The COMPASS Education

Programme incorporating the National Early Warning Score is a

work stream of the National Acute Medicine Programme
in association with other National Clinical Programmes, Quality &
Patient Safety Division, Patient Representative Groups, Office of the
Nursing and Midwifery Services Director, Clinical Indemnity
Scheme, Acute Hospital Services, Irish Association of Directors of
Nursing and Midwifery (IADNAM) and Health & Social Care
Professionals.

The National Early Warning Score: National Clinical Guideline Number 1

is quality assured by the National Clinical Effectiveness Committee
and endorsed by the Minister for Health in February 2013.
www.patientsafetyfirst.ie

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COMPASS is an interdisciplinary education programme, designed to
enhance understanding of deterioration in patients conditions and the
significance of altered clinical observations.

The programme was adapted from the Australian COMPASS

programme and shared with the Irish Health system by The Health
Directorate, ACT Government, Australia.

The COMPASS Education Programme was developed in conjunction with the

National Early Warning Score which standardises the assessment of
acute illness severity.

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 The National Early Warning Score
The National Early Warning Score is a cumulative
scoring system which standardises the assessment of
acute illness severity
Simple bedside tool
Physiological Track & Trigger Warning System
Used in all acute hospitals in Ireland
Indicates early signs of deterioration
The score is calculated using the patients vital signs
The scoring parameters are based on the ViEWS
parameters validated for medical and surgical patients

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NEWS Validation for Medical & Surgical Patients
using ViEWS Parameters

1. Bleyer A.J. et al. (2011). Longitudinal analysis of one million vital signs in
patients in academic medical centre. Resuscitation doi:10.1016/j.
Resuscitation, 2011.06.033
2. Kellett J & Kim A. (2011). Validation of an abbreviated VitalpacTM Early
Warning Score (ViEWS) in 75,419 consecutive admissions to a Canadian
Regional Hospital Resuscitation. doi:10.1016/j.resuscitation.2011.08.022
3. Prytherch D, Smith G, Schmidt P, Featherstone P. (2010). ViEWS Towards
a national early warning score for detecting adult inpatient deterioration.
Resuscitation. 81(8), 932-7.
4. Mitchell I., McKay H., Van Leuvan C., Berry R., McCutcheon C., Avard B.,
Slater N., Neeman T. and Lamberth P. (2010). A prospective controlled trial
of the effect of a multi-faceted intervention on early recognition and
intervention in deteriorating hospital patients. Resuscitation. 81, 658666.
5. National Institute for Health and Clinical Excellence (NICE), (2010). Acutely
ill patients in hospital. Available at: http://www.nice.org.uk/guidance/index

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 Important Points
The National Early Warning Score does not replace
competent clinical judgement

When staff are concerned about a patient care must

be escalated regardless of the score

The NEWS triggers screening for Sepsis when there

is a NEWS of 4 (or 5 if a patient is on
supplementary oxygen)

In a small percentage of patients the NEWS does not

identify deterioration in a patients condition

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 Aim of the COMPASS / NEWS
Education Programme

To enable Healthcare Professionals to:

Recognise the deteriorating patient

Initiate appropriate interventions
Initiate timely interventions

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 Learning Outcomes
On completion of this programme participants
should be able to:
Understand the importance and relevance of
observations and the underlying physiology
Recognise and interpret abnormal observations
Communicate effectively to the right people and
at the right time
Recognise and manage deteriorating patients
Facilitate teamwork within the multi-disciplinary
team and develop management plans
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 Overall COMPASS / NEWS Education
Programme incorporates:
Categorisation of patients
SEVERITY of illness for EARLY
detection of clinical deterioration
A TRACKING system using the
NEWS based on the patients vital
signs
A definitive plan to ESCALATE
care
TRIGGERING a swift response i.e.
activation of an early response
appropriate to the level of the score
The use of a structured
COMMUNICATION tool (ISBAR),
(more information on this later)
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 In the event of a cardiac or
respiratory arrest activate cardiac
arrest system

Some patients may require immediate

medical review but will not trigger a high
score.
The protocol is activated with a score of 3
in any single parameter or total score of 3.

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 Questions
Which of the following statements are true

When staff are concerned about a patient

care must be escalated regardless of the
score
The NEWS does not replace competent
clinical judgment
NEWS identifies deterioration in the
condition of all patients
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 Questions

What score triggers sepsis screening?

