THE ROYAL CORNWALL HOSPITALS NHS TRUST RESPONSE TO INFORMATION REQUEST. Date Request Received: 20 October 2014 FOI Ref: 567

FREEDOM OF INFORMATION ACT 2000 THE ROYAL CORNWALL HOSPITALS NHS TRUST RESPONSE TO INFORMATION REQUEST Date Request Received: 20 October 2014 FOI Ref: 567 Requested Information I would like to know whether the early warning score of patient s physiological observations have been carried out appropriately and escalated appropriately in the deteriorating patient. 1) I would like any information you may have regarding the above in the form of recent audits if these are carried out?; or Any audit results following cardiac arrest and whether the early warning score was used appropriately prior to the cardiac arrest? 2) How are staff trained in relation to early warning scores e.g. study day / workbook / competences / observed practice or e- learning? 3) Please could you search the DATIX system for related incidents to determine if the early earning score of patient s physiological observations have been carried out appropriately and escalated appropriately in the deteriorating patient? *For Questions 1) and 3), please can you provide data for the last 3 years Response In April 2013, the Royal Cornwall Hospitals Trust (RCHT) introduced the National Early Warning Score (NEWS); this replaced the Modified Early Warning System (MEWS). NEWS is a standardised physiological assessment tool, designed to monitor and track acutely and critically ill patients, which enforces the necessity of early escalation and clinical review. The NEWS is based on a simple scoring system in which a score is allocated to physiological measurements already undertaken when patients present to, or are being monitored in hospital. 1) Each month, data is collected from our clinical areas with regards to the Nursing Quality Indicators which form part of the Quality Domain of the Wards and Divisional Performance, Assurance Framework and in this data collection, there are 4 questions relating to Early Warning Scores (EWS); a total of 10 NEWS charts per clinical area (where applicable) will be audited. Attached as Appendix 1 are the results of the EWS Question Analysis 1. Please be advised that the EWS and Risk Assessment questionnaire only goes as far back as October 2012 data prior to this date is not held. We do not hold any audit reports following cardiac arrest; in January 2015, the Trust will join the National Cardiac Arrest Audit and it is hoped that a new robust reporting system will include this information. 2) Registered Nurses are deemed competent to carry out patient observations by virtue of their 3 year training. With regards to the use of EWS, they are required to undertake the e-learning module 000 National Early Warning Scores (NEWS) which is accessed through the National Learning Management System. The skills of registered nurses in relation to the recording of patient observations, recognition of deterioration, NEWS, accountability and delegation and Nurse Led Escalation/management is further supported through their Continuing Professional Development (CPD) options such as the ALERT course, Intermediate Life Support (ILS), Advanced Life Support (ALS), Excellence in Practice Clinical Update for Registered Nurses and HEA 332 (Care of Critically Ill Adults in Non - 1 Please note that some data in the report is shown as 0% or blank this is because not all the questions are relevant to every patient. Page 1 of 2

Critical Care Acute Areas) 40 credit degree module. Healthcare Support Workers (HCSW) undertake the Patient Observations and NEWS Training when they have fully completed their induction and skills portfolio. Once they have completed their induction (usually in the region of 3 months for HCSWs new to acute healthcare), they attend a patient observations study day which incorporates the NEWS training. They are also required to undertake the e-learning module 000 National Early Warning Scores (NEWS) and the 156 patient observations and NEWS online via the National Learning Management System. They must then undertake supervised practice and the supervised practice workbook in their ward area prior to undertaking patient observations and NEWS scoring without supervision. (Please note, prior to the availability of the e-learning, staff completed the self directed learning pack and successful completion is recorded on the skills database). Healthcare assistant competencies in this skill are expected to be reviewed annually. They can also attend the ALERT course which is funded for them via Learning and Development. Please note that as part of on-going quality and safety initiatives, over the months of October and November 2014, the NEWS and Escalation (SBARD) educational toolkit will be delivered to all clinical staff across the site. This is frontline training which is delivered face to face at Safety Briefings at ward or unit level, at divisional meetings and/or existing training and development sessions (please refer to Appendix 2 please note that the scenario in the training toolkit is taken from a national case-study). 3) A search on DATIX 2 over the past 3 years has identified 28 reported incidents where Early Warning Scores and escalation in deteriorating patients were reported as a concern; however, due to the way information is recorded on DATIX, we are unable to determine (within the appropriate limit 3 ) if these claims were upheld, as to do so we would have to manually retrieve and decipher patient notes and any other reports produced for all 28 reported incidents. Attachment(s)? Appendix 1 Early Warning Score Questions Analysis (October 2012 2014) Appendix 2 The NEWS and Escalation (SBARD) Educational Toolkit Date Response Sent: 14 November 2014 2 DATIX is patient safety software for healthcare risk management, incident and adverse event reporting. 3 The appropriate limit is specified in regulations and for the Royal Cornwall Hospitals Trust (RCHT) this is set at 450. This represents the estimated cost of one person spending 2½ working days in determining whether the RCHT hold the information, and locating, retrieving and extracting the information. Consequently the RCHT is not obliged under Section 12 of the Freedom of Information Act 2000 to respond to this part of your request. Julie Hughes, FOI Officer Version No. V1 Review Date: 01 December 2024 Page 2 of 2

