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Physiological Observations of Adult Patients in the Community Setting within their own homes V3 1 December 2015

PHYSIOLOGICAL OBSERVATIONS OF ADULT PATIENTS IN THE COMMUNITY SETTING

POLICY

To be read in conjunction with Physiological Observations Policy for Inpatients

and Minor Injury Units (including Wessex House)

Version: 3

Ratified by: Senior Managers Operational Group

Date ratified: December 2015

Title of originator/author: Community Night Nurse

Senior Nurse for Clinical Practice

Title of responsible committee/group: Clinical Governance Group

Date issued: December 2015

Review date: November 2018

Relevant Staff Groups: All clinical staff in a Community Health setting

This document is available in other formats, including easy read summary versions and other languages upon request. Should you require this please contact the Equality and Diversity

Lead on 01278 432000


DOCUMENT CONTROL

Reference LB/Jan16/POAPC

Version 3

Status FINAL

Author Senior Nurse Clinical Practice Community Night Nurse

Amendments Revised Policy format post acquisition Updated to include the NEWs observation chart and parameters

Document objectives: To set out a minimum standard of type and frequency of observations to be taken in the community setting and to ensure that abnormal results are acted on appropriately and in a timely manner.

Intended recipients: All clinical staff in Community Health setting

Committee/Group Consulted: District Nursing Best Practice Group

Monitoring arrangements and indicators: See relevant section of policy

Training/resource implications: Training provided by Clinical Skills Facilitators

Approving body and date Clinical Governance Group

Date: December 2015

Formal Impact Assessment Impact Part 1 Date: May 2015

Clinical Audit Standards NO Date: N/A

Ratification Body and date Senior Managers Operational Group

Date: December 2015

Date of issue December 2015

Review date November 2018

Contact for review Senior Nurse for Clinical Practice

Lead Director Director of Nursing & Patient Safety

CONTRIBUTION LIST Key individuals involved in developing the document

Name Designation or Group

Mary Martin Professional Lead for District Nursing

Members DN Best Practice Group

Members Clinical Policy Review Group

Members Clinical Governance Group

Lisa Stone Interim Lead for Clinical Practice

Suzi Davies Clinical Skills Facilitator (East)

Liz Berry Senior Nurse Clinical Practice

Robin Payne Clinical Skills Facilitator (West)


CONTENTS

Section Summary of Section Page

Doc Document Control 2

Cont Contents 3

1 Introduction 4

2 Purpose & Scope 4

3 Duties and Responsibilities 4

4 Explanations of Terms used 5

5 Documentation 5

6 Physiological Observations that should be undertaken on adult, non-labouring patients 6

7 Fluid Charts 10

8 Assessing the Patient 10

9 Seeking Help 11

10 Immediate Measures 11

11 Training Requirements 12

12 Equality Impact Assessment 12

13 Monitoring Compliance and Effectiveness 12

14 Counter Fraud 13

15 Relevant Care Quality Commission (CQC) Registration Standards

13

16 References, Acknowledgements and Associated documents

13

17 Appendices 15

Appendix A National Early Warning Score (NEWS) - A Guide to Scoring

16

Appendix B Sepsis Proforma for Community Settings 17

Appendix C Adult Observation Chart 18

Appendix D Competency Assessment for Physiological Observations

20


1. INTRODUCTION 1.1 To set a minimum standard of type and frequency of observations to be taken

on adult patients in the community setting within their own homes by:

Staff identifying deteriorating patients early by observation

Understanding the use of NEWS scoring to highlight changes in patients’ condition

Staff following the Sepsis Proforma to ensure all steps have been taken

Advising staff when and who to inform of deterioration 2. PURPOSE & SCOPE 2.1 Support the use of the National Early Warning Score (NEWS) to guide clinical

decision making (Appendix A) 2.2 Highlight the abnormal ranges of observations that should cause concern 2.3 Provide resources to support community staff and training 2.4 Reinforce the Communication Standard of when to call for help. Situation,

Background, Assessment & Recommendation (SBAR) 3. DUTIES AND RESPONSIBLITIES 3.1 The Trust Board has a duty to care for patients receiving care and treatment

from the Trust. 3.2 The Director of Nursing and Patient Safety is responsible for this policy, but

will delegate authority for the overall implementation and ongoing management of this policy to the Leads of Services this policy applies to.

