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CONTINUING PROFESSIONAL DEVELOPMENT
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Patient deterioration
multiple choice
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Prevention of deterioration
in acutely ill patients in hospital
NS555 Steen C (2010) Prevention of deterioration in acutely ill patients in hospital. Nursing Standard.
24, 49, 49-57. Date of acceptance: May 18 2010.

Summary
The shift towards providing critical care in general wards has
changed the way acutely ill patients are identified, treated and
managed in hospital. This requires the expertise of knowledgeable,
informed and capable staff. Effective education and appropriate
knowledge and skills are required to aid identification of the
deteriorating patient and provide prompt, timely and appropriate
intervention to prevent further deterioration and possibly death.
This article provides information about a systematic approach
that will enable healthcare professionals to intervene to prevent
deterioration in acutely ill patients.

Author
Colin Steen, lecturer in critical care and acute care pathway leader,
School of Nursing, Midwifery and Social Work, University of
Manchester. Email: colin.steen@manchester.ac.uk

Keywords
Acute care, morbidity and mortality, track and trigger
systems, vital signs
These keywords are based on subject headings from the British
Nursing Index. All articles are subject to external double-blind peer
review and checked for plagiarism using automated software. For
author and research article guidelines visit the Nursing Standard
home page at www.nursing-standard.co.uk. For related articles
visit our online archive and search using the keywords.

Aims and intended learning outcomes

This article aims to explore how suboptimal care
of the acutely ill patient outside intensive care or
high dependency units affects mortality and
morbidity rates. The term suboptimal in this
context is used to describe care that has fallen
below the standard expected to be delivered by
staff who would normally have the knowledge
and resources to manage acutely ill patients.
NURSING STANDARD

It has been recognised that staff who do not

work in critical care areas may not have the
required knowledge and skills. However, these
staff are important in implementing timely and
appropriate intervention to prevent deterioration
and reduce mortality and morbidity. The rationale
for many of the strategies on implementing timely
and appropriate intervention to prevent patient
deterioration is to educate and inform staff, and
provide them with the necessary skills.
This article identifies the normal physiological
markers that enable the healthcare professional
to recognise any change in the patients
condition. Strategies that can be used to identify
the deteriorating patient are also highlighted.
A systematic approach that enables staff to
identify patient deterioration and promote
recovery is presented.
After reading this article and completing
the time out activities you should be able to:
4Describe the normal physiological markers used
to detect deterioration in acutely ill patients.
4Identify key areas of assessment in the acutely
ill patient.
4Outline a strategy for assessment and
intervention in acutely ill patients.
4Identify a tool that can be used to improve
communication between members of the
multidisciplinary team.

Introduction
Evidence suggests that hospital patients and
expectant mothers who experienced cardiac
arrest or acute deterioration showed signs of
clinical deterioration for many hours before this
event, and that intervention could have been
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managed more effectively (Schein et al 1990,
Franklin and Mathew 1994, Garrard and Young
1998, Berlot et al 2004, Confidential Enquiry into
Maternal and Child Health 2004, Cullinane et al
2005). Further evidence relating to critical care
admission suggests that up to 50% of patients
receive suboptimal care before admission to
intensive care units (ICUs) (Goldhill et al 1999a,
McGloin et al 1999, Chellel et al 2002,
Hillman et al 2002).
The mortality of patients transferred from
acute medical and surgical areas to ICU is
significantly higher than that of patients admitted
from the emergency department or theatre
(Goldhill 2001, Cullinane et al 2005). Evidence
suggests that there is a higher than average
mortality rate for the 12 months following
discharge from ICU (Wallis et al 1997, Smith
and Nielsen 1999).
Early recognition of patient deterioration and
appropriate and timely intervention, using a
structured systematic approach to assessment
and treatment, helps to prevent admission to ICU
and reduces the incidence of in-hospital cardiac
arrest (Morgan et al 1997, Goldfrad and Rowan
2000, DH and NHS Modernisation Agency
2003, Confidential Enquiry into Maternal and
Child Health 2004, Priestley et al 2004, Lewis
2007). The National Institute for Health and
Clinical Excellence (NICE) (2007) recommends
that staff should be provided with the education
and skills necessary to respond promptly to
acutely ill patients. These recommendations are
supported by the findings of various studies
(Goldhill 1997, McGloin et al 1999, Cullinane et
al 2005). Clinical governance, with its emphasis
on audit, risk management and continuing
education and training, should provide an
impetus for the increase in education and
knowledge relating to the management of acutely
ill patients. NICE (2007) recommends that staff
caring for patients in acute hospitals should be
competent in the monitoring and interpretation
of patient observations to enable timely
intervention and appropriate management
of these acutely ill patients.

