Recognising and responding to serious deterioration and minimising harm

Serious deterioration in a patient’s physical, mental or cognitive health may occur at any time. In some circumstances, healthcare providers may observe this change while delivering health care and be required to assist. In these instances, healthcare services should have a process for healthcare providers to:

• Respond appropriately to a patient within their scope of clinical practice. For instance, the assistance that a physiotherapist may provide may differ from the assistance a nurse practitioner is able to provide, and will be dependent on the support, equipment and service offering of the healthcare service
• Call for emergency assistance. In most instances this would be for an ambulance service; however, it may include direct transfer arrangements or emergency consultation with specialist healthcare providers based on formal or informal partnerships
• Notify other relevant healthcare providers, carers and family members.

Establishing processes to respond to serious deterioration and escalation of care and calling for emergency assistance will ensure healthcare providers can respond consistently and effectively. The mechanisms need to be appropriate for the size and location of the healthcare service and the population it serves. Other considerations include the available resources, healthcare provider skills mix and capacity to engage specialist help.

Multiple mechanisms may be necessary in escalation systems to allow different responses to varying levels or types of deterioration. These mechanisms may include:

• Landline phones
• Mobile or satellite-navigation phones
• Two-way radio devices
• Dedicated mobile, on-call and emergency telephone numbers.

Consider:

• Distance and location of response services (ambulance or aerial medical service) providers
• Mechanisms that can assist the response service to locate the patient
• Backup systems or processes in the event of equipment failure
• Processes for maintaining any relevant equipment
• Training on the processes for escalating care, including for new, casual, locum, and agency members of the workforce.

In rural and remote community settings it may be helpful to develop processes for obtaining emergency advice from specialist providers - such as ambulance, aerial medical services, general practitioner, emergency or mental health services, or intensive care clinicians - by phone, video link, or two-way radio.

• Develop a process to support healthcare providers to:
  • recognise deterioration in a patient’s physical, mental or cognitive health
  • respond to a patient within their scope of practice and call for emergency assistance
  • notify a patient’s other relevant healthcare providers, carers or family when health care is escalated
• Ensure that healthcare providers and the workforce have the necessary skills and equipment to recognise and respond to serious deterioration within their scope of clinical practice

• What are some examples of serious deterioration in a patient?
• What emergency assistance would be called for in the event of a patient experiencing serious deterioration, and why?
• What training do healthcare providers complete to support them to respond to a patient experiencing serious deterioration?

• Healthcare service’s process for recognising and responding to serious deterioration or distress and escalating care
• Training documents about mechanisms for escalating care and calling for emergency assistance
• Posters and other resources such as flow charts that are accessible and displayed in appropriate locations for the workforce

Australian Commission on Safety and Quality in Health Care: NSQHS Standards User Guide for health service organisations providing care for patients with cognitive impairment or at risk of delirium. Provides practical support for healthcare services where specific efforts or additional attention is required to meet the health needs of this patient population, based on the National Safety and Quality Health Service (NSQHS) Standards. The principles and strategies outlined in this resource are broadly applicable.

Australian Commission on Safety and Quality in Health Care: NSQHS Standards User Guide for health services providing care for people with mental health issues. Provides practical support for healthcare services where specific efforts or additional attention is required to meet the health needs of this patient population, based on the National Safety and Quality Health Service (NSQHS) Standards. The principles and strategies outlined in this resource are broadly applicable.

Risk of self-harm

Adverse outcomes relating to patients who are distressed or have thoughts of self-harm or suicide or who have self-harmed are prevented through early recognition and effective response. Always consider self-harm seriously.

Healthcare services should consider whether a patient may be at risk of experiencing harm from others. The level of risk may be increased by factors such as alcohol or drug use, disinhibition and other risk-taking behaviours, domestic and family violence, intimate partner violence, child abuse, discrimination and neglect.⁴⁸

Risk of harm to others

Healthcare services should consider how to respond appropriately to a patient who discloses thoughts of harm to others or if they are assessed as representing a risk to others. Situations where there is a higher risk of harm to others include where:

• Patients are experiencing mental health issues
• History of violence is evident or known
• Abuse of alcohol and/or other drugs is present or known
• Neglect to children is evident or known. 

Responding to patients who present a risk of harm to others may include referring to a specialist mental health service for assessment or to an emergency service   if a crisis response is needed, and notification to child welfare services. Information about when legislation requires crisis intervention should be made available to the workforce, patients, families and carers.

• Develop and implement a process to:
  • respond to patients who are distressed, have expressed thoughts of self-harm or suicide, or have self-harmed
  • respond to patients who present a risk of harm to others

• Facilitate training for the workforce to effectively recognise and respond to patients who are distressed or exhibit aggression, have expressed thoughts of self-harm or suicide, or have self-harmed
• Source and make information available on accessing other mental health services beyond the scope of the service. In most instances this will involve referring a patient to a general practitioner, community mental health service or hospital emergency department

• How does the workforce respond to patients who are distressed, have expressed thoughts of self-harm or suicide, or have self-harmed?
• What information on other services can the healthcare provider give to patients when their healthcare needs are beyond the scope of the healthcare service?

• Processes that outline collaborative processes for identifying and treating patients at risk of self-harm or suicide, or who have self-harmed
• Training documents about identifying and responding to patients at risk of self-harm or suicide, or who have self-harmed
• Patient resources about strategies for accessing health services beyond the scope of the service

Australian Commission on Safety and Quality in Health Care: NSQHS Standards User Guide for health services providing care for people with mental health issues. Provides practical support for healthcare services where specific efforts or additional attention is required to meet the health needs of this patient population, based on the National Safety and Quality Health Service (NSQHS) Standards. The principles and strategies outlined in this resource are broadly applicable.

Mental Health First Aid. Offers skills based, early-intervention training programs to mobilise and empower communities by equipping people with the knowledge and confidence to recognise, connect and respond to someone experiencing a mental health problem or mental health crisis.

Australian Government Department of Health: Mental health and suicide prevention resources. A list of resources about mental health and suicide prevention in Australia.

Life in Mind: Suicide Prevention. A knowledge exchange portal providing translated evidence, policy, data and resources in suicide prevention.  

National Institute for Health and Care Excellence: Violence and aggression: short-term management in mental health, health and community settings. Aims to safeguard both staff and people who use services by helping to prevent violent situations and providing guidance to manage them safely when they occur.