DOCUMENT CONTROL PAGE

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1 DOCUMENT CONTROL PAGE Title Supersedes Originator or modifier Ratification Title: Observation Policy Version: 3 Reference Number: CG003 Supersedes: Observation Policy V3 Description of Amendment(s): Addition of neurological observation chart, Alteration to NHSP staff assessment processes Pulse is measured prior to Blood pressure Addition of BORAS for observation collection Addition of pain information and assessment of pain in critical care Guidance for confused patients or refused consent. Originated By: Sarah Ingleby Designation: Lead Nurse Acute Care Team Modified by: Sarah Ingleby1 Donna Egan2 Designation: Lead Nurse Acute Care Team1 Outreach Coordinator2 Referred for approval by: Professional Forum Date of Referral:4/08/10 Application Patients Adults only ( aged 16 years and over) Circulation Review Issue Date: Oct 2010 Circulated by: Sarah Ingleby/ Donna Egan Dissemination and Implementation: Refer to section 7 Review Date: Oct 2012 Responsibility of: Acute Care Team / Outreach Team Date placed on the intranet: 28/10/10 EQIA Registration Number: IP/94/2010 Refer to section 5 : Equality, Diversity and Human Rights Impact Assessment Observation Policy CG003 Page 1 of 36

2 Section Contents Page 1 Introduction 3 2 Purpose 3 3 Roles and Responsibilities 4 4 Detail of Procedural Documents Equality, Diversity and Human Rights Impact Assessment 14 6 Consultation, Approval and Ratification Process 14 7 Dissemination and Implementation 15 8 Monitoring Compliance of Procedural Documents Standards and Key Performance Indicators KPIs References and Bibliography Associated Trust Documents Appendices Appendix 1- TPR chart Appendix 2- Neurological observation chart Appendix 3-SBAR 23 Appendix 4- Observation audit tool 24 Appendix 5- Competency documentation Appendix 6- CSW assessment of clinical observation skills 30 Appendix 7- Flow chart for assessment 31 Appendix 8- Flow chart for CSW AIM assessment 32 Appendix 9- Behavioral Pain assessment Appendix 10- Observation competency for NHSP CSW 35 Appendix 11- Policy monitoring Planning form 36 Observation Policy CG03 Page 2 of 36

3 1. Introduction This policy should be read in conjunction with the Early Warning Score (EWS) see trust intranet policy as this will highlight the frequency of clinical observations for specific patient groups based on clinical presentation to staff involved in the recording of clinical observations and subsequent patient management. This policy covers Central Manchester University Hospitals Foundation NHS Trust adult in-patient areas, including theatre areas and all day case areas for adult patients. Nurses, midwives and doctors have a pivotal role in the early identification of patients at risk of deterioration through the monitoring of patient observations and assessment. The importance of accurate observations is clearly documented and essential according to the NPSA (NPSA, 2007). The NICE clinical guidance 50 Caring for the Acutely ill Patient and linked competency document also ensure that standards are set for the assessment and treatment of patients within hospitals. This observation policy sets the standard for the accurate monitoring of observations, utilising research and best practice and by referring to the NICE competency document to ensure that the national standard is met and maintained. 2. Purpose 2.1 General Points Outpatient areas are not to be included within this policy; however the lead clinician and lead nurse of the outpatient clinics will determine the frequency of observations and the type of observations required following a risk assessment of patients as a general principle to be treated in each area. If the patient deteriorates the local policy should be followed All patients being cared for in in-patient clinical areas, should have their observations performed, with the frequency as stated in point When observations are taken, a full set of observations should always be recorded, to include Pulse Rate, Respiratory Rate, Blood Pressure, Temperature and Neurological Status and oxygen saturation (see EWS policy), the exception is St Mary s Obstetric areas (see Maternity EWS policy). If an observation is unrecordable or undetectable e.g. SaO2 or blood pressure, escalate to the nurse in charge to assess the patient, refer to medical team if required A full set of observations including the EWS, must be undertaken on admission to all clinical areas (except theatre when they will be undertaken on discharge). Thereafter the frequency of subsequent observations will depend on the specialty and clinical condition of the patient (see section 4.3). The only exception to this is St Mary s Obstetric areas where a robust assessment criteria is in place, designed to assess appropriateness for individual patients to determine who is eligible for the maternity EWS (see Maternity EWS policy) When patients are transferred from one ward/ department to another, a full set of observations must be completed by the receiving practitioner within 10 minutes of arrival, with the exceptions as above. Observation Policy CG003 Page 3 of 36

