1 QUALITY ASSURANCE AND VERIFICATION DIVISION HEALTHCARE AUDIT SUMMARY REPORT Title Audit of Compliance with the Irish Paediatric Early Warning System National Clinical Guideline No. 12. Number QAV008/2016 Timeframe December 2016 May 2017 Team Members Approved by Audit Liaison Mr. Alfie Bradley (Lead), Healthcare Auditor, Quality Assurance and Verification Division Ms. Lia Evans, Healthcare Auditor, Quality Assurance and Verification Division Dr. Edwina Dunne, Assistant National Director, Quality Assurance and Verification Division. Dr. Niamh O Rourke, Clinical Effectiveness Officer, Clinical Effectiveness Unit, Department of Health Source of Evidence Request for Evidence Site Visits Issued between 6 and 20 January 2017 to all four sites. Returned by all sites on or before 3 March 2017 Cork University Hospital 24 January 2017 Temple Street Children s University Hospital 31 January 2017 Midland Regional Hospital Portlaoise 14 February 2017 Portiuncula University Hospital 03 March 2017 Report Distribution Date: 24 May 2017 Name Mr. Liam Woods Mr. Patrick Lynch Dr. Niamh O Rourke Ms. Cora McCaughan Mr. Gerry O Dwyer Ms. Susan O Reilly Mr. Maurice Power Ms. Eilish Hardiman Title National Director, Acute Hospital Services National Director, Quality Assurance and Verification Division Clinical Effectiveness Officer, Clinical effectiveness Unit, Department of Health Assistant National Director, Healthcare Audit, Quality Assurance and Verification Division Chief Executive Officer, South South/West Hospital Group Chief Executive Officer, Dublin Midlands Hospital Group Chief Executive Officer, Saolta University Healthcare Group Chief Executive Officer, Children s Hospital Group 1
2 1. BACKGROUND / RATIONALE The National Clinical Guideline No. 12 (NCG) for the Irish Paediatric Early Warning System (PEWS) was developed in November 2015. This guideline is a multifaceted approach to improving patient safety and clinical outcomes. It supports a renewed focus on prevention, early detection through early warning systems and scores, and appropriate timely responses to the clinically deteriorating child. Implementation of the PEWS NCG involves completion, by nursing staff, of a paediatric observation chart for each patient. A PEWS score is calculated for each set of patient observations including six core parameters which are scored individually. The core parameters are; respiratory rate and effort, oxygen therapy, heart rate, conscious level and clinician/family concern. There are five additional parameters, namely; oxygen saturations, central capillary refill time, blood pressure (systolic), skin colour and temperature. Additional parameter measurement is determined on a case-by-case basis and depends on the presenting condition, treatments and interventions and on current and predicted clinical status. When a PEWS score 3 is recorded, an escalation guide setting out the clinical response for the patient should be followed. Among the indicators for successful implementation of PEWS are clear documentation of management plans, a targeted training programme and on-going audit, evaluation and feedback. An audit of compliance of selected recommendations from the NCG was accepted by the National Director for Quality Assurance and Verification Division as part of the Healthcare Audit Programme for 2016. 2. AIM AND OBJECTIVES The objectives of this audit were to establish if there was evidence of: An appropriately documented PEWS chart to include scoring of six core physiological parameters and additional parameters (Recommendations 3 and 4 NCG). Adherence to the escalation guideline for PEWS (Recommendations 6 and 8). PEWS training undertaken at site level (Recommendation 16). PEWS audits undertaken at site level (Recommendation 18). 2
3 3. FINDINGS The criteria measured in these findings were based on a selection of recommendations within the NCG. The original audit sample size for each site was 20 cases. Four acute hospital sites were chosen for audit: Cork University Hospital (CUH), Midland Regional Hospital Portlaoise (MRHP), Portiuncula University Hospital (PUH) and Temple Street Children s University Hospital (TSCUH). Objective 1: Establish if PEWS was appropriately documented to include scoring of six core physiological parameters and additional parameters. Core Parameters: Each of the core physiological parameters must be completed and recorded for every set of observations (Recommendation 3, NCG). The recording and scoring of core parameters at all times was critical to the successful identification of changes and escalation of the child s deteriorating condition. The table below lists the six core parameters and the percentage compliance with the NCG for each site. Core Parameter Table 1: Compliance - Core Parameters and Scores Percentage compliance with NCG (%) CUH PUH MRHP TSCUH Concern 80 26 84 94 Respiratory rate 80 79 100 100 Respiratory effort 85 63 100 100 Oxygen therapy 85 74 100 100 Heart rate 80 74 95 94 Conscious level 85 53 100 94 PEWS recorded correctly 70 0 