PREVENTION AND MANAGEMENT OF THE DETERIORATING …

PREVENTION AND MANAGEMENT OF THE DETERIORATING

ADULT PATIENT including the (CRITICAL CARE OUTREACH TEAM OPERATIONAL

POLICY)

Primary Intranet Location Version Number

Next Review Year Next Review

Month

Critical Care 3 October 2017

Current Author

Karen McGuire/ Nicola Cook

Author’s Job Title

Associate Chief Nurse Elective Division/

Nurse Consultant Critical Care Outreach Team

Department

Trustwide

Approved by

Clinical Governance Committee

Date

13th January 2015

Ratifying Committee

Policy Review Standards Committee

Ratified Date

23rd October 2014

Owner

Dr Beverley Watson

Owner’s Job Title

Medical Director

It is the responsibility of the staff member accessing this document to ensure that they are always

reading the most up to date version, - This will always be the version on the intranet

The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust

Prevention and Management of the Deteriorating Adult Patient V3 of 29

Related Policies

Critical Care Complex Operational Policy

DNA-CPR Policy

Resuscitation policy and Procedure

Stakeholders

Critical Care Governance Committee

Resuscitation Committee

Patient Safety Committee

Quality, Risk and Standards Committee


Version Date Author Author’s Job Title Changes

V1 March

2009

Karen

McGuire

Nurse Consultant

Critical Care

Outreach Team

V2 July

2012

Karen

McGuire

Nurse Consultant

Critical Care

Outreach Team

V3 Oct

2014

Nicola Cook Associate Chief

Nurse Elective

Division/Nurse

Consultant Critical

Care Outreach

Team

4.4

4.5

13 Appendix 4

14 Appendix 5

V4

V5

V6

Summary of the policy

This policy outlines the roles and responsibilities of staff within the Trust when caring

for acutely ill and deteriorating patients. It highlights the identification, escalation and

support processes in place to facilitate the current recommendations for best practice.

Key words to assist the search engine

Critical Care Outreach team, Early Warning Scoring System (EWSS), Escalation, Acutely

ill/deteriorating patient



CONTENTS

1. INTRODUCTION ...................................................................................................................... 4

2. PURPOSE ................................................................................................................................ 4

3. RESPONSIBILITIES ................................................................................................................... 5

4. PROCEDURE AND PROCESS ................................................................................................... 9

5. EQUALITY IMPACT ASSESSMENT ........................................................................................ 11

6. DISSEMINATION OF DOCUMENT ........................................................................................ 11

7. REFERENCES ......................................................................................................................... 12

8. OBSERVATIONS .................................................................................................................... 13

9. ADMISSIONS ........................................................................................................................ 13

APPENDIX 1 - TRUST OBSERVATION STANDARD ....................................................................... 15

APPENDIX 2 - THE EARLY WARNING SCORING SYSTEM MATRIX (EWSS) ................................. 19

APPENDIX 3 – THE EARLY WARNING SCORING SYSTEM ALGORYTHM .................................... 20

APPENDIX 4 - CRITICAL CARE OUTREACH TEAM ORGANISATION STRUCTURE ........................ 21

APPENDIX 5 – GLOSSARY OF TERMS .......................................................................................... 21

APPENDIX 5 – GLOSSARY OF TERMS .......................................................................................... 22

APPENDIX 6 MONITORING COMPLIANCE ................................................................................... 23

APPENDIX 7 EQUALITY IMPACT ASSESSMENT ........................................................................... 26

ARRANGEMENTS FOR MONITORING COMPLIANCE WITH THIS POLICY.................................... 28

STAGE 1 - SCREENING.................................................................................................................. 28

STAGE 2 – EQUALITY IMPACT ASSESSMENT ........................ ERROR! BOOKMARK NOT DEFINED.

APPENDIX 8 – PLAN FOR DISSEMINATION OF PROCEDURAL DOCUMENTS .............................. 29



PREVENTION AND MANAGEMENT OF THE DETERIORATING ADULT PATIENT including the (CRITICAL CARE OUTREACH TEAM OPERATIONAL POLICY)

1. INTRODUCTION

1.1 National Institute for Health and Clinical Excellence (2007) noted that any patient in

hospital may become acutely ill. The recognition of acute illness is often delayed and its

subsequent management may be inappropriate. This may result in late referral and

avoidable admissions to critical care, and may lead to unnecessary patient deaths,

particularly when the initial standard of care is suboptimal.

1.2 The Outreach team is a nurse led service with the objective of supporting care delivery

to the sick and deteriorating patients across the Trust. The Outreach team works across

the Trust and is available for advice, support and guidance on the management

planning and treatment options for the sick and deteriorating patients in the ward and

assessment areas.

1.3 The team is a complementary support system who work with the parental nursing and

medical teams when invited to offer support and guidance. The Outreach team and its

service provision should not replace traditional medical teams in the care of inpatients

(Comprehensive Critical care 2000, ICS 2002, NCEPOD 2005).

1.4 Early intervention relies on effective recognition of patient deterioration or already

established critical illness through the patient’s physiological observations and the use

of the Trust Early Warning Scoring System (EWSS). The use of the EWSS facilitates and

supports the nursing and medical teams in the identification of sick and deteriorating

patients throughout the hospital. The Outreach team should be informed of patients

deteriorating or in established critical illness through ward staff’s use of the EWSS and

the Trust escalation criteria.

1.5 Clinical review of the Trust EWSS and escalation process supported by national guidance

and the introduction of a Trust Critical Care Outreach team have resulted in the

introduction of a revised Trust wide clinical observation policy.

