Management of the Deteriorating Adult Inpatient

Introduction

The National Institute for Health and Clinical Excellence (NICE) has produced evidence which suggests that patients who are or become acutely unwell in hospital may receive suboptimal care. This may be because their deterioration is not recognised, or despite indications of clinical deterioration it is not recognised or acted upon quickly enough. NICE CG50 (2007) advocate the use of a physiological track and trigger systems to ensure early recognition of all patients with potential or established acute illness ensuring early, appropriate treatment from appropriately skilled staff. The goal of using this system is to prevent harm, reduce in-hospital cardiac arrests and mortality rates, and facilitate appropriate use of critical care resources, through early recognition and treatment of the deteriorating patient.

A report by the Chief Medical Officer for England found the most frequent problems with preventable deaths in hospital related to clinical monitoring. Clinical monitoring problems included failure to act upon clinical signs or to set up monitoring systems to respond to patient deterioration or to increase the intensity of care when required. It is well documented that patients who deteriorate and require admission to critical care or who suffer cardiac arrest have abnormalities that are detectable by physiological observations well in advance (Dubois 1988; Kause et al, 2004; McGloin et al, 1997; McQuillan et al, 1998; NCEPOD, 2005).

The current Trust physiological track and trigger system used for adults is the National Early Warning Score (NEWS) which is a well validated track-and-trigger early warning score system that is used in the majority of UK hospitals to identify and respond to patients at risk of deteriorating. It is based on a simple scoring system in which a score is allocated to physiological measurements already undertaken when patients present to, or are being monitored in health care settings. The following six simple physiological parameters are included in the scoring system:

1. Respiratory rate
2. Oxygen saturations
3. Temperature
4. Systolic blood pressure
5. Pulse rate
6. Level of consciousness or new confusion *

*The patient has new-onset confusion, disorientation and/or agitation, where previously their mental state was normal – this may be subtle. The patient may respond to questions coherently, but there is some confusion, disorientation and/or agitation. This would score 3 or 4 on the GCS (rather than the normal 5 for verbal response), and scores 3 on the NEWS system.

A score is allocated to each parameter as they are measured, with the magnitude of the score reflecting how extremely the parameter varies from the norm. The score is then aggregated and uplifted by 2 points for people requiring supplemental oxygen to maintain their recommended oxygen saturation. An elevated NEWS score does not provide a diagnosis; it helps identify a sick patient who requires urgent clinical review in a standardised way. NEWS also allows healthcare professionals to communicate about deteriorating patients in a common language.

The Trust has just completed the process of implementing Vital PAC, an award-winning software system that helps monitor the condition of hospital patients, ensuring deteriorating patients are quickly identified and making it easier to determine which patients are well enough to be discharged. Vital PAC utilizes NEWS.

Policy Details