Recognising serious deterioration or distress and escalating care

Serious deterioration in a patient’s physical, mental or cognitive health may occur at any time. In some circumstances, healthcare providers may observe this change while delivering health care and be required to assist. In these instances, healthcare services should have a process for healthcare providers to:

• Respond appropriately to a patient within their scope of clinical practice, for example, the assistance that a physiotherapist may provide may differ from the assistance a nurse practitioner is able to provide, and will be dependent on the support, equipment and service offering of the healthcare service 
• Call for emergency assistance, for example, in most instances this would be for an ambulance service; however, it may include direct transfer arrangements or emergency consultation with specialist healthcare providers based on formal or informal partnerships 
• Notify other relevant healthcare providers, carers and family members.

Establishing processes to respond to serious deterioration and escalation of care and calling for emergency assistance will ensure that healthcare providers can respond consistently and effectively. The mechanisms in place need to be appropriate for the size and location of the healthcare service and the population it serves. Other considerations include the available resources, healthcare provider skills mix and capacity to engage specialist help. Multiple mechanisms may be necessary in escalation systems to allow different responses to varying levels or types of deterioration. These mechanisms may include: 

• Landline phones
• Mobile or satellite-navigation phones
• Two-way radio devices
• Dedicated mobile, on-call and emergency telephone numbers. 

Consider: 

• Distance and location of response services (ambulance or aerial medical service) providers
• Mechanisms that can assist the response service to locate the patient 
• Backup systems or processes in the event of equipment failure 
• Processes for maintaining any relevant equipment
• Training on the processes for escalating care, including for new, casual, locum, and agency members of the workforce 
• Information for family members who care for unwell, aged or palliative care relatives about recognising and responding to serious deterioration.

In rural and remote community settings it may be helpful to develop processes for obtaining emergency advice from specialist providers – such as ambulance, aerial medical services, general practitioners or rural generalists, emergency or mental health services, or intensive care clinicians – by phone, video link or two-way radio.

• What are some examples of serious deterioration in a patient?
• What emergency assistance would be called for in the event of a patient experiencing serious deterioration, and why? 
• What training do healthcare providers complete to support them to respond to a patient experiencing serious deterioration?

Key tasks

• Develop a process to support healthcare providers to:
  • recognise deterioration in a patient’s physical, mental or cognitive health
  • respond to a patient within their scope of practice and call for emergency assistance 
  • notify a patient’s other relevant healthcare providers, carers or family when health care is escalated. 
• Ensure that healthcare providers and the workforce have the necessary skills and equipment to recognise and respond to serious deterioration within their scope of clinical practice.

The type and comprehensiveness of evidence used is dependent on each healthcare service context. The content and complexity of the policies and processes will likely depend on the size of the healthcare service , but could include:

• Healthcare service’s process for recognising and responding to serious deterioration or distress and escalating care 
• Training documents about mechanisms for escalating care and calling for emergency assistance
• Posters and other resources such as flow charts that are accessible and displayed in appropriate locations for the workforce.

Commission resources

The principles and strategies outlined in these resources are broadly applicable.

• NSQHS Standards User Guide for health service organisations providing care for patients with cognitive impairment or at risk of delirium – provides practical support for healthcare services where specific efforts or additional attention is required to meet the health needs of this patient population, based on the NSQHS Standards. 
• NSQHS Standards User Guide for health services providing care for people with mental health issues – provides practical support for healthcare services where specific efforts or additional attention is required to meet the health needs of this patient population, based on the NSQHS Standards.