The Critical Care Outreach Team has 3 main objectives:

To avert inappropriate admissions to the critical care unit – through identifying and

treating patients whose condition is deteriorating, therefore preventing admissions or

ensuring that necessary admissions are timelier.

Enable and support discharges from higher levels of care- by supporting patients

discharged from critical care areas and supporting ward based clinicians.

To share critical care skills – by educating and supporting ward based staff.

2. PURPOSE

2.1 The introduction of Critical Care Outreach teams was first recommended in the

Comprehensive Critical Care document (2000). Subsequent publications continue to

recommend its introduction with gradual uptake nationally by acute Trusts.



2.2 The introduction of a critical care Outreach teams was to collaborate with and support

ward based clinicians. The outreach teams utilize their critical care skills to prevent

further clinical deterioration in patients with impending or established critical illness,

through collaboration with the parental teams.

2.3 The National Institute for Health and Clinical Excellence (2007) recommends all adult

patients in acute hospital settings are monitored using a physiological track and trigger

system. The model used within this Trust is the Early Warning Scoring System (EWSS).

Any patient admitted to hospital has the potential to deteriorate but recognition of

acute illness is often delayed resulting in late referral and avoidable admissions to

critical care and can lead to poor outcomes (McQuillan et al 1998, NCEPOD 2005). Lack

of recognition and failure to document clinical observations is also highlighted as a

prime concern of the National Patient Safety Agency (2007).

2.4 The use of the EWSS facilitates and supports the nursing and medical teams in the

identification of sick and deteriorating patients throughout the hospital and continues

to be strongly recommended in all of the literature and guidance (Comprehensive

Critical Care 2000, NICE 2007, NPSA 2007)

3. RESPONSIBILITIES

3.1 Medical Team

The parental medical team are responsible for the patients review and care within

working hours.

The on-call medical teams are responsible for speciality reviews and care out of working

hours.

The medical teams reviewing patients are responsible for assessing and clearly

documenting a management plan in the patient’s medical notes. The assessment should

be clearly recorded using the ABCDE taxonomy. The management plan should include

the observational frequency, parameters of concern, and any planned treatments. The

management plan should be clearly communicated to the registered nurse responsible

for the patient’s care (see Appendix 3).

3.2 EWSS score = 3 OR Where There Is Clinical Concern

The junior doctor is required to review the patient within 30 minutes.

The junior doctor reviewing the patient is responsible for assessing and clearly

documenting a clear management plan in the medical notes. This plan should include

the planned treatments and planned observational frequency to include the parameters

of concern.

The management plan should be clearly communicated to the registered nurse

responsible for the patients care.

Consider calling the Critical Care Outreach Team or Hospital at Night Team for advice.



3.3 EWSS score 4 OR when one parameter scores 3 points OR where there is clinical concern.

The junior doctor is required to review the patient within 30 minutes.

The junior doctor reviewing the patient is responsible for assessing and clearly

documenting a clear management plan in the medical notes as noted above. This plan

should include the planned treatments and planned observational frequency to include

the parameters of concern. The plan should include increasing the frequency of EWSS

and considering fluid balance monitoring.



The management plan should be discussed with the relevant registrar and/or consultant.

Consider calling the Critical Care Outreach Team or Hospital at Night Team for advice

3.4 EWSS 6 OR Escalating EWSS scores

Immediate review by the registrar.

The registrar is responsible for discussing management with the consultant.

The registrar reviewing the patient is responsible for assessing and clearly documenting

a clear management plan in the medical notes.

This plan should include the planned treatments and planned observational frequency

to include the parameters of concern.



Consider calling the Critical Care Outreach Team or Hospital at Night Team for advice.

The parental or on call consultant is responsible for discussing referrals and admissions

to critical care with the critical care consultant if admission is felt appropriate. 3.5 Nursing Team

The registered or unregistered nurse completing the observations is responsible for

ensuring a complete and accurate set of physiological observations is recorded with a

completed EWSS.

The unregistered nurse is responsible for ensuring that the registered named nurse or

the nurse in charge is aware of any EWSS scores of 3 or more, or any patients they are

concerned about that may require a registered nurse review.

The nurse in charge is responsible for ensuring all observations are accurately completed

during their shift.

The ward manager is responsible for ensuring observations standards are completed on

their clinical area adhering to the Trust observational policy guidance.



The lead nurses are responsible for ensuring observational standards are completed on

their clinical area adhering to the Trust observational policy guidance.

3.6 EWSS score = 3 OR Where There Is Clinical Concern

The registered nurse is responsible for assessing all patients with EWSS scores of 3 or

more.

This should include repeating a set of physiological observations and EWSS score. If the

registered nurse notes the EWSS to be 3 or more the observational frequency should be

increased.

The registered nurse should contact the relevant junior doctor to assess the patient. This

assessment by the junior doctor should be within 30 minutes from the trigger time.

3.7 EWSS score 4 OR when one parameter scores 3 points OR where there is clinical concern


more, or when 1 parameter triggers a score of 3, or where there is clinical concern.

This should include repeating set of physiological observations and EWSS score. The

observational frequency should be increased.

The registered nurse should contact the relevant junior doctor to assess the patient. This

assessment by the junior doctor should be within 30 minutes from the trigger time.

If the junior doctor fails to respond, then the nurse should contact a more senior doctor

(registrar and then consultant, if still no response).

