Management of the Deteriorating Patient Policy Version Version 2 Name of responsible (ratifying) committee Patient Safety Working Group Date ratified 19th December 2013 Document Manager (job title) Resuscitation Manager Date issued 10th January 2014 Review date 19th December 2016 (unless requirements change) Electronic location Clinical Policies Related Procedural Documents Cardiopulmonary Resuscitation Policy Procedural Documents Development And Management Policy Generic Competency Framework for Registered and Unregistered Practitioners Modified Early Obstetric Warning (MEOWs) – Guideline Key Words (to aid with searching) early warning score; early warning system; EWS; medical emergency; response; deteriorating patient; critically ill; VitalPAC; escalation protocol; vital signs; ViEWS; MEOWs; PEWS; NEWS; heart rate; respiration rate; temperature; oxygen saturation; systolic blood pressure; level of consciousness; AVPU; monitoring; physiological observations; risk of deterioration; track and trigger; graded response strategy; clinical deterioration; professional staff; health professionals; patients; audit; clinical guidelines; transfer Version Tracking Version Date Ratified 1 15th Dec 2011 2 19th Dec 2013 Brief Summary of Changes Author Resuscitation Manager References updated including the reference to NHSLSA removed and the National Early Warning System added Management of the Deteriorating Patient Policy. Version 2 Issued 10/01/2014 (Review date 19th December 2016 (unless requirements change) Page 1 of 21 CONTENTS 1. 2. 3. 4. 5. 6. 7. 8. 9. QUICK REFERENCE GUIDE....................................................................................................... 3 INTRODUCTION.......................................................................................................................... 4 PURPOSE ................................................................................................................................... 4 SCOPE ........................................................................................................................................ 5 DEFINITIONS .............................................................................................................................. 5 DUTIES AND RESPONSIBILITIES .............................................................................................. 6 PROCESS ................................................................................................................................... 7 TRAINING REQUIREMENTS ...................................................................................................... 9 REFERENCES AND ASSOCIATED DOCUMENTATION .......................................................... 10 MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL DOCUMENTS ............................................................................................................................ 10 APPENDICES: APPENDIX 1: VitalPAC Early Warning Score (ViEWS) parameters from April 2010….……………...12 APPENDIX 2: ViEWS Escalation Protocol from April 2010 ..…………………………………………… 13 APPENDIX 3: Modified Early Obstetric Warning System (MEOWS) ………………………………….14 APPENDIX 4: Paediatric Early Warning System (PEWS)...………………………………… ………….16 APPENDIX 5: NICE CG50 Audit Tool……………………….………………………………… ………….18 Management of the Deteriorating Patient Policy. Version 2 Issued 10/01/2014 (Review date 19th December 2016 (unless requirements change) Page 2 of 20 QUICK REFERENCE GUIDE This policy must be followed in full to ensure that all patients within Portsmouth Hospitals NHS Trust (PHT), who are acutely ill or at risk of physical deterioration, are identified and responded to promptly and appropriately at all times. For quick reference the guide below is a summary of actions required. This does not negate the need for all staff to be aware of and follow the detail of this policy. All patients admitted to PHT will: 1. Have physiological observations recorded at the time of admission or initial assessment, immediately prior to transfer to another healthcare setting, for example ward to ward transfers, and within 15mins of arrival in the new healthcare setting; 2. Have a clear written monitoring plan in the patient’s notes that specifies which physiological observations should be recorded, and how often; 3. Have physiological observations recorded at least every 12 hours and the frequency increased if abnormal physiology is detected. A rationale for deviation from this standard must be recorded in the patient’s notes by a senior doctor; 4. Be monitored using a relevant physiological track and trigger system (Appendix 1, 2, 3 & 4). The track and trigger system will identify the appropriate graded response to abnormal physiological observations recorded or guide clinicians who are concerned; 5. Receive a graded response if they become acutely ill or are at risk of physical deterioration as per appropriate escalation protocol (Appendix 2, 3 & 4). The healthcare professional who has recognised a response is required must record their actions, related to the escalation, in the patient’s notes