Procedure No: M15p M15p MEWS Modified Early Warning Scores

Procedure No: M15p M15p MEWS Modified Early Warning Scores Procedure Relates to Primary Policy: B4 - Basic Life Support Version: Approved by: M15p/02 Trust Management Team Date approved: 9 th May 2012 Title of Author: Responsible ED: Director of Primary Care Director of Nursing & Patient Experience Date issued: 11 th May 2012 Review date: May 2015 Target audience: NHSLA relevant: Disclosure Status (B) All Clinical Staff Trust wide Yes B Can be disclosed to patients and the public EIA EIA MEWS approved mmv 2012.doc Implementation Plan Implementation Plan MEWS.xls Monitoring Plan NHSLA Monitoring template MEWS.xls West London Mental Health NHS Trust Page 1 of 15

Equality & Diversity statement The Trust strives to ensure its policies are accessible, appropriate and inclusive for all. Therefore all policies will be required to undergo an Equality Impact Assessment and will only be approved once this process has been completed. The Trust aspires to: Ensure the health and wellbeing of those we serve and be a leader in the development of mental health care and treatment. To achieve such an aim, the Trust will need to address the issues raised by its stakeholders and deliver the kind of service developments and outcomes they describe. Such an endeavour needs to be underpinned by a core set of values. West London Mental Health NHS Trust Page 2 of 15

Version Control Sheet Version Date Title of Author Status Comment 0.01 Aug 10 Lynne Read, Draft New Policy. Assistant Director of Circulated to key Primary Care members of the Physical Healthcare Group for initial comment. 0.01 Sept 10 Lynne Read, Assistant Director of Primary Care 0.01 Oct 10 Lynne Read, Assistant Director of Primary Care 0.01 Dec 10 Dr A Cohen, Director of Primary Care 0.01 Jan 11 Lynne Read, Assistant Director of Primary Care 0.02 Jan 12 Director of Primary Care 0.02 April 12 Director of Primary Care 02 May 12 Director of Primary Care Draft Final Draft Final Draft Final Draft Reviewed Procedure Reviewed Procedure Ratified Revised to incorporate comments. To go to the CSSC September 2010. To be approved as a working document at the October 2010 CSSC For debate/discussion at CSSC To PRG for approval and minor amendments made Ratified by CEC Implementation & monitoring Plans updated Ratified by TMT 9 th May 2012 West London Mental Health NHS Trust Page 3 of 15

CONTENTS Page No 1.0 Introduction 5 2.0 Purpose 5 3.0 Scope 5 4.0 What is MEWS? 6 5.0 Recognising a physically deteriorating patient 6 6.0 When to use MEWS 7 7.0 Observation Chart 8 8.0 MEWS Score 8 9.0 Trigger Scores 8 10.0 How to respond to MEWS 8 11.0 Recording MEWS 9 12.0 MEWS Training 9 13.0 Monitoring & Audit 10 14.0 Associated polices 10 Appendices Appendix 1 - MEWS Flow Chart 11 Appendix 2 MEWS Observation Recording Chart 12 Appendix 3 List of symptoms to be concerned about 13 West London Mental Health NHS Trust Page 4 of 15

