Policy No: OP76 - NHS Gateshead · Policy No: OP76 Version: 1.0 ... The combination of CCOT and...

Acute Response Team (ART),Operational Policy v1

Policy No: OP76 Version: 1.0

Name of Policy: Acute Response Team (ART) Operational Policy

Effective From: 13/06/2013

Date Ratified 03/05/2013 Ratified Resuscitation and Deteriorating Patient Committee Review Date 01/05/2015 Sponsor Director of Nursing, Midwifery and Quality Expiry Date 02/05/2016 Withdrawn Date

Acute Response Team (ART),Operational Policy v1 2

Version Control

Version Release Author/Reviewer Ratified

by/Authorised by

Date Changes (Please identify page

no.) 1.0

13/06/2013 Andy Rooks, Senior Charge Nurse

Resuscitation and

Deteriorating Patient

Committee

03/05/2013


Contents

Section Page 1 Introduction ...................................................................................................................... 5 2. Policy scope ....................................................................................................................... 6 3. Aim of policy ..................................................................................................................... 6 4 Duties (roles and responsibilities) ..................................................................................... 6 5 Definitions ......................................................................................................................... 6 6 Main Body of the policy/ Main Roles ................................................................................ 7 ART Nurse responsibility during the day .......................................................................... 7

ART Nurse with Site Responsibility Role ........................................................................... 7 6.1 Starting the Shift ................................................................................................... .7 6.2 Handover Process ................................................................................................. 7 6.3 Change Over .......................................................................................................... 8 6.4 Management of iBleep calls .................................................................................. 8 6.5 Bed Managers ……..…………………………………………………….. ...................................... 8 6.6 Day Site Responsibility………………………….……….……………… .................................... 8 6.7 Fire Responsibility ................................................................................................. 8 6.8 Change Over‐ Week Day……………………………………………... ..................................... 8 6.9 Change Over – Weekends…………………………………………… ...................................... 8 6.10 Escalation Plan………………………………………………………... ......................................... 8 6.11 iBleep Business Continuity .................................................................................... 9

ART Nurse with Nurse Practitioner Role.

6.12 Level 2 / 3 Follow Up………………………………………………….. ...................................... 9 6.13 Level 2 / 3 Concern…………………………………………………… ........................................ 9 6.14 Referral to ART………………………………………………………. ........................................... 9 6.15 Emergency referral / Change of EWS………………………………. ................................. 9 6.16 Acute Pain Management.…………………………………………….. ..................................... 10 6.17 Neck Breathing Patients……………………………………………… ...................................... 10 6.18 Central Venous Access Device (CVAD)…..………………………… ................................. 10 6.19 Patient with Chest Drains insitu ............................................................................ 10 6.20 Discharge Arrangements to Ward Care ................................................................ 10 6.21 Education / Training…………………………………………………... ...................................... 11 6.22 Storage of Records…………………………………………………….. ....................................... 11 6.23 Audit / Research………………………………………………………... ....................................... 11 6.24 Patient Group Directive………………………………………………… .................................... 11 6.25 Oncology / Haematology Out of Hours Assessment ............................................ 11


7. Training ............................................................................................................................. 11 7.1 iBleep..................................................................................................................... 11 7.2 ART Staff Training .................................................................................................. 11 7.3 CVAD Training ....................................................................................................... 12 7.4 Neck Breathing Patients Training .......................................................................... 12 7.5 Acute Pain Education…………………………………………………... ..................................... 12 7.6 Education in management of the Deteriorating Patient……………… ...................... 12 7.7 NEWS training ....................................................................................................... 12

8. Equality and diversity ........................................................................................................ 12 9. Monitoring compliance with the policy ............................................................................ 12 10. Consultation and review ................................................................................................... 13 11 Implementation of policy (including raising awareness) .................................................. 13 12 References and Bibliography ............................................................................................ 13 13 Associated documentation ............................................................................................... 13 Appendices Appendix 1 (Discharge from ART Guideline) ................................................................................ 14 Appendix 2 (ART Initial Assessment Guidelines) .......................................................................... 16 Appendix 3 (ART Daily Assessment Guidelines)............................................................................ 19 Appendix 4 (Pain Management Referral Pathway) ...................................................................... 21 Appendix 5 (Care Standard 1A Acute Pain) .................................................................................. 22 Appendix 6 (Care Standard 1B Chronic Pain) ................................................................................ 24


