THE DETERIORATING PATIENT

POLICY

August 2015

Document Profile

Type i.e. Strategy, Policy Policy, Procedure,

Guideline, Protocol

Title The Deteriorating Patient Policy

Category i.e. Clinical organisational, clinical,

finance

Version 1.0

Author Clare Stewart

Approval Route, Operational Governance Group i.e. Policy & Procedure

Group, Operational

Governance Group

Approved by Chief Executive Officer – Julie Gafoor

Date approved 13/08/15

Review date 13/08/18

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INTRODUCTION This policy outlines the organisational standards for the prevention and

management of the deteriorating patient and aims to reduce patient harm which

can occur from the risk of deterioration incidents. The policy highlights the

importance of using early warning scores which are commonly used for the

assessment of unwell patients; these observations can detect when a patient’s

condition requires a more intense observation and should be a trigger for further

investigation as early intervention can reduce morbidity and mortality in unwell

patients (NICE 2007, NPSA 2007). Clinical deterioration can occur at any stage of

a patients treatment or illness, although there will be certain periods during which

a patient is more vulnerable, such as the onset of illness or during medical,

surgical or dental interventions. Patients who are at risk of deteriorating may be

identified before a serious adverse event by monitoring changes in physiological observations recorded by healthcare staff. The interpretation of these changes

and timely response of appropriate clinical management once physiological

deterioration is identified is of crucial importance to minimise the likelihood of

serious adverse events, including cardiac arrest and death.

STATEMENT OF INTENT The organisation is committed to having standards in place for managing the

risks associated with the deteriorating patient. This policy will outline the risk

reduction strategies FNHC has in place to minimise these risks, as safety of

patients is a key priority for the organisation.

Strategic objectives for the organisation include the aims to:

Improve quality outcomes and patient satisfaction

Improve patient safety and risk management

Improve efficiency and effectiveness of care services

The early management of the deteriorating patient is a key objective for the

safety and well being of patients, this is why the organisation is implementing a

standardised early warning score trigger tool. The early warning score supports

new ways of providing care in the community to deliver of care closer to home

and avoid unnecessary hospital admissions (DH 2011). This policy will outline

how staff can provide clinical care to promote the early detection, prevention and

management of the deteriorating patient by:-

Standardising practice for clinical staff in the early detection of clinical

deterioration with the aim of preventing further deterioration and possible

subsequent cardio-respiratory arrest Facilitating the early detection of deterioration by using an early warning

score for the appropriate and timely management of clinical deterioration Reducing the clinical risks associated with inappropriately managed

clinical conditions

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DEFINITIONS

Anaphylaxis Anaphylaxis is a severe, life-threatening, generalised or systemic hypersensitivity

reaction. This is characterised by rapidly developing life-threatening airway and/or

breathing and/or circulation problems usually associated with skin and mucosal

changes.

Advance Care Plan. A plan which allows the individual to express and record wishes about future care

in the final months of life.

Basic Life Support (BLS) Circulation and ventilation maintained by using cardiopulmonary resuscitation

techniques without the use of equipment or drugs.

Track and Trigger Systems Track and Trigger systems rely on the recording and charting of the physiological

status of the patient. The observations include, pulse, respiratory rate, conscious

level, temperature, pulse oximetry (SpO2) and blood pressure. The use of these

multiple parameter or aggregated weighting scores systems are more sensitive in

detecting when a patient is showing deterioration compared with single parameter

systems

National Early Warning Score (NEWS) The Royal College of Physicians (2012) have developed a national early warning

score to facilitate a standardised and national unified approach to alerting clinical

staff to any untoward clinical deterioration and also clinical recovery. Early

Warning Scores are a form of track and trigger scoring system based on routine

observations which is sensitive enough to detect changes in a patient’s

physiology. When vital signs are measured they are converted into a score, the

more abnormal the vital signs the higher the score. If scores reach certain

thresholds this triggers interventions that aim to improve the patient’s condition or

in case of an emergency refer directly to acute hospital

SBAR (Situation Background Assessment Recommendation) An SBAR (NHS 2010) is an easy to remember mechanism that can be used to

frame conversations, especially critical ones requiring a clinician’s immediate

attention and action. It can aid clarity when making an emergency call or when

requesting advice or intervention about patient management from a senior

clinician or General Practitioner

Triage Triage is a complex decision making process designed to manage clinical risk. A

rapid assessment is made to identify or rule out potentially life threatening

conditions to ensure patient safety.