Nursing Metrics - EWS Questions Analysis Month 2012 2013 2014 Grand Total Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Question No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes Cardiac Investigation Unit 3% 97% 0% 100% 5% 95% 15% 85% 3% 97% 3% 97% 4% 96% 0% 100% 1% 99% 9% 91% 5% 95% 2% 98% 2% 98% 9% 91% 2% 98% 5% 95% 0% 100% 6% 94% 5% 95% 10% 90% 0% 100% 4% 96% 0% 100% 100% Are all essential EWS observations for the last 7 entries recorded, totalled and signed off (TPR, B/P, O² Sats, and AVPU)? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Are fluid balance observations documented and the 24 hour balance totalled? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 8% 92% 0% 100% 50% 50% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 50% 50% 0% 100% 0% 100% 0% 100% 100% EWS recordings = documented EWS frequency? 0% 100% 0% 100% 0% 100% 29% 71% 0% 100% 11% 89% 0% 100% 0% 100% 0% 100% 20% 80% 10% 90% 0% 100% 10% 90% 13% 88% 10% 90% 10% 90% 0% 100% 0% 100% 20% 80% 20% 80% 0% 100% 17% 83% 0% 100% 100% EWS risk category being actioned appropriately? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 11% 89% 0% 100% 0% 100% 20% 80% 10% 90% 0% 100% 0% 100% 13% 88% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 10% 90% 0% 100% 0% 100% 0% 100% 100% Is frequency of EWS observations documented and up-to-date? 10% 90% 0% 100% 22% 78% 40% 60% 10% 90% 0% 100% 10% 90% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 13% 88% 0% 100% 10% 90% 0% 100% 20% 80% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Carnkie Ward 8% 92% 33% 67% 13% 87% 0% 100% 9% 91% 22% 78% 2% 98% 0% 100% 0% 100% 0% 100% 0% 100% 8% 92% 0% 100% 0% 100% 4% 96% 9% 91% 2% 98% 2% 98% 2% 98% 0% 100% 7% 93% 0% 100% 8% 92% 100% Are all essential EWS observations for the last 7 entries recorded, totalled and signed off (TPR, B/P, O² Sats, and AVPU)? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 10% 90% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Are fluid balance observations documented and the 24 hour balance totalled? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 17% 83% 20% 80% 0% 100% 0% 100% 0% 100% 0% 100% 50% 50% 0% 100% 0% 100% 25% 75% 67% 33% 0% 100% 10% 90% 17% 83% 0% 100% 20% 80% 0% 100% 50% 50% 100% EWS recordings = documented EWS frequency? 20% 80% 100% 0% 30% 70% 0% 100% 0% 100% 40% 60% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 13% 88% 0% 100% 0% 100% 0% 100% 20% 80% 0% 100% 0% 100% 100% EWS risk category being actioned appropriately? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Is frequency of EWS observations documented and up-to-date? 20% 80% 91% 9% 30% 70% 0% 100% 40% 60% 40% 60% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Casulty Department 0% 100% 100% Are all essential EWS observations for the last 7 entries recorded, totalled and signed off (TPR, B/P, O² Sats, and AVPU)? 0% 100% 100% Are fluid balance observations documented and the 24 hour balance totalled? 0% 100% 100% EWS recordings = documented EWS frequency? 0% 100% 100% Is frequency of EWS observations documented and up-to-date? 0% 100% 100% CDU 0% 100% 50% 50% 100% Are all essential EWS observations for the last 7 entries recorded, totalled and signed off (TPR, B/P, O² Sats, and AVPU)? 0% 100% 100% EWS recordings = documented EWS frequency? 0% 100% 100% 0% 100% EWS risk category being actioned appropriately? 0% 100% 0% 100% 100% Is frequency of EWS observations documented and up-to-date? 100% 0% 100% Coronary Care Unit 0% 100% 5% 95% 0% 100% 3% 97% 0% 100% 0% 100% 0% 100% 0% 100% 7% 93% 11% 89% 0% 100% 0% 100% 0% 100% 7% 93% 10% 90% 0% 100% 0% 100% 0% 100% 0% 100% 4% 96% 100% Are all essential EWS observations for the last 7 entries recorded, totalled and signed off (TPR, B/P, O² Sats, and AVPU)? 0% 100% 20% 80% 0% 100% 9% 91% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 20% 80% 0% 100% 0% 100% 0% 100% 11% 89% 27% 73% 0% 100% 0% 100% 0% 100% 0% 100% 17% 83% 100% Are fluid balance observations documented and the 24 hour balance totalled? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 20% 80% 14% 86% 0% 100% 0% 100% 0% 100% 13% 88% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% EWS recordings = documented EWS frequency? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% EWS risk category being actioned appropriately? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Is frequency of EWS observations documented and up-to-date? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Emergency Department 6% 94% 0% 100% 6% 94% 58% 42% 40% 60% 38% 62% 24% 76% 6% 94% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Are all essential EWS observations for the last 7 entries recorded, totalled and signed off (TPR, B/P, O² Sats, and AVPU)? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Are fluid balance observations documented and the 24 hour balance totalled? 0% 100% 0% 100% 0% 100% 100% EWS recordings = documented EWS frequency? 20% 80% 0% 100% 20% 80% 90% 10% 80% 20% 80% 20% 27% 73% 10% 90% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% EWS risk category being actioned appropriately? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Is frequency of EWS observations documented and up-to-date? 0% 100% 0% 100% 0% 100% 100% 0% 0% 100% 45% 55% 10% 90% 0% 100% 0% 100% 0% 100% 0% 100% 100% Endoscopy Unit 0% 100% 100% Is frequency of EWS observations documented and up-to-date? 0% 100% 100% Frailty Unit 0% 100% 0% 100% 0% 100% 100% Are all essential EWS observations for the last 7 entries recorded, totalled and signed off (TPR, B/P, O² Sats, and AVPU)? 0% 100% 0% 100% 0% 100% 100% Are fluid balance observations documented and the 24 hour balance totalled? 0% 100% 0% 100% 0% 100% 100% EWS recordings = documented EWS frequency? 0% 100% 0% 100% 0% 100% 100% EWS risk category being actioned appropriately? 0% 100% 0% 100% 0% 100% 100% Is frequency of EWS observations documented and up-to-date? 0% 100% 0% 100% 0% 100% 100% Grenville Ward 3% 98% 0% 100% 13% 87% 6% 94% 9% 91% 6% 94% 2% 98% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 4% 96% 0% 100% 0% 100% 0% 100% 0% 100% 2% 98% 0% 100% 0% 100% 5% 95% 0% 100% 100% Are all essential EWS observations for the last 7 entries recorded, totalled and signed off (TPR, B/P, O² Sats, and AVPU)? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Are fluid balance observations documented and the 24 hour balance totalled? 