Tasmanian Health Organisation - North

LAUNCESTON GENERAL HOSPITAL SDMS Id No.: P2012/0454-001 LGH Procedure No.: 40/12

Childrens Early Warning Tool (CEWT) Use LGH Procedure

Application: This procedure applies to all staff involved in the care of paediatric patients in the Launceston General Hospital (LGH). The procedure directly affects family members and patients. CEO Tasmanian Health Organisation - North 14 September 2012 Quality Improvement Nurse, Paediatrics and Neonate Units LGH 14 September 2015 1 N/A

Approved by: Effective Date: Custodian and Review Responsibility: Review Date: Version: Replaces:

Background
It is important to alleviate risk to patient safety by implementing best practice and national recommendations as described in the National Consensus Statement: Essential Elements for Recognising and Responding to Clinical Deterioration. The National Safety and Quality Health Service Standards include the standard Recognising and Responding to Clinical Deterioration in Acute Health Care which describes the systems and processes to be implemented by health service organisations to respond effectively to patients when their clinical condition deteriorates.

Procedure
The Childrens Early Warning Tool (CEWT) is used for the early identification and management of clinical deterioration of paediatric patients in LGH. It is a component of the Tasmanian Health Organisation Norths early recognition and response system DANGERS (Doctors and Nurses Emergency Response System). At all times, clinical staff are responsible for the patient and for delivering appropriate treatment for their condition, within their scope of practice. The CEWT observation chart is a tool to support assessment and together with the clinical emergency response system is designed to enable health care workers to confidently call for help when they and their patient need it.

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The CEWT observation chart must be used for all paediatric patients across LGH, including all paediatric patients in the Department of Emergency Medicine. Exclusions are paediatric patients in the following areas: Intensive Care Unit (ICU) Operating Room Suite (ORS) Day Procedure Unit (DPU)

The CEWT chart is based on a track and trigger scoring system allowing for multiple assessment elements to formulate an escalation process. The numeric CEWT score is colour coded to allow ease of identification for corresponding actions to be taken. The age appropriate CEWT chart must be used: < 1 year 1 4 years 5 11 years 12 years and older

Clinical Alert
The CEWT chart may not be appropriate when a patient has been diagnosed as actively dying or in the terminal phase where an end of life pathway may be suitable.

Observations
All paediatric patients must have a full CEWT score and a pain score taken: on admission once per shift (minimum 8th hourly) and if the patient is deteriorating (increasing score or you are concerned about the patient).

For abnormal observations you must continue to check until normal. Aside from the above, do appropriate observations at an appropriate frequency for the patients clinical status.

Clinical Alert
A full CEWT score = respiratory rate oxygen saturation respiratory distress blood pressure temperature heart rate

If an observation moves into one of the shaded areas on the CEWT chart, add up the patients full score and initiate the actions required for that colour, unless modifications have been made. Where a Clinical Pathway sets out a schedule for varying the frequency of observations, a medical officer (following consultation with the consultant) may document this as consistent with clinical pathway for [insert title of pathway] in the medical record. Varying observation frequency in this manner may only occur provided that this does not reduce frequency further than a minimum of 8 th hourly.
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Observations must be recorded on the CEWT chart in black or blue ink at the time they are taken. When graphing observations, place a dot (.) in the appropriate box and join to the preceding dot. For blood pressure use the symbols indicated on the chart. All paediatric patients are to be visually checked every 30 minutes (including at night) with rise and fall of chest during respiration observed. Interventions and observations must not be withheld or delayed in an attempt to avoid disturbing the sleeping patient. Any clinical staff member can increase the frequency of observations from the required minimum. A full CEWT score must be documented on patients if a family member or carer is concerned about deterioration in the patients clinical condition. A manual reading should be obtained if the automated blood pressure reading is outside the patients usual range (high or low) or if the patient has an irregular heart rate.

Modifications
Modifications to the parameters for individual patients can only be made by the admitting registrar or consultant. These must be clearly documented on the CEWT chart in the modification section and reviewed at least every 24 hours by the home team registrar or consultant. Changes to the modifications must be clearly documented on a new CEWT chart. Special treatment plans which alter calling criteria such as not for cardio-pulmonary resuscitation or an Advance Care Plan/Directive must also be documented in the patients medical record.

Specific Observation Charts

When a specific observation (e.g. respiratory assessment, neurological observations, blood product transfusion) chart is required, a full set of observations must also be documented on the CEWT chart 8th hourly as a minimum. If any of the observations (regardless of which chart they are recorded on) breach CEWT parameters then the appropriate escalation response and actions must be initiated.

Transfer of Patients
Prior to transfer from any exclusion area listed above to 4K a full CEWT score must be recorded on the CEWT chart. If the observations fall into any of the coloured zones on the chart the patient must be medically reviewed and cleared for transfer and a management plan documented in the medical record. Clinical handover must include any breaches of CEWT parameters and ongoing management. All paediatric patients transferred from ORS, ICU, and DPU must have a full CEWT score assessed 4 hourly until clinically stable.

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On return to 4K from specialised procedural areas (including ORS, DPU, Cardiac Cath Lab) all post procedure or post anaesthetic observations must be documented on the CEWT chart. Inter-facility transfer requirements at a minimum are to include: Clinical handover using ISOBAR Management plan Relevant clinical charts (copies) Transfer letters from relevant staff Own medications, private Xrays Details of follow-up Relevant results (copies) Discharge medications (if required

Paediatric patients may be required to leave the ward or area to attend diagnostic or other support services within or external to the LGH. Refer to Escorting of Inpatients Within and External to the Launceston General Hospital (LGH): LGH Policy and Radiology Escort of Patients: LGH Policy.

