Early Warning Score Vital Sign Charts Proposed content

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Early Warning Score & Vital Sign Chart(s) Proposed content for E-Learning

Early Warning Score & Vital Sign Chart(s) Proposed content for E-Learning

CCDHB Early Warning Score (EWS) Welcome to the EWS and vital sign chart e-learning

CCDHB Early Warning Score (EWS) Welcome to the EWS and vital sign chart e-learning site. This resource provides an opportunity to learn about the use of the new adult EWS system, paediatric EWS (PEWS) and maternity (MEOWS). The online training will help you learn how to use the EWS and vital sign chart and operate the escalation pathway. Please note that the adult EWS is designed for use in adults aged 16 years and above. If you work in paediatrics please refer to the PEWS training, and for pregnancy & obstetrics please use the MEOWS training. PEWS Begin E-Learning ADULT EWS Begin E-Learning § § § Links EWS matrix Wellington chart Kenepuru chart CNE’s teaching package EWS & vital sign policy § § Links PEWS matrices PEWS age-specific charts PEWS escalation pathway EWS & vital sign policy MEOWS Begin E-Learning Links § MEOWS matrix § MEOWS chart § MEOWS escalation pathway

Training Session: PAEDIATRIC o Learning objectives o PEWS parameters o Calculating a PEWS &

Training Session: PAEDIATRIC o Learning objectives o PEWS parameters o Calculating a PEWS & recording vital signs o Triggering a PEWS response & escalation o PEWS Quiz

Learning Objectives After completion of this e-learning session you will be able to: 1.

Learning Objectives After completion of this e-learning session you will be able to: 1. Understand the benefits of the PEWS 2. Describe the seven PEWS parameters 3. Calculate an PEWS correctly 4. Use the mandatory PEWS triggers to initiate a mandated response 5. Understand how the PEWS escalation pathway works 6. Know how the PEWS Modification Box is used

1. Benefits of EWS Early Warning Scores (EWS) have been developed internationally, to help

1. Benefits of EWS Early Warning Scores (EWS) have been developed internationally, to help identify acutely ill and deteriorating patients in acute care hospitals EWS focus on EARLY recognition of clinical signs of deterioration. EWS trigger a fast and efficient clinical response, which helps prevent deterioration to cardiac arrest. This EARLY approach to acute deterioration optimises patient outcomes.

Paediatric EWS (PEWS) • In recent years Paediatric EWS have been developed internationally, with

Paediatric EWS (PEWS) • In recent years Paediatric EWS have been developed internationally, with Toronto and Queensland publishing validated PEWS systems these have been implemented in a number of centres around NZ ( Starship, Kidz First and CHCH DHB 1 -4) • The PEWS system (January 2014) is based on the Queensland CEWT system Adopted by CHCH DHB and used with kind permission. There is a move towards a standardised EWS across the sub-regional 3 DHBs (Hutt Valley, Wairarapa & CCDHB)

References 1. Tibballs J, Kinney S, Duke T, Oakley E, Hennessy M. Reduction of

References 1. Tibballs J, Kinney S, Duke T, Oakley E, Hennessy M. Reduction of paediatric in-patient cardiac arrest and death with a medical emergency team: preliminary results. Archives of disease in childhood 2005; 90(11): 1148 -52. 2. Duncan H, Hutchison J, Parshuram CS. The Pediatric Early Warning System score: a severity of illness score to predict urgent medical need in hospitalized children. Journal of critical care 2006; 21(3): 271 -8. 3. Haines C, Perrott M, Weir P. Promoting care for acutely ill children-development and evaluation of a paediatric early warning tool. Intensive Crit Care Nurs 2006; 22(2): 73 -81. 4. Monaghan A. Detecting and managing deterioration in children. Paediatric nursing 2005; 17(1): 32 -5.

