CLINICAL PROTOCOL National Early Warning Score (NEWS) Observation Chart

Transcription

1 CLINICAL PROTOCOL National Early Warning Score (NEWS) Observation Chart November

2 Document Profile Type i.e. Strategy, Policy, Procedure, Guideline, Protocol Title Category i.e. organisational, clinical, finance Version Author Approval Route, i.e. Policy & Procedure Group, Operational Governance Group Approved by Date approved Review date Protocol NEWS Observation Chart Clinical 1.0 Clare Stewart Team Leader for Intermediate Care Operational Governance Group J Gafoor, Chief Executive Officer 20/11/14 20/11/17 2

3 RATIONALE Early warning scores (EWS) are now commonly used for the assessment of unwell patients; These simple observations can detect when a patient s condition requires a more intense observation and should be a trigger for further investigation as early intervention can reduce morbidity and mortality in unwell patients (NICE 2007, NPSA 2007). The National Early Warning Score (NEWS) provides a standardised track and trigger system for acute illness and the tool promotes integration of care, and acts as a method for assessing the efficacy of medical / nursing interventions and can reduce the need for unnecessary hospital admissions. The NEWS score is a tool that is based on physiological parameters and these observations should be recorded at initial assessment and each subsequent visits as part of routine monitoring of patients physiological state; heart rate, respiratory rate, blood pressure, level of consciousness, oxygen saturations and temperature (NICE 2007, RCP 2012). Early Warning Scores have been developed to facilitate early detection of deterioration by categorizing a patient s severity of illness and prompting nursing staff to request a senior / medical review at specific trigger points utilizing a structured communication tool while following a definitive escalation plan. Adopting a National Early Warning Score (NEWS) is beneficial for standardizing the assessment of acute illness severity, enabling a more timely response using a common language across health care nationally. Patient s vital signs are routinely recorded in acute hospitals, but within community nursing this has not been standardized. With the early warning score system each vital sign is allocated a numerical score from 0 to 3, on a colour coded observation chart (A score of 0 is most desirable and a score of 7 is least desirable). These scores are added together and a total score is recorded which is their early warning score. A trend can be seen whether the patient s condition is improving, with a lowering of the score, or deteriorating, with an increase in the score. Management can then be escalated to senior nursing / medical staff in a timely and appropriate manner. TARGET GROUP All registered nurses and health care staff who undertake vital signs monitoring and provide clinical care for adult patients in the community or clinic setting employed by FNHC, including bank staff, are required to follow this protocol as part of their role and job description. AIMS This tool aims to assist the registered nurse and clinical health care support staff to determine a course of action in the event of a patient becoming unwell or presenting with an abnormal physiological status by 3

4 Improving the quality of recording and understanding patient baseline observations Monitoring of the patient s clinical condition and allow for timely intervention or if needed admission to hospital Supporting clinical judgment and aid in securing appropriate timely assistance for unwell patients Improving communication within the multidisciplinary team Provides a validated track and trigger system The NEWS has 3 key elements Identifies the urgency of the response required Identifies the seniority and clinical competence of the staff required to asses the patient Identifies the appropriate setting for which clinical care is to be delivered OUTCOMES All patients will have their vital signs measured on admission to the caseload and these results will provide a baseline score, these observations will be monitored during their episode of care. If a patient s condition suddenly deteriorates or they become increasingly unwell the measurement of their vital signs would provide an indication of the patient s physiological status. This would require a review by a suitably trained professional and/or the patient s General Practitioner for timely interventions, to prevent unavoidable hospital admissions or if deemed necessary the patient may require admission to hospital. TRAINING The skills required to detect when a patients condition is deteriorating lie within the domain of basic nursing assessment skills for registered nurses. All staff will undertake the e-learning training available on HSSD website via the link: Registered Nurses need to be alerted if a physiological sign falls below or above normal parameters so that they can take appropriate action if required: Respiratory Rate of <12 or >20 Systolic blood pressure of < 110 Heart Rate <50 or >90 Oxygen saturations below 95% (unless COPD and known to have low oxygen saturations or on LTOT) The patient is not fully alert and orientated / declining GCS The frequency and specifications of all observations should be clearly documented in the patients care plan and reassessed at each visit. 4

5 INCLUSION CRITERIA Patients admitted onto the Rapid Response Team caseload will require admission NEWS score and subsequent regular monitoring at each visit, due to the unpredictable nature of acute illness. This will enhance safety for both the patient and staff and minimise risk. All Adult Community Nursing services should record baseline observations on admission to the caseload providing a baseline score. If a patient s condition deteriorates or they become increasingly unwell reassessment of their vital signs would provide an indication of the patient s physiological status which would be mapped against the baseline recording. This would indicate physiological stability / instability and enable the nurse to act in a timely and responsive manner. The following patients maybe considered being at high risk of developing abnormal observations and it should be considered best practice to commence these patients on regular observation monitoring with a NEWS chart at the earliest opportunity. This includes: Patients with unstable medical conditions Patients with chronic unstable long term conditions e.g. COPD Patients who have an infection e.g. wound, chest or urine infection Post operative patients who are not improving / progressing Patients known to fall For patients with known hypercapnoeic respiratory failure due to Chronic Obstructive Pulmonary Disease (COPD), recommended British Thoracic Society target saturations of 88-92% should be used. These patients will still score if their oxygen saturations are below 92 unless the target score is reset by an appropriate competent clinician and patient specific target oxygen saturation are prescribed and documented on the NEWS chart and in the patient s nursing records. There are some patients where the NEWS may be inappropriate, for example: Patients who are terminally ill Minor ailments When taking the patient s pulse do this manually, as a machine will not detect volume or rhythm. Respiratory rate is widely accepted as being the most sensitive basic observation in detecting deterioration in the patient s condition (Sterling & Groba, 2002) 5

