The deteriorating patient

The failure to detect clinical deterioration in patients whether in acute-care settings or the community is a significant cause of preventable mortality and morbidity and a concern for patient safety.

Deterioration can be defined as new or increasing signs of pathological physiological disturbance in one or more organ systems, including:

• General: temperature changes; skin changes (pallor, flushing)
• Cardiovascular: changes in heart rate or rhythm
• Respiratory: changes in respiration rate
• Cerebral: altered mental state; slurred speech; discoordination
• Renal: decreased or excessive urine output (polyuria, oliguria)
• Gastro-intestinal: jaundice; abdominal pain; vomiting
• Neuromuscular: weakness; fasciculation; discoordination
• Endocrine: changes in blood sugar levels

These signs, as well as patient-reported concerns (“I think I’m going to die”) or concerns of relatives (“my child looks really ill”) are all ways to detect changes early enough to intervene and ‘rescue the patient’. 

Without detection and early intervention, deterioration may eventually result in the final common pathway of respiratory or cardiac arrest and the possibility of an avoidable death – often referred to as ‘failure to rescue’.

Data on the prevalence of failure to rescue in hospitals is recommended as a better marker of quality care and avoidable death than Standardised Mortality Ratio (SMR), which is a less specific measure of quality.

Improving patient safety and outcomes

Failure to rescue is only one of many causes of avoidable death.  An NHS study from 2015 showed that around 3.6% of all hospital deaths – which equates to several deaths a week in each hospital – may be avoidable. The proportion of these that were caused by a failure to detect clinical deterioration was not reported.

The failure to intervene and reverse deterioration will inevitably lead to worse outcomes, including longer hospital stays and morbidity caused by the deterioration itself, some of which such as cerebral or vascular injury, may be life-changing. 

There is, therefore, a strong link between the detection and reversal of deterioration and improved measures of both safety and outcome. The key to this improvement is early detection and suitably skilled resuscitation.

Early recognition of clinical deterioration

Early recognition of the deteriorating patient relies on regular and effective monitoring of the signs given above. Tools have been developed (e.g. NEWS, PEWS which we discuss below) to help nursing staff to recognise such deterioration, but these usually have application only in care settings where there is enough skilled staffing to use them.

Clinical gestalt is also important in the early detection of deterioration. In the community, especially when the patient is seen only intermittently, or is being cared for by family members or untrained staff, deterioration may in fact rely on ‘a hunch’ by a GP or close friend.

Utilising Modern Digital Systems

The CAREFUL platform serves as an essential tool in bridging the gaps between boundaries – that exist across time, clinical setting and geographical region.

With its ability to integrate real-time data, it ensures clinicians have immediate access to crucial patient information, from specialist input and review to subjective concerns voiced by patients or their families.

When organ systems are seen to exhibit signs of pathological disturbances, CAREFUL can swiftly coordinate care providers, ensuring rapid response and intervention. This is contrast to ad-hoc phone conversations, or worse, waiting for handover.

Whether in a hospital ward or a community setting, its real-time coordination enhances the efficiency of tools like NEWS2.

This not only supports the ‘early detection and call-for-help’ model but also ensures that no patient goes unnoticed, whether they’re under the watchful eyes of clinicians or the more sporadic care in community settings.

Through CAREFUL, the objective isn’t just care, but vigilant, timely, and informed care – a step closer to drastically reducing ‘failure to rescue’ instances and elevating overall patient safety standards.

National Early Warning Score (NEWS)

In response to the recognition of the need for early detection, the NHS set up the National Early Warning Score (NEWS) system, later modified to NEWS2.

NEWS2 is an evidence-based system that combines seven vital signs into a single  score (see chart above):

1. heart rate
2. respiration rate
3. oxygen saturation
4. temperature
5. blood pressure
6. ventilation and
7. level of consciousness 

This score can then be graphed and any significant change alerts the care team to look for causes of deterioration and, if necessary, start resuscitation.

NEWS has since been adapted to several other clinical areas including maternity and paediatrics and to include other parameters such as urine output.

Hospital wards and emergency departments

Such early detection systems are primarily useful in areas where regular observations of vital signs are part of the duties of care staff. Patients with higher acuity will tend to be monitored more regularly to detect more rapid deterioration. 