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4 DUTIES

4.1 Specific Duties within the Organisation

Committee The Committee is responsible for the statutory duty of clinical governance within

the organisation and takes overall responsibility for this policy. They have overall

responsibility for ensuring that the organisation delivers high quality services that

are efficient and effective.

Chief Executive Officer is responsible for ensuring:- All relevant services are compliant with this policy

Operational Leads are responsible for ensuring:- All relevant staff in their service are working within the standards of this

policy All staff have access to appropriate monitoring equipment

Services have clinical procedures for the safe management of clinical

interventions that are known to potentially put patients at risk of

deterioration

Individual Clinical Staff are responsible for:- Complying with the standards in this policy

Using the early warning scoring system as relevant to their service

Documenting their findings in the patients’ health records

Attending Mandatory and service specific Training

4.2 Quality and Governance This group provides information and assurance to the Committee regarding how

the Quality, Patient Safety, Experience and Risk Strategies are being

implemented and managed within the organisation. In addition the group provides

information and assurance to the Committee regarding how risks are being

managed within the organisation in accordance with the organisational Incident

Reporting Policy. Reported incidents that related to significant patient harm from a

deteriorating patient incident report would be subject to a root cause analysis and

SUI and reported via this group. Lessons learnt would be shared as appropriate

and this policy updated if required.

5 TRAINING AND DEVELOPMENT In line with the organisational policy, all staff in the organisation are required to

comply with mandatory training. Clinical Staff are also required to comply with

service specific core training as specified within their training and development

plan. Monitoring of non-attendance at mandatory training will be monitored by the

FNHC Education Department and Operational Leads.

6 USE OF AN EARLY WARNING SYSTEM WITHIN THE ORGANISATION TO

RECOGNISE PATIENTS AT RISK OF DETERIORATION

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For some patients there is a risk of becoming acutely unwell and in this situation,

should their clinical condition deteriorate, it is essential that healthcare staff are

equipped to recognise and manage the deterioration confidently and

competently.

6.1 Early Warning Scores used in the Organisation The National Early Warning Score (NEWS) for Adults (2012) (Appendix One) is

adopted by FNHC and used by HSSD which will enable the transfer of

information using a standardized validated tool.

Current evidence suggests that the combination of early detection, timeliness of

response and the competency of the clinical response is critical to defining clinical

outcomes and planning an effective clinical response to acute illness (Smith GB

et al, 2006, Kause J, Prytherch D et al, 2004, Hillman K M et al, 2001)

6.2 Benefits of using an Early Warning Scoring system:- Improves the quality of patient observation and monitoring

Improves communication within the multidisciplinary team

Allows for timely discussions to support clinical judgment

Aids securing appropriate assistance for poorly patients

Gives a good indication of physiological trends

Provides a sensitive indicator of abnormal physiology

However, the NEWS is not:-

A predictor of outcome

A comprehensive clinical assessment tool

A replacement for clinical judgment

7 NATIONAL EARLY WARNING SCORE FOR ADULTS (Appendix One) There are six physiological parameters included in the NEWS:

1. Respiratory rate

2. Oxygen saturations

3. Temperature

4. Systolic blood pressure

5. Pulse rate

6. Level of consciousness

The NEWS should be calculated for every set of observations

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The NEWS thresholds and triggers for adults are: - (see Appendix Two and

Three)

Appendix Two outlines the expected clinical response to the NEW Scores

adapted for Adult Community Nursing Teams.