using the ViEWS Escalation Sticker; 6. The communication tool ‘RSVP’ should be used to ensure effective communication occurs between healthcare professionals (see Section 6.3) 7. The healthcare professional responding must document their actions and management plan clearly in the patient’s notes; 8. The most senior doctor available should refer to Critical Care. The decision to admit to Critical Care will be made by consultant in critical care in consultation with the referring team; 9. The responsible consultant for the referring team should be aware and have agreed for the need for critical care referral; Any patient transfers from critical care to general ward areas: 1. Should occur as early as possible during the day and whenever possible, be avoided between 22.00-07.00; 2. Should involve both a clear verbal handover and agreed written care plan to promote continuity of care; 3. Will be reviewed by the Critical Care Outreach. Management of the Deteriorating Patient Policy. Version 2 Issued 10/01/2014 (Review date 19th December 2016 (unless requirements change) Page 3 of 20 1. INTRODUCTION This policy reflects NICE guidance CG50 (1) and NPSA Guidance (2) relating to all aspects of the treatment and care of adults who are acutely ill or at risk of physical deterioration throughout Portsmouth Hospitals NHS Trust (PHT). The key recommendations from the NICE CG50 form the basis for the structure of this policy. This policy has also been developed to describe the process for managing and mitigating risks relating to all aspects of the treatment and care of adults who are acutely ill or at risk of physical deterioration. In 2005, the National Patient Safety Agency (2) undertook a detailed analysis of the 1,804 reported serious incidents which resulted in death. There were 576 events in which the death of the patient was, or might have been directly related to a patient safety incident. Of these reported incidents, 425 occurred in an acute/general hospital setting. The analysis found the following themes: 71 were related to diagnostic errors (dealt with under a separate NPSA review) 43 involved a problem with resuscitation. 64 were related to unrecognised physical deterioration (14 – no observations; 30, no recognition of signs of deterioration or assistance sought; 17 delays in receipt of medical attention). On the basis of this review, the key recommendations from the 64 incidents involving unrecognised patient deterioration are: Better recognition of patients at risk or who have deteriorated Appropriate monitoring of vital signs Accurate interpretation of clinical findings Calling for help early and ensuring it arrives Training and skills development Ensuring appropriate drugs and equipment are available 2. PURPOSE The aim of this policy is to standardise the processes by which the patients within Portsmouth Hospitals NHS Trust (PHT), who are acutely ill or at risk of physical deterioration, are identified and responded to. All patients admitted to PHT will: Have physiological observations recorded at the time of admission or initial assessment; Have a clear written monitoring plan in the health record that specifies which physiological observations should be recorded, and how often; Have physiological observations recorded at least every 12 hours and the frequency increased if abnormal physiology is detected; Be monitored using a relevant physiological track and trigger system (Appendix 1, 2, 3 & 4). The track and trigger system will identify the appropriate graded response to abnormal physiological observations recorded or guide clinicians who are concerned; Receive a graded response if they become acutely ill or are at risk of physical deterioration as per appropriate escalation protocol (Appendix 2, 3 & 4); For patients requiring admission to critical care: The decision to admit to Critical Care will be made by consultant in critical care in consultation with the referring team; Patient transfers from critical care to general ward areas: Should occur as early as possible during the day and whenever possible, be avoided between 22.00-07.00; Should involve both a clear verbal handover and agreed written care plan to promote continuity of care; Will be reviewed by the Critical Care Outreach. Management of the Deteriorating Patient Policy. Version 2 Issued 10/01/2014 (Review date 19th December 2016 (unless requirements change) Page 4 of 20 3. SCOPE This policy applies to the care of paediatric (excluding neonates on NICU) and adult patients (excluding patients receiving end of life care and those in Critical Care areas who are directly under the care of Critical Care Consultants) in all of the Trust’s settings, who because of clinical status/conditions, interventions or procedures are at risk of physical deterioration and ultimately of suffering a respiratory or cardiopulmonary arrest. This policy applies to all staff (including voluntary workers, students, locums and agency) of Portsmouth Hospitals NHS Trust, the MDHU (Portsmouth) and Carillion, whilst acknowledging for staff other than those of the Trust the appropriate line management or chain of command will