management of the deteriorating patient …...chairs 6 01/15/19 • updated to include news2 •...

Management of the Deteriorating Patient Policy Version: 7 Issue Date: 06 January 2020 Review Date: 06 January 2022 (unless requirements change) of 34

MANAGEMENT OF THE DETERIORATING PATIENT POLICY

Version Tracking

Version Date

Ratified Brief Summary of Changes Author

7 06/12/19 • Appendix 2 Escalation Protocol for Adult Patients NEWS updated • Appendix 11 Adapted Emergency Department vital signs protocol

added

DPG Co-Chairs

6 01/15/19 • Updated to include NEWS2 • Communication tool RSVP removed • Audit tools in use from 01/04/19 added

DPG Co-Chairs

5 29/01/19 • Section 6.42 added regarding communicating with patients and NOK • Section 6.9 added to include adult patients who do not require NEWS

track and trigger monitoring

DPG Co-Chairs

Version 7

Name of responsible (ratifying) committee Deteriorating Patient Group

Date ratified 6th November 2019

Document Manager (job title) Resuscitation Manager

Date issued 6th January 2020

Review date 6th January 2022

Electronic location Clinical Policies

Related Procedural Documents

Cardiopulmonary Resuscitation Policy

Procedural Documents Development And Management Policy

Generic Competency Framework for Registered and Unregistered Practitioners

Modified Early Obstetric Warning (MEOWs) – Guideline

Key Words (to aid with searching)

early warning score; early warning system; EWS; medical emergency; response; deteriorating patient; critically ill; VitalPAC™; escalation protocol; vital signs; MEOWs; PEWS; National Early Warning Score; NEWS; NEWS2; heart rate; respiration rate; temperature; oxygen saturation; systolic blood pressure; level of consciousness; ACVPU; monitoring; physiological observations; risk of deterioration; track and trigger; graded response strategy; clinical deterioration; professional staff; health professionals; patients; audit; SBAR; clinical guidelines; transfer; and sepsis;


CONTENTS QUICK REFERENCE GUIDE ............................................................................................................. 3

1. INTRODUCTION.......................................................................................................................... 4

2. PURPOSE ................................................................................................................................... 4

3. SCOPE ........................................................................................................................................ 5

4. DEFINITIONS .............................................................................................................................. 5

5. DUTIES AND RESPONSIBILITIES .............................................................................................. 7

6. PROCESS ................................................................................................................................... 8

6.1. Identification of patients at risk of deterioration .................................................................... 8

6.2. Sepsis ................................................................................................................................. 9

6.3. Escalation Protocol and graded response ........................................................................... 9

6.4. Communicating Deterioration ........................................................................................... 10

6.5. Patient transfers ................................................................................................................ 11

6.6. Referral to Critical Care Outreach ...................................................................................... 11

6.7. Referral to Critical Care ..................................................................................................... 11

6.8. Patients discharged from Critical Care ............................................................................... 12 6.9 Adult patients who do not require NEWS2 track and trigger monitoring …………………….12 6.10 Use of NEWS2 SpO₂ Scale’s in Adult Patients…………………………………………………13

7. TRAINING REQUIREMENTS .................................................................................................... 13

8. REFERENCES AND ASSOCIATED DOCUMENTATION .......................................................... 13

9. EQUALITY IMPACT ASSESSMENT .......................................................................................... 14

10. MONITORING COMPLIANCE ................................................................................................... 14

EQUALITY IMPACT SCREENING TOOL ......................................................................................... 15

APPENDIX 1: NEWS2 Scoring System ............................................................................................ 17

APPENDIX 2: NEWS2 Escalation Protocol for Adult Patients ........................................................... 17

APPENDIX 3: Modified Early Obstetric Warning System (MEOWS) ................................................. 18

APPENDIX 4: PHT Paediatric Early Warning Score (PEWS) ............................................................ 20

APPENDIX 5: PHT Deteriorating Patient Pro-forma .......................................................................... 22

APPENDIX 6: Inpatient Sepsis Screening and Action Tool ............................................................... 24

APPENDIX 7: Adult Vital Signs Chart ............................................................................................... 26

APPENDIX 8: Acutely ill patients in hospital NICE clinical guideline 50 ............................................. 28 APPENDIX 9: Deteriorating Patient Data Collection Form………………………………………………31 APPENDIX 10: Sepsis Data Collection Form……………………………………………………………..33 APPENDIX 11: Adapted Emergency Department vital signs protocol………………………………….34


