The deteriorating patient
The failure to detect clinical deterioration in patients, whether in acute-care settings or the community, is a significant cause of preventable mortality and morbidity and a concern for patient safety. Deterioration can be defined as new or increasing signs of pathological physiological disturbance in one or more organ systems, including:
General: temperature changes; skin changes (pallor, flushing)
Cardiovascular: changes in heart rate or rhythm
Respiratory: changes in respiration rate
Cerebral: altered mental state; slurred speech; discoordination
Renal: decreased or excessive urine output (polyuria, oliguria)
Gastro-intestinal: jaundice; abdominal pain; vomiting
Neuromuscular: weakness; fasciculation; discoordination
Endocrine: changes in blood sugar levels
These signs, as well as patient-reported concerns (“I think I’m going to die”) or concerns of relatives (“my child looks really ill”), are all ways to detect changes early enough to intervene and ’rescue the patient’.
Without detection and early intervention, deterioration may eventually result in the final common pathway of respiratory or cardiac arrest and the possibility of an avoidable death—often referred to as ‘failure to rescue’. Data on the prevalence of failure to rescue in hospitals is recommended as a better marker of quality care and avoidable death than a standardized mortality ratio (SMR), which is a less specific measure of quality.
Improving patient safety and outcomes
Failure to rescue is only one of many causes of avoidable death. An NHS study from 2015 showed that around 3.6% of all hospital deaths, which equates to several deaths a week in each hospital, may be avoidable. The proportion of these that were caused by a failure to detect clinical deterioration was not reported.
The failure to intervene and reverse deterioration will inevitably lead to worse outcomes, including longer hospital stays and morbidity caused by the deterioration itself, some of which, such as cerebral or vascular injury, may be life-changing. There is, therefore, a strong link between the detection and reversal of deterioration and improved measures of both safety and outcome. The key to this improvement is early detection and suitably skilled resuscitation.
Early recognition of clinical deterioration
Early recognition of the deteriorating patient relies on regular and effective monitoring of the signs given above. Tools have been developed (e.g. NEWS and PEWS, which we discuss below) to help nursing staff recognise such deterioration, but these usually have application only in care settings where there are enough skilled staff to use them.
Clinical gestalt is also important in the early detection of deterioration. In the community, especially when the patient is seen only intermittently or is being cared for by family members or untrained staff, deterioration may in fact rely on ‘a hunch’ by a GP or close friend.
National Early Warning Score (NEWS)
In response to the recognition of the need for early detection, the NHS set up the National Early Warning Score (NEWS) system, later modified to NEWS2.
NEWS2 is an evidence-based system that combines seven vital signs into a single score (see chart above):
Heart rate
Respiration rate
Oxygen saturation
Temperature
Blood pressure
Ventilation
Level of consciousness
This score can then be graphed, and any significant change alerts the care team to look for causes of deterioration and, if necessary, start resuscitation. NEWS has since been adapted to several other clinical areas, including maternity and paediatrics, and to include other parameters such as urine output.
Hospital wards and emergency departments
Such early detection systems are primarily useful in areas where regular observations of vital signs are part of the duties of care staff. Patients with higher acuity will tend to be monitored more regularly to detect more rapid deterioration.
These are, therefore, most commonly deployed in secondary care areas such as hospital wards and emergency departments. The application of NEWS and similar scoring mechanisms is particularly useful in newly admitted patients and those in perioperative care, where complications such as anastomotic leaks or bleeds are more likely.
Suspected sepsis
The most dramatic benefit of early detection systems for patient deterioration is in the treatment of sepsis.
The evidence shows that the derangements in physiology caused by sepsis (‘incipient sepsis’) are detectable much earlier than previously thought. In particular, small changes in oxygen saturation and respiratory rate can pre-date a rise in temperature by many hours. The recognition of the burden of sepsis through the raising of awareness by organisations such as the Sepsis Trust has ensured that many patients are now receiving earlier treatment for sepsis.
Early intervention
Once deterioration has been detected in a patient, the outcome—their ' rescue'—is dependent on the quality of the interventions that follow.
For patients who need repositioning to improve their ventilation or reduce their pain, general nursing staff can immediately prevent any further slide. For those patients who may need more complex assessment and treatment, a doctor may be able to prescribe antibiotics, or more complex medication such as inotropes, in order to ensure adequate circulation. For perioperative patients with a risk of complications, a surgical consultation may be necessary.
Recognising peri-arrest: calling for help
Even in the best-run establishments, a deteriorating patient may not show signs of deterioration using the standard tools mentioned above, or they may deteriorate too rapidly for early detection. In this case, the key difference to survival will be the willingness of staff to call for help before the patient’s decline becomes irreversible.
The concepts of ‘peri-arrest’ care and a ‘peri-arrest’ call have now become commonplace. In this, staff do not wait until the patient has stopped breathing before calling for help. Senior clinicians can be summoned in time to provide leadership and decision-making in time to make a rescue.
Training in resuscitation
‘Rescuing’ a patient in decline depends, in large part, on the prevention of cardiac and respiratory arrest. Where that does happen, however, there needs to be appropriate resuscitation attempts at cardiopulmonary resuscitation (CPR).
Not all patients will benefit from attempted CPR, and good-quality care must also include adequate advanced decision-making in patients who are near the end of their life, or who will not survive any attempt at CPR. Nonetheless, a well-trained multidisciplinary team capable of rapid and effective resuscitation is an essential component of a high-quality healthcare establishment.
Almost all care staff are now required to take basic life support (BLS) courses yearly, and those who will be leading any resuscitation will require at least ILS (intermediate life support) or ALS (advanced life support). The fact is, however, that cardiac arrest in hospitals is the precursor to death in more than 50% of cases, and fewer than 10% of patients survive an out-of-hospital cardiac arrest to discharge.
Summary
Improving outcomes in patients with clinical deterioration, whatever the setting, relies on four things:
Early detection
Early call-for-help
Appropriate immediate interventions
Skilled resuscitation where necessary
References
Vincent JL, Einav S, Pearse R, Jaber S, Kranke P, Overdyk FJ, Whitaker DK, Gordo F, Dahan A, Hoeft A. (2018). Improving detection of patient deterioration in the general hospital ward environment. Eur J Anaesthesiol. 35(5): 325-333. doi: 10.1097/EJA.0000000000000798 . PMID: 29474347; PMCID: PMC5902137.
Hogan H, Zipfel R, Neuburger J, Hutchings A, Darzi A, Black N. (2015). Avoidability of hospital deaths and association with hospital-wide mortality ratios: retrospective case record review and regression analysis. BMJ 351:h3239 doi: 10.1136/bmj.h3239esfwq
Resources to support the safe adoption of the revised National Early Warning Score (NEWS2) https://www.england.nhs.uk/publication/patient-safety-alert-safe-adoption-of-news2/
Doyle DJ. (2018). Clinical Early Warning Scores: New Clinical Tools in Evolution. The Open Anesthesia Journal. doi: 10.2174/2589645801812010026