79 83 None of the audited sites met the requirement of recording all core parameters for every set of observations and this was reflected in their PEWS score compliance (last row of table). It was of particular concern that PUH did not calculate any of their PEWS scores correctly and in their site report auditors recommended that this required urgent review by the hospital and the senior most accountable persons in the Saolta group and nationally. Additional Parameters: Additional parameter measurement is determined on a case-by-case basis and depends on the presenting condition, treatments and interventions and on current and predicted clinical status. The table below lists the five additional parameters and their compliance with the NCG for all sites. Additional Parameter Table 2: Compliance - Additional Parameters and Scores Percentage compliance with NCG (%) CUH PUH MRHP TSCUH Oxygen saturations 100 94 100 100 Central capillary refill time 100 100 100 100 Blood pressure (systolic) 100 67 100 100 Skin colour 100 95 100 100 Temperature 100 100 100 100 3
TSCUH and CUH and MRHP were fully compliant with the requirements of the NCG with regard to the standards of documentation for the additional parameters. However, PUH had a lower percentage of compliance. Documentation Standards: Compliance with documentation of care in the PEWS chart was audited against the six NCG documentation standards as listed in the table below. Table 3: Compliance with Documentation Standards Documentation Standards recorded on PEWS chart Percentage compliance with NCG (%) CUH PUH MRHP TSCUH Correct chart for child s age 100 95* 95* 95* Date of commencement of PEWS chart present 50 79 84 94 Date of each observation present 40 100 68 89 Time of each observation present 100 84 100 100 Frequency of observations documented 35 32 72 50 Reassess within (mins) documented 15 26 11 44 * PUH, MRHP and TSCUH each had one chart from the audit sample which was the incorrect PEWS chart for the age group of the child. All three of these charts were removed from the audit samples. Documentation standards did not meet the requirements of the NCG at any of the audited sites. In particular, the variables frequency of observations and reassess within (last two rows of the table) were not documented consistently at any audited site. It was suggested by staff at one site that the positioning of these particular variables on the PEWS charts may have had some effect on the recording of the variables where they were clinically required. 4 Objective 2: Determine if the Escalation Guide for PEWS was adhered to. Escalation occurs when there was a PEWS score 3. Higher PEWS scores require expedient and responsive care. Table 4 details the Escalation Guide from the PEWS User Manual (June 2016). It details the minimum frequency for observations, minimum alerts and minimum responses required in relation to escalating PEWS scores. Table 4: Escalation Guide for PEWS Scores 3 PEWS does not replace an Emergency call Score Minimum Observations Minimum Alert Minimum Response 3 1 hourly Nurse in Charge (NIC) + Nurse in Charge review 4-5 30 minutes Doctor on call (Doc 1) Urgent Medical Review 6 Continuous NIC + Doc 1, + Senior Doc+ Consultant Urgent SENIOR Medical Review* 7 Continuous URGENT PEWS CALL Immediate local response team (Note: Pink score = PEWS score of 3) Pink*score in any parameter merits review * PEWS does not replace clinical concern 4
5 Escalation Compliance: All four sites had incorporated local Escalation Guides into the paediatric observation charts, all of which detailed the minimum observation frequency, minimum alert and minimum response. The table below shows the nursing response compliance with the minimum alert and subsequent escalations of the PEWS score 3 by site. The documented medical response to these cases is also demonstrated. Table 5: Compliance with the Escalation Guide in PEWS charts with a Score 3 Escalation Compliance Criteria 1. Number of cases audited requiring a nursing response to a PEWS score 3 site 2. Evidence of a documented nursing response to PEWS score 3 (from the number of escalations in 1. above) 3. Evidence of a documented medical response to requested action or review (triggered by nursing response in 2 above) 4. Signature of doctor present in the medical notes (as per the medical responses/reviews above) 5. Grade of doctor present (as per the medical responses/reviews above) Numbers of escalations and responses CUH PUH MRHP TSCUH 9 of 20 6 of 19 10 of 19 10 of 18 7 of 9 3 of 6 7 of 10 2 of 10 5 of 7 2 of 3 4 of 7 1 of 2 5 of 5 1 of 2 4 of 4 1 of 1 4 of 5 1 of 2 2 of 4 1 of 1 Of the 80 charts audited 35 had a PEWS scores of 3, which requires a minimum nursing and medical alert and a minimum medical response. As outlined in row 2 of the table above deficits were found in the documented nursing response across all four sites. CUH and MRHP had the highest documented compliance. PUH had a documented nursing response in the clinical nursing notes in half of the cases, whilst TSCUH