be followed. In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety. 4. DEFINITIONS Cardiopulmonary Resuscitation (CPR) Cardiopulmonary Resuscitation is a combination of artificial ventilation, chest compressions, drug therapy and defibrillation. Classification of Critical Care Patients (3) Level 0 Level 1 Level 2 Level 3 Patients whose needs can be met through normal ward care in an acute hospital Patients at risk of their condition deteriorating, or those recently relocated from higher levels of care, whose needs can be met on an acute ward with additional advice and support from a critical care team. Patients requiring more detailed observation or intervention including support for a single failing organ system or post operative care, or those stepping down form higher levels of care. Patients requiring advance respiratory support alone or basic respiratory support together with support of at least 2 organ systems, includes all complex patients requiring support for multi organ failure. Clinical Staff A member of staff whose duties involve elements of direct patient care. Critical Care Outreach A multidisciplinary approach to the identification of patients at risk of developing critical illness and those patients recovering from a period of critical illness to enable early intervention or transfer (if appropriate) to an area suitable for care for that patient’s individual needs. Escalation Protocol for use with ViEWS Once the ViEWS has been completed the escalation protocol will prompt staff to take action depending on the ViEWS score. (See Appendix 2) High Dependency Patients requiring observation, care and treatment interventions at Level 2. Monitoring plan This should detail in the patients notes which physiological observations should be recorded, and how often. In addition it should specify the management of the patient and when they will be reviewed by nursing and medical staff. Management of the Deteriorating Patient Policy. Version 2 Issued 10/01/2014 (Review date 19th December 2016 (unless requirements change) Page 5 of 20 Portsmouth Hospitals NHS Trust Hospital Inpatient Areas Wards at Queen Alexandra Hospital Community Birthing Unit at St Mary’s Community Hospital Community Birthing Unit and Cedar Ward at Petersfield Community Hospital Community Birthing Unit and Ark Royal Ward at Gosport War Memorial Hospital. RSVP – A communication tool used by all clinical staff to structure communication when handing on information to a clinical colleague about a deteriorating patient. The RSVP communication tool is Reason, Story, Vital signs and Plan. (4) VitalPAC – An electronic track and trigger system that provides a recording mechanism for patient’s vital signs and essential screening tools. The data entered generates an Early Warning Score (EWS) and when appropriate prompts the clinical practitioner to escalate the patient’s condition appropriately. The system also alerts the practitioner if a set of vital signs are overdue. The recorded vital signs can be reviewed by authorised staff, along with EWS and laboratory data, to enable an accurate overview and prioritisation of patient assessment, treatment and discharge planning. VitalPAC Early Warning System (ViEWS) ViEWS is a tool for bedside evaluation incorporated into VitalPAC. It is based on six physiological parameters: pulse; temperature; systolic blood pressure; respiratory rate; AVPU (the level to which the patient responds), oxygen saturation, plus the patient’s inspired oxygen requirements. A ViEWS score should be recorded for every adult patient observation as detailed in Appendix 1. This has been adapted for the Maternity Dept Appendix 3 and Paediatric Dept Appendix 4. N.B ViEWS has the same physiological parameters and escalation criteria as the National Early Warning System (NEWS) launched in July 2012 (10). Therefore PHT is compliant with NEWS. Vital Signs/ Physiological observations Measures of various statistics taken by health professionals or their assistants in order to assess fundamental physiological functions. For the purposes for ViEWS this is pulse, temperature, systolic blood pressure, respiratory rate, AVPU (the level to which the patient responds) and oxygen saturation, plus the patient’s inspired oxygen requirements. 2222 is the emergency number for fast bleeping an individual or calling the Cardiac Arrest Team at Queen Alexandra Hospital (QAH). 