QUICK REFERENCE GUIDE This policy must be followed in full to ensure that all patients within Portsmouth Hospitals NHS Trust (PHT), who are acutely ill or at risk of physical deterioration, are identified and responded to promptly and appropriately at all times. For quick reference the guide below is a summary of actions required. This does not negate the need for all staff to be aware of and follow the detail of this policy. All patients admitted to PHT will: 1. Have physiological observations recorded at the time of admission or initial assessment, immediately prior to transfer to another healthcare setting, for example ward to ward transfers, and within 15mins of arrival in the new healthcare setting; 2. Have a clear written monitoring plan, determined by the appropriate Early Warning Scoring system (Appendix 1, 2, 3 & 4) that specifies which physiological observations should be recorded, and how often; 3. Have physiological observations recorded at least every 12 hours and the frequency increased if abnormal physiology is detected. A rationale for deviation from this standard must be recorded in the patient’s notes by a senior doctor; 4. Be monitored using a relevant physiological track and trigger system when appropriate (Appendix 1, 2, 3 & 4). The track and trigger system will identify the appropriate graded response to abnormal physiological observations recorded or guide clinicians who are concerned; 5. Receive a graded response if they become acutely ill or are at risk of physical deterioration as per appropriate escalation protocol (Appendix 2, 3 & 4). The healthcare professional who has recognised a response is required must record their actions, related to the escalation, in the patient’s notes; 6. The communication tool ‘SBAR’ (4) should be used to ensure effective communication occurs between healthcare professionals (see Section 6.4) 7. The healthcare professional responding must document their actions and management plan clearly in adult patient’s notes using the current PHT Deteriorating Patient pro forma (Appendix 5); 8. For adult patients who have signs of deterioration such as a NEWS score of 5 or more, and/or soft signs of deterioration, and this could be due to an infection, the Inpatient Sepsis Screening and Action Tool must completed and followed (Appendix 6); 9. The most senior doctor available should refer to Critical Care. The decision to admit to Critical Care will be made by consultant in critical care in consultation with the referring team; 10. The responsible consultant for the referring team should be aware and have agreed for the need for critical care referral; 11. Any patient transfers from critical care to general ward areas:

a) Should occur as early as possible during the day and whenever possible, be avoided between 22.00 hours - 07.00 hours;

b) Should involve both a clear verbal handover and agreed written care plan to promote

continuity of care;

c) Will be reviewed by the Critical Care Outreach when appropriate.


1. INTRODUCTION This policy reflects National Institute for Care Excellence (NICE) guidance CG50 (1) and NPSA Guidance (2) relating to all aspects of the treatment and care of adults who are acutely ill or at risk of physical deterioration throughout Portsmouth Hospitals NHS Trust (PHT). The key recommendations from the NICE CG50 form the basis for the structure of this policy. This policy has also been developed to describe the process for managing and mitigating risks relating to all aspects of the treatment and care of adults who are acutely ill or at risk of physical deterioration, including sepsis. In 2005, the National Patient Safety Agency (2) undertook a detailed analysis of the 1,804 reported serious incidents which resulted in death. There were 576 events in which the death of the patient was, or might have been directly related to a patient safety incident. Of these reported incidents, 425 occurred in an acute/general hospital setting. The analysis found the following themes:

• 71 were related to diagnostic errors (dealt with under a separate NPSA review) • 43 involved a problem with resuscitation. • 64 were related to unrecognised physical deterioration (14 – no observations; 30, no recognition of signs of deterioration or assistance sought; 17 delays in receipt of medical attention).

On the basis of this review, the key recommendations from the 64 incidents involving unrecognised patient deterioration are:

• Better recognition of patients at risk or who have deteriorated • Appropriate monitoring of vital signs • Accurate interpretation of clinical findings • Calling for help early and ensuring it arrives • Training and skills development • Ensuring appropriate drugs and equipment are available

2. PURPOSE The aim of this policy is to standardise the processes by which the patients within Portsmouth Hospitals NHS Trust (PHT), who are acutely ill or at risk of physical deterioration, are identified and responded to.

All patients admitted to PHT will:

• Have physiological observations recorded at the time of admission or initial assessment; • Have a clear written monitoring plan, determined by the appropriate Early Warning

Scoring system that specifies which physiological observations should be recorded, and how often;

• Have physiological observations recorded at least every 12 hours and the frequency increased if abnormal physiology is detected;

• Be monitored using a relevant physiological track and trigger system when appropriate (Appendix 1, 2, 3 & 4). The track and trigger system will identify the appropriate graded response to abnormal physiological observations recorded or guide clinicians who are concerned;

• Receive a graded response if they become acutely ill or are at risk of physical deterioration as per appropriate escalation protocol (Appendix 2, 3 & 4);

• Have an Inpatient Sepsis Screening and Action Tool completed if there is suspicion of sepsis (Appendix 6). All women admitted to the Maternity Department are screened using the pregnancy sepsis tool on admission;


For patients requiring admission to critical care: • The decision to admit to Critical Care will be made by consultant in critical care in

consultation with the referring team consultant. Where involvement of the referring team consultant is not possible, referral should be made by the most senior doctor looking after the patient;

Patient transfers from critical care to general ward areas:

• Should occur as early as possible during the day and whenever possible, be avoided between 22.00 hours - 07.00 hours;

• Should involve both a clear verbal handover and agreed written care plan to promote continuity of care;

• Will be reviewed by the Critical Care Outreach when appropriate.

