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Policy and Guidelines for Vital Signs Assessment (VSA) and the use of Early Warning Scoring (EWS) in Adults

Reference Number:

776 2010

Author & Title:

Julian Hunt, Consultant Nurse Critical Care

Responsible Directorate:

Clinical

Review Date:

January 2013

Ratified by (committee):

Operational Governance Committee

Date Ratified:

January 2010

Version:

2

Related Policies

Resuscitation Policy Critical Care Services Admission and Discharge Policy

Document name: Policy for Vital Signs Assessment (VSA) and the use of Early Warning Scoring (EWS) in Adults Issue date: February 2010 Page 1 of 26

Ref.: 776/2010 Status: Final

Index 1. 2. 3. 4. Purpose of this policy .......................................................................................... 3 Aims and Objectives of this policy ....................................................................... 3 Policy .................................................................................................................. 3 Guideline for review of patient for acute intervention or trigger re-set ................. 6 4.1 4.2 4.3 Patient review or revised monitoring plan / Use of SBAR ............................ 7 Trigger re-setting.......................................................................................... 7 Patients being transferred from critical care to the ward .............................. 8

4.4 Referrals to critical care outreach / night nurse practitioners / critical care medical staff ........................................................................................................... 8 4.5 Patients with a Do Not Attempt Resuscitation (DNAR) decision in place ..... 9 4.6 Transfer of sick patients for investigations or between wards and departments............................................................................................................ 9 5. Duties ................................................................................................................ 10 5.1 5.2 5.3 5.4 5.5 6. 7. 8. Matrons and Senior Nurses ....................................................................... 10 Ward managers ......................................................................................... 10 Critical Care Outreach and Night Nurse Practitioners ................................ 10 Clinical Skills staff ...................................................................................... 10 Bedside Nurses and AHPs and Health Care Assistants ............................ 10

Training ............................................................................................................. 11 Monitoring ......................................................................................................... 11 References and further reading......................................................................... 11 CONSULTATION SCHEDULE ........................................................ 13 ADULT VITAL SIGNS CHART ........................................................ 14 GUIDANCE NOTES FOR VITAL SIGNS ASSESSMENT CHARTS ........................................................................................................ 16

APPENDIX 1 APPENDIX 2 APPENDIX 3 (V5)

APPENDIX 4 SERVICE AVAILABILITY (ACUTE PAIN SERVICE / CRITICAL CARE OUTREACH / NIGHT NURSE PRACTITIONERS......................................... 23 APPENDIX 5 SBAR COMMUNICATION DEVICE ................................................ 25 RATIFICATION CHECK LIST .................................................................................. 26

Document name: Policy for Vital Signs Assessment (VSA) and the use of Early Warning Scoring (EWS) in Adults Issue date: February 2010 Page 2 of 26

Ref.: 776/2010 Status: Final

1. Purpose of this policy The purpose of this policy is to ensure a standardised trust wide approach to the use of Early Warning Scoring (EWS) in adult patients (also referred to as a "Physiological Track and Trigger" system) for adult patients (see 2.5) (NICE, 2007).

2. Aims and Objectives of this policy The primary aim of this policy and guideline is to enhance patient safety through minimizing risks associated with clinical deterioration and ensure that acute changes in patients' vital signs are appropriately dealt with by staff in the multi-disciplinary team. The EWS calculated as part of vital signs assessment should be associated with appropriate communication between medical, nursing and allied health professional staff. The aim of this is to achieve appropriate medical review and a consensus on acceptable physiological parameters for an individual patient and provide a monitoring plan that will prompt medical review where required (NICE, 2007). Early Warning Scoring should be used to signal for acute deterioration in clinical condition, (Gao, 2007) to prompt appropriate and timely escalation of treatment to avoid further physiological deterioration and potential harm. The policy and guidelines are designed to create a standardized approach to the recording of vital signs to assure prompt and timely intervention when patients require medical intervention. Separate vital signs charts exist for children. The adult vital signs chart may on occasion be used with larger children at the discretion of the acute pain team. Where this is done it may be appropriate to use the adult EWS. This should be decided by the Acute Pain Team in consultation with the nurse responsible for the patient.