5. DUTIES AND RESPONSIBILITIES Patient Safety Working Group The Patient Safety Working Group is responsible, through the receipt of quarterly reports from the Deteriorating Patient Group, for monitoring that there is continuous and measurable improvement in the quality of the services provided. Deteriorating Patient Group The Deteriorating Patient Group is responsible for ensuring that: This procedural document is up to date, technically accurate, is in line with evidencebased best practice and has been produced following consultation with stakeholders (5). Through the Chair, assurance on the effectiveness of this policy and the Trust’s procedures for the identification and management of the deteriorating patient, is provided through the receipt of quarterly reports to the Patient Safety Working Group, including any necessary recommendations to address identified deficits; Processes are in place to enable an annual audit of compliance using the audit tool from the NICE Clinical Guideline 50 (Appendix 5) and that the actions identified as a result of those audits are implemented. Management of the Deteriorating Patient Policy. Version 2 Issued 10/01/2014 (Review date 19th December 2016 (unless requirements change) Page 6 of 20 Line Managers Line Managers are responsible for: Ensuring all clinical staff receive training in the use of VitalPAC on local induction to the clinical areas. Monitoring data from VitalPAC to ensure there is a local plan to address any areas for improvement such as number of overdue flags. Ensuring that the clinical staff they are responsible for are aware of and apply this policy into clinical practice. 6. PROCESS 6.1 Identification of patients at risk of deterioration 6.1.1 The Trust uses an Early Warning Scoring (EWS) and graded response system to detect and monitor patients who are acutely ill or at risk of physical deterioration. During an adult in-patient episode all patient observations are recorded and scored as per ViEWS systems detailed in Appendix 1. For Maternity the adapted MEOWS system (Appendix 3) will be used and in Paediatrics the adapted PEWS system (Appendix 4) will be used. 6.1.2 All physiological observations must be recorded and acted upon by staff that have been trained to undertake these procedures and understand their clinical relevance. Registered and unregistered nursing staff caring for adult patients will undertake the relevant competency assessment (6, 7 & 8) 6.1.3 All patients must have physiological observations recorded at the time of admission or initial assessment, including patients in the Emergency Department. 6.1.4 All patients must have a clear written monitoring plan in their health record that specifies which physiological observations should be recorded, and how often. In addition it should specify the management of the patient and when they will be reviewed by nursing and medical staff. 6.1.5 All patients must have physiological observations recorded at least every 12 hours and the frequency should increase if abnormal physiology is detected as per escalation protocol (Appendix 2, 3 & 4). The exception to this will be individual patients who, following senior medical review, have the frequency of observations decreased. The rationale for this change in frequency must be documented in the patient’s notes. 6.2 Escalation Protocol and graded response 6.2.1 All patients will be monitored using the appropriate physiological track and trigger system (Appendix 2, 3 & 4). The track and trigger system will identify the appropriate graded response to abnormal physiological observations recorded or guide clinicians who are concerned. 6.2.2 By using the appropriate escalation protocol (Appendix 2, 3 & 4) as a framework it will ensure that a clinician with the expertise to respond is called and asked to attend within a specified timeframe. This will make sure that patients who are acutely ill or at risk of physical deterioration receive prompt care and decisions are made in a timely manner. 6.2.2 The person recording the vital signs and triggering an escalation response must document their actions in the patient’s notes using the ViEWS escalation sticker. 6.2.3 The person responding must document their actions and management plan in the patient’s notes. Management of the Deteriorating Patient Policy. Version 2 Issued 10/01/2014 (Review date 19th December 2016 (unless requirements change) Page 7 of 20 6.3 Communicating Deterioration (RSVP) 6.3.1 To improve communication it is recommended that the person calling for help uses a structured communication tool. The Reason-Story-Vital Signs-Plan system (4) is easy to remember in an emergency and ensures the essential information is communicated enabling an appropriate timely response. Reason: It’s ……………….on ward……………… I’m calling about (patient’s name) The reason I’m calling is……………….. Story: Reason for admission Relevant history Immediately preceding events Vital Signs: Heart rate…..BP…….. RR……. CRT……... SaO2………. FiO2………. AVPU……….. Temp……. ViEWS…………Urine Output…………. Gluc………... Plan: My plan is ………. What investigations? How often to monitor? Parameters for action? 6.4 Patient transfers 6.4.1 The member of staff responsible for patient care prior to transfer to a new location, must ensure a complete set of vital signs and an early warning score has been recorded immediately prior to transfer. The escalation protocol must be followed and if the nurse in charge or doctor have been informed of an increased EWS score (>3) they must assess the patient to determine if the transfer should be delayed for clinical reasons. 6.4.2 The member of staff responsible for patient care in the new location must complete set of vital signs and an early warning score within 15 minutes of the patient’s arrival in the new locality. 6.4.3 Patient transfers from critical care to general ward areas should occur as early as possible during the day and whenever possible be avoided between 22.00-07.00. 