1. NEWS 2

2. NEWS 7 (8 if on supplementary oxygen)

3. NEWS of 4 (or 5 if a patient is on

supplementary oxygen) and Infection Suspected

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Why do we need a National Early Warning
Score and Education Programme?

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The National Confidential Enquiry into Patient
Outcome and Death (UK 2005) reported:

Avoidable admissions to ICUs in 21% of cases

Communication failures between teams

contributed to delays in referrals and in
delivering appropriate essential care, which
contributed to increased morbidity and mortality

In 11% of cases deficiencies in care might have

contributed in death
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 NCEPOD Report Time to Intervene (2012)

68% of patients (394/583) had been in hospital for

longer than 24 hours prior to cardiac arrest

Warning signs for cardiac arrest were present in

344/462 (75%) of cases. These warning signs
were recognised poorly, acted on infrequently,
and escalated to more senior doctors infrequently

Cardiac arrest was predictable in 289/454 (64%)

and potentially avoidable in 156/413 (38%) of
cases
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 NCEPOD Report Time to Intervene (2012)

More than half of the cardiac arrests in this

study occurred on medical/surgical wards
(429/781; 55%)

458/776 cardiac arrests (59%) occurred

out of hours

Most cardiac arrests where the cause was

known were secondary to non-cardiac
disease (356/591; 60%)
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 Cardiac Arrest Calls in a General
Hospital
Gallagher, J. Groarke, J.D. & Courtney, G. (2006) IMJ. 99(6),114-116.

Retrospective study of cardiac arrest over

24 month period (2002-2004)
Subgroup of 20 patients progress in
preceding 24 hours-

Decline in patients condition evident in 45-
75%

Respiratory rate infrequently recorded

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 COMPASS Pilot
Mitchell et al. (2010) A prospective controlled trial of the
effect of a multi-faceted intervention on early recognition
and intervention in deteriorating hospital patients.
Resuscitation. 81, (658-666).

Four Pilot wards

An Early Warning Score
Redesigned observation chart
Education
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 Data Collection
Control period
4/12 Feb-June 06 (1171pts)

Intervention period
4/12 Feb-June 07 (1006 pts)
Data: Patient Demographics
Hospital LOS
Hospital Outcome
25% Random Sample:
Collection of vital signs
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 Results
Control Pilot p-value

No. of Patients (%) 1157 985

Unplanned ICU admissions 21(1.9) 5(0.5) 0.005

Unexpected hosp. deaths 11(1.0) 2(0.2) 0.03

All hosp. deaths 30(2.6) 6(0.6) <0.001

Cardiac arrests 4(0.4) 0(0)

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 The National Institute for Clinical Excellence,
UK (NICE) Guideline 50 (2007) includes the
following:
Recommendation 1.2.2.3
States that physiological track and trigger systems
should be used to monitor all adult patients in acute
hospital settings.

Recommendation 1.2.2.4
States that track and trigger systems should use
multiple-parameter or aggregate weighting scoring
systems, which allow a graded response. These scoring
systems should: define the parameters to be measured
and the frequency of observations, include a clear and
explicit statement of the parameters, cut-off points or
scores that should trigger a response.
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 National Recommendations

HIQA (2011) stated that the HSE should, as a priority,

agree and implement a national early warning score to
ensure that there is a system of care in place for the
prompt identification and management of clinically
deteriorating patients
The Clinical Indemnity Scheme (State Claims Agency)
recommend its implementation
The first National Clinical Guideline: National Early
Warning Score was signed off by the National Clinical
Effectiveness Committee (Department of Health, and
endorsed by the Minister for Health in February 2013.
This means that it is now national policy and applicable
to private and public hospitals.
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Airway and Breathing

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Chain of Oxygen Delivery (DO2)
This equation calculates the amount of oxygen
delivered to the tissues per minute-

DO2 = (SVxHR) x (HB) x SaO2 x 1.39)+PaO2 x 0.003

Arterial Saturation depends on-

Airway
Breathing
Circulation
(DO2 = Delivery of Oxygen)
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 DO2 depends on:
Adequate airway and ability to protect the
airway