1 Introduction

This policy sets out the function, role and respomsibilities of the Acute Response Team (ART). ART is the joining together of two established teams the Emergency Ward Response Team (EWRT) and the Critical Care Outreach Team (CCOT) A brief understanding of the driving forces of the original teams is set out below: E.W.R.T The Emergency Ward Response Team (EWRT) were introduced after a period of audit that identified a multiprofessional team was the most appropriate way to address the management of the site and triage of the many non‐urgent calls at night using a centrally coordinated approach to delivering safe, high quality patient care whilst adhering to the Working Time Directive (2004). This model was extended so that the service provided cover throughout weekend and bank holiday day shifts. C.C.O.T The C.C.O.T service provided a specialist level of assessment and intervention within a ward or department setting. The identification of the critically ill or deteriorating patient was paramount to the success of C.C.O.T. A key part of this was the development and utilising of a track and trigger system, Intensive Care Society (I.C.S) (2002). The essential elements were that the approach enabled and supported ward based teams through education and training, guided support and intervention, Department of Health (D.O.H) (2000). ART The combination of CCOT and EWRT has formed the new ART The fundamental driving force and vision of each of the teams are now interwoven. The existing skills and knowledge base of each team is very important to the success of the team. The rationale for this amalgamation was to: • Streamline service provision. This has a benefit to patients and the trust as it will

allow care to be given in a safe, effective and timely manner. • Increase resources allowing for a flexible workforce that can change direction

depending on the needs of the service at the time. The site coordinator role may have to take priority over the clinical role for example.

• Improve the quality of ward based patient care using the, National Early Warning Score, (N.E.W.S) chart (Gateshead Health NHS Trust, RM Policy 64). The National Confidential Enquiry into Patient Outcomes and Death (N.C.E.P.O.D) (2012) identified the main reasons why patients died were delayed recognition coupled with inappropriate treatment.

• Continuie to provide clinical and managerial support to clinical staff within the trust. Emphasis on the need to ensure “out of hours” is especially well supported. W.T.D, (2004)

• Provide a comprehensive responsive service to meet clinical need and management of the hospital site at night


2 Policy scope

This policy will apply to all members of staff working within Gateshead NHS Foundation Trust at the Queen Elizabeth Hospital site who would utilise ART or work as part of ART

3 Aim of policy The aim of this policy is to give a clear understanding of the roles and responsibilities of ART personnel when attending patients who are clinically unwell or in the role as site coordinator. It also includes the knowledge, expertise and support they require and the expectations of the trust on the service.

4 Duties (Roles and responsibilities)

Trust Board is responsible for implementing a robust system of corporate governance across the organisation. The Chief Executive is ultimately responsible for ensuring effective corporate governance within the organisation and therefore supports the trust‐wide implementation of this policy. The Deputy Director of Nursing, Midwifery and Quality is responsible for ensuring that systems are in place to support implementation of this policy The ART are managed by Deputy Director of Nursing and Midwifery. The Resuscitation and Deteriorating Patient Committee oversee the programme of work for the ART The ART team are responsible for the local implementation of this policy and to ensure aherence. All staff within Gateshead NHS Foundation trust are responsible for ensuring the principles outlined in this policy are universally applied.

5 Definitions

ART: A team of experienced qualified nurses who undertake the roles of site coordinator,and nurse practioner. Two members of the team have the remit is to lead ART both clinically and on day to day management issues. Deputy Director of Nursing, Midwifery and Quality has overall managerial and strategic control of the team. Ibleep and PDA,s ART will be responsible for the ibleep system which is utilised by the trust to triage clinical jobs created by wards and departments. The triage system involves a RAG coded system


operated around clinical priority. The system operates from 22.00 untill 08.00 Monday to Thursday and for from Friday 22.00 untill Monday 08.00. Bank holidays also invoke 24 hour cover from ibleep. All calls will be assigned to the appropriate team member through the iBleep PDA’s. ART Site Nurse Responsibilty at Night ART will assume site responsibility from 18.45 untill 08.00 each day. Site Nurse Responsibilty at all other times Site responsibility is via a hospital wide rota system. ART Fire Nurse Responsibilty ART will have fire responsibility from 18.45 untill 08.00 Monday to Thursday and Friday 18.45 untill Monday 08.00. Fire Nurse Responsibilty at all other times Outside of ART hours for responsibility, fire responsibility is via a hospital wide rota system. Multi‐ Displinary Team (M.D.T) M.D.T is a group of health care professionals who are experts in planning and implementing treatment programs for complex medical conditions.

