Trigger Response Team Operational Policy (Adults) Type: Policy Register No: 12042 Status: Public Developed in response to: Patient Safety Contributes to CQC Outcome number: 9,12 Consulted With Post/Committee/Group Date Trigger and Response June 2016 team Cathy Geddes Chief Nurse June 2016 Professionally Approved By Dr Ronan Fenton Chief Medical Officer June 2016 Version Number 3.0 Issuing Directorate Emergency & Critical Care Ratified by: DRAG Chairmans Action Ratified on: 1 st August 2016 Executive Management Board Sign Off Date August 2016 Implementation Date 2 nd August 2016 Next Review Date May 2019 Author/Contact for Information Dr Katherine Rowe/Shevaun Mullender Policy to be followed by (target staff) All staff Distribution Method Intranet & Website Related Trust Policies (to be read in Incident Policy conjunction with) Serious Incidents Requiring Investigation Policy (SIRI) Risk Management Strategy & Policy Learning from Experience Training Needs Analysis Policy Document Review History Version No Authored/Reviewed by Active Date 0.2 Chairmans action to issue as WD Lea Seager 21.11.12 1.0 Primary version Lee Seager 24.01.13 1.1 To record change from PAR to NEWS Lee Seager 17.02.14 1.2 Scope of Practise added Katherine Rowe 25.2.15 2.0 Lee Seager 7 June 2016 3.0 Katherine Rowe/Shevaun Mullender 2 August 2016 1
INDEX 1. Purpose 2. Scope 3. Responsibilities 4. Arterial blood gas sampling 5. X-ray requesting 6. Blood cultures 7. Acute kidney injury follow up 8. Staffing and training 9. Breach reporting 10. Audit and monitoring 11. Implementation 12. References 2
1.0 Purpose 1.1 The Trust will provide an effective Trigger Response Team to enhance the care of acutely ill patients in hospital by supporting appropriate and prompt management of patients at risk of deterioration, thereby reducing clinical risk and enhancing patients care. 1.2 The purpose of this document is to ensure that the National Early Warning Score (NEWS) system alerts staff to recognise acutely/critically ill patients early and enable them to initiate prompt and appropriate action to manage these patients. 1.3 It will ensure that the Trigger Response Team (TRT) is utilised appropriately for acutely unwell patients supporting clinical assistance in order to manage the patients appropriately, this may include facilitating their transfer to higher levels of care (ICU/HDU). 1.4 This policy outlines the operational arrangements for the TRT. It includes the NEWS tool which has been developed and implemented as a result of research which indicates that NEWS: Helps reduce the risk to patients by early intervention. Assists staff to identify signs of deterioration. Is a useful tool in initiating appropriate responses and management of patients. Includes standards for the recording of nursing observations. 1.5 To promote the NEWS treatment and escalation policy with all members of the multidisciplinary team to enable them to recognise and effectively treat patients at risk of deterioration within wards areas. 1.6 To identify educational and training needs and ensure that these are put into place. 1.7 All care provided by the TRT will be delivered in accordance with the Scope of Professional Practice, Patient Group Directions, trust policies and guidelines. 2.0 Scope 2.1 The service will run from 08:00-23:00 seven days a week, with the bleep covered overnight by the Clinical Operations Mangers (COMS) team 2.2 The TRT will respond and review all adult and child patients on wards within MEHT as well as in the emergency department either on request by nursing and medical staff or following a high NEW score as recognised by Vital Pacs. 2.3 The TRT will respond to all cardiac/paediatric/trauma arrest calls within MEHT. 3.0 Responsibilities 3.1 Chief Executive is responsible for ensuring that the policy is in place. 3.2 Chief Nurse is co-responsible for the development of the policy and its 3
