observations and the deteriorating patient for registered nurses

Observations and the Deteriorating Observations and the Deteriorating PatientPatient

for Registered Nursesfor Registered Nurses

Shane Moody, Lead Nurse & Vikki Crickmore, Sister. Critical Care Outreach Service

September 2013

Competency framework

ObjectivesObjectives• Gain awareness of the national approach and Gain awareness of the national approach and

MEWS.MEWS.• Discuss observations in detail and physiological Discuss observations in detail and physiological

relevance.relevance.• Consider appropriate escalation response to Consider appropriate escalation response to

deterioration and barriers to this.deterioration and barriers to this.• Examine useful communication tools. Examine useful communication tools. • Consider additional elements relevant to patient Consider additional elements relevant to patient

care when considering deterioration. care when considering deterioration. • Carry out a practical assessment of taking Carry out a practical assessment of taking

observations and management of case studies.observations and management of case studies.

AssessmentsCCOS to assess Band 7’s

↓CCOS to do Train the Trainer sessions for senior

nurses

↓ Band 7’ and senior nurses to assess own staff


AssessmentsAssessmentsPresentation

↓Questions

↓

Station 1 ← → Station 2

Practical taking obs Case studies & and documenting completing

competencyin pairs document

Conclude and finish


IntroductionIntroduction2005 – NCEPOD: An Acute problem2005 – NCEPOD: An Acute problem2007 – NPSA: Safer care for the acutely ill patent 2007 – NPSA: Safer care for the acutely ill patent 2007 – NPSA: Recognising & responding appropriately to 2007 – NPSA: Recognising & responding appropriately to

early signs of deterioration early signs of deterioration

Consistent themes are obvious throughout these documents:Consistent themes are obvious throughout these documents:

• Failure to measure basic observations.Failure to measure basic observations.

• Lack of recognition of the importance of worsening vital signsLack of recognition of the importance of worsening vital signs

• Delay in response to deteriorating vital signs.Delay in response to deteriorating vital signs.


2007 – NICE published - 2007 – NICE published - Acutely Ill patients in hospital – Acutely Ill patients in hospital – recognition of and response to acute illness in adults recognition of and response to acute illness in adults

in hospital.in hospital.

The key priorities of this document are:The key priorities of this document are:

• Physiological observations at the time of their admissionPhysiological observations at the time of their admission • A written monitoring plan (diagnosis, co-morbidities and plan)A written monitoring plan (diagnosis, co-morbidities and plan)

• Observations taken by staff that have been trained and Observations taken by staff that have been trained and understand clinical relevance. understand clinical relevance.

• A Track and Trigger system and observations recorded 12 A Track and Trigger system and observations recorded 12 hourly as a minimum – increased if signs of deterioration. hourly as a minimum – increased if signs of deterioration.


Used to aid recognition of deteriorating patients, Used to aid recognition of deteriorating patients, and are based on physiological parameters. and are based on physiological parameters.

An aggregated score calculated. Escalation An aggregated score calculated. Escalation pathway activated if specific scores. Track and pathway activated if specific scores. Track and Trigger approach.Trigger approach.

The escalation pathway outlines actions required The escalation pathway outlines actions required for timely review ensuring appropriate for timely review ensuring appropriate interventions.interventions.


Modified Early WarningModified Early Warning

• Limitations to MEWS and professional judgment Limitations to MEWS and professional judgment should be usedshould be used

• Taking observations is not just generating Taking observations is not just generating numbers – need to understand clinical relevancenumbers – need to understand clinical relevance

• Delegating needs to be appropriateDelegating needs to be appropriate• Failure to act has significant consequences – Failure to act has significant consequences –

effects on patient, ↑ cardiac arrest, effects on patient, ↑ cardiac arrest, ↑ length of ↑ length of stay, ↑ ICU admissions. stay, ↑ ICU admissions.

