Rationale for rapid response to acute physiological deterioration in hospital

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Rationale for rapid response to acute
physiological deterioration in hospital

• Dr Stephen Hull
• Consultant Physician/Endocrinologist
• Safer Patients Initiative Clinical Lead, Mater
  Hospital, Belfast HSC Trust

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Safer Patient Initiative Aims

• Crash Calls- decrease by 30
• Mortality- decrease by 15
• Reduce Adverse Events
• Reduce ICU LOS
• Early warning scores and rapid response may help
  all of these?

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Care of the critically ill patient is frequently
sub-optimal

• Confidential enquiry into ICU admissions
• 40 admissions avoidable
• 37 admissions occurred late
• Lack of attention to
• Airway, Breathing and Circulation
• McQuillan P et al BMJ 19983161853-1858

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Can cardiac arrest be prevented?

• 30-70 patients who suffer a cardiorespiratory
  arrest in hospital have signs of physiological
  deterioration prior to the arrest and failure to
  respond appropriately increases the likelihood of
  arrest. (Smith AF Wood J, 1998 Schein RMH et
  al, 1990 McGloin H et al 1999)

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Outcome from cardiorespiratory arrest
Gwinnutt C et al Resuscitation 200047 125-135
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Early warning scores

• Various scoring systems based on changes in
  physiological parameters have been developed and
  validated in medical and surgical patients
• ( Subbe CP et al, 2001 Stenhouse C et al, 1999)

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CREST

• Guidelines on the use of physiological early
  warning scores, May 2007
• Developed following RQIA report
• Early warning score should be used in all acute
  hospitals
• Need for policy, training, agreed local action
  protocols including possible adaptations for
  maternity/paeds etc, audit
• Examples of charts, action protocol and audit tool

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Acutely ill patients in hospital
Implementing NICE guidance
July 2007
NICE clinical guideline 50
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Assessment and monitoring

• Adult patients in acute hospital settings,
  including patients in the emergency department
  for whom a clinical decision to admit has been
  made, should have
• physiological observations recorded
• a clear written monitoring plan
• Physiological observations should be recorded and
  acted upon by staff who have been trained and are
  competent.

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Assessment and monitoring physiological
observations

• Initial assessment should include at least
• heart rate
• respiratory rate
• systolic blood pressure
• level of consciousness
• oxygen saturation
• temperature
• (hourly urine output)

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Assessment and monitoring track and trigger
systems

• Physiological track and trigger systems should be
  used to monitor all adult patients in acute
  hospital settings.
• Observations should be monitored at least every
  12 hours.
• Senior-level decision to increase or decrease the
  frequency of observations.
• Increase (graded response) if abnormal physiology
  is detected.

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Response

• A graded response strategy for patients
  identified at risk should be agreed and delivered
  locally. It should consist of three levels.
• Low-score group.
• Medium-score group.
• High-score group.

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Graded response strategy