refer to Appendix J 11. REVIEW AND REVISION ARRANGEMENTS This policy will be reviewed every 3 years and led by the Critical Care Outreach Service. 12. MONITORING COMPLIANCE AND EFFECTIVENESS All adult patients will have observations; recorded, monitored and responded to as per the AOC Policy, except in circumstances as described in section 6.9 of this policy. Monthly audits will be undertaken in all clinical areas which use the AOC and MEWS Policy to ensure compliance by the ward/team leader and local action plans developed in response to poor compliance. (See Appendix G). To measure the impact of this policy the following Key Performance indicators will be reviewed to quantify impact. Reduced unplanned admissions to the Intensive Care Unit. Reduction in cardiac arrests in ward areas. Reduced serious incidents requiring investigation relating to failure to recognise and respond to the deteriorating hospital patient. Reduction of adverse clinical incidents pertaining to failure to recognise and respond to the deteriorating adult hospital patient. NHS IOW compliant with NICE 50 guidelines annually audited by CCOS Version No. 6 Page 14 of 32

15 13. LINKS TO OTHER ORGANISATION POLICIES/DOCUMENTS Resuscitation Policy South Central Unified DNACPR Policy Patient Safety Strategy Capability and Disciplinary Policy Appraisal Policy Blood Transfusion Policy Patient Group Directions for Oxygen and Saline Standard Operating Procedure for the Critical Care Outreach Service 14. REFERENCES National Institute for Health and Clinical Excellence (2007) Acutely ill Patients in Hospital/.London: HMSO. Royal College of Physicians (2012) NEWS. London: RCP 15. DISCLAIMER It is the responsibility of all staff to check the Trust intranet to ensure that the most recent version/issue of this document is being referenced Version No. 6 Page 15 of 32

16 Appendix A KE DEFINITIONS FOR DOCUMENTATION MEWS (Modified Early Warning Scoring System): This is a tool which enables the recognition and response to sick and deteriorating patients in the acute care setting. This is used on all adults. MEOWS - (Modified Early Obstetric Warning Score): This is a tool which enables the recognition and response to sick and deteriorating obstetric patient. COAST - (Paediatric Early Warning Scoring System): This is a tool which enables the recognition and response to sick and deteriorating patients in the acute care setting. This is used on all Children. S.B.A.R (Situation, Background, Assessment and Recommendation): This is a communication tool to support the accurate verbal and written communication between professionals in critical situations. AOC Adult Observation Chart NEWS National Early Warning Scoring Version No. 6 Page 16 of 32

17 ADULT OBSERVATION CHART Appendix B Version No. 6 Page 17 of 32

18 Appendix C PAIN SCORING SSTEM Pain score on 0-3 scale 0= No pain at rest, No pain on movement 1= No pain at rest, slight pain on movement 2= Intermittent pain at rest, moderate pain on movement 3= Continuous pain at rest Version No. 6 Page 18 of 32

19 A SSTEMATIC A, B, C, D, E ASSESSSMENT Appendix D A Airway B Breathing C Circulation D Disability E Exposure Assessment Is patient talking Abnormal noises (snoring, gurgling etc.) See-saw breathing Respiratory distress Respiratory rate Depth Pattern Auscultation Use of accessory muscles Sp02 Pulse rate Capillary refill time (CRT) Hands & feet warm/cold Blood pressure Urine output Conscious level (AVPU or GCS) Pupil reactions Blood glucose Posture Head-to-toe check, observing for: Rashes Oedema Bleeding Trauma Distended abdomen Interventions (as indicated by clinical assessment) Suction Positioning (head-tilt/chin lift or jaw-thrust) Airway adjunct (oral or nasal) OXGEN Advanced airway management OXGEN Positioning Physiotherapy Nebulisers Bag & mask ventilation IV access Take bloods (U&E, FBC, coag, cultures etc.) IV fluids Urinary catheter Recovery position Treat hypoglycaemia Check drug chart Maintain dignity during exposure Prevent hypothermia Version No. 6 Page 19 of 32

20 S B A R Communication Tool Appendix E S Situation Patient Name: Ward: MEWS Score: Nurse reporting: I am concerned about B Background A Assessment Describe What ou Admission diagnosis & admission date RELEVANT medical history Resuscitation status Treatment to date: (refer to patients notes) Airway Breathing Circulation Exposure Next of kin aware: Relevant social circumstances: See Hear Feel R Recommendation What response would you like from doctor: What time is the doctor due to arrive: Medical advice given: Version No. 6 Page 20 of 32