The Critical Care Outreach Team (in-hours) and the Hospital at Night team (out of

hours) should also be called to review the patient, if appropriate.

3.8 EWSS 6 OR Escalating EWSS scores


more, or escalating EWSS scores, immediately.

This should include repeating set of physiological observations and EWSS score. The

observational frequency should be increased.

The registered nurse should contact the registrar to assess the patient immediately.

If the registrar fails to respond, then the nurse should contact a more senior doctor

(associate specialist or consultant).

The Critical Care Outreach Team (in-hours) and the Hospital at Night Team (out of

hours) should also be called to review the patient.

3.9 The Critical Care Outreach Team

The Outreach team operate between 7.30hrs and 19.30hrs Monday – Sunday (12 hours a

day 7 days a week). Cover out of hours the team are supported by the Hospital at Night

Team. They are responsible for covering all areas of the Trust except Women and Child.

The Outreach team are responsible for responding to all calls received with patients

scoring 4 or more, or when a single parameter scores 3 points, or where there is clinical

concern, where possible within 30 minutes.



The Outreach team are responsible for assessing, supporting, and guiding parental and

on call medical teams and the nursing staff. The ultimate decisions regarding

management plans will reside with the parental or on-call consultant or registrar

following discussion with the consultant.

Any treatment plans and interventions will be clearly documented and then effectively

communicated by the Outreach team.

The Outreach team alongside the parental or on-call teams and the responsible nursing

staff will assess and prescribed clear physiological parameters for further action and

observational frequency.

The Outreach team are responsible and will liaise with the critical care unit staff

regarding referrals when the consultant has referred the patient.

The Outreach team are responsible for ensuring patients are transferred to critical care

in the most timely and effective fashion.

The Outreach team are responsible for seeking medical advice and support as necessary

from the on call critical care consultant.

The Outreach team will ensure the consultant for critical care and the on call junior

doctor are aware of unstable and sick patients under the care of the Outreach team.

The Outreach team with the parental or on-call teams and the patients will support and

advice regarding patients resuscitation status. The ultimate decisions regarding

management plans will reside with the parental or on-call consultant or registrar

following discussion with the consultant.

The Outreach team have specific responsibilities regarding Trust education and training.

Refer to Education and training.

The Nurse Consultant and Medical lead for the Outreach team are responsible for

ensuring team training and development.

The Nurse Consultant and Medical lead for the Outreach team are responsible for

ensuring data collection, recording decisions on the Outreach team activities and

developments and for effectively reporting this to ITU clinical governance group.

The Outreach team are responsible for completing data collection tools regarding their

activities on a day to day basis. These will be effectively stored electronically and form

part of the annual report, submitted to the Patient Safety Committee.

The Outreach team is responsible for supporting care delivery to the sick, deteriorating

and unstable patients across the Trust.

The Outreach team is responsible for working across the Trust and is available for

advice, support and guidance on the management planning and treatment options for

the sick, deteriorating and unstable patients in the ward and assessment areas.



The Outreach team is responsible for complementary support working with the parental

nursing and medical teams when invited to offer support and guidance. The Outreach

team and its service provision should not replace traditional medical teams in the care

of inpatients (Comprehensive Critical care 2000, ICS 2002, NCEPOD 2005)

The Nurse Consultant and medical lead for the Outreach team are responsible for the

annual review of the operational policy and Trust observation standards, submitted to

the Patient Safety Committee annually.

3.10 Hospital at Night Team

The hospital at night team coordinator is responsible for the appropriate delegation of

personnel from within the team to review the patients according to the EWSS score and

the escalation procedures.

The hospital at night team is responsible for the handover to the outreach team on any

deteriorating/unstable patients identified overnight.

The hospital at night team is responsible for the handover to the outreach team on

patients stepped down or transferred overnight.

The hospital at night team are responsible for receiving handover from the outreach

team on patients stepped down or transferred from critical care areas and/or on any

deteriorating/unstable patients identified requiring monitoring and interventions

overnight.

4. PROCEDURE AND PROCESS

4.1 Observations

The taking and recording of patient observations is a fundamental assessment tool in

the patients stay in the hospital.

The recording of accurate observations and then interpretation and action on these

observations provides the basis of patient safety. The recognition of deteriorating

patients is often poor and some patients have long periods of physiological

deterioration (McQuillan et al 1998, Schein et al 1990, NCEPOD 2007, NPSA 2007).

The frequency of the clinical observations should match the severity of illness of the

patient (Resuscitation Council 2005).

It is important to record completed sets of observations because it allows vital early

detection of any deterioration or change in the patient’s condition (McQuillan et al

1998, Kenward et al 2001).

Accurate and frequent clinical observations improve patient safety through easily

identifiable indicators of patient assessment (Chellel et al 2002).

Patient observations should follow the standards within the Trust observational

guidelines (appendix 1).

4.2 Key Areas

The frequency of the clinical observations should be clearly recorded at the top of the

observation chart. This should be reviewed at least daily.



A full set of clinical observations should be accurately recorded at the documented

frequency.

Mandatory EWSS score to accompany each set of clinical observation.

Staff completing the observations should initial each set of clinical observations.

A mandatory EWSS and full set of clinical observations is to be recorded and

documented on patient admission and transfer to new clinical areas.

In acute care areas the clinical observations should be recorded at least twice daily (NICE

2007) unless a decision is clearly documented at a senior clinician level to reduce the

frequency.

Staff should refer to the Trust’s graded response escalation pathway if a patient triggers

on the EWSS.

