What is Patient Deterioration?
Clinical deterioration means there is a sudden decline in a person’s condition. It could manifest in many ways, presenting physically, cognitively or mentally and requiring rapid intervention (Bourke-Matas, Bosley, Smith, Meadley & Bowles, 2024).
As a critical care nurse in a busy intensive care unit, I participated in Standard 8 of the NSQHS Standards committee, ‘Recognising and Responding to Acute Deterioration’. As part of this experience, I assisted with clinical investigations of patients admitted to the intensive care unit following a code blue or escalation call. I applied my critical care skills to help the committee identify trends, red flags, and areas for improvement within the organisation.
What Causes Patient Deterioration?
Clinical deterioration can result from various factors, such as underlying medical conditions, acute events, medication errors, and surgical complications. Other contributing factors include inadequate monitoring, delayed or inappropriate treatment, communication breakdowns, environmental factors, psychological issues, and age-related frailty (Honarmand, Wax & Penoyer, 2024 & Burke, Downey & Almoudaris, 2022).
In many cases, healthcare teams may not adequately recognise and respond to the often subtle signs of patient deterioration. Failure to recognise deterioration would lead to an intensive care admission. Research indicates that early identification and intervention of deterioration can reduce the need for high-acuity care admissions (Vincent, Einav & Pearse, 2018). Despite this, early warning signs and red flags are not always identified or acted upon promptly, resulting in an admission to an intensive care unit or death (ACSQHC 2019).
How Can Education Improve Outcomes?
So why might a clinical or a healthcare team fail to identify an early sign of deterioration? Several factors may contribute to this issue, including limited resources, inadequate staff-to-patient ratios, the complexity of implementing systematic changes across healthcare settings or insufficient staff training.
The 2024 Guidelines on Recognising and Responding to Clinical Deterioration Outside the ICU recommend direct-care non-ICU hospital clinicians receive focused education to improve their ability to recognise early signs of clinical deterioration.
What is the Role of Training?
The National Safety and Quality Standards and the Aged Care Quality Standards(ACSQHC 2019, ACQSC, 2019) document the need for training and education on patient deterioration. These critical sets of Quality Standards, which underpin the aged and acute care sectors, state that an organisation is responsible for ensuring its staff members are competent in recognising and responding to deterioration.
Relevant Standards
Action 8.04: Patient monitoring processes
- Patients have vital sign monitoring plans, which are individualised and monitored as required based on the plan
- Changes in observations are documented to detect acute deterioration over time
Action 8.05: Recognising acute deterioration in patient mental state
- Use comprehensive care plans to guide monitoring patients susceptible to mental state deterioration
- Workforce members are made aware and alert to these patients
- Workforce members are made aware and alert to signs of delirium
- Workforce can instigate initial response to keep patients safe until specialist review arrangements are made
Action 8.10: Deterioration response systems
- Processes are in place to ensure clinicians with appropriate skills manage acute deterioration episodes
Action 8.11: Deterioration support
- Processes are in place to ensure at least one clinician (with relevant skills) is available at all times for rapid access, and can deliver advanced life support
Action 8.12: Mental state escalation processes
- Escalation processes are in place for patient's experiencing deterioration - including designation of responsibilities and roles for staff (including timeframes for response)
- Partnerships with relevant organisations are in place if responding to acute mental state deterioration is outside of your organisation's services
- Staff are aware of and use (where necessary) the escalation protocol
Action 8.13: Physical deterioration management and referrals
- Causes of acute deterioration are mapped against your organisation's capacity to ensure definitive management
- Systems are in place for rapid referral to other services if your organisation cannot provide definitive care
National Safety and Quality Health Service (NSQHS) Standards
- Recognise risks or concerns related to an older person’s health, safety and well-being.
- Identify deterioration or changes to an older person’s ability to perform activities of daily living, mental health, cognitive or physical function, capacity or condition.
- Respond to and escalate risks promptly.
Action 5.3.2 states: The provider has processes to ensure medication reviews are conducted, including:
- At the commencement of care, at transitions of care and annually when care is ongoing.
- When there is a change in diagnosis or deterioration in behaviour, cognition, mental or physical condition or when a person is acutely unwell.
- When there is polypharmacy and the potential to deprescribe.
- When a new medicine is commenced or a change is made to an existing medicine or medication management plan.
- When there is an adverse event potentially related to medicines.
Action 5.4.5 states: The provider implements processes to monitor clinical conditions and reassess when there is a change in diagnosis or deterioration in behaviour, cognition, mental, physical or oral health, and at transitions of care.
