Wessex Regional All Cause Deterioration (including Sepsis) Guidance
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1 Wessex Regional All Cause Deterioration (including Sepsis) Guidance For Adult ( 16 non-pregnant) patients WACDG v1 11 th May 2018 Guidance includes models for the following healthcare settings Hospital (Acute and Community) Primary Care including Out of Hours (In Practice and in Patient s homes) Care Homes (Nursing & Residential) This document outlines guidance for different healthcare settings and includes templates which organisations can adapt for use in their own local care settings in alignment with Wessex regional guidance.
2 Wessex Regional All Cause Deterioration (including Sepsis) Guidance For Adult ( 16) non-pregnant patients in Hospital settings (Acute and Community) Worry ABCDE (1) Do Physiological observations NEWS 0 NEWS 1-2 NEWS 3-4 NEWS 5 or +3 from baseline 12 hrly obs 4-6 hrly obs & fluid 4-6 hrly obs 1 hrly obs Continuous monitoring balance monitoring Follow organisational NEWS/ condition specific protocol Urgent (2) Clinical Assessment (3) Emergency (2) Clinical Assessment (3) Mottled / ashen skin / cyanosis / new rash Inadequate urine output Lactate 2 Cap Refill > 2 sec No concerning features present Follow organisational NEWS protocol or condition specific protocol Concerning features present Use Clinical Judgement Is Sepsis Suspected? No Yes** Commence appropriate Treatment Follow organisational NEWS protocol Closely monitor patient Consider existing End of Life Care Plans / Advanced Directives Senior Review (4) Patients reviewed urgently if non-responsive to treatment within 1 hr **Sepsis High Risk Factors Age 75 years Immunosuppressed Chemotherapy IV Drug Abuse Surgery / Trauma <6/52 Broken Skin Indwelling line / catheter in-situ Current / recent antibiotics 1. ABCDE = Airway, Breathing, Circulation, Disability, Exposure; 2. Urgent/Emergency response times to be defined locally by organisation 3. Clinical assessment /senior review: to be completed by a competent healthcare professional as per organisational protocol. ** Represents CQUIN time zero in hospitals (If Suspected Sepsis is diagnosed in the community, CQUIN time zero is the time of entry to hospital)
3 AN Other Trust All Cause Deterioration (including Sepsis) Guidance For Adult ( 16) non-pregnant patients in Hospital settings (Acute and Community) This organisational guidance has been developed in partnership with the Wessex Patient Safety Collaborative Worry ABCDE (1) Do Physiological observations Indicates parameters which need to be agreed locally (and defined in relevant Trust policies where appropriate) A N Other NHS Trust Replace example logo with organisations own logo / branding NEWS 0 NEWS 1-2 NEWS 3-4 NEWS 5 or +3 from baseline 12 hrly obs 4-6 hrly obs & fluid 4-6 hrly obs 1 hrly obs Continuous monitoring balance monitoring Follow organisational NEWS/ condition specific protocol Urgent (2) Clinical Assessment (3) Emergency (2) Clinical Assessment (3) Mottled / ashen skin / cyanosis / new rash Inadequate urine output Lactate 2 Cap Refill > 2 sec No concerning features present Follow organisational NEWS protocol or condition specific protocol Concerning features present Use Clinical Judgement Is Sepsis Suspected? No Yes** Commence appropriate Treatment Follow organisational NEWS protocol Closely monitor patient Consider existing End of Life Care Plans / Advanced Directives Senior Review (4) Patients reviewed urgently