4.3 Recording the EWSS

The EWSS is the track and trigger system used within the Trust and is recognized as a

national scoring system (NICE 2007).

The main function of the EWSS is to ensure the timely recognition of impending or

established critical illness, so that timely attendance and review from appropriately

skilled staff results (Gao et al 2007).

The EWSS uses 6 physiological scoring parameters, which are added and scores of 3 or

more result in the escalation cascade becoming activated.

4.4 The Graded response (Escalation strategy)

The EWSS provides an early indicator of deterioration and the nursing staff are directed

to request an early medical review. This has significant implications for the overall

patient outcome in terms of hospital and critical care mortality.

The graded response recognises the importance of the EWSS and the positive impact of

timely review and interventions in patient outcome and safety.


on the EWSS (appendix 3).

All staff should use the Situation, Background, Assessment, Recommendation (SBAR)

communication tool to effectively communicate between staff groups.

The guidelines prompting the urgency of the clinical response depend on the EWSS

value but clinicians may override the score if there is sufficient clinical concern, not

prompted by the EWSS, and initiate a clinical review.

This graded response is only a guide and each clinical situation should be treated as

unique and a patient requiring urgent response and review should be a 2222 (cardiac

arrest) call or 3333 fast bleep to a specific team member.



Critically ill patients should always be assessed using the A-B-C-D-E taxonomy system

(ALERT, ALS, ILS, and IMPACT).

Patients with Do Not Attempt-Cardiopulmonary Resuscitation (DNA-CPR) decisions in

place but with a ceiling of treatment clearly outlined and documented should still be

monitored using appropriate physiological observations and escalated according to the

graded response strategy.

4.5 Exceptions

Patients receiving anaesthesia or those patients within the Critical Care unit who are

receiving close continual monitoring do not require EWSS.

Patients within the paediatric and maternity service areas receive track and trigger

scoring but these have been specifically modified for these specialties and monitoring

should be in accordance with the agreed operational policy for these clinical areas.

Where patients are deemed medically fit for discharge by the parental consultant and

the multi-disciplinary team, the frequency of the clinical observations may be reviewed

and decreased to once a day. This frequency should only be reduced upon consultant

review and should be clearly documented.

Patients undergoing endoscopic procedures should have complete sets of clinical

observations recorded with EWSS prior to transfer to acute ward areas and as

appropriate throughout the procedure.

Patients requiring interventional diagnostic imaging should have a completed set of

clinical observations and EWSS prior to and following the procedure and as appropriate

throughout the procedure.

If a EWSS score remains high and the patient is considered clinically stable the patients

medical team will be required to agree a management plan. This will include

normalizing the EWSS physiological range for that patient, if the scoring system is

deemed too sensitive, resulting in the inappropriate scoring for that patient. Any

changes need to be documented on the clinical observation chart, signed and the

reasons recorded in the medical and nursing notes.

If the patient has an individual management plan for end of life and has a Do Not

Attempt-Cardiopulmonary Resuscitation (DNA-CPR) is documented on the ceiling of

treatment form, then EWSS recording and the graded response escalation is not

required

5. EQUALITY IMPACT ASSESSMENT

See appendix 7

6. DISSEMINATION OF DOCUMENT

See appendix 8



7. REFERENCES

Intensive Care Society (2002)

Guidelines for the transport of the critically ill adult

Intensive Care Society

London

McQuillan P, Pilkington S, Allan A et al (1998)

Confidential inquiry into quality of care before admission to intensive care

British Medical Journal

316 (7148) : 1853-1858

National Confidential Enquiry into Patient Outcomes and Deaths - NCEPOD (2009) Caring to the End? A review of the care of patients who died in hospital within four days of

admission

NCEPOD

London

National Confidential Enquiry into Patient Outcomes and Deaths - NCEPOD (2007) An acute problem? A report of the national confidential enquiry into patient outcome and death

NCEPOD

London

7.1 References to Standards

Department of Health (2000) Comprehensive Critical Care: a review of adult Critical care services

Department of Health

London

National Patient Safety Agency (NPSA) (2007) Recognising and responding appropriately to early signs of deterioration in hospitalised patients

London

NPSA

National Institute for Health and Clinical Excellence (NICE) (2007) Acutely ill patients in hospital

NICE Clinical Guideline 50 (CG 50)

London

7.2 Guidance

National Institute for Health and Clinical Excellence (NICE) (2007) Acutely ill patients in hospital

NICE Clinical Guideline 50 (CG 50) London



8. OBSERVATIONS

8.1 Additional detailed clinical audit and review through other methodological approaches of

the Trust observational standards, EWSS completion and escalation procedures will continue.

8.2 Data collection will include correlation with wards and areas completing the Productive

ward concept.

8.3 Data will be collected and reviewed regarding EWSS scores and patient acuity on

admission and discharge from the Critical care area.

8.4 Cardiac arrest calls will be audited annually including data demographics, patient

outcome, and numbers of calls.

9. ADMISSIONS

Admissions to Critical care including re-admissions, EWSS scores on admission, patient acuity,

numbers, and length of stay are correlated and reported by the Medical lead and Nurse

Consultant for Outreach.

Training and educational delivery will be reviewed through the audits and specific training

needs analysis. The Nurse Consultant for Critical care Outreach will co-ordinate, facilitate and

ensure accurate records of all training and education delivered or facilitated by the Outreach

team are accurately recorded and stored.

9.1 Step Down

The Outreach team will review all patients transferred from the critical care unit

within 24 hours of discharge or within the identified time frame requested by the

discharging critical care consultant if this is within the teams working hours.

