Modified Early Warning Score Policy.

Trust Policy and Procedure Modified Early Warning Score Policy. Document ref. no: PP(15)271 For use in (clinical areas): For use by (staff groups): For use for (patients): Document owner: Status: All clinical areas All clinicians For all adult patients admitted to the Trust Critical Care Education and Outreach Team Approved Contents... Page 1. Introduction... 2 2. Background... 2 3. Scope... 2 4. Roles and Responsibilities... 3 5. Process Guidelines for the use of MEWS... 4 6. Process for monitoring the effectiveness of this policy... 7 7. Adjusting the MEWS Parameters... 8 8. Appendices... 7 Page 1 of 13

1. Introduction. The purpose of this document is to provide all staff with a clear framework for the identification and management of patients at risk of physiological deterioration. This policy is only applicable for adult (> 16 years) inpatients. Clinical deterioration can occur at any stage of a patient s illness, although there will be certain periods during which a patient is more vulnerable. These periods of vulnerability occur at the onset of illness, during surgical or medical interventions and during recovery from critical illness. Patients on general wards, acute assessment areas and emergency departments who are at risk of deteriorating may be identified and treated before a serious adverse event occurs. The timely recording and interpretation of changes in physiological observations and the effective use of a Track and Trigger system can achieve this. 2. Background. The Modified Early Warning Score (MEWS) is a form of Track and Trigger scoring system. 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 score should the patient s condition be improving or deteriorating (Appendix 1). MEWS was originally developed with two specific aims: To facilitate timely recognition of patients with established or impending critical illness To empower nurses and junior medical staff to facilitate timely senior review All patients have their observations measured and these are converted into a score. The higher the score the more abnormal the observations. This in turn should ensure the Graded Response Strategy is adhered to, whereby the higher the score the more senior input is required. 3. Scope. This policy will provide a consistent approach across the Trust in the recognition and management of the deteriorating patient. The policy allows the Trust to adhere to Department of Health recommendations NCEPOD 2005, Optimising Early Warning Scoring Systems, NICE 2007, Clinical Guideline 50 Acutely Ill Patients in Hospital and Patient Safety First 2008, Reducing Harm from Deterioration. The policy includes all adult patients where a decision has been made to admit the patient to hospital, but excludes patients under the care of the Midwifery Unit, where the MEOWS (Modified Early Obstetric Warning Score) is utilised. Adult patients attending specialist areas such as the Day Surgery Unit and Outpatients, it is recommended that the MEWS is used, however instead of the Graded Response Strategy there needs to be in place a defined strategy for getting senior input when clinically indicated. The policy applies to all health care professionals who measure, record and act on the findings of patient physiological observations. This policy is to be read and used in conjunction with: Clinical Guideline -Recording Respiration, Pulse Blood Pressure, Temperature, Oxygen Saturation and using the MEWS and Callout Cascade. Clinical Guideline - Prescription and Administration of Oxygen, Clinical Guideline. Patient Group Direction - Bolus infusion of Intravenous 0.9% Sodium Chloride. Admission / Transfer of a Patient Policy C4 (section containing the Risk Assessment Tool (RAT), for Intra-hospital transfers). Page 2 of 13

