SW150 Tertiary and Secondary Queensland Adult ... · DO NOT WRITE IN THIS BINDING MARGIN DO NOT WRITE IN THIS BINDING MARGIN Emergency call if: •Airway Threat •Respiratory or

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Emergency call if:• Airway Threat• Respiratory or

cardiac arrest• Q-ADDSScore≥8• Any observation in

a purple area (E)• O2 saturation <90%

without response tooxygen

• Seizure >2 minutes• Sedation score of 3

(severe)• You are concerned about

the patient but they do notfittheabovecriteria

AdultDate

Time

Respiratory Rate

(breaths / min)Measure for a

full minute

E ≥35 E3 30–34 32 25–29 21 21–24 1

0 17–20 013–161 9–12 1E ≤8 E Indicate which systolic BP scoring

preference is in use (Usual or Default). If the Usual systolic BP is selected, write the Usual systolic BP in the space provided:

Usual systolic BP: ......................... mmHg Default systolic BP: 120mmHg

Name:

Signature:

Designation: Date:

Target Systolic BP (SMO / Registrar ONLY):

mmHgName:

Signature:

Designation: Date:

O2 Saturation(%)

0 ≥98 095–971 90–94 12 85–89 23 ≤84 3

Oxygen* (L / min or

% delivered)*If on HF / NIV use % delivered

E NRM E3 >11 >50% 32 >5–11 >40–50% 21 2–5 28–40% 10 <2 <28% 0

FM Face mask NP Nasal prongs HFNP HighflowHF Highflow NRM Non re-breather nasal prongsNIV Non invasive RA Room air

Mode Circle the column showing the patient’s Usual / Default / Target systolic BP

HighflowrateinL/min Actual BP 180s 170s 160s 150s 140s 130s 120s 110s 100s 90s 80s

Blood Pressure

(mmHg)

Score systolic BP

≥200 ≥200190s 190s 0 0 1 1 1 2 2 3 3 4 4180s 180s 0 0 0 0 1 1 2 2 3 3 4170s 170s 0 0 0 0 1 1 2 2 3 3 3160s 160s 1 0 0 0 0 0 1 1 2 2 2150s 150s 1 1 0 0 0 0 0 1 1 2 2140s 140s 1 1 1 0 0 0 0 0 1 1 1130s 130s 2 1 1 0 0 0 0 0 0 0 1120s 120s 2 2 1 1 0 0 0 0 0 0 0110s 110s 2 2 2 1 1 0 0 0 0 0 0100s 100s 3 3 2 2 2 1 1 0 0 0 0

90s 90s 3 3 3 2 2 2 2 1 1 0 080s 80s 1 070s 70s60s 60s

Systolic BP score

Heart Rate(beats / min)

E ≥140 E3 130s 3

2 120s 2110s1 100s 1

0

90s

080s70s60s50s

2 40s 2E 30s E

Temperature(°C)

2 ≥39.5 238.5–39.41 38–38.4 1

037.5–37.9

037–37.436.1–36.9

1 35.1–36 12 34.1–35 23 ≤34 3

ConsciousnessIf necessary, wake

patient before scoring

0 Alert 01 Voice 14 New confusion / agitation 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

E Pain EUnresponsive

Modifications in use M

TOTAL Q-ADDS SCORE

Interventions (e.g.‘A’)

Initials

EMERGENCY CALL

(Affixidentificationlabelhere)

URN:

Family name:

Given name(s):

Address:

Date of birth: Sex: M F I

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Contact:P

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omms@

health.qld.gov.au

Score Legend0 Score 01 Score 12 Score 23 Score 34 Score 4E Emergency call

EMERGENCY CALL

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Actions Required for Tertiary and Secondary FacilitiesQ-ADDS

ScoreObservations

(minimumfrequency) Notify Escalate(if no review)