had the lowest compliance. In cases where there was a documented nursing response to a PEWS score of 3, evidence of a medical response was subsequently reviewed (see row 3 above). There were deficits found in the documented medical response across all sites. As demonstrated in the table, CUH and PUH had the highest compliance rates whilst MRHP and TSCUH were lower. The last two criteria examined (see rows 4 and 5 above) regarding the signature and grade of the doctor, also showed deficits in compliance with the NCG. In addition to the detail provided in the table above it was further noted that medical escalation suspensions were not referenced in either the nursing and medical management plans in nine of fourteen cases across all sites. Neither of the two parameter amendments found were referenced either. Nursing staff did not comply with the minimum observations frequency at MRHP, PUH and CUH. There were delays in performing/recording the next set of observations in instances where they were clinically indicated in response to elevated PEWS scores. Objective 3: Determine if PEWS training was undertaken at site level. Staff stated at interview that PEWS training courses had followed the National Guidelines. Proactive and ongoing training initiatives were in place for staff at three of the four sites, namely CUH, MRHP and TSCUH. In MRHP, however, it was noted as significant, that not all of the current cohort of non-consultant hospital doctors had been trained at the time of the audit. PUH, as one of the pilot sites for PEWS, had trained high percentages of their staff initially but the levels of training had lessened appreciably through 2016 and 2017. Staff stated at interview during the site visit that this was due to a lack of time and resources on the part of the trainers. Although PEWS training did take place at PUH, the audit team recommend that, due to the observed low 5
compliance with the NCG, an evaluation of training is undertaken. Further, it is recommended by the audit team that there should be a robust evaluation of the effectiveness of training in all acute hospitals. It was suggested by interviewees at some sites that consideration should be given to including regular refresher courses in the training schedule. Medical personnel interviewed at one site suggested that more time should be spent on delivering education on medical escalation suspension and parameter amendments as these merited extra attention due to their complexity. 6 Objective 4: Determine if PEWS audits were undertaken at site level. The quality, effectiveness and robustness of the PEWS audit programmes varied from site to site. A robust culture of PEWS audit existed within TSCUH and included PEWS audits of chart compliance, outcomes and PEWS calls as required by the NCG. Escalation of PEWS audit outcomes to relevant hospital committees within TSCUH and dissemination of outcomes to staff was also evident. It was stated by staff at interview in TSCUH that further PEWS audit initiatives were planned, e.g. an in-depth review of patient outcomes 24 to 48 hours after PEWS calls. The QAVD audit team recognise this as a proactive and positive approach to local PEWS audit. CUH undertook chart compliance and variance audits using NCG templates but there was limited evidence of recommendations and/or actions from these audits. Escalation of outcomes to relevant hospital committees was evident at CUH. PUH completed chart compliance; variance and response audits and those completed in 2016 had action plans attached. At the time of this audit CUH and PUH were not undertaking outcomes audits such as PEWS calls audits as recommended by the NCG. MRHP had undertaken no formal audit of PEWS to date. 4. CONCLUSION There were issues with the integration of the PEWS policy into practice to varying degrees in each of the four hospitals audited. Conclusions for each site are gathered individually under the four audit objectives: Objective 1: Establish if PEWS was appropriately documented to include scoring of six core physiological parameters and additional parameters: The audit team can provide limited assurance that three sites (CUH, MRHP and TSCUH) appropriately documented PEWS in line with the NCG and/or local policy. In particular, for these three sites, the core parameters which are essential for accurate PEWS scoring and escalation showed documentation deficits. Additional parameters were documented appropriately. For all sites, documentation standards in the PEWS charts did not adhere to the required national standard. No assurance can be given to PUH with regard to the documentation of PEWS. None of the PEWS charts audited had the correct PEWS score calculated. This rate of zero compliance was due to a number of issues: Core parameters had either not been scored correctly, or not scored at all. This led to the overall PEWS score being incorrectly calculated or in some instances the PEWS score had not been calculated at all and was left blank. The audit team suggest that the lack of compliance with the completion and documentation of the variables for frequency of observations and reassess within may be mitigated by a review of the current location for these variables on the PEWS chart. Objective 2: Determine if the Escalation Guide for PEWS was adhered to: Limited assurance can be given for all four sites with regard to compliance with the escalation guide as a number of cases at all sites did not have a clearly documented nursing or medical response. 6