6 Main Roles To be read in conjuction with the standard operational procedure (SOP) for ART ART Nurse Responsibility During Weekdays Within normal working hours, the role of the team is to provide support to ward staff in the care of patients who have special requirements including patients with Central Venous Access Devices and patient who are neck breathers with either a tracheostomy or laryngectomy. Alongside this, the team review all patients who have been discharged from Critical Care. These patients are regularly assessed until the care that they require is at ward level only. Ward staff have the ability to refer patients to ART for assistance in the care of patients they are concerned about using the NEWS chart system. ART Nurse with Site Responsbilty Role 6.1 Starting the Shift

The Site Nurse Coordinator starts daily at 18.45 telephoning all wards and departments to identify:‐ Bed situation (from Bed Manager) Activity in Accident and Emergency Patients at risk Staffing issues Identify medical staff on duty and assign a PDA This is followed by visiting the clinical areas as appropriate.


6.2 Handover process Once the medical staff and other members of the ART are assigned their PDAs’ the handover will be led by the Site Nurse Co‐ordinator using the SBAR format. The SBAR tool is adopted Trust‐wide and provides a framework for communication between members of the multi‐disciplinary team about a patient’s condition S ‐ Situation (what is going on) B ‐ Background (brief pertinent history) A ‐ Assessment (what you think is happening) R ‐ Recommendation (what is needed including a timeframe)

6.3 Change over At 22:00 the hospital will transfer to the iBleep system which will channel all calls from the clinical areas to the Site Nurse Coordinator to manage the calls. For weekend cover the handover will start at 22:00 on the Friday evening and responsibility will remain with the ART until 08.00 on the following Monday morning.

6.4 Management of iBleep calls The Site Nurse Coordinator will manage the iBleep calls across the organisation. Calls are RAG rated according to clinical urgency and given to appropriately trained members of the M.D.T. All calls will be assigned to the appropriate team member through the iBleep PDA’s.

6.5 Bed Managers The evening handover to the ART from the bed manager should be completed by 19.00 and include a complete handover of the whole hospital bed situation and staffing. Any instruction from the senior team should be communicated effectively.

6.6 Day Site Responsibilty The Nurse holding site responsibility during the day (1200 Pager) is responsible for handing over the pager, and all associated relevant information to the ART Site Nurse at 18:45. The Nurse holding site responsibility will be given the 1200 Pager from the ART when they take over responsibility the next morning.

6.7 Fire responsibility The Nurse holding the fire bleep (1104) on weekend days will handover fire responsibility to the ART at 18.45 untill 08.00 weekdays. From 18.45 untill 08.00 on a weekend ART will have continued fire responsibility.

6.8 Change over – Week day At 08:00 the hospital will transfer back to the telephone pager system. The Site Nurse Coordinator for ART will forward an e‐mail night site report at the end of each night shift to the heads of service and senior managers. The report will provide detail of: • Hospital bed state • State of boarders


• 4‐Hourly targets • Clinical staffing issues

6.9 Change over – Weekends

From 07:30 the Site Nurse Coordinator and all of the ART will hand over(as in Section 6.6) to the next shift and forward a site report to the relevant parties . Clarification and identification of “remaining jobs” from the previous shift will be sought and dealt with as a priority

6.10 Escalation plan In times of increased activity the hospital may need to implement the Bed Management and Escalation Plan. The Night Site Co‐ordinator in conjunction with the medical registrar will make this decision and will inform the Senior Nurse on Call and the relevant consultant on call

6.11 iBleep Business Contuinity In the event the iBleep PDA’s fail, or the iBleep system is inaccessible, the ART will revert back to the use of pagers operated through the hospital switchboard.

ART Nurse with Nurse Practioner Role definition 6.12 Level 2 / 3 Follow Up

The ART will collect details of patients who have been transferred out of level 2/3 care using Ward Watcher system. ART will follow up all the identified patients on the general wards. During this visit the ART member will introduce themselves to either the nurse in charge of the ward or the nurse responsible for that patient. Any concerns that the nurse / doctor on the ward have can be highlighted. The ART member will then review the patient’s current state using a system based approach and assess how often visits are required (if any) or if further intervention by ART are required. A patient should have a full systems review utilising the guidelines in appendix two within 24 hours of discharge from level 2 / 3. Following review ART may recommend further investigations / actions. ART will implement actions / investigation within the scope of their role or liase with appropriate MDT. This information will be documented in the patient’s medical notes,utilising the guidelines of the ART paperwork (appendix 2 and 3) and verbally communicated in all cases back to the ward nurse and medical staff if available using SBAR.

