Acutely ill adults in hospital: recognising and responding to deterioration

Track and trigger/early warning systems for recognition of patients whose clinical condition is deteriorating or who are at risk of deterioration

We searched for evidence on the use of any tool (for example, track and trigger or early warning score) which triggers a set response to predetermined patterns of physiological derangements and includes 'periodic observation' of parameters compared with any other track and trigger system/early warning score or no track and trigger system/early warning score.

Electronic and paper-based warning systems for recognition of patients whose clinical condition is deteriorating or who are at risk of deterioration

We searched for evidence on the use of electronic alert/monitoring/warning systems compared with any other electronic alert/monitoring/warning system, paper-based alert system, or no alert/monitoring/warning system.

Response strategies for patients identified as having a deteriorating clinical condition

We searched for evidence on the effects of any response strategy (for example, formal approach agreed within setting) to deterioration (for example, critical care outreach team) compared with any other response strategy to deterioration or no specific response strategy to deterioration.

We included a total of 126 studies from these focused searches.

We also included:

From all sources, we considered 194 studies to be relevant to the guideline.

See appendix A for details of all evidence considered, and references.

Need for the guideline to be updated to support the use of the NEWS2 tool

One stakeholder (NHS England) commented that this guideline should be updated to indicate support for the NEWS2 tool, for reasons including alignment of the guideline with the standardisation of NEWS2 that is occurring at a national level, that such standardisation is important to patient safety, and the availability of research evidence to support NEWS/NEWS2.

In this surveillance review we performed a focused search to identify evidence on the use of track and trigger tools/early warning scores in the recognition of clinical deterioration. We also included 4 studies that were suggested in stakeholder consultation comments in the summary of evidence. These 4 additional studies that were included did not change the conclusion of the evidence summary. Only 4 comparative studies were identified for NEWS2. Two of these studies were performed in the UK but were in specific study populations with respiratory conditions. The other 2 studies were undertaken in Canadian hospital and Spanish prehospital settings. Therefore, the 4 NEWS2 comparative studies were mixed in terms of the populations, settings, and tested comparisons, limiting the conclusions that can be made. We concluded that further evidence is required to demonstrate superior performance of NEWS2 compared with other available tools. However, we acknowledge the value of providing a consistent message to healthcare professionals. We consider that the amendment of recommendation 1.4 that was made in April 2019 (to state that NEWS2 has been endorsed by NHS England) is supportive of the use of NEWS2 and serves to provide a consistent message to professionals.

Need for the guideline to be updated to include guidance on the use of objective monitoring of vital signs

One commercial organisation commented that the guideline should recommend that objective monitoring of vital signs be performed for reasons including that the quality of vital signs measurement (for example, respiratory rate) is key to the accuracy and effectiveness of NEWS and allowing hospitals to choose the modality most suited to their clinical environment. We did not identify evidence on this topic in the surveillance review. We examined the studies that were suggested in this stakeholder comment but did not consider them to be eligible for inclusion in the summary of evidence.

Need for the guideline to be updated to include other factors related to recognition of deterioration

Two stakeholders commented on the frequency of observations as addressed in recommendation 1.3 (that states physiological observations should be recorded at least every 12 hours unless this frequency is increased or decreased for an individual patient at a senior level, and monitoring frequency should increase if abnormal physiology is detected). Searches to identify evidence specifically on monitoring frequency were not performed in this surveillance review (based on topic expert feedback). However, one randomised controlled trial was included in the summary of evidence comparing 8-hourly with 12-hourly early warning score (EWS) measurements and did not find any significant differences in negative clinical outcomes between groups. This was based on a single study and so overall findings were considered to support the frequency of monitoring in recommendation 1.3.

Two stakeholders commented that the guideline should include patient worry and relative concern in activating response to deterioration. No evidence was identified on this topic in this surveillance review. This point will be considered at the next surveillance review.

Need to update the section on response strategies for patients identified as having a deteriorating clinical condition

One stakeholder commented that more specific guidance is needed on response times, the nature of response and potential outcomes from response. Based on topic expert feedback, we had performed a focused search to identify evidence in this area. The evidence we identified was consistent with the guideline in that no specific configuration of response strategy can be recommended.

Need to update the section on transfer of patients from critical care areas

One stakeholder commented that recommending adverse event reporting for out of hours transfer of patients from critical care (as in recommendation 1.14) should be reconsidered. While focused searches for evidence were not performed for this section of the guideline, evidence identified on timing of discharge was considered on balance to be consistent with recommendation 1.14 to avoid transfer out of critical care to the general ward during nighttime hours.

Areas excluded from the scope of the guideline

The following areas were flagged by one stakeholder each as being areas that should be within the scope of the guideline:

Validity of the research recommendations in the guideline

It was concluded following the 2019 exceptional surveillance review that this guideline's research recommendations on the evaluation of early warning scores/track and trigger systems should be promoted with the NIHR.

Due to the considerable period that has elapsed since the publication of this guideline (in July 2007), we decided to check in this surveillance review whether stakeholders consider that the existing research recommendations are still valid. A question was included at stakeholder consultation for this purpose.

Seven stakeholders stated that they still considered the research recommendations to be valid, 1 stakeholder disagreed, and 3 stakeholders did not provide a response. Several areas and potential research questions were noted within responses (as detailed in appendix B). As the guideline is not being updated at this time, we will note these suggestions in our guideline issues log for future consideration. We will continue to promote the existing research recommendations with the NIHR.

See appendix B for full details of stakeholders' comments and our responses.

See ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual for more details on our consultation processes.