Literature review
The Department of Health (DH) (2000) review
of critical care services illustrated a deficiency in
the ability of healthcare professionals to care
for acutely ill adults. This resulted in
suboptimal care, inappropriate admissions
to ICU and increased mortality and morbidity
(Goldhill et al 1999b, McGloin et al 1999,
50 august 11 :: vol 24 no 49 :: 2010

Smith and Nielsen 1999, DH 2000, Hillman

et al 2002). The review findings are supported
by further evidence that 85% of all cardiac
arrests in hospital are preceded by clear signs
of deterioration that are often undetected and
inadequately treated by ward staff (Wallis et al
1997, McQuillan et al 1998, Berlot et al 2004,
Considine 2005). McQuillan et al (1998)
argued that a lack of access to relevant
education for healthcare professionals
contributed to the increased stay of patients
in, and unnecessary readmissions to, ICU,
resulting in increased mortality and morbidity
(Goldfrad and Rowan 2000). Cullinane et al
(2005) examined the care of medical patients
referred to ICU. Their findings supported those
of previous studies in that suboptimal care was
frequently related to poor management of the
patients airway, poor organisation, lack of
knowledge, failure to appreciate the clinical
urgency of a situation, lack of supervision,
failure to seek advice and poor communication,
resulting in potentially preventable mortality
and morbidity.

Time out 1
List the observations that should
be recorded for an adult patient
in an acute hospital setting?

Time out 2
Identify the normal ranges for
the following physiological
measurements:
4Normal respiratory rate.
4Tachypnoea.
4Bradypnoea.
4Tachycardia.
4Bradycardia.
4Normal blood pressure.
4Hypotension.
4Hypertension.
4Pyrexia.
4Hypothermia.
4Oxygen saturation.

Recognising patient deterioration

NICE (2007) states that all adult patients in
acute hospitals should have their vital signs
recorded on initial assessment. It recommends
recording the patients level of consciousness,
respiration rate, oxygen saturation, pulse rate,
blood pressure and temperature (NICE 2007)
(Table 1). Knowledge of normal physiological
parameters and competency in measuring them
are essential. Following initial assessment,
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decisions about the frequency and range of

observations should be made. These decisions
should be informed by the underlying condition
of the patient, any comorbidities and
the intended treatment plan.
A track and trigger system is recommended
to help the healthcare professional identify
possible signs of patient deterioration (DH
2005, Critical Care Stakeholders Forum and
National Outreach Forum 2007, NICE 2007).
A track and trigger system is an algorithm that
produces a score the lower the score the more
stable the patient, the higher the score the
greater the deterioration. It has been identified
as a tool to enhance communication between
the multidisciplinary team (Andrews and
Waterman 2005). The system is designed to
identify possible critical illness and to procure
timely and suitable clinical intervention; it is not
designed to be a predictor of outcome (Morgan
et al 1997). This monitoring system only works
where its process of calculating and reporting
is carried out in full.
The National Patient Safety Agency (2007)
identified patients who experienced
deterioration where the track and trigger
system was in place, but the score was either
not calculated properly or the trigger to seek
help was not implemented appropriately.
NICE (2007) recommends that track and
trigger tools should be used on all adult
patients in acute hospital settings and that
these observations should be monitored every
12 hours. This early intervention prevents
admission to ICU and reduces the incidence
of in-hospital cardiac arrest (Morgan et al 1997,
Goldfrad and Rowan 2000, DH and NHS
Modernisation Agency 2003, Confidential
Enquiry into Maternal and Child Health 2004,
Priestley et al 2004, Lewis 2007).
According to their track and trigger score,
patients should be put into a graded response
category: low grade, medium grade or high grade
(Table 2). Depending on the score awarded to
the patient, decisions to increase or decrease
the frequency of observations should be made
at a senior level.
A low-score group should have the frequency
of their observations increased and the nurse
in charge should be notified. A medium-score
group requires an urgent call to a team with
primary medical responsibility for that patient
and a simultaneous call to personnel with
critical care skills and knowledge. Examples
of personnel who can provide critical care
skills are critical care outreach teams,
hospital-at-night staff or specialist trainees
in acute medicine or surgery. A high-score
group requires an emergency call to a team
with critical care competencies and diagnostic
NURSING STANDARD

TABLE 1
Vital signs recorded on initial assessment
Parameter

Normal

Abnormal

12-20 breaths per minute

Apnoea* 0
Bradypnoea <12
Tachypnoea >20

Breathing
Rate

Oxygen saturation >94%

<94%

88-92% in patients at
risk from hypercapnic
failure respiratory
Peak flow

<88% in patients with

hypercapnic respiratory
failure

Dependent on sex, age

and height

Circulation
Pulse rate

60-100 in normal
healthy resting adult

Rates outside the

expected normal values

Blood pressure

100-140/60-90mmHg

Hypotension
systolic <100mmHg
Hypertension
>140/90mmHg
(continuously over
a certain period)

Capillary refill time <2 seconds

>2 seconds

Neurological
Alert (A)
Voice (V)
Pain (P)
Unresponsive (U)
(AVPU tool)

Alert

Any deterioration in
conscious level is a
warning sign and must
be acted on

Glasgow Coma
Scale

15

<8

Temperature

35.5-37.5oC

Hypothermia <35oC
Pyrexia >37.5oC

Blood glucose

Approximately 4-8mmol/L Measurements outside

in non-diabetic patients
expected normal values

Exposure
Skin temperature

Warm to touch

Cold and/or clammy

Skin turgor

When grasped between

two fingers skin returns
rapidly to its original
position

Decreased turgor skin

remains elevated and
returns slowly to its
original position.
Increased turgor taut
skin that cannot be
grasped or raised

Skin colour

Well perfused

Pallor and/or
peripheral cyanosis

* Where the respiratory rate is inadequate or absent it should be treated as a

respiratory arrest.

skills. This emergency team should consist

of a medical practitioner skilled in the
assessment of the critically ill patient and
who is competent in advanced airway
management and resuscitation.
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Time out 3
Reflect on your practice and the
importance of track and trigger
systems in identifying patients
who are deteriorating. Describe
the responses required for patients
who present with a low, medium and
high score when assessed using the system.

