1 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019 SH CP 43 Physical Assessment and Monitoring Policy Version: 4 Summary: The purpose of this policy is to provide the minimum standards of integrated care provision by all clinical staff of Southern Health NHS Foundation Trust for physical health assessment, monitoring and management of identified physical health needs in both inpatient and community settings. For guidance on implementing this policy, please refer to the Physical Assessment and Monitoring Procedure for Mental Health and Learning Disabilities or the Physical Assessment and Monitoring Procedure for Integrated Community Services as appropriate. Keywords (minimum of 5): Physical; Assessment; Monitoring; Policy; SH CP 44; Deteriorating, Deteriorating patient, Deterioration; Vital signs, NEWS 2, PEWS, Non-contact observations Target Audience: All clinical and healthcare support staff Next Review Date: August 2019 Approved & Ratified by: Patient Safety Group Date of meeting: 23 August 2018 Date issued: March 2019 Author: Steve Coopey, Simon Johnson, Dr Juanita Pascual Consultant, Dr Rachel Anderson Consultant, Paula Hull Interim Director of Operations ISD, Sara Courtney Acting Director of Nursing Accountable Executive Lead: Paula Hull, Director of Nursing and Allied Health Professionals
Transcript
1 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
SH CP 43
Physical Assessment and Monitoring Policy
Version: 4
Summary:
The purpose of this policy is to provide the minimum standards of integrated care provision by all clinical staff of Southern Health NHS Foundation Trust for physical health assessment, monitoring and management of identified physical health needs in both inpatient and community settings. For guidance on implementing this policy, please refer to the Physical Assessment and Monitoring Procedure for Mental Health and Learning Disabilities or the Physical Assessment and Monitoring Procedure for Integrated Community Services as appropriate.
Patient Safety Group Date of meeting: 23 August 2018
Date issued:
March 2019
Author:
Steve Coopey, Simon Johnson, Dr Juanita Pascual Consultant, Dr Rachel Anderson Consultant, Paula Hull Interim Director of Operations ISD, Sara Courtney Acting Director of Nursing
Accountable Executive Lead:
Paula Hull, Director of Nursing and Allied Health Professionals
2 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
Version Control
Change Record
Date Author Version Page Reason for Change
18/06/12 Kayode Osanaiye / Amit Malik / Steve Coopey / Simon Johnson
June 13 1 5 8
Clarification of exclusion criteria Clarification All patients to have Physiological observations as part of base line assessment
April 2017
Dr Rachel Anderson, Dr Juanita Pascual
2 Policy review
May 2017 Paula Hull, Sara Courtney
2 Policy review
August 2017
Briony Cooper 2 Policy review
July 2018 Kerry Lewis 3 Removal of section 4.4 and addition to section 4.3 Amendments to section 5. Addition of section 5.1.8 Addition of appendices.
February 2019
Kerry Lewis 4 Addition of reference to Non-Contact observations throughout document
February 2019
Hayley Stockford 4 Addition of reference to Paediatric Early Warning Score tool throughout document
April 2019
Kerry Lewis 4 8 Addition of New Forest Frailty Team NEWS 2 SOP reference
Reviewers/contributors
Name Position Version Reviewed & Date
Sarah Garland
Paula Hull Interim Head of Nursing and Quality (ICS)
Shelley Mason
Sandi Igafell Team Manager
Jude Diggins
Abigail Barkham
Trudi Archer
Sarah Baines
Una Hobson Locality Senior Nurse (Learning Disability)
Lesley Stevens Clinical Director, AMH
Fiona Hartfree Divisional Lead Nurse, AMH
Dr Rachel Anderson
Dr Juanita Pascual
Sara Courtney Acting Director of Nursing
Paula Hull Interim Director of Operations ISD
Kerry Lewis Resuscitation Officer Version 3, July 2018
Hayley Stockford Resuscitation Officer Version 3, July 2018
3 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
Physiological Observation Chart, Track and Trigger Southern Health all cause deterioration (including sepsis) guidance Southern Health all cause deterioration (including sepsis) guidance (for 12-18 year olds in inpatient settings) Non-contact observations
4 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
Physical Assessment and Monitoring Policy
1. Introduction 1.1 The purpose of this policy is to provide minimum standards of integrated care provision by
all clinical staff of Southern Health NHS Foundation Trust for physical health assessment, monitoring and management of identified physical health needs in both inpatient and community settings. The policy covers the following:
Initial examination and/or clinical risk assessment of existing and new patient/service user
On-going assessment and screening to ensure early identification of physical health problems
Timely investigation, monitoring and follow-up of physical health problems, including appropriate referral to other health services as necessary
Promotion of positive lifestyle change e.g. healthy eating, smoking cessation, where indicated
Informing service users of the nature, purpose and likely side effects of their individual medications and in particular, the effect on their physical health.
Standards in relation to sharing clinical information i.e. handover 1.2 The terms ‘patient’ and ‘service user’ are used interchangeably to relate to anyone
accessing physical and/or mental health services, social care and learning disability services. Whilst this policy outlines the role that Trust clinical staffs have in supporting the physical health and well-being of service users, it also recognises that this is often provided in partnership with primary care. In some settings the main role of Trust clinical staff is in promoting and enabling access to mainstream health promotion, health screening and physical health services in primary and secondary care. The overarching principles will apply to all services; the implementation of this policy will be in close co-operation with primary care, secondary care, Ambulance service and all SHFT services in line with established practice as per the procedures defined within this policy.
1.3 This policy is intended to manage the following:
Promote awareness of the importance of physical health monitoring.
Identify service users that may have a pre-existing physical health problem or medical condition.
