DETERIORATING PATIENT POLICY GENERAL POLICY NO. 50

DETERIORATING PATIENT POLICY GENERAL POLICY NO. 50 Applies to: Committee for Approval Date of Approval September 2012 Date Ratified: September 2012 Review Date: September 2015 Name of Lead Manager Version: V. 1 All clinical or administrative staff contributing to the prevention and management of the deteriorating patient Quality and Governance Committee Nurse Consultant UNLESS THIS VERSION HAS BEEN TAKEN DIRECTLY FROM THE TRUST WEB SITE THERE IS NO ASSURANCE THIS IS THE CORRECT VERSION

Contents Section Page 1 Introduction 4 2 Statement of Intent 4 3 Definitions 5 4 Duties 6 4.1 Specific Duties within the Organisation 6 4.2 Specific Duties of Staff 7 5 6 7 Use of an early warning system within the organisation to recognise patients at risk of deterioration Requirement for a documented plan for vital signs monitoring that identifies which variables need to be measured, including the frequency of measurement Actions to be taken to minimise or prevent further deterioration in patients 8 Do not attempt resuscitation orders 14 9 10 How the organisation documents that resuscitation equipment is checked, stocked and fit for use How the organisation trains staff in line with the training needs analysis 11 Incident Reporting Process 15 12 Equality Impact Assessment 15 13 How the organisation monitors compliance 16 14 References 16 15 Bibliography 16 16 Associated Documents 16 Appendix One National Early Warning Score ( NEWS) 18 Appendix Two Outline Response to NEWS Triggers ( Adults) 19 Appendix Three NEWS Thresholds and Triggers 20 Appendix Four NEWS Observation Chart for Adults 21 Appendix Five Paediatric Early Warning Score System (Children) 22 Appendix Six Outline Response to PEWS Triggers 23 Appendix Seven SBAR Tool example 24 7 11 12 14 15 2/27

Section Page Appendix Eight Resuscitation pathway 25 Appendix Nine Monitoring Tool 26 Review and Amendment Log Version No Type of Change Date Description of change 3/27

1 INTRODUCTION This policy outlines the Trust s standards for the prevention and management of the deteriorating patient and aims to reduce patient harm which can occur from the risk of deterioration incidents. The policy highlights the importance of using early warning scores which are commonly used for the assessment of unwell patients; these observations can detect when a patient s condition requires a more intense observation and should be a trigger for further investigation as early intervention can reduce morbidity and mortality in unwell patients (NICE 2007, NPSA 2007). Clinical deterioration can occur at any stage of a patients treatment or illness, although there will be certain periods during which a patient is more vulnerable, such as the onset of illness or during medical, surgical or dental interventions. Patients who are at risk of deteriorating may be identified before a serious adverse event by monitoring changes in physiological observations recorded by healthcare staff. The interpretation of these changes and timely institution of appropriate clinical management once physiological deterioration is identified is of crucial importance to minimise the likelihood of serious adverse events, including cardiac arrest and death. 2 STATEMENT OF INTENT The Trust is committed to having standards in place for managing the risks associated with the deteriorating patient. This policy will outline the risk reduction strategies Wirral Community NHS Trust has in place to minimise these risks, as safety of patients is a key priority for the organisation. (NHS LA 2012) Strategic objectives for the Trust include the aims to: Improve quality outcomes and patient satisfaction Improve patient safety and risk management Improve efficiency and effectiveness of care services The early management of the deteriorating patient is a key objective for the safety and well being of patients, this is why the Trust is implementing a standardised early warning score trigger tool. The early warning score supports new ways of providing care in the community to deliver of care closer to home and avoid unnecessary hospital admissions (DH 2011). This policy will outline how staff can provide clinical care to promote the early detection, prevention and management of the deteriorating patient by:- Standardising practice for clinical staff in the early detection of clinical deterioration with the aim of preventing further deterioration and possible subsequent cardio-respiratory arrest Facilitating the early detection of deterioration by using an early warning score for the appropriate and timely management of clinical deterioration Reducing the clinical risks associated with inappropriately managed clinical conditions 4/27 The Deteriorating Patient Policy Version 1