These are therefore most commonly deployed in secondary care areas such as hospital wards and emergency departments. The application of NEWS and similar scoring mechanisms is particularly useful in newly admitted patients and those in perioperative care, where complications such as anastomotic leaks or bleeds are more likely.

Suspected sepsis

The most dramatic benefit of early detection systems for patient deterioration is in the treatment of sepsis.

The evidence shows that the derangements in physiology caused by sepsis (‘incipient sepsis’) are detectable much earlier than previously thought. In particular, small changes in oxygen saturation and in respiratory rate can pre-date a rise in temperature by many hours.

The recognition of the burden of sepsis through the raising of awareness by organisations such as the Sepsis Trust have ensured that many patients are now receiving earlier treatment for sepsis.

Early intervention 

Once deterioration has been detected in a patient, the outcome – their ‘rescue’ – is dependent on the quality of the interventions that then follow.

For patients who need repositioning to improve their ventilation, or reduce their pain, general nursing staff can immediately prevent any further slide.

For those patients who may need more complex assessment and treatment, a doctor may be able to prescribe antibiotics, or more complex medication such as inotropes, in order to ensure adequate circulation.

For perioperative patients with a risk of complications, a surgical consultation may be necessary.

Recognising peri-arrest: calling for help

Even in the best run establishments, a deteriorating patient may not show signs of deterioration using the standard tools mentioned above, or they may deteriorate too rapidly for early detection. 

In this case, the key difference to survival will be the willingness of staff to call for help before the patient’s decline becomes irreversible.

The concepts of “peri-arrest” care and a “peri-arrest” call have now become commonplace. In this, staff do not wait until the patient has stopped breathing before calling for help. Senior clinicians can be summoned in time to provide leadership and decision-making in time to make a rescue. 

The concepts of ’peri-arrest‘ care and a ’peri-arrest‘ call have now become commonplace. In this, staff do not wait until the patient has stopped breathing before calling for help. Senior clinicians can be summoned to provide leadership and decision-making in time to make a rescue.

Training in resuscitation

‘Rescuing’ a patient in decline depends, in large part, on the prevention of cardiac and respiratory arrest. Where that does happen, however, there needs to be appropriate resuscitation attempts at cardiopulmonary resuscitation (CPR).

Not all patients will benefit from attempted CPR, and good-quality care must also include adequate advanced decision-making in patients who are near the end of their life, or who will not survive any attempt at CPR.
Nonetheless, a well-trained multidisciplinary team capable of rapid and effective resuscitation is an essential component of a high–quality healthcare establishment.

Almost all care staff are now required to take basic life support (BLS) courses yearly, and those that will be leading any resuscitation will require at least ILS (intermediate life support) or ALS (advanced life support).

The fact is, however, that cardiac arrest in hospital is the precursor to death in more than 50% of cases and fewer than 10% of patients survive an out-of-hospital cardiac arrest to discharge.

Summary

Improving outcomes in patients with clinical deterioration, whatever the setting relies on two things:

1. Early Detection
2. Early call-for-help
3. Appropriate immediate interventions
4. Skilled resuscitation where necessary

References

Vincent JL, Einav S, Pearse R, Jaber S, Kranke P, Overdyk FJ, Whitaker DK, Gordo F, Dahan A, Hoeft A. Improving detection of patient deterioration in the general hospital ward environment. Eur J Anaesthesiol. 2018 May;35(5):325-333. doi: 10.1097/EJA.0000000000000798 . PMID: 29474347; PMCID: PMC5902137. 

Hogan H, Zipfel R, Neuburger J, Hutchings A, DarziA, Black N et al. Avoidability of hospital deaths and association with hospital-wide mortality ratios: retrospective case record review and regression analysis BMJ  2015;  351 :h3239 doi:10.1136/bmj.h3239esfwq

Resources to support the safe adoption of the revised National Early Warning Score (NEWS2) https://www.england.nhs.uk/publication/patient-safety-alert-safe-adoption-of-news2/

Doyle DJ., (2018). Clinical Early Warning Scores: New Clinical Tools in Evolution. The Open Anesthesia Journal, 2018. DOI: 10.2174/2589645801812010026