A&E Documentation Booklet Banda Label Emergency Department Nursing Documentation Date Time Triage Documentation Allergies: Date Time Signature PC: HPC: Drugs given in ambulance prior to arrival: Patient’s own medication? Yes / No PMH: SH: Mobility: Triage colour: D&V? Yes/No Notes: STA2335
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
A&E Documentation Booklet
Banda Label Emergency Department
Nursing Documentation
Date Time
Triage Documentation Allergies: Date Time Signature PC: HPC:
Drugs given in ambulance prior to arrival:
Patient’s own medication? Yes / No PMH:
SH:
Mobility: Triage colour: D&V? Yes/No Notes:
STA2335
Emergency Care Safety Checklist Action Time Initials Comments
1st Hour Completed
by
Assessment/Triage Mews Chest Pain ECG recorded (within 10 minutes) ECG reviewed by Dr (within 30 minutes – time on ECG)
Undressed and gown Wristband Pain score assessed Analgesia administered (if appropriate) Sepsis suspected? Investigations Initiated (as appropriate) IV access and care plan Blood tests Imaging Stroke, NOF xray within 30 mins Specific Pathway Triggered – see Box 1 Pathway commenced : Stroke, DKA, NOF, GI bleed, Sepsis
2nd Hour Completed
by
Mews Pain score assessed Analgesia administered (if necessary) Next of Kin aware Refreshments offered (if not NBM) Pressure Area Care Assessment undertaken Patient Good To Go Patient ready for transfer Speciality bed confirmed
3rd Hour Completed
by
Mews Pain score assessed Analgesia administered (if necessary) Refreshments offered (if not NBM) Review by senior doctor
Assess Severity of Sepsis Is at least one of these RED FLAG signs present?
Systolic BP <90mmHg or >40mmHg below normal Heart Rate >130 Blood Lactate (Arterial, Venous or Capillary) >2 Respiratory rate >25/min Oxygen Saturations <92% on air (88% in COPD) V, P or U on AVPU scale Non-Blanching rash, mottled / ashen or cyanotic skin Not passed urine in last 18hr Urine Output less than 0.5 ml/kg/hr for last 2 hours Neutropenic
Moderate Risk of Sepsis Contact FY1 FY2 or Outreach Now!Ensure review within 60 mins.Rescreen if patient deteriorates
Red Flag Sepsis Present High Risk of Sepsis:
Contact FY1 FY2 or Outreach Now!Ensure review within 15 mins.
Start Sepsis Six Immediately Inform Seniors Complete pathway -overleaf
Y
N Y
RReferred to: Grade Time: : .
N
CCOT/ Medical Review: Name . . . . . . . . . . . . . . . . . . . . . . . . . . Grade . . . . . . . . . . . . Time . . . . . . . . hQuick check (and completion) of the above sepsis screen Any difference in assessment: document overleaf
Are any of the Red Flag Sepsis signs present?
Yes, High Risk of Sepsis
No, Moderate Risk of Sepsis
▪Consider Starting Antibiotics▪Ensure differential tests are prioritised.▪Inform Seniors- review within 60 mins
Yes
No, Treat as Low Risk of Sepsis.
Review if deterioration
Sepsis Six and Red Flag Sepsis are copyright to and intellectual property of the UK Sepsis Trust, registered charity no. 1158843. sepsistrust.org
Review tests: Confirmed Infection
and New Organ Dysfunction, esp AKI?
Dr.
Sam
Geo
rge
/ Bar
ry O
’Kee
ffe (R
GN
) Mar
ch 1
6
Sep
sis
Six
Ti
me
Nam
e
When Sepsis Six Delivered and Blood results available Confirm infection and SOFA score