3 DEFINITIONS Anaphylaxis Anaphylaxis is a severe, life-threatening, generalised or systemic hypersensitivity reaction. This is characterised by rapidly developing life-threatening airway and/or breathing and/or circulation problems usually associated with skin and mucosal changes. Track and Trigger Systems Track and Trigger systems rely on the recording and charting of the physiological status of the patient. The observations and may include, pulse, respiratory rate, temperature, pulse oximetry (SpO2) and blood pressure. The use of these multiple parameter or aggregated weighting scores systems are more sensitive in detecting when a patient is showing deterioration compared with single parameter systems Early Warning Score Early Warning Scores are a form of track and trigger scoring system based on routine observations which is sensitive enough to detect changes in a patient s physiology. When vital signs are measured they are converted into a score, the more abnormal the vital signs the higher the score. If scores reach certain thresholds this triggers a range of interventions that aim to improve the patient s condition or in case of an emergency refer directly to urgent care services. National Early Warning Score (NEWS) The Royal College of Physicians (2012) have developed a national early warning score to facilitate a standardised and national unified approach to alerting clinical staff to any untoward clinical deterioration and also clinical recovery. The NEWS clinical observation chart To facilitate standardisation, a colour coded clinical chart has been developed to record routine clinical data and track a patient s clinical condition. This tracking will alert the healthcare professional of any untoward clinical deterioration and also clinical recovery. This in turn determines the urgency and scale of the clinical response. SBAR (Situation Background Assessment Recommendation) An SBAR (NHS 2010) is an easy to remember mechanism that can be used to frame conversations, especially critical ones requiring a clinician s immediate attention and action. It can aid clarity when making an emergency call or when requesting advice or intervention about patient management from a senior clinician or General Practitioner 5/27

Triage Triage is a complex decision making process designed to manage clinical risk. A rapid assessment is made to identify or rule out life/limb threatening conditions to ensure patient safety. 4 DUTIES 4.1 Specific Duties within the Organisation Chief Executive The Chief Executive is responsible for the statutory duty of clinical governance within the Trust and takes overall responsibility for this policy. Trust Board The Trust Board have overall responsibility for ensuring that the Trust delivers high quality services that are efficient and effective. The Board is made up of the Chairman, Chief Executive, Executive Directors, Medical Director and Non-Executive Directors. The Trust Board oversee the running of the Trust, make the decisions that shape future direction, monitor performance and ensure accountability. Quality and Governance Committee The primary function of the Quality and Governance Committee is to provide assurance to the Board of overall compliance with all statutory and regulatory obligations and will ensure the effective management of Incidents, Complaints, Claims and Inquests and subsequent dissemination of lessons learnt. The committee reports to the Board on all aspects of quality, governance and compliance and receives assurance that Wirral Community NHS Trust meets all relevant statutory and regulatory obligations in relation to quality, clinical governance and compliance. Quality, Patient Experience and Risk Group This group provides information and assurance to the Quality and Governance Committee regarding how the Quality, Patient Experience and Risk Strategies are being implemented and managed within the organisation. In addition the group provides information and assurance to the Quality and Governance Committee regarding how risks are being managed within the organisation and escalates them when appropriate to the Quality and Governance Committee in accordance with the Incident Reporting Policy. Reported incidents that related to significant patient harm from a deteriorating patient incident report would be subject to a root cause analysis and reported via this group. Lessons learnt would be shared as appropriate and this policy updated if required. This group accepts the action plans of the Resuscitation Group to monitor compliance with all relevant standards and guidance 6/27

Resuscitation Group This Group agrees policies and procedures relating specifically to resuscitation, which are then sent to the Quality, Patient Experience and Risk Group for formal approval. This Group monitors incidents and action plans arising from resuscitation incidents in order to learn from incidents and share wider learning. Reporting by exception to the Quality and Governance Committee as required 4.2 Specific Duties of Staff Clinical Directors and Divisional Managers are responsible for ensuring:- All relevant services are compliant with this policy Service Managers are responsible for ensuring:- All relevant staff in their service are working within the standards of this policy All staff have access to appropriate monitoring equipment Services have clinical procedures for the safe management of clinical interventions that are known to potentially put patients at risk of deterioration Team Leaders/Managers are responsible for ensuring:- All relevant staff in the team are working within the standards of this policy Clinical handovers include patient status reports, as relevant, that relate to the prevention and management of clinical deterioration of patients both internally within /or across teams and externally if transferring patients to another hospital or care setting Individual Clinical Staff are responsible for:- Complying with the standards in this policy Using the early warning scoring system as relevant to their service Documenting their findings in the patients health records Attending Essential Learning Training as per Trust Training Matrix 5 USE OF AN EARLY WARNING SYSTEM WITHIN THE ORGANISATION TO RECOGNISE PATIENTS AT RISK OF DETERIORATION For some patients there is a risk of becoming acutely unwell and in this situation, should their clinical condition deteriorate, it is essential that healthcare staff are equipped to recognise and manage the deterioration confidently and competently. Early Warning Scores used in the Trust The National Early Warning Score (NEWS) for Adults (2012) A Paediatric Early Warning Score (PEWS) for Children. Appendix One Appendix Five Current evidence suggests that the combination of:- i) Early detection ii) Timeliness of response iii) Competency of the clinical response 7/27