Assessment of the acutely ill patient

The ABCDE (airway, breathing, circulation,
disability, exposure) systematic approach
to assessment of the acutely ill patient is
recommended by the Resuscitation Council (UK)
(2005). Each letter should be approached using
the look, listen and feel method of assessment,
followed by intervention. This systematic process
is easy to remember and ensures that no obvious
issues that may affect patient survival will be
missed. Each section should be thoroughly
assessed and managed, ensuring the necessary
interventions have been implemented to prevent
further deterioration, before moving on to the
next section. If the patients condition does not
improve or deteriorates further following the
intervention, the ABCDE assessment should be
started again.
This approach is designed to provide a baseline
for future measurement and to identify areas
where the patient needs support. It aims to provide
a provisional diagnosis and to enable staff to
TABLE 2
Graded response to identify patients at risk of deterioration
Level 1
Low-score group

Increased frequency of observations.

The nurse in charge should be alerted.

Level 2
Medium-score group

Urgent call to a team with primary medical

responsibility for the patient.
Simultaneous call to personnel with core
competencies in acute illness. These competencies
can be delivered by a variety of models at a local
level, such as a critical care outreach team,
a hospital-at-night team or a specialist trainee
in an acute medical or surgical specialty.

Level 3
High-score group

Emergency call to a team with critical care

competencies and diagnostic skills. The team
should include a medical practitioner skilled in
the assessment of the critically ill patient and
who possesses advanced airway management
and resuscitation skills. There should be an
immediate response.

(National Institute for Health and Clinical Excellence 2007)

52 august 11 :: vol 24 no 49 :: 2010

recognise when they need additional support from

the multidisciplinary team. It should also guide the
healthcare professional in planning the frequency
of ongoing assessment.
Before beginning any assessment of the patient,
healthcare professionals need to consider their
own personal safety and observe for any
environmental dangers that may affect them.
Airway The airway should be assessed to ensure
it is clear of obstruction. Assessment relates to
the structures that start at the lips and finish
at the trachea. It is not to be confused with
the section related to breathing. The airway
can be compromised by allergic reaction
(anaphylaxis), which causes swelling of the
tongue and airway; laryngospasm; reduced
consciousness; a foreign body; secretions;
infection and abscesses; trauma or burns.
The healthcare professional should follow the
look, listen and feel approach.
Look The airway should be observed for signs
of obstruction from foreign objects (for example,
loose teeth or caps, crowns or dentures) or
swelling (for example, anaphylaxis, burns,
inhalation of toxic gases or heat). It is important
to look for secretions and signs of vomit.
Visualisation of the lips may indicate central
cyanosis blue colouration caused by a lack of
oxygen in the blood. A deteriorating level of
consciousness should alert the practitioner to the
risk of a compromised airway. This arises from
a reduction or loss of gag or cough reflex or loss
of airway muscular tone, resulting in poor
control of the tongue. In the supine patient the
tongue can fall backwards and occlude the
airway. Observation of a see-sawing
paradoxical chest/abdominal movement
indicates the presence of a life-threatening,
completely obstructed airway. The simplest way
of assessing for a patent airway is to ascertain if
the patient is able to respond verbally
(Resuscitation Council (UK) 2005).
Listen When air passes over a partially open
airway it becomes turbulent. Turbulent air creates
sound. Different sounds are created depending
on the nature of the partial blockage. These added
sounds can be described as snoring as a result of
vibration of the tongue, soft palate or epiglottis;
crowing caused by laryngospasm or a solid
foreign object; gurgling as a result of air passing
through fluid such as secretions or vomit; and
stridor, a loud musical sound often heard in
children, indicating swelling in the airway.
Feel Feeling air on the back of the hand or cheek
indicates that the airway is patent. The loss of air
flow through the airway either indicates a loss
of a patent airway or that the patient may not be
breathing. In the absence of any indicators of an
obstructed airway, the healthcare professional
should assess breathing.
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Intervention If a patient displays signs of partial

