Transcript CCDHB Vital Sign Charts

CCDHB Early Warning Score &
Vital Sign Charts
eLearning Package
September 2015
Welcome Page
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 which is being introduced across
Capital & Coast and Hutt Valley DHBs.
The online training will help you learn how to fill in the new
charts and operate the escalation pathway.
Please note that the adult EWS is designed for use in adults aged
16 years and above. For children please refer to the PEWS
system or for pregnant patients please use MEOWS.
Resources
Begin Training
Pdf 1. EWS matrix
Pdf 2. EWS chart
Pdf 3. Escalation pathway
Training Session
o Learning objectives
o EWS parameters
o Calculating an EWS & recording vital signs
o Triggering an EWS response & escalation
o EWS Quiz
Learning Objectives
After completion of this e-learning session you will
be able to:
1. Understand the benefits of CCDHB’s EWS
2. Describe the seven EWS parameters
3. Calculate an EWS correctly
4. Describe CCDHB’s EWS triggers for initiating a
response
5. Outline how the EWS escalation pathway works
6. Understand how the EWS Modification Box is
used
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 systems focus on the EARLY recognition of the
clinical signs of deterioration. Having recognised at-risk
patients, the system then trigger an escalation
response to prevent further deterioration that may lead
to a cardiac arrest. This EARLY approach to acute
deterioration optimises patient outcomes.
The CCDHB EWS
The NEWS (National Early Warning Score from the UK
NHS) is the only evidence-based EWS system. It is
better at predicting death, cardiac arrest or ICU
admission than any other published EWS system.
(Prytherch, Smith, Schmidt & Fetherstone, 2010)
The new CCDHB EWS system is based on NEWS and
modified to include emergency escalation for patients
at high risk of imminent death.
2. EWS Parameters
There are 7 parameters that form the basis for
CCDHB’s EWS:
– Respiratory rate
– Oxygen saturation
– Supplemental oxygen administration
– Temperature
– Systolic blood pressure
– Heart rate
– Level of consciousness
Respiratory Rate
• An elevated respiratory rate is one of the most
sensitive indicators of acute illness in adult
patients
• A reduced respiratory rate may be an indicator
of narcosis or neurological depression
• To measure respiratory rate accurately, the
patient’s breathing must be assessed for a full
minute
Oxygen Saturations
• Measurement of oxygen saturation by pulse
oximetry is now standard practice in acute
care settings
• Decreased oxygen saturations can be an
indicator of impaired pulmonary or cardiac
function
• When using a pulse oximeter, make sure that
the nail/skin interface is clean from anything
that might impair the trace such as nail polish
Supplemental Oxygen
• Patients who acutely require any
supplemental oxygen (via face mask or nasal
cannula) to maintain oxygen saturation are, by
the fact they need oxygen, recognised to be at
a higher risk of deterioration
• As such a score of 2 is added to the EWS when
supplemental oxygen is used on any patient
• Oxygen is a drug and must be prescribed along
with the intended target oxygen saturations
Temperature
• Extremes of body temperature are sensitive
markers of acute illness
• A low temperature (hypothermia) may be an
indicator of severe infection or endocrine
derangement
• A high temperature (hyperthermia) can be an
indicator of acute infection, inflammation,
brain injury or a reaction to certain types of
drugs
Systolic Blood Pressure
• A low blood pressure (hypotension) is a significant marker of
acute deterioration and may be due to sepsis, dehydration,
cardiac failure or rhythm disturbances as well as the effects of
medication
• A high blood pressure (hypertension) is an important risk
factor for cardiovascular disease and may be related to
another acute process (such as a stroke or severe pain)
• To capture the most accurate blood pressure, it is necessary
to use a manual blood pressure cuff. When measuring blood
pressure with a rapid irregular heart beat, automatic devices
are less accurate
Heart Rate
• Heart rate is an important indicator of any acute condition
• A fast heart rate (tachycardia) may be due to a number of causes:
– An arrhythmia
– Sepsis
– Metabolic disturbances
– Pain, nausea or distress
– Medications or reactions to them
• A slow heart rate (bradycardia) may be due to a heart block, altered
conscious state, or electrolyte disturbances. It may also be a
consequence of medication (beta blockers) or physical fitness
• When assessing the heart rate it is best practice to manually feel
(palpate) the pulse, rather than rely on pulse oximetry. Palpation
will provide additional important clinical information such as skin
temperature, regularity and strength of the pulse
Level of Consciousness
A decreased level of consciousness may be a late sign of
deterioration. It can be caused by a large number of conditions
including sepsis, low blood pressure, stroke or drug effects
The AVPU assessment is a quick tool to measure a patient’s level
of consciousness. The best response should be recorded:
A – alert or awake
V – responds to voice
P – responds to a painful stimulus
U – unresponsive to all stimuli
3. Using EWS
• When a patient is admitted acutely, a full set of vital signs
with EWS calculation must be carried out every SIX hours for
the first 24 hours of admission (Essential Vital Sign
Measurement & EWS protocol 1.3091)
• The frequency for taking vital signs should be increased or
decreased according to the clinical need of the patient
• Each vital sign is scored so that the more abnormal it is, the
higher the EWS. The scores range from 0 (normal) to 3 (very
abnormal)
• The individual scores for each parameter are added together
to calculate a total EWS that, if abnormal, triggers a clinical
response
The vital sign charts are colour-coded to 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
CCDHB’s EWS system also allows for single parameter scoring
i.e. if any vital sign falls in a coloured zone, the associated action
is triggered
EWS Process
1. Measure &
document a
full set of vital
signs
2. Calculate &
document the
EWS
3. Use the
4. Consider
EWS to
identify the
appropriate
level of
escalation
most
appropriate
clinical setting
for ongoing
care
4. CCDHB EWS Matrix
18
Wellington Adult Vital Sign Chart
Other Charts
In addition to the general adult vital signs chart,
there are different charts for certain specialties:
– Neurology/Neurosurgery
– Cardiology
– Cardiothoracic
– High Dependency Area
Paediatric & Maternity services have different
EWS systems (PEWS & MEOWS) adjusted for the
different vital sign values with age & pregnancy
5. Escalation Pathway
The escalation pathway is MANDATORY across
all clinical areas where EWS is in use
There are four levels to the CCDHB escalation
pathway
EWS 1-5
EWS 6-7
EWS 8-9
EWS 10+
• The EWS system does not replace sound clinical
judgment
• If the ‘Mandatory Action’ does not occur within
the time specified, escalate to the next coloured
zone
• If you are seriously concerned about any
patient, regardless of their vital signs or their
EWS, dial 777 immediately & ask for a Medical
Emergency Team (or ‘MET’). Give your location
& stay with the patient until help arrives.