3. Policy All clinical staff will have training in the use of vital signs assessment and EWS as part of their trust or local induction or as part of their ongoing training. For specific training that includes vital signs and EWS see section 6 Routine vital signs assessment will be documented on the version 5 VSA chart for adults. (Version earlier than version 4 must not be used, nor are photocopied charts acceptable) (See Appendix 2) All in-patients, including patients in the Emergency Department for whom a decision to admit has been made, will have EWS calculated at a frequency appropriate to clinical need or at a minimum standard frequency (NICE, 2007). (For critical care see paragraph 3.18 and section 5)

Document name: Policy for Vital Signs Assessment (VSA) and the use of Early Warning Scoring (EWS) in Adults Issue date: February 2010 Page 3 of 26 Ref.: 776/2010 Status: Final

The frequency of VSA and EWS appropriate to clinical need will be determined by medical staff in consultation with nursing staff. This frequency will be based on individual clinical need or according to set departmental standard or protocol, and will be changed in accordance with changes in the patient's clinical condition. The frequency with which vital signs assessment (observations) is required must be recorded in the text section of the vital signs chart and amended as clinical condition warrants. Where appropriate, frequency of EWS and vital signs assessment will be according to locally agreed (ward-based) standards or specific treatment protocols (e.g. blood transfusion). These standards should be agreed by senior sisters and staff in all wards and departments in consultation with Matrons who will link to divisional governance groups. Local standards must not be made that fall short of a 12 or 24 hours standard. Each ward will identify its own standards for who should have EWS done (and how often). Standards will be audited at a frequency determined by ward managers and matrons. Audit results will form part of the matron's score card for reporting. Where vital signs assessment is undertaken it should be based on systematic assessment and not on over-reliance on electronic monitoring equipment. A full assessment of vital signs is required at least twelve hourly, (NICE, 2007) for patients who require acute care. For patients where discharge from the acute trust is delayed (e.g. awaiting residential home transfer) it is appropriate to record vital signs once every 24 hours. For patients on an end of life pathway there is no requirement to record vital signs or EWS Where a patient is not co-operative with having vital signs assessed and will not consent this must be written on the VSA chart and documented in the nursing documentation. Compliance with a twelve hourly standard or other locally agreed standard or protocol will be audited every eighteen months. Non-professional staff (health care assistants) completing vital signs assessment of a patient must report any vital signs that are outside an acceptable range to a registered nurse or other professional. If a patient has a EWS of greater than 0 the registered nurse (or other professional) responsible for that patient must be informed. (This applies even when a patient has chronic ill health which is likely to result in higher than normal EWS scores.) Any patient with a EWS of 4 or above must have a clearly documented monitoring plan which includes the required frequency of observations, frequency of EWS

Document name: Policy for Vital Signs Assessment (VSA) and the use of Early Warning Scoring (EWS) in Adults Issue date: February 2010 Page 4 of 26 Ref.: 776/2010 Status: Final

recording (if different) and acceptable parameters for review if different from those stated in the EWS. This will normally require medical input. The Awake-responding to Voice-Responding to Painful Stimulus-Unresponsive (AVPU) device is the routine way in which conscious level is assessed for EWS. Where a more detailed neurological assessment is required a supplemental neurological observations (adult) chart should be used alongside the vital signs assessment chart to record the Glasgow Coma Score (GCS). Glasgow Coma Score (GCS) may be used to calculate EWS if it is being recorded, but it is important to ensure consistency in using one or the other. When neurological assessment is undertaken by non-professional staff (health care assistants) any patient observation of P or U must be immediately reported to the registered nurse (or other professional) responsible for the patient. Non-professional staff may undertake more detailed neurological assessment if they have been trained and have documented evidence of their competence. Telephone referrals for urgent clinical review should be made using the Situation, Background, Assessment and Recommendation (SBAR) tool and using information derived from vital signs assessment and Early Warning Scoring. The appropriate SBAR code should be documented (i.e. trigger reset / doctor informed / or both). Details of referrals made and telephone communications with dates times and names should be recorded in the clinical records and may also be noted in the text section of the vital signs chart. Patients within Critical Care Services (Intensive Therapy and High Dependency Unit) receive closer monitoring and surveillance and do not require EWS to be recorded until they are ready for transfer to the ward. Patients on the Coronary Care Unit will have their EWS calculated as part of their VSA as in other in-patient areas.

Document name: Policy for Vital Signs Assessment (VSA) and the use of Early Warning Scoring (EWS) in Adults Issue date: February 2010 Page 5 of 26

Ref.: 776/2010 Status: Final

4. Guideline for review of patient for acute intervention or trigger re-set

Decision made about frequency of vital signs assessment (made by medical team as part of management plan, local ward standards or as part of care plan) Monitoring plan delivered as agreed. Consider trigger reset if treatment optimal or if chronic ill health makes threshold of 4 unsuitable (experienced nurse / doctor only) EWS = 0 EWS = 1-2 Observe (no immediate action) Observe (HCA must report observations & score to nurse) Repeat Respiratory Rate recording, Pulse, Blood pressure, Oxygen saturation, GCS or AVPU Calculate urine output for last two hours (if known) Recalculate EWS If the same observe closely (HCA must report observations and score to nurse) Ensure that all treatment options have been used. Repeat Respiratory Rate recording, Pulse, Blood pressure, Oxygen saturation, GCS or AVPU Recalculate EWS Ensure that EWS trigger has not been re-set Contact doctor immediately (according to local protocol) (HCA must report observations and score to nurse) Patient is at risk of deterioration and complications. If treatment plan is not appropriate or in place escalate treatment with urgency and seek medical or specialist nurse practitioner review. RESUSCITATION TEAM CALLING CRITERIA ON FINDING ANYONE IN · · ·