0% 100% 0% 100% 13% 88% 0% 100% 0% 100% 11% 89% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 29% 71% 0% 100% 0% 100% 0% 100% 0% 100% 11% 89% 0% 100% 0% 100% 25% 75% 0% 100% 100% EWS recordings = documented EWS frequency? 0% 100% 0% 100% 31% 69% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% EWS risk category being actioned appropriately? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Is frequency of EWS observations documented and up-to-date? 10% 90% 0% 100% 31% 69% 20% 80% 40% 60% 30% 70% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Harlyn 0% 100% 0% 100% 0% 100% 0% 100% 100% Are all essential EWS observations for the last 7 entries recorded, totalled and signed off (TPR, B/P, O² Sats, and AVPU)? 0% 100% 0% 100% 0% 100% 0% 100% 100% Are fluid balance observations documented and the 24 hour balance totalled? 0% 100% 0% 100% 0% 100% 100% EWS recordings = documented EWS frequency? 0% 100% 0% 100% 0% 100% 0% 100% 100% EWS risk category being actioned appropriately? 0% 100% 0% 100% 0% 100% 0% 100% 100% Is frequency of EWS observations documented and up-to-date? 0% 100% 0% 100% 0% 100% 0% 100% 100% ITU 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Are all essential EWS observations for the last 7 entries recorded, totalled and signed off (TPR, B/P, O² Sats, and AVPU)? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Are fluid balance observations documented and the 24 hour balance totalled? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% EWS recordings = documented EWS frequency? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% EWS risk category being actioned appropriately? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Is frequency of EWS observations documented and up-to-date? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Lowen 0% 100% 0% 100% 0% 100% 23% 77% 2% 98% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 2% 98% 2% 98% 0% 100% 4% 96% 0% 100% 0% 100% 4% 96% 5% 95% 0% 100% 14% 86% 18% 82% 22% 78% 34% 66% 26% 74% 100% Are all essential EWS observations for the last 7 entries recorded, totalled and signed off (TPR, B/P, O² Sats, and AVPU)? 0% 100% 0% 100% 0% 100% 73% 27% 10% 90% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 10% 90% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 10% 90% 17% 83% 16% 84% 9% 91% 0% 100% 100% Are fluid balance observations documented and the 24 hour balance totalled? 0% 100% 0% 100% 0% 100% 33% 67% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 20% 80% 0% 100% 29% 71% 0% 100% 0% 100% 29% 71% 67% 33% 0% 100% 67% 33% 50% 50% 67% 33% 91% 9% 0% 100% 100% EWS recordings = documented EWS frequency? 0% 100% 0% 100% 0% 100% 9% 91% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 30% 70% 15% 85% 20% 80% 18% 82% 60% 40% 100% EWS risk category being actioned appropriately? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 11% 89% 5% 95% 33% 67% 0% 100% 100% Is frequency of EWS observations documented and up-to-date? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 15% 85% 25% 75% 18% 82% 50% 50% 100% Marie Therese House 3% 98% 0% 100% 0% 100% 3% 98% 3% 98% 3% 98% 11% 89% 5% 95% 2% 98% 3% 98% 13% 88% 6% 94% 3% 98% 0% 100% 6% 94% 8% 93% 8% 93% 8% 93% 3% 98% 5% 95% 3% 98% 5% 95% 100% Are all essential EWS observations for the last 7 entries recorded, totalled and signed off (TPR, B/P, O² Sats, and AVPU)? 10% 90% 0% 100% 0% 100% 11% 89% 10% 90% 10% 90% 36% 64% 18% 82% 0% 100% 10% 90% 50% 50% 22% 78% 0% 100% 0% 100% 8% 92% 20% 80% 20% 80% 20% 80% 10% 90% 0% 100% 10% 90% 20% 80% 100% Are fluid balance observations documented and the 24 hour balance totalled? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% EWS recordings = documented EWS frequency? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 8% 92% 0% 100% 10% 90% 0% 100% 0% 100% 10% 90% 0% 100% 0% 100% 100% EWS risk category being actioned appropriately? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 9% 91% 0% 100% 9% 91% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 8% 92% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Is frequency of EWS observations documented and up-to-date? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 10% 90% 0% 100% 0% 100% 10% 90% 0% 100% 10% 90% 0% 100% 10% 90% 0% 100% 0% 100% 100% MED1 Ward 17% 83% 7% 93% 8% 92% 11% 89% 5% 95% 0% 100% 11% 89% 11% 89% 2% 98% 2% 98% 2% 98% 11% 89% 6% 94% 11% 89% 28% 72% 0% 100% 2% 98% 17% 83% 33% 67% 11% 89% 53% 47% 32% 68% 26% 74% 2% 98% 7% 93% 100% Are all essential EWS observations for the last 7 entries recorded, totalled and signed off (TPR, B/P, O² Sats, and AVPU)? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 25% 75% 0% 100% 0% 100% 0% 100% 0% 100% 100% Are fluid balance observations documented and the 24 hour balance totalled? 50% 50% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 33% 67% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 50% 50% 0% 100% 0% 100% 50% 50% 50% 50% 0% 100% 67% 33% 67% 33% 33% 67% 0% 100% 25% 75% 100% EWS recordings = documented EWS frequency? 0% 100% 33% 67% 33% 67% 25% 75% 0% 100% 0% 100% 25% 75% 25% 75% 10% 90% 10% 90% 10% 90% 25% 75% 25% 75% 25% 75% 50% 50% 0% 100% 10% 90% 25% 75% 50% 50% 0% 100% 75% 25% 50% 50% 50% 50% 10% 90% 0% 100% 100% EWS risk category being actioned appropriately? 0% 100% 0% 100% 0% 100% 25% 75% 25% 75% 0% 100% 25% 75% 0% 100% 0% 100% 0% 100% 0% 100% 25% 75% 0% 100% 25% 75% 50% 50% 0% 100% 0% 100% 25% 75% 50% 50% 25% 75% 50% 50% 0% 100% 25% 75% 0% 100% 0% 100% 100% Is frequency of EWS observations documented and up-to-date? 50% 50% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 25% 75% 25% 75% 50% 50% 50% 50% 25% 75% 0% 100% 20% 80% 100% MED2 Ward 7% 93% 7% 93% 13% 87% 14% 86% 6% 94% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 18% 82% 56% 44% 100% Are all essential EWS observations for the last 7 entries recorded, totalled and signed off (TPR, B/P, O² Sats, and AVPU)? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Are fluid balance observations documented and the 24 hour balance totalled? 25% 75% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% EWS recordings = documented EWS frequency? 20% 80% 33% 67% 40% 60% 13% 88% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 50% 50% 100% 0% 100% EWS risk category being actioned appropriately? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Is frequency of EWS observations documented and up-to-date? 0% 100% 0% 100% 20% 80% 50% 50% 25% 75% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 40% 60% 100% 0% 100% Medical Assessment Unit 23% 77% 7% 93% 10% 90% 7% 93% 12% 88% 0% 100% 0% 100% 0% 100% 0% 100% 4% 96% 0% 100% 5% 95% 0% 100% 100% Are all essential EWS observations for the last 7 entries recorded, totalled and signed off (TPR, B/P, O² Sats, and AVPU)? 20% 80% 10% 90% 0% 100% 10% 90% 13% 88% 0% 100% 0% 100% 0% 100% 0% 100% 10% 90% 0% 100% 10% 90% 0% 100% 100% Are fluid balance observations documented and the 24 hour balance totalled? 25% 75% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% EWS recordings = documented EWS frequency? 30% 70% 10% 90% 20% 80% 10% 90% 13% 88% 0% 100% 0% 100% 0% 100% 10% 90% 0% 100% 100% EWS risk category being actioned appropriately? 10% 90% 0% 100% 0% 100% 0% 100% 13% 88% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Is frequency of EWS observations documented and up-to-date? 30% 70% 10% 90% 20% 80% 10% 90% 13% 88% 0% 100% 0% 100% 0% 100% 0% 100% 100% Neonatal Unit 0% 100% 0% 100% 14% 86% 0% 100% 67% 33% 29% 71% 33% 67% 25% 75% 0% 100% 100% Are fluid balance observations documented and the 24 hour balance totalled? 0% 100% 0% 100% 17% 83% 0% 100% 67% 33% 29% 71% 33% 67% 25% 75% 0% 100% 100% EWS recordings = documented EWS frequency? 0% 100% 100% Pendennis Ward 8% 92% 42% 58% 15% 85% 4% 96% 100% Are all essential EWS observations for the last 7 entries recorded, totalled and signed off (TPR, B/P, O² Sats, and AVPU)? 20% 80% 0% 100% 10% 90% 11% 89% 100% Are fluid balance observations documented and the 24 hour balance totalled? 20% 80% 0% 100% 0% 100% 0% 100% 100% EWS recordings = documented EWS frequency? 0% 100% 100% 0% 11% 89% 0% 100% 100% EWS risk category being actioned appropriately? 0% 100% 10% 90% 20% 80% 0% 100% 100% Is frequency of EWS observations documented and up-to-date? 0% 100% 100% 0% 30% 70% 10% 90% 100% Phoenix Ward 0% 100% 18% 82% 13% 87% 30% 70% 7% 93% 0% 100% 0% 100% 2% 98% 11% 89% 6% 94% 13% 88% 12% 88% 20% 80% 0% 100% 0% 100% 20% 80% 0% 100% 3% 97% 0% 100% 0% 100% 0% 100% 5% 95% 5% 95% 16% 84% 16% 84% 100% Are all essential EWS observations for the last 7 entries recorded, totalled and signed off (TPR, B/P, O² Sats, and AVPU)? 0% 100% 0% 100% 0% 100% 10% 90% 13% 88% 0% 100% 0% 100% 0% 100% 20% 80% 10% 90% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 50% 50% 100% Are fluid balance observations documented and the 24 hour balance totalled? 0% 100% 22% 78% 22% 78% 0% 100% 29% 71% 0% 100% 0% 100% 13% 88% 29% 71% 17% 83% 67% 33% 0% 100% 100% 0% 0% 100% 0% 100% 67% 33% 0% 100% 17% 83% 0% 100% 0% 100% 0% 100% 25% 75% 25% 75% 0% 100% 13% 88% 100% EWS recordings = documented EWS frequency? 0% 100% 30% 70% 0% 100% 33% 67% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 20% 80% 0% 100% 0% 100% 25% 75% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 40% 60% 0% 100% 100% EWS risk category being actioned appropriately? 0% 100% 10% 90% 0% 100% 11% 89% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 20% 80% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 40% 60% 0% 100% 100% Is frequency of EWS observations documented and up-to-date? 0% 100% 30% 70% 40% 60% 80% 20% 0% 100% 0% 100% 0% 100% 0% 100% 20% 80% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Poldark Ward 0% 100% 4% 96% 0% 100% 0% 100% 6% 94% 0% 100% 10% 90% 0% 100% 0% 100% 0% 100% 6% 94% 14% 86% 22% 78% 100% Are all essential EWS observations for the last 7 entries recorded, totalled and signed off (TPR, B/P, O² Sats, and AVPU)? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 10% 90% 0% 100% 0% 100% 0% 100% 0% 100% 10% 90% 40% 60% 100% Are fluid balance observations documented and the 24 hour balance totalled? 0% 100% 10% 90% 0% 100% 0% 100% 9% 91% 0% 100% 11% 89% 0% 100% 0% 100% 0% 100% 10% 90% 10% 90% 0% 100% 100% EWS recordings = documented EWS frequency? 0% 100% 10% 90% 0% 100% 0% 100% 18% 82% 0% 100% 10% 90% 0% 100% 0% 100% 0% 100% 20% 80% 40% 60% 40% 60% 100% EWS risk category being actioned appropriately? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 11% 89% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 10% 90% 100% Is frequency of EWS observations documented and up-to-date? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 10% 90% 0% 100% 0% 100% 0% 100% 0% 100% 10% 90% 20% 80% 100% Polkerris Ward / Paed HDU / Assesment Unit 0% 100% 0% 100% 0% 100% 8% 92% 0% 100% 23% 77% 5% 95% 16% 84% 100% Are all essential EWS observations for the last 7 entries recorded, totalled and signed off (TPR, B/P, O² Sats, and AVPU)? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 20% 80% 0% 100% 100% Are fluid balance observations documented and the 24 hour balance totalled? 0% 100% 0% 100% 0% 100% 40% 60% 0% 100% 0% 100% 0% 100% 100% EWS recordings = documented EWS frequency? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% 0% 0% 100% 40% 60% 100% EWS risk category being actioned appropriately? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Is frequency of EWS observations documented and up-to-date? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 40% 60% 100% Roskear Ward 4% 96% 6% 94% 6% 94% 6% 94% 0% 100% 0% 100% 0% 100% 2% 98% 0% 100% 27% 73% 37% 63% 2% 98% 5% 95% 0% 100% 4% 96% 4% 96% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 51% 49% 100% Are all essential EWS observations for the last 7 entries recorded, totalled and signed off (TPR, B/P, O² Sats, and AVPU)? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 9% 91% 50% 50% 0% 100% 0% 100% 0% 100% 10% 90% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Are fluid balance observations documented and the 24 hour balance totalled? 14% 86% 30% 70% 20% 80% 0% 100% 0% 100% 0% 100% 0% 100% 10% 90% 0% 100% 43% 57% 33% 67% 11% 89% 0% 100% 0% 100% 11% 89% 33% 67% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% EWS recordings = documented EWS frequency? 10% 90% 0% 100% 10% 90% 10% 90% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 36% 64% 30% 70% 0% 100% 17% 83% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 80% 20% 100% EWS risk category being actioned appropriately? 