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
12 • • • •
Early warning systems and clinical monitoring
Bedside PEWSystem
13 • • • • • • •
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
16 • •
Early warning systems and clinical monitoring
Bedside PEWSystem
17 • • • • •
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
23
I Early
• • •
warning systems and clinical monitoring
Saturation
24
Early warning systems and clinical monitoring • •
Oxygen
25
Early warning systems and clinical monitoring • •
Oxygen therapy: special cases
Early warning systems and clinical monitoring
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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
32
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
38 • •
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
43
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?
47
Early
systems and clinical
warning
monitoring
Clinical graphs
48
Early warning systems and clinical monitoring • • •
49 Early warning systems and clinical monitoring
Monitoring criticalities
Early warning systems and clinical monitoring
50 • • • • •
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
54
Early warning systems and clinical monitoring
Risk perception
55
Early warning systems and clinical monitoring
Readmission to the ICU < 48 h
Risk perception
56
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
57
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
60
Early warning systems and clinical monitoring • • • • •
Systematic review
61
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
65
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
68
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
69
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