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Covid-19 HSE Clinical Guidance and Evidence

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Clinical Assessment Navigation

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Guidance on how to use NEWS chart for staff who are unfamiliar with it (CD19-029b / 22.12.21)


Introduction

This information is a brief overview for staff unfamiliar with the revised National Clinical Guideline No. 1. INEWS V2 (September 2020)  The NCEC National Clinical Guideline (NCG) No.1 NEWS was introduced into acute hospitals in 2013 • Since 2020 The revised guideline INEWS – (Irish National Early Warning System) V2 has been in place • INEWS is an adjunct to clinical judgement and is used to support the clinician in recognising and responding to the deteriorating patient; INEWS does not supersede clinical judgement

Mandatory Education for Healthcare Professionals (HCP) on INEWS
  • INEWS education is mandatory for all relevant HCPs
    Choose the relevant training module at HSELand.ie:
  • Irish National Early Warning System (INEWS) V2:Doctor Focus
  • Irish National Early Warning System (INEWS) V2:Nursing/HSCP Focus
  • HCPs should be familiar with their hospitals INEWS Escalation and Response Protocol
  • INEWS education is included in most clinical undergraduate programme
Irish Early Warning Systems (EWS): There are five EWS National Clinical Guidelines in Ireland

ews pictures

What is INEWS?

INEWS is an early warning system to assist staff to recognise and respond to clinical deterioration. Early recognition of deterioration can prevent:

  • Unanticipated cardiac arrest
  • Unplanned ICU admission/readmission
  • Delayed care resulting in prolonged length of stay, patient or family distress, or more complex interventions
  • Requirement for more complex interventions

 

What’s NEW in INEWS V2?
  • NEWS to INEWS
  • System versus Score
  • Emphasis on clinical judgement
  • Recognition of healthcare worker, patient and family concern as a key indicator of deterioration
  • Increased emphasis on changes in respiratory rate as a key early indicator of deterioration
  • New confusion’ a key early sign of deterioration… AVPU becomes ACVPU where ‘C’ = ‘new confusion/altered mental status/delirium’
  • Minimum 6 hourly observations x 24 hours following admission
  • Adjustments of INEWS parameters or score not permitted
  • Modified Escalation and Response Protocol (Consultant or Registrar)
  • Option for a short period of escalation deferral by an RGN
  • 3-tiered response model
  • Consultant champions with protected time
  • Closed loop governance
  • Safety huddles
  • Move towards digital INEWS
  • Revised INEWS patient observation chart

  • ‘Cues for Caution’ as prompts for staff to consider when monitoring patients


INEWS as a SYSTEM

Anticipate

  • Clinical judgement combined with
  • Situation awareness using ‘cues for caution’,
  • Staff, patient and/or family concern
  • Safety huddles to anticipate and manage potential for deterioration in hospitalised patients.
anticipate

Recognise:

  • Clinical judgment plus
  • Patient assessment
  • Supported by the bedside track-and-trigger tool; i.e. the INEWS patient observation chart

Escalate and Respond

  • INEWS Escalation and Response Protocol to
  • Guide decisions on escalation for nursing or medical review
  • Provision of a structured mechanism for a tiered clinical response  -
  • Bedside, urgent or  emergency response
  • A move towards an ANP-response service

Evaluate

  • INEWS V2 supports a closed loop governance system involving:
  • Bedside clinical evaluation of the effectiveness of treatment interventions
  • System-wide evaluation of the management of patient deterioration e.g. after-action review,
  • Cycles of audit and improvement
evaluate

Systems Approach to Patient Assessment

  • A systems approach to patient assessment helps ensure that you don’t miss any of the subtle changes associated with deterioration
  • INEWS V2 emphasises changes in respiratory rate and new confusion/altered mental status/delirium as key early signs of deterioration
system approach


Brief overview of physiological changes during deterioration

Respiratory Rate (RR):