EWS = 3

Consider Outreach or NNP support on grounds of clinical concern only

EWS = 4

Level of doctor contacted will vary in different areas

Consider critical care outreach or night nurse practitioner support

EWS greater than 4

Cardiac arrest Respiratory arrest Unrousable / not responding to pain

OR

With one or more of the following signs: · Respiratory rate < 8 per minute · Respiratory rate > 30 per minute · Heart rate < 40 per minute · Heart rate > 150 per minute · BP < 90 systolic · Oxygen saturation < 90% Dial

If EWS is high, sudden deterioration is likely. 2222

Document name: Policy for Vital Signs Assessment (VSA) and the use of Early Warning Scoring (EWS) in Adults Issue date: February 2010 Page 6 of 26

Ref.: 776/2010 Status: Final

4.1 Patient review or revised monitoring plan / Use of SBAR If a patient requires review as guided by the flow chart above, the standard for communication by telephone is to use SBAR. The combination of information derived from SBAR / VSA / EWS gives enough information to inform whether an immediate or a scheduled review is required. If an immediate review is recommended by the nurse or AHP requesting review, but the doctor disagrees or is unable to attend within a reasonable timescale, then advice should be sought from senior nurse on ward, senior nurse (bleep holder), critical care outreach, night nurse practitioner. It is not sufficient to document nonattendance and take no further action. 4.2 Trigger re-setting EWS is set to trigger if a patient has abnormal physiology apart from systolic hypertension which is not an acute emergency unless severe. EWS may trigger through acute changes or because of chronic ill health The standard trigger setting of 4 to prompt a medical review is deliberately set to ensure that any patient with disordered physiology is appropriately reviewed and assessed as to whether they need a revised management and monitoring plan or a different trigger setting. Trigger resetting is possible in one of two ways: · It is possible to simply elevate the number at which a medical review is prompted. This should only be done by an experienced nurse or doctor able to judge that the current treatment plan is both appropriate and optimal. · It is also possible to alter the scores attributed to particular parameters within the EWS system. This requires considerable skill and should only be done by experienced staff. If the EWS trigger is reset, the new trigger for review should be documented in the text section on the front of the vital signs chart with a time, date and signature Where the trigger is reset it is important to document the trigger reset in the text section with the words. "Review if EWS is greater than....." and importantly to add "or if a new parameter contributes to the EWS" Where a patient has normal vital signs when well, it is desirable to re-set the review trigger on a time-limited basis so that re-review will be automatically prompted. This should be clearly documented within the monitoring plan. Because the EWS is based on absolute numbers rather than numbers relative to an individual patient care should be taken with deciding what is an acceptable blood pressure. Patients who are normally hypertensive may not trip a review score even if they become relatively hypotensive. Care must be taken in ensuring that these patients receive a review appropriately. For some clinical situations EWS is inadequate and a single parameter may be

Document name: Policy for Vital Signs Assessment (VSA) and the use of Early Warning Scoring (EWS) in Adults Issue date: February 2010 Page 7 of 26 Ref.: 776/2010 Status: Final

identified as a trigger for review.(e.g. review if systolic blood pressure is less than 110 mm Hg or review if respiratory rate greater than 26) For some patients a parameter that is not recorded on the vital signs chart may be the prompt for review of a patient. Where this is the case it should be documented in the text section on the front of the vital signs chart (e.g. review if Forced Vital Capacity less than 1.0 ­ see FVC chart) 4.3 Patients being transferred from critical care to the ward EWS is not routinely recorded in critical care where more detailed charting processes are used. Any patient being discharged to the ward will have VSA recorded which will include at least two calculations of EWS and a monitoring plan. If the EWS is 4 or more when a patient leaves critical care then critical care outreach / night nurse practitioner will be informed at the earliest opportunity. Where a patient has abnormal physiology but is still regarded as suitable for transfer to ward or other department it may be appropriate to re-set the trigger to a more appropriate level. No patient should be transferred from critical care to the ward without an appropriate management plan and a monitoring plan documented on the discharge summary 4.4 Referrals to critical care outreach / night nurse practitioners / critical care medical staff Referral for admission to critical care should be made by ward doctors directly to the Critical Care medical team (Bleep 7002), but only after discussion and review by senior doctors of the parent team. The standard for critical care referral should be consultant to consultant (See critical care admission and discharge policy). Referral to critical care outreach or to night nurse practitioners is not a part of the referral process for admission to critical care, but their help may be sought in optimizing patient care whilst a senior review is being sought by parent team junior doctor. Acutely unwell patients should be referred to critical care outreach by day and night nurse practitioners (NNPs) by night. These individuals do not need necessarily to respond to EWS trigger thresholds, but will be responsive to clinical concern, regardless of recorded EWS (Note that outreach and NNPs do not provide consistent 24 hour cover). Where NNPs or outreach are not available referral can be made to medical / surgical bleep holder. In some situations it may be possible to get telephone advice from critical care services (ITU & HDU) staff or from staff in other specialist areas (e.g. respiratory ward, coronary care unit). In all instances clinical concern should be expressed to junior doctors (either parent team or on-call team) as the first response to acute illness deterioration unless the patient meets criteria for a resuscitation

