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Guiding Framework and Policy

for the National Early Warning Score System

to Recognise and Respond to Clinical Deterioration

Document reference number:V1290611

Revision number:

Document approved by:

e-... ,.t'(>_~."""""==.Ms laverne McG~ National DirectorInt rated ervlces rate

,Mf. MictllIel Shannon, Nurslng andMidwifery 5erv\ca Director

Document Developed by:The National Early Warning ProjectGovemance and Advisory Groups as aWork streilm of the Acute MedicinePro ramme

Date: s1t~ l§:>1/

'gs;)~Dr. aarry Wtl~,~""!<l;zo.,c"';;;::,~::::o=,.-a"";"=;a""Strategy and Programm

Approval date: Responsibility for implementation:All healthcare staff

Revision date: Responsibility for review and audit:Each acute hos ltal service

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Table of Contents: Page 1.0 Guiding Framework Statement 4 2.0 Purpose 4 3.0 Scope 5 4.0 Legislation/other related policies 5 5.0 Glossary of Terms and Definitions 6 6.0 Roles and Responsibilities 7 6.1 HSE 7 6.2 Regional Director of Operations/Senior managers 7 6.3 Senior management acute healthcare facility 7 6.4 Heads of Department 7 6.5 All clinical staff 7 7.0 Guideline 8 7.1 Guiding Principles 8 7.2 Essential elements 9 7.2.1 Clinical processes 9 7.2.1.1 Measurement and documentation of observations 9 7.2.1.2 Escalation of care 10 7.2.1.3 Rapid response systems 12 7.2.1.4 Clinical communication 13 8.0 Implementation Plan 13

8.1 Organisational supports 13 8.2 Education 14

9.0 Evaluation and Audit 15

10.0 References and Bibliography 17

11.0 Appendices 19 Appendix I Model Patient Observation Chart incorporating MEWS 20

Appendix II MEWS Protocol (Escalation Flow Chart) 23 Appendix III Pathway schema for the acutely ill patient using Acute 24

Medicine Programme Hospital Models

Appendix IV ISBAR Communication Tool 25 Appendix V National EWS and associated education programme –

Implementation Guide 26 Appendix VI Governance Structures for the Implementation of the National 29

Early Warning Score and associated Adult Education programme

Appendix VII Overview of COMPASS© training programme 31

Appendix VIII Outline of Recommended Audits and evaluations to support implementation of the national EWS system 32

Appendix IX National Policy and Procedure for use of the Modified Early Warning Score System to recognise and respond to Clinical Deterioration (template for local adaptation) 34

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Acknowledgements: The ‘Guiding Framework and Policy for the National Early Warning Score System Policy to Recognise and Respond to Clinical Deterioration’ has been primarily derived from the ACSQHC (2010) ‘National Consensus Statement: essential elements for recognising and responding to clinical deterioration’, and has been amended to suit the Irish context, with kind permission from Dr Nicola Dunbar, Program Manager, Recognising and Responding to Clinical Deterioration Programme, Australian Commission on Safety and Quality in Health Care. Acknowledgement is also extended to Australian Capital Territory, ACT Health, for granting permission to utilise and amend the COMPASS© programme to suit the Irish Healthcare system..

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1.0 Guidance Framework Statement 1.1 The Health Service Executive (HSE) is committed to the provision of safe, high quality health services. 1.2. Patient safety and quality are central to the delivery of healthcare. The HSE, among others, is

a signatory to the 'Patient Safety First' declaration of commitment. The National Early Warning Score and associated Education Programme for the early detection and management of deteriorating patients is about improving outcomes for patients by improving the safety record in our health services. The HSE is committed to ensuring that patients at risk of clinical deterioration in acute healthcare facilities are promptly identified and managed according to their clinical need.

1.3 On admission to hospital patients may be acutely unwell or, due to their clinical condition,

they may deteriorate to the extent that they may be at risk of becoming acutely ill during their period of hospitalisation. Patients are entitled to the best possible care and need to be confident that should their clinical condition deteriorate that they will receive prompt and effective treatment. Early recognition of clinical deterioration, followed by prompt and effective action, can minimise the occurrence of adverse events such as cardiac arrest, and may mean that a lower level of intervention is required to stabilise a patient.

1.4 More recent evidence, and international experience, has identified that a systematic approach

to identification and management of the deteriorating patient can improve patient outcomes, prevent death and reduce morbidity. Early warning scores have been developed to facilitate early detection of deterioration by categorising a patient’s severity of illness and prompting nursing, and other healthcare professionals, to request a medical review at specific trigger points, utilising structured communication tools whilst following a definitive escalation plan.

1.5 This Guiding Framework defines the nationally agreed practice for recognising and responding

to clinical deterioration. The national standard for recognising and responding to clinical deterioration is the National Early Warning Score, the Modified Early Warning Score (MEWS) system, which must be implemented in acute healthcare facilities. To achieve this acute hospitals need to have systems in place to address all the elements in the framework.

1.6 ‘Consistent use of a single agreed EWS system will ensure that all patients are objectively

assessed in the same way, regardless of the clinical expertise of the clinician or where the patient is assessed. This will ensure that the severity of illness and the rate of deterioration can be explicitly stated and understood throughout the entire Irish hospital service. This will facilitate the early detection and transfer of patients who are likely to deteriorate. The EWS will also facilitate reverse flow of stabilised patients. This should ensure improved inter-professional communication and facilitate better and more uniform patient care. It will also enable audit of outcomes and performance comparison between different health care facilities’ (Report of the Acute Medicine Programme, 2010 p41).

1.7 The National Early Warning Score initiative, and associated education programme, is a work

stream of the Acute Medicine Programme, in association with the Critical Care, Emergency Medicine, and Elective Surgery programmes, Quality and Patient Safety, Office of the Nursing and Midwifery Services Director, Clinical Indemnity Scheme, the Assistant National Director, Acute Hospital Services – Integrated Services Directorate, Irish Association of Directors of Nursing and Midwifery (IADNAM) and Therapy Professionals.

2.0 Purpose 2.1 The purpose of the Guiding Framework is to describe the elements that are essential for

prompt and reliable recognition of, and response to, clinical deterioration of patients in acute healthcare facilities.

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2.2 The Guiding Framework should guide healthcare facilities in developing recognition and response systems tailored to their patient population, and to the resources and personnel available.

2.3 The Guiding Framework supports the implementation of the national standard for the

Modified Early Warning Score (MEWS) system and supporting multidisciplinary educational programme (COMPASS©), and the standard communication tool ‘ISBAR’ (Identification; Situation; Background; Assessment; Recommendation).

3.0 Scope 3.1 The Guiding Framework relates to the situation in the acute healthcare setting, where a

patient’s physiological condition is deteriorating. The general provision of care in a hospital or other facility is outside the scope of this document.

3.2 The Guiding Framework focuses on ensuring that a track and trigger system is in place for patients whose condition is deteriorating, and outlines the organisational supports required to operationally progress implementation. It does not indicate the specific clinical treatments or interventions that may be needed to stabilise a patient.

3.3 The Guiding Framework applies to all patients in acute care facilities (HSE Model 1,2,3 and 4

hospitals). This includes: • All inpatients on initial assessment, and as per clinical condition and clinical treatment. • Any outpatients/day services patients who attend acute healthcare facilities for an invasive procedure or who receive sedation. • All patients attending the Acute Medical Unit/ Acute Medical Assessment Unit/

Medical Assessment Unit • In the Emergency Department clinical assessment in triage will identify the

patients requiring MEWS. This is to be undertaken at the Advanced Triage stage in the patient journey that occurs after the initial Manchester triage. However, all patients identified for admission should have a MEWS assessment incorporated, as part of the triage process.

• Any patient where the professional judgement of staff indicates a need to carry out a MEWS because of concerns about their condition.

3.4. The Guiding Framework does not apply to patients in paediatric departments or in obstetric

care. 3.5. The Guiding Framework applies to healthcare professionals and managers responsible for the

development, implementation, review and audit of recognition and response systems in individual hospitals or groups of hospitals.

3.6. The Guiding Framework also applies to training and education support staff involved in the

organisation and delivery of the COMPASS© training programme. 4.0 Legislation/other related policies

o An Bord Altranais (2000) The Code of Professional Conduct for each Nurse and Midwife

o An Bord Altranais (2000) Scope of Nursing and Midwifery Practice Framework o An Bord Altranais (2002) Recording Clinical Practice Guidance to Nurses and Midwives o Health Act (2004) Government of Ireland o National Hospitals Office (2007) Code of Practice Standards for Healthcare Records

Management o Health Service Executive (2008) Code of Practice for Integrated Discharge Planning

HSE

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o Health Service Executive (2009) Framework for the Corporate and Financial Governance of the HSE Document 1.1 (V3)

o Health Service Executive (2007) Quality and Risk Management Standard.

5.0 Glossary of Terms ands Definitions

Acute healthcare facility: A hospital or other healthcare facility providing health care services to patients for short periods of acute illness, injury or recovery. Advanced life support: The preservation or restoration of life by the establishment and/or maintenance of airway, breathing and circulation using invasive techniques such as defibrillation, advanced airway management, intravenous access and drug therapy. AMAU: Acute Medical Assessment Unit AMU: Acute Medical Unit

Early Warning Score (EWS): Early warning scores have been developed to facilitate early detection of deterioration by categorising the patient’s severity of illness and prompting nursing staff to request a medical review at specific trigger points utilising structured communication tools whilst following a definitive escalation plan. (Mitchell IA, McKay H, Van Leuvan C, et al. 2010) Emergency Response Team (ERT): The emergency response team must be identified in each acute hospital for daytime, out of hours, weekends as appropriate to the hospital model (refer to hospital models in the Report of the National Acute Medicine Programme (2010)). Escalation protocol: The protocol that sets out the organisational response required for different levels of abnormal physiological measurements or other observed deterioration. The protocol applies to the care of all patients at all times HSE: Health Service Executive

ISBAR: a mnemonic to encourage consistent language and to improve multidisciplinary communication. ISBAR correlates to:

o IDENTIFY: Identify yourself, who you are talking to and who you are talking about o SITUATION: What is the current situation, concerns, observation, MEWS. o BACKGROUND: What is the relevant background? This helps set the scene to

interpret the situation above accurately. o ASSESSMENT: What do you think the problem is? This requires the interpretation of

the situation and background information to make an educated conclusion about what is going on.

o RECOMMENDATION: What do you need them to do? What do you recommend should be done to correct the current situation?

