PAT I ENT MONI TORING
“The individual can only do their best job if we get everything right within the organisation. There are critical care outreach teams, hospital at night/out of hours teams, deteriorating patient teams, medical emergency teams and various other associated specialties, but what we actually need is for these teams to come together; to no longer work in silos. This will mean we get the early recognition and appropriate escalation required for these patients,” she commented.
She added that organisations need the relevant policies, guidelines and Standard Operating Procedures (SOPs) to support the appropriate escalation procedures, such as NEWS, PEWS (paediatric early warning score) and MEOWS (modified early obstetric warning score). However, she pointed out that there is only a national early warning score for adults. “We don’t have a national early warning score for paediatrics or maternal patients as yet, so there is still room for improvement. Currently, each hospital works on their own local or regional version. We need to ensure there is the appropriate number of staff in the bed space, but we also need to ensure they have the right tools, appropriate training, and the technology. We must address governance and issues with quality assurance, so there needs to be audit processes with an external auditor, such as CQC, to ensure each hospital is achieving the standard. “As well as having all of this in place, we need to have the ability to look into and learn from incidents when things go wrong. This requires an incident reporting system. We need to ensure that, when these incidents are looked into, the feedback reaches the shop floor. If the staff concerned don’t receive feedback, they will not learn from mistakes and practice will not improve,” she warned. Siân commented that technology cannot replace the human factor of having the nurse within the bedspace assessing the patient.
Karen Nagalingam previously highlighted the importance of carrying out an A-E assessment, but Siân added that it is crucial that this is undertaken appropriately – such as counting the respiratory rate for a full minute. “We don’t just look at the patient’s heart rate on screen but feel the patient’s pulse. You get so much more information when you are hands-on with the patient…you find out much more and can use your gut instinct. Technology is no substitute for parental concern that ‘this is not how my child is normally’. Healthcare professionals have this same concern. “We have all had that patient with unremarkable observations on paper, but they are not the same patient you were looking after 10 minutes ago – we have to have the ability to escalate that healthcare concern and use an appropriate communication tool, such as SBAR (Situation-Background-Assessment- Recommendation), so we can be that patient’s advocate,” she asserted. Sepsis is not just the responsibility of the person in the bedspace, the ward manager or the doctor – it is everyone’s responsibility, Siân pointed out. It is important to obtain the patient’s vital signs in a timely manner, but appropriate treatment plans are also vital. Siân explained that the ‘Sepsis Six’ needs to be carried out within the first 60 minutes. The Sepsis Six is the name given to a bundle of medical therapies designed to reduce mortality in patients with sepsis. Drawn from international guidelines that emerged from the Surviving Sepsis Campaign the Sepsis Six was developed by The UK Sepsis Trust. “To carry out the Sepsis Six in a timely
manner, we need early recognition of deterioration. If someone has a NEWS score of five or more, they need to be on hourly observations. As soon as they hit seven, they need to be on more frequent observations or continuous monitoring. We also need
to recognise that, for some patients, there needs to be an appropriate escalation plan, and this may include using documents such as ReSPECT (‘Recommended Summary Plan for Emergency Care and Treatment’) or a DNACPR (‘Do not attempt cardiopulmonary resuscitation’),” Siân explained, adding that hospitals must ensure that the end of life process is as dignified as possible. In summary, Siân highlighted the
importance of using more than technology; it is just as important to use ‘gut instinct’. Some patients will be at risk because they will compensate for longer or they will ‘hide’ their vital signs.
“Someone who is neutropenic, for example, may not trigger in the same way on a NEWS2 score. Also, paediatric patients may compensate for a long time before they decompensate. That is why it is so important to have the human element – the nurse in the bedspace – to know their patients, to perform that A-E assessment and be that patient’s advocate. It is important to recognise that not every deterioration is due to sepsis. But we need to stop deterioration for each sepsis patient, as much as we can, and get them to an appropriate place of care,” she concluded.
A patient’s experience: the importance of gut instinct Sepsis survivor, Laura Williams, explained how sepsis was a life-changing experience and how deterioration can happen very quickly. She highlighted the importance of following gut instinct.
Laura, a podiatrist from Sussex, had no idea that she was suffering from sepsis, when the condition first struck. She went to work as usual on the 3 February 2019 and travelled to a nursing home to treat patients, where she was given a hug by one of her regular clients. Laura later discovered that the patient was developing uncontrollable sickness and diarrhoea. Two days later she woke in the middle of the night with sickness and diarrhoea herself, which she feared might have been caught from the patient. She also had toothache. In fact, she wasn’t suffering from a sickness bug, but the first signs of sepsis from a bacterial infection underneath her tongue. On the 7 February, Laura knew she needed further medical advice. The onset of sepsis was having serious effects. In a harrowing account, she explained: “I went to the doctors; my blood pressure
wasn’t excessively low, and my temperature wasn’t excessively high. However, something wasn’t right. I was finding it difficult to breathe. I was actually at the point where I was shaking so much that I looked like I was having a fit and I had no neck [sic]. I was in a massive amount of pain and breathing really fast.
MARCH 2021
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