Monitor service users’ physical health problems which may change while under our care.
Identify deterioration or improvement to physical health of service users through effective communication and handover.
Improve service users awareness and adequate knowledge of the potential side effects of their medications and lifestyle behaviours which may affect their physical and mental health.
Lack of awareness of previous use of alcohol, nicotine and other substances could adversely affect management of both physical and mental wellbeing.
Raise awareness of accessing health promotion/ screening/ primary and secondary physical health care.
Introduce a standardised physical assessment appropriate to the needs of the service user.
Offer education and training to ALL clinical staff in order to develop clinical decision making skills in physical health assessment monitoring.
Acknowledge that a service user may be too disturbed or may refuse physical examination or assessment and to ensure this is followed up and documented appropriately.
5 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
1.4 A holistic approach is essential to all aspects of good physical and mental health care and this includes the active identification and management of physical health needs. People with an existing physical and/or mental illness are prone to physical illness than the general population, may not receive the optimum physical healthcare that they need and have an associated higher morbidity and mortality than the general population. Physical illness can have a significant impact on a person’s mental health and conversely mental illness can seriously impact on a person’s physical health. Prescribed medications are associated with important and sometimes serious physical side effects which can result in increased risk of disease e.g. cardiovascular disease. Patients with poor physical health and/or mental illness may be prone to the effects of poverty and poor quality life-style.
1.5 People with Learning Disabilities have a lower life expectancy compared to the general
population. They have a high prevalence of general health problems, noted within the public health strategy for England (DH, 2010) which stated that people with learning disabilities have significantly poorer life expectancy than would be expected based on their socioeconomic status alone. Health problems include Cancer, Coronary Heart Disease, Respiratory Disease, Epilepsy, Dementia, Mental Illness, Osteoporosis, Poor Oral Health, Hypertension, Thyroid disorder, Diabetes: Michaels J (2008); The Confidential Inquiry team (2011), St. Georges: University of London (2012).
1.6 It is the responsibility of all Southern Health NHS Foundation Trust staff to be actively involved in health promotion which should include open discussion and use of appropriate literature.
1.7 Areas to be considered should include exercise, smoking cessation, information about
alcohol and safe drinking, physical effects of substance misuse, dietary advice and sexual health. In in-patient settings, the ward manager will ensure healthy choices and opportunities to be physically active are available to service users.
1.8 Some service users/ patients can be reluctant to visit their GP and are generally less likely
to report physical problems or access preventive health services. It is therefore essential that the physical health of both in-patients and community patients should be actively monitored and any identified health needs managed. For community patients, arrangements for physical monitoring and treatment should where possible be made in partnership with the patient’s GP. However, clinical decisions around frequency of observations can be made by Nurse in charge.
1.9 Physical observations may not be appropriate in certain circumstances where alternative forms of documentation are already in place. Exclusions may include:
I) End of Life Care ii) Patients in Minor Injuries Unit iii) Patient undergoing an invasive procedure e.g. theatre / ECT / endoscopy
1.10 The NHS continues to face the challenge of responding to patients’ needs and expectations
by encouraging and supporting new ways of working, and this includes patient choice. One of the biggest changes is to challenge traditional roles and views of how to deliver care by appropriately skilled practitioners.
1.11 Our patients are very much at the centre of this change, and the recognition of those whose
health condition is deteriorating or is at risk of doing so is key to avoiding unnecessary hospital admissions and keeping care closer to home. Critical care without walls (outside specialist units) (DH, 2000b) ensures that appropriately trained, highly skilled, safe practitioners deliver the best possible care in the community
1.12 The handover of crucial clinical service user information is vital to ensuring appropriate
monitoring of a service user during all aspects of care in particular during transfers of care.
6 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
A systematic evidence based handover tool that is appropriate to the service user area should be used e.g. SBAR (d).
2. Scope 2.1 This policy does not cover every aspect of good physical health care or detail monitoring
requirements relating to specific drugs and so must not replace a comprehensive clinical assessment and judgment.
2.2 All clinical staffs are required to carry out on-going monitoring of the health and wellbeing of
service users and to support service users to access their GP and other relevant health services as required.
3. Definitions 3.1 Health - The World Health Organization (WHO, 1946) defined Health in its broader sense
as “a state of complete physical, mental and social well being and not merely the absence of disease or infirmity”. The main determinants of health include the social and economic environment, the physical environment and the person’s individual characteristics of behaviours.
3.2 Physical Health is the overall condition of a living organism at a given time, the soundness
of the body, freedom from disease or abnormality and the condition of optimal well being (Ron Kurtus, 2012) Good physical health in an individual is a state of well being that would enable an individual to perform their daily routine activities without any hindrance (Daily Health News).
3.3 Integrated Care is a term that reflects a concern to improve patient experience and
achieve greater efficiency and value from health delivery systems. The aim is to address fragmentation in patient services and enable a better coordinated and more continuous care, frequently for an ageing population which has increasing incidence of chronic disease (What is Integrated Care? Sara Shaw et al; 2011).
4. Duties / Responsibilities 4.1 The Patient Safety Group Southern Health Foundation Trust has a responsibility to provide an effective and
appropriate service to their service users and appropriate training to their staff. The Patient Safety Group will monitor compliance of this Policy.
4.2 Clinical leads / Managers / Supervisors
Will ensure that sufficient priority is given to the successful implementation of the policy both in in-patient wards and the community.
Will ensure that all staff attend appropriate training
Monitor compliance with current standards by all clinical staff
Ensure the availability, functioning and maintenance of all appropriate materials plus equipment and that staff have appropriate training to use them.