0% 100% 0% 100% 0% 100% 10% 90% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 18% 82% 40% 60% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 50% 50% 100% Is frequency of EWS observations documented and up-to-date? 0% 100% 0% 100% 0% 100% 10% 90% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 36% 64% 30% 70% 0% 100% 8% 92% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 80% 20% 100% Sennen / CLIC / Fistral Wards 2% 98% 0% 100% 2% 98% 2% 98% 2% 98% 0% 100% 2% 98% 0% 100% 2% 98% 100% Are all essential EWS observations for the last 7 entries recorded, totalled and signed off (TPR, B/P, O² Sats, and AVPU)? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Are fluid balance observations documented and the 24 hour balance totalled? 0% 100% 0% 100% 10% 90% 10% 90% 11% 89% 0% 100% 14% 86% 0% 100% 17% 83% 100% EWS recordings = documented EWS frequency? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% EWS risk category being actioned appropriately? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Is frequency of EWS observations documented and up-to-date? 10% 90% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% South Crofty Ward 17% 83% 30% 70% 18% 82% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Are all essential EWS observations for the last 7 entries recorded, totalled and signed off (TPR, B/P, O² Sats, and AVPU)? 20% 80% 0% 100% 20% 80% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Are fluid balance observations documented and the 24 hour balance totalled? 38% 63% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% EWS recordings = documented EWS frequency? 10% 90% 80% 20% 30% 70% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% EWS risk category being actioned appropriately? 10% 90% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Is frequency of EWS observations documented and up-to-date? 10% 90% 60% 40% 30% 70% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% St Josephs Ward 9% 91% 4% 96% 22% 78% 17% 83% 3% 97% 0% 100% 6% 94% 0% 100% 0% 100% 0% 100% 100% Are all essential EWS observations for the last 7 entries recorded, totalled and signed off (TPR, B/P, O² Sats, and AVPU)? 0% 100% 0% 100% 0% 100% 9% 91% 10% 90% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Are fluid balance observations documented and the 24 hour balance totalled? 0% 100% 0% 100% 20% 80% 0% 100% 0% 100% 0% 100% 38% 63% 0% 100% 0% 100% 0% 100% 100% EWS recordings = documented EWS frequency? 22% 78% 20% 80% 50% 50% 36% 64% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% EWS risk category being actioned appropriately? 0% 100% 0% 100% 17% 83% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Is frequency of EWS observations documented and up-to-date? 22% 78% 0% 100% 20% 80% 27% 73% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% St Mawes 0% 100% 10% 90% 4% 96% 6% 94% 100% Are all essential EWS observations for the last 7 entries recorded, totalled and signed off (TPR, B/P, O² Sats, and AVPU)? 0% 100% 20% 80% 0% 100% 0% 100% 100% Are fluid balance observations documented and the 24 hour balance totalled? 0% 100% 30% 70% 20% 80% 30% 70% 100% EWS recordings = documented EWS frequency? 0% 100% 0% 100% 0% 100% 0% 100% 100% EWS risk category being actioned appropriately? 0% 100% 0% 100% 0% 100% 0% 100% 100% Is frequency of EWS observations documented and up-to-date? 0% 100% 0% 100% 0% 100% 0% 100% 100% St Michaels Ward 5% 95% 16% 84% 20% 80% 9% 91% 11% 89% 0% 100% 14% 86% 0% 100% 4% 96% 0% 100% 0% 100% 100% Are all essential EWS observations for the last 7 entries recorded, totalled and signed off (TPR, B/P, O² Sats, and AVPU)? 10% 90% 10% 90% 0% 100% 0% 100% 20% 80% 0% 100% 30% 70% 0% 100% 10% 90% 0% 100% 0% 100% 100% Are fluid balance observations documented and the 24 hour balance totalled? 50% 50% 0% 100% 20% 80% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% EWS recordings = documented EWS frequency? 0% 100% 30% 70% 40% 60% 0% 100% 20% 80% 100% EWS risk category being actioned appropriately? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Is frequency of EWS observations documented and up-to-date? 0% 100% 30% 70% 40% 60% 40% 60% 10% 90% 0% 100% 100% Surgical Admission Lounge 30% 70% 0% 100% 8% 92% 18% 82% 0% 100% 19% 81% 20% 80% 0% 100% 100% Are all essential EWS observations for the last 7 entries recorded, totalled and signed off (TPR, B/P, O² Sats, and AVPU)? 0% 100% 0% 100% 11% 89% 10% 90% 0% 100% 0% 100% 10% 90% 0% 100% 100% Are fluid balance observations documented and the 24 hour balance totalled? 0% 100% 0% 100% 30% 70% 0% 100% 43% 57% 40% 60% 100% EWS recordings = documented EWS frequency? 100% 0% 0% 100% 10% 90% 0% 100% 20% 80% 10% 90% 0% 100% 100% EWS risk category being actioned appropriately? 0% 100% 30% 70% 0% 100% 10% 90% 20% 80% 0% 100% 100% Is frequency of EWS observations documented and up-to-date? 0% 100% 0% 100% 22% 78% 10% 90% 0% 100% 30% 70% 20% 80% 0% 100% 100% Surgical Receiving Unit 12% 88% 18% 82% 25% 75% 2% 98% 100% Are all essential EWS observations for the last 7 entries recorded, totalled and signed off (TPR, B/P, O² Sats, and AVPU)? 20% 80% 0% 100% 100% 0% 0% 100% 100% Are fluid balance observations documented and the 24 hour balance totalled? 0% 100% 50% 50% 0% 100% 100% EWS recordings = documented EWS frequency? 30% 70% 0% 100% 0% 100% 10% 90% 100% EWS risk category being actioned appropriately? 0% 100% 0% 100% 0% 100% 0% 100% 100% Is frequency of EWS observations documented and up-to-date? 10% 90% 40% 60% 0% 100% 0% 100% 100% Surgical Unit 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Are all essential EWS observations for the last 7 entries recorded, totalled and signed off (TPR, B/P, O² Sats, and AVPU)? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Are fluid balance observations documented and the 24 hour balance totalled? 0% 100% 100% EWS recordings = documented EWS frequency? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% EWS risk category being actioned appropriately? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Is frequency of EWS observations documented and up-to-date? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Tolgus Ward 2% 98% 0% 100% 2% 98% 2% 98% 8% 92% 2% 98% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 5% 95% 4% 96% 2% 98% 2% 98% 100% Are all essential EWS observations for the last 7 entries recorded, totalled and signed off (TPR, B/P, O² Sats, and AVPU)? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Are fluid balance observations documented and the 24 hour balance totalled? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 13% 88% 0% 100% 100% EWS recordings = documented EWS frequency? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 10% 90% 10% 90% 0% 100% 0% 100% 100% EWS risk category being actioned appropriately? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Is frequency of EWS observations documented and up-to-date? 10% 90% 0% 100% 8% 92% 10% 90% 33% 67% 10% 90% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 10% 90% 10% 90% 0% 100% 10% 90% 100% Trauma Unit 18% 82% 21% 79% 16% 84% 4% 96% 2% 98% 2% 98% 2% 98% 7% 93% 6% 94% 100% Are all essential EWS observations for the last 7 entries recorded, totalled and signed off (TPR, B/P, O² Sats, and AVPU)? 0% 100% 10% 90% 10% 90% 20% 80% 0% 100% 0% 100% 0% 100% 10% 90% 0% 100% 100% Are fluid balance observations documented and the 24 hour balance totalled? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 20% 80% 13% 88% 33% 67% 14% 86% 100% EWS recordings = documented EWS frequency? 40% 60% 40% 60% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 10% 90% 100% EWS risk category being actioned appropriately? 0% 100% 10% 90% 10% 90% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Is frequency of EWS observations documented and up-to-date? 40% 60% 40% 60% 50% 50% 0% 100% 10% 90% 0% 100% 0% 100% 0% 100% 10% 90% 100% Wellington Ward 19% 81% 17% 83% 14% 86% 5% 95% 0% 100% 5% 95% 22% 78% 0% 100% 0% 100% 13% 87% 0% 100% 2% 98% 0% 100% 4% 96% 9% 91% 8% 92% 2% 98% 4% 96% 6% 94% 11% 89% 7% 93% 5% 95% 7% 93% 0% 100% 32% 68% 100% Are all essential EWS observations for the last 7 entries recorded, totalled and signed off (TPR, B/P, O² Sats, and AVPU)? 9% 91% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 10% 90% 0% 100% 0% 100% 0% 100% 100% Are fluid balance observations documented and the 24 hour balance totalled? 25% 75% 0% 100% 33% 67% 0% 100% 0% 100% 14% 86% 33% 67% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 14% 86% 40% 60% 30% 70% 33% 67% 20% 80% 11% 89% 40% 60% 50% 50% 100% 0% 40% 60% 0% 100% 0% 100% 100% EWS recordings = documented EWS frequency? 36% 64% 75% 25% 8% 92% 20% 80% 0% 100% 10% 90% 25% 75% 0% 100% 0% 100% 30% 70% 0% 100% 0% 100% 0% 100% 0% 100% 10% 90% 10% 90% 0% 100% 0% 100% 10% 90% 20% 80% 0% 100% 0% 100% 0% 100% 0% 100% 40% 60% 100% EWS risk category being actioned appropriately? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 25% 75% 0% 100% 0% 100% 0% 100% 0% 100% 10% 90% 0% 100% 0% 100% 10% 90% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 10% 90% 0% 100% 50% 50% 100% Is frequency of EWS observations documented and up-to-date? 18% 82% 0% 100% 33% 67% 0% 100% 0% 100% 0% 100% 25% 75% 0% 100% 0% 100% 30% 70% 0% 100% 0% 100% 0% 100% 10% 90% 0% 100% 0% 100% 0% 100% 0% 100% 10% 90% 7% 93% 0% 100% 0% 100% 0% 100% 0% 100% 50% 50% 100% Wheal Agar Ward 0% 100% 0% 100% 14% 86% 6% 94% 2% 98% 0% 100% 0% 100% 0% 100% 2% 98% 0% 100% 9% 91% 17% 83% 37% 63% 5% 95% 17% 83% 100% Are all essential EWS observations for the last 7 entries recorded, totalled and signed off (TPR, B/P, O² Sats, and AVPU)? 0% 100% 0% 100% 25% 75% 10% 90% 0% 100% 0% 100% 0% 100% 0% 100% 11% 89% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Are fluid balance observations documented and the 24 hour balance totalled? 0% 100% 0% 100% 7% 93% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 40% 60% 63% 38% 78% 22% 100% 0% 14% 86% 100% EWS recordings = documented EWS frequency? 0% 100% 0% 100% 20% 80% 10% 90% 10% 90% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 20% 80% 20% 80% 0% 100% 0% 100% 100% EWS risk category being actioned appropriately? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 10% 90% 100% Is frequency of EWS observations documented and up-to-date? 0% 100% 0% 100% 15% 85% 10% 90% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 20% 80% 10% 90% 90% 10% 0% 100% 60% 40% 100% Wheal CoatesWard 6% 94% 6% 94% 16% 84% 24% 76% 9% 91% 10% 90% 12% 88% 0% 100% 11% 89% 9% 91% 4% 96% 12% 88% 8% 92% 2% 98% 100% Are all essential EWS observations for the last 7 entries recorded, totalled and signed off (TPR, B/P, O² Sats, and AVPU)? 10% 90% 0% 100% 10% 90% 30% 70% 0% 100% 10% 90% 10% 90% 0% 100% 10% 90% 10% 90% 0% 100% 10% 90% 0% 100% 0% 100% 100% Are fluid balance observations documented and the 24 hour balance totalled? 10% 90% 10% 90% 20% 80% 30% 70% 23% 77% 10% 90% 10% 90% 0% 100% 20% 80% 0% 100% 14% 86% 11% 89% 10% 90% 10% 90% 100% EWS recordings = documented EWS frequency? 0% 100% 10% 90% 20% 80% 30% 70% 18% 82% 20% 80% 10% 90% 0% 100% 10% 90% 20% 80% 10% 90% 10% 90% 20% 80% 0% 100% 100% EWS risk category being actioned appropriately? 0% 100% 0% 100% 10% 90% 10% 90% 0% 100% 0% 100% 10% 90% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Is frequency of EWS observations documented and up-to-date? 10% 90% 10% 90% 20% 80% 20% 80% 5% 95% 10% 90% 20% 80% 0% 100% 10% 90% 10% 90% 0% 100% 20% 80% 10% 90% 0% 100% 100% Wheal Prosper Ward 2% 98% 8% 92% 2% 98% 18% 82% 0% 100% 0% 100% 0% 100% 41% 59% 0% 100% 4% 96% 6% 94% 0% 100% 0% 100% 0% 100% 18% 82% 16% 84% 0% 100% 7% 93% 0% 100% 18% 82% 0% 100% 2% 98% 100% Are all essential EWS observations for the last 7 entries recorded, totalled and signed off (TPR, B/P, O² Sats, and AVPU)? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 30% 70% 0% 100% 10% 90% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 10% 90% 0% 100% 10% 90% 100% Are fluid balance observations documented and the 24 hour balance totalled? 0% 100% 0% 100% 13% 88% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% EWS recordings = documented EWS frequency? 9% 91% 20% 80% 0% 100% 44% 56% 0% 100% 0% 100% 0% 100% 60% 40% 0% 100% 20% 80% 0% 100% 0% 100% 0% 100% 50% 50% 40% 60% 0% 100% 0% 100% 0% 100% 40% 60% 0% 100% 0% 100% 100% EWS risk category being actioned appropriately? 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 50% 50% 0% 100% 10% 90% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 10% 90% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 0% 100% 100% Is frequency of EWS observations documented and up-to-date? 0% 100% 20% 80% 0% 100% 44% 56% 0% 100% 0% 100% 0% 100% 50% 50% 0% 100% 10% 90% 0% 100% 0% 100% 0% 100% 25% 75% 30% 70% 0% 100% 33% 67% 0% 100% 40% 60% 0% 100% 0% 100% 100% Grand Total 7% 93% 7% 93% 8% 92% 14% 86% 5% 95% 4% 96% 7% 93% 4% 96% 2% 98% 4% 96% 4% 96% 5% 95% 2% 98% 4% 96% 6% 94% 3% 97% 2% 98% 6% 94% 4% 96% 4% 96% 8% 92% 6% 94% 6% 94% 4% 96% 17% 83% 100%

