The ROHNHSFT Experience: Implementing BWCH PEWS Alison Warren Clinical Matron for Children and Young Peoples Services The Royal Orthopaedic Hospital NHS Foundation Trust RGN, RSCN, ENB 415 & 998 PG Cert (HE) MA Ed (cand) APLS,EPALS,PHPLS, GIC & pils Instructor
Background BWCH PEWS working group since first introduced in 2006 Involved in a number of iterations of charts and policy (Working Group) Data collection for unplanned PICU admissions SIM scenario training Wards / NQN programme Development of the BWCH Moodle E learning Package 2013 Incorporated into Skills and Simulation training for BCU Student Nurses UoB Student PEWS simulation Day Robust working knowledge of PEWS and PEWS education
Review of existing ROH Early Warning System Chart adapted from: Stanmore/Oswestry/BCH No Policy to support Score 0-4, escalation excluded senior medical staff/kids 4 Triggers HR, RR, Temp and CRT Numeric recording (unable to see trends) included components of fluid balance 3 age related parameters 2-5; 5-12; 12-16 First time user impression, supportive reason to change
Potential Clinical Risk Supported by RCPCH recommendation But be careful!!! Rationale for Change
What the Papers say: The recommended standards for measurement of vital signs and observations: UK Royal College of Nursing Standards for Assessing, Measuring and Monitoring Vital Signs in Infants, Children and Young People (2013). The baseline frequency of observations depend on the child s individual clinical circumstances (range: dailycontinuous monitoring) regardless of reason for admission The escalation guide details the minimum observation frequency for any child triggering PEWS It is essential to note any individual outlying parameters, observe trends and be aware that a child showing no signs of improvement may quickly lose the ability to compensate.
What the Papers say: Team members should be appropriately trained and maintain their competency in the management of an acutely ill child https://www.resus.org.uk/quality-standards/acute-care-qualitystandards-for-cpr/ NHS England ReACT (Response to ailing children tool) http://www.england.nhs.uk/ourwork/patientsafety/re-act/ PEWS should complement care, not replace clinical judgement Clinician or family concern is a core parameter and an important indicator (PEWS score should never undermine the intuition of the child s family or clinician) Observations and monitoring of vital signs should be undertaken in line with recognised, evidence-based standards
What the Papers say: Hospitals should support additional safety practices that enhance the Paediatric Early Warning System and lead to greater situation awareness among clinicians and multidisciplinary teams. Paediatric Early Warning System s should be supported through the application of quality improvement methods, such as engagement strategies, testing, and measurement to ensure successful implementation, sustainability and future progress. Communication between all multidisciplinary team members is essential for the effective interpretation of clinical concern. Clinicians should use their clinical judgement when determining the level of response required to the concern expressed and act accordingly
Drivers for ROHNHSFT Change Paediatric early warning scores need to be part of a system of in-hospital care but also link with tertiary centres The identification of evolving critical illness and escalation of concerns then allows experienced clinical staff to respond quickly to assess and stabilise patients in a timely manner using the same language Communication between all multi-professional team members is essential for the effective interpretation of clinical concern Give clear escalation guidance for transfer or retrieval to an area of higher dependency (CYPHDU) or intensive care at Birmingham Women s and Children s Hospital (BWCH)
Exploring Risk and Gaining Support Champion the cause! Presenting the facts and identifying the risks Scoping other centres and best practice examples Senior Nurse support
PEWS at ROHNHSFT: Applying the BWCH Model The Paediatric Early Warning Scoring (PEWS) System at ROHNHSFT consists of the following 5 components: An Observation, Monitoring and Escalation Policy Standardised Observation Sheets with an embedded, validated age-related Paediatric Early Warning Scoring System and standardised fluid balance charts The PEWS Response referral algorithm including SBAR communication Audit of unplanned admissions to the CYPHDU or retrieval to BWCH from ward 11, CYPHDU or theatres An education and learning package
PEWS Implementation Audit of unplanned CYPHDU admissions/ KIDS Referrals /Retrievals Education and learning package Score 1-4 or in GCS of 1 point Discuss with nurse in charge and consider increasing frequency of observations. Score of 5-8 or in GCS of 2 points or concern Inform nurse in charge, call pt s own team (day) +/- Anaesthetist/Critical Care Outreach/call KIDS for clinical advice 03002001100 LIFE THREATENING - CALL 2222 Score 9, GCS 11 or VERY concerned Call Anaesthetist / Critical Care Outreach / call KIDS for urgent referral / retrieval 0300 200 1100
No E Learning Platform! The Learning Resource
Paediatric Early Warning Systems Self Guided Learning and Assessment The How to guide and assessment
Calculation and recording of bedside PEWS Bedside PEWS Score
PEWS Response Algorithm Ensure early escalation. Remember KIDS offer clinical advice, they also like to be aware if there are any CYP within region that are showing signs of deterioration
Patient Specific Parameters Ensure the following before charting the patient s observations and calculating the PEWS score : The correct age chart is being used The patient name and details (demographics) are correctly recorded Patient specific parameters are documented at the top of the observation chart. For many patients, the parameters will be as expected for the age and this should be documented accordingly. However, discussion with the medical team may be required as to when to escalate concerns dependent on individual patient requirements, for example: an infant with chronic lung disease on home oxygen may have an elevated PEWS score on admission, which is normal for him/her. Identification of patient specific parameters will enable you to be record the PEWS score on the observation chart which will trigger further escalation and review. Alarm Limits are documented for any medical device used for monitoring