Ensure clinical documentation is completed in line with SHFT policy
Ensure that any change in practice recommendations are notified to all clinical staff
Review audit results relating to the policy and feedback to staff on deficits identified
Ensure all staff participate in audit process and any action plans developed to address deficits
7 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
4.3 Clinicians / Staff responsibilities
Registered staff will be accountable as per their Professional Body.
Maintaining clinical competency as per competency framework (SHFT 2011)
Attending relevant training provided by the Trust and put it into practice
Bringing to the attention of appropriate senior staff any deficiencies in knowledge, ability or resources that may mediate against safe clinical practice.
Participate in audit programmes related to measuring the quality and safety of physical assessment and monitoring. This would include addressing any improvements required and celebration of good practice.
Ensuring they are familiar with relevant policies and procedures in their area of practice.
It is the responsibility of individual staff to make sure that the equipment they use is in correct working order and within servicing dates. For further information refer to SH CP 40 Medical Devices Management Policy.
5. Process 5.1 All patients must have an appropriate holistic assessment of their physical and mental
health needs. This assessment must be appropriately documented as per record keeping guidance (SHFT). Physiological observations are required for all patients as part of their base line assessment. For adults in hospitals, the NEWS 2 (National Early Warning Score 2) should be used for initial assessment on admission and for continuous monitoring of physical observations throughout their stay in hospital (Royal College of Physicians (RCP), 2017). See appendix 1b. In hospitals where NEWS 2 is not yet implemented, Track and Trigger must continue to be used to record and escalate physical observations, see appendix 1a. For inpatient child and adolescents, the Paediatric Early Warning Score (PEWS) should be used (Appendix 1c). Additional content and the procedure for this will vary depending on the person’s mental or physical illness, medication, age, initial findings and the involvement of primary care. Issues of sensitivity, gender, ethnicity and preference should also be considered. See separate Physical Assessment and Monitoring Procedure for Integrated Community Services and Physical Assessment and Monitoring Procedure for Mental Health and Learning Disability.
5.1.2 Relevant patient documentation will be obtained from the referring service (for example GP
or Hospital clinician) including current problems, past medical history and medication history.
5.1.3 The on-going accountability and responsibility for service user physical assessment is with
the relevant health care professional e.g. GP, Consultant, Registered Nurse, Allied Health Professional (AHP).
All patients must have a clear written monitoring plan in their health record that specifies
which physiological observations should be recorded, and how often. In addition, it should specify the management of the patient and when they will be reviewed by nursing and responsible medical staff.
5.1.4 Registered Professionals or delegated staff undertaking physical health assessment and
monitoring must be competent to do so, see section 6 – Training requirements All staff are accountable for their actions and omissions.
5.1.5 Informed verbal consent must be obtained from the patient to undertake observations.
When a patient refuses, give clear explanations of the importance of observations and why they are necessary. Always document if a patient refuses consent and refer to the Mental Capacity Act Policy.
8 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
5.1.6 Physical observations may not be appropriate in certain circumstances where alternative
forms of documentation are already in place: a) End of Life care b) Patients in Minor Injury Units c) Patients undergoing an invasive procedure eg surgery/ECT/Endoscopy 5.1.7 NEWS 2
When the NEWS 2 tool is in use, all patients should have their oxygens saturations recorded on SpO2 Scale 1 unless they have confirmed hypercapnic respiratory failure on blood gas analysis on either a prior or their current hospital admission in which case scale 2 can be used (RCP, 2017). This decision must be made by a suitably qualified clinician who is able to interpret blood gas analysis. For the avoidance of doubt, the clinician making this decision about which oxygen scale is used should cross through the scale which is not in use, sign next to this amendment and ensure the medical notes clearly reflect the decision made. The New Forest Frailty support team are trialling NEWS 2 prior to the Community team rollout. There is a local SOP in place for this.
5.1.8 Non-Contact Physical Health Observations
There may be circumstances when taking a full set of physical observations is not possible or considered to pose significant risk to the service user and/or staff, for example:
It is not safe to approach the service user
Approaching the service user may cause significant distress or antagonise the situation
The service user declines physical observations (the rationale for taking physical observations must be explained to the service user if appropriate)
In the above circumstances where it is not possible to utilise Track and Trigger/NEWS 2/ PEWS, the Non- Contact Physical Heath Observations Guidance and Assessment Framework (Appendix 1D)should be used to assess the service user. This framework provides guidance for staff to assess the service user safely using ABCDE and highlights important escalation processes to guide interventions moving forward. The use of this framework is a Registered Nurse decision on a case by case basis.
5.2 Escalation Protocol and graded response 5.2.1 All patients will be monitored using the appropriate physiological Track and Trigger/NEWS
2/PEWS tool (appendix 1a, 1b and 1c). These systems will identify the appropriate graded response to abnormal physiological observations recorded or guide clinicians who are concerned.
5.2.2 By using the appropriate escalation protocol (appendix 1a, 1b and1c) as a framework, this
will make sure that patients who are acutely ill or at risk of physical deterioration receive prompt care and decisions are made in a timely manner.
5.2.3 The healthcare professional recording the vital signs and triggering an escalation response
must document their actions and the management plan in the patients records and escalate to more senior healthcare professional.
5.2.4 The handover of crucial clinical service user information is vital to ensuring appropriate
monitoring of a service user during all aspects of care in particular during transfers of care. A systematic evidence based handover tool that is appropriate to the service user area should be used e.g. SBAR(d) (see Appendix 2).