2. PEWS Parameters There are 7 parameters that form the basis for the EWS:

2. PEWS Parameters There are 7 parameters that form the basis for the EWS: – Respiratory rate – Oxygen saturation – Supplemental oxygen – Respiratory distress – Systolic blood pressure – Heart rate – Level of consciousness

PEWS charts There are 5 age-specific PEWS vital sign charts: – 0 -3 months

PEWS charts There are 5 age-specific PEWS vital sign charts: – 0 -3 months – 4 -11 months – 1 -4 years – 5 -11 years – 12 + years Link to chart Link to chart For the purposes of this training, the 4 -11 month chart is used for all clinical examples

Respiratory Rate (4 -11 mth) The PEWS triggers are sensitive to deterioration. PET call

Respiratory Rate (4 -11 mth) The PEWS triggers are sensitive to deterioration. PET call criteria are triggered at <10 or >60 per minute

Measuring Respiratory Rate • An elevated respiratory rate is one of the most sensitive

Measuring Respiratory Rate • An elevated respiratory rate is one of the most sensitive indicators of acute illness in paediatric patients. • To calculate an accurate respiratory rate, the patient’s breathing must be assessed for a full minute.

Respiratory Distress The degree of effort (work of breathing) allows clinical assessment of the

Respiratory Distress The degree of effort (work of breathing) allows clinical assessment of the severity of respiratory disease.

Measuring Respiratory Distress • Along with respiratory rate you are looking at the following:

Measuring Respiratory Distress • Along with respiratory rate you are looking at the following: Ø Recession Ø Inspiratory or expiratory noises Ø Grunting Ø Accessory muscle use Ø Flaring nostrils Ø Gasping Ø Efficacy of breathing e. g. decreased air entry, chest expansion

Supplemental Oxygen The scoring system allows you to use either Fi. O₂ or O₂

Supplemental Oxygen The scoring system allows you to use either Fi. O₂ or O₂ L/min, as part of the EWS. Talk to Charlotte Regularly review your patient’s need for oxygen and if they don’t need it, remove it All oxygen administration MUST be prescribed by a doctor, and regularly reviewed. Advanced Oxygen Therapy i. e BCPAP and Hi Flow Oxygen must be prescribed on the blue Advanced Oxygen prescription either prior to or at commencement of therapy.

Oxygen Saturation For patients receiving supplemental O₂, Sp. O₂ targets must be documented in

Oxygen Saturation For patients receiving supplemental O₂, Sp. O₂ targets must be documented in the patient’s clinical record, or medication chart

Measuring Oxygen Saturations • Measurement of Sp. O₂ by pulse oximetry is now a

Measuring Oxygen Saturations • Measurement of Sp. O₂ by pulse oximetry is now a standard practice in acute care settings. • Decreased oxygen saturations can be an indicator of impaired pulmonary and cardiac function. • When using a pulse oximeter, make sure that the nail/skin interface is clean from anything that might impair the trace e. g. nail polish

Systolic Blood Pressure • Normal Blood Pressure varies with age. • Use of the

Systolic Blood Pressure • Normal Blood Pressure varies with age. • Use of the correct cuff size is crucial if an accurate blood pressure measurement is to be obtained. (width should cover 2/3 of the length of the upper arm, inside of cuff (bladder) no more than 1/3 of arms circumference)

Measuring Blood Pressure • Blood pressure is to be recorded as per existing standards;

Measuring Blood Pressure • Blood pressure is to be recorded as per existing standards; on admission, preoperatively and on return to ward postoperatively. • In neonates and infants, blood pressure should be recorded if renal disease or co-arctation of aorta are suspected or if there are signs of hypotension. • Any child or adolescent should also have their blood pressure measured with symptoms of hypotension, hypertension, renal or cardiac disease, diabetes or adrenal disorder, head injury or trauma. • Blood pressure should be recorded 4 -8 hourly or more frequently if indicated. Use correct cuff size. • Blood pressure must be recorded if the PEWS score is 3 or greater based on other parameters.

Heart Rate Tachycardia is triggered at 160 per minute and bradycardia at 100. PET

Heart Rate Tachycardia is triggered at 160 per minute and bradycardia at 100. PET call criteria is a heart rate ≤ 60 per minute

Measuring Heart Rate • Heart rate is an important indicator of any acute condition

Measuring Heart Rate • Heart rate is an important indicator of any acute condition • The normal heart rate varies with age and activity • Tachycardia may be due to a number of causes: – Fever – Anaemia – Shock – Dysrhythmia – Sepsis – Metabolic disturbances especially due to dehydration – Pain/nausea/distress – Medications • Bradycardia is often a sign of an impending cardiorespirtaory arrest. Other causes of bradycardiac may be an indicator of hypothermia, CNS depression, heart block or hypothyroidism. • When assessing the heart rate it is best practice to manually feel for the pulse, rather than rely on pulse oximetry. Palpation will provide important clinical information e. g. skin temperature, regularity and strength of pulse