Action 5.5.6 states: The provider implements processes to optimise mental health by:
- Actively promoting an older person’s mental health and wellbeing.
- Responding to signs of deterioration in an older person’s mental health.
- Responding supportively to distress and symptoms of mental illness, including self-harm and suicidal thoughts, minimising risks to the psychological and physical safety of each older person.
Action 5.6.1 states: The provider identifies and responds to the complex clinical care needs of people with delirium, dementia and other forms of cognitive impairment by:
- Identifying and mitigating clinical risks.
- Delivering increased care requirements.
- Being alert to deterioration and underlying contributing clinical factors.
Systems are in place for rapid referral to other services if your organisation cannot provide appropriate care.
Strengthened Quality Standards framework analysis - Aged Care Quality Standards
Related Training Requirement
Healthcare staff and clinicians can use the training requirements listed below to learn the importance of recognising normal and abnormal vital signs in acute physiological, mental, or cognitive deterioration.
Training Requirement: Clinical Assessment
Training Requirement: Comprehensive Care Plans
Training Requirement: Adverse Drug Reaction
Training Requirement: End-of-Life-Care
Training Requirement: Blood Availability and Management
Training Requirement: Delirium and Cognitive Impairment (Prevention and Management)
Training Requirement: Dementia Care
How to Identify Patient Deterioration
Patient assessment is a vital skill. Early identification of patient deterioration is crucial to ensure the patient receives rapid care and further minimises adverse health outcomes and admission to intensive care settings. The patient must be assessed from head to toe, including vital signs. Therefore, education and training should focus on the following:
This short video is part of the Clinical Deterioration: Cardiac Course here.
Vital signs include:
- Blood Pressure
- Temperature
- Oxygen saturation
- Respiratory rate
- Heart Rate
- Level of consciousness
- New onset confusion or behaviour change
Head to Toe assessment includes the following:
- Neurological
- Cardiovascular
- Respiratory
- Gastrointestinal
- Renal
- Musculoskeletal
- Integumentary
- Social
How to Respond to Person Who is Deteriorating
The following steps will help you systematically work through a clinical situation; however, please refer to your hospital policies and procedures.
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- Call for help: Immediately seek help using the call alert button on the wall or dialling the facility’s emergency number on a landline phone. The operator will broadcast the emergency over the general speaker system. This will alert additional healthcare staff or emergency services to come to the location and support.
- Head-to-toe assessment: Conduct a comprehensive clinical evaluation of the patient's condition, checking vital signs and inquiring about medical history to inform the subsequent course of action.
- Basic life support: If the patient is unconscious or unresponsive, initiate basic life support measures, such as cardiopulmonary resuscitation, while waiting for further assistance.
- Escalation protocol: Follow your healthcare facility's guidelines for escalating the care of a deteriorating patient. This may involve alerting specific medical teams or transferring the patient to high-acuity care areas such as a high-dependency unit, intensive care unit, or operating theatre.
- Prepare for intervention: Assemble necessary equipment and medications in anticipation of medical interventions, ensuring everything is at hand for quick access.
- Documentation: Accurate record-keeping is crucial. An experienced clinician would be the scribe. However, if this differs from the case, allocate someone within the team to take notes.
Documentation notes should include the following:
- Timekeeping of resuscitation cycles, administration of medicines
- People present in the room
- Vital signs and frequency
- Medical interventions
- Transport plans
Reflecting on my experience as a nurse in charge, the sound of the ‘CODE BLUE’ announcement over the hospital speakers would always startle me. As I made my way up the lift with my colleagues, I would gather my thoughts, revise the process, and ensure we were all clear on the plan. I was reminding the team to act respectfully and communicate clearly.
Skills Required by Healthcare Staff for Identifying and Responding to Patient Deterioration
Identifying and responding to patient deterioration are complex tasks that require a multi-faceted skill set. Here, we break down these essential skills:
| Skill | Description |
|---|---|
| Observation Skills |
|
| Communication Skills |
|
| Clinical Judgement |
|
| Technical Skills (Staff require appropriate training for this area) |
|
| Professional Skills |
|
How to Assess Staff Competency in Identifying and Responding to Patient Deterioration
Staff competency assessment ensures that healthcare professionals and health workers are assessed and deemed competent to deliver safe and quality care in clinical scenarios involving clinical deterioration. The following methods are commonly used:
- Haemodynamic interpretation: Monitoring and recording patients' vital signs allows health practitioners to examine the patient and identify physical signs of deterioration.
- Clinical scenarios: Regularly conducting simulated medical emergencies allows staff to engage in real-life situations within a safe and controlled environment. This approach enables them to make mistakes and reflect on their practice.
