A&E Documentation Booklet

Banda Label Emergency Department

Nursing Documentation

Date Time

Triage Documentation Allergies: Date Time Signature PC: HPC:

Drugs given in ambulance prior to arrival:

Patient’s own medication? Yes / No PMH:

SH:

Mobility: Triage colour: D&V? Yes/No Notes:

STA2335

Emergency Care Safety Checklist Action Time Initials Comments

1st Hour Completed

by

Assessment/Triage Mews Chest Pain ECG recorded (within 10 minutes) ECG reviewed by Dr (within 30 minutes – time on ECG)

Undressed and gown Wristband Pain score assessed Analgesia administered (if appropriate) Sepsis suspected? Investigations Initiated (as appropriate) IV access and care plan Blood tests Imaging Stroke, NOF xray within 30 mins Specific Pathway Triggered – see Box 1 Pathway commenced : Stroke, DKA, NOF, GI bleed, Sepsis

2nd Hour Completed

by

Mews Pain score assessed Analgesia administered (if necessary) Next of Kin aware Refreshments offered (if not NBM) Pressure Area Care Assessment undertaken Patient Good To Go Patient ready for transfer Speciality bed confirmed

3rd Hour Completed

by

Mews Pain score assessed Analgesia administered (if necessary) Refreshments offered (if not NBM) Review by senior doctor

4th Hour Completed

by

Mews Pain score assessed Analgesia administered (if necessary) Refreshments offered (if not NBM) Regular medication administered /NA

Referrals & Pathway/Speciality Triggers if Required Adult Safeguarding Mental Health If positive alcohol withdrawel Score – ETOH CNS

Box 1 Speciality Bed Trigger for appropriate ward Stoke/TIA Upper GI bleed DKA Cardiology NIV / chest drain #NOF

Date

Time40

39.53

2

1

0

1

1

2

3

2

0

1

3

3

2

1

0

1

3

3

2

1

0

23

39

38.5

38

37.5

37

36.5

36

35.5

35

34.5

34

200

190

180

170

160

150

140

130

120

110

100

90

80

70

60

50

40

170

160

150

140

130

120

110

100

90

80

70

60

50

40

35

30

25

20

15

10

8

Resp Rate

O2 Sats

O2 Delivered

Urine MEWS

AVPU

Pain

TEMP

BLOODPRESSURE

PULSE

RESPRATE

= 0 = 1 = 2 = 3

INITIALS

MEWS Action

TOTAL MEWS

GRADE

Saturation

Urine OutputCatheterized

Urine Output NOTCatheterized

Fluid Challenge

AVPU

Less than 87 88 - 91 92 - 94

Mild

95 - 100

30mls or less FOR more than 2 hrs

30mls / hr or not onfluid balance

More than 40%oxygen

Low volume onbladder scan after 6 hrs

More than one

Unresponsive Responsive topain

Responsive tovoice

New confusionAlert

Unreleived by analgesiaPain

O2

Date:

ECG

Sepsis / Neutropenic Sepsis Screening and Treatment Pathway -Apply if MEWS= 4 or more-Apply if patient looks sick

In A&E: If patient has had chemotherapy in last 6 weeks or known Neutropenic: Go directly to ‘Red Flag Sepsis Positive’

Sepsis Unlikely Follow standard MEWS escalation protocol

Look for other causes for Illness. Review if deteriorates

Is there Suspected or Documented Infection?

Pneumonia/ productive cough UTI/Dysuria Abdominal pain/ distension Device related infection Cellulitis/ wound infection Meningitis Infection but Unclear Source Other (please state) . . . . . . . . . . . . . . . . .

Date: ………………. Time: ....................... Ward / Area: ..............................…………… Assessed By: ..............................................

Patient Details Or Patient Label

Assess Severity of Sepsis Is at least one of these RED FLAG signs present?

Systolic BP <90mmHg or >40mmHg below normal Heart Rate >130 Blood Lactate (Arterial, Venous or Capillary) >2 Respiratory rate >25/min Oxygen Saturations <92% on air (88% in COPD) V, P or U on AVPU scale Non-Blanching rash, mottled / ashen or cyanotic skin Not passed urine in last 18hr Urine Output less than 0.5 ml/kg/hr for last 2 hours Neutropenic

Moderate Risk of Sepsis Contact FY1 FY2 or Outreach Now!Ensure review within 60 mins.Rescreen if patient deteriorates

Red Flag Sepsis Present High Risk of Sepsis:

Contact FY1 FY2 or Outreach Now!Ensure review within 15 mins.

Start Sepsis Six Immediately Inform Seniors Complete pathway -overleaf

Y

N Y

RReferred to: Grade Time: : .

N

CCOT/ Medical Review: Name . . . . . . . . . . . . . . . . . . . . . . . . . . Grade . . . . . . . . . . . . Time . . . . . . . . hQuick check (and completion) of the above sepsis screen Any difference in assessment: document overleaf

Are any of the Red Flag Sepsis signs present?

Yes, High Risk of Sepsis

No, Moderate Risk of Sepsis

▪Consider Starting Antibiotics▪Ensure differential tests are prioritised.▪Inform Seniors- review within 60 mins

Yes

No, Treat as Low Risk of Sepsis.