3. SCOPE This policy applies to the care of paediatric (excluding neonates on NICU) and adult patients (excluding patients receiving end of life care and those in Critical Care areas who are directly under the care of Critical Care Consultants) in all of the Trust’s settings, who because of clinical status/conditions, interventions or procedures are at risk of physical deterioration and ultimately of suffering a respiratory or cardiopulmonary arrest. This policy applies to all staff (including voluntary workers, students, locums and agency) of Portsmouth Hospitals NHS Trust, the Defence Medical Group South (DMGS) and FM Services, whilst acknowledging for staff other than those of the Trust the appropriate line management or chain of command will be followed. In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety.

4. DEFINITIONS ACVPU A change in the level of consciousness is an important indicator of acute illness severity. In NEWS2 new confusion has been included so the clinical staff now record if the patient is Alert, has new Confusion, responding to Voice, responding to Pain or Unresponsive. Cardiopulmonary Resuscitation (CPR) Cardiopulmonary Resuscitation is a combination of artificial ventilation, chest compressions, drug therapy and defibrillation.

Classification of Critical Care Patients (3) Level 0 Patients whose needs can be met through normal ward care in an acute hospital Level 1 Patients at risk of their condition deteriorating, or those recently relocated from

higher levels of care, whose needs can be met on an acute ward with additional advice and support from a critical care team.

Level 2 Patients requiring more detailed observation or intervention including support for a single failing organ system or post operative care, or those stepping down from higher levels of care.

Level 3 Patients requiring advance respiratory support alone or basic respiratory support together with support of at least 2 organ systems, including all complex patients requiring support for multi-organ failure.

Clinical Staff A member of staff whose duties involve elements of direct patient care.


Critical Care Outreach A multidisciplinary approach to the identification of patients at risk of developing critical illness and those patients recovering from a period of critical illness to enable early intervention or transfer (if appropriate) to an area suitable for care for that patient’s individual needs. Deteriorating Patient pro forma The deteriorating patient pro forma (Appendix 5) is used to document the initial escalation, focused clinical assessment, treatment plan, senior review and escalation plan. It is filed in the medical notes in date order. Early Warning System (EWS) EWS is a tool for bedside evaluation and is based on assigning a score to physiological parameters such as pulse; temperature; systolic blood pressure; respiratory rate; ACVPU - Alert, new Confusion, Voice, Pain, Unresponsive (the level to which the patient responds), oxygen saturation, plus the patient’s inspired oxygen requirements for adult patients. In adults it is the National Early Warning Score (NEWS2) (9) and this is used for adult patient observation as detailed in Appendix 1 & 2 There is a EWS for Maternity Dept (MEOWS) as in Appendix 3 and Paediatric Dept (PEWS) as in Appendix 4. Escalation Protocol for use with the appropriate Ea rly Warning System (EWS) Once the EWS has been completed the escalation protocol will prompt staff to take action depending on the EWS score. (See Appendix 2, 3 & 4) High Dependency Patients requiring observation, care and treatment interventions at Level 2 (3). Inpatient Sepsis Screening and Action Tool From July 2017 the Inpatient Sepsis Screening and Action Tool must completed and followed (Appendix 6) for adult patients who have signs of deterioration such as a NEWS2 score of 5 or more, and/or soft signs of deterioration, and this could be due to an infection, the Inpatient Sepsis Screening and Action Tool must completed and followed (Appendix 6). There are Paediatric and Maternity versions of sepsis screening tool available in relevant departments; Monitoring plan The appropriate Early Warning Scoring System will detail which physiological observations should be recorded, and how often. Details of the on-going management of the patient and when they will be reviewed by nursing and medical staff should be recorded in the patient notes. Nervecentre Nervecentre is an electronic system used in PHT by the Hospital at Night Team which enables doctors and nurses to enter tasks for patients who need to be reviewed or to have an intervention performed overnight. Alerts, tasks and escalations are then prioritised by an experienced clinical coordinator/nurse practitioner and allocated to the most appropriate clinician or member of staff electronically. This information is stored electronically enabling workforce development and learning from incidents. Portsmouth Hospitals NHS Trust Hospital Inpatient A reas Wards at Queen Alexandra Hospital Portsmouth Maternity Centre at St Mary’s Community Hospital Grange Maternity Centre at Petersfield Community Hospital Blake Maternity Centre at Gosport War Memorial Hospital. SBAR - A communication tool used by clinical staff to structure communication when handing over information to a clinical colleague about a deteriorating patient. The SBAR communication tool is Situation, Background, Assessment, Recommendation (4).