MAU: Medical Assessment Unit

MEWS Protocol is an outline of the graded track and trigger response to the MEWS. It outlines the escalation procedure and key responsibilities of nursing and medical staff in initiating the response to the clinically deteriorating patient.

Modified Early Warning Score (MEWS) is a bedside score and track and trigger system that is calculated by nursing staff from the observations taken, to indicate early signs of a patient’s deterioration. It is a valuable additional tool, that will be utilised in conjunction with clinician’s clinical judgement about the patient’s condition, to facilitate detection of a deteriorating patient. The MEWS is a multi-parameter aggregate scoring system which allows both identification and progress monitoring of at risk patients. It includes respiratory rate, oxygen saturations, inspired oxygen, temperature, blood pressure, heart rate, level of

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consciousness and urine output. A score is attributed to each of these parameters, with one score per parameter, and the scores are then totalled to calculate the Modified Early Warning Score. If a score is 1 or more the MEWS Protocol is activated. The MEWS does not replace the clinical judgement of the healthcare professional. Model 1, 2, 3 and 4 HSE Hospitals : The models of hospitals involve 4 levels of acute hospitals in relation to acute medicine patients, as proposed by the national clinical programmes. The models are: Model 4 - tertiary hospital; Model 3 - general hospital; Model 2 - local with selected (GP-referred) medical patients; and Model 1 - community/district (Report of the National Acute Medicine Programme, 2010)

Monitoring plan: A written plan that documents the type and frequency of observations to be recorded in the patients medical records and progress notes in the healthcare record. Primary medical practitioner or medical team: The treating doctor or team with primary responsibility for caring for the patient.

Track and trigger: A ‘track and trigger’ tool refers to an observation chart that is used to record vital signs or observations graphically so that trends can be ‘tracked’ visually and which incorporates a threshold (a ‘trigger’ zone) beyond which a standard set of actions is required by health professionals if a patient’s observations breach this threshold (Clinical Excellence Commission NSW Health (2010)).

Treatment-limiting decisions: Decisions that involve the reduction, withdrawal or withholding of life-sustaining treatment. These may include ‘no cardiopulmonary resuscitation’ (CPR), ‘not for resuscitation’ and ‘do not resuscitate’ orders.

6.0 Roles and responsibilities 6.1 HSE

To develop and implement a national early warning score to ensure that there is a system of care in place for the prompt identification and management of clinically deteriorating patients.

6.2 Regional Directors of Operations/ Senior Managers • To assign personnel and responsibility to implement the national early warning score

system. • To provide managers with support to implement the early warning score system. • To ensure local policies and procedures are in place in each acute health care facility

to support implementation. • To monitor the implementation of the early warning score system.

6.3 Senior management acute healthcare facility

Overall accountability and responsibility rests with the CEO/General Manager, working with the Clinical Director and Director of Nursing, for the implementation of the National Early Warning Score system to recognise and respond to clinical deterioration within their service. Senior management’s role is to:

• provide a local governance structure to support the implementation of the National Early Warning Score System. • ensure clinical and educational staff are supported to implement the National Early Warning Score System education programme. • ensure development of local policy to support MEWS implementation and

management of the clinically deteriorating patient.

6.4 Heads of Department • To ensure all relevant staff members are aware of this Guiding Framework and

supporting policies

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• To monitor local implementation of the National Early Warning Score System, incorporating the MEWS and the MEWS Protocol.

• To ensure staff are supported to undertake the COMPASS© education programme and related training, as appropriate to the acute healthcare facility.

6.5 All clinical staff

Must comply with this guiding framework and related policies, clinical guidelines, procedures and protocols. Each employee must adhere to their professional scope of practice guidelines and maintain competency, in recognising and responding to patients with clinical deterioration, including the use of the Modified Early Warning Score System, where this is within their scope of practice. In using this guideline professional healthcare staff must be aware of the role of appropriate delegation.

6.6. The national standard for recognising and responding to clinical deterioration is the Modified Early Warning Score. The MEWS system is a clinical assessment tool and does not replace the clinical judgement of a qualified healthcare professional. If there are concerns regarding a patient’s condition, healthcare staff should not hesitate in contacting a senior member of the patient’s medical team to review the patient, irrespective of the MEWS.

7.0 Guideline 7.1. Guiding Principles 7.1.1. Recognising patients whose condition is deteriorating and responding to their needs in an

appropriate and timely way are essential components of safe and high quality care. 7.1.2. Recognition and response systems must apply to all patients, in all patient care areas (as

per Section 3.3), at all times. 7.1.3. Primary responsibility for caring for the patient rests with the primary medical practitioner

or team. The utilisation of a Modified Early Warning score system and the MEWS escalation protocol/response system should therefore promote effective action by ward staff and the primary medical practitioner or team, or the attending medical practitioner or team. This includes calling for emergency assistance when required.

7.1.4. Effectively recognising and responding to deterioration requires appropriate

communication of diagnosis, including documentation of diagnosis in the healthcare record.

7.1.5. Effectively recognising and responding to deterioration requires development and

communication of plans for monitoring of observations and ongoing management of the patient.

7.1.6. Recognition of and response to deterioration requires access to appropriately qualified,

skilled and experienced staff. 7.1.7. Recognition and response systems should encourage a positive, supportive response to

escalation of care, irrespective of circumstances or outcome. 7.1.8. Care should be patient-focused and appropriate to the needs and wishes of the individual

and their family or carer. 7.1.9. Organisations should regularly review the effectiveness of the recognition and response

systems they have in place.

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7.2. Essential Elements

These elements describe the essential features of the systems of care required to implement the National Early Warning Score System, incorporating the Modified Early Warning Score and the MEWS Protocol for escalation, to recognise and respond to clinical deterioration. Four elements relate to clinical processes that need to be locally delivered, and are based on the circumstances of the facility in which care is provided (Section 7.2.1). A further three elements relate to the structural and organisational prerequisites that are essential for recognition and response systems to operate effectively (detailed in Sections 8.0 and 9.0). The core seven elements to implement the National Early Warning Score System are as follows: Clinical processes 1. Measurement and documentation of observations 2. Escalation of care 3. Rapid response systems 4. Clinical communication Organisational prerequisites 5. Organisational supports 6. Education 7. Evaluation, audit and feedback

The elements do not prescribe how this care should be delivered. Hospitals need to have systems in place to address all elements in the Guiding Framework; however the application of the elements in an individual healthcare facility will need to be carried out in a way that is relevant to its specific circumstances.

7.2.1 Clinical Processes

7.2.1.1. Measurement and Documentation of Observations

Measurable physiological abnormalities occur prior to adverse events such as cardiac arrest, unanticipated admission to intensive care and unexpected death. These signs can occur both early and late in the deterioration process. Regular measurement and documentation of physiological observations is an essential requirement for recognising clinical deterioration. 1 Observations should be taken on all patients admitted to hospital (refer to Section

3.3) 2 Observations should be taken on patients at the time of admission or initial

assessment, and must be documented in the patient’s healthcare record and recorded on a chart that incorporates the national Modified Early Warning Score System.

3 For every patient, a clear monitoring plan should then be developed and documented,

that specifies the physiological observations to be recorded and the frequency of observations, taking into account the patient’s diagnosis and proposed treatment.

4 The frequency of observations should be consistent with the clinical situation of the

patient. In the hospital setting the minimum standard for the assessment of vital signs, utilising the MEWS parameters, is every 12 hours. The frequency of patient observations must be reconsidered and modified according to changes in the patient’s clinical condition, and this should be documented in the monitoring plan, detailed in the medical notes and nursing care plan. This decision should be made in collaboration between nursing staff and the medical team.

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5 Physiological observations should include:

• Respiratory rate • Oxygen saturation • Heart rate • Blood pressure • Temperature • Urine output over 4 hours • Level of consciousness, and, • Inspired oxygen.

6 In some circumstances, and for some groups of patients, some observations will need

to be measured more or less frequently than others, and this should be specified in the monitoring plan, and documented in the medical notes and nursing care plan.

7 The minimum physiological observations should be documented in a structured

observation chart, incorporating the National Early Warning Score System, the MEWS. 8 Patient observation charts should display physiological information in the form of a

graph. A patient observation chart should include: • a system for tracking changes in physiological parameters over time, • thresholds for each physiological parameter or combination of parameters that

indicate abnormality, • information about the response or action required when thresholds for

abnormality are reached or deterioration identified, • the potential to document the normal physiological range for the patient, • the key MEWS parameters based on the model national MEWS Patient

Observation Chart (Appendix I).

9 Clinical staff may choose to document other observations and assessments to support timely recognition of deterioration. Examples of additional information that may be required include fluid balance, occurrence of seizures, pain, chest pain, respiratory distress, pallor, capillary refill, pupil size and reactivity, sweating, nausea and vomiting, as well as additional biochemical and haematological analyses.

10 There are also patients in whom the use of MEWS may be inappropriate, such as

during the end stages of life, advanced palliative care. Although the majority of patients will benefit from utilisation of MEWS the clinician’s own clinical judgement dictates whether the patient to be requires to be regularly scored for the MEWS, and how regularly vital signs assessment is required. Where a Consultant’s decision is that a MEWS score is not appropriate then this should be clearly written onto the front of the observation chart. An annotation should also be made in the patient’s healthcare record documenting why the decision was made not to use MEWS.

7.2.1.2 Escalation of care

It is the responsibility of each acute hospital service to outline clearly their escalation protocol for deteriorating patients at present and in the future, taking into account the recommendations of the Acute Medicine and Critical Care Programmes in line with requirements of the regulatory body, the Health Information and Quality Authority (HIQA).

An escalation protocol sets out the organisational response required in dealing with different levels of abnormal physiological measurements and observations. This response may include appropriate modifications to nursing care, increased monitoring, review by the primary medical practitioner or team or calling for emergency assistance from intensive care or other specialist teams.

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Primary responsibility for caring for the patient rests with the primary medical practitioner or team. In this context, the escalation protocol describes the additional supporting actions that must exist for the management of all patients. Although these actions should be tailored to the circumstances of the facility, it should include some form of emergency assistance where advanced life support can be provided to patients in a timely way. A protocol regarding escalation of care is an essential requirement for responding appropriately to clinical deterioration. 1 A formal documented escalation protocol is required that applies to the care of all

patients at all times. 2 The escalation protocol should authorise and support the clinician at the bedside to

escalate care until the clinician is satisfied that an effective response has been made. 3 The escalation protocol should be tailored to the characteristics of the acute

healthcare facility, including consideration of issues such as: • size and role (such as whether a tertiary referral centre or small community hospital), • location, • available resources (such as staffing mix and skills, equipment, telemedicine systems, external resources such as ambulances), • potential need for transfer to another facility.

