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RECOGNISING AND RESPONDING TO EARLY SIGNS OFDETERIORATION INADULT HOSPITAL PATIENTS
This guidance does not override the individual responsibility ofhealth professionalsto make appropriate decision according to thecirc*mstances of the individual
patient in consultation with the patient and /or carer. Healthcare professionals
must be prepared to justify any deviation from thisguidance.
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 forPatient 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 DETERIORATIONINHOSPITAL PATIENTS
INTRODUCTION
Any patient in hospital may become acutely ill. However, therecognition of acuteillness is often delayed and its subsequentmanagement may be inappropriate. Thismay result in late referraland avoidable admissions to critical care, and may leadtounnecessary patient deaths, particularly when the initialstandard of care issuboptimal (NICE 2007).
It is widely agreed that clear identifiable signs ofdeterioration can be seen in patientsbecoming critically ill in thehours preceding either an ICU admission or a cardiacarrest (Schien1990, Franklin and Mathew 1994). Ridley (2005) highlights, thattheearly recognition and management of critical illness isessential for the effectivemanagement of the patient. The use of asystem to score the patients observationscan then be used totrigger early identification and appropriate management. Thereareseveral types of these scoring systems but they all essentiallyfunction in thesame manner.
The Patient at Risk Score (PARS) is used in the WorcestershireAcute Hospitals.This system is based on objective physiologicalparameters being scored accordingto the amount of deviation fromnormal. The scores are weighted depending on the
severity of deviation. The aggregate score is then calculatedand acted uponaccordingly.
The use of PARS was supported in The Nursing Contribution to theProvision ofComprehensive Critical Care for Adults (DOH 2001) andis 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) shouldbe recorded wheneverobservations are made as they are a clearindicator of a deteriorating patient.
This guideline concerns the reduction of harm for patients whosephysiologicalcondition deteriorates and makes evidence-basedrecommendations on therecognition and management of acute illnessin acute hospitals.
Worcestershire Acute NHS trust has pledged to staff that itregards the safety ofpatients as the highest priority.
Aim: To Reduce in-hospital cardiac arrest and mortality ratethrough earlierrecognition and treatment of the deterioratingpatient
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DETAILS OF GUIDELINE
NICE (2007) advocate that adult patients in acute hospitalsettings, including patientsin the emergency department for whom aclinical decision to admit have been mademust have:
Physiological observations recorded at the time of theiradmission or initialassessment
A clear written monitoring plan that specifies whichphysiological observationsshould be recorded and how often. Theplan should take account of the:- patients diagnosis-presence of comorbidities-agreed treatment plan.
Physiological observations be recorded and acted upon by staffwho havebeen trained in these procedures and understand theirclinical relevance.Staff caring for patients in acute hospitalsettings must have competencies inmonitoring, measurement,interpretation and prompt response to the acutelyill patientappropriate to the level of care they are providing. Educationand
training will be provided to ensure staff are competent(Competencyguidelines available on hospital intranet and each wardarea has a PARS linknurse who can provide training andassessment).
Early Warning Scoring (EWS) to be completed at each set ofphysiological
observations. The system implemented across the Worcester AcuteTrust is
NOTE: There is a scoring tool available for obstetric patients.Worcester
Obstetric Warning Score ( WOW) supported by guidance on intranetWHAT-
OBS-099
Patient at Risk Score(PARS)(appendix 1)
Patient at risk scoring systems are based on objectivephysiological parameters andhelp in the early identification ofdeteriorating patients on the wards. Thephysiological aspectsconsidered are the patients blood pressure, heart rate,respiratoryrate, urine output, temperature and level of consciousness. Thescoresare weighted depending on the severity of deviation from thenorm. The aggregatescore is then calculated and acted uponaccordingly.
PARS should include AVPU and UO in the calculation (seebelow).
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PARS should be calculated when an adult patient is transferredto a new ward
including on transfer from the Emergency Department.
PARS should be calculated on ALL adult in-patients within theacute hospital.
PARS should be calculated on adult in-patients exiting theatrerecovery 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 frequentlyobservations needto be performed and a graded response strategy forpatients identified as beingat risk of clinical deteriorationshould 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 ofobservations, but aminimum ofonce per shift.
MEDIUM score PARS 2; increase frequency of observations to aminimum 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 ofobservations to 2 4 hourly.(In recovery patients with PARS >3should have a senior review prior totransfer.)
Important note; PARS 6 > patients are at extreme risk andrequire immediatereview by personnel with skills to assesscritically ill patients (NICE 2007).
OBSERVATIONS
Physiological observations should be monitored at least once pershift, unless adecision has been made at a senior level to increaseor decrease this frequency foran individual patient.
To be able to calculate accurate PARS the following should beassessed 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 ofclinicaldeterioration.