7.1 Registered Nurses Adult Community Nurse Services will refer to a medical colleague / GP or refer

directly to acute services when using the triggers scores and following

recommended responses. They will utilize the SBAR handover tool to ensure

accurate and appropriate information is handed over to ensure a timely and

appropriate response. They will provide information required for the succinct and

seamless handover of a patient to alternative services.

7.2 Adults Inclusion Criteria:- Acutely unwell patients are considered to be at risk of developing a critical illness

therefore health professionals need to commence NEWS at the earliest

opportunity. This includes:-

Patients who are acutely ill – planned or unplanned contacts/visits

Patients with chronic unstable long term conditions

Patients who have an infection e.g. chest, wound or urine infection who

are not responding to treatment

Post operative patients who are not improving / progressing

Patient who are undergoing treatment / tests which may cause a sudden

deterioration in the patient’s condition e.g. dental sedation

Patients whose wounds suddenly deteriorate

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If a patient’s condition suddenly deteriorates or becomes increasingly unwell re

assessment of vital signs would provide an indication of the patients’

physiological status.

7.3 Adults Exclusion criteria:- Patients at End stage of Life who request palliation only

8. REQUIREMENT FOR A DOCUMENTED PLAN FOR VITAL SIGNS MEASURES,

INCLUDING THE FREQUENCY OF MEASUREMENT

In order to monitor patients there needs to be a documented plan to minimise or

prevent further deterioration in patients. This should include the escalation

process between healthcare professionals and the process for escalation in and

out of hours. The following standards need to be documented:-

The frequency of monitoring required must be recorded in the care plan /

treatment of care, this is important in order to provide continuity of care by

the team, especially for home visiting services

All observations need to be recorded in the patients’ health records.

There are some patients where the NEWS may be inappropriate, for example: Patients who are terminally ill and at end stage of life

Minor ailments – if the decision not to undertake NEWS observations the

Team Leader will need to document the rationale for this decision in the

patient record.

Additional factors to consider:- In some COPD patients inappropriate oxygen supplementation could raise

oxygen saturations above the target range, this emphasizes the need for

close monitoring and supervision of these patients

Urine output has been included on the NEWS chart to highlight the importance or recording urine output when considered clinically

appropriate to do so

Pain has been included as part of the NEWS observation chart to

encourage routine recording of pain symptoms, however it does not form

part of the aggregate score for the NEWS

Other exceptions may be appropriate in individual circumstances (e.g.

physiological abnormalities due to long term conditions / COPD) The decision

for a patient to have an adapted range of an acceptable physiological

measurements needs to be made in partnership with either a GP or medical

practitioner and the rational documented in the patients’ health records

9 ACTIONS TO BE TAKEN TO MINIMISE OR PREVENT FURTHER DETERIORATION IN PATIENTS The range of actions to minimise or prevent further deterioration in a patient’s

condition can include:-

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Immediate clinical intervention and treatment

Basic Life Support

Urgent transfer arrangements to secondary care

There may be specific circumstances where sudden deterioration may occur:- Anaphylaxis

Adverse Drug reactions

Following a clinical intervention

Following dental surgery

This list is not exhaustive as there are a range of clinical interventions that may

trigger a sudden deterioration.

9.1 ACTIONS IN RESPONSE TO DETERIORATION IN THE NEWS The organisation advises a range of clinical response to the NEWS trigger scores

(Appendix Two) to meet the needs of a community setting. The NEWS is not a

replacement for clinical judgement and assessment of a patient’s condition.

9.2 SBAR: COMMUNICATION TOOL FOR THE ESCALATION OF CARE AND

TREATMENT AMONGST ALL HEALTHCARE PROFESSIONALS IN THE

ORGANISATION

SBAR stands for: S = Situation B = Background A = Assessment R = Recommendation SBAR is a communication tool for the escalation of care and treatment amongst

all healthcare professionals. SBAR is an easy to remember mechanism that can

be used to frame communications or conversations.

