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Acutely Ill Patients in Hospital: Recognition of and Response to Acute Illness in Adults in Hospital [Internet]. London: National Institute for Health and Clinical Excellence (NICE); 2007 Jul. (NICE Clinical Guidelines, No. 50.)

Cover of Acutely Ill Patients in Hospital

Acutely Ill Patients in Hospital: Recognition of and Response to Acute Illness in Adults in Hospital [Internet].

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1Summary

1.1. Patient-centred care

This guideline offers best practice advice on the care of adult patients within the acute hospital setting.

Treatment and care should take into account patients’ needs and preferences. People with an acute illness should, if appropriate, have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If patients do not have the capacity to make decisions, healthcare professionals should follow the Department of Health (2001) guidelines – ‘Reference guide to consent for examination or treatment’ (available from www.dh.gov.uk). From April 2007 healthcare professionals will need to follow a code of practice accompanying the Mental Capacity Act (summary available from www.dca.gov.uk/menincap/bill-summary.htm).

Good communication between healthcare professionals and patients is essential. It should be supported by evidence-based written information tailored to the patient’s needs. Treatment and care, and the information patients are given about it, should be culturally appropriate. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English.

If the patient agrees, carers and relatives should have the opportunity to be involved in decisions about treatment and care.

Carers and relatives should also be given the information and support they need.

1.2. List of recommendations and care pathway

1.2.1. Key priorities for implementation

  • 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 at the time of their admission or initial assessment

    a clear written monitoring plan that specifies which physiological observations should be recorded and how often. The plan should take account of the:

    patient’s diagnosis

    presence of comorbidities

    agreed treatment plan.

    Physiological observations should be recorded and acted upon by staff who have been trained to undertake these procedures and understand their clinical relevance.
  • Physiological track and trigger systems should be used to monitor all adult patients in acute hospital settings.

    Physiological observations should be monitored at least every 12 hours, unless a decision has been made at a senior level to increase or decrease this frequency for an individual patient.

    The frequency of monitoring should increase if abnormal physiology is detected, as outlined in the recommendation on graded response strategy.

  • Staff caring for patients in acute hospital settings should have competencies in monitoring, measurement, interpretation and prompt response to the acutely ill patient appropriate to the level of care they are providing. Education and training should be provided to ensure staff have these competencies, and they should be assessed to ensure they can demonstrate them.
  • A graded response strategy for patients identified as being at risk of clinical deterioration should be agreed and delivered locally. It should consist of the following three levels.

    Low-score group:

    Increased frequency of observations and the nurse in charge alerted.

    Medium-score group:

    Urgent call to team with primary medical responsibility for the patient.

    Simultaneous call to personnel with core competencies for 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.

    High-score group:

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

  • If the team caring for the patient considers that admission to a critical care area is clinically indicated, then the decision to admit should involve both the consultant caring for the patient on the ward and the consultant in critical care.
  • After the decision to transfer a patient from a critical care area to the general ward has been made, he or she should be transferred as early as possible during the day. Transfer from critical care areas to the general ward between 22.00 and 07.00 should be avoided whenever possible, and should be documented as an adverse incident if it occurs.
  • The critical care area transferring team and the receiving ward team should take shared responsibility for the care of the patient being transferred. They should jointly ensure:

    there is continuity of care through a formal structured handover of care from critical care area staff to ward staff (including both medical and nursing staff), supported by a written plan

    that the receiving ward, with support from critical care if required, can deliver the agreed plan.

The formal structured handover of care should include:

a summary of critical care stay, including diagnosis and treatment

a monitoring and investigation plan

a plan for ongoing treatment, including drugs and therapies, nutrition plan, infection status and any agreed limitations of treatment

physical and rehabilitation needs

psychological and emotional needs

specific communication or language needs.

1.2.2. All recommendations

Physiological observations in acute hospital settings (section 2.1.3)

1.2.2.1Adult 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 at the time of their admission or initial assessment
  • a clear written monitoring plan that specifies which physiological observations should be recorded and how often. The plan should take account of the:

    patient’s diagnosis

    presence of comorbidities

    agreed treatment plan.