4 2.1.6 Patient observations should be measured by an appropriately trained and competent member of staff (see EWS policy) The frequency of observations should be determined by the nurses in charge of the shift / registrar or consultant managing the patient care and should be clearly documented on the observation chart or inputted into BORAS; unless a patient has a EWS of 3 when it is expected observations will be recorded hourly as a minimum (see EWS policy) and point All observations should be documented on the Trust Temperature, Pulse and Respiration Chart (TPR) (see Appendix 1), or agreed local documentation that has been reviewed by the critical care delivery group for use. Observations should then be initialed or inputted into the bedside observation recognition and alerting system. (BORAS) Only the Trust TPR chart should be used; if specific local documentation is required this must be agreed by the Critical Care delivery group. This local documentation must have EWS, frequency and space for initialing observations. A list of the alternative TPR charts is to be kept by the Outreach team. The outreach team will keep a live list of all Trust TPR charts in use The frequency should be documented on the TPR chart or patient documentation by the medical team or nurse in charge of the patient or inputted into the BORAS system All chart entries should be clear, legible, written in black pen and the time and date of the observations clearly documented (see EWS policy) Ensure appropriate infection control measures have been taken between patients and isolation policy utilized when appropriate as per Trust policy It is important to remember that all medical devices require pre use and post use checks in accordance with training guidance. All staff must aware of the indications and contraindications for use and the device is used for its intended purpose. Medical device users must be aware of the battery functionality of devices they use and how to identify, troubleshoot any user issues and report faulty devices to MEAM and via the Incident reporting system. To ensure that observations taken and recorded are as accurate as possible, it is important to remember that equipment can fail and provide false readings if the user is unfamiliar with all of the above. Review the patient using clinical skills and question and check any spurious readings. 3 Roles and Responsibilities: 3.1 Duties within the organisation - Heads of Nursing to ensure that policy is disseminated and audited and corrective action taken as required - Lead Nurses/Matrons- to ensure that delivery of care to all patients within the Division adhere to the policy and all staff groups are educated to the level required, whilst keeping up to date with current practice. - Ward Managers-to ensure that delivery of care to all patients within the ward adheres to the policy and all staff groups are educated to the required level, whilst keeping up to date with current practice. - Ward Staff- to ensure that delivery of care to all patients within the ward adheres to the policy and keeps up to date with current practice. Observation Policy CG003 Page 4 of 36

5 - Clinicians- to ensure that in all patients under their care there is adherence to the policy and all staff groups are educated to the level required, whilst keeping up to date with current practice. To review and respond to issues highlighted by the policy. 4 Detail of Procedural Document: 4.1 Standards for clinical observations Why measured? Standard A. Respiratory monitoring The Respiration rate is taken to: Determine baseline respiratory status Identifies respiratory disease. Identifies other complications (e.g. such as infection, shock, Acute Renal Failure, etc.) Monitor fluctuations and potential deterioration. Observe pattern and character of breathing. Explain procedure to patient and gain consent. Ensure you have a clear view of the patients ribcage. Inspiration and expiration counts as one cycle. Count the patient s respiratory rate for one full minute.(ensure a clock or watch with a second hand is visible). During o r a f t e r c o u n t i n g t h e rate, assess the character of breathing. Note: Remember normal breathing is smooth and quiet; signs of difficulty breathing are shallow breathing, noisy breathing, wheezing, and the inability to speak clearly. Lifting the shoulders and use of accessory muscles on inspiration are signs of increased respiratory effort. Document the respiratory rate as a number on the TPR chart, agreed documentation or patientrack system and other respiratory observations in the nursing notes. Report any deterioration or other o b v i o u s c h a n g e s t o a senior member of staff. Respond to any EWS triggers as per policy Observation Policy CG003 Page 5 of 36

6 B. Pulse Rate Monitoring Why measured? The pulse or heart rate is taken to: Determine baseline cardiovascular status. Monitor fluctuations and potential deterioration. Assess cardiovascular function. Standard Explain procedure to patient and gain consent. Place one or two fingers over the pulse site (radial pulse is area of choice, use the third finger and fourth finger- not thumb or index finger), applying gentle pressure prior to taking the blood pressure. Identify the pulse. Count the beats felt for one full minute (ensure a clock or watch with a second hand is visible) During counting the rate; assess the rhythm and strength of the pulse. Remember a normal rhythm is regular; missing beats, irregularities and weak thready or bounding pulses may need further investigation and should be reported to a senior member of staff. If the patient has an irregular heart rate, a radial and apex pulse can be measured simultaneously by two practitioners to assess variance Document heart rate on the TPR chart, agreed local documentation or patientrack system and other pulse observations in the nursing notes. Report any deterioration or other obvious changes to a senior member of staff. Respond to any EWS triggers as per policy. Observation Policy CG003 Page 6 of 36

7 Why measured? Standard C. Automated Blood pressure monitoring The blood pressure recordings are taken to: Determine a baseline. Monitor fluctuations and potential deterioration. Assess response to treatments and / or medications. Explain procedure to patient and gain consent. Remove restrictive clothing from patients arm. Ensure t h e p a t i e n t s a r m i s supported, with the cuff sitting around the arm at heart level. (The inflatable part of the cuff should cover at least 80% of the upper arm). For automated machines press start and wait until the device indicates the reading is complete Note: Remember; a very low BP is dangerous as this reflects a lack of blood and oxygen to the brain, kidneys, gut and skin. Just as a very high BP is dangerous as this may cause stroke, heart failure or renal failure. Either of these may require further investigation. Automated machines can be inaccurate; recheck manually if in any doubt of reading or blood pressure alters significantly; Systolic by 30 or is <90 or > 160 mmhg Diastolic by 20 or is <50 or > 90 mmhg or the pulse rate is irregular Document the reading on the TPR chart, agreed documentation or patientrack system report any significant rise or fall in BP recordings to a senior member of staff. Respond to any EWS triggers as per policy Observation Policy CG003 Page 7 of 36 See the Intranet for the latest version. Version Number:-3