if non-responsive to treatment within 1 hr **Sepsis High Risk Factors Age 75 years Immunosuppressed Chemotherapy IV Drug Abuse Surgery / Trauma <6/52 Broken Skin Indwelling line / catheter in-situ Current / recent antibiotics 1. ABCDE = Airway, Breathing, Circulation, Disability, Exposure; 2. Urgent/Emergency response times to be defined locally by organisation 3. Clinical assessment /senior review: to be completed by a competent healthcare professional as per organisational protocol. ** Represents CQUIN time zero in hospitals (If Suspected Sepsis is diagnosed in the community, CQUIN time zero is the time of entry to hospital)
4 Wessex Regional All Cause Deterioration (including Sepsis) Guidance For Adult ( 16) non-pregnant patients in Primary Care settings NEWS 0-2 NEWS 3-4 NEWS 5 OR Concerning Features (see box) NEWS 0-2 This score indicates the Patient is at LOW RISK Follow organisational NEWS protocol. Consider: if the patient is safe to be left at home and/or safe to be reviewed in 4-12 hrs with safety netting Or if clinically appropriate, referral NEWS 3-4 This score indicates the Patient is at LOW RISK BUT may require secondary care assessment Follow organisational NEWS protocol. Consider: Early repeat observations until NEWS improves Prompt Clinical review & based on judgement: Hospital admission or Planned review in 4-12 hours with open self-referral if deterioration. *NB. knowledge of previous observations (within last 6 mths) is very important as some patients normally run a low BP or hypoxia. NEWS 5 Patient is at MEDIUM RISK Pt s physiological parameters indicates systemic distress & organ dysfunction OR Concerning clinical features are present (see box) It is Likely that Urgent (1hr) hospital assessment will be required based on Clinical judgement Consider any existing End of Life Care Plan / Advanced Directive NEWS 7 Patient is at HIGH RISK Severe systemic distress likely 999 escalation with continuous monitoring until transfer High Risk Patient (*see box) Mottled / ashen / cyanosis / new rash Not passed urine in 8 hrs Feeling short of breath *High Risk Patient Age 75 years Immunosuppressed Chemotherapy IV Drug Abuse Surgery / Trauma <6/52 Broken Skin Indwelling line / catheter in-situ Current / recent antibiotics A NEWS 5 or more in the presence of suspected infection should prompt the clinician to THINK SEPSIS! WACDG v1-11 th May 2018
5 NEWS 0-2 NEWS 3-4 NEWS 5 OR Concerning Features (see box) A N Other All Cause Deterioration (including Sepsis) Guidance For Adult ( 16) non-pregnant patients in Primary Care settings This organisational guidance has been developed in partnership with the Wessex Patient Safety Collaborative NEWS 0-2 Patient is at LOW RISK NEWS 3-4 Patient is at LOW RISK BUT may require secondary care assessment NEWS 5 Patient is at MEDIUM RISK Pt s physiological parameters indicates systemic distress & organ dysfunction OR Concerning clinical features are present (see box) A N Other NHS Trust Replace example logo with organisations own logo / branding High Risk Patient (*see box) Mottled / ashen / cyanosis / new rash Not passed urine in 8 hrs Feeling short of breath *High Risk Patient Age 75 years Immunosuppressed Chemotherapy IV Drug Abuse Surgery / Trauma <6/52 Broken Skin Indwelling line / catheter in-situ Current / recent antibiotics NEWS 7 Patient is at HIGH RISK Severe systemic distress likely A NEWS 5 or more in the presence of suspected infection should prompt the clinician to THINK SEPSIS!
