How can I recognize a deteriorating patient?

How to Recognize the Deteriorating Patient

Ward staff must acquire complete and accurate vital signs when ordered and whenever there is additional concern, immediately escalating significant abnormalities to appropriate clinicians, as this represents the foundation of deterioration detection. 1

Core Vital Sign Monitoring

Traditional vital signs are the simplest, cheapest, and most widely accepted indicators of clinical deterioration and must be measured accurately: 1

• Temperature changes indicate inflammatory or infectious responses 2
• Heart rate abnormalities (tachycardia or bradycardia) signal compensation or decompensation 2
• Respiratory rate alterations are often the first sign of deterioration and warrant immediate attention 2
• Blood pressure changes (particularly hypotension) indicate shock or hemodynamic decompensation 2
• Oxygen saturation decline (hypoxemia) indicates respiratory compromise 2

Supplemental Clinical Indicators Beyond Standard Vital Signs

The Society of Critical Care Medicine emphasizes monitoring additional signs that traditional vital signs may miss: 1, 2

• Altered mental status (confusion, somnolence, lethargy, or agitation) indicates potential neurological deterioration 2
• Pain intensification or change in pain pattern signals potential deterioration 2
• Prolonged capillary refill time indicates compromised peripheral perfusion 1
• End-tidal carbon dioxide should be measured in patients using patient-controlled analgesia 1
• Lactate levels may indicate tissue hypoperfusion 1

Neurological Assessment

Monitor level of consciousness and pupillary function in high-risk patients: 2

• Pupillary changes (dilation or constriction) indicate potential herniation or brainstem compression 2
• Progressive somnolence or decreased responsiveness requires urgent evaluation 2

Patient and Family Recognition

Patients, families, and care partners can recognize subtle differences in clinical status that may signify deterioration and should be empowered to alert appropriate personnel including the rapid response system. 1, 2 This represents a critical but often overlooked component of early detection, as family members spend more continuous time with patients than clinical staff and notice baseline changes that intermittent assessments may miss. 1

Patient and family concerns should be incorporated into hospital early warning systems. 1, 2

Staff Education and Training

Focused education of direct-care non-ICU hospital clinicians on recognizing early clinical deterioration is recommended, though it should be part of a comprehensive system rather than a standalone intervention. 1, 2 Studies show this education may be associated with reduced cardiac arrests outside the ICU and decreased ICU length of stay. 1

Timing of Deterioration

Clinical deterioration often begins 24 hours before a critical phase, not suddenly as it may appear. 3 This underscores the importance of trending vital signs over time rather than relying on single measurements. Regular documentation and assessment are essential to identify these gradual changes. 3

Common Pitfalls to Avoid

Incomplete or incorrect vital sign measurement is common in hospitalized patients and leads to failure to detect key signs of deterioration. 1 The panel noted that education, audits, and feedback are necessary to encourage proper measurement techniques, accurate documentation, and prompt response to physiologic abnormalities. 1

Do not ignore isolated respiratory rate changes - these are frequently the earliest indicator of deterioration but are often overlooked or measured inaccurately. 2

Do not dismiss family concerns - violations of escalation protocols were common in 81% of cases where monitoring frequency was not adhered to, and doctors were not notified in 42% of cases prior to serious adverse events. 4

Rapid Response System Activation

Hospital-wide deployment of rapid response teams (RRT) or medical emergency teams (MET) with explicit activation criteria is strongly recommended. 1 This represents the strongest recommendation in the 2024 Society of Critical Care Medicine guidelines (strong recommendation, moderate certainty evidence). 1

Quality improvement processes should be part of the rapid response system to continuously evaluate and improve detection and response to deterioration. 1