Acutely ill adults in hospital: recognising and responding to deterioration

Introduction

Patients who are admitted to hospital believe that they are entering a place of safety, where they, and their families and carers, have a right to believe that they will receive the best possible care. They feel confident that, should their condition deteriorate, they are in the best place for prompt and effective treatment.

Yet there is evidence to the contrary. Patients who are, or become, acutely unwell in hospital may receive suboptimal care. This may be because their deterioration is not recognised, or because – despite indications of clinical deterioration – it is not appreciated, or not acted upon sufficiently rapidly. Communication and documentation are often poor, experience might be lacking and provision of critical care expertise, including admission to critical care areas, delayed.

We have endeavoured to produce practical guidance with recommendations for the measurement and recording of a set of physiological observations, linked to a 'track and trigger' system. We have emphasised the importance of a full clinical assessment, and of tailoring the written monitoring and management plans to the individual patient's clinical circumstances. Throughout the document we have emphasised the importance of training; by ensuring that routine measurements are accurately taken and recorded by staff that understand their clinical relevance, and by linking these observations to a graded track and trigger system, care can be escalated appropriately. The foundations for patient safety are laid through doing and recording simple measurements well and having agreed response strategies in place.

The guideline development group struggled with the lack of evidence to identify any 1 best model of response. It needed to balance making clear recommendations about the level and nature of the response with the absence of evidence regarding optimal configuration. Given this, the guideline development group considered that the optimal configuration of response should be agreed and delivered locally. Whatever model of care is agreed, the clinical team must have the necessary competencies. Where admission to a critical care area is considered necessary, we have emphasised the importance of involving both critical care consultants and the team caring for the patient on the ward.

The guideline development group recognised the pressure on both critical care beds and inpatient hospital beds, and the difficulties of ensuring smooth, planned transfer from critical care areas back to the wards. Nevertheless, we have set out recommendations to avoid transfer out of critical care areas between the hours of 10:00pm and 7:00am. If this occurs, it should be documented as an adverse incident. We have been prescriptive about the need for a formal, structured handover of care between the transferring and receiving teams, recognising the understandable anxiety of patients and their carers and the need to provide reassurance and information to them at this time.

This is the first NICE short guideline to be developed. The methodology is of the same rigour as for the standard NICE guidelines, but the scope is narrower, and the development and consultation phases have been compressed. The guideline development group recognises the importance of producing guidance rapidly in an area in which patients and clinicians need advice urgently to ensure patient safety. This philosophy sits well with our emphasis on a timely and rapid response to the acutely ill hospital patient. We hope that the guideline will be welcomed by all who plan, deliver, or experience hospital inpatient clinical care.

Dr Mary Armitage
Guideline development group chair