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Early recognition of the

deteriorating patient

Based on the:

National Consensus Statement: essential elements for recording &

responding to clinical deterioration.

www.safetyandquality.gov.au

Element 1

• Measurement and documentation of observations

Element 2 • Escalation of care

Element 3 • Rapid response system

Element 4 • Clinical communication

Clinical processes

Element 5 • Organisational supports

Element 6 • Education

Element 7 • Evaluation, audit and feedback

Element 8 • Technological systems and solutions

Organisational prerequisites

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Do we need to/should we commence

resuscitation?

‘Advanced Care Directives’

‘Guidelines for end-of-life care and decision making’

Specify principles of care for patients who will not

benefit from further resuscitative measures

because their illness is beyond recovery or they

have expressed a wish not to be admitted to

critical care

Reference gmct discussion document 2006

Clinical Excellence Commission developed -

Between the Flags http://www.cec.health.nsw.gov.au

Some background:

“Evidence derived from the NSW Patient Safety

and Clinical Quality Program has demonstrated

that lack of recognition and appropriate

management of patients whose condition either

progressively or suddenly deteriorates in acute

hospital wards…”

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Element 1

• Measurement and documentation of observations

Standard Adult

General Observation

(SAGO) Chart

Recommended minimal

observations in acute care:

•Respiratory rate

•Oxygen saturation

•Heart rate

•Blood pressure

•Temperature

•Level of consciousness

The thresholds for altering

criteria may be altered up or

down

Alteration must be signed by

a medical officer

Clinical Excellence Commission Annual Report 2007-2008

Why this task is important?

1. Appropriate observations and assessments are monitored considering the

diagnosis and proposed treatments

2. Frequency is suitable considering the clinical condition

3. Monitoring requirements are clearly communicated to all members of the team

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From the Clinical Excellence Commission – Between the Flags report, 2008

Element 2

• Escalation of care

Escalation policy: a document outlining the

principles and processes for escalating care for

patients whose condition is deteriorating.

Escalation policies need to consider the size and

role of each facility.

Why is this task important:

•Patients who deteriorate can experience delays in

treatment if clinicians are unsure of the levels of

physiological abnormality at which care should be

escalated

•A graded response to abnormal physiological

observations provides treatment to patients earlier

•An escalation protocol clearly outlines when care

should be escalated and the required responses

and treatments

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Element 3

• Rapid response systems

Two key tasks

•Provide a rapid response system capable of delivering

timely, specialised emergency assistance to patients whose

condition is deteriorating

•Ensure rapid response systems operate in partnership with,

and as an extension of, the treating team

Why this task is important?

•Patients need timely and appropriate emergency

care

•Seamless transition in care between healthcare

teams

•All members need to understand the systems

purpose and benefits

•Poor communication between rapid response

providers and other clinicians, or uncooperative

behaviour, will reduce team effectiveness and

potentially hinder the rapid response

Element 4

• Clinical communication

•What information is it important to convey and how to

convey it effectively

•Poor written and verbal communication between

clinicians is a leading cause of adverse health events

•Patients, families and carers often identify signs of

deterioration and report this to clinicians, but little

action may be taken

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Associated issues may also include

communication between staff at critical times:

•Emergency department to ward

•Emergency department to intensive care

units

•Operating theatre to ward/HDU/ICU

•Shift handover; or when multiple consulting

medical teams are involved in care

ISBAR – A structured communication tool

I – INTRODUCTION

Introduce yourself and your role in the patient’s care

State the unit you are calling from when speaking with physician

over the phone

S – SITUATION

Specify the patient’s name and current condition

Explain what has happened to trigger this conversation

B – BACKGROUND

State the admission date diagnosis and pertinent history

Give a brief synopsis of what’s been done so far

A – ASSESSMENT

Give a summary of the patient’s condition or say “I’m not sure

what the problem is , but the patient is deteriorating”

R – RECOMMENDATION

Explain what you would like to see done

Element 5 • Organisational supports

Element 6 • Education

Element 7 • Evaluation, audit and feedback

Element 8 • Technological systems and solutions

Organisational prerequisites

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Element 5

• Organisational supports

Provides a clinical governance framework to support

systems for recognising and responding to clinical

deterioration

Element 6

• Education

Treatment of clinical deterioration will be delayed if

clinicians cannot identify and interpret signs of clinical

deterioration

Task:

To provide education to the clinical and non-clinical

workforce to support recognition and response systems

Why this task is important?

•Identify of observations that are needed to detect

clinical deterioration

•Identify the most appropriate frequencies for

measuring observations

•Accurately measure observations

•Interpret abnormal observations

•Communicate physiological changes

•Identify and provide appropriate treatments

•Correctly use “track and trigger” systems for escalation

•Work effectively as part of a team

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Education

Three tiers of education have been defined and are required:

Tier 1 Awareness Training: ALL clinical staff should be able to identify

clinical deterioration and activate the hospital response system

Tier 2 Ward Staff: All clinical staff who are first line responders. The

primary or ‘home’ care team who conduct clinical assessment and

early intervention

Tier 3 Rapid Response Team: including the designated Rapid Response

Officer – will have advanced clinical and resuscitation skills

Element 7

• Evaluation, audit and feedback

New systems need evaluation to establish their efficacy

and determine if changes are needed to optimise

performance

Data obtained from evaluating recognition and

response systems are fed back to healthcare workers

and external stakeholders as required

Element 8

• Technological systems and solutions

Consideration of the use of technological systems and

solutions to improve recognition and response systems

e.g.

