PEWS one year down the line Lorraine Major Advanced Paediatric Nurse Practitioner
Clinical Incident 3mth old boy born at 30 weeks gestation Tracheo-oesophagel fistula and oesophageal atresia Under shared care with London and regional centre Recent admission for bronchiolitis Inadequate discharge plan Maternal Asperger s syndrome. ED attendance accompanied by mother Triaged within mins by Band 5 general SN ObservationsT,P,R,O2 sats recorded
Change our PEWS
Realities of the DGH No paediatric nurses in ED Trying to squeeze expert knowledge into novice heads All the undocumented subtle signs of the sick child Rotation doctors and nurses All we have left are VITAL signs
Aim Empower staff Educate staff Recognise sick children sooner Prevent avoidable deterioration
What do we do Measured what we were doing in regards to taking Temperature, respiratory rate and pulse. Measured against national standards for taking vital signs in children
Teaching Each member of staff re-taught on how to do vital signs Chunks of staff at all times of day and night Agreement on standards
Choose the charts Audited three charts with student nurses One came out top
Rolled them out
Audit Correct and age appropriate Observations completed Scored Accurately
Started July 2011 Dec 2011 After 6mths of use PEWS charts on G2 and CDU 170 charts audited of acute admissions 85 in CDU 85 in G2
Correct age appropriate CDU 100% Correct G2 100% Correct
Observations Complete CDU CDU 100% correct Majority one two observations at the beginning of the presentation Fewer observations done in the admission
Observations complete G2 G2 65% correct Respiratory rate complete Heart rate completed Temperature not so consistent Saturations completed A lot Pts with respiratory tract infections Use of monitor for HR and Sats
Scored accurately CDU Scored accurately 55% O not always scored Always score 1 and above
Scored accurately G2 Scored accurately 48% Again O missed out and scoring 1 and above When there was the same score over a long period the scoring system failed
Pews score and response 2 pts scored 5 on PEWS both respiratory patients and registrar was called on admission to CDU 1pt scored 4 on G2 registrar response IV Salbutamol given. One patient scored 1-2 on PEWS and had meningitis. It was the babies handling and irritability that raised concerns.
PEWS score and response 10 pts scored 3 seen by SHO or PANP and treatment activated Parent/nurse/ doctor concern not scored as often as anticipated
What s Good? Clear trend and visual improvement in documentation Observation are plotted and written in the appropriate boxes Easy to find in the nursing notes Have been implemented with no problems
What s not so Good? Audit part not working only 3 actions documented The example of the temperature dot (38 ) it is sometimes conceived that the child is pyrexial No pain score
Changes Add weight to top right hand corner Remove audit box and add? Pain score? SBAR Re-training about the importance of scoring the totals accurately
Dec 2011 to July 2012 CDU 70 charts one year after implementation Age appropriate = 100% Observations completed= 86% Scored correctly = 89%
Dec 2011 to July 2012 70 charts G2 one year after implementation Age appropriate = 100% Observations completed= 95% Scored correctly = 85%
One Sample of Escalation 7 month old admitted 18.20 Bronchiolitis S/B Dr 18.50 PEWS score 3 on arrival Inc to 4 at 19.00 until 22.30 4 = Reg review and to be seen by Cons Not seen by Cons Plan O2, Nurse prongs, 1hrly NG
Sample of escalation PEWS remained at 3 but the only difference was that the family concern was not scored Otherwise it would have been a 4 the observations were scoring the same until 02.00 03.30 PEWS > 4 post feed then escalation reported and documented Action -nil by mouth NIV and rest
Dec 2011 and July 2012 G2 Age appropriate 100% and 100% Observations completed 65% and 95% Scored Accurately 48% and 85%
Dec 2011 and July 2012 CDU Age Appropriate 100% and 100% Observation Completed 100% and 86% Scored Accurately 55% and 85%
Bad news One escalation not acted on appropriately It only takes one!!!
Good News Scoring has improved across the floor The visual look of the charts makes them easier to read Nurses empowered with information and the tools to escalate
Keep It Simple (KIS)