effectiveness 3.3 Chief Medical Officer is co-responsible for the development of the policy and its effectiveness 3.4 The Head of Nursing and Clinical Lead Consultants are responsible for ensuring that the policy is implemented and monitored. 3.5 Clinical Lead Consultant for the TRT will have overall responsibility for the team and for updating the operational policy. 3.6 Matron for Critical Care 3.6.1 The TRT will be line managed by the matron for Critical Care 3.6.2 The matron for Critical Care is responsible for ensuring that all staff are aware of the policy and any revisions or new developments. 3.6.3 The matron for Critical Care is responsible for ensuring the effectiveness of the policy is monitored by audit and dissemination of those findings to senior and local operational management as appropriate. 3.6.4 The matron is responsible for the yearly appraisal of the members of the trigger response team. 3.7 The TRT Team 3.7.1 The TRT will be contacted by a designated bleep number (#6555 2043) and will respond to any adult or child who is an inpatient within MEHT or who is within the emergency department who triggers on the early warning score (or equivalent) or that is giving cause for concern to nursing or medical staff. 3.7.2 The TRT will always, except in extreme emergencies, liaise in the first instance with the nursing staff and medical or surgical team who has overall responsibility for the care of the patient. 3.7.3 The TRT will provide cover to facilitate the early identification of patients at risk of deterioration through the implementation and support of NEWS. 3.7.4 The TRT core responsibilities are to: Do regular ward rounds to offer assistance to any area that feels that they have a patient who has triggered or that the staff are concerned about. Review patients with high NEW scores throughout MEHT identified in real time by Vital Pacs and ensure that these patients have a treatment escalation plan in place which has been made by a senior clinician and is documented in the medical notes. Work in tandem with the nursing and medical team in charge of the patient. Provide advice, clinical support, education and training where required for those patients identified by an increasing NEWS in the ward areas. 4
Contribute to the decision making process in patients who have triggered with regard to appropriate management. Undertake/request appropriate investigations e.g. ECG, bloods etc. Where appropriate, support the admission process to the critical care areas. Share critical care skills through education and training programmes for all members of the multidisciplinary team. Ensure that their competencies remain up to date and are able to practise all procedures/tasks 4.0-7.0 within this policy. 3.7.5 All patients referred to the trigger and response team will be reviewed and an appropriate management plan will be put in place working with the ward medical and nursing staff. 3.7.6 Each member of the trigger response team is responsible for ensuring that their mandatory training policy and competencies are up to date 3.7.7 The TRT will cover the hours 08:00-23:00 seven days a week and hand over to the MEHT COMS team. 4.0 Arterial Blood Gas sampling 4.1 The TRT team once completed their arterial blood gas competency will be able to sample arterial blood gases in accordance with this policy in: A patient who scores an amber or red (on the NEWS observations) on either saturations (below <92%) or respiratory rate (>21) If the patient is able to consent to the procedure and perform a satisfactory Allens test. There are no contra-indications to the procedure Maximum of two attempts The radial artery preferably in the non-dominant hand will be punctured only 4.2 The following are contra-indications to the procedure A patient with chronic renal failure or creatinine >150 An AV fistula in either arm The inability to landmark An indeterminate Allens test An INR >1.4 or Platelet count <100 Inability to access recent blood results (last 48hrs) A patient with diabetic ketoacidosis or hyperosmolar hyperglycaemic state Any issue not mentioned above where a member of the Trigger Response Team feels that it would not be appropriate 5.0 X-ray requesting 5.1 The TRT team once completed their IRMER competencies will be able to request chest x-rays in accordance with this policy in: A patient who scores an amber or red (on the NEWS observations) on either saturations (below <92%) or respiratory rate (>21) 5