4. Roles and responsibilities. 4.1 General Managers and Lead Clinicians are responsible for maintaining an overview of the effectiveness of care through the review of audit findings. 4.2 Matrons are responsible for: Supporting ward and departmental managers in the implementation of this policy. Monitoring the implementation and compliance with this policy. Ensuring staff access training in line with their roles and responsibilities. 4.3 Ward Managers are responsible for: Implementing this policy within their clinical area. Ensure all their staff understands their accountability and responsibility in relation to complying with this policy. Ensure staff has the knowledge, skills and competence commensurate with their role and responsibilities to assess the acutely ill patient within their clinical area. Incorporate MEWS training into all staff induction programs and continued professional development through yearly updates, the appraisal process and staff performance review. Monitor compliance with the MEWS policy and the Graded Response Strategy via audit and review (see Appendix 6 MEWS Audit data Collection tool). 4.4 Health Care professions are responsible for practicing in accordance with the clinical guidance set out in this policy. 4.5 Clinical Skills Trainers are responsible for ensuring all students, i.e. CGC, Student Nurses / Midwives and student allied professionals are taught and comply with this policy whilst working within the Trust. 5. The process guidelines for the use of MEWS. 5.1 The MEWS should be used on all inpatients or when a decision has been made to admit. In the case of postoperative patients being cared for in the Post Anaesthetic Care Unit, the Operative Nursing Record and Pain Chart will continue to be the document utilised for recording observations until the patient is fit for transfer to the ward. At this point the last two sets of observations and MEWS scores will be entered onto to the observation chart for continuation by ward staff. In Critical Care when the decision has been made to transfer the patient to the ward, prior to transfer at least two sets of observations and MEWS scores should be recorded on the Observation chart prior to transfer. In the Emergency Department (ED) the Trust observation chart should be used as soon as the decision has been made to admit the patient. Whilst in ED all full sets of Observations should be accompanied by a MEWS score the only exception to this is when a patient is brought in with a cardiac arrest in progress. All patients triggering with a MEWS score or appear clinically unwell should be escalated using the ED Graded response. (See Appendix 3). Page 3 of 13

5.2 All patients should have: Physiological observations recorded at the time of their admission or initial assessment. A clear written monitoring plan that specifies which physiological observations should be recorded and how often. The plan should take account of the: Patients diagnosis Presence of co- morbidities Agreed treatment plan. 5.3 Physiological observations should be recorded and acted upon by staff that has been trained to undertake these procedures and understand their clinical relevance. 5.4 As a minimum, the following physiological observations should be recorded at the initial assessment and as part of routine monitoring: Heart rate Respiratory rate Blood pressure Level of consciousness (using AVPU) Temperature Oxygen saturations Urine output Oxygen saturations must be managed as described in the Oxygen Prescription Guidelines. All patients requiring 40% Oxygen or more to achieve their prescribed saturation target should be referred to the Critical Care Education and Outreach team (CCEOT). Each patient must have a Target saturation range ticked on the observation chart. Each set of observations must be accompanied by a calculated MEWS score (Appendix 1) and include the initials of the staff member undertaking those observations. 5.5 The MEWS should be used to monitor all adult inpatients in the Trust. This includes patients undergoing invasive procedures such as radiological procedures and endoscopy. The Observation Chart should accompany the patient to the department where the procedure is being carried out for continued use / monitoring of the patient. All patients should have a full set of observations carried out prior to transfer, either to a different area of care, or to undergo any diagnostic investigations or invasive procedures. These observations should be used as a guide in conjunction with the intra-hospital Transfer Risk Assessment Tool prior to transfer. 5.6 Physiological observations should be monitored at least every 12 hours. If a decision has been made by the Consultant or Registrar to decrease this frequency in agreement with the Nursing team this should be documented in the patient s multi-professional notes. Page 4 of 13