is critical to defining clinical outcomes and planning an effective clinical response to acute illness Benefits of using an Early Warning Scoring system:- Improves the quality of patient observation and monitoring Improves communication within the multidisciplinary team Allows for timely discussions to support clinical judgement Aids securing appropriate assistance for poorly patients Gives a good indication of physiological trends Provides a sensitive indicator of abnormal physiology However, the NEWS is not:- A predictor of outcome A comprehensive clinical assessment tool A replacement for clinical judgement NATIONAL EARLY WARNING SCORE FOR ADULTS (Appendix One) There are six physiological parameters included in the NEWS:- Respiratory rate Oxygen saturations Temperature Systolic blood pressure Pulse rate Level of consciousness The NEWS should be calculated for every set of observations 8/27

The NEWS thresholds and triggers for adults are:- (see Appendix Two and Three) Appendix Two outlines the expected clinical response to the NEW Scores Medical Practitioners Medical Practitioners in the Trust will be using the early warning scores, they will use their clinical judgement to determine the most appropriate clinical intervention and escalate care accordingly to meet the patient health needs. Whereas, nurse led services will refer to a medical colleague or refer directly to acute services when using the triggers scores and following recommended responses. Adults Inclusion Criteria:- Acutely unwell patients are considered to be at risk of developing a critical illness therefore health professionals need to commence a NEWS at the earliest opportunity. This includes:- Patients who are acutely ill planned or unplanned contacts/visits Patients with chronic unstable long term conditions Patients who have an infection e.g. chest, wound or urine infection who are not responding to treatment Post operative patients who are not improving / progressing Patient who are undergoing treatment / tests which may cause a sudden deterioration in the patient s condition e.g. dental sedation Patients whose wounds suddenly deteriorate 9/27

If a patient s condition suddenly deteriorates or becomes increasingly unwell re assessment of vital signs would provide an indication of the patients physiological status. Adults Exclusion criteria:- Minor ailments Patients on the End of Life Care Pathway, which in agreement with a General Practitioner need to commence on the Liverpool Care Pathway. These patients do not need regular vital signs monitoring but if they deteriorate may require a medical review for symptom control. PAEDIATRIC EARLY WARNING SCORE (PEWS) FOR CHILDREN. Appendix Five Initial clinical assessment This may be a part of a triage process or may occur subsequently. This requires not only the vital signs to be measured but also includes a brief history and immediate plan of care. This process allows the clinician to start any immediate treatment needed and to order relevant investigations prior to the definitive clinician assessment allowing a faster and more efficient pathway for the patient. Triage and the PEWS Triage is a complex decision making process designed to manage clinical risk. A rapid assessment is made to identify or rule out life/limb threatening conditions to ensure patient safety. This assessment may take the form of a few specific questions selected to rule in or out serious conditions and includes the need to record the child s physiological status. The result is the assignation of a priority to the patient thus helping manage workload and ensure the sickest patients are seen first. This process needs to be undertaken by a trained clinician. The PEWs should be calculated for every set of observations and recorded in the child health records, along with relevant actions and treatment plan Documentation will be directly into the electronic health record for Unplanned Care and Primary Care See Appendix Six for an expected outline of clinical responses to the PEWS triggers 10/27