Limited assurance can be given to TSCUH that medical escalation suspensions were documented appropriately. No assurance can be given for MRHP as the majority of the cases were not documented in accordance with the NCG. It was not possible to give a level of assurance on the implementation of the medical escalation suspension at CUH and PUH as there were insufficient instances of these found within the audit samples at these sites. As there were only two cases of parameter amendment over all four sites (one in CUH and one in TSCUH) there were insufficient cases to provide a level of assurance. Objective 3: Determine if PEWS training was undertaken at site level: Reasonable assurance can be given that TSCUH and CUH had implemented a PEWS training programme in line with national requirements. Although MRHP had implemented the PEWS training programme, only limited assurance can be given due to the fact that not all the current cohort of NCHDs had received PEWS training. PEWS training did take place at PUH; however, no assurance can be given on the application of the training due to the lack of compliance with the NCG. An evaluation of the training process is urgently required in PUH. It is further recommended that a national evaluation of the effectiveness of PEWS training in all acute hospitals is undertaken. Objective 4: Determine if PEWS audits were undertaken at site level: Reasonable assurance can be given that TSCUH have a robust culture of audit in place. Limited assurance can be given that CUH and PUH have an audit programme in place as their audit schedules did not include the full audit programme recommended by the NCG. Outcomes audits including PEWS calls audits did not take place at these sites. No assurance can be given on audit in MRHP as no audits have been undertaken at the time of this audit. Recommendations made in this report identify actions that the senior most accountable person nationally must implement in order meet the requirements of the PEWS policy and guidelines. 5. RECOMMENDATIONS Audit reports containing specific findings and recommendations were issued to each site (see Appendix A). The National Director of Acute Hospitals must ensure that all acute hospitals are aware of their responsibilities and their accountability for the effective implementation of PEWS as a nationally agreed tool and standard. Based on the findings in this report, the National Director must: 1. Ensure that an evaluation of the effectiveness of PEWS training is undertaken in all relevant acute hospitals. 2. Liaise with the PEWS Steering Group to ensure a review of the education on and the positioning of the frequency of observations and reassess within variables on the PEWS chart, given the low percentage compliance with completing these variables where they were clinically required. 3. Communicate/Circulate to aall hospitals the following recommendations which were common to the four sites audited and the need for all hospitals to ensure their compliance with same: PEWS charts must be documented in line with the national guidelines as follows: o All relevant staff must document all core parameter scores on the PEWS chart and ensure that the overall score is correct to deliver an effective clinical response. o Nursing staff must complete the frequency of observations and reassess within sections as clinically appropriate on the PEWS charts. o Nursing staff must complete a full set of observations in the required timeframe (minimum observation frequency specified for PEWS Scores) as per each hospital s paediatric observation chart escalation. o The correct PEWS chart for the appropriate age is used at all times. All relevant staff must adhere to the local PEWS Escalation Guide; in particular all staff must document within a child s record the rationale for the decision not to escalate scores of 3. 7 7
All relevant staff must document within a child s healthcare record any responses to PEWS scores 3, so that the minimum alert and minimum response are clearly demonstrated. Medical staff must date, time and sign all entries in the HCRs (as per the HSE Standards and Recommended Practices for Healthcare Records Management 2011). Medical and nursing staff must include a reference to PEWS scores (when relevant) in the documented management plans Medical staff must document medical escalation suspensions and parameter amendments in medical management plans as per the standards detailed within the NCG and relevant PEWS User Manuals. An audit programme must be developed and adhered to in line with the NCG to include patient outcome such as PEWS alert calls audits. 8 Acknowledgements: The audit team wish to acknowledge the co-operation and goodwill afforded to them by the management and staff at all hospitals included... Lead Auditor Alfie Bradley Signature Date 24 May 2017 AND QAVD Ms Cora McCaughan Signature Date 24.05.17 8
