Observations and the Deteriorating Patient
for Registered Nurses
Shane Moody, Lead for Critical Care Services Vikki Crickmore, Sister.
Critical Care Outreach Service
September 2013
Competency framework
Objectives• Gain awareness of the national approach and
MEWS.• Discuss observations in detail and physiological
relevance.• Consider appropriate escalation response to
deterioration and barriers to this.• Examine useful communication tools. • Consider additional elements relevant to patient
care when considering deterioration. • Carry out a practical assessment of taking
observations and management of case studies.
AssessmentsCCOS to assess Band 7’s
↓CCOS to do Train the Trainer sessions for senior
nurses
↓ Band 7’ and senior nurses to assess own staff
Competency framework
AssessmentsPresentation
↓Questions
↓
Station 1 ← → Station 2
Practical taking obs Case studies & and documenting completing
competencyin pairs document
Conclude and finish
Competency framework
Introduction2005 – NCEPOD: An Acute problem2007 – NPSA: Safer care for the acutely ill patent 2007 – NPSA: Recognising & responding appropriately to
early signs of deterioration
Consistent themes are obvious throughout these documents:
• Failure to measure basic observations.
• Lack of recognition of the importance of worsening vital signs
• Delay in response to deteriorating vital signs.
Competency framework
2007 – NICE published - Acutely Ill patients in hospital – recognition of and response to acute illness in adults
in hospital.
The key priorities of this document are:
• Physiological observations at the time of their admission • A written monitoring plan (diagnosis, co-morbidities and plan)
• Observations taken by staff that have been trained and understand clinical relevance.
• A Track and Trigger system and observations recorded 12 hourly as a minimum – increased if signs of deterioration.
Competency framework
Used to aid recognition of deteriorating patients, and are based on physiological parameters.
An aggregated score calculated. Escalation pathway activated if specific scores. Track and Trigger approach.
The escalation pathway outlines actions required for timely review ensuring appropriate interventions.
Competency framework
Modified Early Warning
• Limitations to MEWS and professional judgment should be used
• Taking observations is not just generating numbers – need to understand clinical relevance
• Delegating needs to be appropriate• Failure to act has significant consequences –
effects on patient, ↑ cardiac arrest, ↑ length of stay, ↑ ICU admissions.
• Observe patient – not just using machines• MEWS adapted for paediatrics and obstetrics &
head injury patients
Competency framework
Applying to practice
• Respiratory rate• Oxygen Saturations• Pulse• Systolic (BP)• AVPU/GCS• Temp• Urine Output
Competency framework
Vital signs to assess
• Relevant in a number of compensatory mechanisms within the body
• Normal rate should be between 12 and 20.• The most sensitive indicator of potential
deterioration. Rising rates often early sign.• Using in conjunction with other evidence ie: use
of accessory muscles, increased work of breathing, able to speak?, exhaustion, colour of patient.
• Position of patient is important.
Competency framework
Respiratory rate
Blood pumped fromHeart is rich in O2(95%-99% saturated)
Blood pumped back to heart is low in O2(65%-70%)
Competency framework
Saturations
Competency frameworkOxygen demand
If oxygen delivery to the body falls below what is demanded, the tissues extract more oxygen from the haemoglobin and the saturation of blood falls.
• All cells are dependent on an adequate constant supply of O2 as they are unable to store it. A reduction can lead to organ dysfunction and death.
• Dependent on intact respiratory and cardiovascular function – limited by other factors ie: peripherally shut down.
• Be aware of patients ‘target saturations’.
• All acutely unwell patients should receive supplementary Oxygen and then titrate to readings.
• ABG may be required for more in depth assessment.
Competency framework
Oxygen saturations
• Should be taken manually for one minute, noting the rate, volume and regularity.
• Felt at brachial artery• Normal rate can be considered 60-
100bpm.• Abnormal findings need investigating• Abnormalities should be followed with an
ECG• Consider ECG monitoring
Competency framework
Heart Rate
Effects on Heart Rate• Haemorrhage / bleeding• Hypotension• Sepsis • Drugs / medications • Hypoxia• Temperature• Injury / Insult• Electrolytes
Competency framework
Competency frameworkBlood pressure = pressure on wall
of arterySystolic = pumping pressureDiastolic = resting pressure
The pressure in the arteries is carefully regulated by the body. If it drops, immediate circulatory changes occur:
► Heart rate increases
► Constriction of vessels (so BP may remain adequate) - ↓ CRT, ↓ Urine output.
Competency framework
Arterial pressure
• A LATE sign of deterioration – patients will compensate (especially young)
• Adequate BP is essential for delivery of O2 and nutrients to the rest of the body.
• Be aware of what is normal for patient• Organs are very dependent on adequate
pressures to ensure perfusion.• Manual Blood pressure recording may be
appropriate.
Competency framework
Blood pressure
• Sensitive indicator of hydration status• Should be 0.5ml/kg/hr• Due to high demand for blood supply to the
kidneys, urine output is a useful indicator of cardiovascular status.
• Generally is a poorly recorded observation.• Monitoring of fluid balance should be
appropriate depending on patient condition. • Acute Kidney injury - ↓ urine output, ↑ toxic
waste. Needs urgent attention
Competency framework
Urine output
• AVPU or GCS for more in depth assessment. • Consider at what point do you need help?• This should include drowsiness, agitation, new changes.• Assess pupils • Consider reversible causes ie: blood sugar• If only responding to pain or unresponsive – airway is at
risk – 2222 adult emergency.• Neuro obs
Competency framework
Level of Consciousness
• Can have a significant effect on patients condition.
• High or low can indicate sepsis• > 38 degrees consider blood cultures • Significant warming can cause
vasodilation• Low can be as important as high
Competency framework
Temperature
• O2 needed?• Positioning• IV access• ECG• Catheter• IV fluids• Bloods• Escalation status
Competency framework
Considerations
• Any one in hospital!! • Those with co-existing disease• All emergency admissions• Elderly people• Specific acute illness (sepsis, pancreatitis)• Those with altered level of consciousness• Major haemorrhage
Competency framework
Who is at risk?
• Sepsis• Hospital acquired infections• Chronic disease process• Co-morbidities• Failure to manage complications• Iatrogenic• Unavoidable complications• Palliative / end of life
Competency framework
Causes of deterioration
Measure observations and Document↓
Recognise Deterioration↓
Communicate Appropriately↓
Respond efficiently & reassess
Competency framework
Chain of safety
SBARA tool used to communicate critical information succinctly and briefly
Competency framework
Anxious about escalating?Frequency / exposure to deterioration?
Knowledge and Skills?Prioritising workload? Difference of opinion?
Define ‘deterioration’ “To become worse” (English dictionary, 2013)
Competency framework
Barriers to escalation
• Individual Accountability • Risk assessment and delegation• Consent• Risk assessment• Privacy and dignity• Documentation• Infection control• Communication• Safeguarding
Updates on amendments to revised policy
Competency frameworkAdditional elements in relation to
patient care
• Complete action plan for scenarios given
• Discuss rationale for taking observations and increase/decrease frequency
• Correctly taking a full set of observations
• Correct documentation and calculation of scores using trust observation charts.
• Demonstrate awareness of escalation procedures.
Competency framework
Practical assessment