or total compromise of the airway, urgent help
is required. The position of the patient should be
considered as part of airway management. If it
is necessary to sit the patient upright, this should
be implemented with caution in anyone with a
reduced level of consciousness or a suspected neck
or spinal injury. In an unconscious patient, the
healthcare professional should consider simple
airway protection manoeuvres such as head tilt,
chin lift, jaw thrust or the recovery position.
More advanced techniques may include the use
of airway adjuncts (Guedel or nasal airways).
Where there is evidence of fluid, suction should
be available (Resuscitation Council (UK) 2005).
However, it is not appropriate to suction the patient
if the view of the airway is obscured or a foreign
object is suspected. Caution must be exercised not
to push the object further into the airway.
Following confirmation that the airway is
patent, the patient requires high-flow oxygen.
This can be delivered through a non-rebreathing
oxygen mask such as a mask with a reservoir
bag. An oxygen flow rate of 15 litres per minute
is required to maintain oxygen saturation at
normal levels: 94-98%, in most circumstances.
The exception to this is patients with known
chronic obstructive pulmonary disease. These
patients should receive oxygen therapy
to a target oxygen saturation level of 88-92%
and arterial blood gases should be checked as
a matter of urgency (ODriscoll et al 2008). In
these circumstances 24% oxygen therapy should
be administered via a Venturi mask at 4 litres
per minute. Where the partial pressure of carbon
dioxide is found to be normal then the target
oxygen saturation should be elevated
to 94-98% (ODriscoll et al 2008).
Breathing A patients breathing needs to
be assessed to exclude a number of possible
complications, for example exacerbation
of existing disease, central nervous system
depression affecting the respiratory centre,
phrenic nerve problems affecting the nervous
supply to respiratory muscles, muscle weakness
arising from muscle degenerative diseases,
for example, and severe unresolved pain.
Both closed and open trauma to the lungs affect
functioning, for example a lung contusion
(closed) or penetrating injury (open)
(Gray and Robertson 2009).
Look Assessment of breathing starts with the
respiratory rate and trend. For simplification,
this assessment could be classified as rate,
rhythm and depth. For example, the healthcare
professional should be aware of increasing
respiratory rate (tachypnoea) or decreasing
respiratory rate (bradypnoea). Breathing is an
effortless process, under normal circumstances it
should be relaxed, quiet (not silent) and effortless.
NURSING STANDARD

Examining the effort of breathing may show that

the accessory muscles of breathing such as the
neck, shoulder and abdominal muscles are being
used. It is important to observe for pallor and
cyanosis, as well as flushing and redness of the
patients skin. A patient breathing through pursed
lips is adding positive end expiratory pressure,
which helps to keep the lungs inflated and is seen
in patients in respiratory distress. Asymmetry of
chest movement identifies collapse of a lung as
occurs with a pneumonthorax. Measurement of
oxygen saturation should be carried out if not
already done so.
Listen The healthcare professional should
ascertain whether the patient can speak in full
sentences without having to stop to take a breath.
This is a basic assessment of respiratory reserve.
Mental confusion is an early indicator of cerebral
hypoxia, a lack of oxygen supply to the brain,
which may have a number of causes (see
disability). The breathing should be quiet on
chest auscultation. Any added sounds indicate
problems with gas flow in and out of the lungs.
Wheeze occurs when air is forced through
narrowed airways during inspiration and
expiration. This gap causes turbulence, which is
detected as wheeze. Crepitations are rustling
sounds in the lungs in time with breathing and
indicate that there are secretions in the lungs.
A physiotherapist may be required to assist in
clearing the chest. Bronchial breathing is a
symptom of consolidation of the lungs or fibrosis
(Resuscitation Council (UK) 2005).
Feel To complete the assessment, the healthcare
professional should check for symmetrical chest
expansion, evidence of surgical emphysema
(air in the tissues indicating communication
between the respiratory tree the structures that
form the lungs and the tissues around
the lungs), and tracheal deviation indicating
mediastinal shift caused by a tension
pneumonthorax, for example. Percussion helps
in identifying areas of consolidation in the lung
(Gray and Robertson 2009).
Intervention If not already started, high-flow
oxygen should be administered. The patient
should be positioned in an optimal position
for breathing, as his or her condition allows.
Oxygen-driven nebulisers and physiotherapy
may be required. Caution should be exercised in
the administration of nebulisers in patients who
have chronic obstructive pulmonary disease with
hypercapnic respiratory failure. The prolonged
use of oxygen-driven nebulisers may worsen
the condition. Where oxygen is used in the
administration of nebulisers in patients
with hypercapnic respiratory failure, the flow
rate should be limited to 6 litres per minute
(ODriscoll 1997, ODriscoll et al 2008).
Oxygen saturation levels must be monitored
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in all patients. Arterial blood gases may also be
measured and it is vital to ensure that these are
monitored without removing oxygen therapy.
Where the rate and depth of breathing is judged
to be insufficient to maintain adequate gas
exchange, the healthcare professional should
be prepared to implement supported breathing
using a bag-valve-mask resuscitator
(Resuscitation Council (UK) 2006).
Circulation Circulation problems arise as a result
of shock (hypovolaemic, cardiogenic, obstructive
or distributive) (Table 3). Shock occurs due to a
loss of circulating volume through direct loss or
redistribution of fluid, or as a result of the hearts
inability to pump effectively. Hypovolaemic shock
results from a loss of circulating blood volume or
plasma. Cardiogenic shock can occur as a result of
drugs and electrolyte abnormalities, for example,
potassium, magnesium or calcium which affect
the rhythm of the heart, or myocardial ischaemia
which affects the hearts ability to pump
efficiently. Obstructive shock can only be resolved
by removing the obstruction. For example, where
a tension pneumothorax is the cause of shock,
the lung needs to be reinflated using a chest drain.
If the cause is cardiac tamponade, this needs to
be drained via pericardiocentesis. A pulmonary
embolus may cause obstructive shock and
removal of the clot either by drugs or
embolectomy is required. Examples of distributive
TABLE 3
Types of shock
Shock

Causes

Pathology

Hypovolaemic

Haemorrhage.
Burns.

Loss of circulating blood.

Loss of plasma.