Level of Consciousness A decreased level of consciousness is an indicator of CNS depression

Level of Consciousness A decreased level of consciousness is an indicator of CNS depression and narcosis The AVPU assessment is a quick and accurate tool to measure and record a patient’s level of consciousness: A – alert or awake V – responds to voice P – responds to pain stimulus U - unresponsive

3. Using PEWS • The minimum frequency for taking a full set of vital

3. Using PEWS • The minimum frequency for taking a full set of vital signs & calculating the Early Warning Score is every 4 hours (Adult & paediatric vital sign measurement, EWS and escalation policy. Document ID 1. 101901. • The frequency for taking vital signs may be increased or decreased, according to the clinical need of each patient. • Each EWS parameter is weighted, so that the greater the deviation from normal, the higher the EWS score. The weighted scores range from 0 (normal) to 3 (grossly abnormal). • The individual parameter scores are then added together to derive an aggregated EWS. If significant, a clinical response is triggered

The vital sign charts have colour-coding to help identify each EWS zone: o White

The vital sign charts have colour-coding to help identify each EWS zone: o White = normal o Yellow = potential to deteriorate o Orange = indicates acute illness or unstable chronic disease o Red = likely to deteriorate rapidly o Blue = immediately life threatening critical illness The PEWS system also allows for single parameter scoring e. g. if any vital sign falls in a coloured zone, the associated action is triggered.

PEWS Process 1. Measure & document a full set of vital signs 3. Use

PEWS Process 1. Measure & document a full set of vital signs 3. Use the 2. Calculate & document the PEWS to identify the appropriate level of escalation 4. Consider most appropriate clinical setting for ongoing care

4. PEWS Matrix (4 -11 mth) 25 SCORE PET 3 2 1 0 1

4. PEWS Matrix (4 -11 mth) 25 SCORE PET 3 2 1 0 1 2 3 PET ZONE BLUE RED ORANGE YELLOW WHITE YELLOW ORANGE RED BLUE Resp Rate <10 10 -15 15 -20 20 -45 45 -50 50 -55 55 -60 >60 Sp. O₂ ≤ 85 85 -88 89 -92 93 -100 Supplemental O₂ 0 -2 L 21 -30% 2 -10 L 30 -39% 11 -14 L 40 -50% ≥ 15 L >50% Respiratory Distress nil mild moderate severe Sys BP <50 50 -55 55 -65 65 -75 75 -120 >120 Heart Rate <60 60 -80 80 -90 90 -100 100 -160 160 -170 170 -190 >190 Level of Consciousness Alert Voice Pain Unresponsive or fitting

Wellington Hospital’s vital sign chart

Wellington Hospital’s vital sign chart

5. Escalation Pathway The PEWS escalation pathway is MANDATORY and has been endorsed for

5. Escalation Pathway The PEWS escalation pathway is MANDATORY and has been endorsed for use by clinical directors and managers. Any deviations away from this pathway must be documented in the patient’s clinical record

PEWS 1 -3 (4 -11 mth)

PEWS 1 -3 (4 -11 mth)

PEWS 4 -5 (4 -11 mth)

PEWS 4 -5 (4 -11 mth)

PEWS 6 -7 (4 -11 mth)

PEWS 6 -7 (4 -11 mth)

PEWS 8+ (4 -11 mth) The colour associated with paediatric emergency team calls (PET)

PEWS 8+ (4 -11 mth) The colour associated with paediatric emergency team calls (PET) is BLUE

 • The PEWS system does not replace sound clinical judgment • If you

• The PEWS system does not replace sound clinical judgment • If you are seriously concerned about any patient, regardless of vital signs/PEWS, call ‘ 777 PET’ • Alternatively, if there is no timely response to your request for review, escalate to the next coloured zone.

6. Modification to PEWS Triggers • There are cases when clinically stable patients may

6. Modification to PEWS Triggers • There are cases when clinically stable patients may have abnormal vital signs. In order to accommodate this and prevent alarm-fatigue from over-triggering patient reviews, the PEWS can be modified • Any modification to the PEWS must be made by a Consultant or Registrar and be regularly reviewed by the primary team • Modification to PEWS must never be used to normalise abnormal vital signs in clinically unstable patients, or deter ward staff from accessing the help they need e. g. preventing 777 calls from being made

CCDHB PEWS Modification Box

CCDHB PEWS Modification Box

Paediatric EWS Quiz

Paediatric EWS Quiz

True or False? • PEWS focus on early recognition of clinical signs and help

True or False? • PEWS focus on early recognition of clinical signs and help identify deteriorating patients • PEWS have been shown to decrease numbers of in-hospital cardiac arrest & respiratory arrest • CCDHB’s PEWS is based on a validated PEWS system which has been demonstrated to be superior to all others at predicting mortality.