6 Wessex Regional All Cause Deterioration (including Sepsis) Guidance For Adult ( 16) non-pregnant patients in Care Home settings NEWS 0-2 NEWS 3-4 NEWS 5 OR Concerning Features (see box) NEWS 0-2 This score indicates the Patient is at LOW RISK Follow organisational NEWS protocol. Consider: if the patient is safe to be left at home and/or safe to be reviewed in 4-12 hrs with safety netting Or if clinically appropriate, referral NEWS 3-4 This score indicates the Patient is at LOW RISK BUT may require secondary care assessment Follow organisational NEWS protocol. Consider: Early repeat observations until NEWS improves Prompt Clinical review & based on judgement: Hospital admission or Planned review in 4-12 hours with open self-referral if deterioration. *NB. knowledge of previous observations (within last 6 mths) is very important as some patients normally run a low BP or hypoxia. NEWS 5 Patient is at MEDIUM RISK Pt s physiological parameters indicates systemic distress & organ dysfunction OR Concerning clinical features are present (see box) It is Likely that Urgent (1hr) hospital assessment will be required based on Clinical judgement Consider any existing End of Life Care Plan / Advanced Directive NEWS 7 Patient is at HIGH RISK Severe systemic distress likely 999 escalation with continuous monitoring until transfer High Risk Patient (*see box) Mottled / ashen / cyanosis / new rash Not passed urine in 8 hrs Feeling short of breath *High Risk Patient Age 75 years Immunosuppressed Chemotherapy IV Drug Abuse Surgery / Trauma <6/52 Broken Skin Indwelling line / catheter in-situ Current / recent antibiotics A NEWS 5 or more in the presence of suspected infection should prompt the clinician to THINK SEPSIS!
7 NEWS 0-2 NEWS 3-4 NEWS 5 A N Other All Cause Deterioration (including Sepsis) Guidance For Adult ( 16) non-pregnant patients in Care Home settings This guidance has been developed in partnership with the Wessex Patient Safety Collaborative NEWS 0-2 Patient is at LOW RISK NEWS 3-4 This score indicates the Patient is at LOW RISK BUT may require secondary care assessment NEWS 5 Patient is at MEDIUM RISK Pt s physiological parameters indicates systemic distress & organ dysfunction OR Concerning clinical features are present (see box) NEWS 7 Patient is at HIGH RISK Severe systemic distress likely Replace example logo with organisations own logo / branding A N Other Care Home High Risk Patient (*see box) Mottled / ashen / cyanosis / new rash Not passed urine in 8 hrs Feeling short of breath *High Risk Patient Age 75 years Immunosuppressed Chemotherapy IV Drug Abuse Surgery / Trauma <6/52 Broken Skin Indwelling line / catheter in-situ Current / recent antibiotics A NEWS 5 or more in the presence of suspected infection should prompt the clinician to THINK SEPSIS!
8 Wessex All Cause Deterioration (including Sepsis) Guidance For Adult ( 16) non-pregnant patients The Wessex All Cause Deterioration (including Sepsis) Guidance has been developed to help expand the use of the National Early Warning Score (NEWS 2) across Wessex as part of Wessex PSCs Local Change Plan for Deterioration. Our aim in producing this guidance is to encourage the development of a consistent language and approach to the management of physical deterioration across Wessex and to help ensure that escalation pathways within and between healthcare organisations are aligned to a common understanding and set of thresholds. We believe the WACDG is going to make a huge contribution to shaping a consistent approach to Deterioration and the use of NEWS2 across Wessex and thereby, most importantly, improving patient outcomes. The clinical content of the WACDG is based on the NHSE Sepsis guidance implementation advice for adults. (NHSE Sept 2017) and the Royal College of Physicians Standardising the assessment of acute-illness severity in the NHS. (RCP Dec 2017) Please note that providers from non hospital settings may want to seek internal Governance approval for any patient pathway as the RCP NEWS tool has, to date, only been recommended by NHSE for use in hospitals including mental health hospitals and in ambulance services and in prison healthcare. Authors of the Wessex All Cause Deterioration model are: Dr Matt Inada-Kim Consultant, Clinical Lead Deterioration and Sepsis, WPSC & National Clinical Advisor Sepsis & Deterioration, NHSE & NHSI Dr Usha Couderc, GP Clinical lead for Primary Care, Wessex PSC Geoff Cooper, Programme Lead for Deterioration, Wessex PSC A special thank you also to those members of the Wessex Deterioration Network who participated in the workshops and have shared their clinical expertise in helping to produce this resource. Issue date: 11 May 2018
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