Use of this data collection template is optional. Trusts are welcome to use their own collection template, or amend this according to local needs

7 Day Services Survey – Questions List.

Trust name:

1. Site patient admitted to (if trust admits emergencies to multiple sites):

Clinical Standard 2

Question / Response options / Response
2 / Patient ID for Local Use / ? Trust ID/Sequential number/Other(TBC by Trust)
3 / Admitted specialty / sub specialty / List of specialties as drop down list, see below:
Acute Internal Medicine / General Surgery / Neurosurgery / Paediatric Surgical Wards / Trauma and Orthopaedic Surgery
Cardiology / Geriatric Medicine / Obstetrics and Gynaecology / Palliative Care / Urology
Cardio-thoracic Surgery / Haematology / Oncology / Renal Medicine (Nephrology) / Vascular Surgery
Diabetes and Endocrinology / Infectious Diseases / Ophthalmology / Respiratory Medicine (Thoracic Medicine) / Other:
Emergency Medicine / Intensive Care Unit / Paediatric intensive care unit (PICU) / Rheumatology
Gastroenterology / Neurology / Paediatric Medicine / Stroke Medicine
4 / Date and time of arrival at hospital as an emergency / Date Entry & Time Entry
5 / Date and time of admission at hospital as an emergency / Date Entry & Time Entry
6 / Date of Discharge (includes Date of Death, Discharge Date and Transfer out of hospital) / Date Entry
7 / Date and time of the 1st consultant review? / Date Entry / Time Entry
8 / If 1st review was not within 14 hours of arrival at hospital, what is the reason?
7DSAT will flag when > 14 hours elapsed between arrival and 1st consultant review. / Optional Free Text
9 / What was the date and time discussions about initial review, which may include the diagnosis, management plan and prognosis, were had with the patient (and where appropriate families/ carers). / Date Entry
10 / If the patient (and where appropriate families / carers) were not involved in discussions about the initial review within 48 hours of admission, what was the reason? /
  1. The patient was unable to be made aware due to their clinical condition
  2. The patient died within 48 hours
  3. Family/ carers could not be contacted or there are no family/ carers to be informed
  4. None of the above
/ (Enter 1,2,3 or 4 from list on left)

Clinical Standard 8

The questions in this section use question routing based on your response as to whether the patient required twice daily review or once daily review. These questions are to be answered for each day that the patient is subject to reviews (up to a maximum of 5 days). The questions that display for each choice are shown in the table below:

Questions for Once Daily review:

Q No / Question / Response options
1 / Day: Date / Date entry
2 / Day: Specialty / Enter the patients specialty on this day
3 / Did the patient require twice daily review? /
  1. Patient required twice daily review
  2. Patient required once daily review
  3. Patient required no review

4 / Did the patient receive a consultant review on this day (between 00:01-24.00)? /
  1. Yes -patient received a consultant review (record date and time)
  2. Yes -Consultant review was delegated and done by delegate (record date and time)
  3. No –patient review was delegated but not done
  4. No -patient was not reviewed
  5. No, but patient was discharged

5 / What was the date and time of the completed daily review? / Date and time to be entered
6 / Who undertook the daily review? /
  1. The consultant
  2. Senior trainee 3+ (ST3+)
  3. Advanced nurse practitioner/ nurse specialist
  4. Other doctor
  5. Other health care professional

7 / During the period the patient was reviewed were they informed of review outcomes or any changes to care plan?
(Asked once over consultant review period) /
  1. Yes
  2. The patient was unable to be made aware due to their clinical condition. The carers/ family were informed
  3. Neither the patient nor their family was informed
  4. None of the above

Question / Day 2 / Day 3 / Day 4 / Day 5 / Day 6 / Spare
1
2
3
4
5
6
7

Questions for Twice Daily Review:

Q No / Question / Response options
1 / Day: Date / Date entry
2 / Day: Speciality / Enter the patient’s specialty on this day
3 / Did the patient require twice daily review? /
  1. Patient required twice daily review
  2. Patient required once daily review
  3. Patient required no review

4 / Did the patient receive twice daily consultant review on this day (between 00:01-24:00)?
(only applicable if response 1 or 2 selected from Q 3) /
  1. Yes - patient received both reviews by the consultant (date and time)
  2. Yes -consultant reviews were delegated to and both done by delegate (date and time)
  3. Yes - patient received 1 review from the cons and 1 from the delegated team member
  4. No - patient required twice daily review but was only reviewed once on this day
  5. No - patient required twice daily reviews but was not reviewed on this day
  6. No, but patient was discharged

5 / What was the date and time of the 1st completed twice daily review? / Date Entry and Time Entry
6 / Who undertook the 1st review? /
  1. The consultant
  2. ST3+
  3. ANP/ nurse specialist
  4. Other doctor
  5. Other HCP
  6. Other nurse

7 / Date and time of 2nd completed twice daily review / Date and time of second review.
8 / Who undertook the 2nd review? /
  1. The consultant
  2. ST3+
  3. ANP/ nurse specialist
  4. Other doctor
  5. Other HCP
  6. Other nurse

9 / During the period the patient was reviewed were they informed of review outcomes or any changes to care plan?
Asked once over consultant review period /
  1. Yes
  2. The patient was unable to be made aware due to their clinical condition. The carers/ family were informed
  3. Neither the patient nor their family was informed
  4. None of the above

Question / Day 2 / Day 3 / Day 4 / Day 5 / Day 6 / Spare
1
2
3
4
5
6
7
8
9

Standard 8 Managing the Deteriorating Patient Questions: To be asked once.

9 / What was the date and time of the first NEWS score which triggered the need for a response according to your local protocol, during the first 6 days of the inpatient stay /
  • Enter Date and time if applicable.
OR

No trigger over the first 6 Days:
10 / What was the level of the trigger? (only applicable if answered question 9) /
  1. Red / High Score
  2. Amber / Moderate Score

13 / What was the date and time of the response / Date Entry and Time Entry
14 / What were the grade and/or profession of the initial responder? /
  1. Consultant
  2. ST3+
  3. Other doctor
  4. Critical Care Outreach Team (CCOT) nurse
  5. CCOT doctor
  6. Nurse

15 / Was the response followed by a consultant response on the same day? / Yes
No
N/A free text
16 / Is the clinical opinion that the patient deterioration triggering high / moderate NEWS was due to sepsis? /
  • Yes
  • No

17 / Did the patient require an unplanned admission to PICU or ICU during the first six days of the inpatient stay? /
  • Yes
  • No

19 / Was there an unplanned return to theatre during the first six days of the inpatient stay? /
  • Yes
  • No

Document last updated: 5th September 2016.