Rationale for rapid response to acute physiological deterioration in hospital

1. Rationale for rapid response to acute physiological deterioration in hospital Dr Stephen Hull Consultant Physician/Endocrinologist Safer Patients Initiative Clinical Lead, Mater Hospital, Belfast HSC Trust

2. Safer Patient Initiative Aims Crash Calls- decrease by 30% Mortality- decrease by 15% Reduce Adverse Events Reduce ICU LOS Early warning scores and rapid response may help all of these?

3. Care of the critically ill patient is frequently sub-optimal Confidential enquiry into ICU admissions 40% admissions avoidable 37% admissions occurred late Lack of attention to Airway, Breathing and Circulation McQuillan P et al BMJ 1998;316:1853-1858 

4. Can cardiac arrest be prevented? 30-70% patients who suffer a cardiorespiratory arrest in hospital have signs of physiological deterioration prior to the arrest and failure to respond appropriately increases the likelihood of arrest. (Smith AF & Wood J, 1998; Schein RMH et al, 1990; McGloin H et al 1999)

5. Outcome from cardiorespiratory arrest

6. �Early warning scores� Various scoring systems based on changes in physiological parameters have been developed and validated in medical and surgical patients ( Subbe CP et al, 2001; Stenhouse C et al, 1999)

7. CREST Guidelines on the use of physiological early warning scores, May 2007 Developed following RQIA report Early warning score should be used in all acute hospitals Need for policy, training, agreed local action protocols including possible adaptations for maternity/paeds etc, audit Examples of charts, action protocol and audit tool

8. ABOUT THIS PRESENTATION: This presentation has been written to raise awareness of the NICE clinical guideline on acutely ill patients in hospital. Any patient in hospital may become acutely ill. This guideline covers recognition of and response to acute illness in adults in hospital and has been written for all healthcare professionals in acute care who have direct contact with patients. You may want to hand out copies of the quick reference guide at your presentation so that your audience can refer to it. The quick reference guide can be downloaded from www.nice.org.uk/C050quickrefguide or you can order copies � for more details please see the notes of the �Access the guideline online� slide. You can add your own organisation�s logo alongside the NICE logo. We have included notes for presenters amplifying the content of the slides: please feel free to adapt, amend or remove these as you see necessary. The clinical guideline implementation tools symbol found in the bottom right-hand corner of some slides in this presentation is used to clearly distinguish advice on implementing the recommendations of the guideline from the recommendations themselves. Slides with the tools symbol highlight suggested actions that may be useful when implementing recommendations. DISCLAIMER This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself.ABOUT THIS PRESENTATION: This presentation has been written to raise awareness of the NICE clinical guideline on acutely ill patients in hospital. Any patient in hospital may become acutely ill. This guideline covers recognition of and response to acute illness in adults in hospital and has been written for all healthcare professionals in acute care who have direct contact with patients. You may want to hand out copies of the quick reference guide at your presentation so that your audience can refer to it. The quick reference guide can be downloaded from www.nice.org.uk/C050quickrefguide or you can order copies � for more details please see the notes of the �Access the guideline online� slide. You can add your own organisation�s logo alongside the NICE logo. We have included notes for presenters amplifying the content of the slides: please feel free to adapt, amend or remove these as you see necessary. The clinical guideline implementation tools symbol found in the bottom right-hand corner of some slides in this presentation is used to clearly distinguish advice on implementing the recommendations of the guideline from the recommendations themselves. Slides with the tools symbol highlight suggested actions that may be useful when implementing recommendations. DISCLAIMER This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself.