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 DO2 depends on:
Effective lung mechanics neurological and
muscular

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 DO2 depends on:
Functioning lung tissue

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 DO2 depends on:

Adequate pulmonary blood supply

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 Chain of Oxygen Delivery

DO2 = (SVxHR) x (Hb) x SaO2 x 1.39)+PaO2 x 0.003

Haemoglobin-
Normal Adult range / Concentration
(anaemia: causes)

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 Chain of Oxygen Delivery
DO2 = (SVxHR) x (HB) x SaO2 x 1.39)+PaO2 x 0.003
(SVxHR) = Cardiac output (CO)
This depends on:
Contractility of the
heart muscle
Pre-load (venous
return to heart)
After-load (resistance
of ejection of blood
from the ventricle)
Heart rate

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 Airway & Breathing
Decreased oxygen delivery at the tissue level

Anaerobic metabolism

Lactate production

Acidosis

Stimulates respiratory drive

Increases the respiratory rate

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 Airway & Breathing
Points to Note-
Some patients with Chronic Obstructive Pulmonary
Disease (COPD) are CO2 retainers, i.e. they do not
respond to raised CO2 but do respond to low O2 - high
concentrations of O2 may suppress their hypoxic drive.
NB these patients will also suffer end-organ damage or
cardiac arrest if their blood O2 levels fall too low.
In COPD if PCO2 8kPa but hypoxic (PO2 8kPa) DO
NOT TURN O2 DOWN
Dont rely on machines!
Stay with the patient aim to achieve a PaO2 of 8kPa, or
SaO2 of 90%.
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 Airway & Breathing

Remember:
An increase in respiratory rate can occur
with a normal SaO2
Patients die of hypoxia faster than a high
CO2
If a patient is deteriorating do not remove
supplemental oxygen when taking ABGs
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 Questions
1. Supplementary oxygen needs to be prescribed by a
doctor true / false

2. Aerobic Metabolism
a) Generates 2ATP
b) Produces lactate
c) Requires oxygen
d) Causes tachypnoea

3. In a patient with COPD who has a PCO2 > 8kPa but is

also hypoxic PO2 < 8kPa, should you reduce the
prescribed inhaled O2 therapy (Yes/No)
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Circulation

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 Circulation
Blood Pressure (BP)
BP=Cardiac Output X Peripheral Vascular Resistance
Decreased BP (Hypotension) is defined as a
drop of more than 20% from usual blood
pressure or a systolic blood pressure of less
than 100mmHg.
Hypotension can reflect a decrease in
cardiac output which can lead to a decrease
in the amount of oxygen getting to the tissues
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 Circulation
Decreased BP can be a result of:
Decreased intravascular blood volume
Decreased peripheral vascular resistance
Decreased contractility of heart

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 Circulation
Decreased intravascular blood volume
Cardiac output falls from low stroke volume
Stroke volume falling causes tachycardia
To maintain BP, peripheral resistance rises
Hypotension, cool hands & no heart failure
IV fluids

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 Circulation

Decreased peripheral vascular resistance

Vasodilatation causes low BP
Vasodilatation causes low venous return
Low venous return causes low stroke volume
Hypotension, warm hands: IV fluids

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 Circulation
Decreased contractility of heart
Cardiac output falls from low stroke volume
Stroke volume falling causes tachycardia
To maintain BP, peripheral resistance rises

Hypotension, cool hands & signs of heart

failure
- Cease fluids
- ICU/CCU consult
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 The Hypotensive Patient

Consider which is most likely cause for your

patient..

Reduction in preload (volume loss)
(e.g. haemorrhage, sepsis, vomiting)

Reduction in cardiac contractility (pump failure)
(e.g. MI, heart failure)

Reduction in afterload (vasodilation)
(e.g. sepsis, overdose)

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Hypotension & Organ Perfusion

Look, listen and feel.

