Download The Early Warning Score - Canterbury District Health Board

The Early Warning Score –
Recognising the Deteriorating Patient
Tania Fowler
Clinical Nurse Specialist, Intensive Care Outreach
September 2015
What to expect today…………..
• Early Warning Scores – Why?
Health and Disability Commissioner
• Early Warning Scores - Who?
• Early Warning Scores - How?
• A, B and C
• …….. and D
• Patients at risk
• Questions?
Why?
• Despite our best intentions
• Despite our best effort
• Despite providing the best care and
• the focused and astute management of all staff
- the condition of some patients in your care will deteriorate….
the best thing we can all do is to detect this deterioration early and act.
CHECK
Many patients in hospital are complex and time consuming. We have
-
an ageing population – many of whom are frail
complex paediatric patients
less invasive surgical procedures now allow greater access to procedures for some patients
improved anaesthetic techniques allowing frailer patients access to interventions
new drug therapies that are improving and extending lives
higher expectations for access to care for all patients regardless of age and co-morbidities
Health and Disability
Commissioner Report
• 50 year old man admitted to Wellington Hospital in 2005 with a chest
infection –died 40 hours later
• Virtually no clinical observations performed during the last 12 hours of his
life
• Poor handover from RN to RN shift to shift, EN allowed to practise outside
her scope of practise
• Chest XR and bloods not reviewed for 30 hours – by house surgeon,
registrar or consultant
• Did not appropriately respond to the patient’s nicotine addiction
• Inadequate response to shortages in nursing and medical staffing
• Lack of care planning, ineffective communication and discontinuity of care
who….CDHB Patient
Recordings Policy for staff
• Found in Volume D of Canterbury District Health Board Policy and
Procedures manual – Section 6
• Temperature – tympanic, oral, auxilla, rectal
• Heart Rate – if taken manually take for 30 – 60 seconds, if using a
pulse “ox” - palpate the pulse to see if regular or irregular
• Blood Pressure – accurate cuff size is essential – if recording is very
low or very high – check manually
• Respiratory Rate – count for a minimum of 30 seconds, 60 seconds
preferred – also observe “work of breathing”
• “How” to record these is clearly documented on observation chart
So….how does it work?
• Routinely calculate the EWS on every set of observations, every set
must be a complete set as per CDHB policy
• Visually easy to see trends in each component of observation chart
• Follow the management pathway
• ALWAYS involve the home team
• Scores of >6 invite immediate contact with ICU team
• We can be contacted regardless of EWScore – “gut feelings”
• Outreach Service is staffed 24/7 by RN and Registrar
Airway, Breathing and Circulation…..a…b…c…
• A for Airway
• B for Breathing – rate, Sp02,
oxygen delivered and device
used
• C for circulation – heart rate –
regular or irregular?
• C is still for Circulation….blood
pressure
• Temperature
D……… for disability
• Alert – patient reacting reasonably to
normal stimuli, need not be fully
orientated or understanding
• Verbal – patient found with eyes
closed but responds to voice
• Pain – patient rouses to painful
stimuli – central pain only
• Unresponsive - patient does not
rouse to any stimuli
• If mixed response use the best
response they are able to maintain
Urine output…..
• Urine output is a recording that
provides information about the
patient’s blood pressure and
fluid status – and let us know if
we have the balance right – so
two for the price of one.
• Urine maybe a waste product
but it is a very important one!
• Urine EWS is the most
poorly done component of
the total EWS score – ask
your preceptor to explain it
to you and you can both
learn how to do it correctly.
Intensive Care Outreach
• Patients discharged from Intensive Care are seen on the ward the day
following discharge – we can continue to see these patients if they
are not progressing as expected
• Respond to calls/pages regarding deteriorating patients
• Attend Clinical Emergencies on the Christchurch Hospital campus
• We see our service as working with the home team, not taking over
from or dictating to the home team
• Remember…………………….Intensive Care staff recognise the stressful
environment in which we all work and the increasing complexity of
patients in our care
Who is most likely
to deteriorate?
• Emergency admissions
• Particularly severe presentations of acute illness – e.g. pneumonia
• Those who have failed first line therapies
• The elderly and the very young – limited coping mechanisms
• Those with significant comorbidities – diabetes, chronic renal failure,
heart disease, chronic lung disease
• Immunosuppressed – steroid dependent, recent chemotherapy
• Pregnant and post partum women
Questions…………
Thank you
Patients to “think twice about”
• Patients with a history of violence in their backgrounds – difficult trusting
staff, difficulty verbalising how they are, wanting to please, fearful
• Those for whom English is a second language
• When family members are translating – cultural basis to say what we want
to hear, difficulty answering or translating information accurately
• Chronically mentally ill patients – cognitive functioning maybe affected by
long term psychiatric disease or medications – also maybe acutely unwell
and experiencing hallucinations
• Patients with obvious speech difficulties – history of a CVA or cerebral
bleed, head and neck surgery, movement disorders.
• People who say or indicate “yes” a lot – those who do not reply “no”