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WAHT-CRI-016This guideline has been printed from the Worcestershire Acute Hospitals NHS Trust intranet on

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Recognising And Responding To Early Signs Of Deterioration In Hospital Patients

WAHT-CRI-016 Page 1 of 16 Version 2.2

RECOGNISING AND RESPONDING TO EARLY SIGNS OFDETERIORATION IN ADULT HOSPITAL PATIENTS

This guidance does not override the individual responsibility of health professionalsto make appropriate decision according to the circumstances of the individual

patient in consultation with the patient and /or carer. Health care professionals

must be prepared to justify any deviation from this guidance.

THIS GUIDELINE IS FOR USE BY THE FOLLOWING STAFF GROUPS :

All Clinical Staff Groups

Lead Clinician(s)

Ruth Mullett

Steve Graystone

Lead Critical Care Outreach-Worcs SiteMedical Director for Patient Safety

Approved by Resuscitation Committee on: 9 July 2012

Approved by Clinical Management Committeeon:

10 January 2013

This guideline should not be used after : 10 January 2015

Key amendments to the guideline:

Date Key Amendments Approved By:

July2012

Reviewed, but no changes necessary ResuscitationCommittee

Dec2012

Minor changes to monitoring arrangements. S Graystone

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RECOGNISING AND RESPONDING TO EARLY SIGNS OF DETERIORATION INHOSPITAL PATIENTS

INTRODUCTION

Any patient in hospital may become acutely ill. However, the recognition of acuteillness is often delayed and its subsequent management may be inappropriate. Thismay result in late referral and avoidable admissions to critical care, and may lead tounnecessary patient deaths, particularly when the initial standard of care issuboptimal (NICE 2007).

It is widely agreed that clear identifiable signs of deterioration can be seen in patientsbecoming critically ill in the hours preceding either an ICU admission or a cardiacarrest (Schien 1990, Franklin and Mathew 1994). Ridley (2005) highlights, that theearly recognition and management of critical illness is essential for the effectivemanagement of the patient. The use of a system to score the patients observationscan then be used to trigger early identification and appropriate management. Thereare several types of these scoring systems but they all essentially function in thesame manner.

The Patient at Risk Score (PARS) is used in the Worcestershire Acute Hospitals.This system is based on objective physiological parameters being scored accordingto the amount of deviation from normal. The scores are weighted depending on the

severity of deviation. The aggregate score is then calculated and acted uponaccordingly.

The use of PARS was supported in The Nursing Contribution to the Provision ofComprehensive Critical Care for Adults (DOH 2001) and is recommended by theNational Institute for Clinical Excellence (NICE) in the guidelines published in July2007.

The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report(2005), states that Respiratory rates (RRs) should be recorded wheneverobservations are made as they are a clear indicator of a deteriorating patient.

This guideline concerns the reduction of harm for patients whose physiologicalcondition deteriorates and makes evidence-based recommendations on therecognition and management of acute illness in acute hospitals.

Worcestershire Acute NHS trust has pledged to staff that it regards the safety ofpatients as the highest priority.

Aim: To Reduce in-hospital cardiac arrest and mortality rate through earlierrecognition and treatment of the deteriorating patient

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DETAILS OF GUIDELINE

NICE (2007) advocate that adult patients in acute hospital settings, including patientsin the emergency department for whom a clinical decision to admit have been mademust have:

Physiological observations recorded at the time of their admission or initialassessment

A clear written monitoring plan that specifies which physiological observationsshould be recorded and how often. The plan should take account of the:- patients diagnosis-presence of co morbidities-agreed treatment plan.

Physiological observations be recorded and acted upon by staff who havebeen trained in these procedures and understand their clinical relevance.Staff caring for patients in acute hospital settings must have competencies inmonitoring, measurement, interpretation and prompt response to the acutelyill patient appropriate to the level of care they are providing. Education and

training will be provided to ensure staff are competent (Competencyguidelines available on hospital intranet and each ward area has a PARS linknurse who can provide training and assessment).

Early Warning Scoring (EWS) to be completed at each set of physiological

observations. The system implemented across the Worcester Acute Trust is

NOTE: There is a scoring tool available for obstetric patients. Worcester

Obstetric Warning Score ( WOW) supported by guidance on intranet WHAT-

OBS-099

Patient at Risk Score(PARS)(appendix 1)

Patient at risk scoring systems are based on objective physiological parameters andhelp in the early identification of deteriorating patients on the wards. Thephysiological aspects considered are the patients blood pressure, heart rate,respiratory rate, urine output, temperature and level of consciousness. The scoresare weighted depending on the severity of deviation from the norm. The aggregatescore is then calculated and acted upon accordingly.

PARS should include AVPU and UO in the calculation (see below).