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BP (Systolic blood If automated machines giving an inaccurate orsuspectpressure) reading then check with a manualsphygmomanometer.
Temperature Internal body temperature is preferable overaxilla.
UO (urine output) Output is an important indicator of the bodysfunctioningability. A urine output of < 0.5 mls / kg / hr is amarkerthat the kidneys are not functioning correctly(accurateweight is desirable).
AVPU (neurology) Alert: responds to Voice: responds toPain:Unresponsive: AVPU is a quick and easy method toassess levelof consciousness. Change inconsciousness is another sensitiveindicator of clinicaldeterioration.
Note:AVPU system does not remove the necessity for the GlasgowComa Scale (GCS) tobe used on patients within an altered consciouslevel or any neurological conditions.The GCS chart is now formattedin the same manner as a PARS chart and hasallocated space for PARSto be recorded.
ACCURACY OF PARS & COMPLETION OF CHARTS
It is important to calculate accurate PARS to determine theseverity of deteriorationin the patient and allow appropriatetreatment & interventions to be commenced.
To calculate correct PARS it is important to have a complete setof observationsdocumented including AVPU and UO. If UO is unable tobe determined then it stillneeds to be identified and documented onthe PARS chart as U.
FLUID BALANCE MONITORING
Strict fluid balance monitoring is an essential tool for allacutely unwell patients. Acorrect balance provides valuableinformation regarding the patients input (oral andIV) and output(urine / stoma loss / NG loss / diarrhoea). A correct fluidbalancechart will help determine the correct course of treatmentneeded for the patient andenables staff to monitor theeffectiveness of such treatment.
All patients with either a urinary catheter or an intravenousinfusion shouldbe on afluid balance chart. Where possible a pumpshould be used for infusing intravenousfluids, drugs or blood toensure it is delivered over the specified time period.
Correct calculation of UO is discussed above and this needs tobe 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 PARSis triggered or thereare concerns that a patient is deteriorating.A referral should be made to a Doctorand /or Critical Care OutreachTeam or Nurse Practitioner for assessment.Indicate on the PARSobservation chart what action has been taken and who thepatient hasbeen referred to (see appendix 1).All referrals should bedocumented in the patients case notes. There are referralstampsavailable 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 dialling2222 for lifethreatening deterioration.
If you need immediate attendance, fast bleep a team or aparticular Doctor bydialling 2222.
When you have a sick patient it may be prudent to refer tosenior members ofthe Parent team e.g. SHO or Registrar level,rather that the FY1.
If junior medical staff is unavailable, it is acceptablepractice to escalate thereferral up to senior Doctors includingConsultant level.
Nurse Practitioners/ Critical Care Outreach referral (seeClinical Supportsection of this guideline)
CRITICAL CARE REFERRAL
If the team caring for the patient considers that admission to acritical care area isclinically indicated, then the decision toadmit should involve both the consultantcaring for the patient onthe ward and the consultant in critical care.
TRANSFER/STEPDOWN FROM CRITICAL CARE
After the decision to transfer a patient from a critical carearea to the general wardhas been made, he or she should betransferred as early as possible during the day.Transfer fromcritical care areas to the general ward between 22.00 and07.00should be avoided whenever possible, and should be documentedas an adverseincident if it occurs.
The critical care area transferring team and the receiving wardteam should takeshared responsibility for the care of the patientbeing transferred. They should jointlyensure:
there is continuity of care through a formal structured handoverof care fromcritical care area staff to ward staff (including bothmedical and nursing staff),
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there is a written plan that the receiving ward, with supportfrom critical care ifrequired, can deliver the agreed plan.(Transfer/ Step down from Critical Careguidelines can be viewed onthe intranet)
CLINICAL SUPPORT
The Critical Care Outreach service operates from 8AM to 8PM, 7days a week. Out-of -hours Nurse Practitioners are available atnight to support ward staff. At riskpatients are handed overbetween these teams at the commencement of each shift.
The service is available to all staff in all wards anddepartments who may find they
are caring for at risk patients. The service applies to alladult areas only.
At Worcester Royal Hospital, the Outreach Team can be contactedon ext 39555 orbleep no. 421/422.
At the Alexandra Hospital, Outreach can be contacted on ext44233 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 activitiesprovided by the Trust to aidrecognition and response to thedeteriorating patient
Course Provider
ALERT- Acute Life Threatening Events
Recognition and Treatment -MultidisciplinaryResuscitation/Outreach
CERT- Clinical Examination and Response Training- New QualifiedNursing Staff Resuscitation /Outreach
ACT- Assessment and Communication Training- Healthcare AssistantCritical 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 INHOSPITAL
Patient in acute hospital setting:
at the time of admissionto the ward
in the emergency departmentafter a decision to admit has beenmade
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 bloodpressure level of consciousness oxygen saturation temperature.
lWrite a clear monitoring plan specifying thephysiologicalobservations to be recorded and how often. Take intoaccount: diagnosis comorbidities
the agreed treatment plan.