VitalPAC™ - An electronic track and trigger system that provides a recording mechanism for patient’s vital signs and essential screening tools. The data entered generates a National Early Warning Score (NEWS2) (9) and when appropriate prompts the clinical practitioner to escalate the patient’s condition appropriately. The system also alerts the practitioner if a set of vital signs are overdue. The recorded vital signs can be reviewed by authorised staff, along with NEWS2 score and laboratory data, to enable an accurate overview and prioritisation of patient assessment, treatment and discharge planning. From Feb 2019 VitalPAC™ is also known as CareFlow Vitals™ Vital Signs Chart for Adults For adult outpatient areas that don’t use VitalPAC or in the event of VitalPAC being unavailable in adult in-patient areas the vital signs chart in Appendix 7 must be used. The current chart will be available for printing on the Intranet in Forms and Resources - Trust Staff Resources Vital Signs/ Physiological observations Measures of various statistics taken by clinical staff in order to assess a patient’s fundamental physiological function, such as pulse, temperature, systolic blood pressure, respiratory rate, ACVPU (the level to which the patient responds) and oxygen saturation, plus the patient’s inspired oxygen requirements. 2222 is the emergency number for fast bleeping an individual or calling the Cardiac Arrest Teams at Queen Alexandra Hospital (QAH). The cardiac arrest teams on the QAH site are used cardiac arrests and other life threatening emergencies.

5. DUTIES AND RESPONSIBILITIES Trust Board The Trust Board is responsible, through the receipt of monthly reports in the Integrated Performance Report to Quality and Performance Committee from the Deteriorating Patient Group, for monitoring that there is continuous and measurable improvement in the quality of the services provided. Deteriorating Patient Group The Deteriorating Patient Group is responsible for ensuring that:

• This procedural document is up to date, technically accurate, is in line with evidence-based best practice and has been produced following consultation with stakeholders (5).

• Through the Chair, assurance on the effectiveness of this policy and the Trust’s procedures for the identification and management of the deteriorating patient, is provided through the receipt of monthly reports to the Quality and Performance Committee, including any necessary recommendations to address identified deficits;

• Processes are in place to enable an annual audit of compliance using the audit tool from the NICE Clinical Guideline 50 (Appendix 5) and that the actions identified as a result of those audits are implemented.

Line Managers Line Managers are responsible for:

• Ensuring all clinical staff receive training in the use of VitalPAC™ on local induction to the clinical areas.

• Monitoring data from VitalPAC™ to ensure there is a local plan to address any areas for improvement such as number of overdue vital signs.

• Ensuring that the clinical staff they are responsible for are aware of and apply this policy into clinical practice.


6. PROCESS 6.1. Identification of patients at risk of deterior ation

6.1.1 The Trust uses the National Early Warning Scoring (NEWS2) (9) for adult patients and graded response system to detect and monitor patients who are acutely ill or at risk of physical deterioration. On VitalPAC this is called Protocol monitoring. During an adult in-patient episode all patient observations are recorded and scored as per NEWS2 scoring system detailed in Appendix 1.

Maternity use the adapted MEOWS system (Appendix 3) and in Paediatrics the

adapted PEWS system (Appendix 4) will be used. 6.1.2 All physiological observations must be recorded and acted upon by staff that have

been trained to undertake these procedures and understand their clinical relevance. Registered and unregistered nursing staff caring for adult patients will undertake the relevant competency assessment (6, 7 & 8)

6.1.3 All patients must have physiological observations recorded at the time of admission or

initial assessment, including patients in the Emergency Department. 6.1.4 The appropriate Early Warning Scoring System will detail which physiological observations should be recorded, and how often. In addition it should be recorded in the patient notes details of the on-going management of the patient and when they will be reviewed by nursing and medical staff. 6.1.5 All patients must have physiological observations recorded at least every 12 hours and the frequency should increase if abnormal physiology is detected as per escalation protocol or there is cause for concern (Appendix 2, 3 & 4).

The exception to this will be individual adult patients who, following senior medical review, have the frequency of observations decreased. See section 6.9.

6.1.6 It must be emphasised that the EWS system may not trigger a score in some patients who are or becoming acutely unwell. EWS is used as an aid to clinical assessment and is not a substitute for competent clinical judgement. Concern about a patient’s clinical condition should always override the EWS prompts if the clinical professional considers it necessary to increase the frequency of monitoring and escalate care. 6.1.7 The ‘soft signs’ of deterioration: such as new confusion or agitation; change in behaviour; reduced urine output; drowsiness; generally feeling or looking unwell; reduced mobility; and refusing food or fluid may indicate risk of deterioration. This is particularly important for patients who have difficulties with communication i.e. patients with dementia and learning disabilities. Clinical staff should observe for soft signs and escalate patients who are causing concern to them or the patient’s relatives/carers, even if the EWS score is low.

6.1.7 When an increased frequency of observations for a prescribed period of time is required, for example post fall, during a blood transfusion or the immediate post op/procedure period, the patient should remain on the NEWS2 protocol monitoring on VitalPAC and the observations should be entered as required.


6.2. Sepsis 6.2.1 For patients who have signs of deterioration such as a NEWS2 score of 5 (10, 11 & 12) or more, and/or soft signs of deterioration, and this could be due to an infection, the Inpatient Sepsis Screening and Action Tool must completed and followed (Appendix 6). There are Paediatric and Maternity versions for use in the relevant departments. 6.2.2 It is essential that a patient with suspicion of sepsis is escalated and responded to promptly. 6.2.3 Once sepsis has been identified by a senior clinician, Time Zero must be recorded on the Inpatient Sepsis Screening and Action Tool or equivalent, and the Sepsis 6 actioned within an hour of Time Zero.