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PARS should be calculated when an adult patient is transferred to a new ward

including on transfer from the Emergency Department.

PARS should be calculated on ALL adult in-patients within the acute hospital.

PARS should be calculated on adult in-patients exiting theatre recovery prior

to transfer.

When an adult patient is transferred out of a critical care area (i.e. HDU / ITU).

PARS should also be used as an indication of how frequently observations needto be performed and a graded response strategy for patients identified as beingat risk of clinical deterioration should be utilised and consists of the following

three levels. It is found on the reverse of the Observation /PARS chart:-

LOWscore PARS 0-1; continue at current frequency of observations, but aminimum ofonce per shift.

MEDIUM score PARS 2; increase frequency of observations to a minimum of4 hourly, and inform nurse / midwife in charge.

HIGH score PARS 3 >; call for senior review by DR / Nurse / CCOT , patient

requires urgent review within 1 hour, increase frequency of observations to 2 4 hourly.(In recovery patients with PARS >3 should have a senior review prior totransfer.)

Important note; PARS 6 > patients are at extreme risk and require immediatereview by personnel with skills to assess critically ill patients (NICE 2007).

OBSERVATIONS

Physiological observations should be monitored at least once per shift, unless adecision has been made at a senior level to increase or decrease this frequency foran individual patient.

To be able to calculate accurate PARS the following should be assessed anddocumented.

HR (heart rate) Palpate a pulse, assess rhythm and rate.

RR (respiratory rate) Record rate on everyset of observations (NCePOD2005). RR is an important indicator of clinicaldeterioration.

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BP (Systolic blood If automated machines giving an inaccurate or suspectpressure) reading then check with a manual sphygmomanometer.

Temperature Internal body temperature is preferable over axilla.

UO (urine output) Output is an important indicator of the bodys functioningability. A urine output of < 0.5 mls / kg / hr is a markerthat the kidneys are not functioning correctly (accurateweight is desirable).

AVPU (neurology) Alert: responds to Voice: responds to Pain:Unresponsive: AVPU is a quick and easy method toassess level of consciousness. Change inconsciousness is another sensitive indicator of clinicaldeterioration.

Note:AVPU system does not remove the necessity for the Glasgow Coma Scale (GCS) tobe used on patients within an altered conscious level or any neurological conditions.The GCS chart is now formatted in the same manner as a PARS chart and hasallocated space for PARS to be recorded.

ACCURACY OF PARS & COMPLETION OF CHARTS

It is important to calculate accurate PARS to determine the severity of deteriorationin the patient and allow appropriate treatment & interventions to be commenced.

To calculate correct PARS it is important to have a complete set of observationsdocumented including AVPU and UO. If UO is unable to be determined then it stillneeds to be identified and documented on the PARS chart as U.

FLUID BALANCE MONITORING

Strict fluid balance monitoring is an essential tool for all acutely unwell patients. Acorrect balance provides valuable information regarding the patients input (oral andIV) and output (urine / stoma loss / NG loss / diarrhoea). A correct fluid balancechart will help determine the correct course of treatment needed for the patient andenables staff to monitor the effectiveness of such treatment.

All patients with either a urinary catheter or an intravenous infusion shouldbe on afluid balance chart. Where possible a pump should be used for infusing intravenousfluids, drugs or blood to ensure it is delivered over the specified time period.

Correct calculation of UO is discussed above and this needs to be documented onboth fluid balance chart and the PARS chart.

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ESCALATION OF CARE

It is imperative that a patients care is escalated when a PARS is triggered or thereare concerns that a patient is deteriorating. A referral should be made to a Doctorand /or Critical Care Outreach Team or Nurse Practitioner for assessment.Indicate on the PARS observation chart what action has been taken and who thepatient has been referred to (see appendix 1).All referrals should be documented in the patients case notes. There are referralstamps available on all adult clinical areas to facilitate this.

When making referrals consider:

Using referral communication tool (see appendix 2).

Medical Emergency Team (MET) or cardiac arrest call via dialling 2222 for lifethreatening deterioration.

If you need immediate attendance, fast bleep a team or a particular Doctor bydialling 2222.

When you have a sick patient it may be prudent to refer to senior members ofthe Parent team e.g. SHO or Registrar level, rather that the FY1.

If junior medical staff is unavailable, it is acceptable practice to escalate thereferral up to senior Doctors including Consultant level.

Nurse Practitioners/ Critical Care Outreach referral (see Clinical Supportsection of this guideline)

CRITICAL CARE REFERRAL

If the team caring for the patient considers that admission to a critical care area isclinically indicated, then the decision to admit should involve both the consultantcaring for the patient on the ward and the consultant in critical care.