9 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
6. Training Requirements 6.1 Introduction to the Physiological Observation Chart l is included in Basic Life Support and
Immediate Life Support training. Physical assessment and monitoring training is available through LEaD e-video learning. Competence in practice should be demonstrated by completing physical assessment and monitoring clinical competencies, blood glucose monitoring and pain assessment competency (see Appendix 4a)
6.2 All clinical and healthcare support staff that are taking and recording physical observations
on the Track and Trigger/NEWS 2/PEWS tools should have completed training in physical health assessment and the associated competencies for the completion and recording of physical observations (Appendix 4a, , 4b, 4c, 4d, 4e and 4f)) It is the responsibility of the individual staff member and their Line Manager to ensure they are competent and confident in obtaining, recording and escalating physical observations.
6.3 All clinical and healthcare support staff taking and recording physical observations at
Community Hospitals where the National Early Warning Score 2 is used should complete the e-learning training accessed through https://tfinews.helmlms.com/login
Competence in practice must be demonstrated through completion of the Physiological Observation Chart (NEWS 2) and SBAR(d) Competency Assessment (Appendix 4e). In addition, prior to the use of NEWS 2, all staff utilising this tool should complete the online e-learning package, print or save a certificate and complete the Physical assessment competencies in appendix 4. The e-verifications for these tasks are on the LEaD website and must be undertaken to record the completion of training. This is in line with the RCP guidance which recommends that it is mandatory for all staff members utilising the tool to complete training as per local Trust policy (RCP, 2017).
6.4 For staff working in the child and adolescent inpatient areas, competence in practice must be demonstrated through completion of the Physiological Observation Chart (PEWS) and SBAR(d) Competency Assessment (Appendix 4f). The e-verification for this task is on the LEaD website and must be undertaken to record the completion of training.
6.5 All line managers have a responsibility to ensure staff receive appropriate training and additional training where relevant to their role, level of responsibility and area of work.
7. Monitoring Compliance 7.1 Compliance with this policy will be monitored as part of the annual clinical audit
programme/Quality Assessment Tool programme. Where deficits are identified through the audit process or serious incidents, action plans will be developed to ensure these are addressed and learning is shared.
7.2 In addition, spot checks on a random sample of entries on RiO electronic patient clinical
records or clinical notes will take place where issues have been identified. 8. Policy Review 8.1 To be carried out every three years.
10 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
9. Associated Documents
a. Medicines Control, Administration and Prescribing Policy SH CP 01 b. Medical Emergencies and Resuscitation Policy SH CP 30 c. Risk Assessment and Management of Patients/Service Users Policy d. Managing Clinical Risk Practice Guidance SH CP 28 e. Policy for Managing Incidents and Serious Incidents SH NCP 16 f. Mental Capacity Act Policy and Guidance g. Smokefree Trust Policy SH HR 37 h. Physical Observation Chart (Adult Track and Trigger) i. Neurological Observation Chart j. Rapid Tranquilisation Policy and Guidance SH CP 48 k. Medicines Reconciliation Policy SH CP 125 l. Physical Assessment and Monitoring Procedure for Mental Health and Learning
Disability Services SH CP 45 m. Physical Assessment and Monitoring Procedure for Integrated Community Services SH
CP 44 n. Infection Prevention and Control Policy SH CP 10 o. Decontamination of Medical Devices Procedure SH CP 100 p. Clinical Record Keeping Policy SH CP 221 q. Do Not Attempt Cardio Pulmonary Resuscitation Policy SH CP 31 r. Blood Glucose Monitoring Protocol SH CP 158 s. Care Planning t. Medical Device Management Policy SHCP40
10. Supporting References
a. Dept of Health (2006) Choosing Health: Supporting the physical health needs of people with severe mental illness. DH, London, August 2006.
b. An Acute Problem, National Safety Agency, 2005 c. Dept of Health (1999), National Service Framework for Mental Health. DH, London. d. A Systematic Approach to the acutely ill patient (Adapted from the Alert course),
resuscitation Council (UK) June 2005 e. Brown S, Inskip H and Barraclough B (2000), Causes of the excess mortality of
schizophrenia, British Journal of Psychiatry, 177, pp 212. f. The Code Standards of Conduct, Performance and Ethics for Nurses and Midwives,
Nursing and Midwifery Council, April 2008. g. Cohen A and Phelan M (2001), The Physical Health of patients with mental illness: a
neglected area, Mental Health Promotion Update 2, pp 15-16 h. European Resuscitation Council Guidelines & consensus of science, 2005 i. Phelan M, Stradins L and Morrison S (2001), Physical Health of people with severe
mental illness, British Medical Journal, 322, pp443-4 j. Resuscitation Guidelines 2005 for use in the United Kingdom resuscitation Council
(UK),November 2005 k. NICE (2003) Schizophrenia: Full national clinical guidelines on core interventions in
primary and secondary care, NICE, London (www.nice.org.uk) l. CPR Guidance for Clinical Practice and Training, Resuscitation Council (UK) 2004,
(2008 updated) m. Michaels J. (2008): Health Care for All: Report of the Independent Inquiry into Access
to healthcare for People with Learning Disabilities. n. NICE (2003) Schizophrenia: Full national clinical guidelines on core interventions in
primary and secondary care, NICE, London (www.nice.org.uk) o. Advanced Life Support Provider Manual 5th Edition, 2005 p. Phelan M & Blair G (2008), Medical history-taking in psychiatry, Advances in
Psychiatric Treatment, 14, pp229-234 q. Health Service Circular 2000.028 Resuscitation Policy r. Human Rights Act 1998
11 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
s. Acutely ill patients in Hospital. Recognition of and response to acute illness in adults in hospital. NICE clinical guidance 50 July 2007
t. Policy for the use of the Modified Early Warning Score (MEWS), Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Jan 2008
u. Using an early warning score tool in community nursing. Nursing Times, May 2008. v. The Confidential Inquiry team (2011): Improving Health & Lives: Confidential Inquiry.