21 Assessment and monitoring Initial assessment Record at least: Patient in acute hospital setting: heart rate level of consciousness Patient admitted to Hospital into the respiratory rate oxygen saturation Emergency Department, Medical blood pressure temperature Assessment Unit or directly to a ward. Document and sign on the AOC with calculated MEWS score in the emergency department after a decision to admit has been made Write a clear monitoring plan specifying the physiological observations to be recorded and how often. Take into account: Transferred to a general ward from a diagnosis the agreed treatment plan. critical care area. Patients at risk of deterioration Follow MEWS graded response System if: Alerted by track and trigger score There is clinical concern. Appendix F Routine monitoring Use the AOC Chart and MEWS Policy (physiological track and trigger system) to monitor patients. Monitor physiological observations at least every 12 hours, unless decided at a senior level to increase or decrease the frequency for an individual patient. With every set of observations ensure a full set of observations are completed and a MEWS score calculated and acted upon and this is reflected on the AOC chart and within the patients Nursing and Medical documentation. Ensure at every set of observation and MEWS score that is completed that the frequency is documented on the AOC. Consider monitoring: biochemistry (for example, lactate, blood glucose, base deficit, arterial ph) Hourly urine output Pain. See next page for graded response Version No. 6 Page 21 of 32

22 MEWS Score Graded Response or more Stable Potential for Deteriorating Critically ill deterioration Normal observations Extra vigilance Assess & alert Inform Nurse in charge Inform ward F2/SPR Medical Team/CCOS Observation frequency will depend upon patients condition NOTE: Minimum 12 hourly observations Inform Nurse in charge Repeat observations within 1 hour Inform Nurse in charge Assess & treat A.B.C.D.E Call ward F1-F2 medical staff and Critical Care Outreach Team to review within 15 minutes Minimum 30 min observations Assess & treat A.B.C.D.E Dial 2222 for the Adult Emergency Team if U on AVPU Perform observations using normal equipment for temperature, pulse, respirations, blood pressure and pulse oximetry. Monitoring Equipment Attach the patient to continuous monitoring which includes ECG (lead 2), pulse oximetry, and noninvasive blood pressure Transfers from a Critical Care Area Transfers to general wards should be as early in the day as possible. Avoid transfers between and wherever possible. Document as an adverse incident if they occur. The critical care and ward teams have shared responsibility for the patient s care. They should: Use a formal structured handover (including both medical and nursing staff), supported by the ICU multidisciplinary team written plan, to ensure continuity of care. Ensure the ward can deliver the plan, with support from critical Care Outreach service. Document readmission and DNACPR status All discharged patient will be reviewed and followed up by the Critical Care Outreach Service Version No. 6 Page 22 of 32 Handover to the Ward Team should Include: A summary of the critical care stay including diagnosis and treatment A monitoring and investigation plan A plan for ongoing treatment including drugs and therapies, nutrition plan, infection status and any agreed limitations of treatment Physical and rehabilitation needs Psychological and emotional needs Specific communication or language needs. Admission to a critical care area The decision to admit should involve both the patient s consultant and the consultant in critical care and the patient/relative if appropriate.

23 Audit Guidelines Patient Observation Chart Audit Updated May 2013 Scoring and individual chart Appendix G Collect a sample of 10 patient observation charts for patients on the ward. Answer the questions on the checklist below This audit is undertaken monthly. If the 90% target is not achieved, an action plan is required and audits undertaken weekly until the 90% target is achieved. If all items are answered yes then the chart receives a score of 1 If any item is answered no then the chart receives a score 0 Calculating the overall audit score Add up the individual chart scores and convert to a percentage Sum of chart scores X 100 Number of charts audited 1 2 Chart (answer yes or no only) Standard Has the chart got an addressograph or full name and hospital number for the patient? Does the chart indicate the frequency of observations? 3 Is the temperature recorded correctly? 4 Is the BP recorded correctly? 5 Is the pulse recorded correctly? 6 Are respirations recorded correctly? 7 Are O 2 saturations recorded correctly? 8 Are all sets of observations complete (Temperature, BP, Pulse, Respirations,AVPU, Oxygen Saturations and % of Inspired Oxygen) 9 Has the MEWS score been calculated correctly? If a MEWS score has triggered a response, has the appropriate action been taken as per policy? Has the above action been documented on the back of the AOC? If the MEWS has triggered a response has the frequency of observations been increased If the MEWS score is 5 or above has this been escalated to the Medical team and documented on the back of the AOC 14 Has pain assessment been documented? Chart Score Ward: Month: Audit Score Version No. 6 Page 23 of 32

