What’s New in the Patient Safety World
August 2007
Responding
to Patients with Clinical Deterioration
Given IHI’s initiatives on rapid response teams and Joint Commission’s new 2008 National Patient Safety Goal requiring a
plan to “Improve recognition and response to changes in a patient’s condition”
, it is most timely that 2 UK organizations have come out with guidelines on
clinical deterioration in acutely hospitalized patients. The UK NHS National
Patient Safety Agency just published its report “Safer care for the
acutely ill patient: learning from serious incidents” and NICE
(National Institute for Health and Clinical Excellence) has just released its
clinical guideline “Acutely
ill patients in hospital. Recognition of and response to acute illness in
adults in hospital” .
The
National Patient Safety Agency report analyzed serious patient incidents and
found a large number of cases in which patients’ clinical deterioration was
either not recognized early or not acted upon. Subthemes were that vital signs
were often not appropriately observed or there was lack of recognition or lack
of response to deteriorating vital signs. The second major theme was that
rescuscitation skills and/or inadequate equipment often caused problems with
cardiorespiratory rescuscitation. Action points recommended include not only
providing appropriate standards and training, but also performing audits of
codes and emergency equipment and standardization of rescuscitation equipment.
The
NICE guidelines focus on 3 key areas: (1) identification of patients at risk
for clinical deterioration or actually already deteriorating (2) response
strategies, including timing, communication, and coordination of care between
critical care teams and other specialties and (3) discharge of patients from
critical care areas back to ward-based care, including monitoring requirements
and timing of transfer. They stress the need for physiological track and
trigger systems that help identify those patients in need of closer attention
or intervention and use of a graded response strategy to those identified by
the track and trigger scoring system. They discuss several scoring systems
available. They have a good discussion of the key elements in the handover when
patients are transferred back to the wards from critical care units. An
interesting recommendation is that patients should not be transferred back to
wards between 22:00 and 07:00 unless absolutely necessary. This was an
evidence-based recommendation, though most of the studies were done in the UK,
Canada, Australia, or countries other than the United States.
The
NICE documents are well worth reading, particularly if one is interested in the
evidence behind the recommendations.
Note
that ICSI (Institute for Clinical Systems Improvement) has also just updated
its Rapid Response Team Protocol .
Many
hospitals participating in IHI’s 100,000 Lives Campaign did not choose the
Rapid Response Team initiative for a variety of reasons. Hospitals should recognize
that they have not only a significant opportunity to improve patient and
quality outcomes but also considerable opportunity to improve economic
outcomes. Through good identification and response to the clinically
deteriorating patient, one may avoid costly ICU admissions and readmissions and
reduce ICU lengths of stay. The UK work, however, identified the current lack
of a good evidence base on the cost-effectiveness of these systems.
Update: See also our November 27, 2007 Patient Safety Tip of the Week “More on Rapid Response Teams” and our December 2008 What’s New in the Patient Safety World column “Rapid Response Teams Don’t Live Up to Expectations” our April 2009 What’s New in the Patient Safety World “Early Emergency Team Calls Reduce Serious Adverse Events” and our December 29, 2009 Patient Safety Tip of the Week “Recognizing Deteriorating Patients”.
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