MEWS 1.0 INTRODUCTION 1.1 Primary Policy: The Trust s Physical Healthcare Strategy describes interconnection between mental and physical health. They state having a mental problem increases mortality from heart disease (1); coronary heart disease can increase the risk of depression (2). People with schizophrenia have a life expectancy that is significantly lower than that of the general population and have higher rates of serious long term conditions(3)(4) People with mental health problems are also prone to factors that are damaging to overall health, such as poor diet, heavy smoking and drug and alcohol misuse(3). Equally, people who smoke, are obese or take drugs or behave in other ways that put their health at risk are more likely to have mental health problems(5) and may people in Mental Health Services will have co-morbid physical health problems such as long term conditions and complex end of life care needs. (Ref Physical Healthcare Strategy P2). 2.0 PURPOSE 2.1 The aim of this policy is to improve people s outcomes by detecting and acting upon early signs of deterioration in physical health of patients. This will be in part achieved through the implementation of the Modified Early Warning Scores (MEWS) system that: Identifies trends in patient observations; Ensures that timely patient review and appropriate treatment occurs; and Improves the documentation of patient observations. 2.2 Notification should also occur where clinical deterioration occurs other than that assessed by the MEWS criteria, or where sound clinical judgement would suggest that notification is in the best interests of patient care. 3.0 SCOPE 3.1 All staff are to apply the Modified Early Warning Scores (MEWS) system when patient observations are taken. 3.2 It does not only apply to children, or young adults under the age of 18 years 3.3 It ONLY applies to people who are current in-patients of West London Mental Health Trust West London Mental Health NHS Trust Page 5 of 15

4.0 WHAT IS MEWS 4.1 The Modified Early Warning Score (MEWS) is an evidenced based system of care, used in many acute hospitals to monitor the progress of patients, and to identify early, a deterioration in their health. 4.2 The Modified Early Warning Score (MEWS) is a form of track and trigger scoring system. The triggers are based on routine observations and are sensitive enough to detect subtle changes in a patient s physiology which will be reflected in a change of score should the patient be improving or deteriorating. 4.3 All patients have their vital signs measured and these are converted into a score. The higher the score the more abnormal the vital signs are. If the scores reach above a certain threshold, a doctor must be called to assess the patient. 4.4 The system allows for the regular monitoring and recording of blood pressure, pulse, temperature, Conscious state and respiratory rate. 4.5 Early warning scoring systems were originally developed with 2 specific aims: to facilitate timely recognition of the patients with established or impending critical illness; and to empower nurses and junior medical staff to obtain experienced help through the operation of a trigger threshold which, if reached, required mandatory attendance by a more senior member of staff. 4.6 Use of a Modified Early Warning Scoring system can also: Improve the quality of patient observation and monitoring Improve communication within the multidisciplinary team Allow for timely admission to intensive care (Acute Hospital) Support good medical judgement Aid in securing appropriate assistance for sick patients Give a good indication of physiological trends Are a sensitive indicator of abnormal physiology NB It is important that staff understand that MEWS does not replace Clinical Judgement 5.0 RECOGNISING A PHYSICALLY DETERIORATING PATIENT 5.1 Clinical deterioration can occur at any stage of a patient s illness, although there will be certain periods during which a patients is more vulnerable such as at the onset of illness, during surgical or medical interventions and during recovery from critical illness. 5.2 Patients wish a diagnosed physical health condition or illness must have a secondary diagnosis recorded on RIO and agreed care plan must be written detailing the treatment plan including the signs and symptoms associated with deterioration. West London Mental Health NHS Trust Page 6 of 15

5.3 The symptoms below indicate deteriorating health. The more of these symptoms the patient has and the more intense they are and also the longer the patient has had them then the greater the urgency to begin initiating increased observation. 6.0 WHEN TO USE MEWS 6.1 MEWS relies on the routine recording and charting of the physiological status of the patient however, the frequency of monitoring should be increased if abnormal physiology is observed.. These are simple observations that can be performed by a nurse, doctor or other trained staff. These observations include: Pulse Respiratory Rate Temperature Blood Pressure Conscious State (AVPU) 6.2 In specific clinical circumstances additional monitoring should be considered for example: urine output Biochemical analysis Pain assessment 6.3 The MEWS evidence base does not apply to children therefore this guidance is only applicable to adults and older people. All patients who are admitted to an in-patient ward should have, on admission, the five elements recorded: The baseline observations Thereafter, at a minimum, the same observations should be recorded monthly. 6.4 There may be clinical indications when it will be appropriate to record the five elements more frequently. For example: - Unstable patients with a long term condition i.e. Diabetes Service users whose physical condition is causing concern Service users who have been transferred from an acute hospital Service users with a chronic health problem 6.5 Previous recording will provide a base line from which the new observations can be compared, and thus provide important information on how the physical state of the patient has changed. The frequency and specifications of all baseline observations should be prescribed in the Nursing Care plan. It may also be necessary to assess a service user using the MEWS score prior to transferring them to an external healthcare provider. West London Mental Health NHS Trust Page 7 of 15

