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Question 1

score 0 (low)

Answer 1

monitor every 12 hours

Question 2

1-4 (low)

Answer 2

4-6 hourly monitoring, inform nurse who must assess pt

Question 3

3 in single parameter (low-medium)

Answer 3

1 hourly monitoring, nurse to inform medical team who will review

Question 4

5 or more (medium)

Answer 4

1 hourly monitoring, nurse to immediately inform medical team and request urgent assessment from clinician with care competencies in the care of acutely ill pts

Question 5

7 or more (high)

Answer 5

continuous monitoring, nurse to immediately inform medical team + emergency assessment by team with critical care competencies inc practitioner with advanced airway management skills + consider transfer care to level 2 or 3 clinical care facility