24 Appendix H CHECKLIST FOR THE DEVELOPMENT AND APPROVAL OF CONTROLLED DOCUMENTATION To be completed and attached to any document when submitted to the appropriate committee for consideration and approval. Title of document being reviewed: /N/ Comments Unsure 1. Title/Cover Is the title clear and unambiguous? Does the title make it clear whether the controlled document is a guideline, policy, protocol or standard? 2. Document Details and History Have all sections of the document detail/history been completed? 3. Development Process Is the development method described in brief? Are people involved in the development identified? Do you feel a reasonable attempt has been made to ensure relevant expertise has been used? 4. Review and Revision Arrangements Including Version Control Is the review date identified? Is the frequency of review identified? If so, is it acceptable? Are details of how the review will take place identified? Does the document identify where it will be held and how version control will be addressed? 5. Approval Does the document identify which committee/group will approve it? If appropriate have the joint Human Resources/staff side committee (or equivalent) approved the document? 6. Consultation Do you have evidence of who has been consulted? 7. Table of Contents Has the table of contents been completed and checked? 8. Summary Points Have the summary points of the document been included? 9. Definition Is it clear whether the controlled document is a guideline, policy, protocol or standard? 10. Relevance N/A Has the audience been identified and clearly stated? 11. Purpose Are the reasons for the development of the document stated? 12. Roles and Responsibilities Are the roles and responsibilities clearly identified? 13. Content Is the objective of the document clear? Version No. 6 Page 24 of 32

25 Title of document being reviewed: Is the target population clear and unambiguous? Are the intended outcomes described? Are the statements clear and unambiguous? 14. Training Have training needs been identified and documented? 15. Dissemination and Implementation Is there an outline/plan to identify how this will be done? Does the plan include the necessary training/support to ensure compliance? 16. Process to Monitor Compliance and Effectiveness Are there measurable standards or Key Performance Indicators (KPIs) to support the monitoring of compliance with and effectiveness of the document? Is there a plan to review or audit compliance within the document? Is it clear who will see the results of the audit and where the action plan will be monitored? 17. Associated Documents Have all associated documents to the document been listed? 18. References Have all references that support the document been listed in full? 19. Glossary Has the need for a glossary been identified and included within the document? 20. Equality Analysis Has an Equality Analysis been completed and included with the document? 21. Archiving Have archiving arrangements for superseded documents been addressed? Has the process for retrieving archived versions of the document been identified and included within? 22. Format and Style Does the document follow the correct style and format of the Document Control Procedure? 23. Overall Responsibility for the Document Is it clear who will be responsible for co-ordinating the dissemination, implementation and review of the documentation? Committee Approval /N/ Unsure N/A Comments If the committee is happy to approve this document, please sign and date it and forward copies for inclusion on the Intranet. Name of Committee Print Name Date Signature of Chair Version No. 6 Page 25 of 32

26 Appendix I IMPACT ASSESSMENT ON POLIC IMPLEMENTATION Summary of Impact Assessment (see next page for details) Policy Name Adult Observation Chart and MEWS Policy Totals: Manpower costs WTE Time to allocate staff to complete competencies and attend AIM Course Recurring Non- Recurring Training staff Equipment & provision of resources Supported via the CCOS and Resus team Print of new chart Wards already resource their own core observation chart and the cost of the new MEWS Chart would not be any more expensive Summary of Impact: Training of staff in the use of this policy will occur through local induction to clinical areas and through already established mandatory training such as Adult Basic Life Support, Trust Induction etc. The cost of the new AOC for the trial will be supported by the Deputy Chief Nurse then clinical areas using the chart will pick up the cost, which is the current arrangement with the core observation chart already used in the PCT. Risk Management Issues: Benefits / Savings to PCT: Reduced unplanned admissions to the Intensive Care Unit. Reduced Cardiac arrests Reduced serious untoward Incidents relating to failure to recognise and respond to the sick hospital patient. Reduced to length of stay. Contribute to achieving the patient safety agenda and strategic priorities of the PCT. Equality Impact Assessment Has this been appropriately carried out ES Are there any reported equality issues? NO If ES please specify: Version No. 6 Page 26 of 32