8 D. Manual blood pressure monitoring Qualified practitioners and HealthCare support workers who routinely use manual blood pressure monitoring, are only to undertake this type of clinical observation, once successful completion of competence and assessment are demonstrated, as per section 5. If the patients automated blood pressure in any doubt, has significantly dropped from normal limit or has an irregular pulse a manual blood pressure must be checked (see point d). Why measured? The blood pressure recordings are taken to: Determine a baseline. Monitor fluctuations and potential deterioration. Assess response to treatments and or medications. Standard Explain procedure to patient and gain consent. Remove r e s t r i c t i v e c l o t h i n g f r o m patients arm. Ensure the patient s arm is supported, with the cuff sitting around the arm at heart level. (The inflatable part of the cuff should cover at least 80% of upper arm.) Check equipment, ensure: the level is at zero, all tubing is into with no leaks and that the column is upright and visible. Apply appropriately sized cuff. Inflate the cuff until the radial pulse can no longer be felt manually, observe the reading and fully deflate the cuff. This provides an estimation of systolic pressure. Apply the stethoscope over the brachial pulse point and inflate the cuff to 30mmhg greater than the estimated systolic pressure. Deflate the cuff at a rate of 2mmhg per second. On hearing the first pulse sound, note the level in the column. This is the systolic pressure The disappearance of the pulse sound indicates the diastolic pressure. Document the reading on the TPR chart, agreed local documentation or patientrack system; report any significant rise or fall in BP recordings to a senior member of staff. Respond to any EWS triggers as per policy. Observation Policy CG003 Page 8 of 36

9 E. Pulse Oximetry Why measured? The pulse Oximetry reading are undertaken to: Determine a baseline. Monitor fluctuations and potential deterioration. Assess response to treatments Limitations Poor peripheral blood flow Cardiac arrhythmias Bright overhead lights Carboxyhaemoglobin Nail varnish It gives information regarding saturations not patient ventilation or levels of CO2- consider patient status Standard Explain procedure to patient and gain consent Apply probe to finger Look at wave form or signal indicator Document saturation indicated on TPR chart, agreed local Documentation or patientrack system Observation Policy CG002 Page 9 of 36 See the Intranet for the latest version. Version Number:-3

10 F. Alert, Voice, Pain or Unconscious (AVPU) Why measured? The AVPU assessments are undertaken to: Determine a baseline for the patient. Monitor fluctuations and potential deterioration. Assess response to treatments To complete the full EWS assessment for a patient Note; If the patient has a new alteration to their mental state, further assessment and treatment will be required. The patient s ability to manage their airway should be a priority Following an AVPU assessment, further assessment may be required see point 2 Standard Assess patient s mental state by speaking to the patient and assessing whether they are alert and orientated, if so mark as alert If the patient s conscious level is slightly altered and they are newly confused or are not alert but responding only when spoken too, they should be marked as responding to voice/ new confusion If a patient is not responding to voice, administer painful stimuli such as periorbital push (if no facial fractures) or the trapezius pinch, to assess response, if responds should be marked as responding to pain If a patient is not responding to painful stimuli then the patient should be marked as unresponsive, - seek assistance Document AVPU indicated on TPR chart, agreed local Documentation or patientrack system 4.2 Neurological Observations Indications: Patients with; Drugs overdose, head injury, falls with suspected head trauma, patients with new confusion or altered level of consciousness, unstable epileptic, any other patient defined by medical team Registered Practitioners only to undertake neurological observations using the Glasgow Coma Score The entire observations set should be undertaken by the same RN including vital signs to ensure consistency in the assessment process is maintained The same RN should endeavor to perform neurological observation of the patient for their entire shift to ensure consistency in observation taking is maintained The frequency of neurological observations should be defined by the medical team on a patient specific basis and documented clearly in the patient s medical records. Observation Policy CG003 Page 10 of 36

11 4.2.6 For a patient who has had a fall with suspected injury to the head; either witnessed or anecdotal, or obvious sign of injury to the head, neurological observations should be undertaken; ½ hourly for 2 hours Hourly for 4 hours 2 hourly for 6 hours 4 hourly for 12 hours -then until medical review dictates otherwise The designated Trust neurological examination chart should be used see appendix In relation to a patient with a significant head injury, refer to the inpatient adult head injury guidelines for frequency of observations and management plan. 4.3 Frequency of observations As per the EWS policy The frequency of observations should be determined by; a Registered Nurse in charge of the shift, Senior Doctor (Registrar or Consultant) and should be clearly documented on the observation chart; unless a patient has a EWS of 3 when observations will be recorded hourly as a minimum All patients should have a minimum of 12 hourly observations, with the exceptions as per point & All acute (non elective) admissions should have a minimum of 4 hourly observations for 48hrs from the last trigger 3 or for 48hrs from admission/ transfer if not triggering on the EWS Within the Emergency Department frequency is a minimum of hourly as per Trust EWS policy ( latest version available on the intranet) All Post operative patients should have frequency as below unless medical staff document alternative request; 30 minutes for 2 hours Hourly for 2 hours As patient need dictates minimum 4 hourly for 48hrs from the last trigger 3 or for 48hrs post surgery if not triggering on the EWS All transfers from a higher level of care, for example Critical care or the coronary care unit to a ward must have a minimum of 4 hourly observations for 48hrs from the last trigger 3 or for 48hrs from transfer if not triggering on the EWS When a patient is on the Liverpool care pathway the observations may be stopped according to the End of Life Policy If a patient is a delayed discharge home and medically fit, it must be recorded in medical notes that their observations may reduce to daily and observations must be recorded on the day of discharge home Observation frequency can be reduced by a senior team member; Consultant, registrar or Registered Nurse in charge of shift (Trust member only) and should be documented on the TPR chart or / and in the patient case notes with a clear reason for reason for change. Observation Policy CG003 Page 11 of 36