The PEWS thresholds and triggers for children are:- PEWS Score Clinical Risk Low 1-2 (children can deteriorate quickly and situation may need to be escalated if any clinical concerns arise ) 3 Medium Total: 4 or more High 6 REQUIREMENT FOR A DOCUMENTED PLAN FOR VITAL SIGNS MEASURES, INCLUDING THE FREQUENCY OF MEASUREMENT In order to monitor patients there needs to be a documented plan to minimise or prevent further deterioration in patients. This should include the escalation process between healthcare professionals and the process for escalation in and out of hours The following standards need to be documented:- The frequency of monitoring required must be recorded in the care plan / treatment of care, this is important in order to provide continuity of care by the team, especially for home visiting services As not all patients will require every part of the NEWS observation chart to be completed. Specific parameters can be omitted or set as bespoke parameters personalised for individual patients according to their clinical needs, this must be an agreement between senior nurses and medical practitioners and recorded in the health records All observations need to be recorded in the patients health records. Additional factors to consider:- In some COPD patients inappropriate oxygen supplementation could raise oxygen saturations above the target range, this emphasises the need for close monitoring and supervision of these patients Urine output has been included on the NEWS chart to highlight the importance or recording urine output when considered clinically appropriate to do so 11/27

Pain has been included as part of the NEWS observation chart to encourage routine recording of pain symptoms, however it does not form part of the aggregate score for the NEWS Other exceptions may be appropriate in individual circumstances (e.g. physiological abnormalities due to long term conditions) The decision for a patient to be excluded from routine measurements or have an adapted range of an acceptable physiological measurements needs to be made in partnership with either a GP or medical practitioner and the rational documented in the patients health records 7 ACTIONS TO BE TAKEN TO MINIMISE OR PREVENT FURTHER DETERIORATION IN PATIENTS The range of actions to minimise or prevent further deterioration in a patient s condition can include:- Immediate clinical intervention and treatment Defibrillation Post resuscitation care Urgent transfer arrangements to secondary care There may be specific circumstances where sudden deterioration may occur:- Anaphylaxis Adverse Drug reactions Following a clinical intervention Following dental surgery This list is not exhaustive as there are a range of clinical interventions that may trigger a sudden deterioration. ACTIONS IN RESPONSE TO DETERIORATION IN THE NEWS/PEWS SCORE The Trust advises a range of clinical response to the NEWS trigger scores (Appendix Two) to meet the needs of a community setting. The NEWS is not a replacement for clinical judgement and assessment of a patient s condition. The Trust advises a range of clinical response to the PEWS trigger scores (Appendix Six) to meet the needs of a community setting. The PEWS is not a replacement for clinical judgement and assessment of a patient s condition. SBAR : COMMUNICATION TOOL FOR THE ESCALATION OF CARE AND TREATMENT AMONGST ALL HEALTHCARE PROFESSIONALS IN THE TRUST SBAR stands for: S = Situation B = Background A = Assessment R = Recommendation SBAR is a communication tool for the escalation of care and treatment amongst all healthcare professionals in the Trust. SBAR is an easy to remember mechanism that can be used to frame communications or conversations. 12/27

It is a structured way of communicating information that requires a response from the receiver and helps to specify what actions are expected to minimise or prevent further deterioration in patients. Inadequate verbal or written communication is recognised as being the most common root cause of serious clinical errors. There are some fundamental barriers to communication at times across different disciplines and levels of staff within services. As such SBAR can be used very effectively to escalate a clinical problem that requires immediate attention (in conjunction with the NEWS), or to facilitate efficient handover of patients between clinicians and clinical teams. Benefits of using SBAR as a communication tool:- Helps outline the building blocks for communicating critical information that requires attention and action, thus contributing to effective escalation and increased patient safety. Using it helps to prevent breakdowns in verbal and written communication, by creating a shared mental model around all patient handovers and situations requiring escalation, or critical exchange of information SBAR is an effective mechanism to level the traditional hierarchy between physicians and other care givers by building a common language platform for communicating critical events, thereby reducing barriers to communication between healthcare professionals AN SBAR COMMUNICATION SHOULD CONVEY:- S: Situation Identify yourself the site/service you are calling from Identify the patient by name and the reason for your report Describe your concern Firstly, describe the specific situation about which you are calling, including the patient's name, GP, patient location, resuscitation status, and vital signs. B: Background Give the patient's reason for admission ( or presentation on referral in community care setting) Explain significant medical history Overview of the patient's background: admitting diagnosis, date of admission, prior procedures, current medications, allergies, pertinent laboratory results and other relevant diagnostic results. A: Assessment Vital signs Clinical impressions, concerns 13/27

