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Document Details Title Clinical Observations and recognition of the Deteriorating Patient Policy- including NEWS 2, PEWS, SBAR and Sepsis recognition Trust Ref No 2119 - 74419 Local Ref (optional) Main points the document covers This protocol sets out standards for recording and scoring and responding to clinical observations for all patients Who is the document aimed at? All Clinical staff Owner Emily Peer, Associate Medical Director Approval process Who has been consulted in the development of this policy? NEWS2 and Sepsis Steering Group, Resuscitation Group and clinical leads Approved by (Committee/Director) Clinical Policy Group Approval Date 14/0 3 /20 22 Initial Equality Impact Screening Yes Full Equality Impact Assessment
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Lead Director Clair Hobbs, Director of Nursing & Allied Health Professionals Category Clinical Sub Category Review date 14/0 3 /202 5 Distribution Who the policy will be distributed to All SCHT Clinical Staff Method DATIX, Heads of Department Meetings, Team Meetings Keywords Clinical Observations, Physiological Observations, National Early Warning Score, NEWS, NEWS2, Sepsis, Deteriorating Patient, PEWS, Paediatric Early Warning Scores, SBAR, Situation, Background, Assessment, Recommendation, communication tool, assessment tool Document Links Required by CQC No Other No Amendments History No Date Amendment 1 V1 2011 New Policy 2 V2 02/03/2016 Review and change of author and director 3 V3 14/02/2019 Extensive review and updating to NEWS 2 and incorporating PEWS and Sepsis recognition and screening with widening of scope to all services 4 Sep2021 Updated with RCUK 2021 guidance, trust confusion assessment tool, and local PEWS tools 5 V4 March 2 Review, updated consultation., PEWS tools updated and minor amendments
CONTENTS
6.0 Assessing the adult patient with significant deterioration and Sepsis
- 1.0 Introduction Page
- 2.0 Purpose Page
- 3.0 Duties Page
- 4.0 Glossary Page
- 5.0 Measurement of clinical observations and NEWS2 Page
- 7.0 Paediatric Early Warning Scores Page
- 8.0 SBAR Tool: Situation, Background, Assessment, Recommendation Page
- 9.0 Dissemination and Implementation Page
- 10.0 Monitoring Compliance Page
- 11.0 Consultation Page
- 12.0 References Page
- 13.0 Associated Documents Page
- 14.0 Appendix- Prison flowchart Page
The following clinical tools have been chosen for use in our trust:
- NEWS2 – National Early Warning Score- NHS England and NHS Improvement approved tool as the recommended early warning scoring in adults
- PEWS- Paediatric Early Warning Score- locally agreed paediatric early warning scores (in the absence of nationally agreed scores) to ensure safe and consistent assessment of unwell children living in Shropshire
- Sepsis Trust Screening Tools- NHS Improvement approved tools for screening deteriorating patients in different settings for possible sepsis
- SBAR- Situation, Background, Assessment, Recommendation- can be used effectively to escalate a clinical problem that requires immediate attention in conjunction with the Early Warning Score 2.0 Purpose The purpose of this policy is to ensure a standardised Trust wide approach to:
- the recording of clinical observations and
- the actions which should be triggered in the case of abnormality and
- using agreed tools to recognise a deteriorating patient and
- manage deteriorating patients appropriately in community healthcare settings and
- using agreed tools to detect possible sepsis and
- using agreed tools for the effective sharing of clinical information 3.0 Duties 3.1 The Chief Executive The Chief Executive Officer has overall responsible for maintaining staff and patient safety and is responsible for the governance and patient safety programmes within the organisation. 3.2 Directors Directors of Services are responsible for ensuring the safe and effective delivery of services they manage; this includes securing and directing resources to support the implementation of this policy. They are also responsible for ensuring a process is in place to effectively manage patient safety and that the organisation is compliant with the Care Quality Commission (CQC). 3.3 Ward Managers/ Team Leaders Ward Managers/ Team Leaders will ensure that all staff carry out patient observations using the EWS and SBAR tools, and that adequate staff training is undertaken within their area including annual mandatory resuscitation training. 3.4 Staff All staff members must ensure that they understand the relevant EWS and SBAR and the implications of their use and are up to date with their mandatory resuscitation training.