6.13 Level 2 / 3 Concern If, following assessment the ART member is concerned for the safety of a patient within a ward area he / she will discuss this with the medical staff responsible for the patient care. If there is a delay between concern being expressed and appropriate review and the ART member has immediate concerns for the safety of the patient they will contact the anaesthetist for critical care directly. Every effort will be made to ensure the patient’s team is involved throughout.

6.14 Referral to ART Patients in most areas throughout the Trust are monitored using the NEWS chart. Monitoring on the NEWS chart does not automatically warrant ART referral.


The NEWS chart will have specific trigger points and a flowchart for guidance on referral to the ART team. The ART team accept referrals from all members of the multi dispilinary team. These referrals can be for changing NEWS , acute pain, clinical concern, neck breathing patients, chest drains and patients with a central venous access device (CVAD).

6.15 Emergency Referral / Change of EWS / Transfer –

If a patient has triggered on the NEWS, has been assessed by the nursing team and or medical team and there is still concern about the patient, then referral to ART is appropriate. The ART member will complete a patient assessment (appendix 2 guideline). Following review ART may recommend further investigations / actions and will implement actions / investigation within the scope of their role or communicate with appropriate MDT for timely follow up. This information will be documented in the patient’s medical notes,utilising the guidelines of the ART paperwork (appendix 2 and 3) and verbally communicated in all cases back to the ward nurse and medical staff if available using SBAR. It may be that they feel an immediate anaesthetic referral to be appropriate. This referral shall remain the responsibility of the home team however the ART can contact the anaesthetist direct if patient safety is an immeditate issue. If transfer of a patient to level 2/3 from a general ward is necessary ART will assist if required or requested to do so by the anaesthetist or home team. They will liaise with the shift coordinator / nurse in charge of Critical Care regarding the pending transfer. They will ensure that appropriate monitoring equipment is available to safely transfer the patient and will assist in the transfer providing support to the ward nurse as appropriate. The ward nurse is expected to transfer the patient in order for a detailed handover of the patient to be given to the receiving nurse in the Critical Care Department. ART will not normally be responsible for transfer from the hospital to another hospital, look after ventilated patients longer than for a straight forward transfer or for transfer for investigative procedures within the hospital. This must always be balanced against the ART overall hospital responsibility especially in times of escalation.

6.16 Acute Pain Management The ART will deliver a basic level acute pain service within the Trust. Utilising the World Health Organisation Analgesic Ladder (1996). All ART members will receive appropriate education and training from sessions from the Pain Specialist Nurse on an ongoing bases. The Critical Care consultant would be the default if the Pain Specialist Nurse is not available. ART will not see pediatric, pregnant or breast feeding patients under any circumstances but will signpost to other advice available. The Pain Management Referral Pathway gives guidelines on management of acute and chronic pain pathways (appendix 4). Care Standard 1A Acute Pain should be utilised (appendix 5). The Care Standard 2A Chronic Pain (appendix 6) gives a working definition of chronic pain that may help with the correct pathway for a patients pain referral when it states.


. 6.17 Neck Breathing Patients.

The Policy for the management of adult patients with a tracheostomy or laryngectomy (draft form awaiting number) and Care Standard number (draft form awaiting number) specifically state that ART should be informed of any neck breathing patients within the trust, not in the Critical Care Department. These patients must be in a designated places of safety as highlighted in the tracheostomy or larngectomy policy.These patients will be reviewed at least once a day by ART. The overall responsibility of the management of these patient remains with the home team with ART offering survillence and specialist advice.

6.18 Central Venous Access Device (CVAD)

In conjuction with infection control the ART team will offer daily survillence and advice around the management of CVAD outside of the Critical Care Department. The ART will utilse OP41 Central Line Policy and ensure that care standards 25 A and 24 B are fully implemented for all patients. Patients with a CVAD will be seen at least once a day by the team. ART will lead education of these lines for the trust with support from the M.D.T.

6.19 Patient with Chest drains insitu. ART should be informed of any patients with Chest Drains insitu who are not in the Critical Care Department or ward 4 within the trust. ART will review these patients at least once a day and act as clinical educational resource. The overall responsibility of the management of these patient remains with the home team.

6.20 Discharge Arrangements to Ward Care Following assessment the ART will discharge the patient from ART following the guidelines for discharge (appendix 1). As the guideline states this has to be completed on an individual patient basis and ensure patient safety is paramount. The ART nurse will ensure that the nursing staff and home team are aware that ART have stopped seeing the patient routinely. This will be recorded in the hospital medical records. It is important to note that the patient has always been the responsibility of the home team and even if discharged ART will become involved again if re referred. .

