About this toolkit

This guideline provides evidence-based and consensus recommendations for best practice in the management of clinical deterioration in non-pregnant adult patients. The focus is on timely planning, recognition and escalation of those experiencing acute deterioration. It is acknowledged that many with life-limiting illness may have a different focus of care, with the overall aim of palliation of symptoms rather than disease recovery – this is covered by the Scottish Palliative Care Guidelines

The remit of the present guideline includes deteriorating patients within:

• community care settings
• primary care settings
• secondary care settings, including ambulance services. 

It excludes:

• pregnant patients (see specific guidance in the Royal College of Physicians’ Managing acute medical problems in pregnancy toolkit alongside the Scottish Maternity Early Warning System)
• children under 16 years
• patients undergoing palliation at the end of life.

Target users of the guideline

This guideline will be of interest to:

• healthcare professionals who are involved in the care of deteriorating patients in all settings
• relatives and carers of deteriorating patients
• service commissioners.

SIGN is a collaborative network of clinicians, other healthcare professionals and patient organisations and is part of Healthcare Improvement Scotland. SIGN guidelines are developed by multidisciplinary groups of practising healthcare professionals using a standard methodology based on a systematic review of the evidence. Further details about SIGN and the guideline development methodology are contained in ‘SIGN 50: A Guideline Developer’s Handbook’, available at www.sign.ac.uk

This guideline was developed according to the 2019 edition of SIGN 50.

The consensus methodology

The Delphi process

The consensus recommendations (marked by C) in this guideline were developed by a multidisciplinary group of practising healthcare professionals and patient and public representatives using a modified Delphi process. The Delphi process is a methodology designed to reach a group opinion or consensus without the drawbacks inherent within a face-to-face group process. Delphi has been shown to be more accurate than focus groups, conferences, group discussions and other traditional interactive group processes.³³ The modified Delphi process used was a multistaged survey with feedback of group results at each stage in the process. Consensus was deemed to have been reached when 70% of the group either agreed or disagreed on a question.

Participation and response rate

Potential participants were identified through professional networks. To ensure the independence of the responses, group membership was not disclosed to participants during the Delphi process. Email communications were dealt with in a way that ensured no group member saw the email address of another group member and written responses to the questionnaires were anonymised when fed back to the group.

Thirty-eight participants were invited to take part in the modified Delphi process. Sixteen responded to the first survey and 14 responded to the second survey. Sixteen participants did not respond to either survey.

The results for round 1 and 2 can be found in the supporting material section for this guideline on the SIGN website: www.sign.ac.uk.

The content within this app/ website is based on current evidence and best practice, however it is intended to be applied alongside sound clinical judgement.  As such, Healthcare Improvement Scotland is not responsible or liable for any diagnosis or management decision made on the basis of the information provided via this app/website.

Use of this app within patient care settings should always be in accordance with local policies and guidance with regard to clinical practice and mobile device usage.

Healthcare Improvement Scotland is not responsible for the content of any external websites listed, nor do they endorse any commercial product or service mentioned or advised on in any of these websites.

All use of this resource is subject to Scots law and the jurisdiction of the Scottish courts and is subject to this disclaimer.  Any views given on the app/website are not necessarily those of Healthcare Improvement Scotland or anyone connected with us.

Copyright information for the two sources of content within this app/website is shown below.

Scottish Intercollegiate Guidelines Network (SIGN).  SIGN 167: Care of deteriorating patients.  Edinburgh: SIGN; 2023. [cited 29 June 2023]  Available from: https://www.sign.ac.uk/our-guidelines/care-of-deteriorating-patients/

Copyright of this guideline is retained by SIGN. Users may download or print copies for their own use and may photocopy guidelines for the purpose of implementation.

This guidance is licensed under the Creative Commons Attribution-Noncommercial-NoDerivatives 4.0 International Licence. This allows for the copy and redistribution of SIGN guidelines as long as SIGN is fully acknowledged and given credit. The material must not be remixed, transformed or built upon in any way. To view a copy of this licence, visit https://creativecommons.org/licenses/by-nc-nd/4.0/.

Please cite the guideline as: Scottish Intercollegiate Guidelines Network (SIGN). Guideline title. Edinburgh: SIGN; Year. [cited dd mmm yyyy]. Available from URL: http://www.sign.ac.uk.

Users wishing to use reproduce or republish SIGN material for commercial purposes must seek prior approval for reproduction in any medium by completing the form at https://www.sign.ac.uk/media/1558/sign_copyright_request.pdf

Applicants for such permission should be aware that:

• SIGN resources do not endorse specific products
• Reproduction of SIGN material must be verbatim
• Within marketing material there must be a clear separation between any SIGN material and product specific information or marketing
• SIGN does not endorse in any way derivative or excerpted materials based on these guidelines, and it cannot be held liable for the content or use of any such adapted products
• The use of the SIGN name or logo for the purposes of advertising or implied endorsement of any derived product or service is strictly forbidden.

This toolkit makes use of the Flaticon held by “Tactuum as provider of the Right Decisions software.” Icons can be found at www.flaticon.com/free-icons