12 If a patient is on more frequent than hourly observations, then Temperature can be recorded hourly, unless other clinical symptoms suggest a change in Temperature. The previous recording can be used to calculate the EWS If a patient is to be absent from the ward for investigations when observations are due then the observations should be taken prior to transfer (exception when transferred to theatre) If a patient is absent from the ward when clinical observations are due they must be completed with in 10 minutes of return to the ward. 4.4 Communication Ensure concise and effective communication when referring patients to senior members of the team or other team members Use the SBAR tool as a guide for communication to maintain standards and effective Communication (see Appendix 3) 4.5 Patients refusing to consent to have observations completed or confused patients who lack capacity ( see consent policy available on the intranet) Give full explanations regarding the importance of clinical observations With continued refusal, inform the nurse in charge and document in the nursing notes and refer to appropriate member of parent medical team for review within an hour for full assessment. 4.6 Measurement of acute pain / pain scores Accurate pain assessment is essential for effective pain management and g i v e s the patient a n a c t i v e r o l e i n t h e i r c a r e. Good p a i n management improves quality of care, aids recovery and reduces the risk of chronic pain developing There are a number of tools available to assess pain intensity and gauge the effectiveness of a particular treatment. It is important to choose the most appropriate tool for your patient. The preferred scale in the trust is the 0 10 numerical rating scale.0 = No pain & 10 = the worst pain possible If this scale is not appropriate, details of other scales can be found in the acute pain guidelines (on the Trust intranet) or by contacting the acute pain team. Please see appendix 9 for details of the behavioural pain scale for use with ventilated and sedated patients in critical care. Observation Policy CG003 Page 12 of Assessing pain intensity-the patient is asked: What number would you give to your pain right now, if 0 is no pain and 10 is the worst pain possible. The patient s verbal report should be obtained at rest and also during activity such as coughing, deep breathing or moving. Pain scores should be clearly documented at rest and movement, as well as actions taken to relieve pain. All pain scores of 5 or more should result in an intervention being made. If a pain score of 5 or more is given, further information about the pain can be obtained to aid management. This includes assessment of: -Location -Duration: e.g. is it constant or does it come and go? How long

13 does it last? -Quality: can the patient describe what it feels like e.g. burning, aching, sharp Frequency of pain assessment The frequency of pain assessment should be based on patient s pain intensity. At the very minimum pain should be assessed: -On admission -Along with routine recording of other vital signs - Within 1 hour of an analgesic intervention to ascertain its effect. For patients who have a PCA or epidural in place, pain scores should be assessed according to local guidelines. For further information on pain assessment please see the Acute Pain Manual available on every ward and the intranet. Observation Policy CG003 Page 13 of 36

14 5 Equality, Diversity and Human Rights Impact Assessment 5.1 The best way to promote equality is to make sure it is embedded into all procedural documents. All Trust procedural documents must be inclusive. It is important to address, through consultation, the diverse needs of our community, patients, their carers and our staff. This will be achieved by working to the values and principles set out in the Trust's Equality, Diversity and Human Rights Strategic Framework. The Trust is committed to ensuring all new procedural documents and functions are impact assessed and monitored in accordance within the letter and the spirit of the law regarding equality. The Trust's Equality, Diversity and Human Rights Strategic Framework can be found on the Trust s Intranet or from the Service Equality Team. 5.2 Please contact the Service Equality Team (SET) on Ext for support to complete an initial assessment. Upon completion of the assessment, SET will assign the Policy a unique EqIA Registration Number. 6 Consultation, Approval and Ratification Process 6.1 Consultation Process Consultation and Communication with Stakeholders The document was sent to the following groups for review and ratification: Members of Outreach and Acute Care team Critical Care Clinical director Lead Nurse Critical Care Assistant director of Nursing Critical Care Delivery group Clinical governance Lead 6.2 Policy Approval Process and Ratification Process This policy will be approved and ratified by the Critical Care delivery group 7 Dissemination and Implementation 7.1 Dissemination The policy is available to all staff via the Trust intranet site The policy is launched via Team Brief, Trust wide launch event and briefings from the Outreach and Acute Care Team to line managers at Divisional and Department meetings, also through drop in/ ad hoc sessions, ward meetings and the educators in each division.. Observation Policy CG003 Page 14 of 36 See the Intranet for the latest version. Version Number:-3

