Observations and the Deteriorating Patient for Registered Nurses

1. Observations and the Deteriorating Patientfor Registered Nurses Shane Moody, Lead Nurse & Vikki Crickmore, Sister. Critical Care Outreach Service September 2013

2. Competency framework Objectives • Gain awareness of the national approach and MEWS. • Discuss observations in detail and physiological relevance. • Consider appropriate escalation response to deterioration and barriers to this. • Examine useful communication tools. • Consider additional elements relevant to patient care when considering deterioration. • Carry out a practical assessment of taking observations and management of case studies.

3. Competency framework Assessments CCOS to assess Band 7’s ↓ CCOS to do Train the Trainer sessions for senior nurses ↓ Band 7’ and senior nurses to assess own staff

4. Competency framework Assessments Presentation ↓ Questions ↓ Station 1 ←→ Station 2 Practical taking obs Case studies & and documenting completing competency in pairs document Conclude and finish

5. Competency framework Introduction 2005 – NCEPOD: An Acute problem 2007 – NPSA: Safer care for the acutely ill patent 2007 – NPSA: Recognising & responding appropriately to early signs of deterioration Consistent themes are obvious throughout these documents: • Failure to measure basic observations. • Lack of recognition of the importance of worsening vital signs • Delay in response to deteriorating vital signs.

6. Competency framework 2007 – NICE published - Acutely Ill patients in hospital – recognition of and response to acute illness in adults in hospital. The key priorities of this document are: • Physiological observations at the time of their admission • A written monitoring plan (diagnosis, co-morbidities and plan) • Observations taken by staff that have been trained and understand clinical relevance. • A Track and Trigger system and observations recorded 12 hourly as a minimum – increased if signs of deterioration.

7. Competency framework Modified Early Warning Used to aid recognition of deteriorating patients, and are based on physiological parameters. An aggregated score calculated. Escalation pathway activated if specific scores. Track and Trigger approach. The escalation pathway outlines actions required for timely review ensuring appropriate interventions.

8. Competency framework Applying to practice • Limitations to MEWS and professional judgment should be used • Taking observations is not just generating numbers – need to understand clinical relevance • Delegating needs to be appropriate • Failure to act has significant consequences – effects on patient, ↑ cardiac arrest, ↑ length of stay, ↑ ICU admissions. • Observe patient – not just using machines • MEWS adapted for paediatrics and obstetrics & head injury patients

9. Competency framework Vital signs to assess • Respiratory rate • Oxygen Saturations • Pulse • Systolic (BP) • AVPU/GCS • Temp • Urine Output

10. Competency framework Respiratory rate • Relevant in a number of compensatory mechanisms within the body • Normal rate should be between 12 and 20. • The most sensitive indicator of potential deterioration. Rising rates often early sign. • Using in conjunction with other evidence ie: use of accessory muscles, increased work of breathing, able to speak?, exhaustion, colour of patient. • Position of patient is important.

11. Competency framework Saturations Blood pumped from Heart is rich in O2 (95%-99% saturated) Blood pumped back to heart is low in O2 (65%-70%)

12. Competency framework Oxygen demand If oxygen delivery to the body falls below what is demanded, the tissues extract more oxygen from the haemoglobin and the saturation of blood falls.

13. Competency framework Oxygen saturations • All cells are dependent on an adequate constant supply of O2 as they are unable to store it. A reduction can lead to organ dysfunction and death. • Dependent on intact respiratory and cardiovascular function – limited by other factors ie: peripherally shut down. • Be aware of patients ‘target saturations’. • All acutely unwell patients should receive supplementary Oxygen and then titrate to readings. • ABG may be required for more in depth assessment.

14. Competency framework Heart Rate • Should be taken manually for one minute, noting the rate, volume and regularity. • Felt at brachial artery • Normal rate can be considered 60-100bpm. • Abnormal findings need investigating • Abnormalities should be followed with an ECG • Consider ECG monitoring

15. Competency framework Effects on Heart Rate

16. Haemorrhage / bleeding Hypotension Sepsis Drugs / medications Hypoxia Temperature Injury / Insult Electrolytes Competency framework Effects on Heart Rate

17. Competency framework Blood pressure = pressure on wall of artery Systolic = pumping pressure Diastolic = resting pressure

18. Competency framework Arterial pressure The pressure in the arteries is carefully regulated by the body. If it drops, immediate circulatory changes occur: ► Heart rate increases ► Constriction of vessels (so BP may remain adequate) - ↓ CRT, ↓ Urine output.

19. Competency framework Blood pressure • A LATE sign of deterioration – patients will compensate (especially young) • Adequate BP is essential for delivery of O2 and nutrients to the rest of the body. • Be aware of what is normal for patient • Organs are very dependent on adequate pressures to ensure perfusion. • Manual Blood pressure recording may be appropriate.

20. Competency framework Urine output • Sensitive indicator of hydration status • Should be 0.5ml/kg/hr • Due to high demand for blood supply to the kidneys, urine output is a useful indicator of cardiovascular status. • Generally is a poorly recorded observation. • Monitoring of fluid balance should be appropriate depending on patient condition. • Acute Kidney injury - ↓ urine output, ↑ toxic waste. Needs urgent attention

21. Competency framework Level of Consciousness • AVPU or GCS for more in depth assessment. • Consider at what point do you need help? • This should include drowsiness, agitation, new changes. • Assess pupils • Consider reversible causes ie: blood sugar • If only responding to pain or unresponsive – airway is at risk – 2222 adult emergency. • Neuro obs

22. Competency framework Temperature • Can have a significant effect on patients condition. • High or low can indicate sepsis • > 38 degrees consider blood cultures • Significant warming can cause vasodilation • Low can be as important as high

23. Competency framework Considerations • O2 needed? • Positioning • IV access • ECG • Catheter • IV fluids • Bloods • Escalation status

24. Competency framework Who is at risk?

25. Competency framework Who is at risk? • Any one in hospital!! • Those with co-existing disease • All emergency admissions • Elderly people • Specific acute illness (sepsis, pancreatitis) • Those with altered level of consciousness • Major haemorrhage

26. Competency framework Causes of deterioration • Sepsis • Hospital acquired infections • Chronic disease process • Co-morbidities • Failure to manage complications • Iatrogenic • Unavoidable complications • Palliative / end of life

27. Competency framework Chain of safety Measure observations and Document↓Recognise Deterioration↓Communicate Appropriately↓Respond efficiently & reassess

28. A tool used to communicate critical information succinctly and briefly Competency framework SBAR

29. Competency framework Barriers to escalation Anxious about escalating? Frequency / exposure to deterioration? Knowledge and Skills? Prioritising workload? Difference of opinion? Define ‘deterioration’ “To become worse” (English dictionary, 2013)

30. Competency framework Additional elements in relation to patient care • Individual Accountability • Risk assessment and delegation • Consent • Risk assessment • Privacy and dignity • Documentation • Infection control • Communication • Safeguarding Updates on amendments to revised policy

31. Competency framework Practical assessment • Complete action plan for scenarios given • Discuss rationale for taking observations and increase/decrease frequency • Correctly taking a full set of observations • Correct documentation and calculation of scores using trust observation charts. • Demonstrate awareness of escalation procedures.