7.0 OBSERVATION CHART 7.1 The Trust has a standard MEWS system for use across all Trust provided services. 7.2 MEWS is incorporated within the Standard Observation Chart. 8.0 MEWS SCORE 8.1. Where there are concerns that a patient is unwell the MEWS observations are carried out and the results used to gauge the severity of deterioration as indicated. Table 1 Pulse 40 41 50 51-100 101-111 - 131 110 130 Respiratory 8 9-14 15-20 21-29 30 Temperature 0c Conscious State AVPU MEWS Score Systolic BP < 70 71-80 < 35 35.1-36 36.1 38.0 38.6 37.9 38.5 Alert Voice Pain Unresponsive 3 2 1 0 1 2 3 81-100 101-199 > 200 AVPU is a simple assessment where A = Alert V = Responds to verbal commands only P = Responds to Pain U = Completely Unresponsive A flow diagram for the use of MEWS is shown in Appendix A. 9.0 TRIGGER SCORES 9.1 A MEWS Score of 1 in ANY category indicates the need for close and frequent observation of the patient. The senior nurse on duty should be informed immediately, and will assess the patient within 60 minutes. 9.2 A change in the MEWS score of 2 or more indicates that the patient is potentially unwell and means that urgent medical attention is required. The duty doctor should be informed immediately, and should attend within 15 minutes. 10.0 HOW TO RESPOND TO MEWS 10.1 The Senor Nurse will assess the patient and provide guidance to the ward staff on the further frequency of recording of physical signs, and other action that may be West London Mental Health NHS Trust Page 8 of 15

appropriate, depending on the clinical state of the patient. If necessary, the senior nurse will also seek the opinion of the duty doctor, although it may only be telephone advice that is necessary. 10.2 The duty doctor will respond to a patient s physical state changing by more than 2 points within 15 minutes. The duty doctor will assess the patient, and arrange for the appropriate care to be delivered. This may involve further monitoring, administration of medication, seeking specialist review, or transferring the patient to a more appropriate location depending on the clinical symptoms and signs. 10.3 This response should be no different whether or not the recording takes place in hours or out of hours and at weekends. N.B. A failure to attend a MEWS call within an acceptable timescale (<30 minutes) should result in the completion of an incident form. 10.4 A MEWS action plan must be agreed and documented for any patient reviewed. 11.0 RECORDING MEWS 11.1 Observations and MEWS Scores MUST be recorded on the Trust MEWS Observation Chart See Appendix 2. 11.2 The decision to initiate a MEWS Call (that is a significant change from base line) must be recorded in the patient s notes. 12.0 MEWS TRAINING 12.1 Medical staff will receive information, instruction and training on the MEWS System on induction and within core-curriculum teaching. Nursing staff will receive information, instruction and training on the MEWS system and accurate observations as part of Local Induction and as part of local ward/department training. MEWS training will be mandatory for registered nursing staff. 12.2 Staff caring for patients with physical conditions should have competencies in monitoring, measurement, interpretation and prompt response to the acutely ill patients appropriate to the level of care they are providing. Education and training should be provided to ensure staff have these competencies and they should be assessed to ensure they can demonstrate them. Pocket size (laminated) cards will be made available for all nursing staff. Laminated posters will be displayed in all treatment and clinical rooms. An aide memoir regarding MEWS will be included with the RIO Physical Healthcare screening field. West London Mental Health NHS Trust Page 9 of 15