Patient Specific Parameters A B A : Record patient specific parameters, these should be advised and documented by medical staff. This is very important if the patient s condition deviates from the PEWS age related physiological parameters. B : If there is continuous haemodynamic monitoring alarm limits must be recorded
Escalating /De-escalating frequency of Observations When escalating or de-escalating the frequency of observations this should be recorded on the observation chart. The date and 24-hour time should then be documented If there are any specific parental or nursing concerns then you should tick the appropriate box and follow the PEWS Response Algorithm. These concerns should be documented contemporaneously in the patient healthcare records Escalation of concerns should be ticked once the SBAR communication has occurred Any specific events can also be recorded in the Events Box
Patient Specific Risks Any Patient Specific Risk Factors should be circled at the top of the Observation Chart identifying any of the following: Previous life threatening event (within 48 hours) Massive Blood Transfusion policy activated Non invasive ventilation Major Spinal Surgery Immunocompromised
Documenting observations The 7 components of PEWS score: Respiratory Rate Heart Rate Systolic Blood Pressure Oxygen Saturations Oxygen Requirement Respiratory Distress Capillary refill time
Documenting observations: Respiratory Rate, Oxygen Saturations, Oxygen Delivery and Respiratory Distress Assess patient for signs of respiratory distress using a structured approach: Nasal flaring Tracheal tug Head bobbing Sternal recession Intercostal recession Subcostal recession Best Practice Guidance Use a dot to express the rate Record the numeric value Do not join the dots
Documenting observations: Heart Rate Always count the pulse for one full minute Feel the temperature of the patient s hands and feet to check peripheral circulation Consider palpating several sites to check pulse strength Best Practice Guidance: Use a dot to express the rate Record the numeric value Do not join the dots
Documenting observations : BP Blood Pressure needs to be recorded on the PEWS chart using a consistent approach (RCN 2013) therefore inverted and upright arrows Λ / V must be used. Do not draw a line between. Use a dot if mean arterial pressure(map)is being recorded. Score Systolic value. Λ. (MAP) V
Documenting observations: CRT, PEWS Score, Sepsis 6, Temperature, AVPU, Blood Sugar, Pain Score
Hints and Tips: Non-invasive BP Check that the medical device used for monitoring non invasive BP is working correctly. Ideally the same cuff should be used for the duration of the hospital stay Choose the correct size BP Cuff for the age of the child/ young person, align to artery and ensure within range. Best position for accuracy is left arm(closest to the heart)
Hints and Tips: CRT CRT can be assessed either peripherally or centrally. It is best practice to assess CRT centrally. If there are some concerns about the patient an assessment of both peripheral and central CRT provides more information about the patient s haemodynamic status Feel: Press on the sternum or forehead for 5 seconds, release and count how long it takes for the colour to come back. Normal CRT for the PEWS score at ROH is 2 seconds or less
Recognition of Sepsis Guidance is given on the PEWS chart to escalate concerns if sepsis is suspected. The temperature section of the PEWS chart is also shaded to identify if patients temperature trigger a sepsis concern
AVPU/Paediatric Coma Scoring AVPU-crude tool for rapid assessment A coma scale is a tool that instructs the assessor how to perform and record a series of prescribed neurological and haemodynamic observations on a scaled chart Neurological observations enable the practitioner to assess the neurological status of the patient Incorporated into PEWS and guidance for use in Observation, Monitoring and Escalation Policy
Hints and Tips: Neurological Assessment The mode of painful stimuli used should involve applying pressure on the side of the finger sufficient to evoke a rapid response (avoid pressure on the nail bed). If the patient has a significantly reduced conscious level, use central stimuli by applying supra-orbital pressure Ensure that assessment methods are consistent; variations can course scoring anomalies. Consistency is achieved by delivering a concise and accurate bedside handover.
SBAR Communication S Situation Hello this is: name, designation and location I am calling about: ( patients name and location). The problem I am escalating I am worried about.. B Background Brief relevant medical history, i.e. diagnosis and recent events including surgery, etc. A Assessment A Airway B Breathing C Circulation D Disability (AVPU and Glucose) E Exposure PEWS Score R Recommendations I suggest/request that you: Attend immediately Transfer to HDU Review within 30 minutes Review on the next ward round If a change in treatment is required then: How often do you want observations How long before you want us to get in contact again? Is there anything you would like to be performed /set up before you visit? i.e run through IV infusion, set up for cannulation.. Universal language, ensure succinct highlighting key concerns. Use A-E assessment and PEWS score. Make your recommendations clear and document the time and communication outcome.
Key Messages Early identification of increasing PEWS/ recognition of the sick child Understanding the multi-professional team s role in the management of deterioration Understanding the need to take appropriate action in line with the PEWS Response algorithm Awareness of essential clinical guidelines (national/ local) Early escalation according to PEWS Response algorithm Early referral to KIDS if indicated for advice/retrieval
Clinical Assessment of the use of PEWS chart, PEWS Response Algorithm and SBAR communication Case Study Baseline Obs Case progression PEWS Score, clinical decisions, actions recommendations, SBAR Handover
Any Questions? alisonwarren2@nhs.net