9. Adult patients in acute hospital settings, including patients in the emergency department for whom a clinical decision to admit has been made, should have: physiological observations recorded a clear written monitoring plan Physiological observations should be recorded and acted upon by staff who have been trained and are competent. Assessment and monitoring NOTES FOR PRESENTERS: The guideline recommendation in full says: ? Adult patients in acute hospital settings, including patients in the emergency department for whom a clinical decision to admit has been made, should have: � physiological observations recorded at the time of their admission or initial assessment - 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 comorbidities and agreed treatment plan. Physiological observations should be recorded and acted upon by staff who have been trained and are competent to undertake these procedures and understand their clinical relevance.NOTES FOR PRESENTERS: The guideline recommendation in full says: ? Adult patients in acute hospital settings, including patients in the emergency department for whom a clinical decision to admit has been made, should have: � physiological observations recorded at the time of their admission or initial assessment - 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 comorbidities and agreed treatment plan. Physiological observations should be recorded and acted upon by staff who have been trained and are competent to undertake these procedures and understand their clinical relevance.

10. Assessment and monitoring: physiological observations Initial assessment should include at least: heart rate respiratory rate systolic blood pressure level of consciousness oxygen saturation temperature (hourly urine output) NOTES FOR PRESENTERS: Initial assessment of the patient should include the above. The next slide indicates the monitoring frequency of these and other observationsNOTES FOR PRESENTERS: Initial assessment of the patient should include the above. The next slide indicates the monitoring frequency of these and other observations

11. Physiological track and trigger systems should be used to monitor all adult patients in acute hospital settings. Observations should be monitored at least every 12 hours. Senior-level decision to increase or decrease the frequency of observations. Increase (graded response) if abnormal physiology is detected. Assessment and monitoring: track and trigger systems NOTES FOR PRESENTERS: The guideline recommendation in full says: ? Physiological track and trigger systems should be used to monitor all adult patients in acute hospital settings. � 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 the recommendation on graded response strategy.NOTES FOR PRESENTERS: The guideline recommendation in full says: ? Physiological track and trigger systems should be used to monitor all adult patients in acute hospital settings. � 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 the recommendation on graded response strategy.

12. A graded response strategy for patients identified at risk should be agreed and delivered locally. It should consist of three levels. Low-score group. Medium-score group. High-score group. Response NOTES FOR PRESENTERS: The NICE recommendation says: ? A graded response strategy for patients identified as being at risk of clinical deterioration should be agreed and delivered locally. It should consist of the following three levels. � Low score Medium score High score The next slide gives the details of the responses required for each category. NOTES FOR PRESENTERS: The NICE recommendation says: ? A graded response strategy for patients identified as being at risk of clinical deterioration should be agreed and delivered locally. It should consist of the following three levels. � Low score Medium score High score The next slide gives the details of the responses required for each category.

13. Graded response strategy NOTES FOR PRESENTERS: For patients identified in the low-score group it is recommended that the frequency of observations is increased and the nurse in charge alerted. For patients identified in the medium-score group two responses are needed, firstly an urgent call to the team with primary medical responsibility for the patient, and simultaneously a call to personnel with core competencies for acute illness. These competencies can be delivered by a variety of models at a local level, such as a critical care outreach team, a hospital-at-night team or a specialist trainee in an acute medical or surgical specialty. Appropriate interventions should be initiated. For those identified with a high score, the response required is an emergency call to the team with critical care competencies and diagnostic skills. The team should include a medical practitioner skilled in the assessment of the critically ill patient, who possesses advanced airways management and resuscitation skills. There should be an immediate response and the appropriate interventions initiated.NOTES FOR PRESENTERS: For patients identified in the low-score group it is recommended that the frequency of observations is increased and the nurse in charge alerted. For patients identified in the medium-score group two responses are needed, firstly an urgent call to the team with primary medical responsibility for the patient, and simultaneously a call to personnel with core competencies for acute illness. These competencies can be delivered by a variety of models at a local level, such as a critical care outreach team, a hospital-at-night team or a specialist trainee in an acute medical or surgical specialty. Appropriate interventions should be initiated. For those identified with a high score, the response required is an emergency call to the team with critical care competencies and diagnostic skills. The team should include a medical practitioner skilled in the assessment of the critically ill patient, who possesses advanced airways management and resuscitation skills. There should be an immediate response and the appropriate interventions initiated.