6. Modification to EWS Triggers
• There are cases when clinically stable patients may have
abnormal vital signs that are ‘normal’ for them. To
accommodate this and prevent alarm-fatigue from overtriggering patient reviews, the EWS can be modified
• Any modification to the EWS must be made by a Consultant or
Registrar and should be regularly reviewed by the primary
medical team to ensure it is still valid
6. Modification to EWS Triggers
• Modification to EWS must NEVER be used to normalise abnormal
vital signs in clinically unstable patients, or to deter ward staff from
accessing the help they need i.e. to prevent 777 calls from being
made appropriately on deteriorating patients
• Any modification that is not signed & dated must be ignored
• Any patient in whom Cardiopulmonary Resuscitation (CPR) or a
Medical Emergency Team (MET) call is inappropriate can have this
notified on their Vital Signs Chart. All limitations must also be
documented in the patient’s clinical record
EWS Quiz
True or False?
• EWS focus on early recognition of clinical signs and help
identify deteriorating patients
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• EWS have been shown to decrease numbers of in-hospital
cardiac arrest
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• CCDHB’s EWS is based on a validated system which has been
demonstrated to be superior to other EWS systems at
predicting in-patient cardiac arrest or death
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Submit Answer
• What are the 7 EWS parameters?
– Temperature
– Heart rate
– Level of consciousness
– Urine output
– Oxygen saturation
– Systolic blood pressure
– Supplemental oxygen
– Diastolic blood pressure
– Respiratory rate
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Submit Answer
Which of the vital signs is considered the most
sensitive indicator of acute illness?
– Temperature
– Heart rate
– Respiratory rate
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Submit Answer
At CCDHB, what is the minimum frequency of
vital signs to be taken on every patient within 24
hours of admission?
– Daily
– Once per shift
– 6 hourly
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Submit Answer
Use the CCDHB EWS Matrix (insert link to EWS
matrix) to calculate the EWS:
– Respiratory Rate
– Oxygen Saturation
– Supplemental Oxygen
– Temperature
– Systolic BP
– Heart Rate
– Conscious level
32
95%
4L/min
36.6
155
132
Alert, but tired
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Submit Answer
– Respiratory Rate
– Oxygen Saturation
– Supplemental Oxygen
– Temperature
– Systolic BP
– Heart Rate
– Conscious level
Escalation
Response
32
95%
4L
36.6
155
132
Alert, but tired
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The correct
EWS is 9
Use the CCDHB EWS Matrix (insert link to EWS
Matrix here) to calculate the EWS:
– Respiratory Rate
– Oxygen Saturation
– Supplemental Oxygen
– Temperature
– Systolic BP
– Heart Rate
– Conscious level
20
97%
8L
37.8
105
98
Alert
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Submit Answer
– Respiratory Rate
– Oxygen Saturation
– Supplemental Oxygen
– Temperature
– Systolic BP
– Heart Rate
– Conscious level
Escalation
Response
20
97%
8L
37.8
105
98
Alert
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The correct
EWS is 4
Use the CCDHB EWS Matrix (insert link to EWS
Matrix here) to calculate the EWS:
– Respiratory Rate
– Oxygen Saturation
– Supplemental Oxygen
– Temperature
– Systolic BP
– Heart Rate
– Conscious level
9
92%
Room Air
37.2
115
48
Voice
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Submit Answer
– Respiratory Rate
– Oxygen Saturation
– Supplemental Oxygen
– Temperature
– Systolic BP
– Heart Rate
– Conscious level
Escalation
Response
9
92%
Room Air
37.2
115
48
Voice
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

The correct
EWS is 8
Place the EWS processes in the correct
order
Consider most
appropriate
clinical setting
for ongoing
care
Calculate &
document the
EWS
Use the EWS
to identify the
appropriate
level of
escalation
Measure &
document a
full set of vital
signs
True or False?
The general adult EWS chart is used
throughout adult wards at Kenepuru
and Wellington campuses
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The adult EWS is designed for adults
over the age of 16 years
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The colour-codes used to help identify
each EWS zone are: yellow, orange, red
and blue
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True or False?
The EWS replaces sound clinical judgment
The EWS can only be modified by a
Consultant or Registrar
Red is the colour associated with triggering
MET
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