R: Recommendation Explain what you need - be specific about request and time frame Make suggestions Clarify expectations Finally, what is your recommendation? That is, what would you like to happen by the end of the conversation with the clinician? Any order that is given on the phone needs to be repeated back to ensure accuracy. Readback:- Making sure you have been understood Following any communication using SBAR, it is important that the receiver of the information reads back a summary of the information to ensure accuracy and clarity. This should also be documented in the patients health records. Documentation of action taken:- The documentation which is based on the SBAR when escalating the care of an acutely ill patient may follow the recommended sequence in recording actions taken in electronic records a paper copy is not essential. 8 DO NOT ATTEMPT RESUSCITATION ORDERS (DNAR) Refer to the Trust s Do not Attempt Cardiopulmonary Resuscitation Policy (GP4) for full guidance. The decision making resuscitation pathway from the policy is in Appendix Eight which provides a summary of the DNAR decision making framework. 9 HOW THE ORGANISATION DOCUMENTS THAT RESUSCITATION EQUIPMENT IS CHECKED, STOCKED AND FIT FOR USE The provision of resuscitation equipment in services will be approved by the Resuscitation Group, including specialised provision in some services depending on what treatments or interventions are carried out that may put patients at risk of deteriorating. Recommended resuscitation equipment may include:- Airway equipment Circulation equipment Medicines The Resuscitation Officer in the Trust leads on this process by auditing compliance with the following standards for Divisions that require resuscitation equipment at least once a year:- All services that require resuscitation equipment are held on a central record held by the Resuscitation Officer, which is updated yearly (or earlier if new services are developed or change the type of clinical services they provide which would require resuscitation equipment) 14/27

All services will provide a yearly list of their resuscitation equipment which is approved by the Resuscitation Group All medicines must be approved by the Trust s pharmacist All services are required to check their resuscitation equipment on each day the service operates All services have a system for recording the daily checks as above to include the date, time, signature, full name and designation of the nominated person conducting the check. The nominated person needs to have the skills and knowledge to conduct the daily check competently Services must keep a record of all medical devices on the Service Medical Devices Register If there is any equipment failure, the incident must be reported via the Trust s Incident reporting system. Resuscitation training, that is additional to the Trust s basic life support training, must be stated on the Services Core Training Matrix. 10 HOW THE ORGANISATION TRAINS STAFF IN LINE WITH THE TRAINING NEEDS ANALYSIS In line with the Trusts Training Needs Analysis, all staff in the Trust are required to comply with mandatory training as specified in the Trust s Mandatory Training Matrix. Clinical Staff are also required to comply with mandatory service specific core training as specified within their service training matrix. Monitoring of non-attendance at Trust wide mandatory training is monitored via the Learning and Development Group as outlined in the Trust s Learning and Development Policy (GP46). Monitoring of Mandatory Service Specific Training is monitored via Divisional Governance Groups. 11 INCIDENT REPORTING PROCESS Clinical incidents or near misses relating to the standards in this policy must be reported via the Trust s incident reporting system. 12 EQUALITY IMPACT ASSESSMENT OF THIS POLICY During the development of this policy the Trust has considered the needs of each protected characteristic as outlined in the Equality Act (2010) with the aim of minimising and if possible remove any disproportionate impact on patients for each of the protected characteristics, age, disability, gender, gender reassignment, pregnancy and maternity, race, religion or belief, sexual orientation. If staff become aware of any clinical exclusions that impact on patient care that does not comply with this statement must report the incident or a near miss using the Trusts Incident Reporting system and an appropriate action plan put in place. A separate Equality Impact Assessment has been completed. 15/27

