Early systemswarning and clinical monitoring
What is an early warning system
Early warning systems and clinical monitoring 2
What problem?
Lopez-Herce 2004, Nadkarni et al., 2006; Reis, Nadkarni et al., 2002, Suominen et al., 2000
Early warning systems and clinical monitoring
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• • • •
4 Early warning systems and clinical monitoring
What problem?
Preventable = 19
Potentially preventable = 44
Not preventable = 26
Total = 89
Early warning systems and clinical monitoring
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Efficacy of Rapid Response Teams
Low impact of rapid response teams (RRT) in the absence of criteria for their call (M.E.R.I.T. study)
Early warning systems and clinical monitoring
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Components of the Early Warning System
Early warning systems and clinical monitoring
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Monitoring of vital signs
Problems related to clinical monitoring before transfers to the PICU
• Inadequate observation and monitoring
• Inadequate recording
• Absence of a monitoring plan
• Reliance on equipment
• Lack of supervision over less experienced staff
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Early warning systems and clinical monitoring
Paediatric Early Warning Systems
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Early warning systems and clinical monitoring
Development of the Bedside PEWS
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Early warning systems and clinical monitoring • • • • •
Bedside PEWSystem
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Early warning systems and clinical monitoring
Bedside PEWSystem
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Early warning systems and clinical monitoring
Bedside PEWSystem
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Early warning systems and clinical monitoring
Bedside PEWSystem
14 •
Early warning systems and clinical monitoring
Bedside PEWSystem
Early warning systems and clinical monitoring
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Bedside PEWSystem
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Early warning systems and clinical monitoring
Bedside PEWSystem
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Early warning systems and clinical monitoring
Early warning systems and clinical monitoring 18
General information
< 3 m Newborn to less than 3 months
3 - 12 m 3 months and older but younger than 1st birthday
1 -< 5 yr 1 year and younger than 5th birthday
5 -< 12 yr 5th birthday and younger than 12th birthday
≥ 12 yr 12th birthday and older
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Early warning systems and clinical monitoring
Clinical assessment of the patient
Respiratory rate
Systolic blood pressure
Oxygen saturation
Oxygen therapy
Respiratory work
Capillary refilling
Early warning systems and clinical monitoring
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Indicator Score 0 - 26
Heart rate
Heart rate
warning systems and clinical monitoring
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• • •
Early
Heart rate
Early warning systems and clinical monitoring
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• • • •
Systolic blood pressure
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I Early
• • •
warning systems and clinical monitoring
Saturation
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Oxygen
25
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Oxygen therapy: special cases
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Respiratory work
27
I Early warning systems and clinical monitoring • • • •
Capillary refilling time
Early warning systems and clinical monitoring
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• • • •
29 • Recording Early warning systems and clinical monitoring •
30 • Recording Early warning systems and clinical monitoring • • •
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Early warning systems and clinical monitoring
Sub-score
How to calculate the BPEWS score
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I Early warning systems and clinical monitoring
Sub-scores straddling two colour areas
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Early warning systems and clinical monitoring
Recommendations in response to the score
Early warning systems and clinical monitoring
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Care recommendations
Early warning systems and clinical monitoring
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Recording of severity indicators
Early warning systems and clinical monitoring
36 • • • •
Nursing re-evaluation
37 • • •
Early warning systems and clinical monitoring
Medical evaluation
Early warning systems and clinical monitoring
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Resuscitation consultation
39 • •
Early warning systems and clinical monitoring
40 • • • Monitoring Early warning systems and clinical monitoring
Nurse-to-patient ratio
41 • • • • • •
Early warning systems and clinical monitoring
Initial vs. subsequent recommendations
Early warning systems and clinical monitoring
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The Bedside PEWS summarized
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Early warning systems and clinical monitoring
Why do we monitor?
44 • • • • •
Early warning systems and clinical monitoring
Why do we monitor?
45 • • • • • •
Early warning systems and clinical monitoring
Early warning systems and clinical monitoring
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Hospitalized children are not all the same…
How often to monitor?