  • Most neglected vital sign
  • Often estimated by clinicians rather than counted 
  • Any change may be an early sign of deterioration
  • Changes can be seen up to 24 hrs prior to cardiac arrest
  • During early stages of deterioration SpO2 may remain within normal range while RR may change
  • RR may be affected by:
    Some medications (e.g. opiates)
    Altered level of consciousness
hospital bed

Respiratory Rate monitoring

  • Two main determinants of blood oxygen (O2) Concentration are ventilation and perfusion
  • Ventilation is the air that reaches the alveoli
  • Perfusion is the blood that reaches the alveoli via the capillaries respiratory rate measures ventilation
  • Pulse oximetry measures oxygen saturation (SpO2)
monitor

Cardiovascular system:

  • Changes in heart rate (HR) can affect cardiac output
  • High HR and low BP may reflect inadequate O2 delivery to the tissues
cardio
  • ↓BP can reflect a decrease in cardiac output
  • Other signs include dizziness, syncope, nausea, chest pain and diaphoresis
BP image

Neurological System

neurological

Early indicators of deterioration include:

  • New confusion
  • Altered mental status (Subtle or obvious)
  • Delirium

What’s the patient’s baseline status?

  • Consult the patient’s family or friends

Consider causes including:

  • New environment 
  • Hypoxia
  • Hypo/hyperglycaemia
If altered mental status or level of consciousness is noted, measure Glasgow Coma Scale and check blood glucose finger test

Thermoregulation System

  • Both pyrexia and hypothermia are significant
  • Immunocompromised and older persons may not produce a fever
  • Patients with sepsis can present with any temperature
  • Caution if anti-pyretic medication is given as it can mask signs of infection

thermometre

Renal System

  • Decreasing urine output (<0.5mL/kg/hr) is a sign of deterioration
  • Monitor renal profile blood results
renal

Using the INEWS Patient Observation Chart

The INEWS Physiological

Observations are:

  • Respiratory rate
  • SpO2
  • FiO2 (Room air or supplemental O2)
  • Heart rate
  • Blood pressure
  • Neurological response (or ACVPU,
    • where C = new confusion)
  • Temperature

inews chart

The INEWS Scoring Key

INEWS allocates 0-3 points to measurements of each of the 7 physiological parameters.

A score of 0 represents least risk while a score of 3 represents highest risk

Recognising small changes

Documentation of observations over time demonstrates the patient’s individual baseline and trends, which assist in the recognition of the small changes that may signal early deterioration.

score chart

Observe the patient:

  • Introduce yourself
  • Situation awareness
  • Current concerns
  • Physiological observations
  • Background/reason for admission
  • Assessment of the patient
  • Is there a problem?
observation image

If yes, what IS the problem in your clinical judgement?

Recommendation for action – what, if any, escalation is needed?

new to inews image

Healthcare worker (HCW), Patient, Family or Carer Concern

inews chart2

Concern is not scored but triggers patient review by a nurse or escalation for medical review, regardless of a low or no INEWS score.  Insert ‘HCW’ or ‘H’, ‘P’ or ‘F’ as appropriate

If a HCW, patient, family or carer reports concern, a full assessment and a complete set of INEWS observations should be undertaken

Respiratory Rate (RR)

Changes in RR are the earliest sign of deterioration:

  1. Consider affect of patient position on respiration
  2. Count the RR for a full 60 seconds
  3. Assess work of breathing including use of accessory muscles
  4. Is the chest moving bilaterally?
  5. Look at trends in RR
  6. Know the patient’s baseline rate 

rrate image

what is a normal rate

Sp02

O2 saturation (SpO2) is recorded here

  1. SpO2 is the ‘5th vital sign’ and should be checked by trained staff using pulse oximetry
  2. In all breathless and acutely ill patients Increasing supplemental O2 to maintain targeted SpO2 indicates deterioration and should be escalated without delay
  3. INEWS parameters identify normal SpO2 as ≥96%
  4. Some patients with confirmed diagnosis of chronic respiratory conditions may have lower baseline SpO2 levels and a specific plan of care may be required
Sp02

periphal o2 saturation

Causes of inaccurate SpO2 readings

  • Poor peripheral circulation
  • Shivering or restlessness
  • Carbon monoxide/smoke inhalation
  • Nail varnish/synthetic nails
  • Anaemia
  • Inappropriately sized probes or dirty probe sensors
monitor

