Responding to acute deterioration

In addition to ensuring that monitoring and escalation systems are in place and working well, response systems must be in place. Response systems ensure that all patients who acutely deteriorate receive a timely and appropriate response. Timeliness should be determined by a risk assessment process that weighs up the clinical risks for patients when acute deterioration occurs and the frequency with which episodes of acute deterioration occur in the organisation. Appropriateness should also be determined by a risk assessment process that weighs up the clinical risks for patients and the capacity of the organisation to respond when acute deterioration occurs. This means that response systems in acute tertiary hospitals will differ significantly from response systems in remote clinics or free-standing day surgeries.

Regardless of setting, most response systems will include at least two levels of response as part of the graded escalation process. When acute deterioration is recognised early, senior nurses or attending doctors (or both) may respond. For more serious deterioration, a rapid response from clinicians with advanced skills in the management of acute deterioration is required. This rapid response might be provided by a medical emergency team with critical care expertise, a single clinician with advanced clinical assessment and resuscitation skills, or an external service such as the ambulance service.

When acute deterioration in a person’s mental state occurs, rapid referral to a consultation liaison psychiatry service is required. If consultation liaison is not locally available, the health service organisation needs to work with relevant specialist services to provide this response.

Further resources may be needed to ensure that the chosen response system is effective and that responders are competent in the necessary skills. Consider scope of clinical practice when designing the response system, and the roles and responsibilities of response providers.

As a minimum, the outline of the roles and responsibilities of response providers should identify the person who:

• Is responsible for ensuring that equipment for providing emergency assistance will reach the patient
• Is responsible for directing and coordinating the multiple activities and treatments needed when providing emergency assistance
• Is responsible for communicating the outcome of the call to the healthcare team, the patient, and their carers and family
• Has authority to make transfer decisions and refer to other clinicians, as required
• Is responsible for documenting the care provided
• Is accountable for handing over critical information for ongoing care.

Also identify the roles and responsibilities of the clinicians who escalate care. These may include:

• Remaining with the patient and starting further assessments, emergency interventions and other therapies while awaiting the response provider(s)
• Providing structured handover of information on the patient’s clinical condition and reasons for escalating care
• Ensuring that the attending medical officer or team is aware of the patient’s acute deterioration and, if they are not already present, attend to assist, if possible.

Include information about the roles and responsibilities of response providers and clinicians who escalate care in education programs and orientation sessions about the recognition and response systems.

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