All patients discharged from the critical care unit will receive at least 1 visit from the

outreach team except in recognised situations or team absence.

The Outreach team will support and co-ordinate effective and complex discharges

from step down care between Critical care and the receiving ward teams.

The Outreach team will support, advice and facilitate effective and safe discharges

when patients are discharged with tracheostomies from the critical care unit.

The patients receiving outreach follow up care will be discharged when they have a

consistent EWSS score below 3, or have been discussed or the on call critical care

consultant.



9.2 Education and Training

The Nurse Consultant for Critical care Outreach will co-ordinate, facilitate and

ensure delivery of all education and training highlighted below and any additional

training needs identified and within the Outreach practitioners role.

The Medical lead for Critical care Outreach will support, facilitate, and deliver

education and training as identified.

The Outreach team will provide Trust wide training and education on the Trust

observational policy, Track and trigger systems and escalation procedures. This

training will be supported by the Practice development team, resuscitation officer

and other educationalists within the organisation.

The Outreach team will provide training and education on the Trust observational

policy, Track and trigger systems and escalation procedures to all new starters to the

Trust through induction, Return to Practice courses, new starter courses and

preceptorship courses.


ensure delivery of the Trust ALERT course and Prompt Patient Assessment (PPA)

course.


ensure accurate records of all training and education delivered or facilitated by the

Outreach team are accurately recorded and stored.

The Outreach team will support the delivery of all acute education courses delivered

locally e.g. ALERT, PPA, IMPACT, and ILS.


ensure delivery of identified training needs within departments.

The Outreach team will provide telephone advice as requested.

The Nurse Consultant and Medical lead will support delivery of all developments

through effective dissemination and when necessary through education and

training.



APPENDIX 1 - TRUST OBSERVATION STANDARD

The taking & recording of patient observations is a fundamental assessment tool in the

patients stay in the hospital. The recording of accurate observations & then interpretation &

action on these observations provides the basis of patient safety. The recognition of

deteriorating patients is often poor & some patients have long periods of physiological

deterioration (McQuillan et al 1998, Schein et al 1990, NCEPOD 2007, NPSA 2007). The

frequency of the clinical observations should match the severity of illness of the patient

(Resuscitation Council 2005).

A full set of Patient’s observations should be completed according to the documented

frequency. The observations should all be completed, recorded & the EWSS recorded, scored

& initialed with each set of clinical observations. It is important to record completed sets of

observations because it allows vital early detection of any deterioration or change in the

patient’s condition (McQuillan et al 1998, Kenward et al 2001). Accurate & frequent clinical

observations improve patient safety through easily identifiable indicators of patient

assessment (Chellel et al 2002). Key areas

The frequency of the clinical observations should be clearly recorded at the top of the

observation chart. This should be reviewed at least daily.

A full set of clinical observations should be accurately recorded at the documented

frequency.

Mandatory EWSS score to accompany each set of clinical observation.

Staff completing the observations should initial each set of clinical observations.

A mandatory EWSS & full set of clinical observations is to be recorded & documented on

patient admission & transfer to new clinical areas.

In acute care areas the clinical observations should be recorded at least twice daily (NICE


frequency.


on the EWSS.

Respiratory Rate

The patient’s respiratory rate is likely to be the first physiological parameter to change

indicating underlying illness or deterioration. Therefore changes in respiratory rate are

considered prime indicators of clinical deterioration (Schein et al 1990, Fieselmann et al 1993).

The respiratory rate should be counted for a full minute. The patient should be “rested” to

ensure accuracy of the recording. The depth & equality of each breath should also be noted.

The trend in respiratory rate, either a decrease or increase can indicate a change in the

patient’s clinical picture.

A respiratory rate lower than 9 or higher than 15 breaths per minute will begin to score on

the EWSS.

Pulse

The patients pulse should be recorded using a dot on the observation chart. The pulse should

ideally be felt peripherally & manually to assess rate, regularity, depth & skin temperature.



Blood Pressure

The blood pressure should be recorded on the observation chart. The systolic pressure is the

value used to calculate the EWSS score. If a blood pressure value is difficult to obtain using a

machine then manual recordings are recommended. Blood pressure may be normal even in

the presence of shock.

Central Nervous System (CNS)

The assessment of the patients CNS should be completed using the AVPU system. A= Alert, V=

verbalizing or confused, P= Pain responds to pain only, U= unconscious. The brain is very

sensitive to changes in pressure and flow and reacts with changes in the AVPU scores;

therefore patient responsiveness is a key indicator of clinical condition. Accurate assessment is

possible using the AVPU but this may be enhanced through a Glasgow coma score.

Temperature

A temperature should be recorded using a dot on the observation chart & the score given

accordingly.

Trends should be noted on all clinical observations. Trends require referral to previous

hours/days of clinical observations. Trends may indicate clinical deterioration.

Urine Output

The urine output can only be accurately scored if the patient is catheterized & hourly urine

measures recorded. If there is no catheter in-situ the EWSS scoring box should be filled in

using a dash. This indicates that the scoring has been considered but you are unable to

accurately record ensuring there is no doubt on future assessments.

The urinary catheterization & hourly urine measures should be strongly considered if the

patient‘s score is 3, &/or not improving, as this will indicate if the major organs are

adequately perfused. Oliguria is an early sign of poor organ perfusion & that a patient’s

condition may be deteriorating (ALERT 2004).