6.3. Escalation Protocol and graded response

6.3.1 All patients will be monitored using the appropriate physiological track and trigger system (Appendix 2, 3 & 4). The track and trigger system will identify the appropriate graded response to abnormal physiological observations recorded or guide clinicians who are concerned. 6.3.2 By using the appropriate escalation protocol (Appendix 2, 3 & 4) as a framework it will ensure that a clinician with the expertise to respond is called and asked to attend within a specified timeframe. This will make sure that patients who are acutely ill or at risk of physical deterioration receive prompt care and decisions are made in a timely manner. 6.3.3 The responder is responsible for informing colleagues if they are unable to attend within the requested time frame to enable an alternative clinician to be contacted. 6.3.4 Following escalation the clinician with the patient is responsible for ensuring ongoing patient monitoring and repeating escalation or calling an alternative responder as necessary. 6.3.4 The person recording the vital signs and triggering an escalation response must

document their actions on the deteriorating patient pro forma (Appendix 5) and this is placed in the patient’s notes.

6.3.5 The person responding must document their actions and management plan on the Deteriorating Patient pro forma (Appendix 5) and continuation sheets as required. Below is an overview of escalation for the adult in-patient wards on the QAH site.


6.4. Communicating Deterioration

6.4.1 To improve communication between clinical staff it is recommended that the person calling for help uses a structured communication tool. A commonly used tool in healthcare is SBAR (Situation-Background-Assessment- Recommendation) which are easy to remember in an emergency and ensure the essential information is communicated enabling an appropriate timely response.

6.4.2 The clinical staff must confirm the contact details for the Next of Kin (NOK) are accurately recorded in the nursing & medical notes. Communication with the patient and their NOK should always be clear, sensitive and honest. Clinical staff can develop their communication skills in preparation for difficult conversations through learning & development opportunities such as Sage and Thyme (book via ESR) or the Breaking Difficult News course run by the Chaplaincy Dept or E-Learning modules on ESR as below E-Learning modules on ESR


6.5. Patient transfers

6.5.1 The member of staff responsible for patient care prior to transfer to a new location, must ensure a complete set of vital signs and an early warning score has been recorded immediately prior to transfer. The escalation protocol must be followed and if the nurse in charge or doctor have been informed of an increased EWS score (>3) they must assess the patient to determine if the transfer should be delayed for clinical reasons. 6.5.2 The member of staff responsible for patient care in the new location must complete set of vital signs and an early warning score within 15 minutes of the patient’s arrival in the new locality. 6.5.3 Patient transfers from critical care to general ward areas should occur as early as possible during the day and whenever possible be avoided between 22.00 hours - 07.00 hours. 6.5.4The critical care area transferring team and the receiving ward team should work together to ensure the patient is transferred safely. They should jointly ensure there is continuity of care through a formal structured handover of care from critical care area staff to ward staff (including both medical and nursing staff). This must be supported by a written plan and the receiving ward, with support from Critical Care Outreach if required, to ensure the ward can deliver the agreed plan.

6.6. Referral to Critical Care Outreach A referral to Critical Care Outreach (CCO) should be 'considered' for:

• Any acutely ill or deteriorating ward in-patient who is causing concern (excludes the Emergency Department, Obstetrics, NICU and Paediatrics);

• As prompted by the NEWS2 escalation protocol (Appendix 2).

Critical Care Outreach can be contacted between the hours of 07.00 - 20.30 via Bleep 1676 and between 20.30-07.00 a CCO review should be requested via Nervecentre if available, otherwise Bleep 1676.

6.7. Referral to Critical Care

For patients requiring admission to critical care:

• For urgent help bleep the critical care registrar on 1987; • If the critical care registrar is uncontactable or referral does not require an immediate

response, please phone extension 5752, alternatively extension 6385 or 6035.State you wish to make a referral and ask to speak to the critical care registrar. If unavailable you will be passed on to another member of the team;

• The referral should be made by the most appropriate senior doctor involved in the patient care at that time;

• The decision to admit to Critical Care will be made by consultant in critical care in consultation with the referring team;

• The responsible consultant for the referring team should be aware and have agreed for the need for critical care referral.

All relevant patient information will be required by critical care including: - referring clinicians name and grade - patients name and hospital number - patient’s location - relevant patient history - current vital signs and EWS score - recent important investigations and treatment should be at hand when you make the call.


6.8. Patients discharged from Critical Care All patients discharged from Critical Care will be reviewed by the Critical Care Outreach team to monitor progress and provide support to the ward staff when appropriate. After the decision to transfer a patient from a critical care area to the general ward has been made, the patient should be transferred as early as possible during the day. Transfer from critical care areas to the general ward between 22.00 hours and 07.00 hours should be avoided whenever possible, and should be documented as an adverse incident if it occurs.

