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1 DOCUMENT CONTROL PAGE Title Title: Early Warning Score Policy Version: 6 (May 2010) Amended version Reference Number: Supersedes Originator or modifier Approval Supersedes: EWS Policy v August 2009 Significant Changes Addendum includes: Primary nurse responder when escalated care to the higher risk category If the parent team has made the decision not to escalate to critical care the parent team may chose not to escalate New parameters for respiratory rate and oxygen saturations Originated By: Sarah Ingleby Designation: Critical Care Outreach Coordinator Modified by: Sarah Ingleby Lead Nurse Acute Care Team Donna Egan Outreach Coordinator Dr J Eddleston Clinical Director Critical Care Referred for Approval by: Critical Care Delivery Group Date of Referral: August 2010 Professional forum Date of Referral: 4th August 2010 Application Patients Adults only Staff Group- Clinical staff undertaking observations Circulation Review Issue Date: 28/10/10 Circulated by: Donna Egan Dissemination and Implementation: Refer to section 7 Review Date: August 2011 Responsibility of: Donna Egan Date placed on the Intranet: 28/10/10 EqIA registration number: IP/ Refer to section 5: Equality, Diversity and Human Rights Impact Assessment Early Warning Score Policy CG 006 Page 1 of 45

2 Section Contents Page 1 Introduction 4 2 Purpose 4 3 Roles and Responsibilities 5 4 Detail of Procedural documents Equality, Diversity and Human Rights Impact 8 Assessment 6 Consultation, Approval and Ratification Process 9 7 Dissemination and Implementation 9 8 Monitoring Compliance of Procedural Documents References and Bibliography Associated Trust Documents Appendices Appendix 1; Acute care competencies Appendix 2; Training schedule Appendix 3; Observation Chart 34 Appendix 3: EWS Score 35 Appendix 4: Flow Chart day 36 Appendix 5: Flow Chart night 37 Appendix 6: New scoring tool 38 Appendix 7: SBAR 39 Appendix 8: Audit tool Early Warning Score Policy CG 006 Page 2 of 45

3 1. Introduction The close monitoring of patients physiological parameters is the cornerstone in the early detection of critical illness. However research has demonstrated that early changes in patient observations are often not detected or communicated to the appropriate personnel leading to a delay in intervention. 1,2,3,4 The Early Warning Scoring System (EWS) was developed by Morgan et al in with the aim of providing a simple scoring system which could be readily applied by nurses and doctors to help identify patients developing critical illness. The EWS can be described as a aggregate weighted scoring system with five physiological parameters (Respiratory Rate, Heart Rate, Systolic Blood Pressure, Temperature and Neurological Status) scored between 0-3 with a aggregate score of three or more triggering the start of the protocol. The use of such early warning tools has be recommended by the Critical Care Outreach report published in and later advocated in the National Institute in Clinical Excellence (NICE) Clinical guidance 50 Acutely ill hospital patient 7 suggesting these tools enhance equity in care by ensuring timely recognition of all patients with potential or established critical illness and their treatment by individuals with appropriate skills, knowledge and experience to treat the patient effectively. Within Central Manchester University NHS Foundation Trust (CMFT) the EWS has been introduced in acute areas since 2000 and is linked to a protocol to ensure patients are assessed and treated by suitably experienced personnel in a timely fashion. 2. Purpose 2.1 The purpose of the EWS policy is to ensure that an accurate assessment of a patients clinical parameters, followed by an accurate calculation and documentation of the EWS on the observation chart (appendix 3) and appropriate intervention utilising the protocol. This will: Minimise risk; Ensure appropriate personnel respond dependant on the patients level of risk of deterioration ; To ensure complete and accurate communication and documentation of changes in clinical parameters and interventions on the ward, department or unit; The quality of recording and response to EWS changes is of the standards set in this policy. 2.2 Exclusions An EWS should be completed with each set of clinical observations except those patients who have been commenced on the care of the dying pathway. 2.3 Scope This policy will be for adult inpatient areas across the CMFT with the exception of the Emergency Department and maternity wards in St Marys Hospital who have adapted policies. There is also a separate policy for the Children s division. (see latest version on the intranet) This policy is to be utilised in conjunction with the trust observation policy (see latest version on the intranet) Early Warning Score Policy CG 006 Page 3 of 45

4 3. Roles and Responsibilities: - Heads of Nursing to ensure that policy is disseminated and audited and corrective action taken as required - Lead Nurses/Matrons- to ensure that delivery of care to all patients within the Division adhere to the policy and all staff groups are educated to the level required, whilst keeping up to date with current practice. - Ward Managers-to ensure that delivery of care to all patients within the ward adheres to the policy and all staff groups are educated to the required level, whilst keeping up to date with current practice. - Ward Staff- to ensure that delivery of care to all patients within the ward adheres to the policy and keeps up to date with current practice. - Clinicians- to ensure that in all patients under their care there is adherence to the policy and all staff groups are educated to the level required, whilst keeping up to date with current practice. To review and respond to issues highlighted by the policy. 4. Detail of Policy 4.1 The Early Warning Score Use of the EWS can be divided into three areas. These areas will be the measurement of patient parameters, calculation of the EWS and appropriate intervention utilising the protocol. This policy must be read in conjunction with the EWS tool (Appendix 6) and the EWS protocol flowchart. (Appendix 4 and 5) 4.2 General Points Each area utilising the EWS should have a named link nurse / worker who is responsible for ongoing education regarding the EWS and associated audits. (See acute care website on the trust intranet for standards and role of the EWS link nurse) A copy of the EWS policy should be available in all areas utilising the scoring tool and updated version on the intranet The protocol refers to Recorders, Primary and Secondary responders. For the purpose of this policy the competencies held by each group are held within the acute care competencies (see Appendix 1). Primary responders will include Band 5, (through the second gateway), band 6, 7 and FY1 and FY2. Secondary responder will include the ST1 and 2 and above. Critical care will include the ST3 and above from Critical Care The patients named consultant, will be ultimately responsible for patient care and ensuring adherence to the EWS policy The protocol is split into three categories; low, medium and high risk of deterioration, each defined by the EWS calculated following the observations To implement the changes a phased approach will be utilised. (see appendix 2, 4 and 5) The bedside observation response and alerting system is being implemented across the Trust this will automatically alert the correct personnel as per the EWS policy, manual alerting can also occur as is deemed appropriate. The patientrack policy will have all details and actions for the use of this system (see the intranet for the latest policy). Early Warning Score Policy CG 006 Page 4 of 45

5 4.3 The Measurement of Patient Parameters Patient parameters / observations should be measured by an appropriately trained and competent member of staff as per the Observation policy All chart entries should be clear, legible, written in black pen and the time and date of the observations clearly documented on the Trust observation chart or agreed local documentation or inputted into patientrack system. (See the Trust observation policy) A full set of observations should always be recorded, to include pulse rate, respiratory rate, blood pressure, temperature and neurological status and oxygen saturation. If an observation is unrecordable or undetectable e.g. oxygen saturations (SaO2) or blood pressure (BP), escalate to the nurse in charge to assess the patient, refer to medical team if required. This is an automatic score of 3 unless assessed and registrar has altered parameters The observations should be initialled on the observation chart if used, by the person undertaking the observations Frequency of observations see observation policy The frequency of observations should be determined by; a registered nurse in charge of the shift, senior doctor (Registrar or Consultant) and should be clearly documented on the observation chart; unless a patient has a EWS of 3 when observations will be recorded hourly as a minimum All patients should have a minimum of 12 hourly observations, with the exceptions as per point 4.4.6, 4.4.7, All acute (non elective) admissions should have a minimum of 4 hourly observations Within the Emergency Department (ED) frequency is as per local ED EWS policy. (appendix 9) All Post operative patients should have frequency as below unless medical staff document alternative request; 30 minutes for 2 hours Hourly for 2 hours As patient need dictates minimum 4 hourly When a patient is on the Liverpool care pathway the observations may be stopped If a patient is a delayed discharge home and medically fit their observations may reduce to daily Observation frequency can be reduced by a senior team member; consultant, registrar or registered nurse in charge of shift (Trust member) only and should be documented on the observation chart and in the medical notes. 4.5 Calculation of the Early Warning Score The EWS should be calculated for every set of observations. (appendix 3) The total EWS and individual parameters scores should be documented for every set of observations on the patients observation chart. Early Warning Score Policy CG 006 Page 5 of 45