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Early
systems and clinical
warning
monitoring
Clinical graphs
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Early warning systems and clinical monitoring • • •
49 Early warning systems and clinical monitoring
Monitoring criticalities
Early warning systems and clinical monitoring
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Risk perception
51 • • • •
Early warning systems and clinical monitoring
Unexpected outcomes
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Early warning systems and clinical monitoring
Preventable deaths = 19
Potentially preventable = 44 Not preventable = 26 Total = 89
Costs related to cardiac arrests
53 Early warning systems and clinical monitoring
Risk perception
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Early warning systems and clinical monitoring
Risk perception
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Early warning systems and clinical monitoring
Readmission to the ICU < 48 h
Risk perception
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Early warning systems and clinical monitoring Transfer to the subintensive care unit BedsidePEWS 4-4-7-7-6-7-7-9
Risk perception
BedsidePEWS 9-15-10-10
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Early warning systems and clinical monitoring
to the intensive care unit
Transfer
BedsidePEWS complex intervention
Human factors
58 • • • •
Early warning systems and clinical monitoring • • • •
Bedside PEWSystem
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Early warning systems and clinical monitoring
Goals of the BedsidePEWS
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Early warning systems and clinical monitoring • • • • •
Systematic review
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Early
and clinical
• • •
warning systems
monitoring
62 Early warning systems and clinical monitoring • •
EPOCH Project
63 Early warning systems and clinical monitoring • • • •
Bedside PEWS severity scores
warning systems and clinical monitoring
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• • • •
Early
Recommendations in response to the score
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Early warning systems and clinical monitoring
BedsidePEWS
Score Iniziali Risposta Successive 0-2 Routine Routine Routine Monitoring Nursing re-evaluation Medical evaluation Routine Routine Routine 3-4 2-4 hours < 8 hours < 8 hours Monitoring Nursing re-evaluation Medical evaluation 2-4 hours Every 8 hours Every 8 hours 5-6 1-2 hours < 4 hours < 4 hours To be assessed 1-2 Monitoring Nursing re-evaluation Medical evaluation Continuous monitoring (O2Sa) Similar patients managed by the nurse 1-2 hours < 8 hours < 8 hours To be assessed 1-2 7-8 15-60 min. < 2 hours < 2 hours To be assessed To be assessed 0-1 Monitoring Nursing re-evaluation Medical evaluation Continuous monitoring (ECG, O2Sa) Resuscitation consultation Similar patients managed by the nurse 15-60 min. < 4 hours < 4 hours To be reassessed To be reassessed 0-1 >8 15 minutes < 15 minutes < 15 minutes Continuous To be assessed None Monitoring Nursing re-evaluation Medical evaluation Continuous monitoring (ECG, O2Sa) Resuscitation consultation Similar patients managed by the nurse 15-60 min. < 2 hours < 2 hours Continuous To be reassessed None
Recommendations in response to the score
66
Early warning systems and clinical monitoring
in response to the score Score Iniziali Risposta Successive 0-2 Routine Routine Routine Monitoring Nursing re-evaluation Medical evaluation Routine Routine Routine 3-4 2-4 hours < 8 hours < 8 hours Monitoring Nursing re-evaluation Medical evaluation 2-4 hours Every 8 hours Every 8 hours 5-6 1-2 hours < 4 hours < 4 hours To be assessed 1-2 Monitoring Nursing re-evaluation Medical evaluation Continuous monitoring (O2Sa) Similar patients managed by the nurse 1-2 hours < 8 hours < 8 hours To be assessed 1-2 7-8 15-60 min. < 2 hours < 2 hours Valutare Valutare 0-1 Monitoring Nursing re-evaluation Medical evaluation Continuous monitoring (ECG, O2Sa) Resuscitation consultancy Similar patients managed by the nurse 15-60 min. < 4 hours < 4 hours To be reassessed To be reassessed 0-1 >8 15 minutes < 15 minutes < 15 minutes Continuous To be assessed None Monitoring Nursing re-evaluation Medical evaluation Continuous monitoring (ECG, O2Sa) Resuscitation consultancy Similar patients managed by the nurse 15-60 min. < 2 hours < 2 hours Continuous To be reassessed None • • • • •
Recommendations
Obstacles and critical issues in the OPBG
67 • • • • • • •
Early warning systems and clinical monitoring
Educational materials for the staff and multimedia resources on the intranet
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Early warning systems and clinical monitoring • • •
Efficacy of Rapid Response Teams
Low impact of rapid response teams (RRT) in the absence of criteria for their call (M.E.R.I.T. study)
Early warning systems and clinical monitoring
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70 Early warning systems and clinical monitoring
to the resuscitator and transfer to the ICU BedsidePEWS 1-2-8-5-9-8-8-6-6-9-10
to the on-duty doctor • • • •
Call
Call