9 APPENDIX A: SITE SPECIFIC RECOMMENDATIONS The senior most accountable person on each site must ensure that: Cork University Hospital Temple Street Children s University Hospital Midland Regional Hospital Portlaoise Portiuncula University Hospital 1. PEWS charts are documented in line with the national guidelines: All nursing staff must document all core parameter scores on the PEWS chart and ensure that the overall score is correct to deliver an effective clinical response. Nursing staff must document the frequency of observations and reassess within as clinically appropriate on the PEWS chart. 2. All relevant staff must adhere to the local PEWS Escalation Guide; in particular all staff must document within a child s record the rationale for the decision not to escalate scores of 3. 3. Medical staff must date, time and sign all entries in the HCRs (as per the HSE Standards and Recommended Practices for Healthcare Records Management 2011). 4. An audit programme must be developed in line with the National Clinical Guideline to include patient outcome and PEWS alert calls audits. 1. PEWS charts are documented in line with the PEWS Training Manual. All nursing staff must document all core parameter scores on the PEWS chart and ensure that the overall score is correct to deliver an effective clinical response. Nursing staff must document the frequency of observations and reassess within as clinically appropriate on the PEWS chart. The correct chart for the appropriate age group is used at all times. 2. All relevant staff must adhere to the local PEWS Escalation Guide; in particular all staff must document within a child s clinical notes record the rationale for the decision not to escalate, or follow the minimum alert for scores of 3. 3. Medical escalation suspensions and parameter amendments must be documented as per the PEWS Training Manual 2015. 4. Medical staff must date and time all entries in the HCRs (as per the HSE Standards and Recommended Practices for Healthcare Records Management 2011). 1. PEWS charts are documented in line with the PEWS User Manual. All nursing staff must document all core parameter scores on the PEWS chart and ensure that the overall score is correct to deliver an effective clinical response. Nursing staff must complete a full set of observations in the required timeframe (minimum observation frequency specified for PEWS scores) as per each hospital s paediatric observation chart escalation. Nursing staff must document the frequency of observations and reassess within as clinically appropriate on the PEWS chart. The correct chart for the appropriate age group is used at all times. 2. All relevant staff must adhere to the PEWS Escalation Guide; in particular all staff must document within a child s clinical notes record the rationale for the decision not to escalate, or follow the minimum alert for scores of 3. 3. Medical escalation suspensions and parameter amendments must be documented as per the PEWS User Manual 2016. 4. Medical staff must date, time and sign all entries in the HCRs (as per the HSE Standards and Recommended Practices for Healthcare Records Management 2011). 5. An audit programme must be developed in line with the National Clinical Guideline to include patient outcome and PEWS alert calls audits. 1. PEWS charts are documented in line with the PEWS national guidelines: All nursing staff must document all core parameter scores on the PEWS chart and ensure that the overall score is correct to deliver an effective clinical response. 9
Nursing staff must document the frequency of observations and reassess within as clinically appropriate on the PEWS chart. Nursing staff must complete a full set of observations in the required timeframe (minimum observation frequency specified for PEWS scores) as per each hospital s paediatric observation chart escalation guide. The correct chart for the appropriate age is used at all times. 2. All relevant staff must adhere to the local PEWS Escalation Guide; in particular all staff must document within a child s healthcare record the rationale for the decision not to escalate, or follow the minimum alert for scores of 3. 3. Medical staff must include a reference to PEWS in any documented management plans. 4. Medical staff must date, time and sign all entries in the HCRs (as per the HSE Standards and Recommended Practices for Healthcare Records Management 2011). 5. The training programme must be reviewed within PUH to ensure that staff are fully aware of their responsibilities in documenting and scoring PEWS as per the NCG. 6. An audit programme must be developed in line with the National Clinical Guideline to include patient outcome such as PEWS alert calls audits. 10 10