6 4.6 Appropriate intervention utilising the Protocol An EWS of three or more triggers the start of the EWS flowchart which clearly highlights the steps to be taken. (appendix 4 and 5) When a patient has an EWS trigger, observations should be undertaken hourly as a minimum, until the EWS is reduced < Low Risk category: Following the first trigger of an EWS = 3, the primary nurse responder must be informed. They should attend the patient within an hour and assess the patient and institute an appropriate intervention. If the intervention does not reduce the EWS within an hour the next referral should be made the primary medical responder and primary nurse responder If a patient has triggered 4 times at an EWS = 3, then an arterial blood gas should be considered. If the EWS does not reduce following intervention the patient should be referred to the primary nurse responder and the secondary responder within the hour Following a full assessment, which may include an arterial blood gas(abg) the parameters for the patient can be discussed with the senior medical team and it may be deemed appropriate to alter the parameters. (See 4.7) Medium Risk category: If a patient triggers an EWS = 4 or 5, or an EWS = 3 for a fifth time, the primary nurse responder and the secondary responder must be informed and should attend within one hour If the patient triggers EWS = 4 or 5 for a second time, or has an EWS = 3 for a sixth time, then the doctor should re-attend within the hour and an arterial blood gas should be taken and further assessment and treatment implemented If the patient triggers EWS = 4 or 5 for a forth time or EWS = 3 for a eighth time the patient should be directed to the high risk category High Risk category: If the EWS 6 or a patient triggers EWS = 4 or 5 for a fourth time or a static EWS =3 for the eighth time, the primary nurse responder should be contacted and a ST3 or above from the parent team and the critical care medical team should be contacted directly. If the EWS 6 for a second time, EWS = 4 or 5 for a fifth time, EWS= 3 for a ninth time the critical care medical team (Bleep 4716). The teams should both attend within 30 minutes If the parent team has made the decision not to escalate to critical care the parent team may chose not to escalate but document in the medical notes treatment plan and adapted parameters At any time, in the light of actual or anticipated severe deterioration or there is cause for concern, consider immediate direction to high risk category, where a senior doctor and the critical care medical team must be contacted immediately All EWS triggers must be documented in both medical and nursing notes For the first EWS 6 an ABG should be taken, for others in the high risk group an ABG should be considered to assess response to interventions. 4.7 Alteration of EWS parameters If a patient has a chronic alteration to one or more of the measured parameters E.g. elevated heart rate due to chronic atrial fibrillation or Type 2 respiratory failure where the patients usual SaO2 is less than 94%. It may be appropriate to alter the scoring criteria for that parameter Scoring criteria may only be changed following a full medical assessment which may include an ABG, by a senior doctor. Early Warning Score Policy CG 006 Page 6 of 45

7 4.7.3 The triggering threshold e.g. EWS 3 should never be altered If EWS scoring parameters are altered it must be documented in the patient s medical and nursing notes and the new scoring criteria recorded on the observation chart or bedside observation recognition alerting system (BORAS) system with the clinician altering the parameters printing and signing their name. They must also document the date and time of alteration on the observation chart. A review date for the new parameters may also be documented. 4.8 Transfer of patient with early warning scores of If a patient requires transfer to another clinical area and has an EWS of 3 a doctor (ST1 or above) must assess the patient. This assessment should determine if the patient is medically fit for transfer or if intervention is required to stabilise the patient prior to transfer. See Trust transfer policy (latest version on intranet) The assessment and decision to transfer should be documented in the patient medical and nursing notes The Trust intra-hospital transfer form should be used. (See Trust transfer policy available on the intranet) 4.9. Communication Ensure concise and effective communication when referring patients to senior members of the team or other team members Use the SBAR tool for communication to maintain standards and effective communication. (See appendix 7) 5 Equality, Diversity and Human Rights Impact Assessment 5.1 The best way to promote equality is to make sure it is embedded into all procedural documents. All Trust procedural documents must be inclusive. It is important to address, through consultation, the diverse needs of our community, patients, their carers and our staff. This will be achieved by working to the values and principles set out in the Trust's Equality, Diversity and Human Rights Strategic Framework. The Trust is committed to ensuring all new procedural documents and functions are impact assessed and monitored in accordance within the letter and the spirit of the law regarding equality. The Trust's Equality, Diversity and Human Rights Strategic Framework can be found on the Trust s Intranet or from the Service Equality Team. 5.2 Please contact the Service Equality Team (SET) on Ext for support to complete an initial assessment. Upon completion of the assessment, SET will assign the Policy a unique EqIA Registration Number. 6 Consultation, Approval and Ratification Process 6.1 Consultation and Communication with Stakeholders The document was sent to the following groups for review and ratification: Members of Outreach and Acute Care team Critical Care Clinical director Early Warning Score Policy CG 006 Page 7 of 45

8 Lead Nurse Critical Care Assistant director of Nursing Critical Care Delivery group Clinical governance Lead 6.2 Policy Approval Process and Ratification Process Amendments to this policy will be approved and ratified by the Critical Care delivery group. 7 Dissemination and Implementation 7.1 Dissemination 7.11 The policy is available to all staff via the Trust intranet site The policy will be re- launched via Team Brief, Trust wide launch event and briefings from the Outreach and Acute Care Team to line managers at Divisional and Department meetings, also through drop in/ ad hoc sessions, ward meetings and the educators in each division Implementation of Procedural Documents 7.21 All staff receive training detailing the new principles and systems for the policy and implementation date, distributed through their line manager, Early Warning Score Link nurses and departmental meetings The policy is implemented through local training sessions provided in departments by the Outreach, Acute Care Team and divisional educators. 8 Monitoring Compliance of Procedural Documents 8.1 Competency The NICE guidance 50 (2007) states that staff caring for patients in acute hospital settings should have competencies in monitoring, measuring interpretation and prompt response to the acutely ill patient appropriate to their level of care that they are providing All new to the Trust nurses, midwives and clinical support workers will receive training during their induction period utilising a presentation provided by the Critical Care Outreach Team that will be supplied to all ward managers, divisional educators and EWS link nurses throughout the Trust. This is also available on the Trust Intranet Yearly clinical mandatory training also encompasses EWS training via a study day or E learning package. Consultants also have access to the Consultants EWS e learning package for yearly update All new FY1 medical staff have training on the acute illness management course ST1 s and registrars will have training as part of the induction period and clinical mandatory training. Early Warning Score Policy CG 006 Page 8 of 45