Cardiogenic

Acute coronary syndrome. Cardiac ischaemia

Arrhythmias.
loss of contractility.
Cardiac contusion
Reduced cardiac output.
(bruising or blunt trauma).

Obstructive

Cardiac tamponade.
Tension pneumonthorax.

Compression of heart
obstructing the filling
of the cardiac chambers.
Valve disorders.
Mediastinal shift
obstructing blood flow
through the great vessels.

Distributive

Septic shock.
Anaphylactic shock.
Neurogenic shock.

Poor distribution of blood

flow (venous pooling).
Decrease in vascular
tone or resistance.
Loss of intravascular fluid
to the extravascular space
(tissue oedema).

54 august 11 :: vol 24 no 49 :: 2010

shock are sepsis, which leads to a reduction in

venous return and profound vasodilation; and
dehydration arising from a poor fluid intake,
which may be acute or chronic.
Look Assessment of circulation starts with
observation of the patients skin, looking for
signs of sweating, cyanosis, pallor or flushing.
This should be followed by visual observation
for haemorrhage and urine output, and any
evidence of infection.
Listen As part of the circulation assessment, the
healthcare professional should measure the
patients blood pressure. Typically this is carried
out using automated equipment. However, if there
is any doubt about the accuracy of the blood
pressure recording this should be checked
manually. Automated blood pressure machines
may be inaccurate in patients with arrhythmia or
very low blood pressure. A low blood pressure
(hypotension) is a late sign of cardiovascular
compromise and resuscitation should not be
delayed in the presence of other indicative factors
that suggest shock is occurring.
Feel The feel assessment involves the pulse
character, rate, rhythm and depth. If concerned,
the healthcare professional should make a
comparison between central and peripheral
pulses. Temperature and the capillary refill
time should be recorded.
Intervention In most cases of shock, fluid
resuscitation is considered first-line treatment.
However, rapid fluid resuscitation in cardiogenic
shock may make the situation worse. When
considering fluid resuscitation it is necessary to
consider the underlying pathophysiology to
determine the desired therapeutic end points.
These may differ from patient to patient and will
depend on the underlying pathophysiology.
For example, Rivers et al (2001) gave precise
therapeutic end points for the management of
sepsis, and in burns patients, there are precise
formulae and therapeutic end points for fluid
resuscitation (Williams 2008). In some patients
with major trauma, aggressive fluid resuscitation
is undesirable (Rudra et al 2006).
The purpose of fluid resuscitation is to restore
circulating volume and therefore perfuse the tissues
as rapidly as possible. The Resuscitation Council
(UK) (2005) recommends that in the absence of
a cardiac insult, 500-1000mL crystalloid should
be administered to a hypotensive patient while
monitoring the response closely. The type of fluid
to be used is largely irrelevant. Crystalloid such as
0.9% sodium chloride or a colloid are commonly
used. Usually, larger volumes of crystalloid are
required as this fluid leaks into the extravascular
space and rehydrates the cells, resulting in a loss
of fluid from the intravascular circulation. Colloid,
however, remains in the circulation. Five per cent
glucose solutions contain a large quantity of water.
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This alters the electrolyte balance, resulting in cell

death and hyperglycaemia, when rapidly infused in
large quantities. Throughout the fluid resuscitation
the response to treatment must be monitored
continuously and treatment altered accordingly.
Patients who require continuous fluid resuscitation
are considered unstable and require further
investigation and management.

Time out 4
Using the look, listen and feel
approach, describe how you
would assess a patients
neurological status. Compare
your answer with the text below.
Disability The causes of neurological dysfunction
can be split into two categories. Primary injuries
include brain injury, compressive lesions,
epilepsy and infection. Secondary injuries
include hypoxia, arising from either a lack of
oxygen or a lack of perfusion of the brain, and
metabolic disorders, such as diabetic coma
or alcohol, drug or gas intoxication.
Look, listen and feel In this category look, listen
and feel can be grouped together. Observation
begins with assessment of the patients conscious
level. A simple, but effective and descriptive tool
is the AVPU tool. Patients are given an A if they
are alert, V if they only respond to voice
commands and P if they only respond to painful
stimuli. They are given a U if they do not
respond. If there is an indication of neurological
deficit then assessment using the Glasgow Coma
Scale is necessary.
A reduced conscious level is associated with
potentially life-threatening complications. Any
patient displaying a reduced or worsening level
of consciousness is at risk of airway obstruction
and loss of the gag or cough reflex, resulting in
occlusion of the airway and aspiration of gastric
contents. In these circumstances, the airway needs
to be reassessed to ensure airway protection.
Limb weakness, changes in mood or agitation,
pupil size and reaction, or the presence of
seizures indicate deterioration in brain function.
To exclude a hypoglycaemic coma, blood glucose
should be checked and if less than 3mmol/L,
50mL 10% glucose should be administered,
blood glucose rechecked and treatment repeated
if required. A blood glucose of greater than
4mmol/L is the therapeutic end point
(Stanisstreet et al 2010).
Acute pain can cause severe complications.
Pain can be assessed, investigated and treated
accordingly through the use of an objective
scoring tool. For example, the numerical rating
scale of 0-10 (where 0 represents no pain and
10 represents the worst pain imaginable) allows
NURSING STANDARD

