First choice for orthopaedic care

The ROHNHSFT Experience: Implementing BWCH PEWS

Alison Warren Clinical Matron for Children and Young

Peoples Services The Royal Orthopaedic Hospital NHS

Foundation Trust RGN, RSCN, ENB 415 & 998 PG Cert (HE) MA Ed (cand)

APLS,EPALS,PHPLS, GIC & pILS Instructor

First choice for orthopaedic care

Background

• BWCH PEWS working group since first introduced in 2006 • Involved in a number of iterations of charts and policy (Working

Group) • Data collection for unplanned PICU admissions • SIM scenario training Wards / NQN programme • Development of the BWCH Moodle E learning Package 2013 • Incorporated into Skills and Simulation training for BCU Student

Nurses • UoB Student PEWS simulation Day • Robust working knowledge of PEWS and PEWS education

First choice for orthopaedic care

Review of existing ROH Early Warning System

• Chart adapted from: Stanmore/Oswestry/BCH

• No Policy to support

• Score 0-4, escalation excluded senior medical staff/KIDS

• 4 Triggers HR, RR, Temp and CRT

• Numeric recording (unable to see trends) included components of fluid balance

• 3 age related parameters 2-5; 5-12; 12-16

• First time user impression, supportive reason to change

First choice for orthopaedic care

Rationale for Change

• Potential Clinical Risk

• Supported by RCPCH recommendation

• But…be careful!!!

First choice for orthopaedic care

What the Papers say:

• The recommended standards for measurement of vital signs and observations: UK Royal College of Nursing Standards for Assessing, Measuring and Monitoring Vital Signs in Infants, Children and Young People (2013).

• The baseline frequency of observations depend on the child’s individual clinical circumstances (range: daily-continuous monitoring) regardless of reason for admission

• The escalation guide details the minimum observation frequency for any child triggering PEWS

• It is essential to note any individual outlying parameters, observe trends and be aware that a child showing no signs of improvement may quickly lose the ability to compensate.

First choice for orthopaedic care

What the Papers say:

• Team members should be appropriately trained and maintain their competency in the management of an acutely ill child https://www.resus.org.uk/quality-standards/acute-care-quality-standards-for-cpr/ NHS England ReACT (Response to ailing children tool) http://www.england.nhs.uk/ourwork/patientsafety/re-act/

• PEWS should complement care, not replace clinical judgement • Clinician or family concern is a core parameter and an

important indicator (PEWS score should never undermine the intuition of the child’s family or clinician)

• Observations and monitoring of vital signs should be undertaken in line with recognised, evidence-based standards

First choice for orthopaedic care

What the Papers say:

• Hospitals should support additional safety practices that enhance the Paediatric Early Warning System and lead to greater situation awareness among clinicians and multidisciplinary teams.

• Paediatric Early Warning System’s should be supported through the application of quality improvement methods, such as engagement strategies, testing, and measurement to ensure successful implementation, sustainability and future progress.

• Communication between all multidisciplinary team members is essential for the effective interpretation of clinical concern. Clinicians should use their clinical judgement when determining the level of response required to the concern expressed and act accordingly

First choice for orthopaedic care

Drivers for ROHNHSFT Change • Paediatric early warning scores need to be part of a system

of in-hospital care but also link with tertiary centres • The identification of evolving critical illness and escalation

of concerns then allows experienced clinical staff to respond quickly to assess and stabilise patients in a timely manner using the same language

• Communication between all multi-professional team members is essential for the effective interpretation of clinical concern

• Give clear escalation guidance for transfer or retrieval to an area of higher dependency (CYPHDU) or intensive care at Birmingham Women’s and Children’s Hospital (BWCH)

First choice for orthopaedic care

Exploring Risk and Gaining Support

• Champion the cause!