• Observe patient – not just using machinesObserve patient – not just using machines• MEWS adapted for paediatrics and obstetrics & MEWS adapted for paediatrics and obstetrics &

head injury patientshead injury patients


Applying to practiceApplying to practice

• Respiratory rateRespiratory rate

• Oxygen SaturationsOxygen Saturations

• PulsePulse

• Systolic (BP)Systolic (BP)

• AVPU/GCSAVPU/GCS

• TempTemp

• Urine OutputUrine Output


Vital signs to assessVital signs to assess

• Relevant in a number of compensatory Relevant in a number of compensatory mechanisms within the body mechanisms within the body

• Normal rate should be between 12 and 20.Normal rate should be between 12 and 20.• The most sensitive indicator of potential The most sensitive indicator of potential

deterioration. Rising rates often early sign.deterioration. Rising rates often early sign.• Using in conjunction with other evidence ie: use Using in conjunction with other evidence ie: use

of accessory muscles, increased work of of accessory muscles, increased work of breathing, able to speak?, exhaustion, colour of breathing, able to speak?, exhaustion, colour of patient.patient.

• Position of patient is important.Position of patient is important.


Respiratory rateRespiratory rate

Blood pumped fromBlood pumped from

Heart is rich in O2Heart is rich in O2

(95%-99% saturated)(95%-99% saturated)

Blood pumped back Blood pumped back

to heart is low in O2to heart is low in O2

(65%-70%)(65%-70%)


SaturationsSaturations

Competency frameworkOxygen demandOxygen demand

If oxygen delivery to the body falls below what is demanded, the tissues extract more oxygen from the haemoglobin and the saturation of blood falls.

• All cells are dependent on an adequate constant supply of O2 as All cells are dependent on an adequate constant supply of O2 as they are unable to store it. A reduction can lead to organ they are unable to store it. A reduction can lead to organ dysfunction and death.dysfunction and death.

• Dependent on intact respiratory and cardiovascular function – Dependent on intact respiratory and cardiovascular function – limited by other factors ie: peripherally shut down. limited by other factors ie: peripherally shut down.

• Be aware of patients ‘target saturations’.Be aware of patients ‘target saturations’.

• All acutely unwell patients should receive supplementary Oxygen All acutely unwell patients should receive supplementary Oxygen and then titrate to readings. and then titrate to readings.

• ABG may be required for more in depth assessment.ABG may be required for more in depth assessment.


Oxygen saturationsOxygen saturations

• Should be taken manually for one minute, Should be taken manually for one minute, noting the rate, volume and regularity. noting the rate, volume and regularity.

• Felt at brachial arteryFelt at brachial artery• Normal rate can be considered 60-Normal rate can be considered 60-

100bpm.100bpm.• Abnormal findings need investigatingAbnormal findings need investigating• Abnormalities should be followed with an Abnormalities should be followed with an

ECGECG• Consider ECG monitoring Consider ECG monitoring


Heart RateHeart Rate


Effects on Heart RateEffects on Heart Rate

Effects on Heart RateEffects on Heart Rate

• Haemorrhage / Haemorrhage / bleedingbleeding

• HypotensionHypotension• Sepsis Sepsis • Drugs / medications Drugs / medications • HypoxiaHypoxia• TemperatureTemperature• Injury / InsultInjury / Insult• ElectrolytesElectrolytes


Competency frameworkBlood pressure = pressure on wall Blood pressure = pressure on wall

of arteryof artery

Systolic = pumping pressureSystolic = pumping pressureDiastolic = resting pressureDiastolic = resting pressure

The pressure in the arteries is carefully The pressure in the arteries is carefully regulated by the body. If it drops, regulated by the body. If it drops, immediate circulatory changes occur:immediate circulatory changes occur:

► ► Heart rate increasesHeart rate increases

► ► Constriction of vessels (so BP may Constriction of vessels (so BP may remain adequate) - ↓ CRT, ↓ Urine output.remain adequate) - ↓ CRT, ↓ Urine output.


Arterial pressureArterial pressure

• A LATE sign of deterioration – patients will A LATE sign of deterioration – patients will compensate (especially young)compensate (especially young)

• Adequate BP is essential for delivery of O2 and Adequate BP is essential for delivery of O2 and nutrients to the rest of the body. nutrients to the rest of the body.

• Be aware of what is normal for patientBe aware of what is normal for patient• Organs are very dependent on adequate Organs are very dependent on adequate

pressures to ensure perfusion.pressures to ensure perfusion.• Manual Blood pressure recording may be Manual Blood pressure recording may be

appropriate. appropriate.


Blood pressureBlood pressure

• Sensitive indicator of hydration statusSensitive indicator of hydration status• Should be 0.5ml/kg/hrShould be 0.5ml/kg/hr• Due to high demand for blood supply to the Due to high demand for blood supply to the

kidneys, urine output is a useful indicator of kidneys, urine output is a useful indicator of cardiovascular status.cardiovascular status.