9 8.2 Quality Assurance and Audit 8.2.1Any deviation from this policy leading to deterioration of the patient requires completion of an incident report the level of which will be determined on a patient specific basis All in-patient areas of the Trust will be subject to yearly audit to ensure compliance with the accurate calculation of EWS on observation charts and compliance to the referral pathway are completed to the Trust standard as set out in this document. This will also be monitored via the matrons ward round Responsibilities for conducting the monitoring/audit EWS audit activity will be coordinated by the Critical Care Outreach Team and performed in conjunction with Ward Managers, EWS link nurses or their appointed deputies Method to be used for monitoring/audit see appendix Frequency of monitoring/audit- yearly with point prevalence audit as required (appendix 8) Process for reviewing results and ensuring improvements in performance occur: -If the level of accuracy is amber or red then the manager for each area will be expected to inform the education development practitioner and lead nurse and heads of nursing for the division so monitoring procedures can be instigated. In conjunction the ward or medical team can receive training as required in the accurate recording of EWS and the referral pathway supported by the Critical Care Outreach team. -All acute in patient areas not meeting a target of green for accuracy on routine audit are subject to random audit by the Critical Care Outreach team if deemed appropriate and Senior Nursing Management as required. -Responsibility for audit compliance lies with the Senior Clinical Nurses/Matrons or Directors. Action plan contingencies may include: -A thorough evaluation of priorities within the ward area -Evidenced meetings and awareness sessions with staff. These should demonstrate that each member of staff has been briefed -If a shift in prioritisation impacts on other cares then it will be up to the ward manager to decide how this will be addressed -Attendance at an AIM course -Personal responsibility framework for non compliant staff Audit results will be disseminated at both a Trust and local level as Appropriate. Early Warning Score Policy CG 006 Page 9 of 45

10 8.3 Standards and Key Performance Indicators KPIs The policy is available to all staff via the Trust intranet site This policy must be reviewed at least every three years or when there are significant changes to the document Training, as required by this policy, will be made available throughout the Trust and supported by the Outreach. Training will be reviewed for attendance and content.yearly audit reports will be produced by the Outreach Team will be disseminated at both a Trust and local level as appropriate. 9 References 1. Franklin.C & Mathews JK (1994) Developing strategies to prevent in hospital cardiac arrests: analysing responses for physicians and nurses in the hours before the event. Critical Care Medicine; 22; pg Sax F & Charlson M (1987) Medical patients at high risk for catastrophic deterioration; Critical Care Medicine; 15; pg Smith AF, Wood J (1998) Can some in-hospital cardio-respiratory arrests be prevented? A prospective survey; Resuscitation; 37; pg Schein RMH, Hazaday N (1990) Clinical Antecedents to in-hospital cardiopulmonary arrest; Chest; 98 Pg Morgan R J M, Williams F & Right M (1997) An Early Warning Scoring System For Detecting Developing Critical Illness; Clinical Intensive Care; 8 (2); pg DoH & Modernisation Agency (2003) Critical Care Outreach 2003 Progress in developing services. 7. NICE clinical guidance 50, Acutely ill patient in hospital July 2007, 10 Associated Trust documents 10.1 Observation policy 10.2 Transfer policy 10.3 Maternity EWS policy 10.4 Emergency department EWS policy 10.5 Childrens EWS policy 10.6 Sepsis Pathway 10.7 Oxygen policy 10.8 BORAS policy Early Warning Score Policy CG 006 Page 10 of 45

11 Appendix 1 Acute care competencies Airway, Breathing, Ventilation and Oxygenation Competency Group Non-Clinical Staff "Recorder" "Recogniser" "Primary Responder" "Secondary Responder" Critical Care Description of group Calls for help Records and interprets Recognises and interprets Delivers a primary Delivers a secondary Delivers role within T&T protocol observations in the context of response and response and a tertiary the patient intervention intervention response and interventi on NICE Response Level Low Risk Low Risk Low Risk Medium Risk High Risk Respiratory Rate Recognises Measures respiratory Interprets trigger in context of Identifies inadequate Evaluates effectiveness Respiratory rate. Records result and patient and responds in respiratory effort and of treatment, refines Arrest and calls assigns trigger score for accordance with local institutes clinical treatment plan if respiratory rate. Has escalation protocols. Adjusts management necessary, formulates a knowledge of what frequency of observations in therapies. diagnosis and constitutes an abnormal keeping with trigger. recognises when value. referral to Critical Care is indicated. Oxygen Saturation Measures oxygen saturation. Records result and assigns trigger score. Has knowledge of limitations of pulse oximetry and recognises abnormal result. Interprets measurements in context and intervenes with basic measures in accordance with local escalation protocols including oxygen and airway support. Adjusts frequency of observations in keeping with trigger. Identifies possible cause of hypoxia, prescribes oxygen therapy and institutes clinical management therapies. Formulates diagnosis, evaluates effectiveness of treatment, refines treatment plan if necessary and recognises when referral to Critical Care is indicated. Refer to critical care competencies as defined by the CoBaTrICE framework and mirrored in the Intercollegiate Board's training framework for Intensive Care Medicine in the United Kingdom Early Warning Score Policy CG 006 Page 11 of 45

12 Assessment adequacy ventilation oxygenation of of and Common causes of breathlessness Tension Pneumothorax Peak Spirometry Flow, Use of airway adjuncts and suction Recognises Respiratory Arrest and calls Identifies equipment and seeks advice if unclear, transports equipment to ward. Identifies equipment and seeks advice if unclear, transports equipment to Measures respiratory rate, and oxygen saturation. Assesses pattern of ventilation. Records measurements, has knowledge of abnormal values. Measures respiratory rate, and oxygen saturation. Assesses pattern of ventilation. Records measurements, has knowledge of abnormal values. Supervises performing expiratory measurement records result. patient peak flow and Same as Non-Clinical staff. Interprets measurements in context and intervenes with basic measures in accordance with local protocols including oxygen and airway support. Adjusts frequency of observations in keeping with trigger. Describes the common causes of breathlessness. Recognises when a patient is breathless. Describes the common causes of breathlessness. Recognises when a patient is breathless. Interprets reading in context, can undertake bedside spirometry when instructed to do so. Identifies inadequate Formulates ventilation and evaluates institutes clinical ess of treatment, management therapies. reatment plan if y and recognises ferral to Critical dicated. Identifies cause of breathlessness and institutes clinical management therapies. Identifies tension pneumothorax as a possible cause of breathlessness. Has knowledge of the management of a tension pneumothorax. Has knowledge of which additional diagnostic tests are appropriate, institutes them and formulates a clinical management plan. Uses adjuncts and suction. Same as "recogniser". Formulates diagnosis, evaluates effectiveness of treatment, refines treatment plan if necessary and recognises when referral to Critical Care is indicated. Formulates a diagnosis for and confirms the presence of a tension pneumothorax. Performs chest drain insertion and directs subsequent management. Reviews diagnosis, evaluates effectiveness of treatment, refines treatment plan if necessary and recognises when referral to Critical Care is indicated. Same as "recogniser". Early Warning Score Policy CG 006 Page 12 of 45