• Presenting the facts and identifying the risks

• Scoping other centres and best practice examples

• Senior Nurse support

First choice for orthopaedic care

PEWS at ROHNHSFT: Applying the BWCH Model

• The Paediatric Early Warning Scoring (PEWS) System at ROHNHSFT consists of the following 5 components:

• An Observation, Monitoring and Escalation Policy • Standardised Observation Sheets with an embedded,

validated age-related Paediatric Early Warning Scoring System and standardised fluid balance charts

• The PEWS Response referral algorithm including SBAR communication

• Audit of unplanned admissions to the CYPHDU or retrieval to BWCH from ward 11, CYPHDU or theatres

• An education and learning package

First choice for orthopaedic care

PEWS Implementation

Score 1-4 or ↓ in GCS of 1

point

Score of 5-8 or ↓ in GCS of

2 points or concern

Score ≥ 9, GCS ≤ 11 or

VERY concerned

Discuss with nurse in

charge and consider

increasing frequency of

observations.

Inform nurse in charge, call

pt’s own team (day) +/-

Anaesthetist/Critical Care

Outreach/call KIDS for

clinical advice

03002001100

Call Anaesthetist / Critical Care Outreach / call KIDS for urgent referral / retrieval 0300 200 1100

LIFE THREATENING - CALL 2222

Education and learning package

Audit of unplanned CYPHDU admissions/

KIDS Referrals /Retrievals

First choice for orthopaedic care

The Learning Resource

No E Learning Platform!

First choice for orthopaedic care

Paediatric Early Warning Systems Self Guided Learning and Assessment

The “How to” guide and assessment

First choice for orthopaedic care

Bedside PEWS Score

Calculation and recording of bedside PEWS

First choice for orthopaedic care

PEWS Response Algorithm

Ensure early escalation. Remember KIDS offer clinical advice, they also like to be aware if there are any CYP within

region that are showing signs of deterioration

First choice for orthopaedic care

Patient Specific Parameters

Ensure the following before charting the patient’s observations and calculating the PEWS score : • The correct age chart is being used • The patient name and details (demographics) are correctly recorded • Patient specific parameters are documented at the top of the observation

chart. For many patients, the parameters will be as expected for the age and this should be documented accordingly. However, discussion with the medical team may be required as to when to escalate concerns dependent on individual patient requirements, for example: an infant with chronic lung disease on home oxygen may have an elevated PEWS score on admission, which is normal for him/her. Identification of patient specific parameters will enable you to be record the PEWS score on the observation chart which will trigger further escalation and review.

• Alarm Limits are documented for any medical device used for monitoring

First choice for orthopaedic care

Patient Specific Parameters

A : Record patient specific parameters, these should be advised and documented by medical staff. This is very important if the patient’s condition deviates from the PEWS age related physiological parameters. B : If there is continuous haemodynamic monitoring alarm limits must be recorded

A

B

First choice for orthopaedic care

Escalating /De-escalating frequency of Observations

• When escalating or de-escalating the frequency of observations this should be recorded on the observation chart.

• The date and 24-hour time should then be documented • If there are any specific parental or nursing concerns then you

should tick the appropriate box and follow the PEWS Response Algorithm. These concerns should be documented contemporaneously in the patient healthcare records

• Escalation of concerns should be ticked once the SBAR communication has occurred

• Any specific events can also be recorded in the Events Box

First choice for orthopaedic care

Patient Specific Risks

Any Patient Specific Risk Factors should be circled at the top of the Observation Chart identifying any of the following:

• Previous life threatening event (within 48 hours)

• Massive Blood Transfusion policy activated

• Non invasive ventilation

• Major Spinal Surgery

• Immunocompromised

First choice for orthopaedic care

Documenting observations

The 7 components of PEWS score:

• Respiratory Rate

• Heart Rate

• Systolic Blood Pressure

• Oxygen Saturations

• Oxygen Requirement

• Respiratory Distress

• Capillary refill time

First choice for orthopaedic care

Documenting observations: Respiratory Rate, Oxygen Saturations, Oxygen Delivery

and Respiratory Distress

Assess patient for signs of respiratory distress using a structured approach: • Nasal flaring • Tracheal tug • Head bobbing • Sternal recession • Intercostal recession • Subcostal recession

Best Practice Guidance Use a dot to express the rate Record the numeric value Do not join the dots

First choice for orthopaedic care

Documenting observations: Heart Rate

•Always count the pulse for one full minute •Feel the temperature of the patient’s hands and feet to check peripheral circulation •Consider palpating several sites to check pulse strength

Best Practice Guidance: Use a dot to express the rate Record the numeric value Do not join the dots

First choice for orthopaedic care

Documenting observations : BP Blood Pressure needs to be recorded on the PEWS chart using a consistent approach (RCN 2013) therefore inverted and upright arrows Λ / V must be used. Do not draw a line between. Use a dot if mean arterial pressure(MAP)is being recorded. Score Systolic value.