6.4.4 The critical care area transferring team and the receiving ward team should work together to ensure the patient is transferred safely. They should jointly ensure there is continuity of care through a formal structured handover of care from critical care Management of the Deteriorating Patient Policy. Version 2 Issued 10/01/2014 (Review date 19th December 2016 (unless requirements change) Page 8 of 20 area staff to ward staff (including both medical and nursing staff). This must be supported by a written plan and the receiving ward, with support from Critical Care Outreach if required, to ensure the ward can deliver the agreed plan. 6.5 Referral to Critical Care Outreach A referral to Critical Care Outreach should be 'considered' for: Any acutely ill or deteriorating ward in-patient who is causing concern (excludes the Emergency Department, Obstetrics, NICU and Paediatrics); As prompted by the ViEWS escalation protocol (Appendix 2). Critical Care Outreach can be contacted between the hours of 07.00 - 20.30 via Bleep 1676. 6.6 Referral to Critical Care For patients requiring admission to critical care: For urgent help bleep the critical care registrar on 1987; If the critical care registrar is uncontactable or referral does not require an immediate response, please phone extension 5752 (if engaged alternatives are 6035 / 6385 / 6852 / 6853). State you wish to make a referral and ask to speak to the critical care registrar. If unavailable you will be passed on to another member of the team The referral should be made by the most appropriate senior doctor involved in the patient care at that time. The decision to admit to Critical Care will be made by consultant in critical care in consultation with the referring team; The responsible consultant for the referring team should be aware and have agreed for the need for critical care referral. All relevant patient information will be required by critical care including: - referring clinicians name and grade - patients name and hospital number - patient’s location - relevant patient history - current vital signs and ViEWS score - recent important investigations and treatment should be at hand when you make the call. 6.7 Patients discharged from Critical Care All patients discharged from Critical Care will be reviewed by the Critical Care Outreach team to monitor progress and provide support to the ward staff. After the decision to transfer a patient from a critical care area to the general ward has been made, the patient should be transferred as early as possible during the day. Transfer from critical care areas to the general ward between 22.00 and 07.00 should be avoided whenever possible, and should be documented as an adverse incident if it occurs. 7. TRAINING REQUIREMENTS 7.1 An introduction to VitalPAC and all Early Warning Systems is included on Trust Induction. 7.2 All Line Managers have a responsibility to ensure that following induction all clinical staff received additional training relevant to their role, level of responsibility and clinical area. For areas using VitalPAC, this must include recording vital signs, responding to the escalation prompts appropriately and care and maintenance of the equipment. 7.3 All Registered and Unregistered Practitioners caring for adult patients must undertake competency assessments in the taking, recording and assessment of vital signs in Adults Management of the Deteriorating Patient Policy. Version 2 Issued 10/01/2014 (Review date 19th December 2016 (unless requirements change) Page 9 of 20 and Assessing the Physical Well-being of an Adult Patient as per current Generic Competency Framework for Registered and Unregistered Practitioners 7.4 All Trust Resuscitation Training embodies the statements and guidelines published by the Resuscitation Council (UK). This recommends that resuscitation training incorporates the identification of patients at risk of deterioration, ViEWS and the escalation protocol. All clinical staff must be trained annually in cardiopulmonary resuscitation to a level appropriate to their clinical roles and responsibilities, which will include an annual update in aspects of care of the deteriorating patient and calling for help, including the relevant Early warning System. 8. REFERENCES AND ASSOCIATED DOCUMENTATION 1. NICE Clinical Guideline 50. Acutely ill patients in hospital. Recognition of and response to acute illness in adults in hospital. July 2007. 2. NPSA. PSO/5. Safer care for the acutely ill patient: learning from serious incidents (2007) 3. Comprehensive Critical Care. A Review of Adult Critical Care Services. DoH. (2000) 4. Featherstone P, Chalmers T, Smith GB. RSVP: a system for communication of deterioration in hospital patients. Br J Nursing. 