Medium score
Increase frequency of observations and inform nurse incharge
Initiate appropriate interventions.
Assess response.
Formulate a management plan, including location and
level of care
PATIENT AT RISK OF DETERIORATIONFollow graded response strategyas Patient at Risk Score
PARS
Routine Monitoring
Monitor physiologicalobservations at leastevery 12hours,unlessdecided at a senior levelto increase or decreasethefrequency for an
individual patient.
Use Patient at Risk
ScoringConsider monitoring:biochemistry (forexample,lactate,blood glucose, base deficit, arterialpH)
hourly urine output
pain
High scoreCall a senior nurse/doctor/midwife/ or outreachforurgent review with 1 hr.
Admission to a criticalare areahe decision to admit shouldinvolve both theatients consultant and the consultant in criticalcare.
Transfers from a critical care areaTransfers to general wardsshould 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 careand ward teams have shared responsibility for thepatients care.Aformal structured handover should be used (including both medicaland nursing staff), supported by a written plan, to ensurecontinuity ofcare ensure the ward can deliver the plan, withsupport from critical care if required.
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Monitoring table;
Page/Section ofKeyDocument
Key control: Checks to be carried out toconfirm compliance withthepolicy:
How oftenthe checkwill becarried out:
Responsiblefor carryingout the check:
Results of check reportedto:(Responsible for alsoensuringactions aredeveloped to address any
areas of non-compliance)
Frequencyof reporting:
Page 4 Each patient should havecomplete sets of observationsanda PARS score calculated
Compliance with Patient atRisk Scoring will bemonitored by auditof patientobservation charts
Twice Yearly OutreachTeam
Director of Nursing,Matrons and deterioratingpatient &resusccommittee
TwiceYearly
Page 6 Patients who trigger a PARS >=3 should be escalatedandreferred to medical staff and oroutreach team /practitionernurse
Compliance with escalationwill be monitored by auditofobservation charts andpatients notes
Twice Yearly OutreachTeam
Director of Nursing,Matrons and deterioratingpatient &resusccommittee
TwiceYearly
Page 6 Transfers from critical careshould avoided between22:00and 07:00
Compliance with avoidanceof out of hours transfers willbemonitored via ICNARCdata
Twice Yearly OutreachTeam
Consultant Clinical LeadICCU
TwiceYearly
Page 7 Patients transferred from criticalareas should have aformaldocumented structured handoverof care
Compliance with transferdocumentation will bemonitored by auditof 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 theevent
Crit ical Care Medicin e22 (2) 244-247
National Institute for Clinical Excellence (2007)Acutely illpatients 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 fromtheirdirectorates / 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 forcomments
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 keydocumentsThis checklist is designed to be completed whilst a keydocument is being developed / reviewed.
A completed checklist will need to be returned with the documentbefore it can be published on the intranet.
For documents that are being reviewed and reissued withoutchange, this checklist will still need to becompleted, to ensurethat the document is in the correct format, has any newdocumentation included.
1 Type of document Guideline
2 Title of document RECOGNISING AND RESPONDING TO EARLYSIGNS OFDETERIORATION IN HOSPITALPATIENTS
3 Is this a new document? Yes NoIf no, what is the referencenumber 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 relevantdocumenttemplate)
Yes No
9 If this is a new document have
properly completed EqualityImpact and FinancialAssessments beenincluded?
Yes No
Review document, not new.
10 Please describe the consultationthat has been carried out forthisdocument
See contribution list.
11 Please state how you want thetitle of this document to appearonthe intranet, for search purposesand which specialty thisdocumentrelates to.
RECOGNISING AND RESPONDING TO EARLYSIGNS OF DETERIORATION INHOSPITALPATIENTS
Once the document has been developed and is ready for approval,send to the ClinicalGovernance Department, along with thispartially completed checklist, for them to check format,mandatorycontent etc. Once checked, the document and checklist will besubmitted to relevantcommittee for approval.
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ImplementationBriefly describe the steps that will be taken toensure that this key document is implemented
Action Person responsible Timescale
No changes to this version. Previous implementationplancompleted.
- -
Plan for dissemination
Disseminated to Date
All staff, via intranet.
1
Step 1 To be completed byClinical Governance DepartmentIs thedocument 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) ClinicalManagement 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 andcompleted checklist to the ClinicalGovernance Department, andensure that a copy of the committee minutes is also provided.
Office use only Reference Number Date form received Datedocument
published
Version No.
WAHT-CRI-016 03/09/2012 03/09/2012 2.1
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