4 The escalation protocol should allow for a graded response commensurate with the level of abnormal physiological measurements, changes in physiological measurements or other identified deterioration. The graded response should incorporate options such as: • increasing the frequency of observations, • appropriate interventions from the nursing and medical staff on the ward and review by the primary medical practitioner or team, • obtaining emergency assistance or advice, • transferring the patient to a higher level of care locally, or to another facility.

5 The escalation protocol should specify:

• the levels of physiological abnormality or abnormal observations at which patient care is escalated, • the response that is required for a particular level of physiological or observed abnormality, • how the care of the patient is escalated, • the personnel that the care of the patient is escalated to, noting the responsibility of the primary medical practitioner or team, • who else is to be contacted when care of the patient is escalated, • the timeframe in which a requested response should be provided, • alternative or back up options for obtaining a response.

6 The way in which the national MEWS Protocol for escalation is applied should take into account the clinical circumstances of the patient, including both the absolute change in physiological measurements and abnormal observations, as well as the rate of change over time for an individual patient.

7 The escalation protocol may specify different actions depending on the time of day or

day of the week, or for other circumstances. 8 The escalation protocol should allow for the capacity to escalate care based only on

the concern of the clinician at the bedside in the absence of other documented abnormal physiological measurements (‘staff member worried’ criterion).

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9 The escalation protocol should allow for the concerns of the patient, family or carer to trigger an escalation of care.

10 The escalation protocol should include consideration of the needs and wishes of

patients where treatment-limiting decisions have been made. 11 The escalation protocol should be disseminated widely and included in education programmes.

7.2.1.3. Rapid response systems Where severe deterioration occurs it is important to ensure that the capacity exists to obtain appropriate emergency assistance or advice prior to the occurrence of an adverse event such as a cardiac arrest. A deteriorated patient should activate a direct on-site response (HIQA 2011). Different models that have been used to provide this assistance include senior medical staff, emergency response team, and critical care outreach (if available). The generic name for this type of emergency assistance is a ‘rapid response system’. The emergency assistance provided as part of a rapid response system is additional to the care provided by the attending medical practitioner or primary medical team.

For most facilities, the rapid response system will include clinicians or teams located within the hospital who provide emergency assistance (such as the emergency response team or staff accredited in advanced life support). In some facilities the system may be a combination of on-site and external clinicians or resources (such as the ambulance service or local general practitioner). However comprised, and however named, a rapid response system should form part of an organisation’s escalation protocol.

1 Some form of rapid response system should exist to ensure that specialised and

timely care is available to patients whose condition is deteriorating. 2 Criteria for triggering the rapid response system should be included in the escalation

protocol. Where severe deterioration occurs it is important to ensure that the capacity exists to obtain appropriate emergency assistance or advice prior to the occurrence of an adverse event such as a cardiac arrest.

3 The nature of the rapid response system needs to be appropriate to the size, role,

resources and staffing mix of the acute health care facility. 4 The clinicians providing emergency assistance as part of the rapid response system

should: • be available to respond within agreed timeframes, • be able to assess the patient and provide a provisional diagnosis, • be able to undertake appropriate initial therapeutic intervention, • be able to stabilise and maintain the patient pending definitive disposition, • have authority to make transfer decisions and to access other care providers to deliver definitive care.

5 As part of the rapid response system there should be access, at all times, to at least one clinician, either on-site or accessible, who can practice advanced life support.

6 The clinicians providing emergency assistance should have access to a medical staff member of sufficient seniority to make treatment-limiting decisions. Where possible these decisions should be made with input from the patient, family and the primary medical practitioner or team.

7 In cases where patients need to be transferred, to another site to receive emergency assistance, appropriate care needs to be provided to support them until such assistance is available.

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8 When a call is made for emergency assistance, the attending medical practitioner or team should be notified at the same time that the call has been made, and where possible they should attend to provide relevant medical information regarding their patient, provide support and learn from the clinicians providing assistance.

11 9 All opportunities should be taken by the clinicians providing emergency assistance to

use the call as an educational opportunity for ward staff and pre-registered medical, nursing and therapies students.

10 The clinicians providing emergency assistance should communicate in an appropriate,

detailed and structured way with the primary medical practitioner or team about the consequences of the call, including documenting information in the healthcare record.

11 Events surrounding the call for emergency assistance and actions resulting from the

call should be documented in the healthcare record and considered as part of ongoing quality improvement processes.

7.2.1.4. Clinical Communication

Effective communication and team work among clinicians is an essential requirement for recognising and responding to clinical deterioration. Poor communication at handover and in other situations has been identified as a contributing factor to incidents where clinical deterioration is not identified or properly managed. A number of structured communication protocols exist that can be used for handover and as part of ongoing patient management. The recommended communication tool for healthcare professionals, when communicating in relation to the deteriorating patient, is ISBAR (Appendix IV).

1 Formal communication protocols should be used to improve the functioning of

teams when caring for a patient whose condition is deteriorating. 2 The value of information about possible deterioration from the patient, family

or carer should be recognised. 3 Information about deterioration should be communicated to the patient, family

or carer in a timely and ongoing way, and documented as appropriate in the healthcare record.

8.0 Implementation Plan 8.1. Organisational supports

Recognition and response systems should be part of standard clinical practice. Nonetheless, the introduction of new systems to optimise care of patients whose condition is deteriorating requires organisational support and executive and clinical leadership for success and sustainability. The acute healthcare facility should consider the process and stages of implementation for the National Early Warning Score System, the MEWS system and the MEWS Protocol for escalation (Appendix V).

1 A formal policy framework regarding recognition and response systems should exist

and should include issues such as: • governance arrangements, • roles and responsibilities, • communication processes, • resources for the rapid response system, such as staff and equipment, • training requirements, • evaluation, audit and feedback processes, • arrangements with external organisations that may be part of the rapid response system

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2 This policy framework should apply across the acute healthcare facility, and identify the planned variations in the escalation protocol and responses that might exist in different circumstances (such as for different times of day).

3 Any new recognition and response systems or procedures should be integrated into

existing organisational and safety and quality systems to support their sustainability and opportunities for organisational learning.

4 Recognition and response systems should encourage healthcare staff to react

positively to escalation of care, irrespective of circumstances or outcome. 5 Appropriate policies and documentation regarding ‘Do not Resuscitate’ decisions,

treatment-limiting decisions and end-of-life decision making are critical in ensuring that the care delivered in response to deterioration is consistent with appropriate clinical practice and the patient’s expressed wishes.

6 A formal governance process (such as an Early Warning System Committee) should

oversee the development, implementation and ongoing review of recognition and response systems locally. The overall accountability and responsibility for the implementation of the National Early Warning Score System, to recognise and respond to clinical deterioration, rests with the CEO/General Manager, working with the Clinical Director and Director of Nursing (Appendix VI).

The Early Warning System Committee should:

• have a nominated chair, • have defined terms of reference signed off by the CEO/General Manager, • have clarity as to who the committee reports to within the organisational

structure, • have appropriate responsibilities delegated to it, and be accountable for its decisions and actions, • monitor the effectiveness of interventions and education, • have a role in reviewing performance data, audits, • provide an annual report, and clarify where this is submitted, • provide advice about the allocation of resources, • include service users, clinicians, managers and executives.

7 Organisations should have systems in place to ensure that the resources required to

provide emergency assistance (such as equipment and pharmaceuticals) are always operational and available.

8.2. Education

Having an educated and suitability skilled and qualified workforce is essential to provide appropriate care to patients whose condition is deteriorating. Education should provide knowledge of observations and identification of clinical deterioration, as well as appropriate clinical management skills. Skills such as communication and effective team work are needed to provide appropriate care to a patient whose condition is deteriorating, and should also be part of staff development.

The education programme recommended by the HSE is the COMPASS© programme, and this will be available to healthcare staff such as doctors, nurses and therapy professionals. The COMPASS© programme should be delivered in full (Appendix VII). In addition, training in the use of the patient observation chart incorporating the MEWS should be facilitated. The training needs to be coordinated by designated staff within, or supporting, the healthcare facility. In addition continuation of training in basic life support and professional development training in advanced life support programmes, appropriate to the clinical facility, is advised.

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1 All clinical and non-clinical staff should receive education about the local escalation protocol relevant to their position. They should know how to call for emergency assistance if they have any concerns about a patient, and know that they should call under these circumstances. This information should be provided at the commencement of employment and as part of regular refresher training.

2 All doctors and nurses should be able to:

• systematically assess a patient, • understand and interpret abnormal physiological parameters and other abnormal observations, • understand and operationalise the Modified Early Warning Score system and MEWS

Protocol for escalation of response, • initiate appropriate early interventions for patients who are deteriorating, • respond with life-sustaining measures in the event of severe or rapid deterioration, pending the arrival of emergency assistance, • communicate information about clinical deterioration in a structured and effective way to the primary medical practitioner or team, to clinicians providing emergency assistance and to patients, families and carers, • understand the importance of, and discuss, end-of-life care planning with the patient, family and/or carer, • undertake tasks required to properly care for patients who are deteriorating, such as developing a clinical management plan, writing plans and actions in the healthcare record and organising appropriate follow up.

3 As part of the rapid response system competency in advanced life support should be

ensured for sufficient clinicians who provide emergency assistance to guarantee access to these skills according to local protocols.

4 A range of methods should be used to provide the required knowledge and skills to

staff. These may include provision of information at orientation and regular refreshers using face-to-face and online techniques, as well as simulation centre and scenario-based training.

9.0 Evaluation and Audit 9.1 Evaluation of new systems is important to establish their efficacy and determine what

changes might be needed to optimise performance. Ongoing monitoring is necessary to track changes in outcomes over time and to check that these systems are operating as planned.

9.2 Data should be collected and reviewed locally and over time regarding the implementation and effectiveness of recognition and response systems, namely the Modified Early Warning Score system.

9.3. The Modified Early Warning Score system should be evaluated to determine whether it is

operating as planned. Evaluation may include checking the existence of required documentation, policies and protocols (such as the MEWS Protocol) and compliance with policy (such as completion rates of observation charts or proportion of staff who have received training).