3.3 The Senior Nurse for Clinical Practice is the author of this policy and also the

Lead for Deteriorating Patients. This role includes the monitoring of all unplanned transfers and investigation of incidents where appropriate action, such as observations or calling for help, has not been taken. Any learning needs are fed back to the team leader/ward manager. This is reported quarterly to the Clinical Governance Group in the Deteriorating Patients Improvement Action Plan.

3.4 The Clinical Governance Group will discuss the quarterly report and may

decide on actions to be taken by the relevant Best Practice Groups. 3.5 The appropriate Best Practice Groups will review the physiological

observation audit and will oversee and report on the action plan.


3.6 All Team Leaders have a duty to ensure that the staff working in their team are

trained, competent and confident to undertake physiological observations. It is the responsibility of the person delegating the task to ensure the member of staff undertaking the delegated duty is competent. The person delegating the task remains accountable for that delegation. The team leader is also responsible for ensuring staff complete a DATIX for all unplanned transfers, and for assisting in the investigation process of any incidents, as well as feeding back any learning to their team.

3.7 The Clinical Practice Team will provide a rolling programme of training in

Physiological Observations and Recognition and Rescue of Deteriorating Patients, accessible via the learning and development intranet page. They are also responsible for assisting in the investigation of any unplanned transfers.

3.8 All Staff working and undertaking physical observations within patient’s own

homes are responsible for complying with this policy. 4. EXPLANATIONS OF TERMS AND SYMBOLS USED

NEWS – National Early Warning Score

AIM - Acute Illness Management - Early Intervention and Treatment. A training course for qualified nursing staff

BLS - Basic Life Support. Mandatory resuscitation for all community staff

AVPU - Alert, responds to Voice, responds to Pain, Unresponsive. An assessment tool for conscious level

RR - Respiratory Rate

HR - Heart Rate

SBP - Systolic Blood Pressure

SpO2 - Saturation (peripheral) of oxygen

GCS - Glasgow Coma Score

CRT - Capillary Refill Time

SBAR - Situation, Background, Assessment, Recommendations. A method of handing information over in a concise and logical manner

< means ‘smaller than’ > means ‘greater than’

5. DOCUMENTATION 5.1 All patients should have temperature, pulse, respiration rate, blood pressure,

oxygen saturation, AVPU and urinalysis recorded during first visit to provide baseline measurements.

5.2 Numerals should not be written on the observation graph, except when

extreme values are recorded outside the graph limits. 5.3 All patients should have a NEWS score attributed to every set of observations. 5.4 If possible the patient’s normal observations should be noted for comparison,

especially if they suffer from chronic illnesses.


5.5 All patients should have their weight recorded on admission to the case load. This may be obtained using the Malnutrition Universal Screening Tool (MUST). Refer to Food and Nutrition Policy.

5.6 All patient observations should be recorded on the organisation’s generic

physiological observation chart. 5.7 Patients must retain the same observation chart, especially when moving

between wards, departments and home so that physiological trends can be seen.

5.8 All patients should have a set of observations recorded during first visit. The

frequency of observation can be agreed after the patient has been assessed and a rationale documented in the patients’ records.

5.9 Physiological observations charts should be electronically scanned and then

uploaded into a patients electronic RiO records when the patient is discharged from the caseload, or is transferred to another healthcare provider

6. PHYSIOLOGICAL OBSERVATIONS THAT SHOULD BE UNDERTAKEN ON

ADULT PATIENTS 6.1 There are five main physiological observations that are regularly measured as

“vital signs”. These are all included in the NEWS system.

Temperature

Pulse

Respiration rate

Blood pressure (systolic)

Oxygen saturation

Conscious level

Plus additional observations that can provide important physiological information in the deteriorating patients

Urine output * includes completion of a fluid balance chart

Capillary Blood Glucose

Pain score – recorded on separate chart 6.2 Abnormal observations should initiate an “alert”. Abnormal ranges are provided

by the NEWS scoring (Appendix A). The NEWS score consists of five measured variables; respiratory rate (RR), heart rate (HR), systolic blood pressure (SBP), conscious level and urine output. Temperature and oxygen saturation do not score a NEWS score, but can suggest patient deterioration.