A standard MEWS training resource pack will be provided to (and made available on The Exchange s Physical Healthcare Page) for all Clinical Leaders and Clinical Managers. 13.0 MONITORING & AUDIT An audit of implementation of MEWS will be undertaken annually by the Clinical Service Units (CSU). Results of the audit will be presented to the Physical Health Group and Clinical Effectiveness Group The Trust Physical Healthcare Group will review this policy annually. 14.0 ASSOCIATED POLICES The Physical Healthcare Policy (P15) Physical Healthcare Strategy. First Aid (F3) Slips, Trips and Falls (F8) Health and Safety (H3) Infection Control Policies (ICP1) West London Mental Health NHS Trust Page 10 of 15

Appendix 1 Mews Flow Chart MEWS score on admission Monthly recording of MEWS Patient unwell, record MEWS MEWS score of 1 MEWS score of 2 or more i.e. Amber or Red Initiate close/frequent monitoring Urgent medical attention required Inform Nurse in Charge Inform Ward/Duty Doctor Nurse in Charge to assess within 60 minutes Doctor to assess within 15 minutes Document action in notes Revise Care plan West London Mental Health NHS Trust Page 11 of 15

Appendix 2 Physical Healthcare Observation Recording Chart Modified Early Warning Score (MEWS) Patient.Ward.. Score 1 compared to baseline Call Senior Nurse Score 2 or 3 compared to baseline Call Duty Doctor Urgently Systolic blood pressure Heart Rate Resp. Rate Temp AVPU* Score Date Time mmhg Beats Per Minute Breaths Per Minute oc 3 2 1 0 1 2 3 Systolic <70 71-80 81-100 101-199 > 200 Heart Rate < 40 41-50 51-100 101-110 111 130 >131 Resp Rate < 8 9-14 15-20 21 29 >30 Temp. < 35 35.1 36 36.1 37.9 38.0 38.5 >38.6 AVPU Alert Voice Reaction Pain Reaction Unresponsive West London Mental Health NHS Trust Page 12 of 15 Procedure M15p First Date of Issue: Jan 2012 This is current version M15p/02 May 2012

Appendix 3 General Physical Symptoms 1. Pain Anywhere in the Body 2. Pressure Anywhere in the Body 3. Headaches 4. Low Energy 5. Insomnia 6. Anaemia 7. Shortness of Breath 8. Faintness Between Meals 9. Weakness From Ordinary Activities 10. Poor Stamina 11. Heart Pain 12. Fast Heartbeat 13. High Cholesterol (Above 200) 14. Hyper Environmental Sensitivity 15. Frequent Illness 16. Frequent Fevers or Infections 17. Candida Yeast Infection 18. Inability to Gain or Lose Weight 19. Excessive Hair Loss 20. Premature Greying of Hair 21. Uncomfortable, No Matter What 22. Blurry or Unclear Vision 23. Deteriorating Eyesight 24. Drooling While Sleeping 25. Damp Lips at Night 26. Dry Lips During the Day 27. Itchy Ears, Nose, Anus 28. Grinding Teeth While Asleep 29. Bed Wetting 30. Bloody Nose Digestion/Elimination 1. Food Allergies 2. Constipation (less than 1-2 BM/day) 3. Persistent Flatulence or Gas 4. Bloating 5. Stomach Pains 6. Diarrhoea 7. Loss of Appetite 8. Intestinal Pain 9. Intestinal Irritation 10. Difficulty Breathing After Eating 11. Adverse Reactions After Eating 12. Burning Sensation in the Stomach 13. Eating Above Normal, But Still Hungry 14. Cravings For Sweets or Alcohol West London Mental Health NHS Trust Page 13 of 15