6.9. Adult patients who do not require NEWS2 track and trigger monitoring 6.9.1 There are some adult patients who do not require track and trigger monitoring as per NEWS2 protocol these include: • patients for ward based ceiling of care including AMBER care bundle and patients

approaching but not actively receiving End of Life (EoL) care • medically stable patients but have a complex discharge pathways • physiologically stable patients with significant dementia where there is no clinical

indication for frequent observations • patients with chronic medical conditions who are at their physiological baseline, for

example patients with chronic respiratory disease where there is no clinical indication for frequent observations

For these patients the limited monitoring function of VitalPAC should be used.

6.9.2 Transfer off NEWS2 protocol monitoring to limited monitoring should only be following Consultant review and authorisation. The authorisation must include clear documentation in the medical notes of:

• the rationale for the decision • the minimum frequency of observations • what to do if the patient deteriorates for example return to NEWS2 protocol, treatment

escalation plan or for EoL care • a review of the patients DNACPR status • duration of limited monitoring i.e. review date or indefinite

6.9.3 The limited monitoring function allows a fixed frequency of observations to be selected and for patient safety the minimum observation frequency for in-patients is 12 hourly. Observations can be done more frequently if needed for example post fall or there is cause for concern. Should a patient on the limited monitoring function deteriorate or there is cause for concern then this must be discussed immediately with the nurse in charge and the medical notes should be reviewed to see the plan documented by the consultant, which may include returning to NEWS2 protocol and escalating care.

6.9.4 For patients on the limited monitoring it is suggested that the routine observations coincide with clinical review and minimise sleep disruption. So for example patients on 12 hourly observations have them done between 07.00 – 09.00 and 20.00-22.00. This ensures the patient’s physiology is checked prior to medical review during the day and at the beginning of the nursing day shift, and prior to sleep so the patient can have a safe undisturbed night’s sleep.


6.9.4 For patients receiving EoL care the no monitoring function should be used.

6.10 Use of NEWS2 SpO ₂ Scales in Adult Patients In NEWS 2 there are two oxygen saturation scales. Scale 1 is the default scale and Scale 2 is for use in patients with confirmed chronic Type 2 (hypercapnic) respiratory failure. The decision to move a patient to SpO₂ Scale 2 will be made by a COPD specialist and documented in the notes. Note: A diagnosis of COPD does not automatically equate to using SpO₂ Scale 2.

7. TRAINING REQUIREMENTS 7.1 An introduction to VitalPAC™ and all Early Warning Systems is included on Trust Induction.

7.2 All Line Managers have a responsibility to ensure that all permanent and temporary clinical staff received a local induction which includes additional training relevant to their role, level of responsibility and clinical area. For areas using VitalPAC™, this must include recording vital signs, responding to the escalation prompts appropriately and care and maintenance of the equipment. Local induction checklists can be found in the Induction and Mandatory Training policy which is on the intranet in Management and HR policies

7.3 All Registered and Unregistered Practitioners caring for adult patients must undertake competency assessments in the taking, recording and assessment of vital signs in Adults as per current Generic Competency Framework for Registered and Unregistered Practitioners

7.4 All Trust Resuscitation Training embodies the statements and guidelines published by the Resuscitation Council (UK). This recommends that resuscitation training incorporates the identification of patients at risk of deterioration, EWS and the escalation protocol. All clinical staff must be trained annually in cardiopulmonary resuscitation to a level appropriate to their clinical roles and responsibilities, which will include an annual update in aspects of care of the deteriorating patient and calling for help, including the relevant Early warning System.

8. REFERENCES AND ASSOCIATED DOCUMENTATION 1. National Institute for Clinical Excellence (NICE) (2007) Clinical Guideline 50. Acutely ill

patients in hospital. Recognition of and response to acute illness in adults in hospital. 2. National Patient Safety Agency (NPSA) (2007) Safer care for the acutely ill patient: learning

from serious incidents PSO/5 3. Department of Health (DoH) (2000) Comprehensive Critical Care. A Review of Adult Critical

Care Services. 4. SBAR communication tool- situation, background, assessment, recommendation | NHS

Improvement 5. Procedural Documents Development And Management Policy

http://pht/PoliciesGuidelines/Pages/default.aspx 6. Current Nursing and Midwifery Competency for taking, recording and assessment of vital

signs in Adults. Generic Competency Framework 7. Generic Competency Framework for Registered and Unregistered Practitioners

http://pht/PoliciesGuidelines/NursingandMidwiferyPolicies/default.aspx?PageView=Shared 8. Resuscitation Guidelines (UK) (2015). Resuscitation guidelines 9. National Early Warning Score (NEWS) 2 | RCP London 10. National Institute for Clinical Excellence (NICE) (2016) Sepsis: recognition, diagnosis and

early management. https://www.nice.org.uk/guidance/ng51 11. National Confidential Enquiry into Patient Outcome and Death (NCEPOD) (2015). Just Say

Sepsis! A review of the process of care received by patients with sepsis. 12. NHS England. Sepsis guidance implementation advice for adults. Sept 2017.