15 7.2 Implementation of Procedural Documents All staff receive training detailing the new principles and systems for the policy and implementation date, distributed through their line manager, Early Warning Score Link nurses and departmental meetings The policy is implemented through local training sessions provided in departments by the Outreach, Acute Care Team and divisional educators. 8 Monitoring Compliance of Procedural Documents 8.1 Monitoring Arrangements for Compliance Annual audits will be undertaken of clinical areas and (see Appendix 3) undertaking observations and also as part of the matrons ward round, to ensure that the observations are undertaken in accordance with the trust standard. Any deviation from this policy leading to deterioration of the patient requires completion of an incident report the level of which will be determined on a patient specific basis All in-patient areas of the Trust will be subject to quarterly audit encompassed within the matron s ward round to ensure that TPR charts are completed to the Trust standard as set out in this document Responsibilities for conducting the monitoring/audit will be coordinated by the Senior Nursing Management via the Matrons ward round and results reported to divisional clinical governance Method to be used for monitoring/audit matrons ward round Frequency of monitoring/audit- quarterly on the Matrons Ward round with point prevalence audit as required (appendix 4) Process for reviewing results and ensuring improvements in performance occur: -If the level of accuracy is less than 100%, then the manager for each area will be expected to inform the education development practitioner and lead nurse and heads of nursing for the division so monitoring procedures can be instigated. In conjunction the ward can receive training as required in the accurate recording of fluid balance supported by the Critical Care Outreach team. -All acute in patient areas not meeting 100% accuracy on routine audit are subject to random audit by the Critical Care Outreach team if deemed appropriate and Senior Nursing Management via the Matrons ward round. -Responsibility for audit compliance lies with the Senior Clinical Nurses/Matrons or Directors Action plan contingencies may include: -A thorough evaluation of priorities within the ward area Observation Policy CG003 Page 15 of 36

16 8.2 Competency -Evidenced meetings and awareness sessions with staff. These should demonstrate that each member of staff has been briefed -If a shift in prioritisation impacts on other cares then it will be up to the ward manager to decide how this will be addressed -Attendance at an AIM course -Personal responsibility framework for non compliant staff. If the audits demonstrate that the standards are not met (i.e.100% compliance), the ward manager will ensure all staff are trained and competency assessed (see Appendix 4 for competency document). For all staff there is a competency framework to follow (see Appendix 6) Competency Registered Nurses The NICE guidance 50 (2007) states that staff caring for patients in acute hospital settings should have competencies in monitoring, measuring interpretation and prompt response to the acutely ill patient appropriate to their level of care that they are providing. All new to the Trust nurses, midwives and clinical support workers will receive training during their induction period utilising a presentation provided by the Critical Care Outreach Team that will be supplied to all ward managers, divisional educators and EWS link nurses throughout the Trust. This is also available on the Trust Intranet. To ensure this level of competence for the practitioners in Central Manchester University Hospital NHS Foundation Trust all practitioners under taking observations are able to demonstrate delivery to the standards set within this policy. All new nursing and midwifery staff to the Trust must have their observation competency assessed during their induction period by a competent practitioner Competency for medical staff For medical staff assessments will be carried out as part of their undergraduate training and Objective Structured Clinical Examination (OCSE) assessments Competency for Clinical Support Workers For all new clinical support workers (CSW) to the Trust they must not perform observations until they have satisfactorily passed the required training and assessment. This is training undertaken in two stages. A theoretical assessment as part of the observation study day run by the NVQ department and a practical ward based component. For this later assessment at least five sets of observations must be observed, assessed and documented by the NVQ assessors team. (See Appendix 5 for CSW competency sheet, B). Observation Policy CG003 Page 16 of 36

17 For CSW and Assistant Practitioners presently in the trust an update and assessment of competency course (CSW Adult acute illness study day) should be attended, when identified as required by ward manager or individual concerned, or for a ward who did not achieve 100% compliance on their audit. If they fail this HCSW AIM course the ward manager is contacted and the observations will be observed till the MCQ is passed, if a second fail occurs the ward managers and NVQ coordinator assessor will work with the HCSW until deemed competent-( see appendix 8 ) Competency for Registered Bank Staff For Bank only Registered Nurses working in the trust; they will be ed by NHSP administrators, with a link to the Observations and EWS Trust Policy with instructions that they must read and sign they have read the Policy. On the orientation sheet when they first work in a ward there will be a check to sign by the nurse in charge and themselves, that they have gone through the policies and understand the processes that occur in CMFT with respect to undertaking and appropriate action relating to observation recording and results Competency for CSW Bank Staff For Bank CSW they will be sent a copy of the observation and EWS supportive reading booklet supplied by the NVQ team and will be sent a copy of the assessment document. The questions should be completed before attendance to the ward and once completed they should call the NVQ assessors to observe them undertaking observations in practice. Once 5 sets have been completed and assessed as competent they will receive a sticker for their badges that indicates they a r e competent to undertake observations, if this assessment is not complete they should not undertake observations in clinical wards unless observed and counter signed. (See appendix 10) 9 Standards and Key Performance Indicators KPIs 9.1. The policy is available to all staff via the Trust intranet site 9.2. This policy must be reviewed at least every three years or when there are significant changes to the document. The policy will be reviewed every 3 years 9.3. Training, as required by this policy, will be made available throughout the Trust and supported by the Outreach and Acute Care Team. Training will be reviewed for attendance and content Yearly audit reports will be produced by the Outreach and Acute Care Team utilising matrons ward round data. Observation Policy CG003 Page 17 of 36

