Detecting and recognising acute deterioration, and escalating care
Acute deterioration is detected and recognised, and action is taken to escalate care.
Monitoring and tracking changes in vital signs and other observations over time plays a significant role in detecting acute deterioration. Acute deterioration may occur at any time during a patient’s admission. If monitoring is intermittent or infrequent, or does not include the right parameters, acute deterioration may not be detected, and recognition and appropriate treatment may be delayed. This can result in serious adverse outcomes for patients.1,2-4
Frequency of monitoring often varies5, perhaps because of differences in individual clinicians’ clinical judgement, poor communication among teams, varying views about the importance of monitoring, and a lack of guidelines to inform practice.6-8 It is therefore necessary to develop systems to ensure that vital signs and other parameters for detecting deterioration in a patient’s physical, mental or cognitive condition are being measured. These systems need to ensure that the right parameters are monitored for each patient, and that monitoring occurs at the appropriate frequency (number of times per day) and for the appropriate duration (number of days or weeks). Consistent documentation of measured vital signs and other observed indicators is important for changes to be tracked over time.
Recognising acute deterioration relies on detecting, understanding and interpreting abnormal vital signs and other observations, and escalating care appropriately. This is a complex process that requires knowledge of:
- How to conduct the appropriate observations
- What indicates acute deterioration for individual patients
- Appropriate treatment for the cause of the acute deterioration
- Which clinicians have the skills to provide this treatment
- Who is available to provide this treatment, considering the time of day or day of the week
- How to contact the appropriate clinicians and communicate information about the abnormality
- The appropriate time frame for clinicians to respond
- Alternative or backup options for obtaining a response.
Recognition systems include identifying the requirements for escalating care. These may be documented on vital sign observation charts, in policies and guidelines, and in escalation protocols. Escalation protocols provide details of the criteria, parameters and thresholds that indicate acute deterioration, the action to be taken when deterioration is detected, the process of calling for help and the expected responses.
A graded response to acute deterioration is needed. Patients whose acute deterioration is detected and recognised during the early stages need clinical care and treatments to prevent further deterioration. Patients who deteriorate very suddenly or severely need a rapid response from clinicians with advanced skills.
It is vital to the effectiveness of recognition and response systems that escalation protocols are developed with local knowledge of the individual clinical area or health service organisation. Criteria for escalation that are appropriate for a large tertiary metropolitan hospital will not necessarily be appropriate for a small rural hospital. The availability of resources and clinical expertise also means that response actions vary considerably from one organisation to another. Different protocols may be needed in different locations within a health service organisation, such as in specialist mental health services, the emergency department or standalone outpatient areas. Different protocols may also be needed for escalation of acute physiological deterioration and escalation for deterioration in a person’s mental state.
- McQuillan P, Pilkington S, Allan A, Taylor B, Short A, Morgan G, et al. Confidential inquiry into quality of care before admission to intensive care. BMJ 1998;316(7148):1853–8.
- Kause J, Smith G, Prytherch D, Parr M, Flabouris A, Hillman K, et al. A comparison of antecedents to cardiac arrests, deaths and emergency intensive care admissions in Australia and New Zealand, and the United Kingdom. The ACADEMIA study. Resuscitation 2004;62(3):275–82.
- Schein RM, Hazday N, Pena M, Ruben BH, Sprung CL. Clinical antecedents to in-hospital cardiopulmonary arrest. Chest 1990;98(6):1388–92.
- Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet 2014;383(9920):911–22.
- Van Leuvan CH, Mitchell I. Missed opportunities? An observational study of vital sign measurements. Crit Care Resusc 2008;10(2):111–5.
- Odell M, Victor C, Oliver D. Nurses’ role in detecting deterioration in ward patients: systematic literature review. J Adv Nurs 2009;65(10):1992–2006.
- Cardona-Morrell M, Prgomet M, Lake R, Nicholson M, Harrison R, Long J, et al. Vital signs monitoring and nurse-patient interaction: a qualitative observational study of hospital practice. Int J Nurs Stud 2016;56:9–16.
- National Patient Safety Agency (UK). Healthcare risk assessment made easy. London: National Health Service; 2007.