Management Plans
Management plans must be clearly documented by the home team so each health care team member understands their responsibilities, and includes orders for: frequency and type of observations expected nursing and allied health interventions other therapy and interventions investigations and when notification is required re condition change

Escalation Protocol
Clinical staff must identify deteriorating paediatric patients who meet the parameters for initiating the escalation protocol and complete the actions required for that level of escalation. In caring for patients who are deteriorating it is important to: recognise that CEWT parameters have been triggered initiate basic treatment including review of oxygen requirements and patient position, reassurance systematically assess the patient seek senior assistance early as per the escalation actions required increase observation frequency and level of care as per the escalation actions required communicate situation clearly with RN in charge activate emergency call if criteria met

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There are four escalation levels in response to breaches in the CEWT parameters. For each escalation level the frequency of observations must be increased at a minimum as below and the corresponding actions required on the CEWT chart completed. Interventions by clinical staff in response to a breach of CEWT parameters are to be recorded on the CEWT chart (see chart for instructions).

Score 1-3 Increased Surveillance

1 Consider increasing frequency of observations to a minimum of 4/24 or more frequently if clinically indicated, until observations stable (i.e. when they fall into the white zones of the CEWT chart), then return to patients usual frequency.

Score 4-5 RMO/Intern Review (in consultation with senior nurse)

1 Record observations at least once every 30 minutes to one hour for 2 hours until observations stable then return to patients usual frequency.

Score 6-7 Clinical Review by Paediatric Registrar and Home Team Registrar
1 2 3 4 5 While waiting for review, assess observations at least every 30 minutes or as clinically indicated Following clinical review the patients observations must be assessed as prescribed and documented by the attending medical officer If at any time the patients observations breach Clinical Review parameters then recommence the above process from step 1 Document on CEWT chart and in the medical record that a clinical review has been requested. The home team Registrar must attend within 15 minutes. If the patient is not reviewed within 15 minutes or if clinically indicated initiate a Code Blue emergency call. If the child is under a surgical or medical team and cannot be reviewed by the home team registrar within 15 minutes then they should be reviewed by the Paediatric Registrar or Paediatrician within that time frame, as well as contacting the home team consultant. If the patients condition has improved prior to review they must still be reviewed by the home team Registrar and a management plan documented in the medical record. NOTE for paediatric patients under surgical/medical teams contact the home team registrar within hours (0800-1640), after hours contact the rostered medical/surgical registrar as per the Switchboard Bulletin escalate as per point 5 above if unable to be reviewed by the nominated registrar.

Score 8+ Code Blue Call

1 2 Record observations as clinically indicated If the patient meets the criteria for a Code Blue Call, activate the Code Blue by dialling 222 Clearly State:
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Code Blue Call and Paediatric and Location NOTE: Within business hours the home team Registrar must be notified by the ward staff and attend the Code Blue.

Communication and Documentation following activation of rapid response system

When escalating care staff must use the communication tool ISOBAR to provide a standardised, sequential approach to give and receive handover. Documentation in the patients medical record following activation of Clinical Review or Code Blue call must include: date/time name of staff notified reason for call time patient is seen for Clinical Review or Code Blue call treatment arising from Clinical Review or Code Blue call outcomes following treatment management plan

Evaluation
Performance measures for CEWT are included in the overarching recognition and response system for THO-North healthcare facilities; these can be found in the DANGERS procedure document. Performance measures will be evaluated six monthly to annually and reports made available to relevant staff within facilities and clinical units to inform improvement to systems. The responsibility for co-ordination of collection and analysis of evaluation data is with the Paediatric Quality Improvement Nurse and Clinical Nurse Educator, Clinical Effectiveness Service, Resuscitation Advisory Group (RAG), and Life Support Coordinator.

Responsibilities/Delegations
All LGH clinical staff and visiting practitioners are responsible for compliance with the requirements outlined in this procedure document. Managers of clinical staff should ensure their staff are able to access and carry out the actions that fulfil the CEWT procedure.

Definitions
Clinical staff: all staff who provide direct patient care (nursing, medical and allied health). Consultant: the senior medical practitioner (visiting medical officer or staff specialist) who has primary responsibility for the patient during the admission.
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Escalation protocol: the protocol that sets out the response required for different levels of abnormal physiological measurements or other observed deterioration. Must: indicates a mandatory action requiring compliance. Patient: for the purposes of this document a person aged 17 years or younger is considered a paediatric patient unless otherwise specified by the admitting doctor. Track and trigger scoring system: an observation charting system used to record routine periodic measurement of observations graphically so trends can be tracked visually and which incorporates predetermined parameters (triggers) beyond which a standard set of actions is required by health professionals if a patients observations breach this parameter.

Related Documents/Legislation
Escorting of Inpatients Within and External to the Launceston General Hospital: LGH Policy Radiology Escort of Patients: LGH Procedure LGH Code Blue response to medical emergency LGH Procedure Procedure for Doctors and Nurses General Emergency Response System (DANGERS) National Consensus Statement: Essential Elements for Recognising and Responding to Clinical Deterioration National Safety and Quality Health Service Standards

Prepared by Through Through Cleared by

Malcolm Gulliver Michael Sherring Dr Neil Atherton THO-N Executive Committee John Kirwan

Quality Improvement Nurse Clinical Nurse Educator Paediatrician

6348 7654 6348 8972

24 July 2012 24 July 2012 13 September 2012

CEO Tasmanian Health Organisation - North

6348 7043

14 September 2012

AUTHORISED BY CHIEF EXECUTIVE OFFICER ... John Kirwan 17 September 2012 Date

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