 • What are the 7 PEWS parameters? – Respiratory distress – Heart rate

• What are the 7 PEWS parameters? – Respiratory distress – Heart rate – Level of consciousness – Urine output – Oxygen saturation – Systolic blood pressure – Supplemental oxygen – Diastolic blood pressure – Respiratory rate

Which of the vital signs is considered the most sensitive indicator of acute illness?

Which of the vital signs is considered the most sensitive indicator of acute illness? – Temperature – Heart rate – Respiratory rate

At CCDHB, what is the minimum frequency of vital signs to be taken on

At CCDHB, what is the minimum frequency of vital signs to be taken on every patient? – Daily – Once per shift – 6 hourly – 4 hourly

Use the 4 -11 month PEWS Matrix (insert link to PEWS matrix) to calculate

Use the 4 -11 month PEWS Matrix (insert link to PEWS matrix) to calculate the PEWS: – Respiratory Rate – Oxygen Saturation – Supplemental Oxygen – Respiratory Distress – Systolic BP – Heart Rate – Conscious level 58 91% 11 L severe 105 132 Alert

– Respiratory Rate – Oxygen Saturation – Supplemental Oxygen – Respiratory Distress – Systolic

– Respiratory Rate – Oxygen Saturation – Supplemental Oxygen – Respiratory Distress – Systolic BP – Heart Rate – Conscious level Escalation Response 58 91% 11 L Severe 105 132 Alert The correct PEWS is 9

Use the 4 -11 month PEWS Matrix (insert link to EWS Matrix here) to

Use the 4 -11 month PEWS Matrix (insert link to EWS Matrix here) to calculate the PEWS: – Respiratory Rate 51 – Oxygen Saturation 97% – Supplemental Oxygen Fi. O 2 33% – Respiratory Distress mild – Temperature 37. 5 – Systolic BP 110/82 – Heart Rate 145 – Conscious level Alert

– Respiratory Rate 51 – Oxygen Saturation 97% – Supplemental Oxygen Fi. O 2

– Respiratory Rate 51 – Oxygen Saturation 97% – Supplemental Oxygen Fi. O 2 33% – Respiratory distress mild – Temperature 37. 5 – Systolic BP 110/82 – Heart Rate 145 – Conscious level Alert Escalation Response The correct PEWS is 4

Use the 4 -11 month PEWS Matrix (insert link to EWS Matrix here) to

Use the 4 -11 month PEWS Matrix (insert link to EWS Matrix here) to calculate the PEWS: – Respiratory Rate 51 – Oxygen Saturation 92% – Supplemental Oxygen 3 L – Respiratory distress mild – Temperature 38. 2 – Systolic BP 115/82 – Heart Rate 171 – Conscious level Voice

– Respiratory Rate 51 – Oxygen Saturation 92% – Supplemental Oxygen 3 L –

– Respiratory Rate 51 – Oxygen Saturation 92% – Supplemental Oxygen 3 L – Respiratory distress mild – Temperature 38. 2 – Systolic BP 115/82 – Heart Rate 171 – Conscious level Voice Escalation Response The correct PEWS is 9

Place the PEWS processes in the correct order Consider most appropriate clinical setting for

Place the PEWS processes in the correct order Consider most appropriate clinical setting for ongoing care Calculate & document the PEWS Use the PEWS to identify the appropriate level of escalation Measure & document a full set of vital signs

True or False? The PEWS chart is used throughout adult wards at Kenepuru and

True or False? The PEWS chart is used throughout adult wards at Kenepuru and Wellington campuses There are 5 age-specific PEWS charts The colour-codes used to help identify each PEWS zone are: yellow, orange, pink and blue

True or False? The PEWS replaces sound clinical judgment The PEWS modification box must

True or False? The PEWS replaces sound clinical judgment The PEWS modification box must only be filled in by a Consultant or a Registrar Pink is the colour associated with triggering PET