for assessment of the patients pain intensity,

guides necessary treatment and enables
reassessment of the effectiveness of treatment
(Williamson and Hoggart 2005).
Intervention Consideration must be given to
the safety and security of any patients airway,
particularly if the individual presents with a
deteriorating level of consciousness.
Measurement of blood glucose and correction
of hypoglycaemia by the administration of 50mL
10% glucose and reassessment of serum levels is
required. Where a patient experiences a seizure,
his or her safety should be maintained. The
primary concern is to protect the airway by
placing the patient on his or her side and moving
any objects out of the way so that the patient
cannot harm him or herself. Timing the duration
of the seizure enables strategic patient planning,
and if necessary sedation and ventilation.
Pain may have a significant effect on the
patients recovery. Assessment using a recognised
tool followed by structured administration of
appropriate analgesia is required with repeated
assessment and monitoring. Referral to the pain
specialist team may be appropriate.
Exposure Complete inspection of the patient is
performed to support or reveal symptoms that
may support a diagnosis. For example, rashes may
indicate anaphylaxis; surgical wounds may reveal
haemorrhage or wound breakdown; drains or
stoma output may show excessive drainage;
abdominal distension may indicate perforation
or haemorrhage; and calf pain, swelling, redness
and heat may indicate deep vein thrombosis.
Sepsis may be indicated by inflamed wounds or
device insertion sites, hot flushed skin, redness and
swelling. Dry skin or mucosa, sunken eyes,
confusion and reduced urine output may indicate
dehydration. Each of these symptoms can support
the diagnosis and indicate appropriate treatment
(Gray and Robertson 2009).

Time out 5
Having reviewed the literature,
reflect on the importance of
your role in the management
of acutely ill patients.

Completion of assessment
At the end of the assessment process, ongoing
planning is required to prevent recurrence and to
ensure the patient is making progress. Planning
for frequency of observations of respiratory rate,
oxygen saturation, blood pressure, pulse and
temperature is required. Pain and sedation scores
may also be necessary. It is helpful to try to
identify the cause of the acute event. A review of
the following should be performed as required:
august 11 :: vol 24 no 49 :: 2010 55

p49-57 w49_LEARNING ZONE 09/08/2010 10:33 Page 56

4Investigations such as full blood count, urea

and electrolyte levels, blood cultures, group
and cross match, and arterial blood gases.

learning zone acute care

4Fluid balance charts.

4X-rays or scans.

4Case notes and clinical history.

4Drug prescriptions, looking for possible
allergic reactions and interactions.

Once the patient is stable, the management plan

should be communicated to the multidisciplinary

TABLE 4
SBAR tool to aid communication between members of the multidisciplinary team
Category

Process

Situation (S)

4Identify yourself and the site or unit from which you are calling.
4Identify the patient by name and give the reason for your report. Include the
consultants details and the patients diagnosis if known.

4Describe your concern. Be specific and avoid the use of colloquial language or jargon.
Background (B)

4Give the patients reason for admission.

4Explain significant medical history, including the patients background, diagnosis, date of
admission, previous procedures, current medications, allergies, pertinent laboratory results
and other relevant diagnostic results. You should have relevant clinical records at hand.

Assessment (A)

4Vital signs.
4Review the patients vital signs and be prepared to present the findings in some detail.

Recommendation (R)

4Explain what you need in terms of equipment, personnel or instruction. Seek

confirmation about the timeframe and review period.

4Offer suggestions.
4Clarify expectations.
4Offer your recommendations.
4Have a clear idea about what you want to obtain at the end of the conversation.
4Orders given over the telephone should be repeated back to ensure accuracy.
(NHS Institute for Innovation and Improvement 2010)

References
Andrews T, Waterman H (2005)
Packaging: a grounded theory
of how to report physiological
deterioration effectively. Journal of
Advanced Nursing. 52, 5, 473-481.
Berlot G, Pangher A, Petrucci L,
Bussani R, Lucangelo U (2004)
Anticipating events of in-hospital
cardiac arrest. European Journal of
Emergency Medicine. 11, 1, 24-28.
Chellel A, Fraser J, Fender V et al
(2002) Nursing observations on
ward patients at risk of critical
illness. Nursing Times. 98, 46, 36-39.
Confidential Enquiry into
Maternal and Child Health (2004)
Why Mothers Die 2000-2002
The Sixth Report on Confidential

Enquiries into Maternal Deaths in

the United Kingdom. CEMACH,
London.
Considine J (2005) The role
of nurses in preventing adverse
events related to respiratory
dysfunction: literature review.
Journal of Advanced Nursing.
49, 6, 624-633.
Critical Care Stakeholders
Forum and National Outreach
Forum (2007) Clinical Indicators
for Critical Care Outreach Services.
www.wales.nhs.uk/sites3/
Documents/768/critical%20care
%20outreach%20clinical%20
indicators%202007.pdf
(Last accessed: July 30 2010.)

56 august 11 :: vol 24 no 49 :: 2010

Cullinane M, Findlay G,
Hargraves C, Lucas S (2005)
An Acute Problem? National
Confidential Enquiry into Patient
Outcome and Death, London.
Department of Health (2000)
Comprehensive Critical Care:
A Review of Adult Critical
Care Services. The Stationery
Office, London.
Department of Health (2005)
Quality Critical Care: Beyond
Comprehensive Critical Care.
A Report by the Critical Care
Stakeholder Forum. The Stationery
Office, London.
Department of Health, NHS
Modernisation Agency (2003)

The National Outreach Report.