15. Lack of Appetite 16. Distress From Eating Fatty Foods 17. Bleeding Gums 18. Discoloration of Gums 19. White Coated Tongue 20. Cold Sores 21. Bad Breath 22. Undigested Food 23. Indigestion, Stomach Upset 24. Haemorrhoids Joints, Muscles, Extremities, & Skin 1. Pain in the Back, Thighs, Shoulders 2. Slow Reflexes 3. Leg Cramps 4. Numb Hands 5. Pale Skin 6. Age Spots 7. Stiff Joints 8. Varicose Veins 9. Easily Bruised 10. Yellowish Face 11. Wrinkling and Aging of Skin 12. Ridges on Fingernails or Toenails 13. Fungus on Fingernails or Toenails 14. Cracking Around Lips 15. Clammy Skin 16. Dry Skin 17. Muscle Pain 18. Muscle Cramps 19. Cold Hands or Cold Feet 20. Pain in the Joints 21. Injuries Slow to Heal Reproductive Problems 1. Problems With the Menstrual Cycle 2. PMS 3. Yeast Infections 4. Excessive Menstrual Flow 5. Low Sex Drive 6. Male Sexual Dysfunction Emotional Symptoms West London Mental Health NHS Trust Page 14 of 15

1. Depression or Suicidal Feelings 2. Addicted to Drugs, Alcohol, Food, Sex, Work 3. Impulsive or Violent Behaviour 4. Anxiety or Panic Attacks 5. Wide Emotional Swings 6. Unexplainable Fear 7. Stubbornness 8. Nervousness 9. Hyperactivity 10. Lethargy 11. Recurring Dreams or Nightmares 12. Character Shifts 13. Voices Inside You 14. Recurring Negative Experiences 15. Poor Relationships 16. Lack of Enthusiasm Mental Symptoms 1. Inability to Concentrate 2. Mental Stress 3. Difficulty Thinking Clearly 4. Rigid Belief Systems 5. Must Be Right All the Time 6. Excessive Competitiveness 7. Inflexibility 8. Forgetfulness West London Mental Health NHS Trust Page 15 of 15

Monitoring Appendix 4 POLICY / PROCEDURE: The Deteriorating Patient MONITORING TEMPLATE M15p MEWS B4 Basic Life Support M7 Managing Medical Devices Minimum Requirement to be Monitored Where described in policy WHO (which staff / team / dept) HOW MONITORED (Audit / process / report / scorecard) - list details HOW MANY RECORDS (No of records / % records) FREQUENCY (monthly / quarterly / annual) REVIEW GROUP (which meeting / committee) OUTCOME OF REVIEW / ACTION TAKEN (Action plan / escalate to higher meeting) 4.8a) requirement for a documented plan for vital signs monitoring that identifies which variouibles need to be measured, including the frequency of measurement (pilot) M15p MEWS procedure physical healthcare group Review of MEWS procedure 25% Annual physical healthcare group CEC 4.8b) use of an early warning system within the organisation to recognise patients at risk of deterioration M15p MEWS procedure Audit team / CSU Audit All MEWS charts Annual physical healthcare group CEC 4.8c) actions taken to minimise or prevent further deterioration in patients 4.8d) do not attempt resusitation orders (DNAR) M15p MEWS procedure B4 BLS Section 10 Audit team / CSU Clinical audit team Audit Audit All MEWS charts and records All DNAR orders Annual physical healthcare group CEC Annual physical healthcare group CEC West London Mental Health NHS Trust Page 16 of 15 Procedure M15p First Date of Issue: Jan 2012 This is current version M15p/02 May 2012

4.8e) How the organisation documents that resuscitation equipment is checked, stocked and fit for use 4.8f) How the organisation monitors compliance with all of the above M7 Managing Medical Devices Section 4.6 Section 6 Section 8 M15p MEWS Section 13 B4 BLS Section 12 M7 Managing Medical Devices Section 9 MEWS App 4 CSU Audit All Annual physical healthcare group CEC West London Mental Health NHS Trust Page 17 of 15 Procedure M15p First Date of Issue: Jan 2012 This is current version M15p/02 May 2012