Λ . (MAP)

V

First choice for orthopaedic care

Documenting observations: CRT, PEWS Score, Sepsis 6, Temperature, AVPU,

Blood Sugar, Pain Score

First choice for orthopaedic care

Hints and Tips: Non-invasive BP

• Check that the medical device used for monitoring non invasive BP is working correctly. Ideally the same cuff should be used for the duration of the hospital stay

• Choose the correct size BP Cuff for the age of the child/ young person, align to artery and ensure within range. Best position for accuracy is left arm(closest to the heart)

First choice for orthopaedic care

Hints and Tips: CRT

• CRT can be assessed either peripherally or centrally. It is best practice to assess CRT centrally. If there are some concerns about the patient an assessment of both peripheral and central CRT provides more information about the patient’s haemodynamic status

• Feel: Press on the sternum or forehead for 5 seconds, release and count how long it takes for the colour to come back. Normal CRT for the PEWS score at ROH is 2 seconds or less

First choice for orthopaedic care

Recognition of Sepsis

Guidance is given on the PEWS chart to escalate concerns if

sepsis is suspected. The temperature section of the

PEWS chart is also shaded to identify if patients temperature

trigger a sepsis concern

First choice for orthopaedic care

AVPU/Paediatric Coma Scoring

• AVPU-crude tool for rapid assessment

• A coma scale is a tool that instructs the assessor how to perform and record a series of prescribed neurological and haemodynamic observations on a scaled chart

• Neurological observations enable the practitioner to assess the neurological status of the patient

• Incorporated into PEWS and guidance for use in Observation, Monitoring and Escalation Policy

First choice for orthopaedic care

Hints and Tips: Neurological Assessment

• The mode of painful stimuli used should involve applying pressure on the side of the finger sufficient to evoke a rapid response (avoid pressure on the nail bed).

• If the patient has a significantly reduced conscious level, use central stimuli by applying supra-orbital pressure

• Ensure that assessment methods are consistent; variations can course scoring anomalies. Consistency is achieved by delivering a concise and accurate bedside handover.

First choice for orthopaedic care

SBAR Communication

S Situation Hello this is: name , designation and location I am calling about: ( patients name and location). The problem I am escalating I am worried about…..

B Background Brief relevant medical history, i.e. diagnosis and recent events including surgery, etc.

A Assessment A – Airway B – Breathing C – Circulation D – Disability (AVPU and Glucose) E – Exposure PEWS Score

R Recommendations I suggest/request that you: Attend immediately Transfer to HDU Review within 30 minutes Review on the next ward round If a change in treatment is required then: How often do you want observations How long before you want us to get in contact again? Is there anything you would like to be performed /set up before you visit? i.e run

through IV infusion , set up for cannulation…..

Universal language, ensure succinct highlighting key

concerns. Use A-E assessment and

PEWS score. Make your

recommendations clear and document

the time and communication

outcome.

First choice for orthopaedic care

Key Messages • Early identification of increasing PEWS/

recognition of the sick child • Understanding the multi-professional team’s role

in the management of deterioration • Understanding the need to take appropriate

action in line with the PEWS Response algorithm • Awareness of essential clinical guidelines

(national/ local) • Early escalation according to PEWS Response

algorithm • Early referral to KIDS if indicated for

advice/retrieval

First choice for orthopaedic care

Clinical Assessment of the use of PEWS chart, PEWS Response Algorithm and SBAR

communication

Case Study Baseline Obs

Case progression PEWS Score, clinical decisions, actions

recommendations, SBAR Handover

First choice for orthopaedic care

Any Questions? alisonwarren2@nhs.net