13 HOW THE ORGANISATION MONITORS COMPLIANCE WITH THE STANDARDS See Appendix Nine for details 14 REFERENCES Department of Health (2011) Transforming Services for Acute Care Closer to Home. Jan11 National Patient Safety Agency (NPSA) (2007) Recognising and responding appropriately to early signs of deterioration in hospitalised patients. London National Institute for Health and Clinical Excellence (2007) Feverish Illness in Children. Clinical Guideline 47. NHS Institute for Innovation and Improvement (2010) Safer Care, SBAR. NHS Litigation Authority (2012) Risk Management Standards National Institute for Health and Clinical Excellence (NICE) (2007) CG50 Acutely Ill Patients in Hospital London: NICE Patient Safety First. How to Reduce Harm from Deterioration Patient Safety First www.patientsafetyfirst.nhs.uk Royal College of Nursing (et al 2011) Triage Position Statement Royal College of Physicians (2012) National Early Warning Score. Standardising the assessment of acute illness in the NHS 15 BIBLIOGRAPHY British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing (2007) Decisions relating to cardiopulmonary resuscitation London Department of Health (2009) Competencies for Recognising and responding to acutely ill patients in hospital London DH National Confidential Enquiry into Patient Outcome and Death (NCEPOD) (2007)Emergency admissions: A journey in the right direction London: NCEPOD National Patient Safety Agency (NPSA) (2004) Patient Safety Alert 2004/02. Establishing a Standard Crash Call Telephone Number in Hospitals NPSA The Resuscitation Council (UK) Resuscitation Guidelines 2010 (2010) 16 ASSOCIATED DOCUMENTATION Do Not Attempt Resuscitation Policy Learning and Development Policy Consent Policy Infection Control Policies Paediatric Basic Life Support Procedure Adult Basic Life Support Procedure Discharge Policy Clinical Handover Policy 16/27

Medical Devices Policy Quality of Health Records Policy Clinical Protocol for Assessing Mental Capacity and Best Interests Procedure for Managing an Anaphylactic Emergency 17/27

Appendix One NATIONAL EARLY WARNING SCORE (NEWS) * Royal College of Physicians 2012 *The NEWS initiative flowed from the Royal College of Physicians' NEWSDIG, and was jointly developed and funded in collaboration with the Royal College of Physicians, Royal College of Nursing, National Outreach Forum and NHS Training for Innovation. A = Alert (fully awake) V = Responds to verbal commands (the patient makes some sort of response when talked to) P = Responds to pain (the person undertaking the assessment should be suitably trained when using pain stimulus as a method of assessing levels of consciousness) U = Completely unresponsive ( commonly referred to as unconscious ) 18/27

Appendix Two WIRRAL COMMUNITY NHS TRUST OUTLINE RESPONSE TO NEWS TRIGGERS ADULTS NEWS SCORE FREQUENCY OF MONITORING CLINICAL RESPONSE 0 Repeat as per care plan to meet clinical needs of patient 1-4 Repeat observations as directed in the patients health records Continue routine NEWS monitoring if clinically indicated Registered nurse to decide if increased monitoring and or escalation of care is required to treat and manage underlying condition Total 5 or more Or 3 in one parameter Total: 7 or more Repeat observations as directed in the patients health records Continuous monitoring Urgently inform a *senior clinical decision maker, and / or Urgent assessment by a clinician who is clinically competent to assess and treat acutely ill patients and can recognise when escalation of care to a secondary care setting is essential Emergency Referral to A&E Ring 999 and if appropriate contact A&E to advise of referral. (refer to Trust Clinical Handover Policy ) *A senior clinical decision maker in the community setting could be a GP, Senior Nurse Practitioner, Community Matron or for the Primary Care Assessment Unit the Medical Registrar on call 19/27

NEWS THRESHOLDS AND TRIGGERS ADULTS Appendix Three THE NEWS TRIGGER SYSTEM ALIGNED TO THE SCALE OF THE CLINICAL RISK A low score (NEW score 1-4 ) should prompt assessment by a competent registered nurse who should decide if a change of frequency of clinical monitoring or an escalation of clinical risk is indicated A medium score (NEW score 5-6 or a RED score) should prompt an urgent review by a clinician skilled in the assessment of acute illness, who will consider if there should be an escalation of care A high score (NEW score of 7 or more) should prompt emergency referral to secondary care *RED score refers to an extreme variation in a single physiological parameter (i.e. a score of 3 on the NEWS chart, coloured RED to aid identification and represents an extreme variation in a single physiological parameter). The consensus of the NEWS Development and implementation Group (2012) was that extreme values in one physiological parameter (e.g. heart rate <40 beats per minute, or a respiratory rate of <8 per minute or a temperature of<35 C) could not be ignored and on its own required urgent clinical evaluation. 20/27