Oxygen Saturations

The patient’s oxygen saturations are not scored on the EWSS but should still be recorded with

every set of clinical observations as they support the overall interpretation of the patient’s

condition. The patient’s oxygen saturations may be regarded as a prime indicator of

deterioration (Cuthbertson et al 2007). The saturations should also be considered when

reviewing patients in the context of supplemental oxygen.

The oxygen percentage (%) the patient is receiving should be recorded or the litres if the

patient is on a simple face mask or nasal specs. Documented literage of inspired oxygen does

not give an accurate, but only estimated oxygen intake, and therefore a venturi mask should

be used whenever possible (BTS 2007). If the patient is not receiving oxygen, this should be

recorded to indicate the patient is breathing air.

A falling oxygen saturation of >3%, a value of 93% for patients on oxygen or <90% for

patients on air (excluding documented COPD patients) provides evidence of acute illness

(British Thoracic Society 2007) requiring review. Oxygen saturations do not measure the

patient’s ventilation.



Recording the EWSS

The EWSS is the track & trigger system used within the Trust & is recognized as a national

scoring system (NICE 2007). Calculating & recording EWSS is mandatory for all patients within

the acute care setting & where the patient is for active intervention (NICE 2007). The main

function of the EWSS is to ensure the timely recognition of impending or established critical

illness, so that timely attendance & review from appropriately skilled staff results (Gao et al

2007).

The EWSS uses 6 physiological scoring parameters, which are added & scores of 3 or more

result in the escalation cascade becoming activated.

The Graded response (Escalation strategy)

The EWSS provides an early indicator of deterioration & the nursing staff is directed to

request an early medical review. This has significant implications for the overall patient

outcome in terms of hospital & critical care mortality.

The graded response recognises the importance of the EWSS & the positive impact of timely

review & interventions in patient outcome & safety. Staff should refer to the Trust’s graded

response escalation pathway if a patient triggers on the EWSS (appendix 3). The graded

response to clinical deterioration is printed on the back of the patient clinical observation

charts to aid early clinical intervention. The guidelines prompting the urgency of the clinical

response depend on the EWSS value but clinicians may override the score if there is sufficient

clinical concern, not prompted by the EWSS, & initiate a clinical review.

This graded response is only a guide & each clinical situation should be treated as unique & a

patient requiring urgent response & review should be a 2222 call or 3333 fast bleep to a

specific team member.

Critically ill patients should always be assessed using the A-B-C-D-E taxonomy system (ALERT,

ALS, ILS, and IMPACT).

Additional

A mandatory EWSS & full set of clinical observations is to be recorded & documented on

patient admission & transfer to new clinical areas. A clear patient management plan should

be recorded in each patient’s medical records & verbally communicated to nursing staff with

the frequency of the required clinical observations documented.

The frequency of the clinical observations should be clearly recorded on the observation

charts. The frequency of the clinical observations should be assessed at least daily & in

changes to the patient’s condition. These changes should be clearly documented & recorded.

In acute care settings the clinical observations should be recorded at least twice daily (NICE


frequency & this is documented.

If a EWSS score remains high & the patient is considered clinically stable the patients’ medical

team will be required to agree a management plan. This will include normalizing the EWSS

physiological range for that patient, if the scoring system is deemed too sensitive, resulting in

the inappropriate scoring for that patient. Any changes need to be documented on the

clinical observation chart, signed & the reasons recorded in the medical & nursing notes.



If the patient is for a documented management plan end of life with a ceiling of treatment

and a clearly documented Do Not Attempt- Cardiopulmonary Resuscitation (DNA-CPR)

decision, then EWSS recording & the graded response escalation is not required.

The assessment areas should complete a full set of clinical observations & EWSS and these

should continue according to the documented frequency.

A full set of Patient’s observations should be completed according to the documented

frequency. The frequency of the observations should match the severity of the patient’s

illness (resuscitation council 2005). The observations should all be completed, recorded & the

EWSS recorded, scored & initialed with each set of clinical observations. It is important to

record completed sets of observations because it allows vital early detection of any

deterioration or change in the patient’s condition (McQuillan et al 1998, Kenward et al 2001).

Accurate & frequent clinical observations improve patient safety through easily identifiable

indicators of patient assessment (Chellel et al 2002).

The EWSS includes six parameters (respiratory rate, pulse, blood pressure, neurological

assessment, temperature & urine output) requiring staff, completing the clinical observations,

to calculate the EWSS score as a mandatory task. The EWSS should be documented

immediately below the clinical observations on every occasion using the scoring parameters.

Exceptions

Patients receiving anaesthesia or those patients within the Critical Care unit who are

receiving close continual monitoring do not require EWSS.

Patients within the paediatric & maternity service areas receive track & trigger scoring but

these have been specifically modified for these specialties & monitoring should be in

accordance with the agreed operational policy for these clinical areas.

Where patients are deemed medically fit for discharge by the parental consultant & the

multi-disciplinary team, the frequency of the clinical observations may be reviewed &

decreased to once a day. This frequency should only be reduced upon consultant review &

should be clearly documented.

Patients undergoing endoscopic procedures should have complete sets of clinical observations

recorded with EWSS prior to transfer to acute ward areas & as appropriate throughout the

procedure.

Patients requiring interventional diagnostic imaging should have a completed set of clinical

observations & EWSS prior to and following the procedure & as appropriate throughout the

procedure.



APPENDIX 2 - THE EARLY WARNING SCORING SYSTEM MATRIX (EWSS)

Pulse

BP Systolic

Resps.

