Optimising care of the deteriorating patient

Serious incidents reported to the National Patient Safety Agency (2007) identified that 11% of deaths were due to patient deterioration not being recognised or acted on appropriately. Key areas for improvement included regular observations, early recognition of deterioration, improved communication and effective response to concerns. A large proportion of patients who suffer cardio-respiratory arrest in hospital have recognisable changes in routine observations during the preceding twenty-four hours including changes in vital signs, level of consciousness and oxygenation. One study showed that 60% of primary events investigated (deaths, cardiac arrests and unplanned ICU admissions) were preceded by documented abnormal physiology.1,2 Action taken during these early stages can prevent deterioration progressing to cardiac arrest, however. The National Confidential Enquiry into Patient Outcome and Death (2005) reported similar findings and admission to an Intensive Care Unit (ICU) was thought to have been avoidable in 21% of cases. Furthermore, communication failures between teams contributed to delays in referrals and in delivering appropriate essential care, which contributed to increased morbidity and mortality. In July 2007, the National Institute for Health and Clinical Excellence (NICE) issued guidelines on the monitoring and treatment of acutely ill patients in hospital. This included advice on the care of adult patients who are or become acutely ill while in hospital, and outlined how serious problems can be avoided by monitoring patients regularly and taking appropriate action if they show signs of becoming worse.3 The National Patient Safety Agency (NPSA) also undertook a programme of work which aimed to identify the underlying causes and contributing factors in deterioration incidents and explore how these factors interrelate. The purpose of this report was to illustrate why deterioration incidents happen and help NHS staff working in acute hospitals to improve patient safety.4 In light of this body of work, Patient Safety First developed the “deterioration intervention”, which focuses on ensuring earlier recognition of the deteriorating patient. The intervention addresses six key areas relating to deterioration:

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 which specifies which observations should be recorded and how often.

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 appropriate to the level of care they are providing.