6.21 Education/Training The ART will provide education and training on both a formal and informal basis. Patient safety will always be a priority. Any of the ward staff can approach the ART regarding any training they require and the ART will work collaboratively with the ward managers and educational links to identify training needs. The topics for training/education will therefore be ascertained by trust wide priorities, general observation, communication between ward areas and the ART and, as a result of any audits that have taken place. The ART are also expected to support the delivery of the AIM course along with other multi professional colleagues throughout the Trust.


6.22 Storage of Records

ART staff write their advice and treatment suggestions direct into the patient health record. For the purposes of audit and recording ART activity the team will obtain data from a handover sheet. This data will be entered onto the Ward Watcher ART database and then the paper documentation shredded the same day.

6.23 Audit / Research The ART will be responsible for the continuous audit and evaluation of the Service which will include regional audits. Audits will be agreed by and presented to the Resuscitation and Deteriorating Patient Committee.

6.24 Patient Group Directives The ART will utilise appropriate Patient Group Directives that are suitable for the requirements of the deteriorating patients and general out of hours work.

6.25 Oncology / Haematology Out of Hours Assessment. The ART will be responsible for the telephone assessment of oncology and haematology patients out of hours utilising the Oncology / haematology 24 hour triage rapid assessment and access tool kit. This will be via a dedicated phone that will be handed over to the team. There is always help and advice available from on call senior doctors for the ART via a roster system. The ART will respond to all telephone enquires within one hour. In exceptional circumstances when this is not possible the default position will be to ask the patient to attend casualty for an assessment. In office hours the Oncology specialist practitioner will follow up all patient that the team have communicated with.

7 Training

7.1 Ibleep Ongoing training is offered as requested basis due to the simplicity of the system. Any training needs should initially be directed towards ART who will address the issue. Medical staff inductions include training in the iBleep system and clinical ward areas cascade the system to members of staff who are unfamiliar with it.

7.2 ART Staff Training A competency based induction booklet will be available for existing staff and new staff to ART. This will involve all the main roles in this policy. As part of the continued development of ART staff the following courses are critical to the role: The Clinical Skills Course or History Taking Course The Foundations of Critical Care The A.L.E.R.T course The trust transfer course. Acute Pain regular teaching sessions. Deteriorating Patient Course Other courses of value: Regional Critical Care Outreach Course C.O.R.C


BSc Critical Care Degree

7.3 CVAD Training Lead CVAD competency based training for medical and nursing staff within the trust working closely with collegues from infection control and chemotherapy.

7.4 Neck Breathing Patients Training Support a competency based assessment for medical and nursing staff within the trust.

7.5 Acute Pain Education Support nursing and medical staff on the wards in education around basic acute pain management both formally and informally.

7.6 Education in Management of the Deteriorating Patient Support the trust transfer course and AIM course. As well as other opportunities both formal and informal to discuss patient management.

7.7 NEWS training Support the M.D.T on the wards in education around track and trigger clinical management of patients both formally and informally.

8 Equality and diversity The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.

9 Monitoring compliance with the policy

Standard/process/issue Monitoring and audit Method By Committee Frequency ART Policy

National Outreach Forum. Operational Standards and Competencies for Critical Care Outreach Services.

Clinical Lead

Resuscitation & Deteriorating Patient Committee

Yearly

10 Consultation and review

This policy has been circulated to members of Resuscitation and Deteriorating Patient / Divisional Managers/ Assistant Divisional Managers, Modern Matrons/ Consultants.


11 Implementation of policy (including raising awareness) This policy has been compiled in compliance with OP27 – Policy for the development, management and authorisation of policies and procedures.

12 References and Bibliography

Department of Health, (2000). Comprehensive Critical Care; a Review of Adult Critical Care Services. Department of Health. London. Department of Health, (2005). Quality Critical Care Beyond Comprehensive Critical care. A Reort by the Critical Care Stakeholder Forum. Department of Health. London. Intensive Care Society, (2002). Guidelines for the Introduction of Outreach Services. I.C.S. London National Confidential Enquiry into Patient Outcomes and Death, (2011). Time to Intervene? A Review of Patients who Underwent Cardiopulmonary Resuscitation as a Result of an in‐hospital cardiorespiratory Arrest? A Report of the National Confidential Enquiry Into Patient Outcomes and Death. N.C.E.P.O.D. London. National Outreach Forum (2012). Operational Standards and Competencies for critical care Outreach services. Intensive Care Society National Patient Safety Agency (2005). Patient safety information 02. Protecting patients who are neck breathers. National Tracheostomy Safety Project (NTSP) 2010 St George’s Healthcare NHS Trust – Tracheostomy guidelines World Health Organization (1996).Cancer Pain Relief. With a Guide to Opioid Availability (2nd Edition) Geneva WHO.