NEWS OBSERVATION CHART FOR ADULTS Appendix Four Royal College of Physicians 2012 Always down load the original version from the web site this form must not be photocopied 21/27

Appendix Five Wirral Community Trust PAEDIATRIC EARLY WARNING SCORE SYSTEM (PEWS) RESPIRATORY RATE AGE Call 3 2 1 0 1 2 3 YRS 2222/999 0-1 Under 10 11-15 16-25 26-45 46-50 51-55 56+ 1-4 Under 10 10-14 15-19 20-34 35-39 40-49 50+ 5-11 Under 9 10-14 15-19 20-30 31-35 36-45 46+ 12+ Under 5 6-10 11-25 26-30 31-39 40+ OXYGEN REQUIREMENT CAP REFILL TIME CONSCIOUS LEVEL AGE 0 1 2 3 Age 0 2 3 Age 0 2 3 YRS 0-1 95+ 90-94 89-85 <85 0-1 <2 2-3 >4 0-1 A VP U 1-4 95+ 90-94 89-85 <85 1-4 <2 2-3 >4 1-4 A VP U 5-11 95+ 90-94 89-85 <85 5-11 <2 2-3 >4 5-11 A VP U 12+ 95+ 90-94 89-85 <85 12+ <2 2-3 >4 12+ A VP U HEART RATE AGE Call 3 2 1 0 1 2 3 In yrs 2222/99 9 0-1 <59 60-69 70-79 80-89 90-159 160-169 170-189 >190 1-4 <59 60-69 70-79 80-149 150-159 >160 5-11 <49 50-59 60-69 70-129 130-139 140-149 >150 12+ <39 40-49 50-59 60-119 120-129 130-149 >150 TEMPERATURE AGE 2 1 0 1 2 3 <3 months (NICE CG47)* >38* 3 months -1 yr (NICE CG47)* <36 36-39 39-39.9* 40+ 1-4 <36 36-39 39-39.9 40+ 5-11 <35 35-38 38-40 40+ 12+ <36 36-39 39-40 40+ Consider: activity, irritability, floppiness, facial colour, rash, respiratory effort, BP, parental concern *To reflect NICE CG47 (2007) height of body temperature alone should not be used to identify children with serious illness. However, children in the following categories should be recognised as being in a high risk group for serious illness:- Children younger than 3 months of age with a temperature of 38 o C or higher Children aged 3-6 months with a temperature of 39 o C or higher 22/27

Appendix Six WIRRAL COMMUNITY NHS TRUST OUTLINE RESPONSE TO PEWS TRIGGERS PAEDIATRIC UNPLANNED CARE / NURSE LED SERVICE PEWS SCORE FREQUENCY OF MONITORING CLINICAL RESPONSE Not indicated 0 Exclude: if single limb, / minor wound / health promotion enquiry. Must document a simple explanation why clinical observations not undertaken 0 0 1-2 Min of hourly Safe to wait and be seen in 4 hours. Must give safety-netting advice, all verbal advice needs to be recorded in the patient s health records Observe patient and if not seen in 1 hour, repeat observations as relevant to the patients presenting complaint and past medical history. Must give safety-net advice. If concerned, discuss with nurse practitioner Consider grading to urgent. Document all discussions and actions taken in consultation notes 3 30 mins Grading to urgent / or emergency as relevant to the patients presenting complaint and past medical history. Observe patient and repeat observations if not seen within 30mins. Must give safety netting advice. Inform senior nurse practitioner of the score and the health status of the patient, patient may require additional interventions if condition is deteriorating. Consider referral to GP / secondary care Total: 4 or more 15 mins Grade to EMERGENCY. Initiate required emergency care. Immediately inform Senior Nurse Practitioner of the score and the health status of the patient, who will undertake a rapid assessment and manage the patient. Patient may require additional interventions if condition is deteriorating If clinically required and not on APH site, ring 999, and if appropriate contact A&E to advise of referral. If on APH site make urgent contact with A&E and arrange transfer. 23/27