Intra-hospitalEscort

0 8hourly

1–3 4 hourly • Team Leader

4–5 1 hourly• Team Leader• Resident review within

30 minutes

• If no review after30 minutes call Registrar Nurse

6–7 ½ hourly

• Team Leader• Registrar review within

30 minutes

• If no review after 30 minutes,or if concerned, initiateEmergency Call, notifyConsultant and Nurse Manager

Nurse

≥8 or E 10 minutely• Initiate Emergency Call• Registrar to ensureConsultantisnotified

• Registrar to ensure Consultantisnotified Nurse and

MedicalOfficer

Interventions Relating to observations from page 2 or the Pain at Rest Table on page 4If an intervention is administered, record here and note letter in Intervention row on page 2 in appropriate time column

A

B

C

D

E

F

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TRAINING ONLY

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Q-A

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S

(Affixidentificationlabelhere)

URN:

Family name:

Given name(s):

Address:

Date of birth: Sex: M F I

Queensland Adult Deterioration Detection System (Q-ADDS)

Facility:

Page 1 of 4 Page 4 of 4

Pain and Sedation Assessment(Affixidentificationlabelhere)

URN:

Family name:

Given name(s):

Address:

Date of birth: Sex: M F I

Date

Time

Pain Score at RestSevere 10

987

Moderate 654

Mild 321

None 0Functional Activity Scale (FAS) Score (perform during cough / movement)Activity severely limited by pain CActivity mild to moderately limited by pain BActivity unlimited by pain AInterventions(documentonpage3e.g.‘B’)* If scores conflict, follow the highest score

• Notify team leader• Administer analgesia• Notifymedicalofficertoreviewifnoimprovement

within 30 minutes of administering analgesia

• Administer analgesia• Considerteamleader/medicalofficer

review if no improvement within 60minutes of analgesia

• Consider simpleanalgesia

Sedation Score (for patients receiving potentially sedating medication)Patient must be woken to assess sedation score

Note: DO NOT add the Sedation Score to theQ-ADDSScore.Followactionsbelow.

0123

0 = Awake • Continue to monitor patient’s Q-ADDS, Sedation and Pain Score in accordance withindividual monitoring plan

1 = Mild (easy to rouse, able to keep eyes open for 10 secs)

• Increase monitoring of Q-ADDS, Sedation and Pain score• Recheck Sedation score before administering potentially sedating medication

2 = Moderate (rouseable, but unable to keep eyes open for 10 secs)

• Ensure patient receives oxygen andmonitor oxygen saturation

• Withhold additional sedatingmedication (until medical review)

• Notify team leader

• Notifymedicalofficertoreviewwithin15minutes(remainwithpatientuntilreview)

• Monitor Q-ADDS, Sedation and Pain score(minimum15minutely)

• If concerned, initiate Emergency Response3 = Severe (difficulttorouseorun-rouseable)

• Initiate Emergency Response• Ensure patient receives oxygen and monitor oxygen saturation• Determineneedforreversalagent(naloxone,flumazenil)

Additional ObservationsDate

Time

Height (cm) BowelsPassed urine

Weight (kg)

Other (e.g.urinalysis)

General Instructions» YoumustrecordallobservationsincludingPain,FunctionalActivityScaleandSedationscores(p4)atafrequencyappropriatetothepatient’sclinicalcondition.

» You must calculate a Total Q-ADDS Score for each set of observations and record it in the Total Q-ADDS Score box, evenifthescoreiszero.(RespiratoryRate+O2Saturation+O2FlowRate+BloodPressure+HeartRate+Temperature+Consciousness).

» ATargetsystolicBPcanbedocumentedintheappropriateboxonpage3bythetreatingRegistrarorSMO.TheTargetsystolicBPwillsupersedetheUsualsystolicBP.

» If there is no Target systolic BP the nurse admitting the patient should determine the patient’s Usual systolic BP and recorditintheappropriateboxonpage3.IftheNurseisunabletodeterminethepatient’susualBPtickthe“DefaultsystolicBP:120mmHg”boxonpage3.