13 ward. Arterial blood gas sampling High flow and controlled oxygen therapy Administration of drugs via nebuliser Continuous Positive Airway Pressure (CPAP) and/or Non- Invasive Ventilation (NIV) Urgent endotracheal intubation Transports sample according to local protocol. Identifies and collects medical gases if designated. Identifies and collects medical gases if designated. Identifies equipment and seeks advice if unclear, transports equipment to ward. Identifies and transports emergency equipment to the patient. Collects equipment and transports sample. Identifies and uses masks /nasal cannulae/venturi adapters at appropriate oxygen flow rates. Records oxygen concentration/flow. Recognises nebuliser devices and can use under supervision. Identifies and transports equipment to the patient. Recognises endotracheal tube and laryngoscope. Assists operator in performing task. Follows oxygen prescription. Understands the context when controlled oxygen is required and applies high flow oxygen effectively in emergency situations. Uses nebuliser device and administer therapy using correct driving gas as prescribed. Uses CPAP and NIV therapy. Identifies the risks associated with CPAP and NIV therapy. Undertakes arterial blood gas sampling and measurement. Has knowledge of and can interpret arterial blood gas measurement. Prescribes oxygen and evaluates effectiveness. Prescribes nebulisers including appropriate driving gas. Has knowledge of indications for CPAP and NIV. Assists with urgent intubation. Same as "recogniser". Chest Radiograph Requests and interprets Chest Recognises need for assistance from Critical Care. Has detailed knowledge of the use of controlled and high flow oxygen therapy. Evaluates effectiveness of oxygen therapy and revises treatment accordingly. Reviews effectiveness of nebuliser therapy and revises treatment accordingly. Prescribes, uses CPAP and/or NIV, evaluates effectiveness of treatment and revises accordingly. Recognises need for assistance from Critical Care. Same as "recogniser". Same as primary responder. Early Warning Score Policy CG 006 Page 13 of 45

14 Radiograph. Chest Drain Recognises that transferring a patient with a chest drain needs clinical assistance. Recognises drain presence. Has knowledge of the use of a chest drain. Records output from drain and/or position (swinging and bubbling). Prepares equipment for and assist with insertion of drain. Manages a patient with a chest drain. Same "recogniser". as Inserts chest drain using either seldinger or traditional technique. Circulation Measurment of Heart Rate ECG monitoring and recording of trace Identifies equipment and seeks advice if unclear, transports equipment to the patient or ward as appropriate. Measures heart rate, records measurement, assigns trigger score and has knowledge of what constitutes an abnormal value. Recognises machine. ECG Interprets trigger in context of patient and responds in accordance with local escalation protocols. Adjusts frequency of observations in keeping with trigger. Uses machine to perform 12 lead ECG. Knowledge of local equipment eg refilling paper/toner. Identifies abnormal heart rate (tachyarrhythmia s and Brady arrhythmias) and institutes clinical management therapies. Has knowledge of common abnormalities and can interpret ECG in the context of the patient. Responds in accord with local protocols and institutes clinical management therapies. Formulates diagnosis, evaluates effectiveness of treatment, refines treatment plan if necessary and recognises when referral to Critical Care is indicated. Formulates diagnosis, evaluates effectiveness of treatment, refines treatment plan if necessary and recognises when referral to Critical Care is indicated. Refer to critical care competenci es as defined by the CoBaTrICE framework and mirrored in the Intercollegia te Board's training framework for Intensive Care Medicine in the United Kingdom Early Warning Score Policy CG 006 Page 14 of 45

15 Measurement Blood Pressure of Measures blood pressure, records measurement, assigns trigger score and has knowledge of what constitutes an abnormal value. Interprets trigger in context of patient and responds in accordance with local escalation protocols. Adjusts frequency of observations in keeping with trigger. Has knowledge of causes of an abnormal blood pressure, and which diagnostic investigations are appropriate. Institutes clinical management therapies. Formulates diagnosis, evaluates effectiveness of treatment, refines treatment plan if necessary and recognises when referral to Critical Care is indicated Arterial catheter Recognises arterial catheter as distinct from venous catheter. Understands principles of invasive arterial pressure measurement and has knowledge of technique for insertion, use and removal of catheter. Samples catheter supervision. from under Inserts arterial catheter, manages independently, displays and interprets arterial pressure waveform. Assessment cardiac output of Fluid status and balance assessment Has knowledge of how to assess adequacy of cardiac output clinically using colour of skin, capillary refill, temperature of skin, presence of sweating and level of consciousness. Alerts senior staff if assessment indicates inadequate cardiac output. Interprets assessment in the context of the patient and responds in accord with local protocols. Identifies low cardiac output and institutes diagnostic investigations and a clinical management plan. Records input and output. Interprets fluid balance status. Identifies when clinical intervention is required and institutes diagnostic investigations and a clinical management plan. Formulates diagnosis, evaluates effectiveness of treatment, refines treatment plan if necessary and recognises when referral to Critical Care is indicated. Formulates diagnosis and evaluates effectiveness of treatment, refines treatment plan if necessary and recognises when referral to Critical Care is indicated. Early Warning Score Policy CG 006 Page 15 of 45

16 Urinary catheter Collects and prepares equipment. Inserts catheter. Same as "Recogniser". Same as "Recogniser". Nasogastric tube Recognises tube, can record input and output. Inserts tube in awake uncomplicated patient and understands local protocol for checking position. Can use for drainage, drug administration and enteral feed administration. Same "Recogniser". as Inserts tube in unconscious nonintubated patients. Peripheral Cannula Intravenous maintenance resuscitation Venous fluid and Recognises infusion equipment (eg in relation to patient transport). Recognises cannula. peripheral Retrieves correct IV fluid, volume and infusion device. Assesses potential sites for peripheral IV access and inserts cannula in "simple" cases. Administers fluid as prescribed and in accord with local protocols. Inserts IV cannula in "difficult" cases. Identifies need for, and initiates fluid challenge for resuscitation and institutes clinical management plan. Prescribes maintenance fluids. Same as primary responder. Evaluates effectiveness of treatment, and refines treatment plan if required. Recognises when invasive monitoring is required and referral to Critical Care is indicated. IV infusions (giving sets and pumps) Hypodermic and syringes needles Recognises presence of IVI and safely transfer patients with IVI's. Recognises and understands safety issues. Assists patient to manoevre with IVI running. Calculate and record hourly fluid input. Has knowledge of how to use device. Has knowledge of safe practice for use and disposal of hypodermic needles and syringes. Prepares infusion device for use and administers fluids and drugs as prescribed. Prescribes intravenous and drugs. fluids Same as "recogniser". Same as "recogniser". Administers larger range of drugs and infusions. Same as "recogniser". Early Warning Score Policy CG 006 Page 16 of 45

17 Care of peripheral venous access Recognises presence of IV access. Undertakes and records observation of IVI in situ in accordance with local protocol. Identifies extravastated IVI and infected IV site. Removes infected IV cannula. Identifies need for replacement. Same as" primary" responder. Alternatives peripheral access to venous Recognition of a Central Venous Catheter. Has knowledge of when central venous access may be required and can assist in preparing equipment. Performs central venous access under supervision. Inserts central venous catheter in accord with NICE guideline and local protocol. Competent in the use of Ultrasound and Landmark techniques. Central catheter venous Recognises a Central Venous Catheter. Has knowledge of when Central Venous Access may be required, understands risk/benefit associated with Central Venous Catheter and uses catheter including the administration of drugs. Performs Central Venous Access under supervision. Inserts central venous catheter in accord with NICE guideline and local protocol. Competent in the use of Ultrasound and Landmark techniques. Ultrasound machine Identifies and transports equipment to the patient. Recognises machine. Has Knowledge of common indications for use. Uses ultrasound under supervision for insertion of central venous catheter. Uses ultrasound independently for insertion of central venous catheter. External haemorrhage Recognises overt blood loss. Same as "Non-Clinical Staff". Assesses severity of overt blood loss and interprets loss in the context of the patient. Initiates first aid management e.g. compression, dressing. Identifies source of bleeding, clinical impact and initiates definitive management. Commences resuscitation. Evaluates effectiveness of resuscitation, management of haemostasis and appropriate use of blood products. Refines treatment plan if necessary and recognises when referral to specialist services and/or Critical Care is indicated. Early Warning Score Policy CG 006 Page 17 of 45