THE SBAR COMMUNICATION TOOL Appendix One Appendix Seven S Situation: I am (name), (X) working at (X) I am calling about (patient X) I am calling because I am concerned that (e.g. BP is low/high, pulse is XX, temperature is XX, Early Warning Score is XX) B Background: Patient (X) has had chest infection They have had (X /procedure/investigation) Patient (X) s condition has changed within the last (XX mins) Their last set of observations were (XX) A Assessment: I think the problem is (XXX) And I have e.g. given O²/analgesia/stopped the infusion) OR I am not sure what the problem is but patient (X) is deteriorating OR I don t know what s wrong but I am really worried R (e.g. Recommendation: I need you to OR Come to see the patient in the next (XX mins) AND Is there anything I need to do in the mean time? repeat the observations) Ask receiver to repeat key information to ensure understanding 24/27

Resuscitation Pathway Appendix Eight Is cardiac or respiratory arrest a clear possibility in the circumstances of this person? NO If there is no reason to believe that the individual is likely to have a cardiac or respiratory arrest it is not necessary to initiate discussion with them (or those close to person who lacks capacity) about Cardio Pulmonary Resuscitation (CPR). If, however, the individual wishes to discuss CPR this should be respected. YES Is there a realistic chance that CPR could be successful? NO When a Do not Attempt CPR (DNACPR) decision is made on these clear clinical grounds, it is not appropriate to ask the person s wishes about CPR but careful consideration should be given as to whether to inform them of the DNACPR decision. Where the individual lacks capacity and has a welfare attorney or court-appointed deputy or guardian, this person should be informed of the DNACPR decision and the reasons for it as part of the ongoing discussion about the individual s care. YES Does the person lack capacity? NO YES Do they have a valid and applicable Advance Decision to Refuse Treatment (ADRT)? If so, this must be respected. If an attorney, deputy or guardian has been appointed they should be consulted. If no, a decision will be made on the basis of best interests. Decision makers have a legal duty to consult with those close to the individual who lacks capacity. If there is no-one appropriate to consult and the person has been assessed as lacking capacity then an instruction to an Independent Mental Capacity Advocate (IMCA) should be considered. Are the potential risks and burdens of CPR considered to be greater than the likely benefit of CPR? NO YES When there is only a very small chance of success and there are questions as to whether the burdens outweigh the benefits of attempting CPR, the involvement of the individual (or if the person lacks mental capacity those close to him/ her) in making the decision is crucial. When the individual has mental capacity their own view should guide the decision making. CPR should be attempted unless the individual has capacity and states that they would not want CPR attempted Adapted from: Decisions relating to cardiopulmonary resuscitation. A joint statement from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing. October 2007. Extract from Trust DNAR Policy 25/27

DETERIORATING PATIENT POLICY MONITORING TOOL APPENDIX NINE Minimum requirement to be monitored Process for monitoring Responsibility for completion Frequency of Monitoring Responsibility for Development of Action Plans Responsibility for Review of Results / Outcomes a. Requirement for a documented plan for vital signs monitoring that identifies which variables need to be measured, including the frequency of measurement b. Use of an early warning system within the organisation to recognise patients at risk of deterioration c. Actions to be taken to minimise or prevent further deterioration in patients d. Do not attempt resuscitation orders (DNAR) Clinical Audit Clinical Audit Clinical Audit Clinical Audit Policy Lead, supported by nominated service lead Policy Lead, supported by nominated service lead Policy Lead, supported by nominated service lead Policy Lead, supported by nominated service lead Minimum of once a financial year Minimum of once a financial year Minimum of once a financial year Minimum of once a financial year Divisional Managers Divisional Managers Divisional Managers Divisional Managers Quality, Patient Experience and Risk Group (QPER) and by exception to the Quality and Governance Committee QPER Group and by exception to the Quality and Governance Committee QPER Group and by exception to the Quality and Governance Committee QPER Group and by exception to the Quality and Governance Committee 26/27

Minimum requirement to be monitored Process for monitoring Responsibility for completion Frequency of Monitoring Responsibility for Development of Action Plans Responsibility for Review of Results / Outcomes e. How the organisation documents that resuscitation equipment is checked, stocked and fit for use f. How the organisation monitors compliance with all of above Compliance Audit Audit of standards outlined in this policy Policy Lead, supported by Resuscitation Officer Policy Lead, supported by nominated service lead Minimum of once a financial year Minimum of once a financial year Divisional Managers Divisional Managers Resuscitation Group QPER Group and by exception to the Quality and Governance Committee 27/27