The frequency of observations should be increased or decreased as indicated by clinical need, by the nurse responsible for the patient. This should be documented both on the observation chart and in the multi-professional notes. 5.7 The frequency of observations should be increased if abnormal physiology is detected, as indicated on the call out cascade. 5.8 Staff caring for patients and using the MEWS should have competencies in monitoring, measurement and interpretation of observations and respond promptly to the acutely ill patient appropriate to the level of care they are providing. Training and assessment should be provided to ensure staff have these competencies. They should also attend annual updates on the above topics. 5.9 The Graded Response Strategy for patients identified as being at risk of clinical deterioration should be triggered by either physiological track and the score or clinical concern. 5.10 The trigger threshold for implementing the Graded Response Strategy is set locally and is clearly stated on the Observation chart. The threshold should be reviewed regularly to optimise sensitivity and specificity. 5.11 A Graded Response Strategy for patients identified as being at risk of clinical deterioration is an integral part of the observation chart and is detailed in Appendix 2. It should consist of three levels Low, Medium and High scores. 5.12 When a patient s MEWS score or clinical condition requires action, the MEWS communication sticker should be completed and placed in the notes (See Appendix 4). 5.13 Once the graded response strategy has been initiated, the patient must be seen within 30 minutes. With a MEWS score of 2-3, both the registered nurse caring for the patient, and the nurse in charge of the ward area must be informed as soon as possible. It is their responsibility to decide whether the patient needs the frequency of their observations increased. They also need to consider if increasing clinical care may be required. With MEWS scores of 4-5 (Or 3 in one parameter) the medical/surgical team responsible for the care of that patient must be informed urgently. The identified doctor and /or the CCEOT are required to attend within the allocated time frame of 30 minutes. For MEWS scores of 6 or more the patient must be referred to the Senior Registrar responsible for the patient. In Surgery out of hours call the FY2, who can refer onto the Registrar if appropriate, CCEOT must also be contacted. If a response hasn t arrived within 30 minutes or the patient deteriorates further during that time, the nursing staff should consider escalating to the appropriate on call consultant. If the patient s condition becomes life-threatening, a peri arrest call should be made immediately to switchboard on ext 2222. Page 5 of 13

5.14 Acutely ill patients who are being closely monitored with frequent observations and continue to trigger despite appropriate treatment being in place, do not need to be rereferred to the Medical team and Outreach unless they fail to improve or deteriorate further. 5.15 When communicating about a deteriorating patient all health care professionals should utilise the RSVP - Reason, Story, Vital signs, Plan, method of communication to facilitate concise and effective dialogue, (See Appendix 5). 5.16 All patients with a MEWS score of 4 (or 3 in one parameter) should have an alert icon added to junior doctor s lists in EPRO and removed once the patient s condition has improved. 5.17 All patients with a MEWS of 4 (or 3 in one parameter) MUST always be highlighted as part of the handover process for both nursing and medical staff. 5.18 All patients being transferred to a new ward area with a MEWS 4 must have been reviewed by a Doctor as per the Graded Response Strategy. They must have a clearly documented robust plan of care and a completed EPARS form as per Trust policy. 5.19 Whilst use of the MEWS system facilitates the assessment, early recognition and response to the deteriorating patient, it should not deter clinicians from exercising their clinical judgement. 5.20 The MEWS chart and its efficacy in relation to track and trigger processes should be reviewed on an annual basis to ensure the tools are fit for purpose and meet local needs. 5.21 MEWS compliance will be audited on a monthly basis and be incorporated within the Trust dashboard. Ward managers are responsible for completion and submission of the audit to the nursing directorate. Any areas of concern will require an action plan to be formulated and communicated to all appropriate staff. (Audit tool Appendix 6) 6.0 Process for monitoring the effectiveness of this policy The Critical Care Education and Outreach Team will be responsible for monitoring the effectiveness of this policy through a programme of education initiatives and audit. The audit of compliance in relation to MEWS will be feedback to ward managers /Matrons and presented to the patient safety committee and other relevant forums. 7.0 Adjusting the MEWS parameters. Patients with conditions such as Atrial Fibrillation or Chronic Obstructive Pulmonary Disease (COPD) often have abnormal physiological observations, which are outside normal parameters and do not compromise the patient or cause distress; however they may trigger the MEWS score. Also, in some circumstances, a patient may continue to trigger the MEWS, despite appropriate treatment being in place. In this situation it may be appropriate to alter specific parameters, within Page 6 of 13