Cerebral hypoxia-agitation, confusion

Renal impairment-reduced urine output

Myocardial ischaemia-angina, MI

Gut ischaemia-abdominal pain, nausea

Peripheral ischaemia-cool limbs

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 The Hypotensive Patient
How do you assess the effect of a fluid bolus? Caution for
patients with suspected/diagnosed cardiac disease -
Look, listen and feel

Heart rate and rhythm
BP

Peripheral pulses
Urine output

Capillary refill
Oxygen saturations

Limb temperature
Colour

Central pulses
Chest Auscultation

JVP
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 Questions
1. Cardiac Output =
a) Blood pressure x heart rate
b) Stroke volume x blood pressure
c) Stroke volume x heart rate
d) Stroke volume x peripheral vascular
resistance

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 Questions

2. A decrease in 3. Which of the

Cardiac Output can following is correct:
be caused by: a) BP = CO x PVR
a) Decreased b) BP = SV x PVR
intravascular blood c) BP = SV x CO
volume
a) Increased
intravascular blood
volume

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 Questions
4. Compensation for a decreased oxygen
delivery will include which of the following:
a) Increased urine output
b) Decreased peripheral vascular resistance
c) Decreased respiratory rate
d) Increased heart rate

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 The Patient with a Disordered
Conscious Level

Airway, Breathing, Circulation

Dont forget the Glucose

AVPU
Pupils Recovery position
Blood Glucose

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 The Patient with a Disordered
Conscious Level
Glasgow Coma Scale

Patients best response to stimuli out of 15

3 components
Eye opening Range 1-4
Best motor response Range 1-6
Best verbal response Range 1-5

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 The Patient with a
Disordered Conscious Level
Glasgow Coma Scale
Assess after resuscitation is complete
Monitor GCS regularly
If GCS falls by > 2 points, call medical
staff
If GCS falls below 9, call ICU or
anaesthetic staff as intubation may be
required
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 Question
1. One of the first tests 2. The Glasgow Coma
to do for a patient Scale is included in
with a decreased the National Early
level of Warning Score
consciousness is:
a) Sodium (True/False)
b) Potassium
c) Glucose
d) Chloride

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 Hypothermia (Temperature 350C)
Possible Causes Signs and Symptoms
Sepsis HR, RR & metabolic rate
Hypoadrenalism, decreases
hypopituatism, hypothyroidism Confusion
Aggressive fluid resuscitation Arrhythmias
Exposure to low temperatures Cardiac Arrest
(Intra-operatively)
Neurological (stroke, trauma,
tumour)
Skin disease (burns,
dermatitis)
Drug induced (sedatives)
Neuromuscular in-sufficiency

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 Urine Output

Urine output should be greater than

0.5mls/kg/hr
Small window when oliguric to prevent
acute renal failure
Do not give Frusemide for low urine output
unless other causes are ruled out & the
patient is clinically fluid overloaded
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 Sepsis
(in the non-pregnant adult patient)

This chapter incorporates the principles outlined in the Sepsis

Management, National Clinical Guideline No. 6
This guideline can be accessed at: http://health.gov.ie/national-clinical-
guideline-no-6-sepsis-management/

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Patients with sepsis have a prolonged
hospital stay and often require critical care
input.
(Sepsis Management - National Clinical
Guideline No. 6, 2014)

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 Sepsis
"Sepsis is a life threatening condition that arises
when the body's response to an infection injures
its own tissues and organs. Sepsis leads to
shock, multiple organ failure and death
especially if not recognised early and treated
promptly. Sepsis remains the primary cause of
death from infection despite advances in modern
medicine, including vaccines, antibiotics and
acute care. Millions of people die of sepsis every
year worldwide."
(Merinoff Symposium 2010)
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 Classifications of Sepsis
SIRS (Systemic Inflammatory Response
Syndrome)
Sepsis
Severe Sepsis
Septic shock

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 Definitions
Infection is defined as a pathological process
caused by invasion of normally sterile tissue or
fluid or body cavity by pathogenic or potentially
pathogenic micro-organisms. It is important to point
out that, frequently, infection is strongly suspected
without being microbiologically confirmed.
Systemic inflammatory Response Syndrome
(SIRS) is defined as an inflammatory state
affecting the whole body, frequently a response of
the immune system to infection, but not necessarily
so. It is the body's response to an infectious or
non-infectious insult.
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 Definitions
Sepsis is the clinical syndrome defined by
the presence of both infection and a
systemic inflammatory response syndrome
(SIRS). However, since infection cannot be
always microbiologically confirmed, the
diagnostic criteria are infection, suspected or
confirmed and the presence of some of the
SIRS criteria.

