Module 10 Online Tutorial: Patient Deterioration and Escalation Notes

Vital Signs

  • Essential for detecting patient deterioration.
  • Include pulse, blood pressure, respiratory rate, temperature, oxygen saturation, pain assessment, functional activity score, and consciousness level.
  • Documentation occurs on track and trigger charts, which track the patient's physiological status over time.
  • A trigger is activated when one or more vital signs are outside the expected normal range, leading to an escalation pathway for review.
  • Expected normal refers to the patient's baseline measurements.

Observation Charts

  • Used to document vital signs and track changes over time.
  • The frequency of observations should increase when a patient's vital signs are outside the normal range.
  • A clinical review should be undertaken when vital signs meet the criteria for review.
  • Key consideration is to avoid long gaps in monitoring and to promptly address any deterioration in the patient's condition.
  • Example:
    • A patient's respiratory rate increased at 10 PM but wasn't reviewed until 6 AM the next day.
    • The patient's blood pressure dropped, heart rate increased, and temperature went up.
    • Urine output had dropped.
    • Half-hourly observations were initiated at 10 AM, indicating concern and likely escalation to medical staff.

Clinical Reasoning

  • Involves using recall knowledge, AMP (Anatomy, Microbiology, and Physiology), and understanding of bodily systems to assess a patient's situation.
  • Example:
    • Low blood pressure and high heart rate. This could be due to vasodilation, where blood vessels widen, leading to decreased blood flow and increased heart rate to compensate.
    • Increased respiratory rate. Tries to eliminate CO_2 and maintain oxygen flow.
    • Decreased urine output. Kidneys retain water due to dehydration and low blood pressure.

Escalation and Emergency Calls

  • Emergency calls (e.g., Code Blue) are made when any observation falls within the purple area of the observation chart.
  • Clinical review is needed for any observation in the orange area or if there is a concern about the patient.
  • A senior doctor should arrive within 30 minutes for a clinical review, which needs to be documented.
  • The frequency of observations should be increased based on hospital protocol.

Indicators of Patient Deterioration

  • Increased respiratory rate.
  • Decreased capillary refill.
  • Agitation and impaired cognition.

Respiratory Rate

  • A very reliable indicator, reflecting changes in multiple systems (respiratory, cardiovascular, neurological, metabolic).

Steps to Follow in Case of Significant Change in Patient's Vital Signs

  1. Escalate care immediately according to the escalation policy.
  2. Document the changes.

MET (Medical Emergency Team) or RRT (Rapid Response Team)

  • A team that responds to emergency calls.
  • It may include doctors, nurses, ICU team, specialists, and anesthetists.
  • The nurse caring for the patient should stay with the patient to provide information and answer questions.
  • Too many people in the room can be overwhelming and distracting.
  • If asked to leave, do so.
  • If feeling upset or distressed, leave the room.

Basic Life Support (BLS)

  • If you walk past a room and see someone collapsed:
    1. Check for danger.
    2. Check for a response (AVPU: Alert, responds to Verbal stimuli, responds to Pain, Unresponsive).
    3. Send for help (call emergency number 2222 on a hospital phone, or 000 outside the hospital).
    4. Move on to Airway, Breathing, Circulation.

Potential Dangers in a Hospital

  • Cords and spills.
  • Tripping hazards (bedding, crutches).
  • Other patients or visitors.
  • Sharps and bodily fluids.
  • Gases (oxygen).
  • Fire.
  • Clutter.

Checking for a Response

  • Call the person's name if known.
  • Ask: "Are you okay?"
  • If no response to verbal stimuli, use painful stimuli such as a trapezius squeeze.

Sending for Help

  • Scream for help.
  • Use a call bell or press the emergency button on the wall.
  • Call the rapid response team using the hospital telephone (2222).
  • If no rapid response team, call 000 to get an ambulance.

Airway and Breathing

  • Assess for breathing by looking, listening, and feeling.
  • If the patient is unconscious, help with their breathing.
  • Do not perform finger sweep method to remove objects from the mouth.

Cardiopulmonary Resuscitation (CPR)

  • Commence chest compressions if the patient is unresponsive and/or breathing abnormally or not breathing.
  • CPR helps maintain blood flow to the brain.
  • If the person is unresponsive and not breathing normally, start CPR.
  • Compression rate: 100 to 120 compressions per minute.
  • Ratio of compressions to ventilations: 30:2 for adults and children.
  • Depth of compression: greater than 5 cm.

AED (Automated External Defibrillator)

  • Sends an electrical pulse to the heart to try and restart the SA node.
  • Detects electrical activity and shocks if required.
  • Place AED pads on the patient as soon as possible, following diagrams on the packaging.
  • Continue CPR while someone applies the pads.
  • The machine will analyze the rhythm and advise if a shock is needed.
  • If defibbing, ensure no one is touching the patient and remove oxygen.
  • Do not place pads over pacemakers or cords.
  • Considerations: hairy chest, pregnancy, wetness, jewelry, piercings, breast tissue.

Codes

  • Code Red: Fire or smoke.
  • Code Blue: Cardiac arrest or medical emergency.
  • Code Purple: Bomb threat or suspicious package.
  • Code Yellow: Infrastructure and other internal emergencies.
  • Code Black: Personal threat to self, staff, or others, generally with a weapon.
  • Code Brown: External emergency (e.g., multi-fatality crash).
  • Code Orange: Evacuation.
  • Code Grey: Unarmed threat.
  • MET or Rapid Response.
  • Senior staff generally call codes, not bedside nurses (except for Code Blue, Code Grey, Code Black).

Members of the Code Blue Team

  • Doctors and nurses from intensive care.
  • Anesthetists.
  • Medical or nursing staff from theater.
  • Emergency care critical care doctors or nurses.
  • Nursing attendants.
  • The nurse caring for the patient.
  • Patient's home medical team.

Role as a Student Nurse

  • Check for danger.
  • Assess for a response.
  • Send for help.
  • Commence CPR.
  • Observe and fix the environment.
  • Potentially get equipment.
  • If distressed, leave and care for yourself.

Documentation During Code Blue

  • Document every event with the time it occurred.
  • Do not scribe or get equipment if not sure what is needed.

After Code Blue

  • If the patient survives, they go to intensive care.
  • Inform the family.
  • Allow family to spend time with the patient.
  • A senior doctor and/or nurse will speak with the family.
  • Debrief with colleagues to ask questions and understand what happened.

Involving Family in Resuscitation

  • Family members should be supported during the resuscitation process.
  • Social workers or senior nurses can provide support and explanations.
  • If family members are interfering, security may need to be involved.

Documentation

  • Only people authorized to access the patient’s medical records should do so.
  • Handwriting must be legible, clear, and in black or blue pen.
  • Use day, month, year date format and 24-hour time.
  • For errors, draw a line through, write "error," and initial.
  • Put a line through any blank areas.
  • Not all abbreviations are acceptable.
  • Sign notes with your name or surname and designation.

Contemporaneous Documentation

  • Means 'at the time'.
  • Document as events happen.
  • If you make a late entry, indicate