9. EQUALITY IMPACT ASSESSMENT Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds. This policy has been assessed accordingly Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace. Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do. We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust:

Working together for patients Working together with compassion Working together as one team Working together always improving

This policy should be read and implemented with the Trust Values in mind at all times

10. MONITORING COMPLIANCE This policy will be monitored to ensure it is effective and to assure compliance

Minimum requirement to be

monitored

Lead Tool Frequency of Report of

Compliance

Reporting arrangements Lead(s) for acting on

Recommendations

Implementation of NICE Clinical Guideline 50

Co-Chairs of Deteriorating Patient Group

NICE Clinical Guideline 50 audit tool (Appendix 8)

Annually Results of audit will be presented annually to the Deteriorating Patient Group

Information on status of action planning and learning, as a result of the audit will be reported quarterly to the Trust Board

Chairs of the Deteriorating Patient Group

Clinical response to NEWS 5 and above and/or cause for concern

Co-Chairs of Deteriorating Patient Group

Deteriorating patient data collection form (Appendix 9)

Monthly Results of audit will be presented via the Integrated Performance Report to the Quality and Safety Committee, Trust Board and Deteriorating Patient Group

Chairs of the Deteriorating Patient Group

% of patients screened for sepsis and % of appropriate patients who receive IV antibiotics within an hour

Co-Chairs of Deteriorating Patient Group and Senior Nurse Improving Patient Outcomes

Sepsis data collection form (Appendix 10)

Quarterly Results of audit will be presented via the Integrated Performance Report to the Quality and Safety Committee, Trust Board and Deteriorating Patient Group

Chairs of the Deteriorating Patient Group and Senior Nurse Improving Patient Outcomes


EQUALITY IMPACT SCREENING TOOL

To be completed and attached to any procedural docu ment when submitted to the appropriate committee for consideration and approval for service and policy

changes/amendments .

Stage 1 - Screening

Title of Procedural Document: Deteriorating Patient Policy (Management) Date of Assessment

30/01/19 Responsible Department

Deteriorating Patient Group

Name of person completing assessment

Nicola Sayer Job Title Resuscitation Manager

Does the policy/function affect one group less or m ore favourably than another on the basis of :

Yes/No Comments

• Age No

• Disability No

• Gender reassignment No

• Pregnancy and Maternity No

• Race No

• Sex No

• Religion or Belief No

• Sexual Orientation No

• Marriage and Civil Partnership No

If the answer to all of the above questions is NO, the EIA is complete. If YES, a full impact assessment is required: go on to stage 2, page 2

More Information can be found be following the link below

www.legislation.gov.uk/ukpga/2010/15/contents


Stage 2 – Full Impact Assessment

What is the impact Level of Impact

Mitigating Actions (what needs to be done to minimise /

remove the impact)

Responsible Officer

Monitoring of Actions

The monitoring of actions to mitigate any impact will be undertaken at the appropriate level

Specialty Procedural Document: Specialty Governance Committee

Clinical Service Centre Procedural Document: Clinical Service Centre Governance Committee

Corporate Procedural Document: Relevant Corporate Committee

All actions will be further monitored as part of reporting schedule to the Equality and Diversity Committee


APPENDIX 1: NEWS2 Scoring System for Adult Patients

APPENDIX 2: NEWS 2 Escalation Protocol for Adult Pa tients


APPENDIX 3: Modified Early Obstetric Warning System (MEOWS)


Modified Early Obstetric Warning System (MEOWS)


APPENDIX 4: PHT Paediatric Early Warning Score (PEW S)

Example of PEWS Vital Signs Chart


PEWS Instructions � Score 1 point for every observation in shaded area

� Score an extra point for any of the additional fact ors

• Temp. above 38°C in baby 0-3months • Temp. above 39°C in baby3-6months • Temp. above 38.5°C in immunosuppressed (e.g. oncology) patient • Requiring Oxygen (or increase in O2 dependant babies) • Capillary refill time greater than 2 • Increasing pain which is causing distress

PEWS score = sum of entries in shaded areas plus 1 point each for any of the additional features present Actions for a new or increasing PEWS score PEWS score Action

0 - 1 Continue monitoring 2 Nurse in charge & SHO review 3 Registrar review, must complete Action Plan 4 Inform Consultant

5 & above Consultant to attend if not already present A PEWS score of 3 should trigger a Registrar review within 1 hour. If Nursing staff are concerned that the child’s condition requires more urgent attention, regardless of the PEWS score, they should be asked to attend sooner. If the Registrar is unable to attend the consultant must be informed. Note All patients should be reviewed by the doctors of the team responsible for their care, however if nursing staff have significant medical concerns or there is a major delay in the attendance of the team, the Nurse in Charge may call the paediatric team to review.