The Stationery Office, London.
Franklin C, Mathew J (1994)
Developing strategies to prevent
inhospital cardiac arrest: analyzing
responses of physicians and nurses
in the hours before the event. Critical
Care Medicine. 22, 2, 244-247.
Garrard C, Young D (1998)
Suboptimal care of patients before
admission to intensive care is caused
by a failure to appreciate or apply the
ABCs of life support. British Medical
Journal. 316, 7148, 1841-1842.
Goldfrad C, Rowan K (2000)
Consequences of discharges from
intensive care at night. The Lancet.
355, 9210, 1138-1142.

NURSING STANDARD

p49-57 w49_LEARNING ZONE 09/08/2010 10:33 Page 57

team and to those who provide follow-up care.

A vital component of the management of the
acutely ill patient is the ability to communicate
clearly and precisely with all members of the
multidisciplinary team to aid timely and
appropriate help and intervention for the patient.
A wide number of communication tools are
available, however many hospitals are using the
SBAR (situation, background, assessment,
recommendation) tool (Table 4). This tool can be
used to structure conversation between members
of the multidisciplinary team. It uses standardised
questions to prompt the conveyor of information
to share the necessary details.

Conclusion
Timely detection of a deteriorating patient
and appropriate intervention using a systematic

Goldhill DR (1997) Introducing the

postoperative care team. Additional
support, expertise, and equipment
for general postoperative patients.
British Medical Journal.314, 7078,
389.
Goldhill DR (2001) The critically ill:
following your MEWS. QJM. 94, 10,
507-510.
Goldhill DR, Worthington LM,
Mulcahy AJ, Tarling M, Lee A,
OConnell T (1999a) Quality of care
before admission to intensive care.
British Medical Journal. 318, 7177,
195.
Goldhill DR, Worthington L,
Mulcahy A, Tarling M, Sumner A
(1999b) The patient-at-risk team:
identifying and managing seriously
ill ward patients. Anaesthesia. 54,
9, 853-860.
Gray A, Robertson C (2009) The
critically ill patient. In Douglas G,
Nicol F, Robertson C (Eds) Macleods
Clinical Examination. Twelfth
edition. Churchill Livingstone,
London, 437-450.
Hillman KM, Bristow PJ, Chey T
et al (2002) Duration of
life-threatening antecedents prior
to intensive care admission.
Intensive Care Medicine. 28, 11,
1629-1634.
Lewis G (Ed) (2007) The
Confidential Enquiry into Maternal

NURSING STANDARD

approach can help to stabilise the individuals

condition and enable recovery. Accurate
assessment prevents organ dysfunction,
multiorgan failure and further deterioration,
thus reducing morbidity and mortality rates
and admission to ICU. Nurses require the
knowledge and skills to provide critical
care in the general ward setting and improve
patient outcomes NS

Time out 6
Now that you have completed the
article, you might like to write a
practice profile. Guidelines to help
you are on page 60.

and Child Health. Saving Mothers

Lives: Reviewing Maternal Deaths
to Make Motherhood Safer
2003-2005. The Seventh Report
on Confidential Enquiries into
Maternal Deaths in the United
Kingdom. CEMACH, London.
McGloin H, Adam SK, Singer M
(1999) Unexpected deaths and
referrals to intensive care of
patients on general wards. Are some
cases potentially avoidable? Journal
of the Royal College of Physicians
of London. 33, 3, 255-259.

NHS Institute for Innovation

and Improvement (2010)
SBAR Situation Background
Assessment Recommendation.
www.institute.nhs.uk/quality_and_
service_improvement_tools/quality_
and_service_improvement_tools/
sbar_-_situation_-_background_-_
assessment_-_recommendation.html
(Last accessed: August 3 2010.)
ODriscoll BR (1997) Nebulisers
for chronic obstructive pulmonary
disease. Thorax. 52, Suppl 2,
S49-S52.

McQuillan P, Pilkington S, Allan A

et al (1998) Confidential inquiry
into quality of care before admission
to intensive care. British Medical
Journal. 316, 7148, 1853-1858.

ODriscoll BR, Howard LS,

Davison AG (2008) BTS guideline
for emergency oxygen use in adult
patients. Thorax. 63, Suppl 6,
vi1-vi68.

Morgan RM, Williams F,

Wright MM (1997) An early
warning scoring system for
detecting developing critical illness.
Clinical Intensive Care. 8, 2,
100-101.

Priestley G, Watson W, Rashidian A

et al (2004) Introducing Critical
Care Outreach: a ward-randomised
trial of phased introduction in a
general hospital. Intensive Care
Medicine. 30, 7, 1398-1404.

National Institute for Health and

Clinical Excellence (2007) Acutely
Ill Patients in Hospital. Recognition
of and Response to Acute Illness in
Adults in Hospital. NICE, London.

Resuscitation Council (UK)

(2005) Resuscitation Guidelines
2005. RCUK, London.

National Patient Safety Agency

(2007) Recognising and Responding
Appropriately to Early Signs
of Deterioration in Hospitalised
Patients. NPSA, London.

