CCDHB Early Warning Score & Vital Sign Charts eLearning Package September 2015

Pdf 3. Escalation pathway Welcome Page CCDHB Early Warning Score (EWS) Welcome to the EWS and vital sign chart e-learning site. This resource provides an opportunity to learn about the use of the new adult EWS system which is being introduced across Capital & Coast and Hutt Valley DHBs. The online training will help you learn how to fill in the new charts and operate the escalation pathway. Please note that the adult EWS is designed for use in adults aged 16 years and above. For children please refer to the PEWS system or for pregnant patients please use MEOWS. NB – Wairarapa DHB TBC Click on blue “Begin Training” box to be taken to logon page (DHB user ID and password) and then to training session Begin Training Resources Pdf 1. EWS matrix Pdf 2. EWS chart Pdf 3. Escalation pathway

Training Session Learning objectives EWS parameters Calculating an EWS & recording vital signs Triggering an EWS response & escalation EWS Quiz

Learning Objectives After completion of this e-learning session you will be able to: Understand the benefits of CCDHB’s EWS Describe the seven EWS parameters Calculate an EWS correctly Describe CCDHB’s EWS triggers for initiating a response Outline how the EWS escalation pathway works Understand how the EWS Modification Box is used

1. Benefits of EWS Early Warning Scores (EWS) have been developed internationally to help identify acutely ill and deteriorating patients in acute care hospitals EWS systems focus on the EARLY recognition of the clinical signs of deterioration. Having recognised at-risk patients, the system then trigger an escalation response to prevent further deterioration that may lead to a cardiac arrest. This EARLY approach to acute deterioration optimises patient outcomes.

The CCDHB EWS The NEWS (National Early Warning Score from the UK NHS) is the only evidence-based EWS system. It is better at predicting death, cardiac arrest or ICU admission than any other published EWS system. (Prytherch, Smith, Schmidt & Fetherstone, 2010) The new CCDHB EWS system is based on NEWS and modified to include emergency escalation for patients at high risk of imminent death.

2. EWS Parameters There are 7 parameters that form the basis for CCDHB’s EWS: Respiratory rate Oxygen saturation Supplemental oxygen administration Temperature Systolic blood pressure Heart rate Level of consciousness

Respiratory Rate An elevated respiratory rate is one of the most sensitive indicators of acute illness in adult patients A reduced respiratory rate may be an indicator of narcosis or neurological depression To measure respiratory rate accurately, the patient’s breathing must be assessed for a full minute

Oxygen Saturations Measurement of oxygen saturation by pulse oximetry is now standard practice in acute care settings Decreased oxygen saturations can be an indicator of impaired pulmonary or cardiac function When using a pulse oximeter, make sure that the nail/skin interface is clean from anything that might impair the trace such as nail polish

Supplemental Oxygen Patients who acutely require any supplemental oxygen (via face mask or nasal cannula) to maintain oxygen saturation are, by the fact they need oxygen, recognised to be at a higher risk of deterioration As such a score of 2 is added to the EWS when supplemental oxygen is used on any patient Oxygen is a drug and must be prescribed along with the intended target oxygen saturations

Temperature Extremes of body temperature are sensitive markers of acute illness A low temperature (hypothermia) may be an indicator of severe infection or endocrine derangement A high temperature (hyperthermia) can be an indicator of acute infection, inflammation, brain injury or a reaction to certain types of drugs

Systolic Blood Pressure A low blood pressure (hypotension) is a significant marker of acute deterioration and may be due to sepsis, dehydration, cardiac failure or rhythm disturbances as well as the effects of medication A high blood pressure (hypertension) is an important risk factor for cardiovascular disease and may be related to another acute process (such as a stroke or severe pain) To capture the most accurate blood pressure, it is necessary to use a manual blood pressure cuff. When measuring blood pressure with a rapid irregular heart beat, automatic devices are less accurate

Heart Rate Heart rate is an important indicator of any acute condition A fast heart rate (tachycardia) may be due to a number of causes: An arrhythmia Sepsis Metabolic disturbances Pain, nausea or distress Medications or reactions to them A slow heart rate (bradycardia) may be due to a heart block, altered conscious state, or electrolyte disturbances. It may also be a consequence of medication (beta blockers) or physical fitness When assessing the heart rate it is best practice to manually feel (palpate) the pulse, rather than rely on pulse oximetry. Palpation will provide additional important clinical information such as skin temperature, regularity and strength of the pulse

Level of Consciousness A decreased level of consciousness may be a late sign of deterioration. It can be caused by a large number of conditions including sepsis, low blood pressure, stroke or drug effects The AVPU assessment is a quick tool to measure a patient’s level of consciousness. The best response should be recorded: A – alert or awake V – responds to voice P – responds to a painful stimulus U – unresponsive to all stimuli

3. Using EWS When a patient is admitted acutely, a full set of vital signs with EWS calculation must be carried out every SIX hours for the first 24 hours of admission (Essential Vital Sign Measurement & EWS protocol 1.3091) The frequency for taking vital signs should be increased or decreased according to the clinical need of the patient Each vital sign is scored so that the more abnormal it is, the higher the EWS. The scores range from 0 (normal) to 3 (very abnormal) The individual scores for each parameter are added together to calculate a total EWS that, if abnormal, triggers a clinical response

The vital sign charts are colour-coded to identify each EWS zone: White = normal Yellow = potential to deteriorate Orange = indicates acute illness or unstable chronic disease Red = likely to deteriorate rapidly Blue = immediately life threatening critical illness CCDHB’s EWS system also allows for single parameter scoring i.e. if any vital sign falls in a coloured zone, the associated action is triggered

EWS Process 1. Measure & document a full set of vital signs 2. Calculate & document the EWS 3. Use the EWS to identify the appropriate level of escalation 4. Consider most appropriate clinical setting for ongoing care

