Track and Trigger Scoring Systems

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Track and Trigger Scoring Systems

• Iain Thomson
• Team Leader
• NHS Greater Glasgow Clyde
• Critical Care Outreach/Shock Team Transfer Service

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How good are we at spotting a sick patient?
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Better Critical Care, Scottish Executive, 2000

• To develop a patient at risk philosophy
• To build on existing scoring systems to help in
  the identification of patients at risk of
  critical illness

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What the research suggests -

• ALS
• 80 show deterioration prior to arrest
• lt10 survive
• McQuillan et al
• 69 admission to critical care late
• 54 suboptimal care
• Up to 41 avoidable admission
• ICU admissions
• Apache II/Mortality

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Outcome of intensive care patients in a group of
British intensive care units, Goldhill, Sumner,
Crit Care Med, 1998 28(8) 1337-1345
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Are there problems?

• Major Concerns
• Lack of knowledge
• Failure to recognise urgency
• Lack of supervision
• Failure to seek advice
• Management of
• Airway, breathing, circulation monitoring
• Oxygen therapy

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Is there cause for concern?

• Failure to recognise signs symptoms of
  deterioration
• Delay in transfer of patients to ICU/HDU

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Early Recognition Is it possible?

• Much debate in recent years
• Early identification treatment will improve
  outcome
• Number of approaches introduced to achieve this
• Evidence seems to support strategies undertaken

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What should we look at?

• Respiratory Rate
• Pulse
• Blood Pressure
• Coma scale/AVPU
• Urine output
• Temperature
• Oxygen saturations
• Intuition
• Bloods
• MEWS

The most sensitive indicator is respiratory rate
but it is the least recorded observation.
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Assessment

• A Airway
• B Breathing
• C Cardiovascular
• D Disability
• E Exposure

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Response to patient developing critical illness

• Initiated by ward staff
• Ward areas able to manage Level 1 patients
• MEWS/SEWS
• Agreed calling criteria
• Identify management plan for patient

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What can you do?

• Lots!
• What is abnormal?
• How/when are observations recorded?

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Prevention is Better than Cure

• Aim to recognise the signs symptoms of the
  patient at risk of developing an acute illness
• Improve patient assessment
• Implement the appropriate intervention
• Assess effectiveness of intervention

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How do we communicate!?
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Monitoring Vital Signs

• Regarded as one of the more mundane tasks in
  nursing
• Routine observations often delegated to least
  experienced member of the team
• Ward based cardiac and respiratory arrest are
  often predictable events
• Often a period of deterioration during which the
  problem could be detected treated

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Vital Signs

• Unless all vital signs are accurately
  monitored, charted, and analysed for overall
  trends or patterns, you will not be alerted to
  a problem developing in time to prevent it

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Track Trigger Scoring Systems

• Simple bedside monitoring tool
• Easy to use and understand
• Establish calling criteria
• Assists in vocalisation
• Shows improvement as well as deterioration
• Facilitates early recognition and intervention
  for the deteriorating patient
• Not infallible

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Choice of Scoring Tool

• There are a number of scoring tools in use
• Some are more complex than others
• Aim for a system that is simple to implement,
  effective and not time consuming.
• A bedside tool to initiate a response
• MEWS/SEWS

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Ranking

• Respiratory Rate
• Heart Rate
• Blood Pressure
• GCS/AVPU
• Urine Output
• Temp
• O2 Saturation

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Medical Emergency Calling Criteria
  Huorihan et al (1995) The medical emergency
team a new strategy to identify and intervene in
high risk patients. Clinical Intensive Care 6
262-272
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Are Scoring Tools Effective?

• Little evidence relating to sensitivity,
  specificity and usefulness
• Anecdotal evidence that scoring tools assist in
  the recognition of deterioration
• Scoring tools are not an indicator of severity of
  illness
• Supported by staff at ward level

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Calling Criteria

• Clearly stated
• Clearly identify path to follow when patient
  triggers
• What medical team to contact
• Ensure that normal in hospital referral process
  is maintained
• Aim to improve communication between disciplines

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CALLING CRITERIA
 

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Score is 1-3 Increase frequency of patient
observations, monitor trends and inform nurse in
charge   Score is 3 in Contact senior nurse,
increase frequency of patient observations one
category   Score total is 4 And
above or Score increasing by 2 points or
more Contact senior nurse and increase
frequency of patient observations Or
Contacting Critical Care Outreach Team Patients
GCS falls By 2 or more Or Any patients
causing concern THE SENIOR NURSE WILL DIRECT
PATIENT CARE AND CONTACT THE APPROPRIATE MEDICAL
STAFF WHEN NECESSARY
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Who to score

• The following patients are considered to be
  at high risk of developing a critical illness
  therefore it would be considered good practice to
  commence MEWS at the earliest opportunity.
• All emergency admissions
• Unstable patients
• Patients whose condition is causing concern
• Patients requiring frequent or increasing
  frequency of observations
• Patients who have stepped down from a higher
  level of care
• Patients with chronic health problem
• Patients who are failing to progress
• Post operative patients
• This is not an exhaustive list. Although the
  majority of patients may benefit from utilisation
  of MEWS the nurses own clinical judgement
  dictates whether he or she feels the patient
  requires scoring. For guidance on the use of
  MEWS refer to the Nurse in Charge

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Who not to score

• There are also patients in whom the use of
  MEWS may be inappropriate.
• Day case patients?
• Patients requiring no observations
• Patients who are TLC
• Planned discharges?
• This is not an exhaustive list. Although the
  majority of patients may benefit from utilisation
  of MEWS the nurses own clinical judgement
  dictates whether he or she feels the patient
  requires scoring. For guidance on the use of
  MEWS refer to the Nurse in Charge

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Your part of a team!

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NMC Code of Conduct
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Any Questions?