TRANSFER/STEPDOWN FROM CRITICAL CARE

After the decision to transfer a patient from a critical care area to the general wardhas been made, he or she should be transferred as early as possible during the day.Transfer from critical care areas to the general ward between 22.00 and 07.00should be avoided whenever possible, and should be documented as an adverseincident if it occurs.

The critical care area transferring team and the receiving ward team should takeshared responsibility for the care of the patient being transferred. They should jointlyensure:

there is continuity of care through a formal structured handover of care fromcritical care area staff to ward staff (including both medical and nursing staff),

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there is a written plan that the receiving ward, with support from critical care ifrequired, can deliver the agreed plan. (Transfer/ Step down from Critical Careguidelines can be viewed on the intranet)

CLINICAL SUPPORT

The Critical Care Outreach service operates from 8AM to 8PM, 7 days a week. Out-of -hours Nurse Practitioners are available at night to support ward staff. At riskpatients are handed over between these teams at the commencement of each shift.

The service is available to all staff in all wards and departments who may find they

are caring for at risk patients. The service applies to all adult areas only.

At Worcester Royal Hospital, the Outreach Team can be contacted on ext 39555 orbleep no. 421/422.

At the Alexandra Hospital, Outreach can be contacted on ext 44233 or bleep no.0004/0031

Out of Hours Practitioner Nurses Bleep 7.30pm-8amWorcester: 103/104 Alex: 0216 /0217

EDUCATION & TRAINING

There are a number of educational and training activities provided by the Trust to aidrecognition and response to the deteriorating patient

Course Provider

ALERT- Acute Life Threatening Events

Recognition and Treatment -Multidisciplinary Resuscitation/Outreach

CERT- Clinical Examination and Response Training- New Qualified Nursing Staff Resuscitation /Outreach

ACT- Assessment and Communication Training- Healthcare Assistant Critical Care Outreach

Assessment Skills Days Critical Care Outreach

Mandatory Training Professional Development

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RECOGNITION OF AND RESPONSE TO ACUTE ILLNESS IN ADULTS IN HOSPITAL

Patient in acute hospital setting:

at the time of admissionto the ward

in the emergency departmentafter a decision to admit has been made

transferred to a general wardfrom a critical care area.

Low scoreContinue observations at current frequency

Initial assessment

l Record at least: heart rate respiratory rate systolic blood pressure level of consciousness oxygen saturation temperature.

lWrite a clear monitoring plan specifying the physiologicalobservations to be recorded and how often. Take into account: diagnosis comorbidities

the agreed treatment plan.

Medium score

Increase frequency of observations and inform nurse in charge

Initiate appropriate interventions.

Assess response.

Formulate a management plan, including location and

level of care

PATIENT AT RISK OF DETERIORATIONFollow graded response strategy as Patient at Risk Score

PARS

Routine Monitoring

Monitor physiologicalobservations at leastevery 12 hours,unlessdecided at a senior levelto increase or decreasethe frequency for an

individual patient.

Use Patient at Risk

ScoringConsider monitoring:biochemistry (for example,lactate,blood glucose, base deficit, arterialpH)

hourly urine output

pain

High scoreCall a senior nurse/doctor/midwife/ or outreachfor urgent review with 1 hr.

Admission to a criticalare areahe decision to admit should involve both theatients consultant and the consultant in critical care.

Transfers from a critical care areaTransfers to general wards should be as early in the day as possible.

Avoid transfers between 22.00 and 07.00 wherever possible.

Document as an adverse incident if they occur The critical care and ward teams have shared responsibility for thepatients care.A formal structured handover should be used (including both medical and nursing staff), supported by a written plan, to ensure continuity ofcare ensure the ward can deliver the plan, with support from critical care if required.

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Monitoring table;

Page/Section ofKeyDocument

Key control: Checks to be carried out toconfirm compliance with thepolicy:

How oftenthe checkwill becarried out:

Responsiblefor carryingout the check:

Results of check reportedto:(Responsible for alsoensuring actions aredeveloped to address any

areas of non-compliance)

Frequencyof reporting:

Page 4 Each patient should havecomplete sets of observationsand a PARS score calculated

Compliance with Patient atRisk Scoring will bemonitored by audit of patientobservation charts

Twice Yearly OutreachTeam

Director of Nursing,Matrons and deterioratingpatient & resusccommittee

TwiceYearly

Page 6 Patients who trigger a PARS >=3 should be escalated andreferred to medical staff and oroutreach team /practitioner nurse

Compliance with escalationwill be monitored by audit ofobservation charts andpatients notes


Director of Nursing,Matrons and deterioratingpatient & resusccommittee

TwiceYearly

Page 6 Transfers from critical careshould avoided between 22:00and 07:00

Compliance with avoidanceof out of hours transfers willbe monitored via ICNARCdata