27 Use additional sheets if necessary. IMPACT ASSESSMENT ON POLIC IMPLEMENTATION Please include all associated costs where an impact on implementing this policy has been considered. A checklist is included for guidance but is not comprehensive so please ensure you have thought through the impact on staffing, training and equipment carefully and that ALL aspects are covered. Manpower WTE Recurring Non-Recurring Operational running costs Additional staffing required - by affected areas / departments: Totals: Staff Training Impact Recurring Non-Recurring Affected areas / departments e.g. 10 staff for 2 days Totals: Equipment and Provision of Resources Recurring * Non-Recurring * Accommodation / facilities needed Building alterations (extensions/new) IT Hardware / software / licences Medical equipment Stationery / publicity Travel costs Utilities e.g. telephones Process change Rolling replacement of equipment Equipment maintenance Marketing booklets/posters/handouts, etc Totals: Capital implications 5,000 with life expectancy of more than one year. Funding /costs checked & agreed by finance: Signature & date of financial accountant: Funding / costs have been agreed and are in place: Signature of appropriate Executive or Associate Director: Version No. 6 Page 27 of 32

28 IMPACT ASSESSMENT ON POLIC IMPLEMENTATION CHECKLIST Points to consider Have you considered the following areas / departments? Have you spoken to finance / accountant for costing? Where will the funding come from to implement the policy? Are all service areas included? o Ambulance o Acute o Mental Health o Community Services, e.g. allied health professionals o Public Health, Commissioning, Primary Care (general practice, dentistry, optometry), other partner services, e.g. Council, PBC Forum, etc. Departments/facilities/staffing Transport Estates o Building costs, Water, Telephones, Gas, Electricity, Lighting, Heating, Drainage, Building alterations e.g. disabled access, toilets etc Portering Health Records (clinical records) Caretakers Ward areas Pathology Pharmacy Infection Control Domestic Services Radiology A&E Risk Management Team / Information Officer responsible to ensure the policy meets the organisation approved format Human Resources IT Support Finance Rolling programme of equipment Health & safety/fire Training materials costs Impact upon capacity/activity/performance Version No. 6 Page 28 of 32

29 Appendix J Equality Analysis and Action Plan This template should be used when assessing services, functions, policies, procedures, practices, projects and strategic documents Step 1. Identify who is responsible for the equality analysis. Name: Shane Moody Role: Lead for Critical Care Services/ANP Other people or agencies who will be involved in undertaking the equality analysis: Relevance Protected Groups Staff Service Users Age Gender Reassignment Race Sex and Sexual Orientation Religion or belief Disability Marriage and Civil Partnerships Human Rights Pregnancy and Maternity Adults only Does not cover pregnant women Wider Community Step 2. Establishing relevance to equality Show how this document or service change meets the aims of the Equality Act 2010? Equality Act General Duty Eliminates unlawful discrimination, harassment, victimization and any other conduct prohibited by the Act. Advance equality of opportunity between people who share a protected characteristic and people who do not share it Foster good relations between people who share a protected characteristic and people who do not share it. Relevance to Equality Act General Duties N/A N/A N/A Version No. 6 Page 29 of 32

30 Step 3. Scope your equality analysis What is the purpose of this document or service change? Who will benefits? What are the expected outcomes? Why do we need this document or do we need to change the service? Scope This policy aims to support early recognition and response to sick adult patients in the hospital setting Adult patients Improved patient outcomes We need to have a early warning scoring system in place for adults as per NICE 50 It is important that appropriate and relevant information is used about the different protected groups that will be affected by this document or service change. Information from your service users is in the majority of cases, the most valuable. Information sources are likely to vary depending on the nature of the document or service change. Listed below are some suggested sources of information that could be helpful: Results from the most recent service user or staff surveys. Regional or national surveys Analysis of complaints or enquiries Recommendations from an audit or inspection Local census data Information from protected groups or agencies. Information from engagement events. Step 4. Analyse your information. As yourself two simple questions: What will happen, or not happen, if we do things this way? What would happen in relation to equality and good relations? In identifying whether a proposed document or service changes discriminates unlawfully, consider the scope of discrimination set out in the Equality Act 2010, as well as direct and indirect discrimination, harassment, victimization and failure to make a reasonable adjustment. Findings of your analysis No major change Description our analysis demonstrates that the proposal is robust and Justification of your analysis Highly focused clinical policy with a clear purpose Version No. 6 Page 30 of 32