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 Definitions
Severe sepsis refers to sepsis complicated
by organ dysfunction. In the 8th Edition of the
ICD-10-AM/ACHI/ACS this is extended to
include organ failure. This difference does not
affect the guideline diagnostic criteria which
identify a minimum level of organ dysfunction
beyond which severe sepsis is diagnosed.

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 Definitions
Septic shock is defined as severe sepsis with
circulatory shock with signs of organ dysfunction or
hypoperfusion in the 8th Edition of the ICD-10-
AM/ACHI/ACS. The diagnostic criteria in the Sepsis
Management National Clinical Guideline No. 6 are
applied after 30mls/kg isotonic fluid has been
administered to reverse any hypovolaemia and are
persistent systolic blood pressure <90 mmHg or
MAP < 65 mmHg; decrease in systolic blood
pressure by 40mmHg from normal and/or lactate >4
mmol/l.

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Prevalence of sources of sepsis
Respiratory 35%
Urinary 21%
Intra-abdominal 16.5%
Catheter-related blood 2.3%
stream infection
Device-related 1.3%
CNS 0.8%
Others e.g. cellulitis, 11.3%
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 4 Steps of Sepsis Management

Note: Screening for Sepsis now linked to the NEWS

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 Patient Assessment
A full history and examination with appropriate
blood tests and radiological investigations can
aid in making a diagnosis
Look.. Listen.. Feel...ABCDE
Record full set of vital signs including GCS and
Glucometer
Is there
pallor/flushing/cyanosis/rashes/wound/posture
Can you hear crackles on chest examination
Any complaints of pain / abnormal posture
Peripheries.are they warm/cold to touch
Feel a pulse for rate / quality
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Sepsis - Deterioration Pathway

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Initial Management

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 SIRS Criteria

Sepsis is a medical emergency

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 Note
Not all patients meeting modified SIRS
criteria have sepsis, OR there may be
additional problems requiring different
management (current Congestive Cardiac
Failure (CCF), Diabetic Ketoacidosis
(DKA), Myocardial Infarction (MI), Gastro-
intestinal (GI) bleed etc.) OR patient may
be receiving chemotherapy OR be
palliated.
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Sepsis Six Regimen

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Severe Sepsis

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Septic Shock

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 High Risk Groups

Infants and the elderly

Immuno-compromised/ Cancer patients

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 Infants and the elderly

Review of the SIRS criteria and more senior

review in order to make or out rule the diagnosis
of sepsis.
Patients in these groups presenting with organ
dysfunction/shock should be treated as severe
sepsis/septic shock if the diagnosis is unclear
and delay > 1 hour in confirming the diagnosis is
anticipated.
If infection is subsequently found not to be the
cause antimicrobials should be stopped.
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 Cancer Patients
NEUTROPENIC SEPSIS IS A MEDICAL EMERGENCY.

SUSPECTED NEUTROPENIC SEPSIS MUST BE TREATED WITH

ANTIBIOTICS WITHIN 1 HOUR OF ARRIVAL IN THE HOSPITAL

FAILURE TO INITIATE ANTIBIOTICS EARLY MAY RESULT IN

OVERWHELMING SEPSIS AND DEATH.

THE POSSIBILITY OF INFECTION MUST BE CONSIDERED IN

ANY PATIENT UNDERGOING TREATMENT FOR CANCER WHO
IS UNWELL AND PARTICULARLY IN THOSE WHO ARE
NEUTROPENIC (NOTE: 2 SIRS CRITERIA MAY NOT BE
PRESENT).

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 NOTE:
Patients with neutropenic sepsis may present
with haemodynamic compromise without fever
(e.g. if elderly, or on steroids)
Neutropenic sepsis with or without fever is a
medical emergency
All clinical signs indicating sepsis need to be
acted upon immediately
The administration of empiric broad spectrum
antibiotics should not be delayed in order to
perform blood cultures

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Sepsis Screening Form

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 Fluid resuscitation
Patients with sepsis develop hypovolaemia
due to increased insensible losses caused
by tachypnoea, pyrexia and third spacing
and
Patients with hypovolaemia without shock
require fluid resuscitation

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 Antibiotic use in Sepsis

It has been demonstrated that there is a

7.6% increase in mortality for each hour
delay in the administration of appropriate
antibiotics in patients with severe sepsis
and septic shock (Kumar 2006).