18 10 References and Bibliography The Royal Marsden Hospital Manual of Clinical Nursing Procedures, 7th Edition (July 2008) L Dougherty, S Lister, Wiley-Blackwell Safer care for the acutely ill patient: learning from serious incidents. National Patient Safety Agency, November 2007 PSO/5 National Institute for Health and Clinical Excellence, Acutely ill patients in Hospital. Department of Health, Associated Trust Documents All available on the intranet Early warning score policy 11.2 Sepsis version guideline Fluid balance policy 12 Appendices Observation Policy CG003 See the Intranet Observation for the latest Policy version. CG002 Version Number:- 3 Page 18 of 36

19 Appendix 1 Observation Policy CG003 Page 19 of 36

20 Measurement of Acute Pain / Pain Score There are a number of scales that can be used at the bedside to evaluate pain intensity and gauge the effectiveness of a particular treatment. The goal of pain measurement is to translate the patient s description of pain intensity into numbers or words. It is important that any measurement scale be applied before and after treatment so that effect can be measured. Various numerical scales exist. The scale used by this Trust is the 0-10 Verbal Rating Scale. 0 = No Pain & 10 = the worst pain possible The patient is asked, What number would you give to your pain right now? When using the scale it is important to request the patient s self report, not only with the patient at rest but also during activity such as coughing, deep breathing or moving. Glasgow Coma Scale, To be used only when requested or following a patient fall where an actual or potential injury to the head may have occurred. Best eye opening response Score Response 4 Patient opens eyes spontaneously when nurse approaches bedside 3 Patient opens eyes in response to speech (spoken or shouted) 2 Patient opens eyes in response to painful stimuli 1 Patient does not open eyes at all C To be recorded if patients eyes are closed due to peri-orbital swelling Best verbal response Score Response 5 Patient is orientated to time, place + person (Allowances are made for minor inconsistencies) 4 Patient is confused in conversation (able to converse but gives completely wrong answers) 3 Patient speaks only in appropriate words (minimal verbal response such as obscenities or interchanges Yes/No) dysphasia 2 Patient makes only incomprehensible sounds (grunts or moans to verbal or painful stimuli) 1 No response Best motor response (best arm response is recorded to central stimuli) Score Response 6 Can only obey simple commands such as put out you tongue, lift your hand etc. 5 Localises to pain (moves hand to remove a source of irritation) 4 Attempts to withdraw from the source of pain 3 Flexion to pain 2 Extension to pain 1 No response, even to painful stimuli, in any limb Observation Policy CG003 Page 20 of 36

21 Appendix 2 Observation Policy CG003 Page 21 of 36 See the Intranet for the Version Number:- 3 latest version.

22 Adult Altered Level of Consciousness Assessment Reference Guide Eye Opening Glasgow Coma Scale Assessing eye opening provides an indication of the patient s arousal ability by observing for the best possible response. Determine if the patient responds to speech (use a loud voice) or to touch. If the patient does not respond, use painful stimuli by applying a trapezius pinch to determine if there is a response. If the patient cannot open his or her eyes due to swelling or eyes continuously open, record C. Verbal Response This determines appropriateness of the patient s speech. The patient s attention should be gained and a conversation attempted, allowing adequate time for the patient to respond. Consider the patient s preferred language; any diagnosed medical problems that may influence the patient s ability to respond, e.g. learning difficulties, deaf, previous stroke, and level of confusion prior and determine if there are any changes to the patient s condition. Record the best possible response: o Orientated: patient can respond appropriately to person/place/time o Confused: patient can talk but is not orientated o Inappropriate words: speaks only a few words, usually only in response to physical or painful stimuli o Incomprehensible sounds: unintelligible sounds such as moans o None: no response after prolonged stimulation Motor Response Assess the patient using simple commands to determine if the patient has the awareness / ability to respond by movement. If the patient does not respond to verbal commands check the patient s best motor response to painful stimuli by performing a trapezius pinch. Consider the patient s usual level of comprehension, usual ability to move his or her body and any existing medical diagnoses that may contribute to the patient s movement. Record the best possible response: o o o o Obeys command: follows your command Localises pain: moves limb away from painful stimuli in a purposeful way or attempts to push painful stimulus away Flexion to pain: responds to painful stimuli by bending arms up but does not localise pain Extension to pain: responds to painful stimuli by straightening arms but does not localise pain Pupil Assessment Assess the patient s pupil size and response to light using a pen torch. This can provide a useful indication if the problem lies within the brain. An assessment should first be made as to whether the patient s pupils are of equal size and then whether they react equally to exposure to light. Bilateral dilation can indicate drug intoxication. Unilateral dilated pupil can be an important sign of intracranial haemorrhage, it should not be ignored. Bilateral constriction is seen in opiate overdose and brainstem infarction. Limb Movement Assessment This assesses all four limbs as to just the best limb response associated with the GCS. To perform the assessment, instruct the patient to lift their limbs up against gravity or resistance. If the patient does not respond to your request, assess limb movement in response to pain. Observe the type of movement the patient can perform, and compare strength of limbs on both sides of the body. In assessing the patient s limb movements and strength, consider the patient s previous condition and any medical diagnoses that may effect normal limb movement. Record: o Normal power movements are within the patient s normal power strength o Mild weakness cannot fully lift limbs against gravity and struggles to move against resistance o Severe weakness can move limbs but cannot move against gravity or resistance o Extension limbs straighten National Institute for Health and Clinical Excellence Head Injury: Triage, assessment, investigation and early management of infants, children and adults. London. NICE GM Critical Care Skills Institute AIM. Manchester. GM Critical Care Skills Institute Observation Policy CG003 Page 22 of 36