18 Administration of blood products including warming Collects blood products according to local protocols. Documents administration of Blood Products. Administers products including the use of a blood warmer. Ensures traceability protocol adhered to. Has knowledge of indications for, and risks associated with blood products. Prescribes blood products. Same as "primary" responder. Blood equipment sampling Collapsed/unresponsi ve patient External compressions chest Transports samples according to local protocols. In hospital resuscitation according to local policy. Recognises when cardio-pulmonary resuscitation is in progress. Same as "Non-Clinical Staff". Same as "Non-Clinical Staff". Has knowledge of which tests are required in an emergency, can perform venesection. Has knowledge of which tests are required in both elective and emergency situations. Can request test/s, performs venesection. Same as "Non-Clinical Staff". Identifies potential causes relevant to the individual patient. In hospital resuscitation. In hospital resuscitation. In hospital resuscitation. Same as "primary" responder. Advanced life support with a broad approach to finding information and treatment of specific causes of collapse. Advanced life support. Cardiac arrest rhythms (VF, pulseless VT, PEA and asystole) Recognises when cardio-pulmonary resuscitation is in progress. In hospital resuscitation. In hospital resuscitation. In hospital resuscitation. Advanced life support. Early Warning Score Policy CG 006 Page 18 of 45

19 Emergency drugs Recognises situations when emergency drugs are used. Automated defibrillator external Non-automated external defibrillation Recognises equipment and +/- in hospital resuscitation according to local policy. Recognises equipment. Selects drug when instructed. Understands rationale for therapeutic intervention and can administer drugs according to in hospital resuscitation standard. In hospital resuscitation. In hospital resuscitation. In hospital resuscitation. In hospital resuscitation. In hospital resuscitation. In hospital resuscitation. Advanced life support. Advanced life support. Advanced life support. Transport Mobility and Patient handling equipment + beds Recognises equipment. Portable suction Can identify equipment and seeks advice if unclear, transports equipment to the ward. Uses in accord with local protocols. Uses in accord with local protocols. Identifies need for specialist bed and handling requirements. Uses equipment and adjuncts (e.g. yakeur sucker and suction catheters). Same "recogniser". Same "recogniser". as as Same as "recogniser". Same as "recogniser". competencies as defined by the CoBaTrICE framework and mirrored in the Intercollegiate Board's training framework for Intensive Care Medicine in Early Warning Score Policy CG 006 Page 19 of 45

20 Portable monitoring Identifies and transports equipment to the patient. Acute Neurological Care Unconsciousness Calls for help. Recognises the danger of airway obstruction and takes remedial action. Blood Glucose measurement and interpretation Acute states confusional Identifies equipment and seeks advice if unclear, transports equipment to the patient or the ward. Supervises patient to undertake own blood glucose measurement. Recognises that confusion may be marker of illness. Assists in setting up of the equipment. Has knowledge of common causes of unconscious state, eliminates these, provides in hospital resuscitation, and institutes local protocol for assistance. Performs blood glucose measurement. Has knowledge to interpret blood glucose value in context of the patient. Initiates local protocol for hypoglycaemia. Understands importance of these signs as markers of pathology, performs additional tests such as capillary blood glucose, checks for hypoxia. Uses portable monitoring equipment to measure heart rate, oxygen saturation, respiratory rate and blood pressure. Identifies the cause of reduced consciousness and institutes clinical management therapies. Identifies when clinical intervention is required and institutes clinical management therapies including the prescription of insulin or intravenous bolus of 50% glucose if the patient is hypoglycaemic. Identifies when clinical intervention is required. Initiates diagnostic tests and institutes clinical management therapies. Same as "primary responder". Evaluates diagnosis and effectiveness of treatment, refines treatment plan if necessary and recognises when referral to Critical Care is indicated. Evaluates effectiveness of treatment, refines treatment plan if necessary and recognises when referral to Critical Care is indicated Evaluates effectiveness of treatment, refines treatment plan if necessary and recognises when referral to Critical Care is indicated. Refer to critical care competen cies as defined by the CoBaTrIC E framework and mirrored in the Intercollegi ate Board's training framework for Intensive Care Medicine in the United Kingdom Early Warning Score Policy CG 006 Page 20 of 45

21 Acute sudden onset headache Altered motor / sensory function Swallowing difficulties Recognises severe sudden onset headache as a problem. Recognises new weakness as abnormal. Understands clinical implications of oral intake. Understands that severe sudden headache, temperature and stiff neck needs further urgent intervention. Interprets clinical signs in context of the patient and responds in accord with local protocol. Interprets clinical signs in context of the patient and responds in accord with local protocol. Identifies when clinical intervention is required. Initiates diagnostic tests and institutes clinical management therapies. Identifies when clinical intervention is required. Initiates diagnostic tests and institutes clinical management therapies. Identifies when clinical intervention is required. Initiates diagnostic tests and institutes clinical management therapies. Differentiates meningitis/encephalitis from other causes of severe sudden onset headache such as subarachnoid haemorrhage. Institutes appropriate interventions and investigations including lumbar puncture if appropriate. Refers for specialist neurological advice. Reviews diagnosis, evaluates effectiveness of treatment, refines treatment plan if necessary and recognises when referral to Critical Care or specialist neurology is indicated. Reviews diagnosis, evaluates effectiveness of treatment, refines treatment plan if necessary and recognises when referral to Critical Care, Speech and Language Therapist or specialist neurology is indicated. Early Warning Score Policy CG 006 Page 21 of 45

22 Seizures Recognises and records seizures. Understands basic practical procedures which need to be done to maintain the safety of the patient eg posture, airway. AVPU Scale (Awake and responsive, Responds to verbal commands, Responds to painful stimuli, Unresponsive) Assessment of pupillary size and light reflex Measures, records, assigns trigger score and has knowledge of what constitutes an abnormal value. Measures size of pupils, assesses light reflex and has knowledge of what constitutes an abnormal reaction and pupil size. Glasgow Coma Score Measures, and records score and has knowledge of what constitutes an abnormal value. Confirms seizure activity, initiates airway protection, oxygen and positioning and responds further in accord with local protocol. Interprets trigger in context of patient and understands clinical importance of an abnormal score.responds in accordance with local escalation protocols. Interprets pupillary size and response to light in context of patient Understands clinical significance of either abnormal pupil size or response to light reflex.responds in accordance with local escalation protocols. Interprets score in context of patient and understands clinical importance of an abnormal score.responds in accordance with local escalation protocols. Has knowledge of the causes of seizures, elliminates hypoglycaemia and hypoxia as causes and responds in accord with local protocol. Has knowledge of the diagnostic and clinical therapies which are indicated in the context of an abnormal score.refers to "secondary responder". Has knowledge of the diagnostic and clinical therapies which are indicated in the context of an abnormal pupil size or light reflex.refers to "secondary responder". Has knowledge of the diagnostic and clinical therapies which are indicated in the context of an abnormal score.refers to "secondary responder". Reviews diagnosis, evaluates effectiveness of treatment, refines treatment plan if necessary and recognises when referral to Critical Care or specialist neurology is indicated. Initiates definitive diagnostic and clinical treatment strategies and recognises when referral to Critical Care or specialist neurology is indicated. Initiates definitive diagnostic and clinical treatment strategies and recognises when referral to Critical Care or specialist neurology is indicated. Initiates definitive diagnostic and clinical treatment strategies and recognises when referral to Critical Care or specialist neurology is indicated. Early Warning Score Policy CG 006 Page 22 of 45