9.4 Clinical audit is recommended to support the continuous quality improvement process in

relation to implementation of the national EWS system (Appendix VIII). The recommended minimum standard for audit includes:

1. Utilization of the ISBAR communication tool, 2. Utilization and accuracy of completion of the patient observation chart incorporating the MEWS, 3. Utilization of the ‘track and trigger’ response mechanism – the MEWS Protocol.

15

9.5 Systems should be evaluated to determine whether they are improving the recognition of and response to clinical deterioration. Evaluation may include collecting and reviewing data about calls for emergency assistance, and adverse events such as cardiac arrests, unplanned admissions to intensive care and hospital deaths.

9.6 The following data should be collated for each call for emergency assistance that is made to

the rapid response system; • Patient demographics • Date and time of call, response time • Reason for the call • The treatment or intervention required • Outcomes of the call, including disposition of the patient.

9.7 Regular audits of triggers and outcomes should be conducted for patients who are

the subject of calls for emergency assistance. Where these data are available, this could include longer-term outcomes for patients (such as 30 and 60 day hospital mortality).

9.8 Evaluation of the costs and potential savings associated with recognition and response

systems could also be considered. 9.10 Information about the effectiveness of the recognition and response systems may also come

from other clinical information such as incident reports, root-cause analyses, cardiac arrest calls and death reviews. A core question for every death review should be whether the escalation criteria for the rapid response system were met, and whether care was escalated appropriately.

9.11 As part of the implementation of new systems, feedback should be obtained from frontline

staff about the barriers and enablers to change. Issues and difficulties regarding implementation should be considered for different healthcare settings.

9.12 Consistent with any implementation process, information collected as part of ongoing evaluation and audit should be:

• fed back to ward staff and the primary medical practitioner or team regarding their own calls for emergency assistance

• fed back to the clinicians providing emergency assistance • reviewed to identify lessons that can improve clinical and organisational systems • used in education and training programs • used to track outcomes and changes in performance over time

9.13 Indicators of the implementation and effectiveness of recognition and response systems

should be monitored at senior governance levels within the organisation (such as by senior executives or relevant quality committees). It is recommended that the audit process in each healthcare facility is overseen by the Early Warning Score Committee.

9.14 It is recommended that the national MEWS parameters are reviewed annually and updated as new information becomes available either from national or international audits or research.

16

10.0 References / Bibliography

ACT Health (2007) Policy: Modified Early Warning Scores Australian Capital Territory Directorate http://www.health.act.gov.au/compass Avard B, McKay H, Slater N, Lamberth P, Daveson K, Mitchell I (2010) Compass ‘Pointing You in the right direction’ Adult Training Manual. http://www.health.act.gov.au/compass Australian Commission on Safety and Quality in Healthcare (2010) National Consensus Statement: Essential elements for recognising and responding to clinical deterioration ACSQHC Clinical Excellence Commission, New South Wales Health (2010) Between the flags: Keeping patient’s safe: guidelines and implementation toolkit. http://www.cec.health.nsw.gov.au/programs/between-the-flags

Commission on Patient Safety and Quality Assurance (2008) Report of the Commission on Patient Safety and Quality Assurance: Building a Culture of Patient Safety Department of Health and Children Council of International Hospitals (2007) Tactics to Manage Deteriorating Patients: Literature Review The Advisory Board Company Washington D.C. CREST (2007) Guidelines on the Use of Physiological Early Warning Systems Clinical Resource Efficiency Support Team – Northern Ireland http://crestni.org.uk/

Department of Health (2009) Competencies for recognising and Responding to Acutely Ill Patients in Hospital NHS http://www.dh.gov.uk/en/Publicationsandstatistics/Publicationspolicyand Guidance/DH_096989 Dellinger,RP., Levy, MM., Carlet, JM., et al (2008) Surviving Sepsis Campaign: International Guidelines for management of severe sepsis and septic shock Critical Care Medicine 36: 296 – 327 http://www.survivingsepsis.com/implement/resources/guidelines

Gao, H., McDonnell, A., Harrison, D.A. et al (2007) Systematic review and evaluation of physiological track and trigger warning systems for identifying at risk patients on the ward. Intensive Care Medicine. 33:667-79 Health Information and Quality Authority (2011) Report of the investigation into the quality and safety of service and supporting arrangements provided by the Health Service Executive at Mallow General Hospital http://www.hiqa.ie/

Health Information and Quality Authority (2010) Guidance on Development of Key Performance Indicators and Minimum Data Sets to monitor Healthcare Quality

Health Service Executive (2011) Training Manual for the National Early Warning Score and associated Education Programme Acute Medicine Programme: National Early Warning Score project and associated Education Programme Governance and Advisory Groups

Health Service Executive (2010) Achieving excellence in clinical governance: Towards a culture of accountability Quality and Clinical Care Directorate Health Service Executive (2009) Towards excellence in clinical governance – a Framework for Integrated Quality, Safety and Risk management across HSE Service providers Framework Document Version 1 HSE Cavan & Monaghan, Louth/Meath Hospitals HSE DNE (2008) Guideline for Vital Signs Assessment of Adults and the use of the Physiological Track and Trigger System ‘POTTS’

17

HSE Mid Western Regional Hospital (2010) Guideline for Vital Signs Assessment of Adults and the use of the Simple Clinical Score (SCS) Assessment Tool and the HOTEL Monitoring Score HSE South Tipperary General Hospital (2009) Modified Early Warning Scoring System: Guidelines for staff HSE Waterford Regional Hospital (2011) Guidelines for Healthcare staff in the use of a Modified Early Warning Score (MEWS)

James Connolly Hospital Blanchardstown (2010) Guideline for use of the Early Warning Score in Connolly Hospital Mitchell, I.A., McKay, H., VanLeuvan, C. , Berry, R. , McCutcheon, C. , Avard, B. , Slater, N., Neeman, T., Lamberth, P. (2010) A prospective controlled trial of the effect of a multi-faceted intervention on early recognition and intervention in deteriorating hospital patients. Resuscitation 81 : 658–666 National Institute for Health and Clinical Excellence (2007) Acutely ill patients in hospital: Recognition of and response to acute illness in adults in hospital. NHS: NICE www.nice.org.uk/nicemedia/pdf/CG50FullGuidance.pdf National Institute for Health and Clinical Excellence (2010) Review of Clinical Guideline (CG50) Acutely Ill patients in hospital NHS: NICE http://www.nice.org.uk/nicemedia/live/11810/52356/52356.pdf National Institute for Health and Clinical Excellence (2007) Audit Criteria: Acutely Ill patients in hospital (NICE clinical guideline 50) NHS: NICE National Institute for Clinical Excellence/ Commission for Health Improvement (2002) Principles for Best Practice in Clinical Audit Oxon: Radcliffe Medical Press

National Patient Safety Agency (2007) Recognising and responding appropriately to early signs of deterioration in hospitalised patients NHS www.npsa.nhs.uk New South Wales (NSW) Health (2010) Policy Directive: recognition and Management of a Patient who is Clinically Deteriorating http://www.health.nsw.gov.au/policies/

New South Wales (NSW) Health (2010) Standard: Recognition and management of Patients who are Clinically Deteriorating http://www.health.nsw.gov.au/policies/

Patient Safety First (2008) The ‘How to Guide’ for Reducing Harm from Deterioration NHS www.patientsafetyfirst.nhs.uk

Perbedy MA, Cretikos M, Abella BS, De Vita M, Goldhill D, Kloeck W, Kronick SL, Morrison LJ, Nadkarni V, Nichol G, Nolan J, Parr M, Tibballs J, van der Jagt EW, Young L (2007) Recommended Guidelines for Monitoring, Reporting and Conducting Research on Medical Emergency Team, Outreach and Rapid Response Systems: An Uystein-Style Scientific Statement : A Scientific statement from the International Liaison Committee on Resuscitation ( American Heart Association, Australian Resuscitation Council, European Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, and the New Zealand Resuscitation Council); the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiopulmonary,Perioperative, and Critical Care; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research Circulation 116: 2481-2500 Royal College of Physicians of Ireland, Irish Association of Directors of Nursing and Midwifery, Therapy Professions Committee, Quality and Clinical Care Directorate, Health Service Executive (2010) Report of the National Acute Medicine Programme http://www.hse.ie/eng/services/Publications/services/Hospitals/AMP.pdf

18

11. 0 APPENDICES

19

20

Table 1. Front page Model Patient Observation Chart (A4 format) or A3 format(folded to A4)

21

Table 2. Model Patient Observation Chart Page 2 (A4 format) or Page 2 & 3 (A3 format)

22

Table 3. Model Patient Observation Chart Page 3 (A4 format) or Page 4/back page (A3 format folded to A4) NOTE: The scoring parameters for the physiological signs identified in the nationally agreed Modified Early Warning Score in Table 1, must be strictly adhered to in the event that an acute hospital decides to design their own observation chart.

23

APPENDIX II: MEWS PROTOCOL (Escalation Flow Chart)

MEWS PROTOCOL (Escalation Flow Chart)  

Modified Early Warning Score Total  MEWS 1              STAGE  1  Inform CNM/Nurse in Charge and 

document in patient record.  

 

MEWS 2‐3 

            STAGE  2  Inform CNM/Nurse in Charge. Inform SHO of MEWS 2 or 3 and request to review within1 hour. Record observations at least every 30 minutes until reviewed. SHO to specify frequency of observations, formulate management plan and document.  

    MEWS of 3 or more in any single parameter  

            STAGE 2a  Inform CNM/Nurse in Charge. Request immediate review by Registrar. Record observations at least every 15 minutes until reviewed. Registrar to specify frequency of observations, formulate management plan and document. Stay with patient.  

      MEWS 4‐6 

            STAGE 3  Inform CNM/Nurse in Charge. Inform Registrar of MEWS 4‐6 and request to review within 30 minutes. Record observations at least every 15 minutes until reviewed. Registrar to specify frequency of observations, formulate  management plan and document. Consider transfer of patient to a higher level of care. Activate Emergency Response Team as appropriate to hospital model. Stay with patient.  

      MEWS ≥ 7 

            STAGE 4        

 

Inform CNM/Nurse in Charge. Request immediate review by Registrar. Record observations at least every 15 minutes until reviewed. Registrar to specify frequency of observations,  formulate  management plan and document. Plan to transfer to a higher level of care. Activate Emergency Response Team as appropriate to hospital model. Stay with the patient.   