» When graphing observations, place a dot (•)intheappropriateboxandjointotheprecedingdot(e.g. ).Forbloodpressure, use the symbols indicated ( ).Youmustwriteanyobservationoutsidetherangeofthegraphasanumber.

Modifications for Patients with Chronic Abnormal Physiology» ModificationscanONLYbemadeonthebasisofchronicabnormalphysiology.Thatis,physiologicalparametersthatareusualforthepatientathome.

» ModificationsmustbeauthorisedbyaSMO/registrar/PHO(orequivalent).» NB:documenttheletter“M”intherowabovetheTotalQ-ADDSScoreonpage2toindicatemodificationsinuse.Diagnosiswhichjustifiesmodification(e.g.chronicobstructive pulmonary disease):

Authorised by (SMO / registrar / PHO):

Doctor’s name (please print):

Designation: Signature:

Date: Time:

Write the acceptable range (will score zero) below:

Respiratory Rate to breaths / min

O2 Saturation to %

O2 Flow Rate to L / min

Heart Rate to beats / min

Scoringnote:forobservationsoutsidethemodifiedrange,reverttotheoriginalscoreonQ-ADDS.For example: if an O2 saturation of 90–94% is tolerated (score of zero), and the O2saturationfallsto89%,itwouldscore2.NB:documenttheletter‘M’intherowabovetheTotalQ-ADDSScoreonpage2toindicatemodificationsinuse.

Temporary Modifications» TemporaryModificationcanonlybemadetoONE of the following - Blood Pressure, Heart Rate or Respiratory Rate» MusthaveexplanationanddetailedmanagementplandocumentedbyMedicalOfficer(MO)inthecasenotes(headed:“TemporaryModificationPlan1,2or3”).

» CautionshouldbeexercisedinprescribingTemporaryModificationsforpatientswithsuspected Sepsis.» TemporarymodificationsmustbeauthorisedbytheSMOaccountableforthepatientorafterconsultationbetweenatleasttwomembersoftheMedicalEmergencyTeam.

» Eachmodificationwilllastamaximumof2hours(1box),sequentialmodificationsarepermittedformaximum6hours(all3boxes)butonly1boxcanbecompletedforeachMOreview(i.e.MUSThaveMOreviewevery2hoursandmodificationprescribedintonextbox).

» ATotalQ-ADDSScoremustbedocumentedatleastevery30minutes.» Documenttheletter“M”intherowabovetheTotalQ-ADDSScoreonpage2toindicatemodificationsinuse.Temporary Modification 1Write the acceptable range (will score zero)

Systolic BP to mmHg

OR (can NOT be modified <80 mmHg)

Heart RateOR

to beats / min

Resp.Rate to breaths / min(can NOT be modified >34 bpm)

Modifying Doctor Name:

Authorising Doctor Name:

Start Date: Time:

Cease Date: Time:

Contact number:

Temporary Modification 2Write the acceptable range (will score zero)

Systolic BP to mmHg

OR (can NOT be modified <80 mmHg)

Heart RateOR

to beats / min

Resp.Rate to breaths / min(can NOT be modified >34 bpm)

Modifying Doctor Name:

Authorising Doctor Name:

Start Date: Time:

Cease Date: Time:

Contact number:

Temporary Modification 3Write the acceptable range (will score zero)

Systolic BP to mmHg

OR (can NOT be modified <80 mmHg)

Heart RateOR

to beats / min

Resp.Rate to breaths / min(can NOT be modified >34 bpm)

Modifying Doctor Name:

Authorising Doctor Name:

Start Date: Time:

Cease Date: Time:

Contact number:

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For tertiary and secondary facilities

• If the patient reports any level of chest pain,please follow local chest pain procedure

• If you are concerned about the patient’s painbuttheydonotfitthebelowcriterianotifyMedicalOfficer

• If documenting pain and sedation on a PCA/Epidural Monitoring form, this section does not need to be completed

TRAINING ONLY