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5 general principles when choosing
antibiotic therapy
1. Clinical assessment - what is the likely site of infection?
2. Is the infection community, healthcare or hospital-
acquired?
3. Has the patient been prescribed antibiotics in the recent
past? (including from other wards/GP/other hospitals).
4. Are there recent microbiology results available?
(including history of colonisation/infection with
antibiotic resistant organisms such as MRSA & ESBL E.
coli)
5. Have I consulted my local antibiotic prescribing
guidelines?

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When prescribing an antibiotic it is important
to document the:
1. Treatment indication
2. Drug name, dose, frequency and route
3. Treatment duration (or review date)

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 Using local antibiotic guidelines is superior
to physicians own choice of antibiotic.
Local antibiotic guidelines must be followed
to guide the best choice of empiric antibiotic
therapy. This is to ensure that the antibiotic
chosen is appropriate for the local
epidemiology. If you are in doubt, contact
your consultant clinical
microbiologist/infectious diseases specialist
for advice.

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 Measures for appropriate Antibiotic use in
Sepsis

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http://health.gov.ie/national-clinical-guideline-no-6-sepsis-management/
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 Questions
1) What does SIRS stand for?
a) Septic Inflammatory Response System
b) Systemic Inflammatory Response
System
c) Systematic Inflammatory Response
Syndrome

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 Questions
2) Aim to complete Sepsis Six within?
a) 1 hour
b) 12 hours
c) 6hrs

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 Questions
3) Commence Sepsis Screening Form
when:
a) The NEWS 4 (5 on supplementary O2)
and if infection is suspected
b) On every patient
c) The NEWS is 7

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 Questions
Sepsis is a consideration for patients
receiving anti-cancer treatment who
present as generally feeling unwell but
do not have the required 2 SIRS
criteria.
True or False.

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Calculating a National Early Warning
Score using the National Patient
Observation Chart
(for non-pregnant adult patients)

The National Patient Observation Chart

uses the Airway, Breathing, Circulation,
Disability, Exposure (ABCDE) assessment
approach

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Version 6
Front Page
of National
Patient
Observation
Chart

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Middle Section
of National
Patient
Observation
Chart

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Back Page
of National
Patient
Observation
Chart

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Respiratory section

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Blood Pressure section

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Heart Rate section

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Level of Consciousness section

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Temperature section

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Practice with NEWS & Obs chart

T - 370C, P - 65, RR - 22, SaO2 - 96%

BP 130/60 patient is alert.

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 Practice with NEWS
& Observation Chart

T - 370C, P - 65, RR - 22,

SaO2 - 96%, BP 130/60 patient is alert.

T - 380C , P - 86, RR - 30, SaO2 - 92%,

BP 110/60, patient is alert.

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 Practice with NEWS
& Observation chart
T 370C, P - 65, RR - 22, SaO2 96%,
BP 130/60, patient is alert.

T 380C, P - 86, RR - 30, SaO2 - 92%,

BP 110/60, patient is alert.

T 380C, P112, RR 32, SaO2 92%

BP 100/60, patient is alert.
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 Responsibilities
Notify the CNM/Nurse in Charge and/or medical
personnel as appropriate.
Increase observation frequency as identified in
escalation protocol.
Escalation protocol may be stepped down as appropriate
and documented in management plan.
If you are concerned about a patient escalate care
regardless of Early Warning Score.
If the response is not carried out as per escalation
protocol CNM / Nurse in Charge must contact the
Registrar or Consultant.

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 Responsibilities

Escort requirements out of the ward area

Consider expertise of personnel &
equipment required for safe transport

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 Questions

1. Who should be 2. What is the frequency

contacted when the of clinical observations
patient has a score of when a patient has a
8? NEWS of 5 ?
a) The Nurse in charge a) 12 hourly
and Registrar
b) hourly
b) The Nurse in charge
c) 1 hourly
c) The Nurse in charge
and SHO

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Communication, Management Plans &
Teamwork

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 Learning Objectives

To be able to communicate clearly and

concisely
To understand the use of ISBAR
To be able to understand the importance
of teamwork
To be able to participate in the
development of management plans