Short Interim Report: February 2011. The Confidential Inquiry Team. Norah Fry Research Centre, University of Bristol, 3 Priory Road, Clifton, Bristol. BS8 1TX
w. St Georges, University of London 2012; Understanding Intellectual Disability: http://www.intellectualdisability.info/mental-health/research-evidence-on -the-health-of-people-with-learning-intellectual-disabilities
x. Royal College of Physicians National Warning Score (NEWS) standardising the assessment of acute-illness severity in the NHS
y. Royal College of Physicians (RCP, 2017) National Early Warning Score (NEWS) 2 Standardising the assessment of acute-illness severity in the NHS
12 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
Appendix 1a – Physiological Observation Chart, Track and Trigger
13 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
14 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
Appendix 1b Southern Health all cause deterioration (including sepsis) guidance. Adapted from Royal College of Physicians NEWS 2 tool, December 2017
15 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
16 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
17 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
Appendix 1c – Southern Health all cause deterioration (including sepsis) guidance (for 12 – 18 year olds in Inpatient settings)
18 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
19 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
20 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
Appendix 1d Non-Contact Observations
21 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
22 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
Appendix 2 – SBARD Tool
23 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
Guidance for using SBAR (d) in Clinical Handovers
Inadequate verbal or written communication is recognised as being the most common root cause of serious error - both clinically and organisationally. There are some fundamental barriers to communication across different disciplines and levels of staff. These include hierarchy, gender, ethnic background and differences in communication styles between disciplines and individuals. SBAR(d) 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. SBAR(d) can be used very effectively to escalate a clinical problem that requires immediate attention, or to facilitate efficient handover of patients between clinicians and clinical teams. SBAR stands for: S = Situation B = Background A = Assessment R = Recommendation D = Decision
These are the key building blocks for communicating critical information that requires attention and action, thus contributing to effective escalation and increased patient safety.
Using it helps to prevent breakdowns in verbal and written communication, by creating a shared mental model around all patient handoffs and situations requiring escalation, or critical exchange of information (handovers).
SBAR(d) 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. Developed by the US Navy, SBAR(d) can be used in the majority of situations and is very transferable to all communication interactions between professionals.
1. When to use SBAR(d)
SBAR(d) allows staff to communicate assertively and effectively, reducing the vagueness and the need for repetition. The SBAR(d) process consists of four standardised stages or prompts that help staff to anticipate the information needed by colleagues and formulate important communications with the right level of detail. The tool can also be used to construct letters, emails or other communication at any stage of the patient’s journey.
Inpatient or outpatient
Urgent or non-urgent communications
Conversations with a physician, either in person or over the phone • Particularly useful in nurse to doctor communications
Also helpful in doctor to doctor consultation
Discussions with allied health professionals- e.g. Respiratory therapy, physiotherapy
Conversations with peers- e.g. change of shift report
Escalating a concern
Handover from an ambulance crew to hospital staff
Verbal or written exchanges
Emails
Clinical or managerial environments
24 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
2. What should an SBAR(d) communication convey? S: Situation
Identify yourself the site/unit you are calling from
Identify the patient by name and the reason for your report
Describe your specific concern B: Background
For this, you need to have collected information from the patient's medical notes A: Assessment
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. D: Decision
What decision has been agreed? Read back: 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. SBAR communications should also be documented in the patients’ medical notes.
Give the patient's reason for admission (or presentation/referral in community care settings)
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.
Status: Voluntary, Informal, lacks capacity or detained under Mental Health Act
Current medications and allergies
Vital signs/physical observations
Clinical impressions, concerns
What interventions have you tried already
What significant risks have been identified? Risk to self Risk to others Self-neglect
25 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
Appendix 3 – Neurological Observations chart
26 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
27 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
28 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
29 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
Appendix 4a: Physical assessment and monitoring clinical competencies
Competency Statement: The participant demonstrates clinical knowledge and skill in undertaking physical observations without assistance and/or direct supervision (level 3 - see level descriptors). Assessment in practice must be by a Registered Health Care Professional who can demonstrate competence at level 4 or above.
Performance Criteria Assessment Method
Level achieved
Date Assessor/self assessed
The Participant will be able to:
1. Demonstrate the ability to perform baseline observations
a) Demonstrate the ability to measure blood pressure, including:
i) recognition of normal blood pressure range ii) use of stethoscope iii) use of manual sphygmomanometer iv) use of automated sphygmomanometer v) correct choice of cuff vi) Documentation vii) Equipment cleaning
Questioning and observation
b) Demonstrate the ability to measure radial pulse: i) rate ii) rhythm iii)amplitude
Observation
c) Demonstrate the ability to measure temperature, including: i) Recognition of normal temperature range ii) Identify factors that may cause changes in temperature iii) Identify sites for temperature measurement iv) Demonstrate use of single use strips v) Demonstrate use of tympanic membrane thermometer vi) Demonstrate use of digital analogue probe thermometer
Questioning and observation
d) Demonstrate the ability to measure respirations i) rate ii) depth ii) pattern
Observation
e) Demonstrate the ability to practice in accordance with IP&C policy, including hand hygiene, standard precautions and sharps when undertaking physical assessment
Observation
30 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
Performance Criteria Assessment Method
Level achieved
Date Assessor/self assessed
2. Demonstrate the ability to perform pulse oximetry
a) Recognise the indications for use of pulse oximetry
Questioning
b) Identify potential sources of error
Questioning
c) Preparation of patient and equipment
Observation
d) Selection of suitable area for the probe
Observation
e) Take reading of oxygen saturation and record in patient notes. Report abnormal readings
Observation
f) Clean and store equipment Observation
3. Demonstrate the ability to perform neurological observations
a) Identify rational for use of neurological assessment
Questioning
b) Assess patient using Glasgow Coma Scale
Observation
c) Limb movement Observation
d) Pupil reaction Observation
c) Document results and report abnormal findings
Observation
4. Demonstrate the ability to measure apex / radial pulse
a) Identify rationale for measuring apical heart beat
Questioning
b) Demonstrate procedure for measuring apical and radial pulse
Observation
c) Document results and report abnormal findings
Observation
5. Demonstrate the ability to collect and analyse urine samples
31 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
Performance Criteria Assessment Method
Level achieved
Date Assessor/self assessed
a) Mid-stream collection and urinalysis test e.g. urine dipstick test
Observation
b) Catheter specimen collection and urinalysis test e.g. urine dipstick test
Observation
Date all elements of Competency Tool completed to level ________
Name _________________________ Signature _____________________Status___________ Date_______
I confirm that I have assessed the above named individual and can verify that he/she demonstrates competency
in physical observations.
