What signs indicate a patient is deteriorating?

From the Guidelines

Patient deterioration is most accurately identified by monitoring changes in vital signs, including increased or decreased heart rate, abnormal blood pressure, elevated respiratory rate, fever or hypothermia, and decreased oxygen saturation, as emphasized by the Society of Critical Care Medicine guidelines 1. These guidelines, published in 2024, highlight the importance of bedside staff promptly and accurately acquiring and documenting all vital signs, with significant abnormalities urgently acted upon. Key signs of deterioration include:

• Changes in vital signs, such as increased or decreased heart rate, abnormal blood pressure, elevated respiratory rate above 20 breaths per minute, fever or hypothermia, and decreased oxygen saturation below 94% on room air
• Altered mental status, manifesting as confusion, disorientation, agitation, lethargy, or unresponsiveness
• Decreased urine output, suggesting poor perfusion or kidney dysfunction
• Worsening pain despite treatment, new or increasing shortness of breath, changes in skin color, and unexplained bleeding or bruising
• Laboratory abnormalities, such as rising lactate levels, decreasing hemoglobin, electrolyte imbalances, or worsening kidney function The guidelines also suggest that patients, families, and care partners should be empowered to alert staff or response teams about signs of deterioration 1, and that a quality improvement process should be part of a Rapid Response System 1. According to the guidelines, vital signs are the most widespread triggers for summoning additional help and evaluation, and are also the core component of multiparameter early warning systems 1. Therefore, healthcare providers should prioritize the acquisition and documentation of accurate vital signs, and empower patients and families to recognize and report signs of deterioration, in order to facilitate prompt intervention and improve patient outcomes 1.

From the Research

Signs of Patient Deterioration

• Changes in vital signs, such as increased heart rate, decreased blood pressure, and decreased oxygen saturation 2
• Decreased level of consciousness, such as confusion, disorientation, or decreased responsiveness 2
• Increased respiratory rate, decreased lung sounds, or other signs of respiratory distress 3, 4
• Decreased urine output, increased creatinine levels, or other signs of acute kidney injury 5
• Signs of shock, such as cool or clammy skin, decreased peripheral pulses, or decreased capillary refill 6

Monitoring and Assessment

• Regular observations and documentation of vital signs and other clinical parameters are crucial in recognizing patient deterioration 2
• Close monitoring of patients at risk of deterioration, such as those with severe respiratory failure or acute kidney injury 5, 3, 4
• Use of early warning systems, such as the Modified Early Warning Score (MEWS), to identify patients at risk of deterioration 2

Interventions

• Fluid resuscitation with crystalloids or colloids to maintain adequate blood volume and perfusion 6, 5
• Oxygen therapy, including high-flow nasal cannula oxygen, to maintain adequate oxygenation 3, 4
• Other interventions, such as vasopressors, inotropes, or renal replacement therapy, as needed to support organ function 6, 5