4. CCDHB EWS Matrix Plans for piloting delayed until New Year 2015.

Wellington Adult Vital Sign Chart TBC once VSC is complete

Other Charts In addition to the general adult vital signs chart, there are different charts for certain specialties: Neurology/Neurosurgery Cardiology Cardiothoracic High Dependency Area Paediatric & Maternity services have different EWS systems (PEWS & MEOWS) adjusted for the different vital sign values with age & pregnancy

5. Escalation Pathway The escalation pathway is MANDATORY across all clinical areas where EWS is in use There are four levels to the CCDHB escalation pathway

EWS 1-5 TBC with clinical leaders

EWS 6-7 TBC

EWS 8-9 TBC

EWS 10+ TBC

The EWS system does not replace sound clinical judgment If the ‘Mandatory Action’ does not occur within the time specified, escalate to the next coloured zone If you are seriously concerned about any patient, regardless of their vital signs or their EWS, dial 777 immediately & ask for a Medical Emergency Team (or ‘MET’). Give your location & stay with the patient until help arrives.

6. Modification to EWS Triggers There are cases when clinically stable patients may have abnormal vital signs that are ‘normal’ for them. To accommodate this and prevent alarm-fatigue from over-triggering patient reviews, the EWS can be modified Any modification to the EWS must be made by a Consultant or Registrar and should be regularly reviewed by the primary medical team to ensure it is still valid

6. Modification to EWS Triggers Modification to EWS must NEVER be used to normalise abnormal vital signs in clinically unstable patients, or to deter ward staff from accessing the help they need i.e. to prevent 777 calls from being made appropriately on deteriorating patients Any modification that is not signed & dated must be ignored Any patient in whom Cardiopulmonary Resuscitation (CPR) or a Medical Emergency Team (MET) call is inappropriate can have this notified on their Vital Signs Chart. All limitations must also be documented in the patient’s clinical record

TBC

EWS Quiz

True or False? EWS focus on early recognition of clinical signs and help identify deteriorating patients  EWS have been shown to decrease numbers of in-hospital cardiac arrest  CCDHB’s EWS is based on a validated system which has been demonstrated to be superior to other EWS systems at predicting in-patient cardiac arrest or death   for True,  for False Submit Answer

What are the 7 EWS parameters? Temperature  Heart rate  Level of consciousness  Urine output  Oxygen saturation  Systolic blood pressure  Supplemental oxygen  Diastolic blood pressure  Respiratory rate   for True,  for False. On quiz, blank answer boxes are provided which when clicked are automatically occupied with a tick. Double click to remove an answer. Press ‘Submit Answer’ once you think you have the correct EWS. The correct answer is then revealed. Submit Answer

Which of the vital signs is considered the most sensitive indicator of acute illness? Temperature  Heart rate  Respiratory rate   for True,  for False Submit Answer

At CCDHB, what is the minimum frequency of vital signs to be taken on every patient within 24 hours of admission? Daily  Once per shift  6 hourly   for True,  for False Submit Answer

Use the CCDHB EWS Matrix (insert link to EWS matrix) to calculate the EWS: Respiratory Rate 32  Oxygen Saturation 95%  Supplemental Oxygen 4L/min  Temperature 36.6  Systolic BP 155  Heart Rate 132  Conscious level Alert, but tired  Click on circle and enter number 0-3 Submit Answer

Escalation Response The correct EWS is 9 Respiratory Rate 32  Oxygen Saturation 95%  Supplemental Oxygen 4L  Temperature 36.6  Systolic BP 155  Heart Rate 132  Conscious level Alert, but tired  Escalation Response = link to appropriate part of escalation pathway (red zone) Escalation Response The correct EWS is 9

Use the CCDHB EWS Matrix (insert link to EWS Matrix here) to calculate the EWS: Respiratory Rate 20  Oxygen Saturation 97%  Supplemental Oxygen 8L  Temperature 37.8  Systolic BP 105  Heart Rate 98  Conscious level Alert  Submit Answer

Escalation Response The correct EWS is 4 Respiratory Rate 20  Oxygen Saturation 97%  Supplemental Oxygen 8L  Temperature 37.8  Systolic BP 105  Heart Rate 98  Conscious level Alert  Escalation Response = link to appropriate part of escalation pathway (yellow zone) Escalation Response The correct EWS is 4

Use the CCDHB EWS Matrix (insert link to EWS Matrix here) to calculate the EWS: Respiratory Rate 9  Oxygen Saturation 92%  Supplemental Oxygen Room Air  Temperature 37.2  Systolic BP 115  Heart Rate 48  Conscious level Voice  Submit Answer

Escalation Response The correct EWS is 8 Respiratory Rate 9  Oxygen Saturation 92%  Supplemental Oxygen Room Air  Temperature 37.2  Systolic BP 115  Heart Rate 48  Conscious level Voice  Escalation Response = link to appropriate part of escalation pathway (blue zone) Escalation Response The correct EWS is 8

Place the EWS processes in the correct order Measure & document a full set of vital signs Calculate & document the EWS Use the EWS to identify the appropriate level of escalation Consider most appropriate clinical setting for ongoing care Drag and drop text boxes into the correct sequential order. If logistically impossible, then have the 4 processes set out in a table format, with blank boxes next to them in which you can enter their order (1-4).

True or False? The general adult EWS chart is used throughout adult wards at Kenepuru and Wellington campuses The adult EWS is designed for adults over the age of 16 years The colour-codes used to help identify each EWS zone are: yellow, orange, red and blue 

True or False? The EWS replaces sound clinical judgment The EWS can only be modified by a Consultant or Registrar Red is the colour associated with triggering MET   Blue is the colour associated with MET