Assessor____________________ Signature __________________ Status ___________ Date _______
Review
Dates:
Competent
Yes / No
Health Care
Professional /
Assessor Signature
Verifier signature Comments
32 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
Appendix 4b: Physiological Observations (Adult Track and Trigger Tool) and SBAR Clinical competencies
Competency Statement: The participant demonstrates clinical knowledge and skill in the use of the Physiological Observation Chart (Adult track and trigger observation tool and SBAR(d) without assistance and/or direct supervision (level 3 - see level descriptors). Assessment in practice must be by a Registered Health Care Professional who can demonstrate competence at level 4 or above.
Performance Criteria Assessment Method
Level achieved
Date Assessor/self assessed
The Participant will be able to:
1. Demonstrate clinical knowledge and skill in the use of the Physiological Observations Chart Adult Track and Trigger Observation Chart
a) Demonstrate knowledge of what baseline observations should be carried out for all patients
Questioning/ Direct observation
b) Demonstrate knowledge of when the Physiological Observations Chart track and Trigger Observation Chart should be used and when inappropriate
Questioning/ Direct observation
c) Demonstrate ability to perform patient observations including AVPU
Direct observation
d) Correctly categorise patients using the Physiological Observation Chart (Adult track and trigger observation tool)
Direct observation
e) Correctly identify immediate actions required relative to the Track and Trigger status
Questioning/ Direct observation
f) Use the management algorithm relative to the clinical area
Questioning/ Direct observation
g) Correctly identify transfer urgency category (if applicable)
Questioning/ Direct observation
h) Construct an appropriate management plan resultant from identified clinical needs. Ensure frequency of observations are documented and updated.
Questioning/ Direct observation
2. Demonstrate clinical knowledge and skill in the use of SBAR(d)
a) Demonstrate knowledge of when SBAR(d) can be used
Questioning
b) Demonstrate knowledge of the four stages and what information should be communicated in each stage
Questioning/ Direct observation
33 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
Performance Criteria Assessment Method
Level achieved
Date Assessor/self assessed
c) Demonstrate accurate recording of SBAR(d) in patients notes
Questioning/ Direct observation
Date all elements of Competency Tool completed to level ________
Name _________________________ Signature _____________________Status___________ Date_______
I confirm that I have assessed the above named individual and can verify that he/she demonstrates competency
in the use of Physiological Observation Chart (Adult track and trigger observation tool and SBAR(d)
Assessor____________________ Signature __________________ Status ___________ Date _______
Review
Dates:
Competent
Yes / No
Health Care
Professional /
Assessor Signature
Verifier signature Comments
34 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
Appendix 4c: Blood glucose monitoring clinical competency Competency Statement The participant demonstrates clinical knowledge and skill in blood glucose monitoring without assistance and/or direct supervision (level 3 - see level descriptors). Assessment in practice must be by a Registered Health Care Professional who can demonstrate competence at level 4 or above.
Performance Criteria Assessment Method
Level achieved
Date Assessor/self assessed
The Participant will be able to:
1. Demonstrate the knowledge and skills to perform blood glucose monitoring
a) The reason for the patient needing blood glucose monitoring
Questioning
b) The limitations of using a blood glucose meter
Questioning
c) The rationale for calibrating meter, ensuring test strips are in date, performing internal Quality Control (QC) and external quality assurance (QA)
Questioning
d) Correct method to obtain blood sample
Questioning
e) Significance of test results and how to interpret
Questioning
f) When it is necessary to refer to a GP or the diabetes nurse specialist
Questioning
2. Demonstrate practical skill in blood glucose monitoring
a) How to ensure accuracy of meter and quality control
Observation
b) Correct calibration procedure if needed for meter
Observation
c) How to operate the meter Observation
d) Correct procedure for skin preparation
Observation
e) Correct method to obtain blood sample
Observation
f) Practices in accordance with Trust Infection Control Policy and Sharps Safety and Management policy to avoid needle stick injury
Observation
g) Practices in accordance with Trust Infection Control policy, Hand Hygiene Policy and Standard Precautions to avoid contamination and cross infection.