Document name: Policy for Vital Signs Assessment (VSA) and the use of Early Warning Scoring (EWS) in Adults Issue date: February 2010 Page 8 of 26 Ref.: 776/2010 Status: Final

team call. 4.5 Patients with a Do Not Attempt Resuscitation (DNAR) decision in place There are two types of patient with DNAR decisions in place. One group consists of patients who are dying and for whom treatment aims are limited to symptom control. (These patients should be on an End-Of-Life clinical care pathway). These patients do not need regular vital signs assessment, but if they deteriorate may require medical review for symptom control and comfort. The other group of patients with a DNAR decision are those who are still requiring active management, such as oxygen, fluids, antibiotics, physiotherapy, etc., but who would not be resuscitated if they had pulseless electrical activity, ventricular fibrillation or asystole. If patients in this group deteriorate may require an urgent senior medical review, as there may still be appropriate treatments that could be instituted. It is not appropriate to call the resuscitation team for these patients. The management plan for all such patients needs to be very specific about acceptable physiological parameters for vital signs. These should be documented in the clinical notes and also in the text section of the adult vital signs assessment chart. Critical care outreach / night nurse practitioner support should be sought for the care of any patient where technical clinical support or advice is required regardless of their DNAR status. Critical Care Outreach is less likely to have a contribution to a patient on an End of Life pathway, but there are circumstances where referral may be appropriate. 4.6 Transfer of sick patients for investigations or between wards and departments Where patients are transferred between wards the level of monitoring and supervision needs to match the clinical needs of the patient. If a patient is unstable or identified at risk of deterioration, then a complete vital signs assessment and EWS should be undertaken immediately prior to transport. Changes in EWS or clinical concern must influence decisions about appropriateness of a nurse escort. The handover between wards needs to match the clinical needs of patients. All transfers without a registered nurse should at least be visually assessed by the registered nurse on the sending ward before transfer. Similarly all patients on the receiving ward should have at least a visual inspection immediately on arrival to the ward. Where a telephone or fax handover is done, the information given should be guided by local protocol. Patients who are deemed unwell enough by clinical staff caring for them will need to have a nurse escort. For complicated patients with high oxygen demands or other technical requirements, help should be sought from critical care outreach or night nurse practitioners. In their absence, telephone advice may be obtained from the critical care unit (ITU & HDU) or from other specialist areas (e.g. respiratory ward).

Document name: Policy for Vital Signs Assessment (VSA) and the use of Early Warning Scoring (EWS) in Adults Issue date: February 2010 Page 9 of 26 Ref.: 776/2010 Status: Final

Particular attention should be paid to the amount of oxygen available for patients receiving high flow or continuous positive airway pressure systems and those requiring continuous pulse oximetry.

5. Duties All staff have a responsibility for ensuring that the principles outlined within this document are universally applied. This policy applies to all members of staff who are involved in any aspect of the development and use of procedure development. Key organisational duties are identified as follows: 5.1 Matrons and Senior Nurses · To ensure that compliance with VSA and EWS standards by wards is achieved through regular audits · To ensure that VSA and EWS forms part of the matron's score Ward managers · To ensure that standards for vitals signs and EWS are established and monitored · To ensure that ward staff are appropriately trained in the use of VSA and EWS · To ensure that non-compliance with standards is reported through the risk reporting process · Critical Care Outreach and Night Nurse Practitioners To provide support for staff in using VSA and EWS as per policy and guideline Clinical Skills staff To provide training that includes VSA and EWS as per policy and guideline

5.2

5.3

5.4 · 5.5

Bedside Nurses and AHPs and Health Care Assistants · To ensure that standards for VSA and EWS are used in routine care of patients · To retain updated skills in VSA and EWS · To be familiar with and apply local and national standards for VSA and EWS

Document name: Policy for Vital Signs Assessment (VSA) and the use of Early Warning Scoring (EWS) in Adults Issue date: February 2010 Page 10 of 26

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6. Training Training specific to use of Vital Signs Assessment, Early Warning Scoring and SBAR communication device · · · · Clinical induction for registered nurses Clinical induction training for health care assistants Preceptorship training for registered nurses Urgent Treatment Of Patients In Adversity (UTOPIA) for registered nurses, health care assistants, Foundation Year 1 doctors (induction programme), Medical Nurse Practitioner Induction Programme.