4.0 Glossary Acronym Term / Definition ACVPU Alert, Confusion, Pain, Verbal, Unresponsive CAM tool Confusion Assessment Method Tool (CH055) ECG Electro cardiogram EWS Early Warning Score- includes NEWS 2 and PEWS GCS Glasgow Coma Score GLUC Glucose IV Intra-venous SCHT Shropshire Community Health Trust NEWS/ NEWS2 National Early Warning Score NICE National Institute for Clinical Excellence NPSA National Patient Safety Agency RCP Royal College of Physicians SP0² Oxygen Saturation WBC White Blood Count PEWS Paediatric Early Warning Score SBAR Situation, Background, Assessment, Recommendation MDT Multi-Disciplinary Team Sepsis Sepsis is characterised by a life-threatening organ dysfunction due to a dysregulated host response to infection. Septic shock Septic shock is a subset of sepsis where particularly profound circulatory, cellular and metabolic abnormalities substantially increase mortality Uncomplicated Infection Viral and bacterial infections where there is no evidence of organ dysfunction or tissue hypo-perfusion that accompanies sepsis or septic shock
in-patient areas. All in-patients should have their weight recorded on initial assessment. All in-patients should have their clinical observations recorded at least every 12 hours (Routine Monitoring). If an observation is unrecordable or undetectable this must be escalated to senior clinical staff to assess the patient. An unrecordable observation should always be given a score of 3, unless assessed otherwise by senior clinical staff. In non-inpatient settings clinical observations will be recorded at initial assessment to establish a baseline and again at any further contact where the patients clinical condition is of concern or if they are at risk of deterioration. Deviation from Routine Monitoring For all patients within in-patient areas clinical observations should be recorded at least every 12 hours and any alteration from this requires a senior clinical staff or MDT decision and the rationale must be detailed in the clinical notes by a senior clinician. Until such time as this has taken place observations must continue 12 hourly. Exclusion from Routine Monitoring For patients who have been commenced on an ‘End of Life’ care plan and/ or are subject to a DNACPR order it may not be appropriate to continue routine clinical observations where deterioration will not result in active treatment. However it is important to understand that some palliative treatments will still require some vital signs to be monitored and recorded. In these circumstances a documented note detailing what parameters should be monitored to facilitate safe treatment and the range of acceptable results is required along with any escalation actions required if results are outside of these ranges. Patient consent Informed verbal consent should always be obtained from the patient to undertake observations. In circumstances where observations are indicated and patient refuses consent it is important to give a clear explanation of the need to perform observations and to explore the reason for refusal, and document in the clinical record and inform senior clinical staff. If there are concerns about the risks and implications of not undertaking observations for a patient that may lack capacity then Mental Capacity must be formally assessed where there is any doubt. 5.1 Adults: NEWS Scoring Clinical Observations 5.1.2 Respiratory rate An elevated respiration rate is a powerful sign of acute illness and distress in all patients. The respiration rate may be elevated as a consequence of generalised pain and distress, sepsis remote from the lungs, central nervous system (CNS) disturbance and metabolic disturbances such as metabolic acidosis. A reduced respiration rate is an important indicator of CNS depression and narcosis. Respiratory rate should be recorded for 60 seconds to account for variations in respiratory rate and pattern. A respiratory rate of <9 or >20 is significant and will generate an alert, this will be form part of the aggregated score and trigger a clinical response. Depth, symmetry and pattern of respiration should also be note and recorded if abnormal together with any associate sounds e.g. wheeze, cough and should form part of any assessment.
5.1.3 Oxygen saturation (SpO2) Oxygen saturation is a powerful tool for the integrated assessment of pulmonary and cardiac function. Oxygen saturation and any supplemental oxygen and delivery device should be recorded. For most patients a target oxygen saturation should be 94% or above on air and recorded on the SpO2 Scale 1. Oxygen is a drug and for all but emergency life saving administration requires a written prescription and rationale for use recorded in the patient record. A saturation ≤ 91%, with or without supplemental oxygen needs to be reviewed urgently. If used the device, flow rate, cylinder or wall outlet should all be checked to ensure optimum oxygenation. The SpO2 Scale 2 should be used for patients with confirmed hypercapnic respiratory failure (usually patients with moderate or severe chronic obstructive pulmonary disease, severe chest wall or spinal disease, neuromuscular disease or severe obesity) with the NEW score adjusted to reflect the lower recommended oxygen saturation range (88–92%). This should be a confirmed diagnosis- such as documentation on the patients Summary Care Record, or GP summary, or Acute Trust Discharge letter, or the admitting doctors medical assessment. Oxygen saturations may be affected by many variables:
- Hypoperfusion conditions eg anaemia, atrial fibrillation or hypothermia, carbon monoxide exposure, oedema, jaundice and vasoconstriction
- Nail Varnish and artificial nails
- Bright or fluorescent room lighting
- Poorly positioned probe
- Movement e.g. shivers, rigors 5.1.4 Blood Pressure Blood Pressure (BP) is routinely measure using electronic devices, however if the pulse is irregular or the BP very low (<80mmHg) the accuracy of electronic BP measuring devices may not be accurate and manual recording of blood pressure must be undertaken. The Systolic BP only is scored on the NEWS2 chart. Diastolic blood pressure does not form part of the scoring system for acute-illness severity because it does not add value in this context however it should be routinely recorded. Hypotension may indicate circulatory compromise due to sepsis or volume depletion, cardiac failure or cardiac rhythm disturbance, CNS depression, hypoadrenalism and/or the effect of blood pressure-lowering medications. It is important to note that some people have a naturally low systolic blood pressure (<100 mmHg) and this might be suspected if the patient is well and all other physiological parameters are normal, or confirmed by reference to previous records of blood pressure. 5.1.5 Pulse Rate The measurement of heart rate is an important indicator of a patient’s clinical condition. Tachycardia (high heart rate) may be indicative of circulatory compromise due to sepsis or volume depletion, cardiac failure or arrythmia, pyrexia, metabolic disturbance, drug intoxication or pain and general distress. Bradycardia (low heart rate) may be normal with physical conditioning or as a consequence of medication, eg with beta blockers, or it may also be an important indicator of hypothermia, CNS depression, hypothyroidism or heart block.
5.2 Calculation of the Adult National Early Warning Score - NEWS 5.2.1 RECORD: Each of the six physiological NEWS parameters are allocated a score according to the magnitude of disturbance to each parameter and are recorded on the NEWS2 chart (or Electronic Patient Record when available). Example NEWS2 Chart : clinical documentation for use is available on SharePoint 5.2.2 SCORE: The individual parameter scores should then be added up, along with a score of 2 for use of supplemental oxygen, to derive the aggregate NEW score for the patient. Example NEWS2 Scoring system: clinical documentation for use is available on SharePoint
5.2.3 ASSESS:
Assess whether the score needs any response: There are four trigger levels for a clinical alert requiring clinician assessment based on the NEWS:
- LOW score: an aggregate NEW score of 1– 4
- A single RED score: an extreme variation in an individual physiological parameter (a score of 3 in any one parameter, which is colour-coded RED on the NEWS chart)
- MEDIUM score: an aggregate NEW score of 5 or 6. A NEW score of 5 or more is a key threshold and is indicative of potential serious acute clinical deterioration and the need for an urgent clinical response
- HIGH score: an aggregate NEW score of 7 or more Example NEWS2 Thresholds and Triggers : clinical documentation for use is available on SharePoint 5.2.4 RESPONSE These triggers should determine the urgency of the clinical response and the clinical competency of the responder, bearing in mind that physiological abnormalities due to long term conditions should be considered at admission.
- A LOW score (NEW score 1–4) should prompt assessment by a competent registered clinician who should decide if a change to frequency of clinical monitoring or an escalation of clinical care is required.
- A MEDIUM score (i.e. NEW score of 5–6 or a RED score) should prompt an urgent (within 1 hour) review by a clinician skilled with competencies in the assessment of acute illness which will be either the Senior Clinician with appropriate skills, GP responsible for the ward, Urgent Care Doctor, Nurse Practitioner or Specialist Paramedic Practitioner with relevant experience, who should consider whether escalation of care to an acute hospital is required. To ensure clinical cover 24/7, this role will be undertaken by an Out of Hours doctor, nurse or emergency care practitioner
- A HIGH score (NEW score of 7 or more) should prompt emergency assessment (immediate) and/ or usually transfer of the patient to an acute care setting. An urgent transfer (999) will be arranged by the senior clinician within the clinical area (where appropriate) using their clinical judgement and this should not be delayed to await a more senior assessment.
5.3.2 Supplemental Oxygen Remember for oxygen therapy the prescription should be to achieve a specified minimum SpO2 rather than the concentration or flow of gas. The method of delivery, device and flow rate therefore need to be recorded within the patients clinical record and the resulting SpO reading obtained marked on the NEWS chart. 5.3.3 Pain Pain is not recorded as part of NEWS however, pain and/or its cause will usually, but not always, generate physiological disturbances that will be captured by the scoring system. Pain should always be assessed, responded to and recorded. 5.3.4 Urine Output In the majority of patients urine output does not need to be routinely measured, but should be considered in the following instances:
- Patients with other abnormal signs such as high fever.
- Patients with other abnormal fluid losses such as vomiting, drains, stomas or diarrhoea.