2008;17(13):860-64 5. Procedural Documents Development And Management Policy http://pht/PoliciesGuidelines/Pages/default.aspx 6. Current Nursing and Midwifery Competency for Taking, recording and assessment of vital signs in Adults. http://www.phtlearningzone.org.uk/index.php?page=generic-nursing-andmidwifery-competency-framework 7. Current Nursing and Midwifery Competency for Assessing the Physical Well-being of an Adult Patient. http://www.phtlearningzone.org.uk/index.php?page=generic-nursing-andmidwifery-competency-framework 8. Current Generic Competency Framework for Registered and Unregistered Practitioners http://pht/PoliciesGuidelines/NursingandMidwiferyPolicies/default.aspx?PageView=Shared 9. Resuscitation Guidelines (UK) 2010. http://www.resus.org.uk/pages/guide.htm 10. National Early Warning Score (NEWS) | Royal College of Physicians 9. EQUALITY IMPACT ASSESSMENT Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds. This policy has been assessed accordingly Management of the Deteriorating Patient Policy. Version 2 Issued 10/01/2014 (Review date 19th December 2016 (unless requirements change) Page 10 of 20 10. MONITORING COMPLIANCE This policy will be monitored to ensure it is effective and to assure compliance Minimum requirement to be monitored Implementation of NICE Clinical Guideline 50 Lead Chair of Deteriorating Patient Group Tool NICE Clinical Guideline 50 audit tool (Appendix 5) Management of the Deteriorating Patient Policy. Version 2 Issued 10/01/2014 (Review date 19th December 2016 (unless requirements change) Frequency Annually Reporting arrangements Results of audit will be presented to the Deteriorating Patient Group and Patient Safety Working Group. Information on status of action planning and learning, as a result of the audit will be reported quarterly to the Patient Safety Working Group Page 11 of 21 Acting on recommendations and Lead(s) Chair of the Deteriorating Patient Group Appendix 1 VitalPAC Early Warning Score (ViEWS) parameters for Adult patients at October 2013 Management of the Deteriorating Patient Policy. Version 2 Issued 10/01/2014 (Review date 19th December 2016 (unless requirements change) Page 12 of 21 Appendix 2 Escalation Protocol for the ViEWS for Adult patients at October 2013. Used on Queen Alexandra Hospital Site Management of the Deteriorating Patient Policy. Version 2 Issued 10/01/2014 (Review date 19th December 2016 (unless requirements change) Page 13 of 21 Appendix 3 Modified Early Obstetric Warning System (MEOWS) Management of the Deteriorating Patient Policy. Version 2 Issued 10/01/2014 (Review date 19th December 2016 (unless requirements change) Page 14 of 21 Appendix 3 (cont) Modified Early Obstetric Warning System (MEOWS) Management of the Deteriorating Patient Policy. Version 2 Issued 10/01/2014 (Review date 19th December 2016 (unless requirements change) Page 15 of 20 Appendix 4 PHT Paediatric Early Warning Score (PEWS) Example of PEWS Vital Signs Chart Management of the Deteriorating Patient Policy. Version 2 Issued 10/01/2014 (Review date 19th December 2016 (unless requirements change) Page 16 of 20 PEWS Instructions Score 1 point for every observation in shaded area Score an extra point for any of the additional factors Temp. above 38C in baby 0-3months Temp. above 39C in baby3-6months Temp. above 38.5C in immunosuppressed (e.g. oncology) patient Requiring Oxygen (or increase in O2 dependant babies) Capillary refill time greater than 2 Increasing pain which is causing distress PEWS score = sum of entries in shaded areas plus 1 point each for any of the additional features present Actions for a new or increasing PEWS score PEWS score 0-1 2 3 4 5 & above Action Continue monitoring Nurse in charge & SHO review Registrar review, must complete Action Plan Inform Consultant Consultant to attend if not already present A PEWS score of 3 should trigger a Registrar review within 1 hour. If Nursing staff are concerned that the child’s condition requires more urgent attention, regardless of the PEWS score, they should be asked to attend sooner. If the Registrar is unable to attend the consultant must be informed. Note All patients should be reviewed by the doctors of the team responsible for their care, however if nursing staff have significant medical concerns or there is a major delay in the attendance of the team, the Nurse in Charge may call the paediatric team to review. Management of the Deteriorating Patient Policy. Version 2 Issued 10/01/2014 (Review date 19th December 2016 (unless requirements change) Page 17 of 20 Appendix 5 Title: Acutely ill patients in hospital NICE clinical guideline 50 Audit criteria: These are the audit criteria developed by NICE to support the implementation of this guideline. Users can cut and paste these into their own programmes or they can use this template Criterion no. Criterion Exceptions Definition of terms and/or general guidance Data source 1 Physiological observations in acute hospital settings None. As a minimum, the following physiological observations should be recorded at the initial assessment and as part of routine monitoring: heart rate respiratory rate systolic blood pressure level of consciousness oxygen saturation temperature. Patient health record. Percentage of patients who have had their physiological observations recorded at the time of admission or initial assessment. (Acute hospital settings) (Standard = 100%) 2 Physiological observations in acute hospital