Quality standard

Quality statement 1: Documented initial assessment

Quality statement 1: Documented initial assessment

Quality statement

Adults first presenting with suspected acute respiratory infection have a documented assessment of symptoms and signs.

Rationale

A clinical assessment of the symptoms and signs of suspected acute respiratory infection at first presentation informs a provisional diagnosis. Considering the symptoms and signs in the context of the person's overall health and circumstances will inform decisions about treatment or referral for further assessment. Including a fully documented assessment in the person's record will promote a consistent approach to diagnosis across remote and in person settings and will support better management of any follow‑up care.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.

Process

Proportion of diagnoses of acute respiratory infection in adults with a documented assessment of symptoms and signs at initial presentation.

Numerator – the number in the denominator with a documented assessment of symptoms and signs at initial presentation.

Denominator – the number of diagnoses of acute respiratory infection in adults.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from electronic patient records.

What the quality statement means for different audiences

Service providers (such as NHS 111, 999 call centres, general practice and community pharmacies) ensure that processes are in place for people first presenting with suspected acute respiratory infection to have a documented initial assessment of symptoms and signs.

Healthcare professionals (such as NHS call handlers, GPs, advanced care practitioners, nurse practitioners and community pharmacists) assess symptoms and signs in people first presenting with suspected acute respiratory infection and document all initial assessments in patient records.

Commissioners ensure that they commission services that have processes for documenting assessment of symptoms and signs in people first presenting with suspected acute respiratory infection.

Adults with suspected acute respiratory infection have an initial assessment of their symptoms and signs that is included in their record.

Definitions of terms used in this quality statement

Acute respiratory infection

An acute illness (present for 21 days or less) affecting the respiratory tract with symptoms such as cough, sore throat, fever, sputum production, breathlessness, wheeze or chest discomfort or pain, and no alternative explanation. [NICE's guideline on suspected acute respiratory infection in over 16s, terms used in this guideline section]

Assessment of symptoms and signs

In people with a suspected acute respiratory infection, think 'could this be sepsis?' and assess for it.

Assessment of symptoms and signs of acute respiratory infection should include identification and recording of severity of symptoms and rate of deterioration as well as noting symptoms and signs of concern, such as:

  • Symptoms of concern for lower respiratory tract infection include, new or increased, breathlessness or confusion.

  • Use FeverPAIN or Centor criteria to identify people with a sore throat who are more likely to benefit from an antibiotic.

  • Bacterial acute sinusitis may be more likely if several of the following are present:

    • symptoms for more than 10 days

    • discoloured or purulent nasal discharge

    • severe localised unilateral pain (particularly pain over teeth and jaw)

    • fever

    • marked deterioration after an initial milder phase.

Acute respiratory infection symptoms and signs should be considered in the context of the person's overall health and circumstances when making decisions about treatment or referral for further assessment. The threshold for treatment or referral for further assessment may be lower for people who are more likely to have a poor outcome, for example, people with comorbidities or multimorbidity and people who are frail. [NICE's guideline on acute respiratory infection in over 16s, recommendations 1.1.1, 1.2.2, 1.2.3 and 1.3.2; NICE's guideline on sore throat (acute): antimicrobial prescribing, recommendation 1.1.3; and NICE's guideline on sinusitis (acute): antimicrobial prescribing, symptoms and signs section]

Equality and diversity considerations

Healthcare professionals should recognise that some pulse oximetry devices have been reported to overestimate oxygen saturation levels in people with darker skin. Adjustments should be made when interpreting the test results to ensure that treatment is provided when appropriate.

Adults should be supported to ensure they can communicate effectively with NHS services during remote and face-to-face assessments. For remote assessments this should include making sure the person is able to use any digital technology and offering alternatives, when necessary. It also includes ensuring services are accessible to those who do not speak or read English. Adults should have access to an interpreter or advocate if needed. Any support provided should be culturally and age appropriate.