NUR244 TOPIC 5 TUTORIAL

The Escalation System Study Notes

THE ESCALATION SYSTEM

Introduction to Deterioration Management

  • Early recognition of patient deterioration can lead to:

    • Reduced adverse outcomes.

    • A decrease in the volume of interventions needed to stabilize deteriorating patients in hospitals.

  • Effective management involves:

    • Accurate measurement and recognition of abnormal clinical observations.

    • Appropriate escalation of care.

  • The ESCALATION system, used in WA health, aims to respond to clinical deterioration effectively.

Components of the ESCALATION System

  • Key components include:

    • Paediatric Acute Response and Recognition Observation Tool (PARROT).

    • Early Warning Score (EWS).

    • Sepsis Pathway.

    • Identification and Communication (ID CEED).

    • Structured communication tool known as ISOBAR.

PARENT'S AND CARER'S ROLE

Importance of Caregivers

  • Parents and caregivers play a crucial role in monitoring children's health.

  • It is essential to communicate concerns regarding any unusual behavior or sickness.

  • Changes to monitor include:

    • Rapid breathing.

    • Increased sleepiness.

    • Confusion.

    • Severe pain.

    • Physical signs like cold, pale skin, or mottled appearance.

Aishwarya's CARE Call

  • A 3-step process for patients, caregivers, and family to express concerns when a patient appears sicker.

    • Step 1: Identify the concern.

    • Step 2: Communicate the change to health professionals.

    • Step 3: Follow-up if concerns persist.

  • This process is applicable in all WA public hospitals.

Paediatric Acute Response and Recognition Observation Tool (PARROT)

General Instructions

  • There are five age-specific charts corresponding to:

    • Less than 3 months.

    • 3-12 months.

    • 1-4 years.

    • 5-11 years.

    • 12 years and above.

  • Important to select the correct chart to identify deviations from age-defined parameters.

  • Calculation of the Early Warning Score (EWS) requires:

    • Assessment and documentation of all values on the chart.

    • Summing the individual values to obtain a total EWS.

Chart Layout Features

  • The layout adheres to the ABCDE approach to facilitate assessment:

    • Airway & Breathing.

    • Circulation.

    • Disability.

    • Exposure.

  • Highlight staff clinical judgment and family knowledge to detect early warning signs.

  • Important properties of the chart include:

    • Use of colors tested for human factors principles.

    • Inclusion of scores/features for oxygen therapy and blood pressure (only systolic scores).

    • AVPU scale for assessing consciousness (Alert, Voice, Pain, Unresponsive).

    • Temperature is indicated with red lines for abnormalities (not used in EWS).

Early Warning Score Escalation Pathway

EWS Score and Clinical Response

  • For each EWS score, specific actions are recommended:

    • Score 1-3:

    • Remain vigilant.

    • Complete a full set of observations.

    • Notify the nurse in charge and document a treatment plan.

    • Score 4-5:

    • Timely medical review within 30 minutes.

    • Reassess observations within the same timeframe.

    • Score 6-7:

    • Urgent assessment by the treating team within 15 minutes.

    • Consider emergency telehealth service or transfer to higher care.

    • Score 8+:

    • Rapid response review needed within 5 minutes.

    • Initiate appropriate clinical care or call a Medical Emergency Call/Code Blue if no response.

Sepsis Recognition and Escalation Pathway

  • Particularly important for suspected infections and abnormal temperatures (e.g., <36°C or ≥38°C).

  • Early identification and response to sepsis as a medical emergency could involve:

    • Immediate evaluation and escalated care for high-risk patients, including those who are immunocompromised, have invasive devices, or are very young.

  • Signs/severity levels to monitor:

    • EWS 6-7 and symptoms such as mottling or confusion.

    • EWS 8+ or any observation in critical zones require immediate escalation.

Distracted Therapy

Importance and Methods

  • Distraction can create a buffer between a child’s fears and the physical experience of medical procedures.

  • Methods of distraction include:

    • Pop-up toys.

    • Blowing bubbles.

    • Musical toys and interactive games.

    • Storytelling and conversation.

    • Puppetry and technology.

Guidelines for Preparing Children

  • Preparation for children undergoing procedures should include:

    • Honest communication using child-friendly language.

    • Awareness of the child's understanding and fears related to the procedure.

    • Timing of information delivery to reduce anxiety pre- and post-procedure.

    • Vigilance for non-verbal cues indicating understanding or distress.

    • Involvement of siblings to contribute to comfort.

Medication Calculations in Paediatrics

Key Considerations

  • In pediatric care, careful dosage is vital, where every mL or microgram counts.

  • During the preparation of IV antibiotics:

    • Consider the volume of the powder and follow instructions for fluid usage.

    • Example: For Amoxicillin/Clavulanic Acid, the powder volume is 0.9mL for the 1g vial, requiring 19.1mL to create a final volume of 20mL with a concentration of 50mg/mL.