settings None. (Standard = 100%) Patient health record. None. (Standard = 100%) Patient health record. Percentage of patients for whom a clear written monitoring plan that specifies which physiological observations should be recorded, and how often, is present in the health record. (Acute hospital settings) 3 Identifying patients whose clinical condition is deteriorating or is at risk of deterioration Percentage of patients monitored using a physiological track and trigger system. Local policy and procedure documents. (Acute hospital settings) 4 Identifying patients whose clinical condition is deteriorating or is at risk of deterioration For 4a: Individual patients for whom the decision to For those patients monitored using a physiological track and increase or trigger system: decrease the a) the percentage whose physiological observations were monitoring monitored at least every 12 hours frequency has b) the percentage of patients for whom there is evidence of been made at a Management of the Deteriorating Patient Policy. Version 2 Issued 10/01/2014 (Review date 19th December 2016 (unless requirements change) For 4b: The frequency of monitoring should increase as outlined in the recommendation on locally agreed and delivered graded response strategies. (Standard = 100% in each case) Page 18 of 21 Patient health record. Criterion no. 5 Criterion Exceptions increased frequency of monitoring in response to the detection of abnormal physiology. (Acute hospital settings) senior level. Graded response strategy None. There is an agreed and locally delivered graded response strategy in place for patients identified as being at risk of clinical deterioration. Definition of terms and/or general guidance Data source Further information, and a description of the recommended graded response strategy, can be found on page 14 of the NICE guideline document (section 1.2.2.10). Local policy and procedure documents. (Standard = 100%) (Acute hospital settings) 6 Graded response strategy None. (Standard = 100%) Patient health record. None. Transfer from critical care areas to the general ward between 22.00 and 07.00 should be avoided whenever possible. Patient health record. For those patients admitted to a critical care area, the percentage of patients for whom there is evidence that the decision to admit was made by both the consultant caring for the patient on the ward and the consultant in critical care. (Acute hospital settings) 7 Transfer of patients from critical care areas to general wards For those patients transferred from a critical care area back to a general ward, the percentage for whom this transfer occurred between 22.00 and 07.00. (Standard = 0%) (Acute hospital settings) 8 Transfer of patients from critical care areas to general wards None. For those patients transferred from a critical care area back to a general ward between 22.00 and 07.00, the percentage where this transfer was documented as an adverse incident. Transfer from critical care areas to the general ward between 22.00 and 07.00 should be avoided whenever possible, and should be documented as an adverse incident if it occurs. (Standard = 100%) (Acute hospital settings) Management of the Deteriorating Patient Policy. Version 2 Issued 10/01/2014 (Review date 19th December 2016 (unless requirements change) Page 19 of 20 Patient health record. Adverse incident reports. Criterion no. Criterion 9 Care on the general ward following transfer Exceptions Patients who have not been Percentage of patients for whom there is a formal structured transferred from a handover of care from critical care area staff to ward staff critical care area to (including both medical and nursing staff), supported by a a general ward. written plan. Definition of terms and/or general guidance Data source The critical care area transferring team and the receiving ward team should take shared responsibility for the care of the patient being transferred. Patient health record.Writte n care plan that details the formal structured handover of care. (Standard = 100%) (Acute hospital settings) 10 Care on the general ward following transfer Percentage of patients for whom the formal structured handover of care (supported by a written plan) includes: c) a summary of the critical care stay, including diagnosis and treatment d) a monitoring and investigation plan e) a plan for ongoing treatment, including drugs and therapies, nutrition plan, infection status and any agreed limitations of treatment f) physical and rehabilitation needs g) psychological and emotional needs h) specific communication or language needs. Patients who have (Standard = 100% in each case) not been transferred from a critical care area to a general ward. (Acute hospital settings) No. of criterion replaced Local alternatives to above criteria (to be used where other data addressing the same issue are more readily available) Management of the Deteriorating Patient Policy. Version 2 Issued 10/01/2014 (Review date 19th December 2016 (unless requirements change) Page 20 of 20 Patient health record. Written care plan that details the formal structured handover of care.