- Patients with primary urological or renal problems Monitoring urine output will be necessary for some patients as dictated by their clinical condition. Urine output is generally assessed over a two hour period. The optimum urine output is 1ml / kg / hr. In a 70kg adult this is equal to 70 mls/hr. The minimum desired urine output is 0.5mls / kg / hr, which is equal to 35 mls/hr. 5.3.5 Fluid Balance Charts The balance of fluids within the body is vitally important, many conditions and situations impact the bodies ability to manage fluids and in such circumstances measurement of input and output may be required. (NICE CG17410) When a fluid balance chart is in use all measures of both input and output fluid quantities and times should be recorded.
- All patients receiving IV or SC fluid require a fluid chart
- All patients required to be “nil by mouth” for any period exceeding four hours require a fluid chart Daily and cumulative balances should be entered onto the fluid chart. Insensible losses are not normally recorded, but should be considered and accounted for in patients with fluid balance problems. Normal insensible loss is approximately 1L in 24 hours but can greatly increase when a patient has a high temperatures or rapid respiratory rate. 5.3.6 Head Injury In patient falls where a head injury cannot be excluded e.g. un-witnessed falls, the patient should be considered at risk of deterioration and observed closely until clinically significant head injury has been excluded. (See also Prevention and Management of Falls Policy).
6.0 Assessing the adult patient with significant deterioration Vital signs and the NEWs score will give an indication of the patients’ condition. If the patient is deteriorating, a more comprehensive assessment is warranted to fully understand any life threatening presentations. The ABCDE model of assessment is recommended as it gives a rapid, initial assessment of the patients’ condition. Concern about a patient’s clinical condition should always override the NEWS if the attending healthcare professional considers it necessary to escalate care. Sepsis should be considered in any patient with a known infection, signs or symptoms of infection, or in patients at high risk of infection, and a NEW score of 5 or more – ‘think sepsis’. Patients with suspected infection and a NEW score of 5 or more require urgent assessment and intervention by a clinical team competent in the management of sepsis and urgent transfer to hospital or transfer to a higher-dependency clinical area within hospitals for ongoing clinical care. 6.1 Suspect Sepsis In deterioration of all patients with known or suspected infection full assessments MUST be undertaken with the view to EXCLUDE THE POSSIBILITY of sepsis.
- In a patient with a confirmed or suspected infection, or at risk of infection, a NEW score of 5 or more should raise the suspicion of sepsis and prompt an urgent clinical response by a clinical team competent in the management of sepsis.
- Sepsis screening using the Sepsis Trust tools should be performed.
- Even where no current signs or symptoms are presently evident clear advice should be given regarding any signs of deterioration. This ‘safety netting’ process should be fully recorded detailing the information given to the patient if deterioration occurs or concern increases. BE SUSPICIOUS, a significant number of patients with early stages of sepsis may ‘look well’, not all will show ‘classic sepsis’ symptoms and can present with high or low temperatures. 6. 2 Assessment of Sepsis Current Sepsis Trust Community screening tools for adults and children can be accessed online at the Sepsis Trust website. They are active PDF tools used to assess deteriorating patients for their risk of acute sepsis. Once completed they can be printed off and uploaded to the patients clinical record: https://sepsistrust.org/professional-resources/clinical/
- Transfer should be by ‘blue light’ ambulance, with a Paramedic crew if immediately available.
- The call should include direct reference to the acuity of the condition, using the term ‘ Red Flag Sepsis’.