levels applicable to the patient s condition. This will highlight changes in the patient s physical state, should an acute event occur. Alterations to MEWS parameters may only be done by Consultant or Registrar. The Consultant or Registrar may adjust these parameters, which could, in turn, alter the trigger and the call-out cascade. Where the MEWS parameter is reset: The level should ensure sufficient sensitivity to alert nursing and medical teams to further deterioration. The adjusted parameters and MEWS score should be documented in the multiprofessional notes along with a clear treatment plan. Reset parameters for pre-existing medical conditions should be reviewed at least every 24 hours. The patient should be closely monitored and any increase above the new parameter level must be reported immediately to the Registrar (Surgical FY2 if the Surgical Registrar is in theatres only). The date, time and value of reset parameter should be documented on the observation chart to ensure that it is reviewed at least every 24 hours. The resetting of the parameter threshold should be on an individual patient basis and should not pass onto possible subsequent readmissions without reassessment. The Critical Care Education and Outreach Team must be informed of any patients who have their MEWS parameters re-set (if not already involved) to ensure continuity and communication throughout the day or night. All patients with parameters reset must be communicated to the Ward Manager or most senior nurse on duty. Author/owner: Other contributors: Approvals and endorsements: Issue no: 4 File name: Supercedes: 3 Additional Information: Denise Combe, Naomi Palmer / Critical Care Education and Outreach Team, Paul Oats, Dr Ian Frost, Dr Joseph Yikona and Dr Clare Laroche Nursing & Midwifery Policies & Practices Committee MEWS Policy.doc Page 7 of 13

Appendix 1: MEWS Score 3 2 1 0 1 2 3 Temperature ( C) <35.0 35.1 36.0 36.1 37.5 37.6 38.2 38.3 39.0 39.1 Systolic BP <90 91-100 101-199 200-219 >220 Heart Rate <40 41-50 51-90 91-110 111-130 >131 Respiration Rate 8 9-11 12-20 21-24 25-29 >30 Oxygen Saturations (SpO2) <91% 92-93% >94% Urine Output With catheter nil With catheter <0.5ml/kg/hr Without catheter 0.5ml/kg/hr 6hrs Without catheter 0.5ml/kg/hr 12hrs Level of Consciousness New Confusion Alert Voice Pain Unresponsive Page 8 of 13

Appendix 2: Graded Response Strategy Clinical Response to MEWS Triggers (Callout Cascade) The Modified Early Warning System (MEWS) score must be calculated with every set of observations. Ensure target SpO2 are identified and documented on admission. Call Outreach if patient requiring > 40% O2 to maintain target SpO2. Implement the following if your patient triggers the MEWS or if you have concerns regarding their condition: Increase frequency of observations to at least hourly Assess Airway, Breathing, Circulation, Disordered conscious level and Exposure Consider oxygen therapy, venous access, blood tests, IV fluids and hourly urine measurements Apply the Sepsis Screening Tool MEWS Score Frequency of Observations Clinical Response 2-3 Minimum of 4 hourly Inform Registered Nurse who must assess the patient Registered Nurse to decide if increased frequency of observations and / or increase of clinical care is required Nurse in Charge to be aware of patient and offer advice / support as required 4-5 or 3 in one parameter Increase to at least hourly Registered Nurse to urgently inform the medical team caring for the patient and the Critical Care Outreach Team Urgent assessment by the Medical / Surgical / Critical Care Outreach Team 6 or more Increase to at least hourly Registered Nurse to immediately inform the Medical / Surgical Team caring for the patient this should be at least at Specialist Registrar level Emergency assessment by the Medical / Surgical / Critical Care Outreach Team Consider referral / transfer to a higher level of care with appropriate monitoring capabilities If the patient is rapidly deteriorating DO NOT DELAY Seek expert help On-Call Medical SpR 434 / Critical Care Outreach Team 666 Page 9 of 13 West Suffolk Hospital NHS Trust Review date: October 2018 On-Call Surgical FY2 SpR / Critical Care Dr 759 Document ref. no: PP(15)271 Medical / Surgical Consultant via switchboard