IF THE RESPONSE IS NOT CARRIED OUT AS ABOVE THE CNM/NURSE IN CHARGE MUST CONTACT 

THE REGISTRAR OR CONSULTANT 

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APPENDIX III: Pathway schema for the acutely ill patient using Acute Medicine Programmes Hospital Models The Acute Medicine Programme has just commenced the implementation phase. Along with other programmes, including the Critical Care Programme, it will take some time before the recommendations are embedded in the system. Regional arrangements are taking place to categorise hospitals into Models e.g. Model 1, 2, 3 or 4. It is the responsibility of each acute hospital service to outline clearly their escalation protocol for deteriorating patients at present and in the future taking into account the recommendations of the Acute Medicine and Critical Care Programmes in line with requirements of the regulatory body, the Health Information and Quality Authority (HIQA). A pathway schema has been identified for the acutely ill patient in the hospital system using Acute Medicine Programme Hospital Models to clarify a concern about the appropriate response to the patient with severe deterioration detected by an Early Warning Score. An Early Warning Score detects the deterioration and triggers the appropriate response for the deteriorated patient, as follows- 1. Model 2 Hospitals: The differentiated patient admitted to a Model 2 Hospital is not acutely ill on admission, has no propensity to deteriorate and has no complex specialty needs requiring bypass or transfer. A differentiated patient may be admitted for other reasons- e.g. not for escalation or resuscitation care. There is no expectation the patient admitted to a Model 2 Hospital will require or receive immediate acute hospital critical care. However, the admitted differentiated patient may undergo gradual or abrupt severe deterioration detected by an Early Warning Score activating an on-site competent Acute Medicine critical care response. 2. Model 3 or Model 4 acute Hospitals: The undifferentiated acutely ill patient admitted to a Model 3 or 4 acute Hospital may undergo gradual or abrupt severe deterioration detected by an Early Warning Score activating an on-site 24/7/365 emergency resuscitation response. This is consistent with the recent HIQA Recommendation SOC1. Both these deteriorations are detected equally well by an Early Warning Score but with different expectations. This distinction, is a strength of Acute Medicine Programme Hospital Models. (Contributed by the Critical Care Programme).

Complex regional/supra‐regional specialty 

needs

Severe illness, multi/neuro‐trauma‐

bypass/transfer protocol, 

Acutely ill patient with a propensity to 

deteriorate

No expectation of immediate 

resuscitation or critical care response

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APPENDIX IV: ISBAR COMMUNICATION TOOL

ISBAR  

IDENTIFY    – Identify yourself, who you are talking to and who you are talking about  

SITUATION     – What is the current situation, concerns, observations, MEWS.  BACKGROUND  – What is the relevant background. This helps to set the scene to interpret the                                             situation above accurately  ASSESSMENT    – What do you think the problem is ? This requires the interpretation                                            of the situation and background information to make an educated                                             conclusion about what is going on.  RECOMMENDATION – What do you need them to do ? What do you recommend should be                                              done to correct the current situation ?  Text box 1. Adapted from COMPASS© programme

26

APPENDIX V

The National Early Warning Score and 

associated Education Programme 

Implementation Guide 

27

                  PTO  Adapted from ACT Health model

Proposed Group – to oversee implementation & evaluation on the site Senior Medical, Nursing, Audit, Quality & Risk, Education Personnel, Therapy Professional, Hospital Manager, Practice Development,

Consult widely 

Decide on EWS observation chart to suit local needs – ranges for observations must remain the same as per nationally agreed MEWS 

Set up sub‐group to work on this 

Organise leadership & change management session for staff  as appropriate‐ National Leadership & Innovation Centre  (ONMSD) 

 Develop local examples for training  

Depts/ Units  

Consultants NCHD’s 

Hospital management 

Therapies, Audit, Quality & Risk personnel, Practice Development 

Aim for Implementation of EWS Observation Chart one month following initial training when 50% of staff are trained in an area. 

Feedback to clinical areas 

Make materials available. (Identify website link) 

Distribute manuals, & CD’s, sample obs. Chart, quiz questions as appropriate  Allow time for e‐learning as appropriate 

Set up EWS project group 

Agree timelines for implementation  

Confirm initial departments/units for implementation 

Develop & approve EWS policy for hospital  ‐ incl. escalation pathway policy, audit trail and training 

Identify staff for Train the Trainer programme, e.g. Medical, BLS, ACLS, ALERT, Practice Development, CNME staff 

Training, Implementation, Audit and Evaluation  Stage 

Conduct Train the Trainer sessions  

Organise staged rollout in Hospital 

Identify lead person/s to co‐ordinate and lead EWS project in acute hospital  

Planning Stage 

NB ‐ Doctors need to be part of the training group to provide training for medical staff on site 

28

Adapted from ACT Health model

Schedule training sessions  

Communicate log in details to staff  for  e‐learning section as required 

Interactive CD Training manual 

Quiz to be completed  and submitted to trainers 2 days in advance of training   

Book participants for each session 

Check quiz results  

Conduct training  

Provide certificate Conduct evaluation of education  

Prepare ward posters as appropriate e.g. ISBAR, Flow charts, Escalation policy etc 

Introduce MEWS obs chart when at least 50% of staff each ward/area have received training 

Conduct observation chart audits one month post introduction agree regular audit schedule

Evaluate outcomes. Create action plans for improvement 

29

APPENDIX VI Governance Structures for the Implementation of the National Early Warning Score and associated Adult Education Programme  

The National Early Warning Score Programme is available on the HSE web site  www.hse.ie and on 

the  HSE  Intranet.    The  fast  access  or  ‘go’  address  is  as  follows: 

www.hse.ie/go/nationalearlywarningscore/ The site will be updated from time to time, therefore, 

the COMPASS education programme on the early detection and management of the deteriorating 

patient programme should only be accessed from the official hse website, as older versions of the 

documents may appear by using search engines such as ‘google’.  

The programme may be delivered in the first instance: on site in the Acute Hospital Services; the 

Centres of Nursing and Midwifery Education (CNME’s); but may also be delivered through other 

non HSE agencies subject to availability of appropriate expertise. 

The overall governance for the management of the programme will rest with the National Early Warning 

Score Project Governance Group, HSE.  

The Adult Education Programme consists of: 

A COMPASS Training Manual, an interactive CD, a quiz to be completed before attending the face to face 

session, a powerpoint presentation to be used as part of a face to face session with four sample interactive 

case studies.  Following the initial training sessions, it is recommended that staff use case studies relevant 

to  their own area of practice, as  learning experiences, and as part of a continuous quality  improvement 

process for the provision of safe quality patient care. 

The education material has been designed by HSE staff based on the Australian COMPASS © Adult 

Programme model  to  be  delivered  in  its  entirety.    Short  session  (1‐2  hrs)  updates  should  be 

provided  for  staff on a  two yearly basis.   An  ‘Issues Log’ will be maintained  to  identify  specific 

issues relating to the programme material, this will be maintained initially by Mary Redmond in 

NMPD administration, email maryn.redmond@hse.ie, issues will be addressed by, or on behalf of, 

(by relevant healthcare professionals,  if  for a specific area of practice) the National Governance 

Group.  

A database of all providers of the programme will be maintained by the HSE and the delivery of 

the programme will be subject to evaluation.  

The National Early Warning Score Project Governance Group will review the programme on a yearly basis. 

This group is chaired by a Nursing and Midwifery Planning and Development Director in the first instance. 

The Board will meet at  lease once a year,  to  review programme content, delivery and uptake and make 

amendments as necessary to ensure it remains fit for purpose.    

30

The  responsibility  for  the delivery and  co ordination of  the programme will  rest with  the Management 

Team within the acute hospital sites in the first instance.  Programmes delivered through other non HSE 

agencies  will  be  their  responsibility  ie  for  the  delivery  and  co‐ordination  of  the  programme  in  their 

respective areas. A database of all staff who attend  the programme should be maintained by  the person 

responsible  for the co ordination of the programme  in each acute hospital site. This  information will be 

required for the Governance Group as part of ongoing review and audit. Any amendments /changes will 

be the sole responsibility of the Governance Group.  

 Eilish Croke  

National Lead & Chairperson, National Early Warning Score Project Governance Group 

June 2011 

Governance Structures Flow Chart for the Implementation of the National Early Warning Score and associated Adult Education Programme 

CEO    

National Directors of     Quality & Patient Safety, Clinical Strategy and Programmes, 

ISD  

  

Regional Director of Operations     

Area Manager     

Clinical Director, Director of Nursing, Hospital Manager/CEO.      

National  

Early  

Warning  

Score  

Project  

Governance  

Group 

Chairperson Early Warning Score Group / Committee in Acute Hospital Site 

31

APPENDIX VII: COMPASS© TRAINING PROGRAMME Compass is a multidisciplinary education program designed to enhance our understanding of patients deteriorating and the significance of altered observations. It also seeks to improve communication between health care professions and enhance timely management of patients. Aim To enable health care professionals to recognise the deteriorating patient and initiate appropriate and timely interventions Objectives

• For participants to understand the importance and relevance of observations and the underlying physiology

• For participants to be able to recognise and interpret abnormal observations • For participants to be able to communicate effectively to the right people and at the right

time • For participants to feel confident in recognising and managing deteriorating patients • To facilitate teamwork within the multi-disciplinary team • To enable nurse, doctors and therapy professions to develop management plans together.

How it Works There are three phases to the package to be completed in the following order:

• The CD and manual to be worked through independently • A multiple choice quiz • A 3 hour face to face session

Details of the COMPASS training programme are available on the HSE website: www.hse.ie The official HSE website should only be used to access the programme as updates will be provided from time to time. Go address:    www.hse.ie/go/nationalearlywarningscore/  Acknowledgement: The COMPASS programme has been modified to suit the Irish healthcare system with the kind permission of Australian Capital Territories (ACT Health), Australia.

32

APPENDIX VIII: Outline of Recommended Audits and Evaluations to Support Implementation of the National EWS System It is recommended that the audit process is coordinated locally in each healthcare facility by the local EWS Committee, as per the National Early Warning Score System Guiding Framework recommendations (Section 9.0). The EWS audit process is recommended to be undertaken from a multidisciplinary perspective where appropriate. In planning the audits to be undertaken to support the implementation and monitoring of the national EWS locally, consideration must be given to frequency of the audits, the standard required (e.g. 100% compliance) and the sample size. The audit results and reports should be discussed at the EWS Committee initially, and thereafter linking into the appropriate hospital forums as required. The clinical audit cycle as part of the continuous quality improvement process should inform the audit plan.