6.3 The range for each observation scored is between 0 and 3; with a score of 0

being in the range, and 3 is the most deranged. A total NEWS score is derived by adding the six scores to get a total between 0 and 18, with 18 being the most deranged. A guide to abnormal ranges in other parameters is discussed in section 8.5

6.4 An alert should cause the practitioner to stop and think about the implications

for the patient. An alert should prompt one or more of the following depending on the severity of the patient’s condition:

extra vigilance (additional observation parameters being measured)


further assessment and intervention by a competent practitioner

book a return visit to reassess all physiological observations in line with NEWS guidelines and clinical judgement of registered nurse

discussion with General Practitioner (GP) or Out of Hours GP service

999 call 6.5 Frequency of Observations are related to the NEWS score (Appendix B) 6.6 The additional importance of “nurse concern” as a factor in predicting

deterioration should not be underestimated and any member of staff who is concerned about a patient should not hesitate to call for help.

6.7 Temperature 6.7.1 Although temperature does not form part of the NEWS score it is one of the

“vital signs” and should be regularly measured. It is especially important if your patient has any type of likely or confirmed infection and especially in neutropenia patients, and for detecting sepsis.

6.7.2 Low temperature is as significant as high temperature. The Surviving Sepsis

campaign defines one of the parameters for sepsis, as having a core temperature of >38˚ C or <36˚c (Appendix B).

6.7.3 Hypothermia is defined as a core temperature <35˚C which can become fatal

at <32˚C. Hypothermic patients should be warmed slowly using blankets. 6.8 Pulse 6.8.1 The pulse is a reflection of the heart rate and is frequently measured via the

saturation probe on the automated blood pressure machine; it will therefore be measuring the pulse in the finger. This poses three issues:

the pulse might not reflect the true heart rate

pulse properties cannot be determined, i.e. volume and regularity

practitioners may not develop expertise in assessing pulse properties 6.8.2 A manual pulse should be taken on first visit to assess the pulse properties

(Rate/rhythm/strength). 6.8.3 A pulse rate of >90 b/min or < 50 b/min should initiate an alert and a manual

pulse should be checked if the heart rate has been read from an automated machine. The rate and regularity should be checked and recorded.

6.8.4 Sepsis should be considered when the heart rate is >90 b/min. 6.8.5 Any patient who is identified as having a new irregular pulse noted, or any

other concerns with their pulse should be discussed with the GP and consideration given to a 12 lead ECG being required.


6.8.6 Patients receiving beta blocker medication will not be able to increase their heart rate to compensate for hypo perfusion conditions, and therefore other abnormal signs (high respiratory rate and low urinary output) will have extra significance.

6.9 Respiration Rate 6.9.1 Respiratory rate is the most sensitive indicator of deteriorating physiology and

must be recorded in all patients. 6.9.2 A respiratory rate of < 12 or > 20 should initiate an alert. 6.9.3 Depth, symmetry and pattern of respiration should also be noted and recorded

if abnormal. 6.10 Blood Pressure 6.10.1 Systolic blood pressure (SBP) less than 110 mmHg should initiate an alert. 6.10.2 A SBP < 90mmHg may be a sign of severe sepsis, fluid loss or cardiac shock

and requires further assessment of the patient. 6.10.3 The SBP should be greater than the heart rate. If the heart rate increases

above the SBP it should initiate an alert. 6.10.4 Falling blood pressure should be regarded as late sign of deterioration. 6.10.5 In cases of very low blood pressure, the electronic BP measuring devices may

not be accurate and a manual sphygmomanometer should be used. Manual sphygmomanometers must be available to all areas and staff should be trained and competent to use them.

6.11 Oxygen Saturation 6.11.1 Oxygen saturation (SpO2) should be recorded on all patients. 6.11.2 Unless normal for patient, saturation < 90% with or without supplemental

oxygen needs to be addressed. Escalation and actions will be based on specific patient presentation.

6.11.3 The concentration of supplemental oxygen should also be recorded and the

oxygen delivery device noted. 6.11.4 If the patient is receiving supplemental oxygen therapy and has an oxygen

saturation reading < 90% (unless normal for patient), the device, flow and equipment should all be checked to ensure optimum oxygenation. Check oxygen cylinder capacity, if in use, and ensure there is an adequate supply.