13 Associated documentation;

Discharge from ART Guidelines ART Initial Assessment Document ART Daily Assessment Document Draft Pain Management Pathway Care standard 1A Acute Pain Care Standard 1B Chronic Pain Operation Policy OP41 Central line policy Care Standard 25 A CVAD Care Standard 25 B CVAD Operation Policy OP? Policy for the management of adult patients with a tracheostomy or laryngectomy. Oncology / Haematology 24 Hour Rapid Assessment and Access Tool Box


Appendix 1 Discharge from ART Guidelines ART by its very nature is involved with a broad spectrum of adults within the trust. These individuals can have numerous pre existing co morbidities that may or may not be affecting their current health issues. The decision around discharge needs to be how the individual is coping with the disease process other than being disease based. This guideline is meant as an aid memoir to ensure that the ART practitioner decision making is a reasoned one. However each patient circumstance for discharge from ART will be individual. Some basic physiological issues to consider on assessment

Consider Discharge Consider Not Discharging Airway Airway patent

Airway Airway not patent If patient has tracheostomy other adjunct etc

Breathing O2 requirements reducing and saturations stable. Respiratory rate within normal range.

O2 requirements increasing. Respiratory rate above/ below their normal

Circulation Blood pressure, pulse, CRT, JVP and temperature within limits. Or plan in place to safely rectify. (Consider medication and disease process within assessment).

Blood pressure, pulse, CRT, JVP and temperature not within limits.

Disability G.C.S 15/15 or G.C.S 14/15 (due to mild confusion). Below this level would require a conversation with home team unless patient normal. A fluctuating G.C.S should never be discharged. Normal blood glucose range using a recognised regime.

A new G.C.S less than 9/15 should never be discharged. Without specific advice. Abnormal blood glucose.

Drains Minimal or significantly decreasing drainage.

Chest drains do not discharge. Frank blood and puss would probably indicate patient should be kept .

Drugs / Treatment On treatment / drugs that the ward staff is used too without any issues.

Requiring specific treatment that staff may require help and advice with e.g. epidural infusion.

Definitive Treatment Patient has already received or does not require definitive treatment.

Patient requires definitive treatment in the near future.

Exposure No concerns on survey or a robust plan in place by home team

Concerns found on examination that do not have a plan in place.


Consider Discharge Consider Not Discharging Environment Place of safety (C.C.D, resuscitation room A and E and theatre). Patient in correct environment for their condition and patient level of care appropriate to environment.

Patient not in a safe environment due to level of care required or nursing staff not used to this disease type. Weekend / out of hours may make you consider keeping longer?

Pain Patient is able to deep breath and cough.

Patient is unable to deep breath and cough.

Other questions to consider prior to discharging a patient from ART are Have the instructions from medical and nursing staff from Critical Care department, if any, been fulfilled? Has the information / support required from the original referral been met? The patients nursing team must be aware and be involved with the discharge decision (consider also speaking with home medical team)? Does the patient (and family in some cases) understand that ART is handing over care to the ward? Has the patients normal co morbidities been taken into account? Has the patient’s normal background pain score been taken into account? Is continued ART support going to make a difference to patient outcome? Is there a need to individualise track and trigger in order to reduce overall N.E.W.S score? Is there an opportunity to influence practice / teach staff by keeping patient? Liverpool Care Pathway would normally indicate a discharge however again look at the patient as an individual and ask the questions above? Andrew Rooks (2013) Version 1.


Appendix 2

Acute Response Team (ART) Initial Assessment Guidelines Patient Name Date of Birth Hospital Number Situation Referred to ART by Reason for Referral Diagnosis (or Provisional Diagnosis) Background History of Presenting Complaint Relevant Past Medical History Current Medication Allergies Social History Smoking Alcohol Other Normal Functional State Assessment General Respiratory Patent / protected airway? Yes No Flo2 Position / distress Respiratory Rate Sputum Cough