Consultant Clinical LeadICCU

TwiceYearly

Page 7 Patients transferred from criticalareas should have a formaldocumented structured handoverof care

Compliance with transferdocumentation will bemonitored by audit of patientsnotes

Once Yearly OutreachTeam

Matron for ICCUOnceYearly

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STANDARDS % CLINICAL EXCEPTIONSPARS completed >95 %

Escalation of PARS 3 100 %

Transfer Step DownGuidelines

100%

Out of Hours Transfermonitored

100%

REFERENCES

Comprehensive Critical Care(2000)DOH

Franklin C and Mathew J (1994)

Developing strategies to prevent in hospital cardiac arrest: Analysing

responses of physicians and nurses in the hours before the event

Crit ical Care Medicin e22 (2) 244-247

National Institute for Clinical Excellence (2007)Acutely ill patients in hospitalDOH

Ridley S (2005)

The recognition and early management of critical illness

Ann als of the Royal Col lege of Surgeons o f England87 (5) 315-322

Schien (1990) Cited in: Ridley S (2005)

The recognition and early management of critical illness

Ann als of the Royal Col lege of Surgeons o f England87 (5) 315-322

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CONTRIBUTION LIST

Key individuals involved in developing the document

Name Designation

Ruth Mullett Lead Critical Care Outreach

Steve Graystone Consultant Anaesthetist

Karen Apps Critical Care Outreach Sister

Karen Hill Critical Care Outreach Sister

Circulated to the following individuals for comments

Name Designation

Alison Spencer Lead Critical Care Outreach

Donna Bagnall Lead Critical Care Outreach

Helen Blanchard Director of Nursing

Chris Doughty Lead Resuscitation Officer

Chris Rawlings Clinical Governance

Sharon Smith Matron A&E/MAU

Circulated to the following CDs /Heads of dept for comments from theirdirectorates / departments

Name Directorate / Department

Tracey Leach Anaesthetics/critical care

Jeremy Thomas Anaesthetics/critical care

Shelley Goodyear Critical Care

Circulated to the chair of the following committees / groups for comments

Name Committee / group

Steve Graystone Patient Safety First Campaign

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Appendix 1 Observation/PARS chart

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Appendix 2

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Supporting Document 1 Checklist for review and approval of key documentsThis checklist is designed to be completed whilst a key document is being developed / reviewed.

A completed checklist will need to be returned with the document before it can be published on the intranet.

For documents that are being reviewed and reissued without change, this checklist will still need to becompleted, to ensure that the document is in the correct format, has any new documentation included.

1 Type of document Guideline

2 Title of document RECOGNISING AND RESPONDING TO EARLYSIGNS OF DETERIORATION IN HOSPITALPATIENTS

3 Is this a new document? Yes NoIf no, what is the reference number WAHT-CRI-016

4 For existing documents, have you

included and completed the keyamendments box?

Yes No

5 Owning department Critical Care - Outreach

6 Clinical lead/s Dr Graystone

7 Pharmacist name (required ifmedication is involved)

N/A

8 Has all mandatory content beenincluded (see relevant documenttemplate)

Yes No

9 If this is a new document have

properly completed EqualityImpact and FinancialAssessments been included?

Yes No

Review document, not new.

10 Please describe the consultationthat has been carried out for thisdocument

See contribution list.

11 Please state how you want thetitle of this document to appear onthe intranet, for search purposesand which specialty this documentrelates to.

RECOGNISING AND RESPONDING TO EARLYSIGNS OF DETERIORATION IN HOSPITALPATIENTS

Once the document has been developed and is ready for approval, send to the ClinicalGovernance Department, along with this partially completed checklist, for them to check format,mandatory content etc. Once checked, the document and checklist will be submitted to relevantcommittee for approval.

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ImplementationBriefly describe the steps that will be taken to ensure that this key document is implemented

Action Person responsible Timescale

No changes to this version. Previous implementationplan completed.

- -

Plan for dissemination

Disseminated to Date

All staff, via intranet.

1

Step 1 To be completed byClinical Governance DepartmentIs the document in the correctformat?

Has all mandatory content beenincluded?

Date form returned03/09/2012

Yes No

Yes No

2 Name of the approving body(person or committee/s) Clinical Management Committee

Step 2 To be completed byCommittee Chair/ AccountableDirector

3 Approved by (Name of Chair/Accountable Director):

Penny Venables

4 Approval date 03/09/2012

Please return an electronic version of the approved document and completed checklist to the ClinicalGovernance Department, and ensure that a copy of the committee minutes is also provided.

Office use only Reference Number Date form received Date document

published

Version No.

WAHT-CRI-016 03/09/2012 03/09/2012 2.1

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