23 Cervical protection spine Recognizes not to move patient after major trauma unless instructed by clinical staff. Maintains immobilisation initiated. spinal once Assesses risk for spinal immobilisation. Initiate spinal immobilisation procedures. Identifies the indications for requesting imaging and when to request senior assistance. Interprets cervical spine radiograph and recognises when referral for specialist advice required. Computerised Tomography Scan of Head (CT) Recognises that CT scan may be needed. Identifies indications and priorities for requesting imaging. "Simple" interpretation of CT scans and recognises when referral for specialist advice required. Lumbar Puncture Transports samples according to local protocols. Assist's with patient positioning. Prepares equipment and labels samples. Performs puncture supervision. lumbar under Independently performs lumbar puncture. Recovery Position Places patient in recovery position. Same as "Non-Clinical Staff". Same as "Non-Clinical Staff". Same as "Non- Clinical Staff". Same as "Non-Clinical Staff". PATIENT-CENTRED CARE, TEAM WORKING AND COMMUNICATION Call for help: arrested or unconscious patient Communicates need for help in accord with local policy. Initiates in hospital resuscitation. Dials Performs resuscitation to "in hospital" standard.. Recognition of potential causes pertinent to the individual patient. Advanced life support with a broad approach to finding information and treatment of specific causes of unconsciousness or cardiac arrest. Early Warning Score Policy CG 006 Page 23 of 45

24 Patient not improving If aware or informed by patient that they are not improving, calls for help in accord with local policy and records communication pathway. Need for management plan Communicates appropriate staff. to Interprets clinical deterioration in the context of the patient, adjusts frequency of observations and level of monitoring and initiates management strategies in accord with local protocols. Identifies when clinical intervention is required. Initiates diagnostic tests and institutes clinical management therapies. Recognises lack of plan. Documents plan request and / or formulates management plan. Formulates diagnosis, evaluates effectiveness of treatment, refines treatment plan if necessary and recognises when referral to Critical Care is indicated. Reviews management plan and refines if necessary. Breaking bad news Supports patients and/or those close to them. End of shift handover Undertakes handover to next shift. Receives information. Documents and communicates appropriately to other members of the multi - disciplinary team. Identifies need to inform primary responder. Contacts friends or relatives, if time, to be with receiver of bad news. Communicates frequency of observations and ongoing management plans for all patients who have reached the low, medium or high trigger and also for those where there is clinical concern. Informs senior clinician and may deliver bad news. Documents discussion. Liaises with carers. Same as "recogniser". Breaks bad news and documents discussion in the notes. Evaluates clinical progress in conjunction with the ongoing management plans for all patients who have reached medium or high trigger and also for those where there is clinical concern. Communicates to next shift. Early Warning Score Policy CG 006 Page 24 of 45

25 Documentation Produces clear, legible documentation of the event. E.g.Note of event, date, time, which is signed, name printed and contact bleep number given. Writes a structured note of the event including a referral plan. Incorporates within the documentation a management plan and timescale for reassessment. Identifies when referral to the secondary responder will be indicated. Incorporates situations when referral to critical care is appropriate and timescale for reassessment after secondary intervention. Team working a) Provides information in a structured format that conveys clinical urgency b) Participation in whole team review and reassessment c) Personal Responsibility and Accountability Professional and respectful in approach. Actively listens. Gives clear information. Communicates with patient/carers. Documents discussion in notes. Informs senior staff. Participates in review, documents actions and communicates to senior staff. Gives clear instructions and communicates with senior staff when appropriate. Feedback given to junior members of the team. Communicates to primary responder after review. Feedback given to junior members of the team. Is aware of accountability. Complies with code of professional conduct, complies with local policies. Recognises when secondary responder needs to be informed. Examines patient, gives clear instructions and communicates with secondary responder. Recognises leadership role within the team and responsibility to refer to secondary responder. Evaluates effectiveness of communication. Recognises when referral to Critical Care is indicated. Leads the team, including giving feedback to all members of the team. Acknowledge s overall responsibility for the care of a patient. Early Warning Score Policy CG 006 Page 25 of 45

26 d) Decision Making Is aware of policies, complies with policies. Interprets observations, adjusts frequency of observations and level of monitoring, provides nursing intervention and communicates with primary responder when escalation of care is required. Feedback given to junior members of the team. Recognises own limitations. e) Leadership Adopts leader or follower role as appropriate. Ethics/ medico-legal Has an awareness of concepts. Acknowledges limitations. Works within established hospital procedures. Acknowledges limitations. Identifies when clinical intervention is required. Initiates treatment,monitors patient response, recognises limitations. Communicates with secondary responder when further escalation or deescalation of care is indicated. Same as "recogniser" Formulates diagnosis if not already done. Evaluates effectiveness of management plan, refines where appropriate and communicates with critical care when further escalation of care is needed. Recognises when deescalation of care is appropriate and the patient requires palliative care in-put. Communicates decisions with team. Reviews team working, develop local teams, identify and work to resolve problems. Same as "recogniser" Works independently, can review and agree plan. Seeks advice or second opinion as needed. Patient Safety: Early Warning Score Policy CG 006 Page 26 of 45

27 a) Electrical Safety Recognises basic electrical safety and associated clinical risk. Communicates concerns to ward staff and instigates appropriate action to avoid patient harm. Recognises and documents clinical risk associated with the equipment on which training has been given. Communicates risk to senior staff and initiates appropriate action. Assesses, quantifies and documents risk in the workplace. Initiates appropriate action to minimise clinical risk and communicates risk to primary responder. Quantifies individual risk, acts to prevent or minimise it. Manages risk-benefit across groups of patients eg triage. b) Moving and Recognises Handling clinical risk associated with moving and handling. Communicates concerns to ward staff and instigates appropriate action to avoid patient and personal harm. c) Falls Recognises clinical risk associated with falls. Communicates concerns to ward staff and instigates appropriate action to avoid harm. Recognises and documents clinical risk associated with the equipment for moving and handling on which training has been given. Communicates risk to senior staff and initiates appropriate action. Recognises and documents clinical risk associated with falls. Communicates risk to senior staff and initiates appropriate action. Assesses, quantifies and documents risk in the workplace. Initiates appropriate action to minimise clinical risk and communicates risk to primary responder. Assesses, quantifies and documents risk in the workplace. Initiates appropriate action to minimise clinical risk and communicates risk to primary responder. Quantifies individual risk, acts to prevent or minimise it. Quantifies individual risk, acts to prevent or minimise it. Manages risk-benefit across groups of patients eg triage. Manages risk-benefit across groups of patients eg triage. Early Warning Score Policy CG 006 Page 27 of 45

28 d) Applies infection Adheres to control policies to Trust's infection minimise risk of control policy. Hospital Acquired Infections Blood culture Can transport samples according to local protocols. Documents infectionrelated hazards and communicates such hazards to all staff. Identifies and transports equipment to the patient. Provides leadership on the ward for Hospital Acquired infections (HAI). Recognises when a blood culture is appropriate and identifies equipment required and procedure to undertake the intervention. As per "Recogniser". Performs blood cultures according to local aseptic policy. Implements measures in collaboration with infection control staff. As per "Primary Responder". Microbiology samples Transports samples according to local protocols. Performs microbiological sampling under supervision Independently performs microbiological sampling as requested. Has knowledge of which microbiological samples are required. Same as "primary "responder. Measurement Temperature of Measures temperature, records result and has knowledge of what constitutes an abnormal value. Interprets trigger in context of patient and responds in accord with local protocols. Identifies abnormal temperature and recognises when clinical intervention is required. Institutes clinical management therapies. Formulates diagnosis, evaluates effectiveness of treatment, refines treatment plan if necessary and recognises when referral to Critical Care is indicated. End of Life Care Respects patient's dignity and privacy. Ensures clear documentation of events. Facilitates expression of a patient's and their family wishes. Provides holistic care. Determines a patient and their family wishes. Communicates end of life wishes to all staff. Institutes appropriate end of life care to comply with the patient's wishes and regularly reviews decisions and plan. Recognises when to refer for palliative care. Early Warning Score Policy CG 006 Page 28 of 45

