Acutely ill adults in hospital: recognising and responding to deterioration

Adult patients in acute hospital settings, including patients in the emergency department for whom a clinical decision to admit has been made, should have:

• physiological observations recorded at the time of their admission or initial assessment

• a clear written monitoring plan that specifies which physiological observations should be recorded and how often. The plan should take account of the:

  • patient's diagnosis

  • presence of comorbidities

  • agreed treatment plan.
    
    Physiological observations should be recorded and acted upon by staff who have been trained to undertake these procedures and understand their clinical relevance.

As a minimum, the following physiological observations should be recorded at the initial assessment and as part of routine monitoring:

• heart rate

• respiratory rate

• systolic blood pressure

• level of consciousness

• oxygen saturation

• temperature.

Physiological track and trigger systems should be used to monitor all adult patients in acute hospital settings.

• Physiological observations should be monitored at least every 12 hours, unless a decision has been made at a senior level to increase or decrease this frequency for an individual patient.

• The frequency of monitoring should increase if abnormal physiology is detected, as outlined in the recommendation on graded response strategy.

Track and trigger systems (NEWS2 [National Early Warning Score] has been endorsed by NHS England) should use multiple-parameter or aggregate weighted scoring systems, which allow a graded response. These scoring systems should:

• define the parameters to be measured and the frequency of observations

• include a clear and explicit statement of the parameters, cut-off points or scores that should trigger a response.

Multiple-parameter or aggregate weighted scoring systems used for track and trigger systems should measure:

• heart rate

• respiratory rate

• systolic blood pressure

• level of consciousness

• oxygen saturation

• temperature.

In specific clinical circumstances, additional monitoring should be considered; for example:

• hourly urine output

• biochemical analysis, such as lactate, blood glucose, base deficit, arterial pH

• pain assessment.

Staff caring for patients in acute hospital settings should have competencies in monitoring, measurement, interpretation and prompt response to the acutely ill patient appropriate to the level of care they are providing. Education and training should be provided to ensure staff have these competencies, and they should be assessed to ensure they can demonstrate them.

The response strategy for patients identified as being at risk of clinical deterioration should be triggered by either physiological track and trigger score or clinical concern.

Trigger thresholds for track and trigger systems should be set locally. The threshold should be reviewed regularly to optimise sensitivity and specificity.

A graded response strategy for patients identified as being at risk of clinical deterioration should be agreed and delivered locally. It should consist of the following 3 levels:

• Low-score group:

  • Increased frequency of observations and the nurse in charge alerted.

• Medium-score group:

  • Urgent call to team with primary medical responsibility for the patient.

  • Simultaneous call to personnel with core competencies for acute illness. These competencies can be delivered by a variety of models at a local level, such as a critical care outreach team, a hospital-at-night team or a specialist trainee in an acute medical or surgical specialty.

• High-score group:

  • Emergency call to team with critical care competencies and diagnostic skills. The team should include a medical practitioner skilled in the assessment of the critically ill patient, who possesses advanced airway management and resuscitation skills. There should be an immediate response.

Patients identified as 'clinical emergency' should bypass the graded response system. With the exception of those with a cardiac arrest, they should be treated in the same way as the high-score group.

For patients in the high- and medium-score groups, healthcare professionals should:

• initiate appropriate interventions

• assess response

• formulate a management plan, including location and level of care.

If the team caring for the patient considers that admission to a critical care area is clinically indicated, then the decision to admit should involve both the consultant caring for the patient on the ward and the consultant in critical care.

After the decision to transfer a patient from a critical care area to the general ward has been made, he or she should be transferred as early as possible during the day. Transfer from critical care areas to the general ward between 10:00pm and 7:00am should be avoided whenever possible, and should be documented as an adverse incident if it occurs.

The critical care area transferring team and the receiving ward team should take shared responsibility for the care of the patient being transferred. They should jointly ensure:

• there is continuity of care through a formal structured handover of care from critical care area staff to ward staff (including both medical and nursing staff), supported by a written plan

• that the receiving ward, with support from critical care if required, can deliver the agreed plan.
  
  The formal structured handover of care should include:

• a summary of critical care stay, including diagnosis and treatment

• a monitoring and investigation plan

• a plan for ongoing treatment, including drugs and therapies, nutrition plan, infection status and any agreed limitations of treatment

• physical and rehabilitation needs

• psychological and emotional needs

• specific communication or language needs.

When patients are transferred to the general ward from a critical care area, they should be offered information about their condition and encouraged to actively participate in decisions that relate to their recovery. The information should be tailored to individual circumstances. If they agree, their family and carers should be involved.

Staff working with acutely ill patients on general wards should be provided with education and training to recognise and understand the physical, psychological and emotional needs of patients who have been transferred from critical care areas.