Review if deterioration

Sepsis Six and Red Flag Sepsis are copyright to and intellectual property of the UK Sepsis Trust, registered charity no. 1158843. sepsistrust.org

Review tests: Confirmed Infection

and New Organ Dysfunction, esp AKI?

Dr.

Sam

Geo

rge

/ Bar

ry O

’Kee

ffe (R

GN

) Mar

ch 1

6

Sep

sis

Six

Ti

me

Nam

e

When Sepsis Six Delivered and Blood results available Confirm infection and SOFA score

Non

-ITU

SO

FA s

core

and

Esc

alat

ion

Giv

e O

2 to

achi

eve

targ

et s

ats

Aim

to k

eep

satu

ratio

ns >

94%

(

88-9

2% if

at r

isk

of C

O2 re

tent

ion,

e.g

. CO

PD

)

FA

scor

e

Cum

ulat

ive

scor

e ≥

2 ab

ove

base

line=

Sep

sis:

In

form

Reg

istra

r / C

onsu

ltant

and

CC

OT

Circ

le S

OFA

sco

re

Pred

icte

d M

orta

lity

2-6

10-1

5%

7-9

15-2

0%

10-1

2 40

-50%

13

-15

50-6

0%

15

>80%

>1

5 >9

0%

Org

an

0 1

2 3

4 R

espi

ratio

n P

aO2/F

iO2

(app

rox.

–S

ats%

on

Air)

≥53.

3 (>

94)

<53.

3 (9

0-94

) <4

0 (<

90)

On

CPA

P,

NIV

or I

PPV

Neu

rolo

gica

l G

CS

15

13-1

4 10

-12

6-9

<6

Car

diov

ascu

lar

MA

BP

mm

Hg

≥70

<70

On

Inot

rope

s

Ren

al

Cre

atin

ine

or

(urin

e ou

tput

ml/2

4hr)

<1

10

110-

170

171-

299

300-

440

(<50

0)

>440

(<

200)

Hae

mat

olog

y P

late

lets

≥1

50

<150

<1

00

<50

<20

Hep

atic

B

iliru

bin

<20

20-3

2 33

-101

10

2-20

4 >2

04

Take

Blo

od C

ultu

res

(at l

east

one

per

iphe

ral s

ets

also

U

&E

, LFT

, FB

C, C

oag,

CR

P)

Fres

h S

tab

Fre

pp U

sed

Th

ink

Sour

ce c

ontro

l! C

all s

urge

on/ r

adio

logi

st if

nee

ded

CXR

and

urin

alys

is fo

r all

patie

nts

Con

side

r e.g

. CSF

, spu

tum

and

wou

nd s

wab

s

Giv

e IV

ant

ibio

tics

Fol

low

trus

t gui

delin

es (a

vaila

ble

on in

trane

t) fo

r tre

atm

ent o

f S

epsi

s/ N

eutro

peni

c S

epsi

s

Giv

e a

fluid

cha

lleng

e H

artm

ann’

s or

0.9

%S

alin

e If

not

hyp

oten

sive

and

lact

ate

norm

al g

ive

at le

ast 5

00m

l bol

us

If hy

pote

nsiv

e or

lact

ate

>2 g

ive

up to

30m

l/kg

( in

500m

l bol

us’)

Che

ck s

eria

l lac

tate

s C

heck

ven

ous/

cap

illary

lact

ate

with

arte

rial s

ampl

e if

lact

ate>

4.

Rec

heck

lact

ate

afte

r eac

h 10

ml/k

g ch

alle

nge

Hou

rly U

rine

Out

put m

easu

rem

ent a

nd M

EWS

M

ay n

eed

cath

eter

isin

g

Avo

id c

athe

ter i

f pos

t-che

mo

/ neu

trope

nic

St

art s

trict

hou

rly fl

uid

bala

nce

char

t

Con

side

r 12-

lead

EC

G

.

.

.

.

.

.

.

.

.

.

Com

plet

e he

re;

W

orki

ng d

iagn

osis

Rea

sons

for a

ny v

aria

tions

, om

issi

ons

and

dela

ys fr

om th

e tre

atm

ent p

athw

ay

Tr

eatm

ent E

scal

atio

n P

lan

A

ny o

ther

com

men

ts

INPU

T O

UTP

UT

– U

rine

30m

ls/h

r or l

ess f

or 2

hrs e

scal

ate

to D

octo

r or O

utre

ach

ORA

L

In

trav

enou

s O

ther

:

Urin

e

NG

T

Vom

it

Bow

els

Oth

er:

Offe

red

Tak

en

Ho

urly

Tot

al

08.0

0

09

.00

10.0

0

11

.00

12.0

0

13.0

0

14

.00

15.0

0

16

.00

17.0

0

18

.00

19.0

0

To

tal f

or 1

2hrs

:

I

ntak

e

Out

put

B

alan

ce

20.0

0

21

.00

22.0

0

23

.00

24.0

0

01

.00

02.0

0

03

.00

04.0

0

05

.00

06.0

0

07

.00

Tota

l for

24h

rs:

In

take

O

utpu

t

Bala

nce

A po

sitiv

e ba

lanc

e of

500

ml o

r mor

e (u

nles

s clin

ical

ly in

dica

ted)

to b

e es

cala

ted.

Notes

Notes