Physiological observations should be recorded and acted upon by staff who have been trained to undertake these procedures and understand their clinical relevance.
1.2.2.2As a minimum, the following physiological observations should be recorded at the initial assessment and as part of routine monitoring:
  • heart rate
  • respiratory rate
  • systolic blood pressure
  • level of consciousness
  • oxygen saturation
  • temperature.

Identifying patients whose clinical condition is deteriorating or is at risk of deterioration (section 2.1.4)

1.2.2.3Physiological track and trigger systems should be used to monitor all adult patients in acute hospital settings.
  • Physiological observations should be monitored at least every 12 hours, unless a decision has been made at a senior level to increase or decrease this frequency for an individual patient.
  • The frequency of monitoring should increase if abnormal physiology is detected, as outlined in the recommendation on graded response strategy (recommendation 1.2.2.10).

Choice of physiological track and trigger system (section 2.1.5)

1.2.2.4Track and trigger systems should use multiple-parameter or aggregate weighted scoring systems, which allow a graded response. These scoring systems should:
  • define the parameters to be measured and the frequency of observations
  • include a clear and explicit statement of the parameters, cut-off points or scores that should trigger a response.

Physiological parameters to be used by track and trigger systems (section 2.1.6)

1.2.2.5Multiple-parameter or aggregate weighted scoring systems used for track and trigger systems should measure:
  • heart rate
  • respiratory rate
  • systolic blood pressure
  • level of consciousness
  • oxygen saturation
  • temperature.
1.2.2.6In specific clinical circumstances, additional monitoring should be considered; for example:
  • hourly urine output
  • biochemical analysis, such as lactate, blood glucose, base deficit, arterial pH
  • pain assessment.

Critical care outreach services for patients whose clinical condition is deteriorating (section 2.2.3)

1.2.2.7Staff caring for patients in acute hospital settings should have competencies in monitoring, measurement, interpretation and prompt response to the acutely ill patient appropriate to the level of care they are providing. Education and training should be provided to ensure staff have these competencies, and they should be assessed to ensure they can demonstrate them.
1.2.2.8The response strategy for patients identified as being at risk of clinical deterioration should be triggered by either physiological track and trigger score or clinical concern.
1.2.2.9Trigger thresholds for track and trigger systems should be set locally. The threshold should be reviewed regularly to optimise sensitivity and specificity.

Graded response strategy (section 2.2.3)

No specific service configuration can be recommended as a preferred response strategy for individuals identified as having a deteriorating clinical condition.

1.2.2.10A graded response strategy for patients identified as being at risk of clinical deterioration should be agreed and delivered locally. It should consist of the following three levels.
  • Low-score group:

    Increased frequency of observations and the nurse in charge alerted.

  • Medium-score group:

    Urgent call to team with primary medical responsibility for the patient.

    Simultaneous call to personnel with core competencies for 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.

  • High-score group:

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

1.2.2.11Patients identified as ‘clinical emergency’ should bypass the graded response system. With the exception of those with a cardiac arrest, they should be treated in the same way as the high-score group.
1.2.2.12For patients in the high- and medium-score groups, healthcare professionals should:
  • initiate appropriate interventions
  • assess response
  • formulate a management plan, including location and level of care.
1.2.2.13If the team caring for the patient considers that admission to a critical care area is clinically indicated, then the decision to admit should involve both the consultant caring for the patient on the ward and the consultant in critical care.

Transfer of patients from critical care areas to general wards (section 2.3.3)

1.2.2.14After the decision to transfer a patient from a critical care area to the general ward has been made, he or she should be transferred as early as possible during the day. Transfer from critical care areas to the general ward between 22.00 and 07.00 should be avoided whenever possible, and should be documented as an adverse incident if it occurs.