6.11.5 Oxygen saturations will not be accurate in patients with hypo perfusion

conditions. A capillary refill time (CRT) test and mottled knee sign can give further information on the patient’s perfusion and may initiate an alert. This will need to be discussed with the GP and / or Nurse Practitioner.


6.12 Conscious Level 6.12.1 Conscious level should be initially assessed on all patients using the AVPU

scale. 6.12.2 If a patient has a primary neurological problem the Glasgow Coma Score

(GCS) should be used by a competent practitioner. For example, a head injury post fall.

6.12.3 Deterioration in conscious level can be caused by many factors, and a more

comprehensive physical assessment should be undertaken by a competent practitioner.

6.12.4 New confusion or a change in conscious level is a significant indicator of

deteriorating physiology and should be recorded as 3 on the NEWS score. 6.12.5 A response only to pain or unresponsive, correlates to a GCS of < 8 and

should be treated as a medical emergency. 6.12.6 Any deterioration in conscious level should be followed by a more in depth

assessment of GCS by a competent practitioner. 6.12.7 Patients having seizures are at significant risk and should have a senior

medical review. 6.13 Urine Output 6.13.1 The optimum urine output is 0.5ml – 1ml / kg / hr. In a 70kg adult this is equal

to 35 to 70mls / hr. The minimum desired urine output is 0.5mls / kg / hr, which is equal to 35mls/hr. Urine output is generally assessed using a fluid balance chart.

6.13.2 In the majority of patients urine output does not need to be routinely measured,

but should be considered in the following instances;

Patients whose NEWS score is rising. For instance, consider measuring urine output for 24 hours if a patient has a NEWS score greater than 4. To be discussed with GP / Nurse Practitioner

Patients with other abnormal signs such as high fever

Patients with other abnormal fluid losses such as vomiting, wound drains, stomas or diarrhoea

Consider urinary catheterisation or weighing of incontinence pads if clinically indicated

6.13.3 If a patient has decreased urine output, the frequency of Community Nursing visits will be increased in order to ensure accurate assessment. The actual

AVPU Scale

A Alert Awake

V Responds to Voice Lethargy

P Responds to Pain Stupor

U Unresponsive Coma


timing is a clinical decision based on the patient’s overall physical condition and presentation.

6.13.4 Patients with primary urological or retention problems may have urine output observations done according to specialist advice.

7. FLUID CHARTS 7.1 When a fluid chart is in use, it should be fully filled in with both input and output

fluid and quantity. 7.2 Completion of accurate fluid balance in the community can be challenging. It is

most often done in partnership with the patient or their relative/carer. The patient, relative or carer may complete their own chart or similar record following guidance from the nurse or a known quantity of fluids may be left for the patient to drink in order to approximate input between visits. Visual clues such as used cups and glasses in the home may also be useful indicators of fluid intake. Suitable receptacles should also be provided in the toilet to inform output volumes.

7.3 Patients receiving subcutaneous fluid must have a fluid chart in progress. 7.4 Daily and cumulative balances should be entered onto the front of the generic

fluid balance chart. 7.5 Fluid losses from respiration and perspiration (insensible loss) are not normally

recorded, but should be accounted for in patients with fluid balance problems. Normal insensible loss is approximately 500-1000mls

8. ASSESSING THE PATIENT 8.1 Staff should ensure the patient is able to understand the information given to

them and are able to give their informed consent. This may necessitate the use of a professional interpreter and the translation of written information. A capacity assessment should be considered for those patients who are unable to consent to the procedure and reference should be made to the relevant Trust policy (refer to Consent and Capacity to Consent to Treatment Policy).

8.2 Vital signs and NEWS scoring will give an indication of the patient’s condition.

If the patient is deteriorating, a more comprehensive assessment is warranted. 8.3 The ABCDE model of assessment is recommended as it gives a rapid, initial

assessment of the patient’s condition:

A = Airway

B = Breathing

C = Circulation

D = Disability

E = Environment

8.4 Basic guidance on ABCDE is part of BLS training.


8.5 Help must be sought as soon as possible if any practitioner feels unable to adequately deal with the situation, or feels that the patient could deteriorate further.

9. SEEKING HELP 9.1 Any concerns about the patient must be relayed to the Nurse Practitioner

and/or GP responsible for the care of the patient, and recorded in the patients’ records.