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 Management Plans

Gather information
Integrate into patients presentation what is
actually happening to this patient?
Communicate your concerns (ISBAR)
Address each team members concerns
Formulate, document and communicate the
management plan
Put it into action
Reassess

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 Gather Information

Verbal
Patients Notes - medical, nursing, therapy
professionals
Observation charts
Fluid charts
Medication charts
Compare current to previous

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Integrate into patients presentation
What is happening with the patient
Clinical Assessment
National Early Warning Score

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 Communicate Concerns

Use the ISBAR communication tool more

on this later

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 Adequate Response to
Concerns

Each team member has different priorities

Reflect if things could have been done
better
Have your concerns been addressed
adequately
Has other team members concerns been
addressed
Ask for HELP!!
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 Management plans

Observation orders
Nursing orders
Physiotherapy orders
Investigations/Interventions
Notification orders

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 Action the plan

Ensure everyone knows their role &

responsibilities
Ensure the plan has made a difference to
the patient
Dont pass the buck
You are accountable

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 Reassess

Always follow up to see if the patient is

improving
Applies to everyone student nurse, RGN,
CNM, Therapy Professionals, Intern, SHO,
Registrar and Consultant
If they are not improving, start again!!

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 Documenting

Helps the flow of information, shift to shift &

day to day
Medico legal requirement
Concrete plan, no assumption
Remember if you didnt write it you didnt do
it!
5 years from now is it enough for you to
justify your action
Approved abbreviations only
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 Documenting

H - History
E - Examination
I Impression/diagnosis
P Management Plan

Always document a provisional working

diagnosis

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Communication

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 Communication

Recognise there is a problem

Communicate to other team members
RGN, CNM/Nurse in charge, Therapy
Professionals, Intern, SHO, Registrar,
Consultant
Convey concerns to the next shift with
outstanding issues to ensure follow up
occurs

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 When Communicating

Who is the most appropriate person to

inform about deterioration
Communicate as much relevant
information as possible
Document the communication and what
actions have been taken

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 ISBAR
Acronym for Identify, Situation, Background, Assessment,
Recommendation

ISBAR is an easy to remember structured communication

tool that healthcare staff can use to frame conversations.
The tool promotes focused communication of important
information about a patient whose condition is
deteriorating requiring a clinician's advice and prompt
action.

It enables staff to clarify what information should be

communicated between members of the team
It can also help to promote teamwork and foster a culture
of patient safety
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 This is the
ISBAR

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 Why use ISBAR?
To reduce the barrier to effective communication
across different disciplines and levels of staff
ISBAR creates a shared mental model across all
patient handovers and situations requiring
escalation, or critical exchange of information
ISBAR is a memory prompt, easy to remember
and encourages prior preparation for
communication
ISBAR reduces the incidence of missed
communications
State the facts-Stop the waffle!
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Communication Exercise

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 ISBAR

Ann Smith is a 75 year old lady with a

history of IHD admitted with a fractured
neck of femur, 12 hours post operatively
she complains of chest pain and her O2
sats have fallen 88% on 2 L oxygen via
nasal prongs. She has a EWS of 6. You
are her nurse and are concerned that she
is acutely unwell and needs attention.

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 Take home message for
participants
Vital signs are vital
Understand why they have changed
Teamwork
Management plans
Communications: ISBAR
Ask for help
Documentation
You can make a difference to a patients
outcome
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 Case Studies

Think about why the observations have

changed (back to the CD again)
Remember the ISBAR communication
strategy
Use the flow chart
Work as a team!
Set your management plans

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 Airway & Breathing
Can the patient Look, listen & feel
maintain his/her own rate - volume &
airway? symmetry, work of
Is the airway open & breathing & pattern
clear High concentration O2
Remember (100%)
Head tilt/chin lift Monitor SpO2
Suction Call for HELP
Call for HELP
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 Circulation
Pulse rate/volume, rhythm/character
Skin colour & temperature
Capillary refill
Blood Pressure
Urine output
IV access
IV Fluids
Call for HELP
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 Disability/CNS
AVPU
Blood Glucose
Pupil reaction
Call for HELP

Environment/Examination
Temperature
Review charts, ECG
Interpret investigations & results
Call for HELP
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ABCDE Assessment
Remember assess and manage A before moving
to B etc.
Re-assess.re-assess..re-assess

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Case Studies

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