Care on the general ward following transfer (section 2.3.4)

1.2.2.15The critical care area transferring team and the receiving ward team should take shared responsibility for the care of the patient being transferred. They should jointly ensure:
  • there is continuity of care through a formal structured handover of care from critical care area staff to ward staff (including both medical and nursing staff), supported by a written plan
  • that the receiving ward, with support from critical care if required, can deliver the agreed plan.
The formal structured handover of care should include:
  • a summary of critical care stay, including diagnosis and treatment
  • a monitoring and investigation plan
  • a plan for ongoing treatment, including drugs and therapies, nutrition plan, infection status and any agreed limitations of treatment
  • physical and rehabilitation needs
  • psychological and emotional needs
  • specific communication or language needs.
1.2.2.16When patients are transferred to the general ward from a critical care area, they should be offered information about their condition and encouraged to actively participate in decisions that relate to their recovery. The information should be tailored to individual circumstances. If they agree, their family and carers should be involved.
1.2.2.17Staff working with acutely ill patients on general wards should be provided with education and training to recognise and understand the physical, psychological and emotional needs of patients who have been transferred from critical care areas.

1.2.3. Care pathway

Flowchart Icon

Assessment and monitoring (PDF, 84K)

1.3. Overview

1.3.1. Recognition of and response to acute illness in adults in hospital

The care of the acutely ill patient in hospital may require input from critical care. Critical care in the NHS is provided within the continuum of secondary and tertiary care, with the majority of services delivered in the secondary care setting. The Department of Health in 2000 recommended that this care should be classified based on the level of care that individual patients need, regardless of location. It identified four levels of care. Level 0: patients whose needs can be met through normal ward care in an acute hospital; level 1: patients at risk of their condition deteriorating, or those recently relocated from higher levels of care, whose needs can be met on an acute ward with additional advice and support from the critical care team; level 2: patients requiring more detailed observation or intervention, including support for a single failing organ system or postoperative care and those ‘stepping down’ from higher levels of care; and level 3: either patients requiring advanced respiratory monitoring and support, or patients needing monitoring and support for two or more organ systems, one of which may be basic or advanced respiratory support.

The aging population, increasing complexity of medical and surgical interventions, and shorter length of hospital inpatient stays have meant that patients in hospital are at increasing risk of becoming acutely ill and may require admission to critical care areas. This has led to increasing demand for level 1 and level 2 care. Clinical deterioration can occur at any stage of a patient’s illness, although there will be certain periods during which a patient is more vulnerable, such as at the onset of illness, during surgical or medical interventions and during recovery from critical illness. Patients on general adult wards and emergency departments who are at risk of deteriorating may be identified before a serious adverse event by changes in physiological observations recorded by healthcare staff. The interpretation of these changes, and timely institution of appropriate clinical management once physiological deterioration is identified, is of crucial importance to minimise the likelihood of serious adverse events, including cardiac arrest and death. Should a patient be admitted to critical care areas for further care, then care on general adult wards following transfer from critical care areas may also have a significant impact on patient outcomes.

There is, however, a consistent body of evidence that shows that patients who become, or who are at risk of becoming, acutely unwell on general hospital wards receive suboptimal care (McQuillan et al. 1998; NCEPOD 2005; Seward et al. 2003). The National Confidential Enquiry into Patient Outcome and Death (NCEPOD 2005) identified the prime causes of the substandard care of the acutely unwell in hospital as being delayed recognition, and institution of inappropriate therapy that subsequently culminated in a late referral. The report found that on a number of occasions these factors were aggravated by poor communication between the acute and critical care medical teams. It also identified examples in which there was a lack of awareness by medical consultants of their patients’ deteriorating health and their subsequent admission to critical care. Admission to an intensive care unit (ICU) was thought to have been avoidable in 21% of cases, and the authors felt that suboptimal care contributed to about a third of the deaths that occurred.

Any intervention delivered to patients in hospital who deteriorate clinically, or who show signs that they may deteriorate unexpectedly, should aim to reduce patient mortality, morbidity and length of stay both in the hospital overall and in a critical care area should they be admitted to critical care. Such interventions could have substantial health economic implications through, for example, reductions in ICU admission and re-admission. A level-3 ICU bed, for example, costs approximately £1716 per day (Department of Health 2006). In addition, a ward bed has been estimated to cost £220 per day (Harrison et al. unpublished).

