CRITICAL CARE OUTREACH TEAM AND THE DETERIORATING PATIENT

CRITICAL CARE OUTREACH TEAM AND THE DETERIORATING PATIENT

Outreach Objectives To avert or ensure more timely admission to DCCQ To ensure that patients discharged from Critical Care continue to progress To share Critical Care skills with ward multi disciplinary staff

Role of the Outreach Team Critical Care Nurses 24 hours a day 7 days week / 365 days year All Ward areas apart from Paediatric referrals / Obstetric emergencies Utilization of patients own team or Critical Care in an emergency PGDs Prompt response Bleep 1676 (07.00-20.30) or via Nerve Centre overnight (if not covered by H@N please continue to Bleep) Role: Assessment, First line treatment and plan, Referral to appropriate personnel, Reassessment, Support and education

ViEWS Part of patients observation chart Universal use throughout QAH Scoring system of pulse, respiratory rate, temperature, CNS and systolic blood pressure VIEWS with Neurological observations Increasing VIEWS a warning of patient deteriorating (especially if increasing from patient baseline) However BEWARE, patients may still be very sick but have low VIEWS score Same scoring for all O2 therapy, will allow a systolic of up to 220mmhg, same score for V,P,U and does not score urine output Consider Outreach for VIEWs 7 or above (or earlier if concerned)

ViEWS Escalation Policy ViEWS Minimum interval between observation sets Escalation Recorder s (e.g. nurse, HCA) action 0 1 6 or 12 hourly Nil 2 6 hourly Nil 3 5 4 hourly Inform nurse in charge of patient s care 6 4 hourly Registered nurse to inform doctor (FY2 or SHO) 7 8 1 hourly Registered nurse to inform doctor (FY2 or SHO) Consider use of continuous patient monitoring 9> 30 mins Registered nurse to inform doctor (SpR) Consider use of continuous patient monitoring Doctors action Doctor to see patient within 2 hours Doctor to see patient within 30 mins Dr to discuss patient with SpR +/ Outreach team Consider use of continuous patient monitoring Doctor to see patient within 15 minutes Dr to discuss patient with Consultant +/ Outreach Team or ICU Consider use of continuous patient monitoring

ViEWS EscalationTriggers Patients score is 7 or more Follow escalation guidelines Alert appropriate personnel RSVP approach when alerting team Observations should be timely and reactive to the patients condition

Outreach Referral Criteria Any patient causing concern to any member of the MDT team The deteriorating patient not responding to treatment As per ViEWS escalation policy As per Sepsis 6 protocol Tracheostomies Educational issues or advise Use of RSVP for referral to Outreach

RSVP

Deteriorating Patient: Assessment

Airway Is the airway patent? Can the patient talk? Partial or complete airway obstruction Position, Naso Pharyngeal or Guedal airway, Suction, Bag Valve Mask

Breathing Rate, pattern, depth, expansion Use of accessory muscles Colour, cyanosis Able to talk in full sentences Patient position Breath sounds O2 saturations Pain on deep breathing, coughing Chest drains Position, O2, ABG +/- Lactate, CXR (portable v department) and specific treatment, physio.

Circulation Pulse (rate, regular, irregular, volume) Blood pressure (manual /automatic) Capillary refill time, Skin turgor, mucus membranes, thirst, oedema Colour, cyanosis Temperature Urine output and Fluid balance Chest pain VTE Bloods Position, Venous access, Bloods, Haemorrhage control, Fluid resuscitation, Investigations eg ECG, ECHO and specific treatment

Disability A V P U (Alert, Voice, Pain, Unresponsive) Glasgow Coma Scale BM Position, Airway, Correction of BMs, specific treatment eg Naloxone, Correction of Sodium, Anti-convulsant Investigations: NB If for CT is the patient safe for transfer and consider escort?? Beware GCS of 8 or less

Exposure Pain Level Wessex scale, mild, moderate, severe Analgesia Nausea and vomiting Abdomen, Flatus, Bowel sounds Wounds (include IV sites) Stomas and drains, PiCC line Nutrition Drug therapy Skin / Pressure areas Analgesia, Anti-emetics, NG tubes, Replacement of losses, Nutrition, Review of all drugs, Source of infection

Ongoing Management and Communication Liaise with Critical Care and High Care areas Initiate discussions regarding ceiling of care and resuscitation Support and education on the wards as required Continued review and support

Sepsis 6 1. Does the patient have SIRs (Temp, HR, Resps, WBC) 2. Does the patient have history or signs of NEW infection If SIRS + Infection = SEPSIS 3. Commence Sepsis 6 : O2, Blood cultures, HB and Lactate, IV Antibiotics, Fluid therapy and urine output 4. Does the patient have any signs of acute organ dysfunction. Yes = SEVERE SEPSIS 5. If systolic BP less than 90mmhg (or Lactate remains above4) despite fluid resus = SEPTIC SHOCK. Requires DCCQ review.

Commence Sepsis 6 O2 give 15L via Non-Rebreath Mask to all acute deteriorating patients, then titrate to achieve normal saturations Fluids 250-500ml bolus rapidly and immediately reassess BP when completed IV anti-biotics within the first hour Bloods Hb and lactate (can be ABG) Blood cultures Urine output catheter and hourly in/output recorded

Reduce Consciousness Think: Blood Sugars : Follow Trust Hypoglycaemia protocol Opiate Toxicity : Naloxone for opiate toxicity Trust protocol available of pharmacy web page. An infusion of naloxone may need to be started. Remember codeine and tramadol are opiates

Continuing Education Outreach will come to the ward for specific teaching at the request of the Ward Sister or the Practice Educator Trust Tracheostomy Teaching via ESR ALERT training for qualified staff AWARE for HCSW BEACH for HCSW

QUESTIONS?

Summary Outreach 24/7, 365 days Bleep 1676 07.00-20.30, via Nerve Center overnight Escalate deteriorating patients Think Sepsis Use RSVP when refering

What is the Outreach Bleep? 1. 1767 2. 1676 3. 1868 2.1676

What are the Sepsis 6? 1. IV fluids, Oxygen, Urine output, Check Hb, IV antibiotics, Lactate 2. Oxygen, Lactate, Blood Cultures, IV Fluids, IV antibiotics, A Cup of Tea 3. IV antibiotics, Oxygen, IV fluids, Hb and Lactate, Blood Cultures, Urine output 3. IV antibiotics, Oxygen, IV fluids, Hb and Lactate, Blood Cultures, Urine output

What volume of IV fluid bolus could be given? 250 500 750 2. 500 250 or less may be given in patients with heart failure.

What is the Escalation Trigger score for referral to Outreach 1. 7 or above 2. 6 or above 3. 5 or above 1. 7 or above. Also any patient causing you concern

What is RSVP? 1. Reason, Signs, Vitals, Plan 2. Reason, Story, Vitals, Plan 3. Rate, Story, Voice, Plan 2. Reason, Story, Vitals, Plan