7. Monitoring Monthly harm event monitoring is undertaken as part of the South West Quality & Patient Safety Improvement Programme and is included in the quarterly patient safety report submitted to the Patient Safety Steering group. The report identifies trends in correct assessment and appropriate actions, in order to identify areas of non-compliance and key risks to the organisation. The report is also reviewed at the Trust Management Board meeting.

8. References and further reading Buist et al. (2004). "Association between clinically abnormal observations and subsequent in-hospital mortality: a prospective study". Resuscitation. 62. 137 ­ 141. Department of Health and NHS Modernisation Agency (2003) The National Outreach Report. London: Department of Health. Gao et al. (2007). "Systematic review and evaluation of physiological track and trigger warning systems for identifying at risk patients on the ward". Intensive Care Medicine 33: 667­79. Joint Commission Perspectives on Patient Safety, (2005). The SBAR technique; step by step February 2005, Volume 5, Issue 2. Joint Commission on Accreditation of Healthcare Organizations McQuillan et al. (1998) Confidential inquiry into quality of care before admission to intensive care. British Medical Journal. 316: 1853­8. NCEPOD. (2005)" An acute problem? A report of the National Confidential Enquiry into Patient Outcome and Death (NCEPOD)". London: NCEPOD. NCEPOD (2007). "Emergency Admissions: A journey in the right direction? A report of the National Confidential Enquiry into Patient Outcome and Death (NCEPOD). London. NCEPOD

Document name: Policy for Vital Signs Assessment (VSA) and the use of Early Warning Scoring (EWS) in Adults Issue date: February 2010 Page 11 of 26 Ref.: 776/2010 Status: Final

National Institute for Health and Clinical Excellence (2007): "Acutely ill patients in hospital: Recognition of and response to acute illness in adults in hospital". Clinical Guideline 50. NICE. London National Patient Safety Agency. (2007) "Safer care for the acutely ill patient: learning from serious incidents. NPSA. London

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APPENDIX 1

CONSULTATION SCHEDULE Date Consulted March 2009 / December 2009 March 2009 / December 2009 March 2009 March 2009 March 2009 March 2009 March 2009 March 2009 March 2009 March 2009 April 2009 / December 2009 December 2009

Name and Title of Individual Francesca Thompson, Director of Nursing Alexandra Lucas, Head of Patient Safety Jan Lynn, Assistant Director of Nursing Gareth Howells, Assistant Director of Nursing / Divisional Manager Lynn Garland, Resuscitation Department Manager Julie Blackman, Clinical Skills Lead Sharon Preston, Assistant Director of Nursing Tim Craft, Deputy Medical Director Bill Palastre, Charge Nurse, Acute Pain Service Mark Bonson, Clinical Skills Trainer Jo Miller, Assistant Director of Nursing, Patient Safety Anne Plaskitt, Practice Development Senior Nurse Name of Committee Policy Group Operational Governance Committee

Date of Committee 05.01.10 13.01.10

Document name: Policy for Vital Signs Assessment (VSA) and the use of Early Warning Scoring (EWS) in Adults Issue date: February 2010 Page 13 of 26

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APPENDIX 2

ADULT VITAL SIGNS CHART

Front of (Version 5) Adult Vital Signs chart

Document name: Policy for Vital Signs Assessment (VSA) and the use of Ref.: 776/2010 Early Warning Scoring (EWS) in Adults Issue date: February 2010 Status: Final Page 14 of 26

Reverse of (Version 5) Adult Vital Signs Chart

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APPENDIX 3

GUIDANCE NOTES FOR VITAL SIGNS ASSESSMENT CHARTS (V5)

Key features and comments on the use of version 5 VSA charts for adults · Respiratory rate (the most important indicator of deterioration in a patient) is emphasised and should be recorded graphically unless its position on the chart might conflict with the recording of another parameter where recording actual numbers might make it clearer. · The Pain, Sedation and Nausea scores are all recorded numerically. · The assessment of pain, sedation, motor function and nausea should be recorded routinely according to the advice on the vital signs chart. · Patient Controlled Analgaesia (PCA) observations will need to be written on to one of the rows on the chart. · Routine neurological assessment uses AVPU. (Note that neurological deterioration is the second most important marker of acute deterioration in acutely ill patients. · A warning line for hypothermia is present on the chart. A trend towards hypothermia may be clinically important and should be investigated particularly if associated with hypotension or other altered physiology even if those changes are minor. · Hypothermia requires treatment by passive or active warming as appropriate. Any hypothermic patient requires close (frequent) observation of vital signs, the frequency of observations should be determined by clinical need.. · Early Warning Scoring (EWS) must be calculated using all available physiological parameters (apart from urine output). · Hypotension should be regarded as a medical emergency until proven otherwise. · Symptomless hypotension is unusual (and not treated in the UK) · It is important to note that the EWS is based on an absolute blood pressure and for patients who are normally hypertensive may underscore illness measure. · Any change in a patient's blood pressure from what appears normal for them should be regarded as clinically significant. This is often signified by a stepwise change in recorded physiological parameters. · EWS is to support clinical decision making not replace it. If there are clinical concerns about a patient they should be acted on regardless of the EWS. · Each ward should identify its own standards for who should have EWS done (and how often). Standards set should be audited. · The chart is designed for adult use only (over 16 years of age). A Paediatric EWS has been devised and is used in paediatric areas, unless the acute pain team, the parent team or critical care outreach recommends use of the adult chart. · Extra rows are provided for specialist ward use, where row titles should be overwritten, for such measures as central venous pressure (CVP) or Noninvasive ventilator pressures. (CVP should be recorded on the vital signs chart and not the fluid chart or elsewhere)