- Where possible, a telephone referral to the receiving Emergency Department should be made, using the term ‘ Red Flag Sepsis’. Elements of treatment within The Sepsis Six may usefully be undertaken whilst transfer is awaited in a number of SCHT locations. There is strong evidence that expedient delivery of ‘basic’ aspects of care limits the maximum acuity of intervention required - early resuscitation can prevent the requirement for invasive monitoring and vasoactive support later in hospital. Within SCHT the range of treatments possible may be severely restricted by the scope of practice within differing services. 6.4 Immediate treatment for RED FLAG SEPSIS:The Sepsis Six The key immediate interventions that increase survival from sepsis are described in a bundle termed the Sepsis Six. This bundle has been shown to be associated with significant mortality reductions when applied within the first hour. The first 4 interventions may be practicable in the community setting and should be considered in our services where it does not delay transfer to an acute settling. The Sepsis Six
- Administer oxygen to maintain saturations >94%
- Take blood cultures and consider infective source
- Administer intravenous antibiotics
- Consider intravenous fluid resuscitation
- Check serial lactates
- Commence hourly urine output measurement Oxygen Patients with sepsis are exempt from British Thoracic Society guidelines for the administration of oxygen to acutely ill adults, the pathophysiology of sepsis is such that organs become critically hypoxic. Hypoxia will kill before hypercapnia. Oxygen should be given to maintain target saturations of 94% or higher. Where patients are known to have moderate to severe pulmonary disease (and where available), the recommend that oxygen be administered remains, but to maintain a lower target oxygen saturations, above 88%. Oxygen will not cause sudden apnoea in such patients. It must be remembered that to titrate oxygen delivery to maintain a specified saturation is provision of oxygen therapy that requires a prescription. High flow continuous oxygen delivery via non-rebreathing mask for the express purpose of life saving does not require prescription. Antimicrobials If transfer times to hospital are routinely in excess of one hour consideration of whether it is appropriate and feasible to administer intravenous (or intramuscular) antimicrobials needs to take place.. It should not delay transfer to an acute settling. A delay of one hour in administering antimicrobials in septic shock is associated with an increase in mortality rates of 8 6 %. Some community facilities may have available the local formulary recommended antimicrobial agents for community-acquired pneumonia, urinary tract infection, skin and soft
tissue infection and intra-abdominal infection which together account for 90% of cases of sepsis. Blood Cultures If clinicians elect to administer antimicrobials, the feasibility of sampling blood for culture should considered where staff have been appropriately trained and have access to appropriate equipment. It should not delay transfer to an acute settling. While modern blood culture media are able to bind antimicrobials and thus increase the capture rate of organisms after antibiotic administration, this is not fully effective and capture rates remain higher if cultures are sampled first. Intravenous Fluids Bolus administration of IV Sodium Chloride (Normal Saline) can be administered to counter hypotension and should considered where staff have been appropriately trained and have access to appropriate equipment. Iv fluids require suitable venous access and it is recognised this may be difficult to achieve in patients with hypotension. It should not delay transfer to an acute settling. 6.5 Management of AMBER FLAG SEPSIS The presence of Amber Flag Sepsis criterion in the absence of Red Flags indicate the patient has sepsis, this may not have yet progressed to cause serious organ dysfunction but careful consideration of the potential need for acute hospital assessment is needed. Treatment is still indicated for the sepsis, clinicians need to consider the appropriateness of the patient location together with the range of treatment options and skillsets of the staff available. Patients with as yet ‘minor’ sepsis can deteriorate rapidly. Uncomplicated sepsis, where the patient does not have the suspected organ dysfunction or tissue hypo-perfusion that accompanies severe sepsis or septic shock may be safely managed without acute hospital admission. However it is often difficult to determine patients that can be safely treated in the community and in circumstances where there is doubt transfer to an acute hospital is recommended. Additional ‘higher risk’ condition factors, patients who live alone with poor access to communication and transport difficulties all need to be taken into account. Where clinical assessment is unable to identify a suspected source of infection, acute hospital assessment must also be very carefully considered and the rationale for decision making explained within the patient record. For those in whom community-based care is deemed safe and appropriate, consideration should be given to providing a scheduled review appointment/visit, clear records should be made of the decision, rationale and the safety netting provided. If transfer to acute hospital is considered necessary the call to the Ambulance Service should include direct reference to the acuity of the condition, using the terms ‘Amber Flag Sepsis’. A brief, clear handover should accompany the patient to include observations, any relevant medical history and antibiotic history including allergies. Where possible, a telephone referral to the receiving Emergency Department should be made, using the terms ‘Amber Flag Sepsis’ or ‘sepsis’ and SBAR communication method. The presence of any risk factors and the rationale for the clinical decision to refer for hospital assessment should be discussed.
assess deteriorating patients for their risk of acute sepsis. Once completed they can be printed off and uploaded to the patients clinical record: https://sepsistrust.org/professional-resources/clinical-tools/ Example General Practice Paediatric <5yr Sepsis assessment tool: Parents or carers of children at risk of sepsis can be helped to recognise the signs and symptoms using information leaflets produced by the Sepsis trust: a detailed advice leaflet here, and a brief reminder card here.
8. 0 Communication: SBAR Tool (Situation, Background, Assessment, Recommendation) Structured handover systems such as SBAR show significant improvements both in the level of information transferred and the ability of clinicians to make appropriate treatment decisions in a timely manner and is the SCHT system of choice. The system offers a sensible effective, timely communications tool that improves information transfer between individuals from differing clinical backgrounds and hierarchies. SBAR is easy to remember and is used to ensure that communication is carried out in a structured way and that clinical problems that require immediate attention are escalated effectively.