EWS Audit Datasets Two datasets of audits for the national Early Warning Score System are outlined: the minimum dataset and the expanded dataset. It is recommended that all healthcare facilities, as a minimum requirement, undertake to audit the minimum dataset to support the implementation and monitoring of the national EWS locally, as part of the continuous quality improvement cycle. It is important that feedback on audits undertaken is given to the relevant staff groups to ensure appropriate action plans for change are implemented. Minimum EWS Audit Dataset: 1. Maintain a database of all patients (HcRN) triggering a MEWS response. In this way each healthcare facility will be able to track frequency of utilisation and this will assist in future audits. 2. Audit three elements of the MEWS system–

1. Utilization of ISBAR communication tool 2. Utilization and accuracy of completion of MEWS Patient Observation Chart 3. Utilization of escalation response to MEWS Protocol for all patients who trigger MEWS

3. Measure Outcomes:

- Basic patient outcome measures (e.g. length of stay) - Disposition of patients triggering a response

- Scope of care decisions – ‘Do Not Resuscitate ‘ or palliative care order Sample audit tools to support the recommended EWS audits will be available on the link to the national HSE EWS website on http://www.hse.ie/go/nationalearlywarningscore/

33

Expanded EWS Audit Dataset: In addition to the minimum requirement for audit the following may be utilised to evaluate the effectiveness of the MEWS system locally, and to support the implementation and sustainability of the MEWS system, as appropriate, according to local resources and expertise. The list provided is not exhaustive: 4. Training audit

- Audit of Compass© training – training evaluation record - Database of staff trained- each hospital to make local arrangement

5. Staff evaluation of the system –

- Should include questions to elicit knowledge and awareness of the system - Should elicit feedback re user friendliness of observation chart - Consider focus groups:

to include nurses/consultants /NCHDs/ therapy professionals as appropriate. 6. Availability of resources:

- Equipment - Higher dependency beds - Personnel

8. Evaluation of crisis antecedents - physiologic variables which triggered the system - duration of deterioration prior to call 9. Audit hospital process improvements

- Case discussions - Clinical outcome review committee - Links with palliative care

10. MEWS system to be re-evaluated at defined time periods as new information becomes

available from audit feedback/ research nationally or internationally. 13. Additional databases should be made available to staff undertaking EWS audits as required, e.g. cardiac arrest/ stroke/ ICU admissions and so forth.

34

APPENDIX IX

HOSPITAL LOGO

National Policy and Procedure

for the use of the

Modified Early Warning Score System

to recognise and respond to clinical deterioration

(template for local adaptation)

Document reference number

Document Developed by: National Early Warning Score System Advisory Group June 2011

Revision number

Document approved by:

Approval date:

Responsibility for implementation: All healthcare staff

Revision date:

Responsibility for review and audit: Recommend local EWS Committee

35

Table of Contents: 1.0 Policy Statement .. 2.0 Purpose .. 3.0 Scope .. 4.0 Legislation/other related policies .. 5.0 Glossary of Terms and Definitions .. 6.0 Roles and Responsibilities .. 7.0 Procedure ..

7.1 Vital signs assessment .. 7.2 Modified early warning score .. 7.3 MEWS Protocol for Escalation of Treatment .. 7.4 Procedure for communication in relation to the

deteriorating patient .. 8.0 Implementation Plan ..

9.0 Evaluation and Audit ..

10.0 References / Bibliography ..

11.0 Appendices

Appendix I Model Patient Observation Chart incorporating MEWS .. Appendix II MEWS Escalation Protocol .. Appendix IV Signature Sheet ..

Disclaimer: The information contained within this policy is the most accurate and up to date, at date of approval. The policy contains a procedural guideline for local adaptation and it is the responsibility of the local organisation to update this guideline, according to best practice.

36

1.0 Policy Statement

1.1. This policy supports the implementation of the Health Service Executive (2011) Guiding Framework and Policy for the national Early Warning Score System to Recognise and Respond to Clinical Deterioration

1.2. (Name of Model 1/2/3/4 hospital /Health Service Executive) is committed to ensuring

that patients at risk of clinical deterioration are promptly identified and managed according to their clinical need.

1.3. Patients admitted to (name of Model 1/2/3/4 hospital /Health Service Executive) are

entitled to the best possible care and need to be confident that should their clinical condition deteriorate that they will receive prompt and effective treatment.

1.4. The purpose of this policy is to ensure a standardised approach to the use of a track

and trigger system, utilising the Modified Early Warning Score system and the MEWS Protocol.

1.5. All healthcare staff must apply the Modified Early Warning Score system and MEWS

Protocol for escalation, as outlined in this policy. 2.0 Purpose

2.1 To improve patient outcomes by detecting and acting upon early signs of deterioration in patients. This will in part be achieved through the implementation of the Modified Early Warning Score ( MEWS) system that:

• Identifies trends in patient vital signs observations • Ensures that timely patient review and appropriate treatment occurs; and • Improves the documentation and communication of patient observations.

2.2.  To provide clinical staff with clear guidelines on the measurement of MEWS vital signs

and the escalation and communication of triggered Modified Early Warning Scores to the appropriate medical personnel.

3.0 Scope

3.1 This policy applies to all patients in acute care facilities (name of HSE Model 1/2/3/4 hospital). This includes: • All inpatients on initial assessment, and as per clinical condition and clinical treatment. • Any outpatients/day services patients who attend acute healthcare facilities for an invasive procedure or who receive sedation. • All patients attending the Acute Medical Unit/ Acute Medical Assessment Unit/

Medical Assessment Unit • In the Emergency Department clinical assessment in triage is to identify the

patients requiring MEWS. This is to be undertaken at the Advanced Triage stage in the patient journey, that occurs after the initial Manchester triage. However, all patients identified for admission should have a MEWS assessment incorporated, as part of the triage process.

• Any patient where the professional judgement of staff indicates a need to carry out a MEWS because of concerns about their condition.

3.2. This policy does not apply to patients in paediatric departments or in obstetric care. 3.3. It also applies to clinicians and managers responsible for the development,

implementation and review of the Modified Early Warning Score System in (name of Model 1/2/3/4 hospital /Health Service Executive).

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3.4 The policy also applies to training and education support staff involved in delivery of the

COMPASS© training programme.   4 Legislation/other related policies

• Health Service Executive (2011) A Guiding Framework for the use of a National Early Warning Score System to recognise and respond to clinical deterioration

• An Bord Altranais (2000) The Code of Professional Conduct for each Nurse and Midwife

• An Bord Altranais (2000) Scope of Nursing and Midwifery Practice Framework • An Bord Altranais (2002) Recording Clinical Practice Guidance to Nurses and Midwives • Data Protection Act (2003) • HSE (2008) Code of Practice for Integrated Discharge Planning • NHO (2007) Code of Practice Standards for Healthcare Records Management • Local Haemovigilance policies • Local Resuscitation policies • Local ‘Do Not Resuscitate’ policies • Local medication management policies, and also including policies relating to Patient

Controlled Analgesia; spinal/ epidural anaesthesia, opioid administration. • Local infection prevention and control policies

5 Glossary of Terms ands Definitions

Acute health care facility: A hospital or other health care facility providing health care services to patients for short periods of acute illness, injury or recovery. Advanced life support: The preservation or restoration of life by the establishment and/or maintenance of airway, breathing and circulation using invasive techniques such as defibrillation, advanced airway management, intravenous access and drug therapy.

Early Warning Score (EWS): Early warning scores have been developed to facilitate early detection of deterioration by categorising the patient’s severity of illness and prompting nursing staff to request a medical review at specific trigger points utilising structured communication tools whilst following a definitive escalation plan. (Mitchell IA, McKay H, Van Leuvan C, et al. 2010)

Emergency Response Team (ERT): The emergency response team must be identified in each acute hospital for daytime, out of hours, weekends as appropriate to the hospital model (refer to hospital models in the Report of the National Acute Medicine Programme (2010)). Escalation protocol: The protocol that sets out the organisational response required for different levels of abnormal physiological measurements or other observed deterioration. The protocol applies to the care of all patients at all times Modified Early Warning Score (MEWS) is a bedside score and track and trigger system that is calculated by nursing staff from the observations taken, to indicate early signs of a patient’s deterioration. It is a valuable additional tool, that will be utilised in conjunction with clinicians’ clinical judgement about the patients condition, to facilitate detection of a deteriorating patient. The MEWS is a multi-parameter aggregate scoring system which allows both identification and progress monitoring of at risk patients. It includes respiratory rate, oxygen saturations, inspired oxygen, temperature, blood pressure, heart rate, level of consciousness and urine output. A score is attributed to each of these parameters, with one score per parameter, and the scores are then totalled to calculate the Modified Early Warning Score. If a score is 1 or more the MEWS Escalation Protocol is activated. The MEWS does not replace clinical judgement of the healthcare professional.

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Monitoring plan: A written plan that documents the type and frequency of observations to be recorded.

Physiological Observation Track and Trigger System is a scoring system that fully integrates physiological observations with early warning scoring to identify patients at risk of clinical deterioration.

Primary medical practitioner or medical team: The treating doctor or team with primary responsibility for caring for the patient.

SBP refers to the systolic blood pressure. Track and Trigger : A ‘track and trigger’ tool refers to an observation chart that is used to record vital signs or observations graphically so that trends can be ‘tracked’ visually and which incorporates a threshold (a ‘trigger’ zone) beyond which a standard set of actions is required by health professionals if a patient’s observations breach this threshold (Clinical Excellence Commission NSW Health (2010)).

Treatment-limiting decisions: Decisions that involve the reduction, withdrawal or withholding of life-sustaining treatment. These may include ‘no cardiopulmonary resuscitation’ (CPR), ‘not for resuscitation’ and ‘do not resuscitate’ orders.

Vital sign: A ‘vital sign’ is a sign that pertains to life, without which life would not exist i.e. pulse, blood pressure, respirations.

6.0 Roles and responsibilities 6.1. All healthcare staff must comply with this policy. 6.2. Key roles and responsibilities are outlined in the HSE (2011) Guiding Framework and Policy

for the National Early Warning Score System to Recognise and Respond to Clinical Deterioration for guidance.

6.3. The MEWS system is a physiological ‘track and trigger’ clinical assessment tool and cannot

replace the clinical judgement of a qualified member of staff. If there are concerns regarding a patient’s condition, nursing/therapy professionals/medical staff should not hesitate in contacting a senior member of the patient’s medical team to review the patient, irrespective of the MEWS.