Inspection Palpation Percussion Auscultation Chest X‐ray (if appropriate) Arterial blood gas (if appropriate) Cardiovascular Heart Sounds Pulse (rate, rhythm, character and volume) Blood Pressure (also trend) J.V.P C.R.T Oedema (what level) Claudication Other significant findings E.C.G (if appropriate) CVAD Type Day Sutures Central nervous system G.C.S (or A.V.P.U) Pupils Pain (type and location). Blood Sugar (if appropriate) Reflexes (if appropriate) C.T (if appropriate) Renal Urine output (trend and colour). Consider Catheter? Gastro intestinal Oral intake / IVT Nutritional state (plan) Drains / N.G.T Vomiting / loose stools


Inspection Auscultation Palpation Percussion Abnormal Bloods Recommendations ART will review this patient at ART will review the patient earlier if you are a concerned or if the following physiological parameters change Bleep 2698 Andrew Rooks (2013) Version 1.


Appendix 3

Daily Review Guidelines Patient demographics Situation Patient’s condition Background Changes since last visit Assessment Respiratory Flo2 (requirements increasing?) Position / distress Respiratory Rate Sputum Cough

Cardiovascular CVAD (type) Sutures Day Pulse (rate, rhythm, character and volume) Blood Pressure (also trend) J.V.P C.R.T Oedema (what level) Other significant findings Central nervous system G.C.S (or A.V.P.U) Pupils Pain (type and location). Blood Sugar (if appropriate) Renal Urine output (trend and colour). Gastro intestinal Oral intake / IVT Nutritional state (plan) Drains / N.G.T Vomiting / loose stools


Abnormal bloods Recommendations ART will review this patient at ART will review the patient earlier if you are a concerned or if the following physiological parameters change Bleep 2698 Andrew Rooks (2013) Version 1.


Appendix 4

Pain Management Referral Pathway

Acute and chronic pain (Non malignant)

Patient must be discussed with medical/ surgical team regarding their

acute and chronic pain management. Acute pain Refer to the acute pain care standard Patients to be reviewed by senior medical team members If a patient has not responded to pain management guidelines as detailed on the back of the EWS chart then please seek review from ward medical team. Advice can be sought from the Acute Response Team (ART). Postoperative patients with uncontrolled acute pain can also be discussed ART team and with their Anaesthetist. Advice can also be sought from the ward pharmacist.

• ART bleep 2698 Chronic pain Refer to the chronic pain care standard. Patients to be reviewed by senior medical team members Patients can be referred to chronic pain out patient service. Please note – there is no in‐patient chronic pain service, however patients can be referred to the chronic pain out patient service, via Anaesthetic Department for an outpatient appointment. Advice can also be sought from the ward pharmacist.

• Anaesthetic Dept Ext: 2645 • Anaesthetic Dept Fax number: 2827


Appendix 5

Care Standard 1A Acute Pain Definition Pain is not a simple sensation but a complex phenomenon having both a physical and an affective (emotional) component. It is defined by the International Association for the Study of Pain (IASP) as ‘an unpleasant sensory & emotional experience associated with actual or potential tissue damage, or described in terms of such damage’ (Merskey 1979). Because pain is subjective the favoured definition for use in clinical practice is: ‘Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does’ (McCaffery 1968) 1. Good analgesia improves a patient’s recovery; try to prevent pain rather than allowing it

to become established. Act in a timely way to alleviate pain by administering prescribed analgesia regularly and monitoring / recording its effect’s.

2. The pain measurement tool chosen, should be appropriate to the individual patient; development, cognitive, emotional & cultural factors should be considered. The patient should be observed for non‐verbal as well as verbal cues of pain.

3. Assessment during the acute admission phase or during the pre‐assessment process is a priority. Pain is an individual, multifactorial experience influenced by culture, previous pain events, beliefs, mood and ability to cope.

4. Consistent use of the EWS chart to monitor levels of pain and the effectiveness of analgesia. Pain should be assessed and recorded as the 5th Vital Sign.

5. Develop good communication and a trusting relationship between the nurse and the patient.

6. Ensure that the patient is in a comfortable position in their bed/chair. The use of a change in position can alleviate some of the pain.

7. Monitor and record the effectiveness of the analgesia given, adjust the medication according to the effect, as well as according to the ‘analgesic ladder’. Combinations of analgesic agents are often the most effective.

8. The nurse should have a good understanding of analgesic agents, their actions, side effects, routes of administration and alternatives.

9. Liaise with the Multi disciplinary team to ensure the appropriate analgesia is prescribed. Gaining advice from the Acute Pain Clinical Nurse specialist, Critical Care Outreach team, Chronic Pain team, Palliative care and the Pharmacy team if needed.