23 Communication Sheet Appendix 3 S o Inform the nurse in charge Perform relevant nursing intervention Situation o Your name is o Patients name is o Age. o Sex Male Female o Bed Number Ward.. B A R o Why you are calling Background o Reason for admission. o Recent Surgery if yes... Assessment Having assessed the patient EWS= A. Airway is Oxygen is at.via a... B. RR is..rhythm... Depth...Symmetry Colour Saturation.. C. Pulse (Reg/ Irreg).BP Temperature..CRT. Urine Output in the last hour...last 4 hours... D. AVPU score Any changes to mental state Blood Glucose..Pupils size / reaction. Pain Score; Movement Rest. E. Head to toe examination; Patient has Blood loss Abnormal swelling Loss from drains/ wounds. Recommendation o What do you want from person calling?.. o How urgent is it?. o What can be done in the meantime..... What time will Medical staff attend?. Time of review o Ensure documentation in kardex o Time of Call o Person Making call and name of medical staff spoken to o Relevant intervention o Assessment and Plan Observation Policy CG003 Page 23 of 36

24 Observation Policy CG003 Page 24 of 36 Appendix 4 Observation Audit tool Question Ob1 Ob2 Ob3 Ob4 Ob5 1 Temperature YES NO YES NO YES NO YES NO YES NO Is the probe placed in the ear according to the Trust Standard? (i.e. fitted snugly and ear lifted a upwards and outwards?)* b Is the temperature correctly recorded? (i.e. has the device indicated reading complete?)* c Is the reading correctly documented on the TPR chart? 2 Pulse a Is pulse monitored using middle fingers only? b Is pulse measured prior to blood pressure? c Is rate counted for 60 seconds using a clock or watch with a second hand? d Is heart rate correctly documented on the TPR chart? 3 Blood Pressure a Is the patient s arm rested? b Is restrictive clothing removed from the patient s arm? c Does the inflatable cuff cover at least 80% of the upper arm? d Is the equipment checked/functioning correctly?* If recording is undertaken using a manual sphygmomanometer: (e/f) e Is the systolic pressure read correctly according to the trust standard?* f Is the cuff deflated at the correct rate?* g Is the reading correctly documented on the TPR Chart? 4 Respiration a Is the chest easily observed? b Is the respiratory rate measured over 60 seconds using a clock/watch with a second hand? 5 Pulse Oximetry a Has the probe been applied correctly?* b Is the saturation indicated accurately on the TPR Chart? 6 AVPU a Has the appropriate EWS been assigned in relation to the patient s level of consciousness 7 TPR Chart a Has black pen been used to complete the TPR Chart? b Has the EWS score been calculated accurately?

25 Appendix 5 Competency documentation; A Name... Assessors name. Assessors Signature Date.. Pass Fail Refer The idea of the following competencies is that you will be competent at observation taking within your areas of work. The competencies have been based on the Acute care competencies and in conjunction with the observation policy in Central Manchester Foundation Trust Aim for all to achieve level 3 prior to undertaking observations in practice Observation Policy CG003 Page 25 of 36 See the Intranet for the latest version. Version Number:- 2

26 Core Competencies Observation Policy CG003 Page 26 of 36

27 Level All All * * All All * Level Equipment Pulse oximetry Dinamaps Stethoscopes Sphygmomanometers Tympanic thermometer 0 2 therapy devices And any other equipment utilized within the clinical environment. Qualified practitioner and those utilising equipment as routine Observations Respiratory rate, rhythm and depth Accessory muscle use Colour/perfusion Chest expansion O 2 saturation (SpO 2) Conscious Level ABG Sputum specimen Assessment Criteria: 1. Demonstrates the ability to perform accurate observation of respiratory rate, rhythm, depth, chest expansion and use of accessory muscles 2. Identifies signs of respiratory distress and hypoxia 3. Demonstrates the ability to prioritise care and act on findings 4. Demonstrates the ability to select and use appropriate equipment to undertake respiratory assessment 5. Demonstrates the ability to perform accurate observation of Pulse rate, including rate, rhythm, volume, and character 6. Demonstrates the ability to perform accurate observation of the blood pressure 7. Demonstrates the ability to select and use appropriate equipment to undertake blood pressures appropriate to competence level (as per Observation protocol) 8. Demonstrates the ability to perform accurate observation of temperature 9. Demonstrates the ability to select and use appropriate equipment to undertake temperature 10. Demonstrates the ability to perform accurate observation of neurological status utilising AVPU scale 11. Demonstrates the ability to perform accurate observation of oxygen saturation 12. Recognises the importance of safely administering 0 2 therapy 13. Demonstrates t h e a b i l i t y t o p r o d u c e a c c u r a t e, c l e a r, l e g i b l e and t i m e l y communication and documentation. 14. Ensure the learner demonstrates understanding of infection control when undertaking observations Observation Policy CG003 Page 27 of 36