In patients only where requested by the on call doctor who understands fully that the x-ray is to be reviewed by a clinician and that the TRT is not responsible for its review The TRT member must document fully which clinician has requested that a chest x-ray be ordered and whom will be responsible for its review and further management 6.0 Blood cultures 6.1 The TRT team once completed their blood culture competencies will be able to take blood cultures in accordance with trust protocol for those patients with severe sepsis or septic shock. 7.0 Acute Kidney injury follow up 7.1 The TRT team once completed their Acute Kidney Injury training will follow up all patients in ward based areas (except for ICU/HDU) who have been identified as suffering from AKI 2/3 and follow the AKI TRT algorithm. 8.0 Staffing & Training 8.1 The TRT practitioners consists of 8 resuscitation officers. 8.2 The individual training and development needs of the TRT practitioner will be identified and reviewed appropriately. This will be undertaken with their line manager annually using the appraisal process. 8.3 The TRT practitioners will undertake mandatory training in accordance with Trust policy. 8.4 The TRT practitioners will function as resuscitation officers and have developed their role in accordance with professional standards and guidelines. 8.5 The TRT practitioner will provide ward based education and training in critical care skills for all members of the multidisciplinary team caring for acutely unwell patients. 8.6 The introduction of the TRT will be included in all trust induction information for both permanent and temporary staff 9.0 Breach Reporting 9.1 All clinical incidents and breaches of this policy will be reported via a trust risk event form and investigated in accordance with Trust policy. 10.0 Audit & Monitoring 10.1 Audit of NEWS will take place on a monthly basis and the results communicated through the DPG. The TRT team will provide action plans and they will be monitored by the DPG Group. 10.2 The DPG discusses issues surrounding NEWS and the TRT. It reviews audits and compliance to the policy 6
10.3 Any incidents or concerns are reported to the DPG meeting held monthly. Issues from the meeting are then reported at the Patient Safety Group (PSG) 11.0 Implementation 11.1 This policy will be published on the Intranet and website 11.2 It is the responsibility of the author to ensure that all clinical staff are made aware of the policy either by email or at directorate meetings. 12.0 References Comprehensive Critical Care: a review of adult critical care services. DOH 2000. http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguida nce/dh_4006585 Critical to success. The Audit commission 1999. http://www.auditcommission.gov.uk/reports/nationalreport.asp?categoryid=&prodid =40B50F26-ED9F-4317-A056-042B31AEA454 Evita MA, Bellomo R, Hillman K et al. Findings of the First Consensus Conference on Medical Emergency Teams. Critical care medicine 2006; 34: 2463-2478 Goldhill DR, Worthington L, Mulachy A et al. The patient-at-risk team: identifying and managing seriously ill ward patients. Anesthesia 1999: 54; 853-60.;Gao H, McDonnell, Harrison DA et al. Systematic review and evaluation of physiological track and trigger warning systems for identifying at risk patients on the ward. Intensive care medicine 2007; 33: 667-679.ICS Guidelines for the introduction of outreach services 2002. Accessed via www.ics.ac.uk McDonnell, L. Esmonde, R. Morgan, R. et al. The provision of critical care outreach services in England: findings from a national Survey Journal of Critical Care; 22: 212-218. An acute problem? NCEPOD 2005. Accessed as http://www.ncepod.org.uk/2005aap.htm Acutely unwell patients in hospital. NICE CG50. http://www.nice.org.uk/guidance/cg50 The 2004 working party from the Royal College of Physicians Acute medicine, making it work for patients http://www.rcplondon.ac.uk/pubs/contents/e4d48ecd-4baf-4b54-8176- 50ae0b2f2768.pdf Acute medical care: the right person in the right setting first time. 2007 RCP working party. http://www.rcplondon.ac.uk/pubs/contents/2a8ed5fa-64af-4b2caf03-85e90b7a6d20.pdf NPSA report: Recognizing and responding appropriately to early signs of deterioration in hospitalized patients. NPSA 2007. Accessed as http://www.npsa.nhs.uk/nrls/alerts-and-directives/directives-guidance/acutelyillpatient/deterioration-in-hospitalised-patients/ NPSA. Safer care for the acutely ill patient: learning from patient safety incidents. Report from Patient Safety Observatory 2007. http://www.npsa.nhs.uk/nrls/alertsanddirectives/directives-guidance/acutely-ill-patient/ 7
http://www.ihi.org/ihi/topics/criticalcare/intensivecare/improvementstories/fsearlywarni ngsystemsscorecardsthatsavelives 8