Observation
35 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
Performance Criteria Assessment Method
Level achieved
Date Assessor/self assessed
h) Demonstrates correct decontamination of equipment according to IP&C policy
Observation
i) Interprets and actions results in accordance with role and responsibilities
Observation
j) Documents all care given in accordance with Trust policy & procedures
Observation
Source: SHFT Blood Glucose Monitoring Protocol SH CP 158 2015
Date all elements of Competency Tool completed to level ________
Name _________________________ Signature _____________________Status___________ Date_______
I confirm that I have assessed the above named individual and can verify that he/she demonstrates competency
in blood glucose monitoring
Assessor____________________ Signature __________________ Status ___________ Date _______
Review
Dates:
Competent
Yes / No
Health Care
Professional /
Assessor Signature
Verifier signature Comments
36 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
Competency Statement: The participant demonstrates clinical knowledge and skill in pain assessment without assistance and/or direct supervision (level 3 - see level descriptors). Assessment in practice must be by a Registered Health Care Professional who can demonstrate competence at level 4 or above.
Performance Criteria Assessment Method
Level achieved
Date Assessor/self assessed
The Participant will be able to:
1. Demonstrate the ability to recognise and assess pain
a) Recognise the possibility of pain in people and be aware of their reluctance to acknowledge or report pain
Questioning
b) Enquire about pain (using a range of descriptors e.g. sore, hurting, aching) when completing a patient health assessment
Questioning / observation
c) Assess the pain from a multidimensional perspective including: i) sensory dimension – nature, location and intensity of pain ii) affective dimension – emotional component and response to pain iii) impact – on functioning at the level of activities and participation
Questioning / observation
d) Identify the location of the pain by: i) asking the patient to point to the area themselves ii) use pain maps to define location and extent
Questioning / observation
e) Use a standardised intensity rating scale, preferably a simple verbal rating scale or numeric rating scale if the patient is able to use these
Questioning / observation
f) Make every effort to facilitate communication particularly with those people who are sensory impaired. Use appropriate self-reporting assessment scales to suit the strength of the individual
Questioning / observation
g) Offer people with moderate to severe communication problems additional assistance. Use an observational assessment of pain behaviour In people with severe impairment, and in situations which may cause pain Include insights from family or carers to interpret the meaning of their behaviours
Questioning / observation
37 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
Performance Criteria Assessment Method
Level achieved
Date Assessor/self assessed
h) Include a careful physical examination to identify any treatable causes
Questioning / observation
i) Re-evaluate pain using the same pain assessment tool to evaluate the effects of treatment
Questioning / observation
Source: The assessment of pain in older people: national guidelines 2007 RCGP, BGS and BPS
Date all elements of Competency Tool completed to level ________
Name _________________________ Signature _____________________Status___________ Date_______
I confirm that I have assessed the above named individual and can verify that he/she demonstrates competency
in the assessment of pain.
Assessor____________________ Signature __________________ Status ___________ Date _______
Review
Dates:
Competent
Yes / No
Health Care
Professional /
Assessor Signature
Verifier signature Comments
38 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
Appendix 4e: Physiological Observation Chart National Early Warning Score (NEWS) 2 and SBAR (D) Competency Assessment
Name:
Role:
Base:
Date initial training completed:
Competency Statement:
The participant demonstrates clinical knowledge and skill in the use of the Physiological Observation Chart (NEWS2 tool and SBAR(d) without assistance and/or direct supervision (level 3 - see level descriptors). Assessment in practice must be by a Registered Health Care Professional who can demonstrate competence at level 4 or above.
The participant demonstrates clinical knowledge and skill in the use of the Physiological Observation Chart PEWS tool and SBAR(d) without assistance and/or direct supervision (level 3 - see level descriptors). Assessment in practice must be by a Registered Health Care Professional who can demonstrate competence at level 4 or above.
Performance Criteria Assessment Method
Level achieved
Date Assessor/self assessed
The Participant will be able to:
1. Demonstrate clinical knowledge and skill in the use of the Physiological Observation Chart PEWS Tool
a) Demonstrate knowledge of what baseline observations should be carried out for all patients
Questioning/ Direct observation
b) Demonstrate knowledge of when the Physiological Observation Chart PEWS should be used and when inappropriate
Questioning/ Direct observation
c) Demonstrate ability to perform patient observations including ACVPU
Direct observation
d) Correctly score patients using the assessment / scoring document (see PEWS scenarios)
Direct observation
e) Correctly identify immediate actions required relative to the PEWS score
Questioning/ Direct observation
f) Use the management algorithm relative to the clinical area
Questioning/ Direct observation
g) Correctly identify transfer urgency category (if applicable)
Questioning/ Direct observation
h) Construct an appropriate management plan resultant from identified clinical needs
Questioning/ Direct observation
2. Demonstrate clinical knowledge and skill in the use of SBAR(d)
a) Demonstrate knowledge of when SBAR(d) can be used
Questioning
b) Demonstrate knowledge of the four stages and what information should be communicated in each stage
Questioning/ Direct observation
c) Demonstrate accurate recording of SBAR(d) in patients notes
Questioning/ Direct observation
41 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
Date all elements of Competency Tool completed to level 3
Name _________________________ Signature _____________________Status___________ Date_______
I confirm that I have assessed the above named individual and can verify that he/she demonstrates competency
in the use of the PEWS and SBARD
Assessor____________________ Signature __________________ Status ___________ Date _______
Appendix 4g
Levels of competency Rating Scale
Review
Dates:
Competent
Yes / No
Health Care
Professional /
Assessor Signature
Verifier signature Comments
42 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
Level of achievement Level
Novice Cannot perform this activity satisfactorily to the level required in order to participate in the clinical environment
0
Can perform this activity but not without constant supervision and assistance
1
Can perform this activity with a basic understanding of theory and practice principles, but requires some supervision and assistance
2
Competent Practitioner
Can perform this activity with understanding of theory and practice principles without assistance and/or direct supervision
3
Can perform this activity with understanding of theory and practice principles without assistance and/or direct supervision, at an appropriate pace and adhering to evidence based practice At this level competence will have been maintained for at least 6 months and/or is used frequently (2-3 times /week) The practitioner will demonstrate confidence and proficiency and show fluency and dexterity in practice This is the minimum level required to be able to assess practitioners as competent
4
Can perform this activity with understanding of theory and practice principles without assistance and/or direct supervision, at an appropriate pace and adhering to evidence based practice. At this level the practitioner will be able to adapt knowledge and skill to special/ novel situations where there may be increased levels of complexity and/or risk
5
Expert Can perform this activity with understanding of theory and practice principles without assistance and/or direct supervision, at an appropriate pace and adhering to evidence based practice. Demonstrate initiative and adaptability to special problem situations, and can lead others in performing this activity At this level the practitioner is able to co-ordinate, lead and assesses others who are assessing competence. Ideally they will have a teaching and /or mentor qualification
6
Adapted from: Herman GD, Kenyon RJ (1987) Competency-Based Vocational Education. A Case Study, Shaftsbury, FEU, Blackmore Press, cited in Fearon, M. (1998) Assessment and measurement of competence in practice, Nursing Standard 12(22), pp43-47.