Appendix 3: Emergency Department MEWS Graded Response The Modified Early Warning System (MEWS) score must be calculated with every set of observations. Ensure target SpO2 are identified and documented on admission. Call Outreach if patient requiring > 40% O2 to maintain target SpO2. Implement the following if your patient triggers the MEWS or if you have concerns regarding their condition: Increase frequency of observations to at least hourly Assess Airway, Breathing, Circulation, Disordered conscious level and Exposure Consider oxygen therapy, venous access, blood tests, IV fluids and hourly urine measurements Apply the Sepsis Screening Tool 2-5 Minimum of 1 hourly Inform Registered Nurse who must assess the patient Registered Nurse to decide if increased frequency of observations and / or increase of clinical care is required Nurse in Charge to be aware of patient and offer advice / support as required 6 7 or 3 in one parameter Increase frequency Registered Nurse to urgently inform the medical team caring for the patient and the Critical Care Outreach Team 8 or more or patient not responding appropriately to treatment Continuous Registered Nurse to immediately inform the Medical / Surgical Team caring for the patient this should be at least at Specialist Registrar level Emergency assessment by the Medical / Surgical / Critical Care Outreach Team Consider referral / transfer to a higher level of care with appropriate monitoring capabilities If the patient is rapidly deteriorating DO NOT DELAY Seek expert help ED (SpR / Staff Grade / Consultant) / On-call Medical SpR 434 / Critical Care Outreach Team 666 / On-call Surgical FY2 SpR / Critical Care Dr 759 Medical / Surgical Consultant via switchboard Page 10 of 13

Appendix 4: MEWS communication Sticker. Deteriorating Patient Alert MEWS Score Commence Oxygen Increase observations to at least hourly Consider fluid balance chart Referral made to Critical Care Outreach Referral made to Medical / Surgical Team Tick When Implemented Referred by: Sign Date Print Time Seen by: Sign Print Date Time Page 11 of 13

Appendix 5: RSVP Communication Tool. COMMUNICATION TOOL RSVP Reason-Story-Vital Signs-Plan This tool is to enable you to communicate information effectively about deteriorating patients to another e.g. a Doctor, or the Outreach Team (666) Example R Reason State your identity State patient s name and location and Consultant State the reason for your call I am. I am calling about Mrs Jones on ward. Her Consultant is. I am worried because she is deteriorating I think the problem might be I m not sure what the problem is S Story Reason for admission Relevant past medical history MEWS score DNAR status Mrs Jones was admitted.. days ago because of. She has a past medical history of.. Her MEWS is And she is/is not for resuscitation V Vital signs A Clear / obstructed B- Respiratory rate, O 2 Saturations, O 2 delivery C- BP, Pulse, temp, IV fluids D- AVPU, Blood glucose E Pain, sweating Her airway is clear Her respiratory rate is. On % oxygen with SpO 2 of. She is hypotensive and/or tachycardic and has some / no IV fluids running She is awake and talking Her blood glucose is She has abdominal pain P Plan My plan is I have commenced I have started / increased the oxygen Shall I increase her fluids? I am not sure what else to do I need you to Please could you come to see her now Is there anything else I could be doing? Reference: Featherstone P, Chalmers T, Smith GB (2008) RSVP; a system for communication of deterioration in hospital patients British Journal of Nursing 17 (13): 860-86 Page 12 of 13

Date of Audit Ward Speciality Appendix 6: MEWS AUDIT DATA COLLECTION TOOL No. of Beds Auditor CRN number Observations completed correctly Yes/No Mews Calculated Yes/No Mews Calculated correctly Yes/No If Mews triggered, was patient escalated as per escalation policy? Yes/No If the patient s condition was escalated, were they seen with 30 mins? Yes/No Please provide additional information to explain no answers. West Suffolk Hospital NHS Trust Review date: October 2018 Page 13 of 13