This intervention focuses on reducing risks to patients from deterioration through early recognition and prompt action
Keywords: Clinical deterioration, Physiological observations, Response strategy
The aim is to prevent harm and reduce in-hospital cardiac arrest and mortality rates through earlier recognition and treatment of deteriorating patients.
Clinical deterioration can occur at any time in a patient’s illness but is more common following an emergency admission, during recovery from serious illness and following surgery. Failure to recognise deterioration and act appropriately may culminate in cardio-respiratory arrest. Fewer than 20% of patients who suffer cardiac arrest survive to discharge.
The intervention involves implementing key elements of the NICE (2007) guidance Acutely Ill Patients in Hospitaland other elements to improve response and communication.
To detect early deterioration, accurate and timely observations are necessary. Timely and appropriate responses are assisted by a track-and-trigger system, an agreed escalation policy, a competent team capable of rapid response and clear communication between staff.
This intervention addresses six key areas relating to deterioration, which are outlined below.
1. Physiological observations should be recorded for all adult patients in acute hospital settings, including patients in the emergency department for whom a clinical decision to admit has been made. This should be done at the time of their admission or initial assessment.
In addition, there should be 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 co-morbidities;
- Agreed treatment plan.
Admission documentation completed by the admitting medical staff should indicate clearly the observations to be carried out and the frequency with which they should be done.
At this early stage, ceilings of therapy should also be established for patients who are acutely ill and who will not benefit from an escalation of therapy beyond ward-based care. This may require training for admitting medical and nursing staff and be assisted by the use of a standard admissions pro forma that includes a section to indicate frequency of observations.
2. Physiological observations should be recorded and acted on by staff who have been trained to undertake these procedures and understand their clinical relevance. This training should include assessment against competencies in monitoring, measurement, interpretation and prompt response that are appropriate to the level of care they are providing.
Local guidelines and protocols for topics such as physiological observation frequency and response strategies lay an important foundation for educating staff in the desired practices, but these alone will not guarantee improved outcomes. Education and training should be provided to ensure staff have the necessary knowledge and competencies, and they should be assessed to ensure they can demonstrate that they have these.
3. Physiological track-and-trigger systems should be used to monitor all adult patients in acute hospital settings.
A track-and-trigger system can only be effective if observations are reliable. 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 no. 4 below) and a track-and-trigger system is an effective way of prompting this.
4. There should be a graded response strategy for patients identified as being at risk of clinical deterioration which should be agreed and delivered locally. It should consist of three levels (see The ‘How to Guide’ for Reducing Harm from Deterioration).
All staff need to be aware of the graded response strategy. It needs to be easily available so that it can be referred to and any necessary action taken without delay.
A critical care outreach team, rapid response team or medical emergency team who have the appropriate skills for dealing with rapidly deteriorating patients should have training as one of their functions, educating ward and medical staff in these skills.
Training programmes should be run on a rolling basis as staff change frequently. Training and accreditation records should be kept. Uptake of training and assessment should be monitored.
5. An escalation protocol should be in place which supports the response strategy and empowers nursing staff by providing timescales and procedures for escalation of concern (see the How to Guide for an example).
Staff should be able to articulate their responsibilities and the action to be taken for each level of risk. The response may be displayed on the observation chart. There should be a trust-wide system for contacting the rapid response, outreach or medical emergency team.
6. A communication tool should be used for all patients to escalate concern between team members.
The tool discussed in the How to Guide is SBAR (situation-background-assessment-recommendation) but there are others which are widely used such as RSVP (reason-story-vital signs-plan). An example of the RSVP tool can be found in the guide.
Case study: Salford Royal NHS Foundation Trust
Installing an old-fashioned sphygmomanometer beside every hospital bed may seem at odds with 21st century quality healthcare. However, this has already contributed to a 30% reduction in unexpected cardiac arrest outside critical care, which Salford Royal NHS Foundation Trust has achieved since signing up to Patient Safety First in 2008.
An expert multidisciplinary steering group investigated the trust’s rate of unexpected cardiac arrests. While this is within national averages, the trust wanted to learn how it could improve. The group found there was an opportunity to further enhance the standard of recording and responding to acutely ill patients. The solution chosen was to move away from electronic clinical observations and return to using the manual blood pressure machine.
‘At first the idea that taking blood pressure manually could be the more accurate option seemed crazy,’ recalls Peter Murphy, assistant director of nursing for quality improvement.
‘In fact it makes good sense,’ he adds. ‘When you take blood pressure manually, you also check the pulse and touch the patient’s skin and look at their face, all very important clinical observations.’
The sphygmomanometer’s reappearance, however, will be a gradual process with the pace dictated at ward level – an essential part of Patient Safety First’s philosophy of small steps to achieve sustained change.
‘Our success is due to executive support, with our trust board signed up to the whole programme,’ says Mr Murphy, who has been closely involved from the outset in his previous role as nurse consultant in critical care. ‘But that support is very different from target-setting.’
Change, he explains, is decided at ward level. ‘It is a continuing opportunity for healthcare teams to redefine their roles and redesign their own working practice. I’m merely a spokesperson for the work that is being done by my colleagues.’
During the campaign’s first year, the deterioration intervention has been tested in 12 wards at Salford with the highest rates of unexpected cardiac arrest. The expert group, which included all key stakeholders from consultants to porters, constructed a driver diagram during a ‘highly focused’ half day; this diagram is now part of Patient Safety First’s suggested guidance. This democratic approach to patient safety is reflected in the change package.
A code-red alert is designed to ensure that every member of staff on the ward, from housekeeper to visiting consultant, is aware that a patient has suddenly become unwell. Identified by a red spot beside the patient’s name on the board by the nurses’ desk, the alert is also communicated verbally in ‘a matter of seconds’ so that ‘everybody is watching out for that person’, explains Mr Murphy.
A nurse-led initiative to respond to acute illness means that, when appropriate in response to an elevated early warning score, nurses are encouraged to first sit the patient up, give oxygen and ensure that medication is up to date.
A checklist, identifying essential components of the regular consultant ward round, has proved popular throughout the hospital. This list ensures that every component is covered reliably for every patient.
Underpinning these life-saving initiatives is a decision-making tool on escalation of care. It provides clarity for staff to reliably identify in advance (and discuss in a ‘ward safety huddle’) whether a seriously ill patient will benefit from resuscitation if they suffer a cardiac arrest.
After 12 months, the view is there is still a long way to go. The good news, says Mr Murphy, is that safer care for patients appears to bring greater job satisfaction for nurses. There is a definite suggestion that these issues are linked: staff involved in Patient Safety First come to work every day to provide improved care to patients, he says.
NICE (2007) Acutely Ill Patients in Hospital: Recognition of and Response to Acute Illness in Adults in Hospital. London: NICE.