Standard 58: Inpatient Ward Care

Sample. Review the admission assessments and daily reviews for every inpatient admitted in the last 3 months, with a sample of daily reviews.

1. Every inpatient has an admission assessment covering falls, pressure, nutrition and VTE.

Method. Check each sampled admission for the four risk assessments and their dates.

Evidence to show. Falls risk assessment tool (PSF-FRM-002, existing, reused); pressure injury risk and prevention record (CLN-FRM-006, existing, reused); nutrition risk screen record (CLN-FRM-005, existing, reused); VTE risk assessment record (CLN-FRM-007, existing, reused).

Pass when. Every sampled admission has all four assessments dated within 24 hours of admission.

2. The plan is reviewed by a clinician every day.

Method. Check each sampled inpatient for a daily review entry for each day of stay.

Evidence to show. Ward admission and daily review record (WRD-FRM-001); admission and daily review procedure (WRD-SOP-001).

Pass when. Every sampled inpatient has a daily review recorded for every day of stay.

3. Changes in risk are acted on in the plan.

Method. Check each recorded risk change for the plan update.

Evidence to show. Ward admission and daily review record (WRD-FRM-001).

Pass when. Every recorded risk change has a plan update.

Immediate fail (any one means the criterion is not met)

• A frail patient is admitted and no falls or pressure assessment is done, and falls on day two with a hip fracture.

Sample. Review the medicines charts and omission records for a sample of inpatients in the last 3 months, including the high-alert medicines.

1. Medicines are reconciled at admission, transfer and discharge.

Method. Check each sampled admission, transfer and discharge for the reconciliation form.

Evidence to show. Medicines reconciliation procedure (HOS-SOP-007, existing, reused); medicines reconciliation form (HOS-FRM-006, existing, reused).

Pass when. Every sampled admission, transfer and discharge has a reconciliation.

2. High-alert medicines are checked before each dose.

Method. Observe the check for each sampled high-alert dose, and review the chart.

Evidence to show. High-alert medicines (HOS-SOP-006, existing, reused); ward medicine administration checks (WRD-SOP-002).

Pass when. Every sampled high-alert dose has the check recorded.

3. Each omitted or refused dose is recorded with the reason.

Method. Check the omission register against the charts for the sample period.

Evidence to show. Medicine administration and omission register (WRD-REG-001).

Pass when. Every omitted or refused dose in the sample has a recorded reason.

Immediate fail (any one means the criterion is not met)

• A high-alert insulin dose is given twice in one shift because the chart was not checked, and the patient becomes hypoglycaemic.

Sample. Review the vital signs charts and early warning score records for every patient who was escalated in the last 3 months, plus a random sample of other inpatients.

1. Vital signs are recorded at the set frequency.

Method. Check each sampled chart against the frequency set for its score band.

Evidence to show. Observation and early warning chart (HOS-FRM-002, existing, reused); vital signs and deterioration response (HOS-SOP-002, existing, reused).

Pass when. Every sampled chart has observations at the set frequency.

2. Scores are recorded and escalated at the threshold.

Method. Check each sampled score at or above the threshold for the escalation record and the time to review.

Evidence to show. Early warning score audit record (DET-FRM-001, existing, reused); sepsis care record (HOS-FRM-003, existing, reused).

Pass when. Every sampled threshold score has an escalation and a senior review within the set time.

3. Handover includes the deteriorating patient.

Method. Check each sampled handover for the deteriorating patient and the plan.

Evidence to show. Structured handover checklist (HND-FRM-001, existing, reused).

Pass when. Every sampled handover of a deteriorating patient includes the plan.

Immediate fail (any one means the criterion is not met)

• A patient with a high early warning score is not escalated for three hours, and is found in septic shock.

Sample. Review falls, pressure injury and infection records for the ward over the last 6 months, with a sample of at-risk inpatients.

1. Each at-risk patient has a falls or pressure prevention plan in use.

Method. Check each sampled at-risk patient for the plan and the review.

Evidence to show. Falls prevention in hospital patients (PSF-GDL-001, existing, reused); pressure injury staging, treatment and recording (PRS-SOP-001, existing, reused); pressure injury register (PRS-REG-001, existing, reused).

Pass when. Every sampled at-risk patient has a plan in use.

2. Hand hygiene is practised at the point of care.

Method. Observe hand hygiene at the point of care during the audit period.

Evidence to show. Hand hygiene at the point of care (HH-SOP-001, existing, reused); hand hygiene observation audit tool (HH-FRM-001, existing, reused).

Pass when. Hand hygiene is observed at each required moment in the audit sample.

3. Healthcare-associated infections are recorded and reviewed.

Method. Check the infection register against the ward records for the period.

Evidence to show. Healthcare-associated infection surveillance and response (HOS-SOP-014, existing, reused); infection surveillance register (HOS-REG-005, existing, reused).

Pass when. Every recorded infection has a review entry.

Immediate fail (any one means the criterion is not met)

• A patient with a known fall risk falls at night with no bed alarm in place, and the event is not recorded.

Sample. Review the discharge records and handover letters for every discharge in the last 3 months, including discharges with follow-up.

1. Each discharge is planned before the day of discharge.

Method. Check each sampled discharge for the planning date against the discharge date.

Evidence to show. Discharge and aftercare planning (HOS-SOP-010, existing, reused); discharge aftercare plan (HOS-FRM-008, existing, reused).

Pass when. Every sampled discharge has a plan dated before the day of discharge.

2. Medicines and written aftercare are given at discharge.

Method. Check each sampled discharge for the reconciled medicines list and the written aftercare sheet.

Evidence to show. Written aftercare plan at discharge (REH-SOP-005, existing, reused); follow-up booking before discharge (AFT-FRM-001, existing, reused).

Pass when. Every sampled discharge has the reconciled medicines and written aftercare recorded.

3. A structured handover is sent to the next clinician.

Method. Check each sampled discharge for the handover record sent to the next clinician.

Evidence to show. Structured handover checklist (HND-FRM-001, existing, reused); post-discharge follow-up register (HOS-REG-003, existing, reused).

Pass when. Every sampled discharge has a handover recorded.

Immediate fail (any one means the criterion is not met)

• A patient is discharged on a changed anticoagulant dose with no reconciliation, and bleeds at home.