6 Normal healthy adult values: Respiratory rate normal rate breaths per minute Normal 0xygen saturation rate above 97%-99% Normal heart rate is between beats per minute Blood Pressure: normal range, systolic mmHg, Diastolic 60-85mmHg. TRIGGER SCORES The trigger does not replace the clinical judgment of the practitioner, there may be occasions where the NEWS underestimates the concern of the practitioner, and in this case the practitioner must escalate this to a senior clinical decision maker. In the instance when the NEWS trigger is not acted upon, rationale must be clearly demonstrated in the clinical notes NATIONAL EARLY WARNING SCORE SYSTEM NEWS SCORE FREQUENCY OF CLINICAL RESPONSE MONITORING 0 Repeat as per care plan Continue NEWS to meet clinical needs of monitoring at each visit patient 1-4 Increase monitoring Community nurses and / or HCAs to discuss patient with Rapid Response Team member who will advise and / or review and decide if increased monitoring and or escalation of care to RRT, GP, ED is required to treat and manage underlying condition Total 5 or more Or 3 Repeat observations as Urgently inform a *senior in one parameter directed in the patients clinical decision maker, health records and / or Review and assessment by a clinician who is clinically competent to assess and treat acutely ill patients and can recognise when escalation of care to a secondary care setting is essential Total: 7 or more Continuous monitoring Immediately life threatening phone 999 or if patient deteriorated but not life threatening phone

7 If appropriate contact A&E to advise of referral handover using SBAR tool. RECORDING EARLY WARNING SCORES Observations must be recorded on the standard NEWS observation chart (see appendix 1) a decision to initiate an early warning referral for medical intervention must be recorded in patient s home nursing records; Report findings to General Practitioner Inform team leader/ senior nurse at earliest opportunity Record all actions in patient s nursing records The observation chart must be dated/timed in all sections as the signing section confirms completion of all the sections of the documentation Discuss results and treatment options with patient/relative Ring for emergency services if required ensure SBAR handover (See appendix 2) information is accurate succinct and relevant to the clinical situation HOW WILL STAFF DEMONSTRATE PROTOCOL IS BEING ACHIEVED Nursing records will include evidence of completed observation charts Nursing records will demonstrate that patient s condition has been monitored Nursing records will evidence how advice has been sought from the patient s General Practitioner or other specialists when needed as required Patients will be managed in a safe environment without inappropriate hospital admission MONITORING AND AUDIT The NEWS will be a new initiative within community nursing therefore data will be collected from all the patients within RRT and audited and evaluated for appropriateness and accuracy in early recognition of the acutely unwell patient. The tool may need to be adapted and will evolve with the service need. An annual nursing process audit that includes use of the NEWS protocol will be maintained. REFERENCES National Institute for Health and Clinical Excellence (2007) Acutely ill patients in hospital: Recognition of and response to acute illness in adults in hospital. National Institute for Health and Clinical Excellence (2006) Hypertension: management of hypertension in adults in primary care. 7

8 National Patient Safety Agency (2007) Recognising and responding appropriately to early signs of deterioration in hospitalised patients Rees, J. E (2003) EARLY WARNING SCORES. World Anaesthesia, Issue 17 Article Royal College of Physicians. (2012) National Early Warning Score (NEWS) Standardising the assessment of acute-illness severity in the NHS. Report of a working party. Sterling C. Groba C.B. (2002) An audit of a patient-at-risk trigger scoring system for identifying seriously ill ward patients. Nursing in Critical Care 7 (5) Subbe, C. P. Kruger, M. Rutherford, P. & Gemmel, L. (2001) Validation of a modified Early Warning Score in medical admissions. Quarterly Journal of medicine, 94: CONSULTATION Operational Leads FNHC Patient Safety Facilitator Clinical Effectiveness Facilitator District Nurse Team Leaders Kirstie Ross Associate Specialist ED JGH 8

9 Appendix 1 Surname: Forename: DOB: URN: Admission Date (NEWS) NEWS Observation Chart 9

10 Alterations to NEWS Scoring Review date must be documented Dr s Date/Time Parameter Details of Alteration and Review Signature/ Instructions Date/Time Grade 10

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13 National Early Warning Score (NEWS) Instructions for use Medical Staff The NEWS score (0,1,2,3) and Clinical Response Triggers (Low, Medium and High) are NOT to be adjusted. Alterations to physiology parameters must be agreed by a Middle Grade Doctor, GP or Advanced Nurse Practitioner or above. All changes to be documented & signed with a review period specified (see front page). All changes must be communicated to the clinical team. Instructions for use Nursing Staff Observations to be recorded by placing a in the appropriate box unless parameter is extreme, i.e. sats of 80% or pulse of 160 this should be written numerically. Insert SBAR Sticker in patient notes to confirm escalation. NEWS Score Frequency of Clinical Response Monitoring 0 Repeat as per care Continue NEWS monitoring at plan to meet clinical each visit needs of patient 1-4 Increase monitoring Community nurses and / or HCAs to discuss patient with Rapid Response Team member who will advise and / or review and decide if increased monitoring and or escalation of care to RRT, GP, ED is required to treat and manage underlying condition Urgently inform a senior Total 5 or more or 3 Repeat observations in one parameter as directed in the clinical decision maker, and / patients health records or Review and assessment by a clinician who is clinically competent to assess and treat acutely ill patients and can recognise when escalation of care to a secondary care setting is essential Total 7 or more Continuous monitoring Immediately life threatening phone 999 or if patient deteriorated but not life threatening phone If appropriate contact A&E to advise of referral handover using SBAR tool. 13

14 Appendix 2 14