It is a structured way of communicating information that requires a response from

the receiver and helps to specify what actions are expected to minimise or

prevent further deterioration in patients. Inadequate verbal or written

communication is recognised as being the most common root cause of serious

clinical errors. There are some fundamental barriers to communication at times

across different disciplines and levels of staff within services. As such SBAR can

be used very effectively to escalate a clinical problem that requires immediate

attention (in conjunction with the NEWS), or to facilitate efficient handover of

patients between clinicians and clinical teams.

Benefits of using SBAR as a communication tool:- Helps outline the building blocks for communicating critical information

that requires attention and action, thus contributing to effective escalation

and increased patient safety.

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Using it helps to prevent breakdowns in verbal and written communication,

by creating a shared mental model around all patient handovers and

situations requiring escalation, or critical exchange of information SBAR is an effective mechanism to level the traditional hierarchy between

physicians and other care givers by building a common language platform

for communicating critical events, thereby reducing barriers to

communication between healthcare professionals

9.2 A SBAR COMMUNICATION SHOULD CONVEY:-

S: Situation • Identify yourself the site/service you are calling from • Identify the

patient by name and the reason for your report • Describe your concern • Firstly,

describe the specific situation about which you are calling, including the patient's

name, GP, patient location, resuscitation status, and vital signs.

B: Background • Give the patient's reason for admission ( or presentation on

referral in community care setting) • Explain significant medical history •

Overview of the patient's background: admitting diagnosis, date of admission,

prior procedures, current medications, allergies, pertinent laboratory results and

other relevant diagnostic results.

A: Assessment • Vital signs • Clinical impressions, concerns

R: Recommendation • Explain what you need - be specific about request and

time frame • Make suggestions • Clarify expectations • Finally, what is your

recommendation? That is, what would you like to happen by the end of the

conversation with the clinician? • Any order that is given on the phone needs to

be repeated back to ensure accuracy.

Readback: - Making sure you have been understood following any

communication using SBAR, it is important that the receiver of the information

‘reads back’ a summary of the information to ensure accuracy and clarity. This

should also be documented in the patients’ health records.

Documentation of action taken: - The documentation for SBAR when

escalating the care of an acutely ill patient must be clearly written in the case

notes and include clear outcomes of escalation and recommendations

10 DO NOT ATTEMPT RESUSCITATION ORDERS (DNACPR) The community DNACPR document is red in colour and is endorsed by the

Primary Care Body, Jersey Hospice Care and Family Nursing and Home Care. It

is solely for community use and is intended to prevent inappropriate, futile and/or

unwanted attempts at cardiopulmonary resuscitation (CPR) in adult patients in

the community aged 18 years and over.

The DNACRP document can only be signed by the patients G.P, Consultant or

Associate Specialist in Palliative Care. The DNARCPR form should be kept in the

front of the FNHC patient held record. The DNACRP is only accepted if it is in

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its original red colour, it is not valid for hospital use and the hospital

documentation is not valid in the community. (Subject to change following

recommendations from the EOL steering Group)

An advance directive, otherwise known as an advance decision to refuse

treatment (ADRT) or a living will is a decision made by a mentally competent

individual to refuse a particular treatment in certain circumstances. A valid

signed and witnessed ADRT is legally binding.

‘Just in Case Box’ (Anticipatory medication) Patients with palliative care needs and those that are in the last weeks of their life

may have been prescribed medication to be used ‘just in case’ should their

condition change or deteriorate suddenly. The policy for the ‘just in case’

anticipatory medication can be found on the FNHC central filing.

11 INCIDENT REPORTING PROCESS Clinical incidents or near misses relating to the standards in this policy must be

reported via the organisational incident reporting system.