10. The use of alternative non invasive techniques such as relaxation, gentle humour, distraction, music, heat and/or cold therapies, exercise, rest & TENS can sometimes be helpful in managing the patient’s experience.

11. Ensure that the patient’s privacy and dignity is maintained throughout their hospital stay. 12. Ensure infection control standards are adhered to at all times, especially before and after

any patient contact. 13. Involve the patient and their relatives/carers in the decision making process around their

care needs. 14. Ensure that the patient is aware of their condition/disease process in order to promote

independence and self management. 15. Ensure you have considered making reasonable adjustments to help meet the needs of

patients with disabilities.


References: ANZCA (2005) Acute Pain Management: Scientific Evidence (2nd Edition). Melbourne The Royal Marsden Manual of Nursing Procedures (2004) Acute Post Operative Pain Management‐Trust Documents‐Departmental documents‐Anaesthetics, Critical Care and Pain Management.


Appendix 6

Care Standard 1B Chronic Pain Introduction: Pain is defined as an unpleasant sensory/emotional experience associated with actual/potential tissue damage. Chronic pain was originally defined as pain lasting 6 months or longer. It is now defined as pain that persists longer than the course of natural healing associated with a particular type of injury/disease process. This can have significant impact on a person’s/families physical, psychological & social well‐being. A significant proportion of the population suffer from chronic pain due to a wide range of conditions. Common conditions are low back pain, headache, arthritis, peripheral/diabetic neuropathy, traumatic nerve damage, pain syndromes, post‐procedural/post‐operative pain, phantom pain, vascular pain, post stroke, post hepatic neuralgia, chronic abdominal pain, fibromyalgia, myalgic encephalomyelitis (ME) and multiple sclerosis (MS).

==================================

1. Ensure that the patients privacy and dignity is maintained throughout their hospital stay, especially when undertaking assessment of the patients’ pain. Family/friends to be involved if the patient requests this.

2. Assessment of patients with chronic pain should include; pain history, physical, psychological, social impact of pain on quality of life, initial pain assessment should include; description, sites affected, duration, pattern, pain scores at rest & on movement (0‐10), etc.

3. Ensure that infection control standards are adhered to at all times, especially before and after patient contact.

4. A full medication history should be recorded. Ensure that the patient has all of their usual medication prescribed and given at the correct times.

5. Safe prescribing and administration of patients’ regular pain medication. Liaise with the patient/GP to ensure that the correct medication/doses are given on arrival to the ward/dept.

6. Patients with chronic pain often present with complex multidimensional problems that need multidisciplinary management. Effective management of long term pain requires coordinated efforts of the multidisciplinary team with timely referral to specialists.

7. Following assessment ensure that the patient is referred to all appropriate multidisciplinary team members e.g., Physiotherapist, Occupational Therapist, Ward Pharmacist, Pain service. An individual multidisciplinary treatment plan should be put in place following assessment & may include formal psychological support.

8. Has the patient been under the care of the chronic pain clinic? If so, ensure the team are notified via the main ext number for the service Ext 2645 or by fax ext 2827. Contact with the team should be before, during & after discharge.

9. Educate and support the patient/family about their condition, treatment and medication. Ensure that medication is used in a safe & effective way and that the patient understands the rationale behind the treatment to aid compliance.

10. Involve the patient /relatives/carers in the decision making process around their care needs using supportive non‐judgemental approach.

11. Information to patients/families/carers should be provided both verbally and in writing. Patients should receive timely advice & support.


12. Realistic expectations in some cases, pain may not always be resolved by available clinical/medical/physical therapies. Ensure that patients are aware of their condition/disease process to promote independence/self management.

13. Consider non‐pharmacological pain relief i.e. TENS, relaxation, complimentary therapies if appropriate/accessible e.g. Acupuncture.

14. Ensure you have considered making reasonable adjustments to meet the needs of chronic pain in patients with disabilities.

15. Nursing, medical staff and other allied health care professionals should have an awareness of chronic pain management and should seek advice from specialist pain teams if advice and support is required.

16. There should be regular evaluation of patients’ pain, outcomes of treatment, medication & care, complications/side effects of treatment.

17. Include key multi disciplinary teams before discharge to ensure seamless care when returning back to the community. On discharge, liaise with GP and relevant community teams.

Policy No: OP76 - NHS Gateshead · Policy No: OP76 Version: 1.0 ... The combination of CCOT and...

Documents

Transcript of Policy No: OP76 - NHS Gateshead · Policy No: OP76 Version: 1.0 ... The combination of CCOT and...