The Deteriorating Patient RCHT Improvement Package - Recognition, Monitoring, Escalation & Communication (SBARD) Jay Over Resuscitation Officer (Part of the Critical Care Group) Adapted from NHS Institute for Innovation & Improvement

A large proportion of patients who suffer cardio-respiratory arrest in hospital have recognisable changes in observations during the preceding 24 hours (including changes in vital signs, level of consciousness and oxygenation). Action taken during these early stages can prevent deterioration progressing to cardiac arrest. There is also a failure to support decisions surrounding the resuscitation status of patients who are deteriorating but would not benefit from resuscitation. NHSLA 2014 NCEPOD 2012 Resuscitation Council 2010 Patient Safety Frist 2009

Xxx died in her bed at xxx Hospital in 2013. The 17 year old trainee hairdresser bled after a routine operation. An artery was torn when she had her appendix removed. She sent a frightened text to her boyfriend of her blood-stained T-shirt. 15 hours after the operation she died in her hospital bed after a series of errors (43 in total!) were identified. Had xxx s observations been monitored and at regular intervals including pulse and blood pressure it is possible that a deteriorating trend may have been recognised. I believe her chances of survival would have significantly increased. Statement from the inquest into her death.

Making a difference Early recognition of the deteriorating patient regular & reliable patient observations (TRACK) Escalation of care to the appropriate clinician use of the escalation matrix to ensure that the correct clinical response occurs within the timeframe specified (TRIGGER) Effective communication using the structured SBAR-D method Establish a plan of care - develop a plan of care for the patient which may include use of care bundles/pathways, ceilings of care and resuscitation decisions

