Recognising and responding to acute illness in hospital patients.
VOL: 103, ISSUE: 32, PAGE NO: 23
Evidence shows that patients who become, or who are at risk of becoming, acutely ill on general hospital wards receive suboptimal care (National Confidential Enquiry into Patient Outcome and Death, 2005; Seward et al, 2003; McQuillan et al, 1998). To reduce the morbidity and mortality associated with such failures, NICE (2007) has published its first short clinical guideline offering practical advice on how to recognise and respond to acute illness in adult hospital patients.
Evidence shows that patients who become, or who are at risk of becoming, acutely ill on general hospital wards receive suboptimal care (National Confidential Enquiry into Patient Outcome and Death, 2005; Seward et al, 2003; McQuillan et al, 1998). To reduce the morbidity and mortality associated with such failures, NICE (2007) has published its first short clinical guideline offering practical advice on how to recognise and respond to acute illness in adult hospital patients. BACKGROUND
The ageing population, increasing complexity of medical and surgical interventions, and shorter length of hospital inpatient stays mean patients in hospital are at greater risk of becoming acutely ill and may have to be admitted to critical care. Clinical deterioration can occur at any stage of an illness but at certain times patients will be more vulnerable, such as at the onset of illness, during surgical or medical interventions and while recovering from critical illness. Patients on general wards and in A&E departments who are at risk of deteriorating can often be identified by changes in physiological observations before a serious adverse event occurs. Correct interpretation of these changes can result in a quick and appropriate response, minimising the chance of serious adverse events, such as cardiac arrest. The care patients receive on general adult wards after transfer from critical care may also have a significant impact on patient outcomes. NCEPOD (2005) identified the main causes of such substandard care as delayed recognition and institution of inappropriate therapy that subsequently culminated in a late referral to critical care professionals. On several occasions these factors were aggravated by poor communication between the acute and critical care medical teams. NCEPOD also identified instances when medical consultants’ lack of awareness of their patients’ deteriorating health led to their critical care admission. It was felt that this was avoidable in 21% of cases and that suboptimal care contributed to about a third of deaths that occurred. Any intervention delivered to a patient whose condition deteriorates, or who shows signs of deteriorating unexpectedly, should aim to reduce mortality, morbidity and length of stay both in the hospital overall and in a critical care area. In addition to benefiting patients, these interventions could lead to substantial cost savings to the NHS through, for example, reductions in critical care admission and readmission. OVERALL RECOMMENDATIONS
NICE (2007) makes recommendations for measuring and recording physiological observations. The importance of a full clinical assessment and of tailoring the written monitoring and management plans to each patient’s clinical circumstances are stressed, as is the importance of training. Routine measurements should be accurately taken and recorded on admission or initial assessment and as part of routine monitoring. They should be undertaken by staff who understand their clinical relevance and linked to a graded track and trigger system so care can be escalated appropriately when a patient’s clinical condition gives reason for concern. In the absence of clear evidence to identify a best model of response, the guidance recommends the optimal configuration of response be agreed and delivered locally. It makes clear that the clinical team must have the necessary competencies and that both the critical care consultants and the team caring for the patient on the ward be involved in those instances when admission to critical care is considered necessary. Although the pressure on beds in both critical care and inpatient wards, and the difficulties of ensuring smooth, planned transfer from critical care to the wards are recognised, the guidance recommends that transfer out of critical care between 10pm and 7am be avoided. If this does occur, it should be documented as an adverse incident. Again, transfers should involve both the transferring team from critical care and the team on the receiving ward. Handover from critical care to a ward should have a formal structure that includes: - A summary of critical care including diagnosis and treatment; - A monitoring and assessment plan; - A plan for ongoing treatment; - A physical treatment plan; - A summary of the patient’s psychological and emotional needs; - Specific communication/language needs. PATIENT-CENTRED CARE
The guidance highlights the importance of providing reassurance and evidence-based information to both patients and their carers at a time when they are likely to be experiencing significant anxiety. Treatment and care should take into account patients’ needs and preferences, be culturally appropriate and, where possible, patients should have the opportunity to make informed decisions with the health professionals. If patients do not have the capacity to make decisions for themselves, Department of Health (2001) guidelines and the Mental Capacity Act 2005 code of practice (Department for Constitutional Affairs, 2007) should be followed. PHYSIOLOGICAL OBSERVATIONS
The aim of physiological observations is to identify patients whose clinical condition is deteriorating or is at risk of doing so. All adults who are admitted to acute hospital settings should have, as a minimum, the physiological observations listed in the box (see below), recorded by appropriately trained staff at the time of their admission or initial assessment, together with a written monitoring plan. Additional observations may be considered in specific clinical circumstances (see box). The plan should be based on a track and trigger system and specify observations that should be recorded and how often (at least every 12 hours, increasing if abnormal physiology is detected). It should also take account of the diagnosis, any co-morbidities and the agreed treatment plan. TRACK AND TRIGGER SYSTEM
The track and trigger system should use a locally agreed scoring system that allows a graded response strategy for patients who are identified as being at risk of deteriorating clinically. The system should be reviewed regularly to optimise its sensitivity and specificity. It should define the parameters to be measured and the frequency of observations, and should include an explicit statement of the parameters, cut-off points or scores that should trigger a response - although a response can be triggered by clinical concern even if observation measurements do not require one. There should be three levels of response: - Low-score group - increased frequency of observations and nurse in charge alerted; - Medium-score group - urgent call to the team responsible for care and to staff with core competencies for acute illness; - High-score group - emergency call for an immediate response from a team with critical care competencies and diagnostic skills, which should include a medical practitioner with skills to assess the patient as well as advanced airway management and resuscitation skills. Aside from those having a cardiac arrest, patients identified as a clinical emergency should be treated in the same way as those in the high-score group and the graded response system should be bypassed. CONCLUSION
The guidance aims to improve the care of patients who are acutely ill in hospital by making evidence-based recommendations on the best way to identify and manage them, and to address the shortcomings in care identified by NCEPOD (2005). It was developed for all who plan, deliver or experience hospital inpatient clinical care, and should inform the development of local policies and procedures governing the acute care of adults in hospital. PHYSIOLOGICAL OBSERVATIONS
Minimum observations - Heart rate - Respiratory rate - Systolic blood pressure - Level of consciousness - Oxygen saturation - Temperature Possible additional observations - Hourly urine output - Biochemical analysis, such as lactate, blood glucose, base deficit, arterial pH - Pain assessment