I do not own this content. It is a slide show presented by John Senior.

1. 8/08/2012
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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