Early recognition Observations should be taken on ALL patients admitted to an acute hospital Medical & Nursing team in collaboration to agree a monitoring plan. To include:- Observations to be recorded including other emergency care monitoring e.g. fluid balance, GCS & blood sugar levels. Frequency dictated by admission route, escalation matrix and clinical condition Variance to the escalation matrix

Frequency Observations should be taken on ALL patients admitted to an acute hospital Admitted via ED/MAU minimum 4 hourly Dictated by NEWS score Dictated by clinical condition and/or other concerns e.g. chest pain All adult in-patients minimum 12 hourly! A sick patient may not trigger!

Escalation of care National escalation protocols allow for a graded response commensurate with the level of deterioration/abnormal physiological measurements The escalation protocols are clear about:- Urgency of the response Seniority of the clinician who responds Clinical setting for ongoing care Frequency of subsequent monitoring! No response = Escalate higher!! Delay in response = Escalate higher!

Escalation of care Assess patients condition using an ABCDE approach Treat life-threatening conditions immediately before progressing Call for help using escalation protocols If peri-arrest and no immediate senior support call 2222 adult crash team

Variance Any changes/variance to either the frequency of observations or escalation protocols MUST be documented clearly and communicated to the multidisciplinary healthcare team These reviewed trigger scores take into account the individual clinical needs of the patient:- If the patient is known to have type 2 respiratory failure and their normal respiratory rate is always high. If the patient is recognised as end of life Considers the needs & wishes of the patient Allows for concerns of the patient, family or carer! A patient who triggers may not be acutely unwell!

Effective communication SBAR-D is a structured method for communicating critical information that requires immediate attention and action SBAR-D improves communication, effective escalation and increases safety Its use is well established in many settings including the military, aviation and some acute medical environments SBAR-D has 5 steps - Situation - Background - Assessment - Recommendation - Decision

Why use SBAR-D? SBAR-D reduces the barriers to effective communication across different disciplines and levels of staff SBAR-D creates a shared mental model around all patient handovers and situations requiring escalation, or critical exchange of information SBAR-D is a memory prompt; easy to remember and encourages prior preparation for communication SBAR-D reduces the incidence of missed communication

SBAR-D - SITUATION Identify yourself and the ward/unit your are calling from Identify the patient by name and the reason for your report Describe your concern Firstly, describe the specific situation about which your are calling, including the patient s name, consultant, patient location, resuscitation status, and vital signs. "This is Sarah Brown, F1 doctor currently on Wellington Ward. The reason I'm calling is that Mrs. Taylor in bedspace C3 has become acutely short of breath, her vital signs have been stable from admission but deteriorated suddenly. She is also complaining of chest pain and there appears to be blood in her sputum.

SBAR-D - BACKGROUND Give the patients reason for admission Explain significant medical history Overview of the patient s background: Consider - Admitting diagnosis, date of admission, prior procedures, current medications, allergies, pertinent laboratory results and other relevant diagnostic results. Mrs Taylor is a 69-year-old woman who was admitted from home three days ago with a community acquired pneumonia. She has been on intravenous antibiotics and appeared, until now, to be doing well. She is normally fit, well and independent and is under the care of Dr Myers.

SBAR-D - ASSESSMENT What assessment tool? NEWS, GCS, fluid balance, blood results & More! Always remember clinical impressions and concerns Consider what might be the underlying reason for your patients condition is there an appropriate care bundle or care pathway? If you do not have an assessment, you may say I m not sure what the problem is, but I am concerned and would like senior review. Mrs Taylor s NEWS Score is 10 - her oxygen saturation has dropped to 88 per cent on room air, her respiration rate is 24 per minute, her heart rate is 110 and her blood pressure is 85/50, in addition, she is also complaining of chest pain and she has had some haemoptysis.

SBAR-D - RECOMMEDATION Explain what you need be specific about your request and the time frame Make suggestions Clarify expectations Finally, what is your recommendation? This is, what would you like to happen by the end of the conversation. I have initiated oxygen therapy to maintain saturations, I have commenced on continuous cardiac monitoring, asked the nurses to give a stat fluid challenge but I would like you to come immediately to offer senior review.

SBAR-D - DECISION Confirm actions to be taken Confirm expectations Clarify expectations Finally, ACT! Any order that is given on the phone needs to be repeated back to ensure accuracy. We have agreed you will come immediately and I will go ahead and take an arterial blood gas sample to assist with your review.

SBAR-D Escalation Tree No response = Escalate Higher Delay in response = Escalate Higher Escalate to a higher level as required Senior Nurse/Manager Senior Medic Consultant Outreach Service Clinical Site Co-ordinator No response = Escalate Higher Delay in response = Escalate Higher

SBAR-D Escalation of Care Label Record SBAR-D communication on the Escalation of Care Label and stick into the medical notes.

PLAN OF CARE Ensure there is a plan of care - consider:- Use of appropriate care bundle/pathway Further escalation if no improvement Care environment Ceiling of care End of life Resuscitation status COMMUNICATE DECISIONS patients & relatives/carers (if appropriate), the healthcare team.

Questions Presentation Based on National Clinical Guideline Recommendations National Clinical Effectiveness Committee Jay Over (Resuscitation Officer) October 2014 SBAR Tool & Content Adapted From: http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/sbar_-_situation_-_background_-_assessment_- _recommendation.html