43 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
APPENDIX 5 - LEaD (Leadership, Education & Development) Training Needs Analysis (TNA) If there are any training implications in your policy, please make an appointment with the LEAD department to complete the TNA before the policy goes through the Trust policy approval process.
Training Programme
Frequency Course Length Delivery Method Trainer(s) Recording Attendance
Strategic & Operational
Responsibility
Physical Assessment and monitoring Holistic Assessment and Care Developing skills to recognise and respond to the unwell patient
Once
Variable depending on mode of delivery One day One day
Classroom or workplace Lecture/group work
Clinical training team
MLE
Director of Nursing
Directorate Division Target Audience
MH/LD/Specialised Services
Adult Mental Health
All clinical staff who attend Basic Life Support (BLS) or Immediate Life Support (ILS) should attend one of the above courses
Learning Disabilities
Specialised Services
ISD
Adults
Older Persons Mental Health
Children and Families
Corporate Services
All (HR, Finance, Governance, Estates etc.)
44 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
APPENDIX 6 - Southern Health NHS Foundation Trust: Equality Impact Analysis Screening Tool
Equality Impact Assessment (or ‘Equality Analysis’) is a process of systematically analysing a new or existing policy/practice or service to identify what impact or likely impact it will have on protected groups.
It involves using equality information, and the results of engagement with protected groups and others, to understand the actual effect or the potential effect of your functions, policies or decisions. The form is a written record that demonstrates that you have shown due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations with respect to the characteristics protected by equality law.
For guidance and support in completing this form please contact a member of the Equality and Diversity team.
Name of policy/service/project/plan:
Physical Assessment and Monitoring Policy
Policy Number: SH CP 43 Department:
Integrated Community Services, Mental Health and Learning Disability
Lead officer for assessment:
Kayode Osanaiye / Amit Malik Steve Coopey / Simon Johnson
Date Assessment Carried Out: July 2012
1. Identify the aims of the policy and how it is implemented. Key questions Answers / Notes
Briefly describe purpose of the policy including
How the policy is delivered and by whom
Intended outcomes
This Policy is for all clinical staffs of Southern Health NHS Foundation Trust providing Physical Health Assessment, Monitoring and Management in both In-Patient and Community settings.
2. Consideration of available data, research and information Monitoring data and other information involves using equality information, and the results of engagement with protected groups and others, to understand the actual effect or the potential effect of your functions, policies or decisions. It can help you to identify practical steps to tackle any negative effects or discrimination, to advance equality and to foster good relations. Please consider the availability of the following as potential sources:
Demographic data and other statistics, including census findings
Recent research findings (local and national)
Results from consultation or engagement you have undertaken
Service user monitoring data
45 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
Information from relevant groups or agencies, for example trade unions and voluntary/community organisations
Analysis of records of enquiries about your service, or complaints or compliments about them
Recommendations of external inspections or audit reports
Key questions
Data, research and information that you can refer to
2.1 What is the equalities profile of the team delivering the service/policy?
This Policy applies to ALL clinical staff.
2.2 What equalities training have staff received? All staff using this policy complies with the mandatory requirements for Equality and Diversity training.
2.3 What is the equalities profile of service users? Service users are able to access this service as identified solely by clinical need.
2.4 What other data do you have in terms of service users or staff? (e.g. results of customer satisfaction surveys, consultation findings). Are there any gaps?
This policy does not discriminate against service users.
2.5 What internal engagement or consultation has been undertaken as part of this EIA and with whom? What were the results? Service users/carers/Staff
This policy and EIA will be circulated to all key service providers before approval/ratification.
2.6 What external engagement or consultation has been undertaken as part of this EIA and with whom? What were the results? General Public/Commissioners/Local Authority/Voluntary Organisations
46 SH CP 43 Physical Assessment and Monitoring Policy Version 4 March 2019
In the table below, please describe how the proposals will have a positive impact on service users or staff. Please also record any potential negative impact on equality of opportunity for the target: In the case of negative impact, please indicate any measures planned to mitigate against this:
Positive impact (including examples of what the policy/service has done to promote equality)
Negative Impact Action Plan to address negative impact
Actions to overcome problem/barrier
Resources required
Responsibility Target date
Age
Service users are able to access this service as identified solely by clinical needs and therefore this policy does not discriminate against service users.