9.2 The following procedure is a guide to calling for help: 9.3 Before calling a GP or Nurse Practitioner, make sure you have all the

information you need to hand. 9.4 Use the SBAR system to communicate. 9.4.1 Situation State your name, position and where you are located State the patients name, age and diagnosis State why you are calling – the current problem, giving the patient’s

physiological observation and your assessment findings 9.4.2 Background State any relevant events leading up to this event, providing further details of

the patient (diagnosis, resuscitation category, team responsible for care and reasons for concern.

9.4.3 Assessment State what you have assessed the situation to be, for example, “I believe the

patient has developed pneumonia”. 9.4.4 Recommendation

Be clear about what you are expecting the GP or Nurse Practitioner to do – for example, attend immediately, attend within one hour.

9.5 Do not hesitate to call 999 if the patient is rapidly deteriorating or you have any major concerns.

10. IMMEDIATE MEASURES 10.1 Simple early measures can often prevent further deterioration of the patient

and avoid the need to admit to secondary care. 10.2 Interventions will depend on the patients’ vital signs and initial assessment but

include some of the following:

Appropriate positioning of the patient

Checking that the optimum amount of oxygen is being delivered if appropriate

Checking that vital medications have been given

Giving appropriate medications

Checking that infusions are running up to date


Simple physiotherapy if trained

Follow Community Sepsis Proforma (if appropriate) (Appendix B)

If you are in any doubt about what to do, or your competency to do it ......call for help.

11. TRAINING REQUIREMENTS

11.1 The Trust will work towards all staff being appropriately trained in line with the organisation’s Staff Mandatory Training Matrix (training needs analysis) where mandatory training is indicated. All training documents referred to in this policy are accessible to staff within the Learning and Development Section of the Trust Intranet.

11.2 All staff working under this policy must be competent to measure Physiological

Observations and be aware of the NEWS Score Guidance (Appendix A). All new staff must be made aware of this in their induction.

11.3 All clinical staff working under this policy must undertake resuscitation training

as outlined in the Resuscitation Policy. 11.4 All non-registered health care professionals and registered professionals

whose basic training does not include measurement of physiological observations and who take observations as part of their role, must be trained and assessed as competent in taking observations. Please see the Competency Assessment for Physiological Observations (Appendix D)

11.5 It is recommended that all registered nurses in community settings attend the

Recognition and Rescue of the Deteriorating Patient training. 12. EQUALITY IMPACT ASSESSMENT

All relevant persons are required to comply with this document and must demonstrate sensitivity and competence in relation to the nine protected characteristics as defined by the Equality Act 2010. In addition, the Trust has identified Learning Disabilities as an additional tenth protected characteristic. If you, or any other groups, believe you are disadvantaged by anything contained in this document please contact the Equality and Diversity Lead who will then actively respond to the enquiry.

13. MONITORING COMPLIANCE AND EFFECTIVENESS 13.1 To monitor compliance, an annual audit will be conducted on the observation

charts. This is part of the Trust Audit Plan. Results and the action plan will be discussed at the appropriate Best Practice Groups and progress reported to the Clinical Governance Group on a 6 monthly basis. Any non-compliance and learning needs identified will be addressed and monitored by the Local team leaders for that area.

13.2 All feedback, complaints, DATIX reports and serious incidents requiring investigation and action plans related to this policy will be monitored by the District Nursing Best Practice Group. Any non-compliance and learning needs


identified will be addressed and monitored by the Local team leaders for that area.

14. COUNTER FRAUD 14.1 The Trust is committed to the NHS Protect Counter Fraud Policy – to reduce

fraud in the NHS to a minimum, keep it at that level and put funds stolen by fraud back into patient care. Therefore, consideration has been given to the inclusion of guidance with regard to the potential for fraud and corruption to occur and what action should be taken in such circumstances during the development of this procedural document.

15. RELEVANT CARE QUALITY COMMISSION (CQC) REGISTRATION

STANDARDS 15.1 Under the Health and Social Care Act 2008 (Regulated Activities)

Regulations 2014 (Part 3), the fundamental standards which inform this procedural document, are set out in the following regulations: Regulation 9: Person-centred care Regulation 10: Dignity and respect Regulation 11: Need for consent Regulation 12: Safe care and treatment Regulation 13: Safeguarding service users from abuse and improper treatment Regulation 14: Meeting nutritional and hydration needs Regulation 15: Premises and equipment Regulation 16: Receiving and acting on complaints Regulation 17: Good governance Regulation 18: Staffing Regulation 19: Fit and proper persons employed Regulation 20: Duty of candour Regulation 20A: Requirement as to display of performance assessments.