England Journal of Medicine. 345,

19, 1368-1377.
Rudra A, Chatterjee S, Sengupta S,
Wankhade R, Sirohia S, Das T
(2006) Fluid resuscitation in
trauma. Indian Journal of Critical
Care Medicine. 10, 4, 241-249.
Schein RM, Hazday N, Pena M,
Ruben BH, Sprung CL (1990)
Clinical antecedents to in-hospital
cardiopulmonary arrest. Chest. 98,
6, 1388-1392.
Smith G, Nielsen M (1999) ABC
of intensive care. Criteria for
admission. British Medical Journal.
318, 7197, 1544-1547.
Stanisstreet D, Walden E,
Jones C, Graveling A (2010)
The Hospital Management of
Hypoglycaemia in Adults with
Diabetes Mellitus. NHS
Diabetes, London.
Wallis CB, Davies HT, Shearer AJ
(1997) Why do patients die on
general wards after discharge from
intensive care units? Anaesthesia.
52, 1, 9-14.

Resuscitation Council (UK) (2006)

Advanced Life Support Manual.
Fifth edition. RCUK, London.

Williams C (2008) Fluid

resuscitation in burn patients 1:
using formulas. Nursing Times.
104, 14, 28-29.

Rivers E, Nguyen B, Havstad S

et al (2001) Early goal-directed
therapy in the treatment of severe
sepsis and septic shock. New

Williamson A, Hoggart B (2005)

Pain: a review of three commonly
used pain rating scales. Journal
of Clinical Nursing. 14, 7, 798804.

august 11 :: vol 24 no 49 :: 2010 57

p58w49_Assessment 09/08/2010 10:22 Page 1

learning zone assessment

Acutely ill patients

TEST YOUR KNOWLEDGE AND WIN A 50 BOOK TOKEN

9. Which of the following is

not a primary cause of
neurological dysfunction?
a) Epilepsy
b) Hypoxia
c) Infection
d) Compressive lesions

10. If blood glucose is less than

3mmol/L, what percentage of
glucose should be given?
a) 1%
b) 3%
c) 6%
d) 10%

HOW TO USE THIS ASSESSMENT

This self-assessment questionnaire (SAQ)
will help you to test your knowledge. Each
week you will find ten multiple-choice
questions that are broadly linked to the
learning zone article. Note: There is only
one correct answer for each question.

59-65 Lowlands Road, Harrow-on-the-Hill,

Middlesex HA1 3AW, or send them by email
to zena.latcham@rcnpublishing.co.uk.
Subscribers can complete the assessment
at www.nursing-standard.co.uk by clicking
on the CPD link on the left of the homepage.

Ways to use this assessment

4 You could test your subject knowledge by
attempting the questions before reading
the article, and then go back over them to
see if you would answer any differently.

Ensure you include your name and address

and the SAQ number. This is SAQ no. 555.
Entries must be received by 10am on
Tuesday August 24 2010.

4 You might like to read the article to update

yourself before attempting the questions.
Prize draw
Each week there is a draw for correct entries.
Please send your answers on a postcard to
Zena Latcham, Nursing Standard, The Heights,

When you have completed your

self-assessment, cut out this page and add it
to your professional portfolio. You can record
the amount of time it has taken. Space has
been provided for comments.
You might like to consider writing a practice
profile, see page 60.

This self-assessment questionnaire

was compiled by Tanya Fernandes
The answers to this questionnaire
will be published on August 25

Report back
This activity has taken me ____ hours to
complete.

1. What percentage of hospital

cardiac arrests are preceded by
clear signs of deterioration?
a) 25%
b) 35%
c) 65%
d) 85%

2. The letter U in AVPU stands for:

a) Unconscious

b) Unresponsive

c) Unwell

d) Underweight

3. What does stridor signify when

assessing a patients airway?
a) Swelling in the airway
b) Vibration of the tongue
c) Laryngospasm
d)Air passing through fluid

4. High flow oxygen should be

delivered through a non-rebreathing
oxygen mask at a rate of:
a) 5 litres per minute

b) 10 litres per minute

c) 15 litres per minute

d) 20 litres per minute

58 august 11 :: vol 24 no 49 :: 2010

5. Initial assessment of patients in

the hospital setting should include:
a) Respiration rate

b) Heart rate

c) Systolic blood pressure

d) All of the above

6. Hypovolaemic shock may be

caused by:
a) Burns
b) Cardiac contusion
c) Anaphylaxis
d) Dysrhythmias

7. Breathing needs to be
assessed to exclude:
a) Central nervous system
depression
b) Phrenic nerve problems
c) Exacerbation of existing disease
d) All of the above

8. During chest auscultation,

crepitations may indicate:
a) Narrowing of the airways
b) Gas escaping
c) Secretions in the lungs
d) Fibrosis

Other comments:

Now that I have read this article and

completed this assessment, I think
my knowledge is:
Excellent
Good
Satisfactory
Unsatisfactory
Poor
As a result of this I intend to:

Answers to respiratory disease

questions
The answers to SAQ no. 553 on
respiratory disease, which appeared in
the July 28 issue, are:
1. b 2. d 3. a 4. d 5. c
6. b 7. d 8. c 9. a 10. c

NURSING STANDARD

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