12 EQUALITY IMPACT ASSESSMENT OF THIS POLICY During the development of this policy the organisation has considered the needs

of each protected characteristic with the aim of minimising and if possible remove

any disproportionate impact on patients for each of the protected characteristics,

age, disability, gender, gender reassignment, pregnancy and maternity, race,

religion or belief, sexual orientation. If staff become aware of any clinical

exclusions that impact on patient care that does not comply with this statement

must report the incident or a near miss using the organizational Incident Reporting

system and an appropriate action plan put in place.

13 HOW THE ORGANISATION MONITORS COMPLIANCE WITH THE STANDARDS Clinical audit will be carried out to monitor compliance with the standards

including: Monitoring that accurate and appropriate documentation on the NEWS

observation chart Monitoring the Parameters and relevance for the community setting with

the cohort of acutely ill patients

Actions taken to minimize deterioration Escalation of patients when NEWS score deranged – as per protocol

Documentation of DNAR status in patients case notes

14 REFERENCES Department of Health (2011) Transforming Services for Acute Care Closer to

Home. Jan 11

Hillman K M et al (2001) Antecedents to Hospital Deaths. Intern Medical Journal.

31 (6) 343-8

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Kause J, Smith G, Prytherch D et al (2004) A comparison of antecedents to

cardiac arrests, deaths and emergency intensive care admissions in Australia

and New Zealand, and the United Kingdom the ACADEMIA Study. Resuscitation

62. 275-82

National Patient Safety Agency (NPSA) (2007) Recognising and responding

appropriately to early signs of deterioration in hospitalised patients. London

National Institute for Health and Clinical Excellence (2007) Feverish Illness in

Children. Clinical Guideline 47.

NHS Institute for Innovation and Improvement (2010) Safer Care, SBAR.

NHS Litigation Authority (2012) Risk Management Standards

National Institute for Health and Clinical Excellence (NICE) (2007) CG50 Acutely

Ill Patients in Hospital London: NICE

Patient Safety First. ‘How to Reduce Harm from Deterioration’ Patient Safety

First www.patientsafetyfirst.nhs.uk

Royal College of Nursing (et al 2011) Triage Position Statement

Royal College of Physicians (2012) National Early Warning Score. Standardising

the assessment of acute–illness in the NHS

Smith GB et al. Hospital-wide Physiological Surveillance. A new approach to the

identification and management of the sick patient. Resuscitation 71. 19-28

15 BIBLIOGRAPHY

British Medical Association, the Resuscitation Council (UK) and the Royal

College of Nursing (2007) Decisions relating to cardiopulmonary resuscitation

London

Department of Health (2009) Competencies for Recognising and responding to

acutely ill patients in hospital London DH

National Confidential Enquiry into Patient Outcome and Death (NCEPOD) (2007)

Emergency admissions: A journey in the right direction London: NCEPOD

National Patient Safety Agency (NPSA) (2004) Patient Safety Alert 2004/02.

Establishing a Standard Crash Call Telephone Number in Hospitals NPSA

The Resuscitation Council (UK) Resuscitation Guidelines 2010 (2010)

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16 ASSOCIATED DOCUMENTATION

Education Policy

Consent Policy

Infection Control Policies

Adult Basic Life Support Guideline

Medical Devices Policy

Procedure for Managing an Anaphylactic Emergency

NEWS protocol

COPD protocol

NATIONAL EARLY WARNING SCORE (NEWS) *

© Royal College of Physicians 2012

*The NEWS initiative flowed from the Royal College of Physicians' NEWSDIG, and was

jointly developed and funded in collaboration with the Royal College of Physicians, Royal

College of Nursing, National Outreach Forum and NHS Training for Innovation.