APPENDIX 5: PHT Deteriorating Patient Pro-forma

PHT Deteriorating Patient pro forma At Feb 2018


APPENDIX 6: Inpatient Sepsis Screening and Action T ool


APPENDIX 7: Adult Vital Signs Chart

Adult Vital Signs Chart NEWS2 at December 2019 - Pa ge 1

Current version available from Medical Photography or Can be printed from the Intranet Forms and Resources - Trust Staff Resources


Adult Vital Signs Chart NEWS2 at December 2019 - Pa ge 2

Current version available from Medical Photography or Can be printed from the Intranet Forms and Resources - Trust Staff Resources


APPENDIX 8: Acutely ill patients in hospital NICE c linical guideline 50

Title: Acutely ill patients in hospital NICE clinic al guideline 50

Audit criteria: These are the audit criteria developed by NICE to support the implementation of this guideline. Users can cut and paste these into their own programmes or they can use this template

Criterion no.

Criterion Exceptions Definition of terms and/or general guidance Data source

1 Physiological observations in acute hospital sett ings

Percentage of patients who have had their physiological observations recorded at the time of admission or initial assessment.

(Acute hospital settings)

None. As a minimum, the following physiological observations should be recorded at the initial assessment and as part of routine monitoring: • heart rate • respiratory rate • systolic blood pressure • level of consciousness • oxygen saturation • temperature.

(Standard = 100%)

Patient health record.

2 Physiological observations in acute hospital sett ings

Percentage of patients for whom a clear written monitoring plan that specifies which physiological observations should be recorded, and how often, is present in the health record.


None. (Standard = 100%) Patient health record.

3 Identifying patients whose clinical condition is deteriorating or is at risk of deterioration

Percentage of patients monitored using a physiological track and trigger system.



Local policy and procedure documents.

4 Identifying patients whose clinical condition is deteriorating or is at risk of deterioration

For those patients monitored using a physiological track and trigger system: a) the percentage whose physiological observations were

For 4a: Individual patients for whom the decision to increase or decrease the

For 4b: The frequency of monitoring should increase as outlined in the recommendation on locally agreed and delivered graded response strategies.

(Standard = 100% in each case)



Criterion no.


monitored at least every 12 hours b) the percentage of patients for whom there is evidence of increased frequency of monitoring in response to the detection of abnormal physiology. (Acute hospital settings)

monitoring frequency has been made at a senior level.

5 Graded response strategy

There is an agreed and locally delivered graded response strategy in place for patients identified as being at risk of clinical deterioration.


None. Further information, and a description of the recommended graded response strategy, can be found on page 14 of the NICE guideline document (section 1.2.2.10).

(Standard = 100%)

Local policy and procedure documents.

6 Graded response strategy

For those patients admitted to a critical care area, the percentage of patients for whom there is evidence that the decision to admit was made by both the consultant caring for the patient on the ward and the consultant in critical care.



7 Transfer of patients from critical care areas to general wards

For those patients transferred from a critical care area back to a general ward, the percentage for whom this transfer occurred between 22.00 and 07.00.


None. Transfer from critical care areas to the general ward between 22.00 and 07.00 should be avoided whenever possible.

(Standard = 0%)


8 Transfer of patients from critical care areas to general wards

For those patients transferred from a critical care area back to a general ward between 22.00 and 07.00, the percentage where this transfer was documented as an adverse incident.


None. Transfer from critical care areas to the general ward between 22.00 and 07.00 should be avoided whenever possible, and should be documented as an adverse incident if it occurs.

(Standard = 100%)


Adverse incident reports.


Criterion no.


9 Care on the general ward following transfer

Percentage of patients for whom there is a formal structured handover of care from critical care area staff to ward staff (including both medical and nursing staff), supported by a written plan.


Patients who have not been transferred from a critical care area to a general ward.

The critical care area transferring team and the receiving ward team should take shared responsibility for the care of the patient being transferred.

(Standard = 100%)

Patient health record.Written care plan that details the formal structured handover of care.

10 Care on the general ward following transfer

Percentage of patients for whom the formal structured handover of care (supported by a written plan) includes: c) a summary of the critical care stay, including diagnosis and treatment d) a monitoring and investigation plan e) a plan for ongoing treatment, including drugs and therapies, nutrition plan, infection status and any agreed limitations of treatment f) physical and rehabilitation needs g) psychological and emotional needs h) specific communication or language needs.


Patients who have not been transferred from a critical care area to a general ward.

(Standard = 100% in each case) Patient health record.

Written care plan that details the formal structured handover of care.

No. of criterion replaced

Local alternatives to above criteria (to be used wh ere other data addressing the same issue are more readily availabl e)


APPENDIX 9: Deteriorating Patient Data Collection F orm


APPENDIX 10: Sepsis Data Collection


APPENDIX 11: Adapted Emergency Department vital sig ns protocol

• All majors adult patients and minors patients requiring admission must have hourly observations using NEWS 2 Scoring System for Adult Patients (Appendix 1), or more frequently if the patient’s clinical condition requires it. This should continue until seen by a clinical decision maker such as a Doctor, Advanced Clinical Practitioner, Consultant Nurse or Emergency Nurse Practitioner.

• The clinical decision maker, following their assessment of the patient, should

document whether the patient must remain on hourly observations or can move to the NEWS 2 Escalation Protocol for Adult Patients (Appendix 2).