28 Assessment Temperature 1 Can the staff member give you two reasons why temp is recorded 2 Can they tell you normal range 3 Does the learner know how to clean the device 4 Does the learner know how often to change the probe 5 Is the probe placed in the ear correctly according to trust standard? 6 Is the reading taken correctly? Pulse 1 Can the learner define what a pulse is? 2 Can learner state why we measure the pulse rate? (One reason is adequate) 3 Can staff members name three sites we can measure the HR? 4 Can the learner state the normal? 5 Is the reading taken correctly according to trust standard? Gently presses over site with second or third finger Count for 60 seconds Can say rhythm and number TPR chart 1 Can the learner fill in the TPR chart and patientrack system (if used) accurately and calculate the EWS? 2 Does the learner know what to do with an EWS > 3? BP 1 Can the staff member give a reason why BP is recorded? Can the learner state 2 things that may effect BP? When using a sphygmomanometer 2 Can the learner tell you when/ how systolic BP is recorded? 3 How is diastolic recorded? 4 Check that the procedure is accurate utilising a sphygmomanometer according to trust standard Patients arm is rested All clothing is removed from arm Arm with fistula is not used Cuff is applied correctly The cuff is inflated, the brachial can no longer be felt; this provides an estimation of systolic Cuff inflated 30 mmhg above systolic Stethoscope placed over brachial artery Cuff deflated 2-3 mmhg per sec When using an automated blood pressure machine 5 Check that the procedure utilising dianamap is accurate Patients arm is rested All clothing is removed Arm with fistula is not used Cuff is applied correctly Is reading taken correctly 6 Can the learner state when a manual BP should be taken and who should take it? Competency achieved Y/ N Observation Policy CG003 Page 28 of 36

29 Respiration 1 Can the learner tell you 3 things to look for when looking at resp rate 2 Can the state how else we could assess respiration/ breathing according to trust standard 3 Can the learner undertake the assessment effectively Patient is comfortable and the chest is easily observed A cycle for 60 seconds is measured Neurological Status 1 Can the learner explain what AVPU stands for? 2 Can they correctly fill in the AVPU score into the TPR chart? Pulse oximetry 1 Can the learner state why we measure oxygen saturations 2 Can the learner name three limitations of Pulse Oximetry 3 Can the learner demonstrate the procedure as the observation standard requests; applying probe and identifying an adequate signal Infection Control 1 Does the learner wash their hands/ apply alcohol gel prior to undertaking the observations Competency achieved Y/N Keep a copy for your records and return a copy to you ward manager / clinical educator Observation Policy CG003 Page 29 of 36

30 Appendix 6 TCSW assessment of Clinical Observation Skills Criteria :- 1. Minimum of five supervised recordings of all parameters must be assessed for competence by band 4 and above, a qualified assessor and be on different clients, 2. Only seven of the recording s for blood pressure may be using electronic equipment. Must detail method of recording on chart (E) = Electronic (M) = Manual 3. Pulse needs to be measured electronically (if using electronic equipment for blood pressure) and also manually for one full minute 4. Respiration rate please indicate whether this was measured over a full minute. 5. All recordings must be within a 4 week period. 6. The Assessor is signing to verify competence, and accuracy of the recording and the documentation of the recording, including the recognition of abnormal recording and appropriate reporting and actions. 7. The worker must not in any circumstances undertake unsupervised recording of the observations identified above until the assessment sheet is fully completed, and this can be signed off by any of the following: the ward manager, education and development practitioner, Clinical Educator or CNL. The TCSW needs to sign the declaration of self competence Method of Blood HR Temp Level of Pulse Resp EWS Aware of Signed by assessor Assessors full name Title Date recording Pressure consciousness Oximetry Rate Completed appropriate (Print) (M) or (E) (AVPU) action to be taken (See note 5 above) Ward manager verifying satisfactory completion of supervised assessed practice within 4 week period. Name Signature Date Signature of worker. I confident to undertake unsupervised practice:- Signature.date have undertaken supervised assessed practice as identified within the assessment criteria, and feel competent and Processed by NVQ Internal Verifier Signature Date Observation Policy CG003 Page 30 of 36

31 Appendix 7 Flow Chart for assessment RGN in Post New RGN starting in trust CSW in post New CSW starting in trust Implement observation standards into ward Audit Areas <100% targeted; Training and competency assessment Audit Competency assessment Given observation standard Competency assessment If further training required, attend CSW, adult acute illness study day Observation study day with NVQ, theoretical and practical assessment On re-audit if area remains non compliance, outreach team will support education in relation to observations, along with divisional educators. Assessments may be retaken on individuals as required. Subsequent audits will take place after following 3 months Observation Policy CG003 Page 31 of 36