Room Air/Supplemental O2

  1. All deteriorating patients should receive supplemental oxygen
  2. INEWS assigns a score of ‘3’ to ‘any O2 ‘
  3. The mode of O2 delivery is documented
  4. When O2 is prescribed the target SpO2 should also be prescribed on the drug chart
room air chart

oxygen delivery devices chart

Measuring the heart rate

  1. Count for 60 seconds.
  2. Consider factors such as:
  • Rhythm
  • Volume
  • Pulse quality (irregular, bounding or weak)
  • Skin condition (dry, sweaty or clammy)
measuring heart rate

Bradycardia of ≤40 requires immediate medical review and more frequent monitoring. Patients being monitored electronically should have their HR checked manually on a regular basis to determine amplitude and volume (as well as rate and rhythm)

chart4 pulse
chart5

Recording Blood Pressure

  1. Establish baseline and identify trends over time.
  2. A normally hypertensive patient may be relatively hypotensive even if their SBP is within normal INEWS parameters
  3. If systolic BP is ≥ 200 mmHg, urgent medical review is needed
chart6
  • Patients having BP measured electronically should have BP checked manually on a regular basis
  • Refer to primary physician for guidance on response to lying and standing BP recordings
  • Following two failed attempts at electronic  BP measurement, a manual BP should be measured
  • Ensure correct cuff size
BP 2 image

chart7

acvpu

Disability (Neurological Response):

  1. ‘New’ confusion, altered mental status or delirium is a common finding in acute illness
  2. Hypoxia can cause confusion or depressed level  of consciousness
  3. Check blood glucose
  4. Think Sepsis
  • Use ACVPU scale to assess neurological response.
  • If ACVPU scores 3 complete the Glasgow Coma Scale
chart8

Recording Temperature:

INEWS temperature parameter ranges are as follows:

  • Normal range is 36.1°C - 38°C
  • Hypothermia: Core temperature of <35°C
  • Hyperthermia extends from low grade pyrexia (38.1°C) to hyperpyrexia (≥40°C)
chart10

exp chart

Urine Output:

  1. Small window of opportunity to recognise Acute Kidney Injury (AKI) to prevent acute renal failure
  2. Monitor fluid balance accurately

urine output

Calculating the INEWS Score:

review of parametres

  • Add the score for each of the seven INEWS parameters to obtain INEWS Score
  • Enter the patient’s INEWS score into the green ‘INEWS Score’ row
chart12
chart11

Single-score triggers:

Score of 3 in any single parameter or a score of 2 for heart rate ≤ 40 requires immediate escalation and increase in monitoring frequency

Reassess within (Mins/Hrs):

Frequency of patient monitoring is determined by:

  • Patient’s clinical condition
  • Clinical judgement
  • INEWS score
  • Document: When the next patient assessment is due
chart13

When to think Sepsis:

If infection is suspected, THINK SEPSIS and check for:

  1. Risk of neutropenia  OR
  2.  Clinically apparent new-onset organ  failure as a result of infection;  OR
  3. Systemic inflammatory response

( ≥2 SIRS  plus at least ≥1 co-morbidity)

sepsis3

sepsis1

sepsis2

escalate 2

combined sepsis form

INEWS Escalation and Response:
  • Calculate INEWS score and escalate care as per the INEWS Escalation and Response Protocol
  • Alert Nurse in Charge of any escalation or concern
patient observation chart

Summary:

  1. Healthcare worker/patient/family/carer concern is an important indicator of patient deterioration
  2. Early indicators of deterioration are changes in respiratory rate and new confusion/altered mental status/delirium
  3. An increasing requirement for supplemental oxygen to maintain target SpO2 levels is a clear sign of deterioration and requires immediate medical review
  4. There is a small window of opportunity to recognise Acute Kidney Injury (AKI) to prevent acute renal failure; monitor urine output accurately
  5. Accurate measurement and calculation of the INEWS score are critical to improving patient outcomes

Determinants for escalating care:

  • Clinical judgement
  • Healthcare worker, patient or family concern
  • Intuition/gut-feeling
  • INEWS score
  • Escalation and Response Protocol
INEWS Escalation & Response Protocol

escalation chart2

Cycle of Clinical Futility:

  • A ‘cycle of clinical futility’ is when a patient is deteriorating and they are reviewed on a number of occasions but despite the patient not responding to interventions they are not escalated for senior medical review i.e. a lot of activity with no improvement  - and even dis-improvement - in patient condition
  • Hierarchical culture in hospitals can lead to reluctance of junior staff to escalate upwards to senior colleagues
  • INEWS escalation and response protocol prompts escalation to Registrar or Consultant if patient does not respond to initial treatment

Recommendation 7: A patient’s INEWS score or the INEWS physiological parameter ranges must not be altered.

However, some patients’ lived baseline observations will fall outside INEWS normal parameter ranges.  To respond to these individuals’ care needs INEWS V2 introduces the Modified Escalation and Response Protocol for use by a Consultant or Registrar once a patient has been admitted for 24 hours or longer i.e. has established a baseline observations trend.

Modified INEWS Escalation and Response Protocol – minimum content:

  • Rationale for modification of escalation and response
  • Timeframe for review of patient and modified response protocol (minimum 24 hourly review)
  • Information about further action(s) and/or escalation. 
    (Note: For the majority of patients the standard Escalation and Response Protocol will be appropriate)

modified inews protocol


Use ‘ISBAR’ to communicate:
ISBAR = Identify, Situation, Background, Assessment and Recommendation
  • It provides a means of structured communication between healthcare professionals
  • Enables clarification of what should be communicated between team members
  • Promotes a shared language to improve patient safety
  • Here is an example of how you might use ISBAR.
isbar comunication tool

doctor at desk

  • A patient was admitted to the Medical ward 24 hours ago with a presenting complaint of breathlessness.
  • After measuring and recording observations, documenting them in the INEWS observation chart and repositioning the patient,  the nurse on duty,
  • Nurse Slattery noticed no improvement and calls the SHO on duty, Dr. Murphy.
Summary:
  • Patient acuity must be clearly stated at the outset of the ISBAR conversation.
  • Patient monitoring must continue during escalation and review.
  • If response to escalation is not timely escalate to a more senior clinician.
  • RGN may defer escalation for up to 30 minutes if immediate measures are likely to improve a patient’s condition.
  • Consultant or Registrar can document a Modified INEWS Escalation and Response Protocol for those small number of patients who’s lived physiological observations baseline fall outside of INEWS normal parameter ranges

Example of a Modified Escalation and Response Protocol

inews example of modified escalation and response

Which of these statements in relation to the modified INEWS Escalation and Response protocol are correct? inews questions
quesionmark
Summary:
  • INEWS is used to aid clinical judgement and clinical decision-making. If worried about a patient, escalate care regardless of the INEWS score
  • When escalating care, use the ISBAR tool.
  • Adhere to the INEWS Escalation & Response Protocol
  • A Registered General Nurse may defer escalation for a short period if immediate simple measures are likely to resolve patient symptoms
  • A Consultant or Registrar may decide to document a modified INEWS Escalation & Response Protocol 

patient image


Link to full PDF for Guidance on how to use NEWS chart for staff who are unfamiliar with it (CD19-029b / 22.12.21)

Health Library Ireland, Health Service Executive. Dr. Steevens' Hospital, Dublin 8. Tel: 01-6352555/8. Email: hli@hse.ie

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