- Competency assessment: Demonstrating competence is essential for fulfilling the criteria set by the healthcare organisation and is a compulsory requirement for people providing care to a person. A health worker's knowledge and skills must be appropriate and reflect their scope of practice.
- Pre-assessment questionnaire: Typically consists of questions designed to assess staff members' knowledge, skills, and attitudes before further training on a particular education session.
- Feedback: This combines input from peers, clinical educators, and managers to give a rounded view of an individual's capabilities.
Strategies to Support Healthcare Staff Improve Skills in Identifying and Responding to Deterioration
Micro-learning is one of many strategies that can be used to help healthcare staff improve their skills. Staff development is crucial for improving patient outcomes. Below are six key strategies to consider:
- Regular Micro-Learning Sessions: Bedside education sessions are an excellent opportunity for learners to be hands-on and apply the theory they have learned into practice.
- Simulation-Based Training: Simulated scenarios allow staff to learn from their mistakes without putting patients at risk. They are a great way to create a real-life situation where the participants must collaborate with other healthcare professionals.
- Mentorship Programs: Mentorship programs are a formal process. The Mentor must be engaged and willing to participate. Before pairing less experienced staff with experienced staff, discussing the expectations of both parties is essential. This ensures that both parties agree to the terms, including time commitments, learning objectives, and feedback methods.
- Team-Based Training: Collaboration between disciplines (e.g., nursing, health workers and physiotherapy) can provide a more holistic approach to patient care.
- Online Learning Modules: Online learning resources offer flexibility, allowing staff to learn independently and revisit materials such as hospital protocols as needed.
- Debrief Sessions: The word ‘debrief’ refers to a retrospective analysis of an incident. It allows all participants to come together to reflect on the event, highlight the lessons learned, and identify opportunities for improvement.
I have used a few strategies listed above throughout my nursing career, particularly with undergraduate students. This approach allowed me to capture a real-time snapshot of the student's knowledge and critical thinking skills during patient interaction. I would then chat with the students and expand on T drawings and patient data to reinforce their knowledge. Students found this extremely helpful.
Sample Training Plan for Identifying and Responding to Patient Deterioration
We can use the staff competency below to identify and respond to patient/client deterioration as an example to create a unique training plan targeting skills that need to be revised.
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Based on the results - "technical" skills require action.
Is your current LMS lacking patient deterioration content?
Contact Ausmed today and see how our solutions can help your organisation meet the patient deterioration standard!
Staff Competency Assessment for Patient Deterioration - Example
The survey below will help you identify your staff's competency levels in recognising patient deterioration.
Staff Survey - Identifying and Responding to Patient Deterioration
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Using an ABCDE approach, can you identify physical signs that may suggest someone is deteriorating?
- [Answer here]
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How do you identify changes in a patient’s mental state that suggest acute deterioration?
- [Answer here]
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How quickly do you respond when a patient is deteriorating, and what are your first steps??
- [Answer here]
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What is the first step when someone is unconscious?
- [Answer here]
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What documentation tool can you use to escalate a deteriorating patient?
- [Answer here]
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What do you do when someone is unconscious?
- [Answer here]
Conclusion
Comprehensive training in identifying and responding to deterioration is critical in any healthcare setting, especially for non-ICU clinicians. The healthcare organisation is responsible for ensuring that its staff are equipped with all the necessary skills to be competent and safe in their practice and prepared to act swiftly in critical situations.
References
- Aged Care Quality and Safety Commission 2021, Strengthened Aged Care Quality Standards guide, Australian Government, viewed 26 May 2024, https://www.agedcarequality.gov.au/providers/quality-standards/stronger-standards-better-aged-care-program
- Australian Commission on safety and Quality in health 2023, Recognising and Responding to Acute Deterioration Standard, Australian Government, Australian Government, viewed 26 May 2024, https://www.safetyandquality.gov.au/standards/nsqhs-standards/recognising-and-responding-acute-deterioration-standard
- Burke JR, Downey C, Almoudaris AM 2022, Failure to rescue deteriorating patients: a systematic review of root causes and improvement strategies, Journal of Patient Safety, vol.18, no.1, pp.140-155, https://psnet.ahrq.gov/issue/failure-rescue-deteriorating-patients-systematic-review-root-causes-and-improvement
- College of Intensive Care Medicine of Australia and New Zealand 2011, Minimum Standards for Intensive Care Units, CICM, viewed 17 April 2023, https://www.cicm.org.au/CICM_Media/CICMSite/CICM-Website/Resources/Professional%20Documents/IC-1-Minimum-Standards-for-Intensive-Care-Units.pdf
- Gerry, S, Bonnici, T, Birks, J, Kirtley, S, Virdee, PS, Watkinson, PJ, Collins, GS 2020, ‘Early warning scores for detecting deterioration in adult hospital patients: systematic review and critical appraisal of methodology’, The British Medical Journal, vol. 369
- Honarmand, K, Wax, RS, Penoyer, D, Lighthall, G, Danesh, V, Rochwerg, B, Cheatham, ML, Davis, DP, DeVita, M, Downar, J & Edelson, D, 2024, 'Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU', Critical care medicine, vol.52, no.2, pp. 314-330.