Temp

Urine Output

CNS

<70

<10ml/ hr for 2

consec. hrs

<40

SCORE

<35.0

<8

Responds to

Voice and/or is

confused

Responds to

PainUnconscious

>38.5

1 - Green 2 - Amber

101 - 110 111 - 129

15 - 20 21 - 29

35.0 - 38.4

Alert &

Orientated

51 - 100

101 - 199

9 - 14

81 - 100

>130

>200

>30

! If Early Warning Score 3 or above - Commence Early Warning Cascade !

<30ml/ hr for 2

consec. hrs

41 - 50

71 - 80

3 - Red 2 - Amber 1 - Green 0 - Normal 3 - Red



APPENDIX 3 – THE EARLY WARNING SCORING SYSTEM ALGORYTHM

EWSS = 3 or clinical concern

EWSS > 4 or 3 in one parameter or clinical concern

EWSS > 6 or escalating

Registered nurse to review patient, check observations and ensure appropriate nursing intervention

Increase frequency of EWSS to 4 hourly, but review at

least once at ½ hour post initial trigger

Full patient review by F1/2 within 30 minutes and re-

evaluate ½ - 1 hour post intervention

Consider calling Critical Care Outreach/ HAN team

Clear management plan documented stating

interventions and physiological barriers by reviewing

medical team

Commence fluid balance monitoring

Registered nurse to recheck EWSS and increase to 2

hourly but review at least once at ½ hourly post initial

trigger

Full patient review by F1/2 within 30 minutes


interventions and physiological parameters by

reviewing Medical Team

Increase frequency of EWSS

Call Critical Care Outreach Team/HAN Team

Immediate review by Registrar

Registrar to discuss management with consultant


interventions and physiological parameters by reviewing Medical Team

Call Critical Care Outreach Team or HAN Team (1231)

If transfer to Critical Care required then Consultant referral required

Monitor patient with at least 2 hourly observation.

Start fluid balance monitoring – Does this patient need catheretisation and hourly urine measures?

Management plan to be discussed with Registrar +/-

consultant



APPENDIX 4 - CRITICAL CARE OUTREACH TEAM ORGANISATION STRUCTURE

Operational Governance

Trust Board

Director of Operations

Emergency Division

Mark Blunt

Val Newton

Karen McGuire

Nicola Cook

Nurse Consultant

Critical Care Outreach

Team

Outreach Practitioners

Quality Committee

Patient Safety Committee

Annual Report


ITU Speciality Review

ITU Clinical Governance

Group



APPENDIX 5 – GLOSSARY OF TERMS

EWSS = Early Warning Scoring System

SBAR = Situation Background Assessment Response

CCOT = Critical Care Outreach Team

ALERT = Acute Life-Threatening Events Recognition and Treatment course

NICE = National Institute for Health and Clinical Excellence

NCEPOD = National Confidential Enquiry into Patient Outcomes and Death

ICS = Intensive Care Society

NPSA = National Patient Safety Agency

ABCDE Taxonomy = Airway, Breathing, Circulation, Disability, Environment

H@N = Hospital at Night

DNA-CPR = Do Not Attempt-Cardiopulmonary Resuscitation


APPENDIX 6 MONITORING COMPLIANCE

Key elements (Minimum Requirements)

Process for Monitoring (e.g. audit)

By Whom (Individual / group /committee)

Frequency of monitoring

Responsible individual / group / committee (plus timescales(for

Review of Results Development of Action Plan

Monitoring of action plan and implementation

Monitoring of Trust

observation standard &

Monitoring of appropriate

escalation

Monthly nursing indicators

Audit

department

Monthly

Nursing

indicators

reviewed and

reported

monthly and

presented to

the Trust

Executive

Board (TEC) in

the patient

safety report

and the Heat

Map. The

results are

reviewed and

disseminated

through the

Divisional

Chief Nurses,

Matrons and

ward

managers. The

results are

additionally

presented and

reviewed at

Divisional

Action plans

developed

within the

ward areas

and these are

monitored

monthly at

the Divisional

performance

reviews, sisters

meetings,

ward

meetings

Divisional QRS

meeting

Divisional chief

nurses

Matrons

Ward managers

Nurse Consultant

Governance leads

Clinical leads

Service line leads

Clinical Directors

Trend analysis is

reviewed at the

Divisional QRS

meetings and the

Nurse Consultant


performance

reviews

monthly,

Divisional

sisters

meetings, QRS,

and

governance

structures

Monitoring of Trust



escalation

Detailed clinical audit

reviews

Nurse

Consultant

lead

As

indicated

Monitored at

the Critical

Care

Governance

meeting

Action plan

developed (as

required) and

disseminated

through the

Divisional QRS

meetings

Divisional Chief

Nurse

Ward managers

Nurse Consultant

Monitoring of Trust



escalation

Case note review

Nurse

Consultant

lead

As

indicated

Monitored at

the relevant

Divisional QRS

meeting (as

required)

Action plan

developed (as

required) and

disseminated

through the

Divisional QRS

meetings

Divisional Chief

Nurse

Ward managers

Nurse Consultant

Monitoring of Trust



escalation

Root cause analysis

Nurse

Consultant

lead

As

indicated

Monitored at

Patient Safety

Committee (as

required)

Action plan

developed (as

required) and

disseminated

through the

Divisional QRS

meetings

Divisional Chief

Nurse

Ward managers

Nurse Consultant


Monitoring of Trust



escalation

Resuscitation audit

Nurse

Consultant

lead and

Resuscitation

officer

Annual Monitored at

the

Resuscitation

Committee

meeting

Resuscitation

officer and

Resuscitation

committee

members

Resuscitation

officer and

Resuscitation

committee

members

Monitoring of Trust



escalation

Mortality and Morbidity

Nurse

Consultant

lead

Monthly

Divisional Divisional

mortality and

morbidity lead

clinicians

Service leads

Divisional Chief

Nurses

Nurse Consultant


APPENDIX 7 EQUALITY IMPACT ASSESSMENT

(To be completed and attached to any policy document when submitted to the appropriate committee for ratification.)