This guideline aims to improve the care of the acutely ill in hospital by making evidence-based recommendations on the best way to identify and manage this group of patients. It is intended that its implementation will improve the quality of care received by these patients and address the shortcomings in care identified by the NCEPOD report.

1.3.2. The NICE short clinical guidelines programme

‘Acutely ill patients in hospital: recognition of and response to acute illness in adults in hospital’ (NICE clinical guideline 50) is the first NICE short clinical guideline.

The Institute has established a ‘short’ clinical guidelines programme that will allow the rapid (9–11 month) development of clinical guidelines that address only part of a care pathway for which the NHS requires guidance rapidly.

Short clinical guidelines are developed by an internal NICE technical team (the Short Clinical Guidelines Technical Team) to the same rigorous methods as existing clinical guidelines developed by NICE’s national collaborating centres. This will be achieved by narrowing down the scope of the guideline so that it addresses a small number of key clinical questions. This will allow the Short Clinical Guidelines Technical Team to prepare evidence reviews of the same high quality as those produced in standard clinical guidelines, but in a shorter time. These reviews will be presented to the Guideline Development Group and used to make recommendations for clinical practice.

The short clinical guidelines programme consists of four phases that follow those of the standard guidelines programme.

  1. Referral of topic to NICE by the Department of Health.
  2. Scoping the guideline topic.
  3. The development phase, which begins with the first meeting of the Guideline Development Group and ends when a draft document is submitted by the Guideline Development Group for stakeholder consultation.
  4. The validation phase, which consists of consultation with stakeholders and the public on the draft guidance, receiving advice from the Guideline Review Panel and expert reviewers, preparation of the final draft, sign off by Guidance Executive and publication.

To meet the time requirements and minimise the complexity of development, key stages of the scoping and development phase of the standard guidelines process have been adapted. An interim process guide to the short clinical guidelines programme, setting out in detail the short guideline development methods, has been the subject of public consultation. It is intended that the revised version of the interim process guide, which will take account of the public consultation comments, will be incorporated into the 2008 update of the ‘The guidelines manual’ (see www.nice.org.uk).

1.3.3. Using this guideline

This document is intended to be relevant to healthcare professionals within acute hospitals who have direct contact with patients. The target population is adult patients in hospitals. This includes patients in the accident and emergency department, once a decision to admit the patient has been made.

The full version of the guideline is available to download free of charge from the NICE website (www.nice.org.uk). NICE will also make available summary versions of this guideline on the website, including ‘Understanding NICE guidance’ (a version for patients) and a quick reference guide.

1.3.4. Using recommendations and supporting evidence

The Guideline Development Group took into consideration the overall benefits, harms and costs of the evidence it reviewed. It also considered equity and the practicality of implementation when drafting the recommendations set out within this guideline. However, healthcare professionals need to use their general medical knowledge and clinical judgement when applying recommendations that may not be appropriate in all circumstances. Decisions to adopt any particular recommendation should be made in the light of the individual patient’s views and circumstances as well as available resources. To enable patients to participate in the process of decision-making to the extent that they are able and willing, clinicians need to be able to communicate information provided in this guideline. To this end, recommendations are often supported by evidence statements that provide summary information to help clinicians and patients discuss options.

1.3.5. Using flowcharts

Deriving an evidence-based rationale for care for acutely ill patients in hospital brings together an understanding of healthcare delivery and a vast literature providing evidence about tests and treatments. Flowcharts are inevitably a simplification and cannot capture all the complexities and permutations affecting the clinical care of individuals managed within the hospital setting. Flowcharts presented in this guideline are designed to help communicate the key elements of treatment, but are not intended for rigid use or as protocol.

Copyright © 2007, National Institute for Health and Clinical Excellence.

All rights reserved. This material may be freely reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the express written permission of the Institute.

Bookshelf ID: NBK45950