15.2 Under the CQC (Registration) Regulations 2009 (Part 4) the requirements which inform this procedural document are set out in the following regulations:

Regulation 18: Notification of other incidents

15.3 Detailed guidance on meeting the requirements can be found at http://www.cqc.org.uk/sites/default/files/20150311%20Guidance%20for%20providers%20on%20meeting%20the%20regulations%20FINAL%20FOR%20PUBLISHING.pdf

Relevant National Requirements

Patient Safety First ‘The how to guide’ for reducing harm from deterioration (2008)

16. REFERENCES, ACKNOWLEDGEMENTS AND ASSOCIATED DOCUMENTS 16.1 References

British Hypertension Society. Found at www.bhsoc.org Jevon, P. (2007) Blood Pressure Measurement – Part 2: using automated devices. Nursing Times Vol: 103, Issue: 19, page 26 Jevon, P; Holmes, J (2007) Blood pressure management _ part 3: lying and

http://www.cqc.org.uk/sites/default/files/20150311%20Guidance%20for%20providers%20on%20meeting%20the%20regulations%20FINAL%20FOR%20PUBLISHING.pdf

http://www.cqc.org.uk/sites/default/files/20150311%20Guidance%20for%20providers%20on%20meeting%20the%20regulations%20FINAL%20FOR%20PUBLISHING.pdf

http://www.bhsoc.org/


standing blood pressure. Nursing Times, Vol 103, issue 20, page 24 GE HealthCare (2010) Temporal Scanner. Temporal Artery Scanner. Found at www.gehealhtcare,com Higgins, D. (2005) Pulse Oximetry. Nursing Times, Vol: 101, Issue 06, Page 34 Intercollegiate information paper between CSP, RCSLT, BDA and RCN. Supervision, accountability and delegation of activities to Support Workers: A guide for registered practitioners and support workers (January 2006) Luton and Dunstable Hospital NHS Foundation Trust. Cited in Patient Safety First (2008). “The ‘How to Guide’ for Reducing Harm from Deterioration Version 1:1 Mooney, G. (2007) Temperature. Nursing Times, 13 August 2007 Mooney, G. (2007) Respiratory Assessment. Nursing Times, 13 August 2007 Mooney GP and Comerford DM (2003) Neurological observations. Nursing Times. 99.17, 24-25 Mooney, G. (2003) Taking the Pulse. Nursing Times, 8 April 2003

Morgan, R.J.M.F, Willams et al (1997) “An early warning system for detecting developing critical illness” Clinical Intensive Care. 8(2):1 National Institute Clinical Excellence (NICE) (2007): Acutely ill Patients in hospital NMC (2015) The Code: Professional standards of practice and behaviour for nurses and midwives. (Published 29 January 2015) RCN. Nursing Standard essential guide: Health care assistants and assistant practitioners Delegation and accountability (February 2007)

Rigby, D, Gray, K (2005) Understanding Urine Testing. Nursing times Vol: 101, issue 12, Page 60 Royal College of Physicians (2012) National Early Warning Score (NEWS). Standardising the assessment of acute illness severity in the NHS. London:RCP

The UK Sepsis Trust Available at http://sepsistrust.org/ [Accessed on 11 November 2015]13.2

16.2 Cross reference to other procedural documents

Admission, Transfer and Discharge Policy (CH)

Blood and Blood Components Transfusion Policy


Cleaning and the Decontamination of Equipment Policy

Consent and Capacity to Consent to Treatment Policies

Do Not Attempt Resuscitation Policy

Hand Hygiene Policy

Health & Safety Policy

Hypoglycaemia Management Policy for Adult Patients

Insulin Management

Infection Prevention and Control Policy

Learning Development and Mandatory Training Policy

Mandatory Training Matrix (Training Needs Analysis)

Medical Device Policy

Medicines Policy

Physical Assessment & Examination of Service Users Guidelines

Rapid Tranquillisation Policy

Recovery Care Programme Approach (RCPA) Policy

Record Keeping and Records Management Policy

Resuscitation Policy

Safer Moving and Handling Policy

Serious Incident Requiring Investigation (SIRI) Policy

Treatment for Anaphylaxis Guidelines

Untoward Event Reporting Policy

Verification of Death Policy All current policies and procedures are accessible in the policy section of the public website (on the home page, click on ‘Policies and Procedures’). Trust Guidance is accessible to staff on the Trust Intranet.