A = Alert (fully awake)

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V = Responds to verbal commands (the patient makes some sort of response when talked to) P = Responds to pain (the person undertaking the assessment should be suitably

trained when using pain stimulus as a method of assessing levels of consciousness)

U = completely unresponsive (commonly referred to as ‘unconscious’)

OUTLINE RESPONSE TO NEWS TRIGGERS ADULTS (Adapted for use

in community setting)

NEWS SCORE FREQUENCY OF CLINICAL RESPONSE

MONITORING

0 Repeat as per care plan Continue NEWS to meet clinical needs of monitoring on each visit

patient

1-4 Increase monitoring Community nurses and / or HCAs to discuss patient with Rapid Response Team member who will advise and / or review and decide if increased monitoring and or escalation of care to RRT, GP, ED is required to treat and manage

underlying condition

Total 5 or more or 3 Repeat observations as Urgently inform a *senior

in one parameter directed in the patients’ clinical decision maker, health records and / or Review and assessment by a clinician who is clinically competent to assess and treat acutely ill patients and can recognise when escalation of care to a secondary care setting is

essential

Total: 7 or more Continuous monitoring Immediately life threatening phone 999 or if patient deteriorated but not life threatening phone 444701. If appropriate contact A&E to advise of referral handover using SBAR

tool.

*A senior clinical decision maker in the community setting could be a GP, Team Leader

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NEWS THRESHOLDS AND TRIGGERS ADULTS

THE NEWS TRIGGER SYSTEM ALIGNED TO THE SCALE OF THE CLINICAL

RISK

A low score (NEW score 1-4 ) should prompt assessment by a competent registered

nurse who should decide if a change of frequency of clinical monitoring or an

escalation of clinical risk is indicated

A medium score (NEW score 5-6 or a RED score) should prompt an urgent review

by a clinician skilled in the assessment of acute illness, who will consider if there

should be an escalation of care

A high score (NEW score of 7 or more) should prompt emergency referral to

secondary care

*RED score refers to an extreme variation in a single physiological parameter (i.e. a

score of 3 on the NEWS chart, coloured RED to aid identification and represents an

extreme variation in a single physiological parameter). The consensus of the NEWS

Development and implementation Group (2012) was that extreme values in one

physiological parameter (e.g. heart rate <40 beats per minute, or a respiratory rate of

<8 per minute or a temperature of<35°C) could not be ignored and on its own required

urgent clinical evaluation.

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NEWS OBSERVATION CHART FOR ADULTS

Surname: Forename:

DOB: URN:

Admission Date……………

NEWS Observation Chart

Alterations to NEWS Scoring – Review date must be

documented

Date/Time Parameter Details of Alteration and Review Dr’s

Signature/

Instructions Date/Time Grade

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National Early Warning Score (NEWS)

Instructions for use – Medical Staff The NEWS score (0, 1, 2, 3) and Clinical Response Triggers (Low, Medium and High) are NOT to be adjusted. Alterations to physiology parameters must be agreed by a

Middle Grade Doctor or above. All changes to be documented & signed with a review period specified (see front page). All changes must be communicated to the clinical & nursing team.

Instructions for use – Nursing Staff

Observations to be recorded by placing a in the appropriate box unless parameter is

extreme, i.e. sats of 80% or pulse of 160 – this should be written numerically. Insert

SBAR Sticker in patient notes to confirm escalation.

NEWS Score Frequency of Monitoring Clinical Response

0 Repeat as per care plan Continue NEWS monitoring at

to meet clinical needs of each visit

patient

1-4 Increase monitoring Community nurses and / or

HCAs to discuss patient with

Rapid Response Team member who will advise and / or review

and decide if increased

monitoring and or escalation of

care to RRT, GP, ED is

required to treat and manage

underlying condition

Total 5 or more or 3 Repeat observations as Urgently inform a senior clinical

in one parameter directed in the patients’ decision maker, and / or

health records Review and assessment by a

clinician who is clinically

competent to assess and treat acutely ill patients and can recognise when escalation of care to a secondary care

setting is essential Total 7 or more Continuous monitoring Immediately life threatening

phone 999 or if patient deteriorated but not life threatening phone 444701. If appropriate contact A&E to advise of referral handover

using SBAR tool.

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Always down load the original version from the web site – this form must not be photocopied SBAR

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