STAGE 1 - SCREENING

Name and Job Title of Assessor: Karen McGuire Date of Initial Screening: Oct 2014

Policy or Function to be assessed: Critical Care Outreach Team Operational Policy

Yes/No Comments

1. Does the policy, function, service or project affect one group more or less favourably than another on the basis of:

Race and Ethnic background No

Gender including transgender No

Disability:- This will include consideration in terms of impact to persons with learning disabilities, autism or on individuals who may have a cognitive impairment or lack capacity to make decisions about their care

Yes Concerns may be expressed by some disabled people that they may not be effectively escalated due to value judgements about quality of life. Patients who lack mental capacity may not be able to participate in discussion and decision-making prior to escalations of care order being applied.

Religion or belief No

Sexual orientation Yes Concerns may be expressed by older people who may feel that clinicians are making value judgements based on age.

Age Yes There is a potential concern in the media regarding how decisions are made about escalation and treatment decisions

2. Does the public have a perception/concern regarding the potential for discrimination?

No

If the answer to any of the questions above is yes, please complete a full Stage 2 Equality Impact Assessment.

Signature of Assessor: Karen McGuire Date: Oct 2014 Signature of Line Manager: Valerie Newton Date: Oct 2014


STAGE 2 – EQUALITY IMPACT ASSESSMENT

If you have indicated that there is a negative impact on any group, is that impact:

Yes/No Comments

1. Legal/Lawful under current equality legislation?

Yes If yes, please provide details: The policy does not contravene the requirements of the European Convention on Human Rights (2000), the Mental Capacity Act 2008 or the Disability Equality Act.

2. Can the negative impact be avoided? Yes Provision is made within the policy to ensure that decisions are made in the best interests of the patient and that due consideration will be taken of any Advanced Decisions made by the patient. Where a patient lacks capacity the policy requires that a consultation takes place with family members, any person with enduring powers of attorney or an independent IMCA to ensure that the best interests of the patient are fully considered.

3. Are there alternatives to achieving the policy/guidance without the impact?

No

4. Have you consulted with relevant stakeholders of potentially affected groups?

Yes The policy has been subject to full consultation at the Clinical Governance Committee at which there is a lay member representing the Patient Experience Group.

5. Is action required to address the issues?

Yes Information will be provided for patients advising how escalation and treatment decisions are arrived at. Ongoing training is required for clinical staff on the requirements and duties in relation to the Mental Capacity Act 2008.

It is essential that this Assessment is discussed by your management team and remains readily available for inspection. A copy

including completed action plan, if appropriate, should also be forwarded to the Equality and Diversity Lead, c/o Human

Resources Department


ARRANGEMENTS FOR MONITORING COMPLIANCE WITH THIS POLICY

Key elements (Minimum Requirements)

Process for Monitoring (e.g. audit)

By Whom (Individual / group /committee)

Frequency of monitoring

STAGE 1 - SCREENING

Name & Job Title of Assessor: Date of Initial Screening:

Policy or Function to be assessed:

Yes/No Comments

1. Does the policy, function, service or project affect one group more or less favourably than another

on the basis of:

Race & Ethnic background

Gender including transgender

Disability:- This will include consideration in terms

of impact to persons with learning disabilities,

autism or on individuals who may have a

cognitive impairment or lack capacity to make

decisions about their care

Religion or belief

Sexual orientation

Age

2. Does the public have a perception/concern regarding the potential for discrimination?

If the answer to any of the questions above is yes, please complete a full Stage 2 Equality Impact

Assessment.

Signature of Assessor: __________________________________________ Date:

Signature of Line Manager: ____________________________________ Date:


APPENDIX 8 – PLAN FOR DISSEMINATION OF PROCEDURAL DOCUMENTS

To be completed and attached to any document which guides practice when submitted to the appropriate committee for consideration and approval.

Acknowledgement: University Hospitals of Leicester NHS Trust

Title of document: Prevention and management of the deteriorating patient including the (Critical Care Outreach Operational Policy)

Date finalised: January 2015 Dissemination lead: Print name and contact details

Nicola Cook

Previous document already being used?

Yes

If yes, in what format and where?

Intranet as a policy

Proposed action to retrieve out of date copies of the document:

Identify a librarian and remove out of date policy

To be disseminated to:

How will it be disseminated, who will do it and when?

Format (i.e. paper

or electronic)

Comments:

Divisional Chief Nurses

Nicola Cook by E-mail when ratified January 2015

Electronic

Medical & Clinical Directors

Nicola Cook by E-mail when ratified January 2015

Electronic

Dissemination Record - to be used once document is approved

Date put on register / library of procedural documents:

12th

February 2015 Date due to be reviewed:

Disseminated to: (either directly or via

meetings, etc.)

Format (i.e. paper or

electronic)

Date Disseminated:

No. of Copies Sent:

Contact Details / Comments:

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