Information
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Audit Title
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Prepared by
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Location
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Personnel
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Select date
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Have you carried out an initial National Early Warning Score (NEWS)?
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Complete a full Patient Assessment: Airway, Breathing, Circulation, Disability, Exposure
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NEWS Escalation Criteria
Frequency of Monitoring: Minimum 4 hourly
Clinical Response: RN must review patient, using ABCDE assessment and discuss with nurse in charge.
The Parent Team should be informed during their routine ward visit to establish a treatment plan. -
Notes of any recommendations or "over-the-phone instructions"
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NEWS Escalation Criteria
Frequency of Monitoring: Minimum of 1 hourly
Clinical Response: RN must review patient, using ABCDE assessment and must discuss with nurse in charge.
Nurse in charge to urgently inform the parent team, response time < 30 minutes -
Escalate to an appropriate senior clinician using SBAR.
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Notes of any recommendations or "over-the-phone instructions"
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NEWS Escalation Criteria
Frequency of Monitoring: Minimum of every 30 minutes
Clinical Response: RN must review patient, using ABCDE assessment and must discuss with nurse in charge.
Nurse in charge must immediately inform the parent team, response time < 15 minutes -
Escalate to an appropriate senior clinician using SBAR.
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Notes of any recommendations or "over-the-phone instructions"
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Are any of the below observations present?
- Temp <36 or >38
- HR >90
- RR >20/min or PaCO2 <32mmHg
- WCC <4 or >12, >10% immature forms
- Acutely altered mental state
- BM >7.7 in absence of Diabetes Mellitus
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Are there 2 or more?
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Act immediately if ANY ONE of the following are present:
- Systolic Blood Pressure <90mmHg (>40mmHg from baseline)
- Heart Rate >130bpm
- New need for O2 to maintain saturations >91%
- Respiratory Rate >25bpm
- Responds only to voice or pain or unresponsive
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Select date
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15l Oxygen via non-rebreathe mask
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Obtain venous access point (if none) and take BLOOD CULTURES
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Take venous blood gas (VBG) Note the LACTATE and HAEMOGLOBIN values from Venous/Arterial Blood Gas sample
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IV FLUIDS: Crystalloid 20-30mls/kg bolus
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Measure URINE output HOURLY via catheter or bottle
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Start ANTI-BIOTICS according to local guidelines
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Antimicrobial Guidelines App.
http://www.stgeorges.nhs.uk/mobile_apps/ -
Refer back to the Escalation Criteria according to the NEWS chart.
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Add signature
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Select date
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How would you rate the usefulness of this checklist?
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Any further information?
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Please sign as complete