•Computerised decision support – interpreting

abnormal diagnostic results – medication

prescribing / managing potential drug reactions.

•Electronic medical records

•Simulation laboratories

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Question - who may be at risk of deterioration?

Patients admitted as emergencies

Patients without a diagnosis

Patients referred to multiple specialities

Elderly patients

Pre-existing co-morbidities such as diabetes, asthma, renal

failure and cardiac disease

Patients whose acute illness is particularly severe

Recovering from anaesthesia

Postoperative patients

Failure to respond to treatment

The shocked patient

What are some of the reasons these patients are at

risk of deterioration?

•Potential to bleed

•Hypotension (MAP – end organ perfusion)

•Hypovolaemia

•Compromised ventilation & perfusion

•Hypoxia

•Multiple system failure

•Altered neurological state

•Etc.

Airway:

You walk into the patient’s room and ask them how

they are and they respond appropriately.

What have you learnt?

1. Their airway is patient

2. They are breathing

3. Their brain is still perfused

Thus indicating no life-threatening emergency

You need to do a secondary assessment

How do assess the patient’s airway?

•Look

•Listen

•Feel

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Look:

•Is the patient conscious

•How does the patient look? Are they in distress?

•Is the chest moving at all?

•Is the patient’s chest and abdomen moving in the

same direction?

•Is there fogging of the face mask

•Is the patient centrally cyanosed?

•Is the patient attempting to use their neck and

shoulder muscles to breathe?

•Does the patient have tracheal tug?

If your findings indicate airway

obstruction you need to call a

medical emergency. Choking

Skin

Colour

Texture

Facial expression

Breathing

Spontaneous

Laboured?

BEWARE of

silence and / or

inability to talk in

sentences.

Posture

For example

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Listen:

•Is there breath sounds at the nose or mouth?

•Is there air entry?

•Is the patient’s breathing noisy?

•What noises are coming from the patient’s airway?

In complete airway obstruction there are no breath sounds

In partial airway obstruction noises can be heard which indicate level

of obstruction e.g.,

Gurgling – may indicate the presence of fluid in the mouth or upper

airway

Snoring – may indicate pharynx is partially obstructed by the tongue

Crowing – may indicate laryngeal spasm

Inspiratory stridor – may be caused by an obstruction above the level

of the larynx BEWARE

Expiratory wheeze – may be caused from airway collapse during

expiration e.g., asthma

Feel:

Can you feel the presence of air movement?

Is there evidence of neck swelling?

If you detect an obstructed airway call for help immediately

Feel:

•What is the position of the trachea? Is it

central?

•Is there any evidence of surgical

emphysema or crepitus?

•Is there evidence of hyper-resonance on

percussion?

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Listen:

•Is the patient able to talk in full sentences?

•Can any noises be heard when breathing,

e.g., stridor, wheeze?

•Is there air entry, is it equal?

•What is the quality of breath sounds?

•Is there evidence of bronchial breathing?

It is important that supplemental oxygen be

administered to prevent end-organ damage or

cardiac arrest

In acute respiratory failure oxygen should be kept

above 90% on a pulse oximeter, this can be achieved

by administering high flow oxygen via a non-

rebreather mask

In chronic obstructive pulmonary

disease a PaO2 target of 66mm Hg

may be appropriate

Circulation:

Look:

•What is the patient’s colour?

•Are they sweaty?

•Is the capillary refill greater than 2 seconds?

•Does the patient have a reduced level of consciousness?

•What is the urine output?

•Are there signs of bleeding?

•Are there signs of abdominal distension?

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What is the patient’s BP?

What is the MAP? Indicates organ perfusion, aim for

>70mmHg

What is the pulse pressure?

Systolic minus Diastolic; indicator of stroke volume

Checking for signs of shock

Feel:

•Is the patient cool to touch? – What causes cool skin?

•On palpation what is the presence, rate, quality,

regularity and equality of peripheral and central pulses?

Listen:

Is the patient complaining of symptoms such as dizziness etc?

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Feel:

•How does the patient respond to pain?

•Is the patient unresponsive to all external stimuli?

•Blood glucose? VERY IMPORTANT

Listen:

•How does the patient respond to verbal stimuli?

•Is the patient able to speak?

•Is the speech slurred?

•Orientated?

Doctor / Nurse: Different styles

•Nurses are trained to be narrative and

descriptive

•Physicians are trained to be problem

solvers (packaging of information)

•Complicating factors: culture, the pecking

order, prior relationships

•Perceptions of teamwork depend on your

point of view

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Arrival of Medical Team

‘Packaged’ information for the MET

•Reason for MET call

•Latest set of vital signs

•Was the deterioration gradual or acute?

•What is the medical history?

•Medications and allergies?

•Organize a review of pathology results

Nursing staff responsibilities

Nurse 1 - the primary nurse who stays with the

patient, assists in cardiac compression, helping

maintain airway, assists in intubation

Nurse 2 - makes the MET call, collects

emergency equipment, attaches suction,

prepares medication, documents

HDU nurse - collects and attaches cardiac

monitor, monitors cardiac rhythm and

defibrillates as necessary

Medical staff responsibilities:

Team Leader maintains airways /

oxygenation and directs the resuscitation

/ treatment

Junior doctor assists, inserts IV cannulae

and administers medication, collects

blood and ABGs