17. APPENDICES 17.1 For the avoidance of any doubt the appendices in this policy are to constitute

part of the body of this policy and shall be treated as such. This should include any relevant Clinical Audit Standards.

Appendix A NEWS – A Guide to Scoring Frequency of Observations

based on NEWS

Appendix B Sepsis Proforma for Community Health

Appendix C Adult Observation Chart

Appendix D Competency Assessment


APPENDIX A

National Early Warning Score (NEWS) – A Guide to Scoring

Prevention of critical events and early detection of organ failure leads to improved outcome and shorter hospital stays for patients.

This table provides an aid to assist in the early identification of patients at risk of deterioration.

Is your patient’s clinical condition causing concern? If “yes”, score your patient from the table below Physiological Parameters

3 2 1 0 1 2 3

Respiratory Rate

<8

9-11 12-20 21-24 >25

Oxygen Saturations

≤91% 92-93% 94-95% ≥96%

Any Supplemental

oxygen

YES NO

Temperature ≤35.0

35.1-36.0 36.1-38.0 38.1-39.0 ≥39.1

Systolic BP ≤90

91-100 101-110 111-219 ≥220

Heart Rate ≤40

41-50 51-90 91-110 111-130 ≥131

Level of consciousness

A V, P or U

The score is obtained by adding the scores obtained for each abnormal physiological observation – the total will assist in making a decision about the appropriate response.


APPENDIX B

Surviving Sepsis Proforma: Patient’s at Home & Mental Health Inpatient Areas

APPENDIX C

Any 2 of the following?

- Temperature >38 or <36 - Resp rate >20 per minute - Heart rate >90 per minute - Acute confusion/reduced

conscious level - Glucose >7.7mmol/l (unless

DM)

Please Tick

Patient Name Address NHS number/DOB

Sepsis Unlikely Continue normal care

Is this likely to be more than a self-limiting condition?

- Symptoms of infection (e.g. recent fever)

- Acute deterioration - Unexplained illness (especially in

immunosuppressed/elderly)

Sepsis Likely Date

Action Time Sign

Urgent GP referral - Hospital admission likely if patient already receiving antibiotics or no clear source of infection

Full bloods - FBC, U&E, CRP, lactate PURPLE, YELLOW, BLUE, GREY(for lactate)

Repeat visit within 12 hours if admission not indicated

Reassess for sepsis within 12 hours if admission not indicated

Ensure patient/carer understand specific ‘safety net’ advice if no admission

NO

YES

YES

Any 1 of the following?

- Systolic BP <90 mmHg - Lactate >2 mmol/l - Heart rate >130 per minute - Resp rate >25 per minute - *Oxygen sats <91% - Responds only to voice/pain - Unresponsive - Purpuric rash/mottled skin

*definitive diagnosis of COPD may negate this

trigger, please ensure these patients have ‘target parameters’ agreed

Please Tick

Red Flag Sepsis Date

Action Time Sign

Dial 999

Arrange blue light transfer

Write a brief handover including observations and any known antibiotic allergies

15l high-flow oxygen via non-rebreathe mask if available

Date Time sign

NO

NO

YES

All red flag sepsis is a time critical condition and

immediate action is required


APPENDIX C

NEW Physiological Observations Chart for Adults (front)


NEW Physiological Observations Chart for Adults (back)

Appendix D


COMPETENCY ASSESSMENT FOR PHYSIOLOGICAL OBSERVATIONS

The competencies are to be used in conjunction with: - Somerset Partnership NHS Foundation Trust

Physiological Observations of Inpatients and MIU Policy

Cleaning and Decontamination of Equipment Policy

Hand Hygiene Policy.

Assessing Competency in Clinical Practice Policy

Record Keeping and Records Management Policy

Consent and Capacity to Consent Policy Other related documents:

NMC (2007), Standards to support learning and assessment in practice. NMC standards for mentors, practice teachers and teachers.