7.0 Procedure 7.1. Vital signs assessment 7.1.1 The minimum vital signs to be recorded with each set of vital signs include:

• respiratory rate • oxygen saturations (SpO2) • heart rate • blood pressure • temperature • level of consciousness

7.1.2 Other specific observations pertaining to adult patients are outlined in Sections 7.2.9 and

7.2.11. 7.1.3. A clear monitoring plan needs to be documented on each patient including the frequency of

observations, taking into account the patient’s diagnosis and proposed treatment. This should be decided in consultation between nursing and medical staff.

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7.1.4. The patient’s diagnosis, the presence of co-morbidities and the treatment plan for the patient

must be taken into account when determining the frequency of observations. Certain patients require more regular observations in the acute setting as per clinical condition and protocol

7.1.5. A full set of vital signs should be documented on all patients at the following times:

• On admission and at time of initial assessment • Postoperatively as per local protocols • Post procedure as ordered • Minimum of 4/24 for 24 hours on any patient admitted from the Emergency

Department or Acute Medical Unit /Acute Medical Assessment Unit/Medical Assessment Unit or transferred from a critical care area (e.g. Intensive Care Unit, Coronary Care Unit, High Dependency Unit) or following an inter‐hospital transfer

• Minimum of every 12 hours on all patients unless otherwise specified In addition : • As directed by the medical team • If the patient’s condition deteriorates • Family member or carer concern, as appropriate • As per MEWS Escalation Protocol (Appendix II) • As per other standard operating procedures (e.g. blood transfusion, Patient Controlled

Analgesia (PCA) ,Epidural/Spinal analgesia /infusions and Intravenous/Subcutaneous Opioid Infusions)

• Following administration of an opioid other than listed above. • Prior to administration of medications that will directly affect the vital signs (e.g.

cardiac medications).  7.1.5. If a single parameter is rechecked to assess the effect of an intervention (i.e. oxygen

saturation if oxygen has been applied, or temperature) a full set of vital signs should be done within 30 minutes.

7.1.6. The vital signs are to be documented on the relevant observation chart, the design of which

should be based on the national MEWS model Patient Observation Chart template, and must include the national MEWS parameters, as outlined in the model chart (Appendix I).

 7.1.7. Any decrease in frequency of vital sign measurement must only be done on the direction

of the CNM/nurse-in-charge in consultation with the medical practitioner and must be documented in the patient’s healthcare record.

 7.1.8. Nursing staff can increase the frequency of vital sign measurement, if determined by patient

need and clinical judgement.

7.1.9 Patients who present to hospital for a day procedure who are having frequent vital sign measurements may not require temperature measurement with each set of vital signs. They should however have a temperature measured on initial assessment/arrival and prior to discharge.

7.2.  Modified Early Warning Score 7.2.1. The MEWS system is to be applied when patient observations are taken (Section 7.1). 7.2.2. A Modified Early Warning score is to be calculated each time a set of observations is taken.

Observations to be scored include: • respiratory rate • oxygen saturation • inspired oxygen • blood pressure • pulse • temperature, • level of consciousness: AVPU • urine output over the past 4 hours

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In addition a score is made on inspired oxygen, in order to calculate the overall MEWS. (Note for local adaptation: For postoperative patients for whom consultants wish to prescribe more than 35%, the inspired oxygen (FiO2%) the consultant considers appropriate as a trigger should be documented in the table for charting parameters outside the normal range). All observations require scoring if falling on a coloured area of the chart. Enter a score for each observation (including zeros) in the relevant box. Add up the score for each observation: (Respiratory Rate, SpO2 Rate, Pulse Rate, Blood Pressure, Temperature, Urine Rate and AVPU), and in addition include score for inspired oxygen. This equates to the total Modified Early Warning Score (MEWS). Review the MEWS score in line with the MEWS Protocol for escalation (Appendix II).

7.2.3. The MEWS may be altered to allow for the usual vital signs relating to an individual patient’s pre‐existing conditions (e.g. chronic lung disease, dialysis patients). This is to be documented in the space provided on the front of patient observation charts by a senior doctor (Consultant or Registrar) (Appendix I).

7.2.4. The initial frequency of the MEWS calculation and vital signs assessment, appropriate to

clinical need, is determined by the registered nurse in collaboration with the medical team, and in view of the MEWS Protocol for escalation. This must be documented in the patient’s healthcare record, and communicated in the nursing notes.

7.2.5. The blood pressure score is determined by comparing the current systolic reading and the

patient’s usual systolic blood pressure (SBP) and the greater the difference the greater the score. The patient’s usual systolic blood pressure is to be recorded on the observation chart in the space provided. (Appendix 1)

7.2.5.1. The usual blood pressure is a guide and can be approximated from:

• preadmission clinic • the discharge blood pressure from previous hospital admission • information from the patient and family, or a general practitioner stable

reading from the emergency department (if 4‐5 readings are similar and the other vital signs are normal)

7.2.5.2 If a usual blood pressure for the patient is unable to be determined then a goal blood

pressure should be determined in consultation with the medical staff and used until further direction.

7.2.5.3. Blood Pressure : Systolic blood pressure only, is scored on the Modified Early Warning

Score; however, the actual systolic and diastolic blood pressure should be recorded as usual on the observation chart.

7.2.5.4. There may be times when the usual SBP may change for a patient during the admission

(e.g. started on an antihypertensive). If this occurs the time and date of the change and the reason for the change should be documented in the clinical record.

7.2.5.5. Lying and Standing Blood Pressure: For patients who require lying and standing blood

pressure, chart both on the MEWS chart and label accordingly. When calculating, ‘the most clinically significant SBP’ should be used in the final scoring.

7.2.5.6. Note: A manual reading should be obtained if the automated blood pressure reading is

outside the patient’s usual range (high or low) or if the patient has an irregular heart rate. If the electronic reading does not measure on the second attempt use a manual cuff.

7.2.6. Urine Output is to be scored as applicable. This is to be done by:

• adding up the urine output in the previous 4 hours preceding the recording of the current set of vital signs • if there are no concerns in relation to the patient’s urine output tick the (0) box

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• If the MEWS is 4 or greater a fluid balance chart should be commenced if not already in place and urine output scored in the MEWS

• The decision regarding urethral catherisation for monitoring of urine output in the clinically deteriorating patient is made by the medical practitioner in liaison with senior nursing staff.

7.2.7. Level of consciousness is assessed in the MEWS by using the AVPU score (New

Agitation/confusion: The Awake; Responding to Verbal Stimulus; Responding to Painful Stimulus; Unresponsive (AVPU)) (Note that neurological deterioration is the second most important marker of acute deterioration in acutely ill patients). All patients who present with a possible neurological pathology or any suspicion of Meningococcal disease should have Glasgow Coma Scale vital signs assessment undertaken in conjunction with the MEWS. A supplemental neurological observations chart should be used alongside the patient observation chart to record the Glasgow Coma Scale (GCS).

7.2.8. There are also patients in whom the use of MEWS may be inappropriate, such as during the

end stages of life, advanced palliative care. Although the majority of patients will benefit from utilisation of MEWS the clinicians own clinical judgement dictates whether s/he requires the patient to be regularly scored. Where a Consultant’s decision is that a MEWS score is not appropriate then this should be clearly written onto the front of the observation chart. An annotation should also be made in the patient’s healthcare record documenting why the decision was made not to use MEWS.

Additional observations: 7.2.9. All patients require urinalysis and weight recorded on admission. These should be repeated

as clinically indicated. 7.2.10. The assessment of pain should be recorded routinely, and as clinically indicated. The

recommended tool is: (local decision regarding type of pain assessment tool) . Pain assessment should also take place after analgesia administration to note effect/side effects of treatment.

7.2.11 The vital signs assessment triggers (refer to Section 7.2) for the MEWS do not detail the

specific physiological parameters for the early detection of sepsis. This needs to be considered, as appropriate, by the clinician.

 7.3. MEWS Protocol for Escalation of Treatment 7.3.1. The purpose of the Modified Early Warning Score is to support clinical staff in monitoring the

condition of patients and to improve communication with the medical team so that an appropriate treatment plan can be promptly implemented for the patient.

7.3.2. Once a patient has a Modified Early Warning Score of 1 or greater the MEWS Protocol

(Appendix II) must be adhered to. 7.3.3. Trigger score: A total MEWS of 2 or more is the trigger point for medical review as per MEWS

protocol, with escalated notification at MEWS 4 and MEWS 7; if the MEWS is 3 in any single parameter; or if the patient is not improving.

7.3.4. Any patient with a MEWS of 2 or above should have a clearly documented monitoring plan

which includes required frequency of observations and Early Warning scoring, and agreed parameters for review, if different from those stated in the escalation protocol. This must be written in the patient’s healthcare record.

7.3.5. If a medical review is not received within the specified time period, the medical team should

be reminded. If response is not carried out as per the MEWS Protocol the CNM/Nurse-in –charge is advised to contact the Registrar or Consultant. This also should be reported to Senior Nursing Management as appropriate.

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7.3.6. The MEWS system is a clinical assessment tool and does not replace the clinical judgement of

a qualified healthcare professional. If there are concerns regarding a patient’s condition, staff should not hesitate in contacting a senior member of the patient’s medical team to review the patient, irrespective of the MEWS.

7.3.7. (Refer also to HSE (2011) A Guiding Framework and Policy for the National Early Warning

Score System to Recognise and Respond to Clinical Deterioration for further guidance). 7.4. Procedure for Communication in relation to the deteriorating patient 7.4.1. The recommended procedure for effective verbal communication between clinical staff, about

the deteriorating patient, is to utilise the Identify, Situation, Background, Assessment and Recommendation (ISBAR) technique in delivering communication (Text box1.). On contacting the doctor the nurse must provide information on the reason for the elevated score, current vital signs, recent procedures undergone by the patient. A record of this communication should be recorded in the patient’s healthcare record including who was contacted, by name, and at what time (Appendix III).

7.4.2. Appropriate documentation must be maintained and updated in the patient’s healthcare

record, to support continuity of care and transfer of essential communications relating to the patients condition and treatment. This includes the patients monitoring and management plan. Once a patient is reviewed a clear medical plan must be documented and communicated to nursing staff looking after the patient. This also must be recorded in the patient healthcare record.

