Recognising and Responding to Acute Deterioration Standard

Background to this standard

Serious adverse events, such as unexpected death and cardiac arrest, are often preceded by observable physiological and clinical abnormalities.¹ Other serious events, such as suicide and aggression, are also often preceded by observed or reported changes in a person’s behaviour or mood that can indicate deterioration in their mental state.

Early identification of deterioration may improve outcomes and lessen the intervention required to stabilise patients whose condition deteriorates in a health service organisation.²

The warning signs of clinical deterioration are not always identified or acted on appropriately.³ The organisational and workforce factors that contribute to a failure to recognise and respond to a deteriorating patient are complex and overlapping, and include^4-6:

• Not monitoring physiological observations consistently, or not understanding changes in physiological observations
• Lack of knowledge of signs and symptoms that could signal deterioration
• Lack of awareness of the potential for a person’s mental state to deteriorate
• Lack of awareness of delirium, and the benefits of early recognition and treatment⁷
• Lack of formal systems for responding to deterioration
• Lack of skills to manage patients who are deteriorating
• Failure to communicate clinical concerns, including in handover situations
• Attributing physical or mental symptoms to an existing condition, such as dementia or a mental health condition.^8,9

Systems to recognise deterioration early and respond to it appropriately need to deal with these factors, and need to apply across the health service organisation. The National Consensus Statement: Essential elements for recognising and responding to acute physiological deterioration has been endorsed by Australian health ministers as the national approach for recognising and responding to clinical deterioration in acute care facilities in Australia. It provides a consistent national framework to support clinical, organisational and strategic efforts to improve recognition and response systems. This standard builds on the national consensus statement to drive implementation in acute care facilities.

The Commission has also developed the National Consensus Statement: Essential elements for recognising and responding to deterioration in a person’s mental state. This outlines the principles that underpin safe and effective responses to deterioration in a person’s mental state, and provides information about the interrelated components that a health service organisation can implement to provide appropriate care.

The Commission’s Delirium Clinical Care Standard highlights the importance of being alert to, and assessing, delirium with any reported or observed changes in a person’s mental state.

This standard supports the provision of appropriate and timely care to patients whose condition is acutely deteriorating. It requires that systems are in place to detect, recognise and respond to acute deterioration in physiological or mental state. It applies to all patients in the health service organisation: adults, adolescents, children and babies, and medical, surgical, maternity and mental health patients.

References

1. Buist M, Bernard S, Nguyen TV, Moore G, Anderson J. Association between clinical abnormal observations and subsequent in-hospital mortality: a prospective study. Resuscitation 2004;62(2):137–41.
2. Calzavacca P, Licari E, Tee A, Egi M, Downey A, Quach J, et al. The impact of a rapid response system on delayed emergency team activation patient characteristics and outcomes: a follow-up study. Resuscitation 2010;81(1):31–5.
3. Hillman K, Chen J, Cretikos M, Bellomo R, Brown D, Doig G, et al. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet 2005;365(9477):2091–7.
4. Cioffi J, Salter C, Wilkes L, Vonu-Boriceanu O, Scott J. Clinicians’ responses to abnormal vital signs in an emergency department. Aus Crit Care 2006;19(2):66–72.
5. Endacott R, Kidd T, Chaboyer W, Edington J. Recognition and communication of patient deterioration in a regional hospital: a multi-methods study. Aus Crit Care 2007;20(3):100–5.
6. McQuillan P, Pilkington S, Allan A, Taylor B, Short A, Morgan G, et al. Confidential inquiry into quality of care before admission to intensive care. BMJ 1998;316(7148):1853–8.
7. Teodorczuk A, Reynish E, Milisen K. Improving recognition of delirium in clinical practice: a call for action. BMC Geriatr 2012;12:55.
8. Iacono T, Bigby C, Unsworth C, Douglas J, Fitzpatrick P. A systematic review of hospital experiences of people with intellectual disability. BMC Health Serv Res 2014;14:505.
9. Shefer G, Henderson C, Howard LM, Murray J, Thornicroft G. Diagnostic overshadowing and other challenges involved in the diagnostic process of patients with mental illness who present in emergency departments with physical symptoms – a qualitative study. PLoS ONE 2014;9(11):e111682.