Intercollegiate information paper between CSP, RCSLT, BDA and RCN. Supervision, accountability and delegation of activities to Support Workers: A guide for registered practitioners and support workers (January 2006).

Royal College of Nursing (RCN) (2008), Nursing Standard Essential Guide: Health Care Assistants and Assistant Practitioners Delegation and Responsibility. The purpose of these competencies is to clarify the knowledge and skills expected of practitioners, both nursing and allied health professionals, to ensure safe practice in measuring physiological observations.

Once the practitioner has reached a satisfactory level of competence following a period of supervised practice, please ensure formal competency is assessed within three months of completing the initial theoretical/practical training. The self–rating scale is to be used by the individual practitioner for self-assessment of present performance during supervised practice, and to help identify learning needs. Their line manager, or other experienced practitioner, must then assess these skills and sign to confirm competency. Only qualified practitioners with an NMC/Allied Health Professional Registering Body recognised teaching and assessing in practice qualification and/or HCAs with an NVQ A1/D32/33 assessor’s award and who have completed recognised training and assessment in obtaining physiological observations can be identified as assessors.


Key for Self-Assessment

1 = No knowledge / experience 2 = Some knowledge / experience 3 = Competent 4 = Competent with some experience 5 = Competent, experienced and able to teach others Authors: Sharon Kirwan (Staff Nurse) Wincanton Community Hospital Jaime Denham Clinical Skills Facilitator (East) Date : December 2015 Review : November 2018


ASSESSMENT OF COMPETENCE FOR PHYSIOLOGICAL OBSERVATIONS I confirm that I have self-assessed as competent to practice physiological observations as below: Practitioner Name:………………………………………………

Practitioner Qualification: ………………………………………………

Practitioner Signature:............................................ Date: ……………….. I confirm that I have assessed the named practitioner above as competent to perform the above skill. Name & Title: ……………………………………………… Signature:………………........................… Date: ………………. A record of your competency will be kept on your electronic staff record

Upon successful completion of your assessment of competency please give a copy to your line manager.

Physiological Observations of Adult Patients in the Community Setting V3 26 December 2015

Knowledge and Skills for Physiological observations

Self-Assessment Formal Assessment

Score Tick Date & Comments Signature Date & Comments

1 Understand the importance of informed consent and demonstrate obtaining consent prior to examination.

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5

2 Demonstrate appropriate infection control measures and hand washing throughout the procedures with each patient.

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5

3 Obtain an accurate respiratory rate. Describe the normal range for respirations and when/how to report concerns.

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5

4 Obtain an accurate manual radial pulse rate and one from an electronic monitoring system (if being used). Describe normal range for pulse rate, regularity and volume and when/how to report concerns, including regular and irregular pulse rates.

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5


Knowledge and Skills for Physiological Observations

Self-Assessment Formal Assessment


5 Accurately obtain a manual blood pressure using the correct cuff size selection and appropriate use of sphygmomanometer and stethoscope.

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5

6 Describe the normal range for blood pressure and when/how to report concerns. Be able to recognise a systolic and diastolic blood pressure.

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7 Understand how to use a vital signs monitor, select appropriate sized cuff. Understand which part of the screen relates to which reading.

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5

8 Understand the reason for NEWS scoring. Demonstrate how to work out and record NEWS scores, knowing when and how to seek advice.

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9 Understand how to take 1


and record a lying and standing (postural) blood pressure.

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5

10 Demonstrate how to record readings accurately, using approved symbols as directed on the observation chart and the frequency of measurement required.

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11 Describe how to maintain and clean equipment between patients and when not in use.

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5

12 Have general understanding of level of consciousness and be able to perform the “Alert, Voice, Pain, Unresponsive” (AVPU) assessment correctly.

1


Knowledge and Skills for

Physiological Observations Self-Assessment Formal Assessment


13 Be able to enter fluid in-put and out-put correctly on fluid balance chart and know when to report concerns.

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5

14 Correctly obtain oxygen saturation levels using pulse oximetry. Describe normal and abnormal oxygen saturation level; recognise levels on air or with supplementary oxygen and when/how to report concerns.

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15 Obtain accurate temperature using a temporal/tympanic thermometer (delete as appropriate). Describe normal and abnormal temperature levels and when/how to report concerns.

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5

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