• Generally is a poorly recorded observation.Generally is a poorly recorded observation.• Monitoring of fluid balance should be appropriate Monitoring of fluid balance should be appropriate

depending on patient condition. depending on patient condition. • Acute Kidney injury - Acute Kidney injury - ↓ urine output, ↑ toxic ↓ urine output, ↑ toxic

waste. Needs urgent attentionwaste. Needs urgent attention


Urine outputUrine output

• AVPU or GCS for more in depth assessment. AVPU or GCS for more in depth assessment. • Consider at what point do you need help?Consider at what point do you need help?• This should include drowsiness, agitation, new changes.This should include drowsiness, agitation, new changes.• Assess pupils Assess pupils • Consider reversible causes ie: blood sugarConsider reversible causes ie: blood sugar• If only responding to pain or unresponsive – airway is at If only responding to pain or unresponsive – airway is at

risk – 2222 adult emergency.risk – 2222 adult emergency.• Neuro obsNeuro obs


Level of ConsciousnessLevel of Consciousness

• Can have a significant effect on patients Can have a significant effect on patients condition.condition.

• High or low can indicate sepsisHigh or low can indicate sepsis

• > 38 degrees consider blood cultures > 38 degrees consider blood cultures

• Significant warming can cause Significant warming can cause vasodilationvasodilation

• Low can be as important as highLow can be as important as high


TemperatureTemperature

• O2 needed?O2 needed?• PositioningPositioning• IV accessIV access• ECGECG• CatheterCatheter• IV fluidsIV fluids• BloodsBloods• Escalation statusEscalation status


ConsiderationsConsiderations


Who is at risk?Who is at risk?

• Any one in hospital!! Any one in hospital!!

• Those with co-existing diseaseThose with co-existing disease

• All emergency admissionsAll emergency admissions

• Elderly peopleElderly people

• Specific acute illness (sepsis, pancreatitis)Specific acute illness (sepsis, pancreatitis)

• Those with altered level of consciousnessThose with altered level of consciousness

• Major haemorrhageMajor haemorrhage


Who is at risk?Who is at risk?

• Sepsis• Hospital acquired infections• Chronic disease process• Co-morbidities• Failure to manage complications• Iatrogenic• Unavoidable complications• Palliative / end of life


Causes of deteriorationCauses of deterioration

Measure observations and DocumentMeasure observations and Document

↓↓Recognise DeteriorationRecognise Deterioration

↓↓Communicate AppropriatelyCommunicate Appropriately

↓↓Respond efficiently & reassess Respond efficiently & reassess

Competency frameworkChain of safety

SBARSBARA tool used to A tool used to

communicate communicate

critical information critical information

succinctly and brieflysuccinctly and briefly


Anxious about escalating?Anxious about escalating?Frequency / exposure to deterioration?Frequency / exposure to deterioration?

Knowledge and Skills?Knowledge and Skills?Prioritising workload?Prioritising workload? Difference of opinion?Difference of opinion?

Define ‘deterioration’ Define ‘deterioration’ ““To become worse” To become worse” (English dictionary, 2013)(English dictionary, 2013)


Barriers to escalationBarriers to escalation

• Individual Accountability Individual Accountability • Risk assessment and delegationRisk assessment and delegation• ConsentConsent• Risk assessmentRisk assessment• Privacy and dignityPrivacy and dignity• DocumentationDocumentation• Infection controlInfection control• CommunicationCommunication• Safeguarding Safeguarding

Updates on amendments to revised policyUpdates on amendments to revised policy

Competency frameworkAdditional elements in relation to Additional elements in relation to

patient carepatient care

• Complete action plan for scenarios given Complete action plan for scenarios given

• Discuss rationale for taking observations and Discuss rationale for taking observations and increase/decrease frequencyincrease/decrease frequency

• Correctly taking a full set of observations Correctly taking a full set of observations

• Correct documentation and calculation of scores using Correct documentation and calculation of scores using trust observation charts. trust observation charts.

• Demonstrate awareness of escalation procedures.Demonstrate awareness of escalation procedures.


Practical assessmentPractical assessment

observations and the deteriorating patient for registered nurses

Documents

physiological observations

patient care

usedtaking observations

basic observations

position of patient

colour of patient

hospital recognition

physiological relevance