Physiological Observations in Adult In-Patients - Recording and Acting upon - Guideline for

Publication: 01/02/2010  --
Last review: 10/03/2017  
Next review: 10/07/2020  
Clinical Guideline
INTERIM REVIEW DATE 
ID: 1971 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2017  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for Recording and Acting upon Physiological Observations in Adult In-Patients

Summary of Guideline/Protocol

All adult in-patients must have observations recorded at the time of admission with a written plan that specifies which observations should be recorded and how often.

All adult in-patients must receive a minimum of 12hrly observations.

A National Early Warning Score (NEWS) must be used to monitor all adult in-patients and recorded with every set of observations.

A graded response strategy must be used in all adult in-patient areas and must be followed to ensure a timely response to abnormal observations.

The frequency of observations must be increased in response to abnormal observations/NEWS and in line with the graded response.

If NEWS is 7 or more Critical Care Outreach or the ICU team and a senior member of the parent team must be contacted immediately.

Physiological observations must be recorded clearly and legibly. Each entry must be dated and timed.

Patients who have a personalised end of life care plan may be excluded from this guideline. This must be clearly documented in the patient’s medical notes.

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Background

It is well documented in the literature that many patients demonstrate clear physiological abnormalities in the hours leading to cardiopulmonary arrest or admission to critical care (NPSA, 2007, NCEPOD, 2006, Vincent et al, 2001, McGloin et al, 1999, McQuillan et al, 1998, Schein, 1990). By closely monitoring changes in physiological observations and timely institution of appropriate clinical management, deterioration is more likely to be identified before a serious adverse event occurs.

Early Warning Scores (EWS) are used to identify and respond to patients at risk of deterioration. NEWS is a National Early Warning Score that is used to prevent harm; reduce in-hospital cardiac arrests and mortality rates; and facilitate appropriate use of critical care resources, through early recognition and treatment of the deteriorating patient.

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Diagnosis

All in patients within LTHT must have physiological observations recorded within 30 minutes of admission and a minimum of 12 hourly thereafter.  The overall responsibility for ensuring this occurs rests with the admitting practitioner (doctor or nurse).

Observations must include as a minimum;

  • Pulse
  • Blood pressure
  • Respiratory rate
  • Temperature
  • Oxygen saturations
  • Level of consciousness (AVPU)
  • NEWS

NEWS must be done with every set of observations.
The frequency with which observations are required must be recorded on the graded response observation chart.  Frequency must be prescribed daily and amended as clinical condition warrants. 

The frequency of observations must be increased in response to a patient’s abnormal observations, NEWS and in line with the graded response.

Patient’s observations must be reviewed following any procedure or treatment and a plan for observations documented in the patients case notes.

This guideline should not replace any existing local guidelines for post procedure observations (i.e. post op observations, blood transfusion observations etc.) but NEWS must be done with every set of observations prescribed.

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Investigation

NEWS is a tool to assist in the early detection of patient deterioration. As such there may be some circumstances in which the NEWS may not reflect the severity of the patient’s condition. If there is clinical concern about a patient the frequency of vital signs assessment and EWS must increase, even if the EWS fails to trigger.  Healthcare practitioners must use their clinical judgement in conjunction with the NEWS at all times.

Additional monitoring to consider includes:

  • Hourly urine output
  • Biochemical analysis
  • Blood glucose
  • Arterial blood gas for(lactate/ base deficit/ arterial pH)
  • Pain assessment
  • ECG
  • CXR

In association with the NEWS, the graded response strategy must be followed to ensure timely response and treatment to prevent further physiological deterioration/cardiopulmonary arrest.

Interventions relating to NEWS escalation must be documented on the reverse of the Graded Response Observation Chart.

Where a NEWS of 5 or more is triggered or 3 in one parameter refer to the Sepsis Screening Tool, BUFALO intervention and STOP AKI. 

A NEWS of 9 signifies a clinical emergency.  In these cases, the Critical Care Outreach Team which supports all adult in-patient areas must be contacted immediately.

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Management

Chain or Response

It is likely that one staff group will cover more than one role in the chain (e.g. the recogniser may also be the primary responder or on occasions fulfil the role of recorder).

The framework below outlines the roles that will be expected for each group of staff when escalating deteriorating adult patients.

Role

Risk

Description

Example

Non Clinical Staff

Low Risk

The ‘alerter’, may include patient or visitor

Clerical Staff

Recorder

Low Risk

Takes designated measurements, records observations and information

Support Worker

Recogniser

Low Risk

Monitors, interprets information and adjusts level of care as required

Qualified Nurse

Primary Responder

Medium Risk

Interpreting information, escalating response and initiating clinical management

Senior Nurse/Junior Medic

Secondary Responder

High Risk

Assess effectiveness, formulate plan, refine plan, initiate escalation of therapy

Senior Medic/Consultant

Tertiary Responder

High Risk

Advanced Critical Care skills

Critical Care

NEWS SCORE

FREQUENCY OF MONITORING

CLINICAL RESPONSE

0

Minimum 12 hourly

  • Routine Observations/NEWS

LOW

 Total
1-4

Minimum 4 hourly

  • Registered Nurse review
  • Increase frequency of monitoring
  • Assess need for escalation of clinical care

MEDIUM

 

Total 5 or more
Or
3 in one parameter

Increase frequency to a minimum of 2 hourly

  • Registered Nurse review
  • Check blood glucose
  • Urgent assessment by medical/surgical team within 30 minutes
  • Hfluid balance (input/output)
  • Sepsis Screening Tool/ BUFALO intervention STOP Acute Kidney Injury (AKI)

HIGH

 Total 7 or more

Increase frequency to a minimum of 1 hourly

  • Registered Nurse review
    Immediate  Medical/Surgical Registrar review
  • Critical Care Outreach review
  • Consider transfer of clinical care/ discuss treatment escalation plan

NEWS Graded Response Strategy

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Provenance

Record: 1971
Objective:

Aims

To improve the recognition and management of patient deterioration in all adult in-patients.

Objectives

To provide direction and guidance for the coordinated approach to identify patient deterioration in patients and the subsequent actions that aim to prevent further deterioration and possible subsequent cardiac arrest.

The guideline outlines the standards by which physiological observations should be monitored and recorded and the scoring system and actions required to respond to changes in a patient’s normal physiological state.

This guideline should be read in conjunction with the policy for ‘The Prevention and Management of the Deteriorating Patient’ 2017.

Clinical condition:

Clinical Deterioration

Target patient group: Adults
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

Evidence Base:   

Department of Health (2008) Competencies for Recognising and Responding to Acutely Ill Patients in Hospital.  Crown, London.

National Confidential Enquiry into Patient Outcome and Death (NCEPOD) (2007) Emergency admissions: A journey in the right direction, London.

National Institute for health and Clinical Excellence (2007) Acutely Ill Patient in Hospital; recognition of and response to acute illness in adults in hospital.  Crown, London.

National Patient Safety Agency (2007) Recognising and Responding appropriately to early signs of deterioration in hospitalised patients, London.

Nursing and Midwifery Council (2008) The NMC code of professional conduct: standards for conduct, performance and ethics. NMC, London.

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Not supplied

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