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 “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”.” and our December 2008 What’s New in the Patient Safety World column “