From the Guidelines
The most effective approach to recognizing and responding to patient deterioration is to implement a hospital-wide deployment of a designated response team coupled with well-defined activation criteria, as recommended by the Society of Critical Care Medicine guidelines 1. This approach is supported by moderate certainty evidence from randomized controlled trials, which shows that the application of explicit activation criteria and deployment of a designated hospital-wide response team leads to a reduction in mortality and cardiac arrest 1.
Key Components of the Algorithm
- Regularly assess vital signs, including heart rate, blood pressure, respiratory rate, oxygen saturation, temperature, and level of consciousness
- Calculate an early warning score (EWS) such as NEWS2 or MEWS to objectively quantify the degree of deterioration
- Escalate care to the charge nurse or rapid response team for moderate deterioration, and immediately activate the rapid response team or code team for severe deterioration
- Incorporate patient and family concerns into early warning systems, and empower them to alert staff or response team about signs of deterioration 1
Implementation Considerations
- Hospitals should consider and address the risk of de-skilling of non-ICU staff by overreliance on response teams for patient care
- Focused education of non-ICU staff in recognizing clinical deterioration is essential to ensure timely and effective response to patient deterioration 1
- A quality improvement process should be a part of a Rapid Response System to continuously evaluate and improve the effectiveness of the response team 1
From the Research
Recognising Patient Deterioration
To recognise and respond to patient deterioration, healthcare professionals can follow a structured approach. The Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach is a widely accepted method for immediate assessment and treatment in clinical emergencies 2. This approach helps healthcare professionals focus on the most life-threatening clinical problems and can improve outcomes by saving valuable time and improving team performance.
Assessment and Intervention
The ABCDE approach involves assessing the patient's:
- Airway: ensuring a patent airway
- Breathing: assessing respiratory rate, depth, and effort
- Circulation: evaluating cardiac output and perfusion
- Disability: assessing neurological function
- Exposure: exposing the patient to assess for other injuries or conditions
Non-Invasive Ventilation
Non-invasive ventilation (NIV) can be used to support patients with respiratory failure, including those with acute pulmonary edema (APE) 3, 4. NIV can be delivered using continuous positive airway pressure (CPAP) or pressure support ventilation (NIPSV). The choice of modality depends on the patient's condition and the healthcare professional's experience.
Key Considerations
When assessing and responding to patient deterioration, healthcare professionals should:
- Use a structured approach, such as the ABCDE approach 2
- Consider the use of NIV in patients with respiratory failure 3, 4
- Prioritize circulation in patients with hypovolemic shock, as evidenced by the CAB approach 5
- Continuously monitor the patient's condition and adjust interventions as needed
Respiratory Assessment
Respiratory assessment is a critical component of recognising patient deterioration 6. Healthcare professionals should assess the patient's respiratory rate, depth, and effort, as well as their oxygen saturation and arterial blood gas results. This information can help identify patients who require ventilatory support and guide the selection of appropriate interventions.