Document name: Policy and Guidelines for Vital Signs Assessment (VSA) and the use of Early Warning Scoring (EWS) in Adults Issue date: Page 16 of 26 Ref.: 776 Status:

·

· · ·

There is a text section for additional comments, e.g. frequency of recommended vital signs assessment, details of EWS trigger reset (doctor, specialist nurse practitioner, critical care outreach or night nurse practitioner or experienced ward nurse only);; pain team comments; bleep numbers etc. The chart is for continuous use ­ If the patient is transferred to another ward it is continued in use. It should be filed when completely filled or the patient no longer requires assessment; death or discharge. Version 5 of the chart has a section for recording Glasgow Coma Score (GCS). Please note that this is for Emergency Department use only The upper temperature alert line is set at 37 degrees Centigrade. This is advisory only. The currently used thermometer (Braun) records a tympanic temperature. A temperature observation of 37 degrees Centigrade does not indicate pyrexia.

Features of new charts Trend information is important in judging the success of treatment and also in identifying deterioration in clinical condition. There is good evidence that most patients having cardiac arrest in hospital show premonitory signs for many hours before they arrest. If warning signs are shown in trend, then in risk management terms we need to do something to intervene before cardiac arrest. Any deteriorating trend in physiological parameters should be regarded with suspicion. Stability is only appropriate if physiological markers are within the patient's normal range. For people with chronic illness chronically deranged physiology may be appropriate for that individual, but changes in physiological markers may be highly significant. Early Warning Scores There is no evidence that a single parameter system (e.g. respiratory rate) is any better at predicting deterioration than a multi-parameter system, which rates several parameters (Gao, 2007) (the system we are adopting at the moment has up to six parameters that may be scored). However a change in a single parameter can be important and so there are some advisory hints structured in to the new charts. The way in which the EWS should be used is discussed in detail below. RECORDING VITAL SIGNS ASSESSMENT Baseline observations are important, but it is changes in physiology reflected through the observations that are recorded that are more important. Respiratory rate Respiratory rate is regarded as a very significant marker of severity of illness in hospital. A respiratory rate of less than 10 is abnormal. In the case of a patient receiving opiate analgesia or an epidural, the protocol of the acute pain team should be followed. (See section on pain team advice below). A respiratory rate above 30 may indicate significant illness and is highlighted on the

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chart. Any increase in respiratory rate, which is acute and sustained and cannot be explained easily should be reported. A rate above 30 is significant, a rate above 40 very significant. The EWS attributes a score for a respiratory rate of 15 and above. Patients with chronic respiratory disease may have a high respiratory rate normally. Changes in respiratory rate are still significant, and the requirement for respiratory rate monitoring is greater. Respiratory rate should be counted for a full minute to rule out influence of irregular breathing patterns. Irregular breathing of itself is likely to be highly significant. Oxygen administration guidance Version 5 charts include guidance on the administration of oxygen for all admitted patients that is consistent with the advice of the British Thoracic Society (2008). The target saturation range suitable for each patient's clinical condition should be indicated on the chart as soon as they are clerked. Most patients should be prescribed a target saturation range of 94-98%. Patients identified as being at risk of hypoxic drive should be prescribed a target range of 88-92%. The instruction should be dated and signed and the target range identified by local protocol, or decision of doctor, specialist nurse practitioner, critical care nursing outreach or night nurse practitioner Where a new chart is used because a previous one is filled the oxygen saturation target should be reviewed and documented on the new chart. It is acceptable to "carry over" the target saturation range from the previous chart onto the new one. That this is done should be documented in the text section of the latest chart in use.. Neurological assessment (AVPU or GCS) Neurological condition is an important marker of deterioration in clinical condition. Changes in conscious level are highly significant. There are particular difficulties with assessing conscious level at night. Sleep and unconsciousness are not the same but may look similar. If a patient requires close neurological monitoring then a Glasgow Coma chart should be used (although Early Warning Scoring) is indicated too). For normal purposes a simple AVPU score is adequate. AVPU is now a basic standard of routine vital signs assessment. The AVPU scale is simple. Each letter describes a neurological state that can describe a patient. A = Alert V = responds to Voice P = responds to Pain only U = Unresponsive. As a general rule, any change from one letter to another is clinically significant and should be noted (A is acceptable; V may have a reasonable clinical explanation, if not it should be reported. P and U should be reported).

