Background On admission to St Gemma’s Hospice (SGH), patient escalation status is determined, guiding decisions when acute deterioration occurs. In August 2018, a modified early warning score (EWS) was implemented to aid identification of deterioration in those appropriate for medical intervention. Similar hospice protocols were reviewed and adapted. Admission baseline EWS and planned observation frequency is recorded, with emphasis on deviation from baseline triggering medical assessment.
Methods Retrospective analysis of patient notes admitted to SGH during August 2018 (n=39). Parameters recorded included: escalation status, planned observation frequency and adherence, baseline admission EWS documentation, EWS deviations prompting medical assessment and any resulting changes to patient management. The audit will continue incorporating September and October.
Results 23 patients (59%) were for best supportive care only. Of the remainder (n=16), 89% had baseline admission EWS documented. Observations were recorded as required in 63% cases (n=10) and once daily in 37% (n=6). All were compliant to planned frequency. EWS deviation prompted medical assessment on seven occasions. Of these, six EWS recordings were triggered by concern from nursing staff or patient. Management was changed on three occasions, with initiation of intravenous antibiotics, fluids or supplemental oxygen. Minor deviation from baseline EWS of up to two points did not automatically trigger medical assessment; this was at the discretion of nursing staff.
Conclusions Modified EWS may benefit the subset of palliative care patients suitable for life prolonging measures by allowing earlier identification of acute deterioration. Recording observations on an as required basis seems sufficient to detect clinical deterioration. Management was changed in the minority of cases, although these interventions were significant. Clear documentation of escalation status to avoid inappropriate observation monitoring is essential.
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