29 Appendix 2 Aims / Objectives For all EWS link nurses to be trained in the new EWS parameters and changes to policy For all registered nurses to be trained in the new EWS parameters and changes to policy Training, how to be achieved Training at EWS link nurse meeting re: changes New EWS to be added to acute care website Posters to be sent to ward re: changes to be displayed To attend EBM study day re: related issues Training on SaO2 monitoring, assessment and intervention Posters to be displayed in all ward areas Clinical Mandatory training Changes on EWS learning package Feedback and training from EWS link nurses All EDPs to be contacted re: changes to feed back in ward areas AIM ACSD Training schedule for rollout Time Resources Completion Date 1 hour meeting 1 study day 1 hour 1 day yearly 1 day 1 day Powerpoint presentation Time to access acute care website and print out posters Time to train ward staff at handover time until all staff are trained- 30 minutes Time to access acute care website Time during handover to have teaching -30 minutes 02/08/10 02/08/10 02/08/10 15/07/10 13/09/10 02/08/10 15/07/10 01/09/10 ongoing 01/09/10 By 01/09/10 15/07/10 Ongoing from July 2010 Ongoing from July 2010 Early Warning Score Policy CG 006 Page 29 of 45

30 For all CSW to be trained in the new EWS parameters and changes to policy EBM study day Outreach Rolling education programme All heads of nursing and ward managers to receive copy of full policy Posters to be displayed in all ward areas Clinical Mandatory training Changes on EWS learning package Feedback and training from EWS link nurses All EDPs to be contacted re: changes to feed back in ward areas CSWAIM Outreach Rolling education programme 1 day if applicable EWS link nurse can feed back 30 minute sessions subject to ward staffing Time to access acute care website Changes to CSW AIM slides 13/09/10 Ongoing from August /07/10 01/09/10 ongoing 01/09/10 By 01/09/10 15/07/10 Ongoing from July 2010 Ongoing from August 2010 For FY1/2 to be trained in the new EWS parameters and changes to policy Posters to be displayed in all ward areas Clinical Mandatory training Changes on EWS learning package AIM course Training on FY1 rolling programme ( next years FY2) 1 day yearly 1 day Time to access acute care website and attend CMT or do e learning package 15/07/10 01/09/10 ongoing 01/09/10 All FY1 attend 27/07/10 and 30/07/10 19/08/10 Early Warning Score Policy CG 006 Page 30 of 45

31 For ward based registrars to be trained in the new EWS parameters and changes to policy Posters to be displayed in all ward areas Clinical Mandatory training Changes on EWS learning package Policy changes to be disseminated through divisions via Time to access acute care website and attend CMT or do e learning package ongoing 01/09/10 For ward based Consultants to be trained in the new EWS parameters and changes to policy Posters to be displayed in all ward areas Clinical Mandatory training Changes on EWS learning package Policy changes to be disseminated through divisions via Time to access acute care website and attend CMT or do e learning package ongoing 01/09/10 For Critical Care nurses to be trained in the new EWS parameters and changes to policy For Critical Care medical staff to be trained in the new EWS parameters and changes to policy Posters to be displayed in all ward areas Clinical Mandatory training Changes on EWS learning package Lunchtime teaching Posters to be displayed in all ward areas Clinical Mandatory training Changes on EWS ongoing 01/09/10 August 2010 Ongoing Early Warning Score Policy CG 006 Page 31 of 45

32 All wards to commence using new EWS policy and new TPR chart 1/09/10 learning package Policy changes to be disseminated through division via New chart to be changed in all areas New chart to be in stock from printing All old charts to be removed 01/09/10 Outreach Team 1 day 01/09/10 01/09/10 01/09/10 Early Warning Score Policy CG 006 Page 32 of 45

33 Appendix 3 TPR Chart Early Warning Score Policy CG 006 Page 33 of 45

34 Early Warning Score Policy CG 006 Page 34 of 45 Appendix 4- EWS Flow Chart Daytime 07:31-20:59 hrs

35 Early Warning Score Policy CG 006 Page 35 of 45 Appendix 5 EWS Flow Chart Night- 21:00-07:30 hrs

36 Appendix 6 Early Warning Score Tool Early Warning Score Policy CG 006 Page 36 of 45

37 Appendix 7 SBAR Communication Sheet S o Inform the nurse in charge Perform relevant nursing intervention Situation o Your name is o Patients name is o Age. o Sex Male Female o Bed Number Ward.. o Why you are calling B A R Background o Reason for admission. o Recent Surgery if yes... Assessment Having assessed the patient EWS= A. Airway is Oxygen is at.via a... B. RR is..rhythm... Depth...Symmetry Colour Saturation.. C. Pulse (Reg/ Irreg).BP Temperature..CRT. Urine Output in the last hour...last 4 hours... D. AVPU score Any changes to mental state Blood Glucose..Pupils size / reaction. Pain Score; Movement Rest. E. Head to toe examination; Patient has Blood loss Abnormal swelling Loss from drains/ wounds. Recommendation o What do you want from person calling?.. o How urgent is it?. o What can be done in the meantime..... What time will Medical staff attend?. Time of review o Ensure documentation in kardex o Time of Call o Person Making call and name of medical staff spoken to o Relevant intervention o Assessment and Plan Early Warning Score Policy CG004 July 08 Page 37 of 45 See the Intranet for the latest version. Version Number:- 4

38 Appendix 8 EWS Audit Early Warning Score Policy CG004 July 08 Page 38 of 45 See the Intranet for the latest version. Version Number:- 4

39 Early Warning Score Policy CG004 July 08 Page 39 of 45 See the Intranet for the latest version. Version Number:- 4

40 Appendix 9 Early Warning Score Policy for Adult Patients in the A&E Department October Introduction Many critically ill patients will present to the emergency department. The initial clinical assessment of all patients is performed using the Manchester Triage System. Patients will be managed based on their clinical need according to the initial triage assessment. A small but significant number of patients, who were relatively well on their initial assessment, will deteriorate during their stay within the emergency department becoming critically ill and will require further resuscitation. It is important that these patients are identified early and managed appropriately. The early warning score is a physiological scoring system that can help to identify their physiological deterioration. The close monitoring of patients physiological parameters is the cornerstone in the early detection of critical illness. However research has demonstrated that early changes in patient observations are often not detected or communicated to the appropriate personnel leading to a delay in medical intervention. 1,2,3,4 The Early Warning Scoring System (EWS) was developed by Morgan et al in with the aim of providing a simple scoring system which could be readily applied by nurses and doctors to help identify patients developing critical illness. The EWS can be described as a aggregate weighted scoring system with six physiological parameters (respiratory rate, heart rate, systolic blood pressure, temperature, neurological status and oxygen saturations) scored between 0-3 with a aggregate score of three or more triggering the start of the protocol. The use of such early warning tools has been recommended by the Critical Care Outreach report published in suggesting these tools enhance equity in care by ensuring timely recognition of all patients with potential or established critical illness and their treatment by individuals with appropriate skills, knowledge and experience to treat the patient effectively. Within Central Manchester NHS Foundation Trust the EWS has been introduced in acute areas since 2001 and is linked to a protocol to ensure patients are assessed and treated by suitably experienced personnel in a timely fashion. 2. The Early Warning Score Use of the EWS can be divided into three areas. These are: the measurement of patient parameters, calculation of the EWS and appropriate intervention utilising the protocol. This policy must be read in conjunction with the EWS tool (as per the main policy) the EWS protocol flowchart and the Observations Policy. 2.1 General Points Each area utilising the EWS should have a named link nurse / worker who is responsible for ongoing education regarding the EWS and associated audit. A copy of the EWS policy should be available in all areas utilising the scoring tool. Within the Emergency Department the EWS will be recorded within the Resuscitation areas, Majors and Minor areas. The only exception will be the minor injury and primary care presentations where this will be done at the discretion of the nurse assessing the patient. The Clinical Decision Unit (CLDU) will utilise the Trust EWS policy. The protocol is split into three categories low, medium and high risk of deterioration, each defined by the EWS calculated following the observations. Early Warning Score Policy CG004 July 08 Page 40 of 45 See the Intranet for the latest version. Version Number:- 4