- Matas, E, Bosley, E, Smith, Meadley, B & Bowles, KA 2024, ‘Developing a consensus-based definition of out-of-hospital clinical deterioration: A Delphi study’, Australian Critical Care, vol. 37 no. 2, pp.318-325.
- Rueda-Medina, B, Schmidt-RíoValle, J, González-Jiménez, Fernández-Aparicio, Á, Encarnación Aguilar-Ferrándiz, M & Correa-Rodríguez M 2021, ‘Peer debriefing versus instructor-led debriefing for nursing simulation’, Journal of Nursing Education, vol. 60, no. 2, pp. 90-95.
- Stelfox, HT, Bagshaw, M, & Gao, S 2015, ‘A retrospective cohort study of age-based differences in the care of hospitalised patients with sudden clinical deterioration’, Journal of Critical Care, vol. 30, no.5, pp.1025-1031.
- Vincent, JL, Einav, S, Pearse, R, Jaber, S, Kranke, P, Overdyk, FJ, Whitaker, D, Federico, G, Dahan, A & Hoeft, A 2018, ‘Improving detection of patient deterioration in the general hospital ward environment’ European Journal of Anaesthesiology, vol. 35 no. 5, pp.325-333.
- Australian Commission on Safety and Quality in Health, 2023. 'NSQHS Action 8.05'
- Australian Commission on Safety and Quality in Health, 2023. 'NSQHS Action 8.10'
- Australian Commission on Safety and Quality in Health, 2023. 'NSQHS Action 8.11'
- Australian Commission on Safety and Quality in Health, 2023. 'NSQHS Action 8.12'
- Australian Commission on Safety and Quality in Health, 2023. 'NSQHS Action 8.13'
Author
Renee Di Giuseppe
Renee Di Giuseppe is a Critical Care Registered Nurse with over 18 years of experience. She holds a Master of Health Science (Critical Care). She has a background in critical care settings, with significant clinical and management experience working in a large intensive care unit in Melbourne.
As an Associate Nurse Unit Manager (ANUM), Renee enjoyed leading teams throughout her clinical nursing career. Renee has a great passion for nursing leadership and infused her units with a distinct culture of collaboration, respect, and accountability. Renee was a regular, well-evaluated presenter for Ausmed’s face-to-face events, specialising in presenting a 2-day seminar on recognising and responding to clinical deterioration.
In 2020, she transitioned to a non-clinical nursing career at Ausmed, building expertise in education, regulation, clinical governance and community and event management. Renee currently holds a Community Manager role within Ausmed's Marketing Team, which focuses on developing helpful and engaging content and promoting and delivering impactful live and virtual events, drawing on her expertise in presenting and coordinating Ausmed’s events to foster community engagement.
Peer Reviewer
Zoe Youl
Zoe Youl is a Critical Care Registered Nurse with over ten years of experience at Ausmed, currently as Head of Community. With expertise in critical care nursing, clinical governance, education and nursing professional development, she has built an in-depth understanding of the educational and regulatory needs of the Australian healthcare sector.
As the Accredited Provider Program Director (AP-PD) of the Ausmed Education Learning Centre, she maintains and applies accreditation frameworks in software and education.In 2024, Zoe lead the Ausmed Education Learning Centre to achieve Accreditation with Distinction for the fourth consecutive cycle with the American Nurses Credentialing Center’s (ANCC) Commission on Accreditation. The AELC is the only Australian provider of nursing continuing professional development to receive this prestigious recognition.
Zoe holds a Master's in Nursing Management and Leadership, and her professional interests focus on evaluating the translation of continuing professional development into practice to improve learner and healthcare consumer outcomes. From 2019-2022, Zoe provided an international perspective to the workgroup established to publish the fourth edition of Nursing Professional Development Scope & Standards of Practice. Zoe was invited to be a peer reviewer for the 6th edition of the Core Curriculum for Nursing Professional Development.