ISBAR

IDENTIFY – Identify yourself, who you are talking to and who you are talking about

SITUATION – What is the current situation, concerns, observations, MEWS etc BACKGROUND – What is the relevant background. This helps to set the scene to interpret the situation above accurately ASSESSMENT – What do you think the problem is ? This requires the interpretation of the situation and background information to make an educated conclusion about what is going on. RECOMMENDATION – What do you need them to do ? What do you recommend should be done to correct the current situation ? Text box 1. 7.4.3. When documenting a medical entry always document:

H – History E – Examination I – Impression/diagnosis P – Management plan

7.4.4. Management plans should include:

• Observation orders – specification of the frequency of observations • Nursing orders – detail of more intensive monitoring e.g. urine output hourly measurement • Therapy professions orders • Change in therapy orders • Investigations/intervention orders • Notification orders – guidance for when to call team if there are concerns.

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7.4.4. Appropriate handover of information pertaining to the clinically deteriorating patient, including MEWS scores, must be made at shift handover.

7.4.5. The MEWS Patient Observation chart is for continuous use during a patient admission period.

If the patient is transferred to another ward the chart must be continued in use. It should be filed in the patient healthcare record when completely filled or on discharge.

7.4.6. (For further information refer to the HSE (2011) Guiding Framework and Policy for the

National Early Warning Score System to Recognise and Respond to Clinical Deterioration). 8.0. Implementation Plan

Key actions for implementation to be followed as per in the HSE (2011) Guiding Framework and Policy for the National Early Warning Score System to Recognise and Respond to Clinical Deterioration.

Specific detail on implementation locally is to be outlined.

9.0 Evaluation and Audit

Key actions for evaluation and audit to be followed as per in the HSE (2011) Guiding Framework and Policy for the National Early Warning Score System to Recognise and Respond to Clinical Deterioration.

Specific detail on evaluation and audit locally is to be outlined.

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10.0 References/Bibliography

ACT Health (2007) Policy: Modified Early Warning Scores Australian Capital Territory Directorate http://www.health.act.gov.au/compass Avard B, McKay H, Slater N, Lamberth P, Daveson K, Mitchell I (2010) Compass ‘Pointing You in the right direction’ Adult Training Manual. http://www.health.act.gov.au/compass Australian Commission on Safety and Quality in Healthcare (2010) National Consensus Statement: Essential elements for recognising and responding to clinical deterioration ACSQHC Clinical Excellence Commission, New South Wales Health (2010) Between the flags: Keeping patient’s safe: guidelines and implementation toolkit. http://www.cec.health.nsw.gov.au/programs/between-the-flags

Commission on Patient Safety and Quality Assurance (2008) Report of the Commission on Patient Safety and Quality Assurance: Building a Culture of Patient Safety Department of Health and Children Council of International Hospitals (2007) Tactics to Manage Deteriorating Patients: Literature Review The Advisory Board Company Washington D.C. CREST (2007) Guidelines on the Use of Physiological Early Warning Systems Clinical Resource Efficiency Support Team – Northern Ireland http://crestni.org.uk/

Department of Health (2009) Competencies for recognising and Responding to Acutely Ill Patients in Hospital NHS http://www.dh.gov.uk/en/Publicationsandstatistics/Publicationspolicyand Guidance/DH_096989 Dellinger,RP., Levy, MM., Carlet, JM., et al (2008) Surviving Sepsis Campaign: International Guidelines for management of severe sepsis and septic shock Critical Care Medicine 36: 296 – 327 http://www.survivingsepsis.com/implement/resources/guidelines

Gao, H., McDonnell, A., Harrison, D.A. et al (2007) Systematic review and evaluation of physiological track and trigger warning systems for identifying at risk patients on the ward. Intensive Care Medicine. 33:667-79 Health Information and Quality Authority (2011) Report of the investigation into the quality and safety of service and supporting arrangements provided by the Health Service Executive at Mallow General Hospital http://www.hiqa.ie/

Health Information and Quality Authority (2010) Guidance on Development of Key Performance Indicators and Minimum Data Sets to monitor Healthcare Quality

Health Service Executive (2011) Training Manual for the National Early Warning Score and associated Education Programme Acute Medicine Programme: National Early Warning Score project and associated Education Programme Governance and Advisory Groups

Health Service Executive (2010) Achieving excellence in clinical governance: Towards a culture of accountability Quality and Clinical Care Directorate Health Service Executive (2009) Towards excellence in clinical governance – a Framework for Integrated Quality, Safety and Risk management across HSE Service providers Framework Document Version 1 HSE Cavan & Monaghan, Louth/Meath Hospitals HSE DNE (2008) Guideline for Vital Signs Assessment of Adults and the use of the Physiological Track and Trigger System ‘POTTS’

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HSE Mid Western Regional Hospital (2010) Guideline for Vital Signs Assessment of Adults and the use of the Simple Clinical Score (SCS) Assessment Tool and the HOTEL Monitoring Score HSE South Tipperary General Hospital (2009) Modified Early Warning Scoring System: Guidelines for staff HSE Waterford Regional Hospital (2011) Guidelines for Healthcare staff in the use of a Modified Early Warning Score (MEWS)

James Connolly Hospital Blanchardstown (2011) Guideline for use of the Early Warning Score in Connolly Hospital Mitchell, I.A., McKay, H., VanLeuvan, C. , Berry, R. , McCutcheon, C. , Avard, B. , Slater, N., Neeman, T., Lamberth, P. (2010) A prospective controlled trial of the effect of a multi-faceted intervention on early recognition and intervention in deteriorating hospital patients. Resuscitation 81 : 658–666 National Institute for Health and Clinical Excellence (2007) Acutely ill patients in hospital: Recognition of and response to acute illness in adults in hospital. NHS: NICE www.nice.org.uk/nicemedia/pdf/CG50FullGuidance.pdf National Institute for Health and Clinical Excellence (2010) Review of Clinical Guideline (CG50) Acutely Ill patients in hospital NHS: NICE http://www.nice.org.uk/nicemedia/live/11810/52356/52356.pdf National Institute for Health and Clinical Excellence (2007) Audit Criteria: Acutely Ill patients in hospital (NICE clinical guideline 50) NHS: NICE National Institute for Clinical Excellence/ Commission for Health Improvement (2002) Principles for Best Practice in Clinical Audit Oxon: Radcliffe Medical Press

National Patient Safety Agency (2007) Recognising and responding appropriately to early signs of deterioration in hospitalised patients NHS www.npsa.nhs.uk New South Wales (NSW) Health (2010) Policy Directive: recognition and Management of a Patient who is Clinically Deteriorating http://www.health.nsw.gov.au/policies/

New South Wales (NSW) Health (2010) Standard: Recognition and management of Patients who are Clinically Deteriorating http://www.health.nsw.gov.au/policies/

Patient Safety First (2008) The ‘How to Guide’ for Reducing Harm from Deterioration NHS www.patientsafetyfirst.nhs.uk

Perbedy MA, Cretikos M, Abella BS, De Vita M, Goldhill D, Kloeck W, Kronick SL, Morrison LJ, Nadkarni V, Nichol G, Nolan J, Parr M, Tibballs J, van der Jagt EW, Young L (2007) Recommended Guidelines for Monitoring, Reporting and Conducting Research on Medical Emergency Team, Outreach and Rapid Response Systems: An Uystein-Style Scientific Statement : A Scientific statement from the International Liaison Committee on Resuscitation ( American Heart Association, Australian Resuscitation Council, European Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, and the New Zealand Resuscitation Council); the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiopulmonary, Perioperative, and Critical Care; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research Circulation 116: 2481-2500 Royal College of Physicians of Ireland, Irish Association of Directors of Nursing and Midwifery, Therapy Professions Committee, Quality and Clinical Care Directorate, Health Service Executive (2010) Report of the National Acute Medicine Programme http://www.hse.ie/eng/services/Publications/services/Hospitals/AMP.pdf

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Policy Template APPENDIX1: MODEL PATIENT OBSERVATION CHART

Table 1. Front page Model Patient Observation Chart (A4 format) or A3 format (folded to A4)

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Table 2. Model Patient Observation Chart Page 2 (A4 format) or Page 2 & 3 (A3 format)

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Table 3. Model Patient Observation Chart Page 3 (A4 format) or Page 4/back page (A3 format folded to A4) NOTE: The scoring parameters for the physiological signs identified in the nationally agreed Modified Early Warning Score in Table 1, must be strictly adhered to in the event that an acute hospital decides to design their own observation chart.

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Policy template APPENDIX II: MEWS PROTOCOL (Escalation Flow Chart)

MEWS PROTOCOL (Escalation Flow Chart) Modified Early Warning Score Total  MEWS 1             STAGE 1  Inform CNM/Nurse in Charge and 

document in patient record.  

 

MEWS 2‐3 

           STAGE 2  Inform CNM/Nurse in Charge. Inform SHO of MEWS 2 or 3 and request to review within 1 hour. Record observations at least every 30 minutes until reviewed. SHO to specify frequency of observations, formulate management plan and document.  

    MEWS of 3 or more in any single parameter  

            STAGE 2a  Inform CNM/Nurse in Charge. Request immediate review by Registrar. Record observations at least every 15 minutes until reviewed. Registrar to specify frequency of observations, formulate management plan and document. Stay with patient.  

      MEWS 4‐6 

           STAGE 3  Inform CNM/Nurse in Charge. Inform Registrar of MEWS 4‐6 and request to review within 30 minutes. Record observations at least every 15 minutes until reviewed. Registrar to specify frequency of observations,  formulate  management plan and document. Consider transfer of patient to a higher level of care. Activate Emergency Response Team as appropriate to hospital model. Stay with patient.  

      MEWS ≥ 7 

           STAGE 4  Inform CNM/Nurse in Charge. Request immediate review by Registrar. Record observations at least every 15 minutes until reviewed. Registrar to specify frequency of observations,  formulate  management plan and document. Plan to transfer to a higher level of care. Activate Emergency Response Team as appropriate to hospital model. Stay with the patient.   

                                      IF THE RESPONSE IS NOT CARRIED OUT AS ABOVE                                         THE CNM/NURSE IN CHARGE MUST CONTACT THE                                                                      REGISTRAR OR CONSULTANT 

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Policy template Appendix III : Sample ISBAR Report

  

(Adapted from COMPASS© training programme) 

ISBAR Communication Tool

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Policy template  APPENDIX IV: SIGNATURE SHEET

Please sign to indicate you have read and understand the HSE(2011) Guiding Framework and Policy for the National Early Warning Score System to Recognise and Respond to Clinical Deterioration

PRINT NAME SIGNATURE Area of Work Date