41 3. The Measurement of Patient Parameters Patient parameters / observations should be measured by an appropriately trained and competent member of staff. The minimum standard is that observations are performed according to the agreed policy on patients in the Resuscitation, Majors & Minors areas of the department. Observations may occasionally need to be performed more frequently than is stated in the policy and this should be determined by the registered nurse / doctor caring for the patient. Frequency of observations in the minor injury unit should be determined by the registered nurse / doctor caring for the patient. All chart entries should be clear, legible, written in black pen and the time and date of the observations clearly documented or inputted into the patientrack system. A full set of observations should always be recorded, to include respiratory rate, heart rate, systolic blood pressure, temperature, neurological status and oxygen saturations. Observations should be documented on the Patientrack system or the observation chart by the person performing the measurements. Frequency of observations will be determined by the policy flowchart (appendix 1). Minimum observation frequency will be at admission, one hour following admission and four hourly and / or pre-discharge as per Trust policy 3.1 Calculation of the Early Warning Score The EWS will be calculated for every set of observations The total EWS and individual parameters scores will be documented for every set of observations. 3.2 Appropriate intervention utilising the Protocol At any time, in the light of actual or anticipated severe deterioration or there is cause for concern, consider immediate direction to high risk category and be referred to the middle grade or Consultant immediately. Referral to Critical Care should be considered by middle grade of above. Observations and EWS must be performed at triage on all patients excepting isolated limb injuries and primary care presentations. Observations will be repeated within one hour of arrival in the Emergency Department. A EWS 3 triggers the start of the EWS flowchart (appendix 1). In patients triggering EWS 3, observations should be repeated hourly as a minimum. Low Risk category Following an EWS = 3, the primary nurse for the area will be informed who must attend the patient within 1 hour, assess the patient and institute an appropriate intervention. Observations should be rechecked within 1 hour. The nurse co-ordinator will also be informed. Early Warning Score Policy CG004 July 08 Page 41 of 45 See the Intranet for the latest version. Version Number:- 4

42 For a second EWS = 3, the primary nurse and the middle grade doctor will be informed who must attend within 1 hour, assess the patient and institute an appropriate intervention. Observations should be rechecked within 1 hour. The nurse co-ordinator will also be informed. For a third and fourth EWS = 3 the primary nurse for the area and the middle grade doctor will be informed who must attend within 1 hour and consider an arterial blood gas. The nurse co-ordinator will also be informed. For a fifth EWS = 3 go to the medium risk category and continue until score is reduced. Medium Risk category Following an EWS = 4 or 5 or EWS =3 on five consecutive occasions for the same patient. times, the nurse coordinator and the middle grade doctor will be informed who must attend within 20 minutes, assess the patient and institute an appropriate intervention. Observations should be rechecked within 1 hour For a second EWS = 4 or 5 or EWS =3 on six consecutive occasions for the same patient, the middle grade doctor must re-attend within 20 minutes and an arterial blood gas should be taken and further assessment and treatment implemented. Observations should be rechecked within 1 hour For a third EWS = 4 or 5 or EWS =3 on seven consecutive occasions for the same patient, then the doctor must re-attend within 20 minutes and further assessment and treatment implemented. Observations should be rechecked within 1 hour For a fourth EWS = 4 or 5 or EWS =3 on five consecutive occasions for the same patient, go to high risk category High Risk category Any patient triggering an EWS 6, on five consecutive occasions for the same patient EWS = 4 or 5 or EWS =3 nine times, the nurse coordinator will be informed and the patient must be seen by an Emergency Department middle grade or consultant within 10 minutes. They should have observations repeated a minimum of hourly If a second EWS 6, sixth EWS =4 or 5 or EWS = 3 on ten consecutive occasions for the same patient, they must be reviewed by the Emergency Department middle grade or consultant and consider referral to Critical Care. On each subsequent EWS 6 they must be reviewed by the Emergency Department middle grade or consultant within 10 minutes until score improved or parameters altered or an appropriate referral has been made If a patient has a chronic alteration to one or more of the measured parameters e.g. elevated heart rate due to chronic atrial fibrillation it may be appropriate to alter the scoring criteria for that parameter. On the extremely rare occasions that this should be necessary this alteration can only be done by a middle grade or consultant following a full assessment (consider ABGs) The ED team (middle grade and consultant) should consider contacting the Critical Care medical team if they are unable to reduce the EWS to 6 despite full resuscitation. Early Warning Score Policy CG004 July 08 Page 42 of 45 See the Intranet for the latest version. Version Number:- 4

43 If a patient has been accepted by a medical specialty, they will be contacted regarding EWS triggers and the Trust EWS policy should be adhered to All EWS trigger responses must be documented in the patient s medical and nursing notes. A patient must always have a full set of observations one hour after a EWS trigger with recalculation of the EWS (appendix 3). If EWS scoring parameters are altered it must be documented in the patient s medical notes and the new scoring criteria recorded on the observation chart or altered on the Patientrack system. The triggering threshold e.g. EWS 3 should never be altered. All patients being transferred to the wards MUST have a full observation set performed within the fifteen minutes prior to the transfer. If a patient requires transfer to another clinical area (including the ward) and has a EWS 3 or concern is expressed about the clinical course of the patient then under these circumstances an ED middle grade / consultant must assess the patient prior to transfer. See Trust transfer policy (latest version on intranet). This assessment should determine if the patient is medically stable enough for transfer or if intervention is required to stabilise the patient prior to transfer. This policy applies equally to patients admitted from the Emergency Department to the CLDU. Reference List 8. Franklin C & Mathews JK (1994) Developing strategies to prevent in hospital cardiac arrests: analysing responses for physicians and nurses in the hours before the event. Critical Care Medicine; 22; pg Sax F & Charlson M (1987) Medical patients at high risk for catastrophic deterioration; Critical Care Medicine; 15; pg Smith AF, Wood J (1998) Can some in-hospital cardio-respiratory arrests be prevented? A prospective survey; Resuscitation; 37; pg Schein RMH, Hazaday N (1990) Clinical Antecedents to in-hospital cardiopulmonary arrest; Chest; 98 Pg Morgan R J M, Williams F & Right M (1997) An Early Warning Scoring System For Detecting Developing Critical Illness; Clinical Intensive Care; 8 (2); pg DoH & Modernisation Agency (2003) Critical Care Outreach 2003 Progress in developing services. Version 3 Amended by Sarah Ingleby Lead Nurse Acute Care Team John Butler Consultant in Emergency Medicine & Critical Care Steve Jones Consultant in Emergency Medicine & Critical Care Jane Grimshaw Lead Nurse Emergency Services Early Warning Score Policy CG004 July 08 Page 43 of 45 See the Intranet for the latest version. Version Number:- 4

44 Appendix 9 ED EWS flowchart Early Warning Score Policy CG004 July 08 Page 44 of 45 See the Intranet for the latest version. Version Number:- 4