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AVPU is not a replacement for the Glasgow Coma Score, but should be applied to everyone when other observations are recorded. Usually it will be A. Particular attention should be paid to any patient who does not score A. If a patient has a neurological deterioration their assessment should be in primary survey order (ABCDE), but D must include checking blood glucose and acting on low blood glucose levels Either AVPU or GCS (not both) is used to calculate the EWS. Systolic blood pressure This is the upper blood pressure number derived from a "Dinamap" or a manual device. The gold standard for assessing a patient is to use a manual device although there is a role for using an electronic device for regular frequent recordings. Electronic devices may be inaccurate particularly if the device is old or the patient has a tachycardia and/or low blood pressure. The systolic blood pressure is the component of the BP which is used to calculate EWS. It is easier to use than the mean arterial blood pressure, which may be more clinically meaningful, but is less easy to measure reliably. Although BP is important to monitor in patients, it does tend to be a late sign of clinical deterioration. Sick patients can physiologically compensate and only fail to maintain their BP when they are very sick. Pulse The best way of recording the pulse is by feeling it ­ the radial pulse being the most common site. As well as recording the pulse rate, note the pulse volume (how forceful the pulse is) and regularity. Note any pulse irregularity in text on the chart graph. Pulse volume is a subjective evaluation. But it is clinically important if there is a weak pulse volume or a very bounding pulse. Feeling a pulse is also an opportunity to feel if a patient is peripherally cool or warm and if they are sweaty ­ all of which observations may be clinically significant. It is not appropriate to record them on the chart, but may be appropriate to report them. Pulse, pulse volume and peripheral clamminess and temperature are all important measures of perfusion. If there are concerns about a patient's well being then measuring capillary refill time may be helpful. Capillary Refill Time (CRT) Press the pad of a finger (not the nail bed) firmly for five seconds (holding the hand at the level of the heart) and then release the pressure, the capillary refill time (CRT) is the number of seconds that it takes full colour to return to the area that has been pressed. Normal CRT is less than 2 seconds-longer than this indicates poor perfusion. A CRT of > 3 seconds is likely to be clinically significant. (Some people assess CRT by pressing on the sternum rather than a digit - either is acceptable).

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The CRT does need to be documented on the vital signs assessment chart frequently, but could be recorded twice a day in one of the unlabelled rows of the chart if a patient is particularly unwell. Urine output This is a component of the EWS but will not necessarily be scored for all patients. It is possible to derive a EWS without waiting for an hour to see what the urine output is. Having the urine output as a parameter rapidly identifies those patients who have poor urine output. Any patient who does have a poor urine output should probably go onto regular EWS until a clear plan to manage the patient is made. If there are concerns about urine output, a falling urine output is clinically significant. Close observation and recording of urine output is important for any patient who is hypotensive (BP below 90 systolic) or in any patient where the blood pressure is lower than normal for them, e.g. if a patient normally has a BP of 160 systolic - a BP of 120 would be very significant if it was accompanied with a fall in urine output. An hourly output of zero requires a check that the catheter is patent. Outflow obstruction should always be excluded in totally anuric patients. Temperature The new vital signs assessment chart incorporates a red line at 35.5 degrees Centigrade and one at 37.0 degrees centigrade. The lines reflect an acceptable range for tympanic temperatures. It is important to use one electronic thermometer type on a patient for continuous observations. Equipment made by different manufacturers behaves differently on individual patients and can affect accurate recording of trend information. The importance of a high temperature is well recognised but a low temperature is often ignored. If there is a downward trend in temperature, this is often highly significant. Many patients with sepsis or severe infection may become hypothermic. Currently this often goes unnoticed. Falling temperature is particularly important when associated falling blood pressure and reduced urine output. The EWS scores for temperatures inside and outside this range. Early Warning Scoring It is the responsibility of senior staff in each clinical area to decide the rules surrounding which patients should automatically have their EWS scored. Nurses are accountable for the consequences of decisions made. There are two general rules. · Any patient causing for concern should have their EWS calculated for as long

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and as frequently as it is considered necessary. ("I do not like the look of this patient" is a common criterion in Medical Emergency Team protocols that leads to many patients ending up in intensive care). · Any patient sick enough to require vital signs assessment more frequently than four hourly should have their EWS calculated at least four hourly, and immediately if any single observation shows a dramatic change from earlier recorded observations.

