Escalation Algorithm Don t Hesitate... Escalate! August 2013

Transcription

1 Escalation Algorithm August 2013 Staff or Parental Concern? Yes No Notify Charge RN Routine q 4 hr assessment Consider CAT activation Green Yellow Orange Red PEWS= 0-2 PEWS= 3 PEWS= 4 PEWS>/=5 Or score of 3 in any 1 category Continue q4 hour assessment Notify Charge Nurse to confirm PEWS Contact Resident/NP/PA and document notification Resident to contact fellow Reassess PEWS in 2 hours for score of 3 Consider CAT activation Attending Notification 1st line provider (Resident/NP/PA), in house Fellow, Primary RN and Charge RN to bedside (RT if respiratory patient) within 15 minutes Consider CAT activation Mandatory CAT activation Plus Orange Escalation Requirements No CAT Yes CAT Transfer to ICU? Yes No Proceed to: Yellow Escalation (PEWS= 0-3) Orange Escalation (PEWS=4 or 3 in one category) Red Escalation (PEWS>/=5) 12 hrs after ICU admission, acute care RN will evaluate transfer for: Late Rescue Criteria Intubated HFNC started Inotropes given CPAP/BPAP initiated >60 ml/kg fluid resuscitation Care resumed by primary team Q 1 hour PEWS until score =3 or less All PEWS >/= 4 must have a CAT note or Watcher note documenting: -Plan -Expected outcome -Outcome deadline -Escalation plan if outcome not met -PEWS threshold for mandatory CAT

2 Escalation Algorithm PROCEDURE TO MODIFY ESCALATION ALGITHM After consultation with CAT team, the patient s PEWS threshold for mandatory CAT activation can be modified. Documentation must include: 1. New PEWS threshold for mandatory CAT activation 2. Duration of new threshold 3. Specific parameters that necessitate a new CAT activation Consideration to return to the standard PEWS CAT activation threshold must occur daily, and documentation of any modified threshold must be repeated daily by the PRIMARY TEAM. No CAT is required at this time. Modification of mandatory PEWS CAT activation threshold for greater than >6 hours should be a rare occurrence. Initial modifications made to cardiac patients on HKU should include a discussion with the CICU team along with CAT team No changes to Yellow or Orange escalation are permitted without discussion with PERRC leadership (perrcinfo@childrensnational.org) For hospice patients with an active Allow Natural Death () order and agreement not to escalate to ICU settings in the setting of deterioration, nursing staff are not required to perform routine PEWS assessments. A note from either the Panda team or CAT team documenting the status along with communication with the primary team must be placed in Power Note, and then the PEWS orders can be discontinued. PHYSICIAN DOCUMENTATION EXPECTATIONS 1. Event Note To be documented by the LIP when called by bedside RN for a Yellow Zone Escalation. Should include detailed plan. 2. Watcher Note To be documented by primary team during a Orange Zone Escalation following evaluation. This note is similar to the CAT note and must include the following information Specific Plan (example administer 20 ml/kg of 0.9% NaCl and give acetaminophen) Expected Outcome (example Heart Rate drops by 30 points) Outcome Deadline (example 1 hour following fluid and antipyretic administration) Escalation Plan if outcome deadline not is not met (example notify LIP and call CAT) 3. CAT Note To be documented by the CAT team during Red Zone Escalation or any CAT activation. This note includes the required information above in the watcher note, plus If a change is made to the mandatory PEWS CAT activation threshold and duration of change Compliance with documentation will be monitored and expected to be 100% ACUTE CARE NURSING DOCUMENTATION EXPECTATIONS 1. iview Documenting a comment under the PEWS score 2. Physician Notification Note Following all Yellow escalations 3. Nursing Progress Note Following all Orange and Red escalations

3 PEWS Calculation Table Score Behavior Cardiovascular Respiratory Other Playing/Appropriate Sleep HR within Standardized Age- RR within Standardized Age- 0 pattern Baseline behavioral activity Pink and normal capillary refill No retractions or tracheal (1-2 seconds) tug Increased Sleepiness HR within Standardized RR >10 above Standardized Tracheostomy Present Age-Based Range Age- Pink and capillary refill delayed Mild increased respiratory 1 to 3 seconds effort (e.g. nasal flaring, accessory muscle use) Continuous Albuterol Nebs >12 hours after admission to acute care unit Irritable, difficult to console Tachycardia of >20 above Stan- RR >20 above Standardized Persistent vomiting dardized Age- Age- after surgery Increased baseline seizure 2 activity Capillary refill delayed to 4 seconds Moderate increased respiratory effort (e.g. retractions, tracheal tug) Pale >40% FiO 2 or >3 L/min NC Lethargic/confused Tachycardia of >30 above Stan- Severe increased respiratory dardized Age- effort (e.g. severe retractions 3 Reduced Response to Pain Capillary Refill delayed to 5 seconds or more and grunting) >50% FiO 2 or >4 L/min NC Mottled

4 PEWS Calculation Table Score Behavior Cardiovascular Respiratory Other Playing/Appropriate Sleep HR within Standardized Age- RR within Standardized Age- 0 pattern Baseline behavioral activity Pink and normal capillary refill No retractions or tracheal (1-2 seconds) tug Increased Sleepiness HR within Standardized RR >10 above Standardized Tracheostomy Present Age-Based Range Age- Pink and capillary refill delayed Mild increased respiratory 1 to 3 seconds effort (e.g. nasal flaring, accessory muscle use) Continuous Albuterol Nebs >12 hours after admission to acute care unit Irritable, difficult to console Tachycardia of >20 above Stan- RR >20 above Standardized Persistent vomiting dardized Age- Age- after surgery Increased baseline seizure 2 activity Capillary refill delayed to 4 seconds Moderate increased respiratory effort (e.g. retractions, tracheal tug) Pale >40% FiO 2 or >3 L/min NC Lethargic/confused Tachycardia of >30 above Stan- Severe increased respiratory dardized Age- effort (e.g. severe retractions 3 Reduced Response to Pain Capillary Refill delayed to 5 seconds or more and grunting) >50% FiO 2 or >4 L/min NC Mottled

5 Standardized Age-Based Vital Signs Age Pulse (bpm) Respirations (per minute) Newborn-5 months months months 1-2 years years years years >14 years and older