Every patient in the hospital should have his or her EWS calculated at least once every 12 or 24 hours (in some areas the set standard is that this should be done by a trained member of staff). Any patient admitted to hospital as an emergency should be on 4 hourly EWS for 24 hours pending senior review. (This does not include critical care where a high level of surveillance and monitoring is routinely maintained). Any patient on the ward with a recent tracheostomy should have 4 hourly EWS calculated until its discontinuation is advised by a "clinical expert" (experienced ward staff, outreach or critical care team, anaesthetist, head and neck nurse, respiratory nurse specialist, or ENT medical team). For all other patient groups the rules about how EWS should be used should be decided locally since the best use of EWS is determined by the organisation of the ward and the types of patients that are admitted. The purpose of EWS is to support HCA and nursing staff in monitoring the condition of patients so that failure in treatment or acute deterioration because of clinical complication is promptly and appropriately managed by the medical team. It is designed to support decision making not replace it. If a nurse thinks that the doctor should see a patient, their expert view should over-ride the EWS score. It is not designed to be scientifically exact; it is a quick assessment tool and as such will not be flawless. Once a patient has a EWS that requires a medical / specialist nurse practitioner review the accepted time delay before review is 30 minutes. If a review is not received within this time period the doctor should be reminded. Once a patient is reviewed a clear medical plan should be documented and communicated to nursing staff looking after the patient. It may be appropriate to reset the trigger to a different level if there is maximal treatment already in place, e.g. atrial fibrillation is being appropriately monitored and any metabolic condition, intravascular volume and appropriate anti-arrhythmic therapy addressed. The normal trigger reset factor is to add 2 to the printed algorithm scores. Trigger reset should be undertaken by medical staff or by senior nurse. It should be done only when treatment for the physiological markers tripping a high score are maximally treated.

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EWS may be appropriate despite the existence of a DNAR decision; just because a patient is not for resuscitation, does not mean that some complications will not require treatment. EWS is inappropriate for patients with a DNAR decision in place who are on an End-Of-Life Pathway.

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APPENDIX 4

SERVICE AVAILABILITY (ACUTE PAIN SERVICE / CRITICAL CARE OUTREACH / NIGHT NURSE PRACTITIONERS

Acute Pain Service · PCA / epidural observations are mandatory and must be recorded when advance analgesia techniques are in use. · Respiratory rate ­ If respiratory rate falls below 8 - 10 min and patient has PCA/Epidural/Spinal Opiate, stop analgesic therapy and contact APS. · Sedation Score - If sedation score is 3 and patient has PCA/Epidural/Spinal Opiate, stop analgesic therapy and contact APS. · Motor Function ­ If motor function score is 3, stop epidural and contact APS. · Problems with persistent pain, itching, nausea or any technical difficulties with pumps should be addressed to the APS nurse. Availability of Acute Pain Nurse Office hours ­ Bleep 7222 Availability of Acute Pain doctor Out of hours ­ Bleep 7113 Availability of Night Nurse Practitioners Nightly between 20:30 and 08:00 ­ bleep 7428 and 7429 Availability of Critical Care Outreach Variable service subject to availability between 07:30 and 21:00 ­ some week-end and bank holiday service - Bleep 7719

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APPENDIX 5 SITUATION

SBAR COMMUNICATION DEVICE

· · · · · · · What you are calling about? Identify yourself, the unit, the patient Briefly state the problem: what, when and severity Background information related to the situation, including most recent vital signs (fresh set) Admitting diagnosis and date of admission A list of current medications, allergies, intravenous fluids (Lab results, with the date and time each test was performed and results of previous tests for comparison Other clinical information Resuscitation status Your assessment of the situation? What is your recommendation or What do you want?

BACKGROUND

ASSESSMENT RECOMMENDATION

· · · · ·

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RATIFICATION CHECK LIST

Author; attach this to each copy of the policy being sent to a Committee for final ratification. Dear Chairman Please would you review this document at your next meeting and agree final approval and organisational ratification. Title of meeting: Operational Governance Committee Date of meeting: 13 January 2010 Name of document: Policy and Guidelines for Vital Signs Assessment (VSA) and the use of Early Warning Scoring (EWS) in Adults Name of author: Julian Hunt, Consultant Nurse Critical Care Yes No Are there any elements of this policy which present operational issues that require further discussion? If yes, please provide a contact name for the author. Does the document include a training plan? Is the policy referenced? Are up to date National Guidelines included? If you are the appropriate forum, have the necessary resources been agreed to implement this document? Is there a plan for policy implementation? Does your meeting recommend further consultation with groups or staff other than listed at the front of the policy? What are the cost implications of implementing this policy? Equipment Staffing (additional) Training Other £ £ £ £ Yes No x x x x x x x N/A

x

Document approved without further comment (Please circle): Further amendments to document suggested (Please circle)? Name of Chair: Dr Tim Craft Signature: Ratified and signed at the meeting Date: 13.01.10

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Information

27 March 2009

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