Response to deterioration

Recommendation 12: Use of a structured response tool could be considered for deteriorating patients in hospital. The structured response does not replace clinical judgement, but can outline elements required, such as minimum frequency of observations, time to review by an appropriate healthcare professional and what to do if the patient deteriorates despite review.

Quality improvement programmes have proposed that the response to a deteriorating patient by acute care staff who are based outside of critical care settings could be improved by using a specific structure that could take the form of a checklist or standardised proforma, such as the Scottish Patient Safety Programme (SPSP) Principles of Structured Response. Conceptually, such tools may improve the reliability of care and the early identification of goals of care.

The evidence base for structured response tools is minimal. A high-quality systematic review was inconclusive in its findings because of the poor quality of evidence available.¹⁸ Studies included were inconsistent in outcomes, members of the response team and the content of the response. Some small, low-quality studies included showed a reduction in cardiac arrests. However, the studies included were consistent in their finding that social, environmental and professional behaviours, not just the intervention alone, play a role. A narrative review showed that having defined thresholds for escalating to a structured response can remove some barriers to escalation, such as a staff member’s perceived need to justify escalation decision, with a potential benefit to safety culture.¹⁹ A structured response tool could result in generating workload if thresholds for activating the response team are set incorrectly. Finally, a case study used increased numbers of unplanned intensive care unit (ICU) admissions and increased numbers of inappropriate DNACPR decisions as balancing measures, but these did not increase during the study.²⁰

Recommendation 13: A critical care outreach team to support the response to the deteriorating patient in hospital settings should be considered. Where this is not possible, there should be clear escalation guidelines and a senior decision maker should be available to assist the deteriorating patient.

Many healthcare systems use either a nurse- or doctor-based rapid response team to respond to the deteriorating patient within secondary care. These teams are usually led or include those with critical care skills and are operated by the hospital’s critical care service. They are often referred to as critical care outreach teams.

A systematic review concluded that much available evidence is of low quality.²¹ Some, but not all, of the studies included showed a benefit. More studies suggested benefit in in-hospital surgical populations than other groups. The composition of the response team was not consistent across the included studies.

A low-quality before-and-after study (Australian study of 296 patients) concluded that implementing medical emergency teams in a regional hospital was associated with reduced hospital-wide mortality rates, ICU admissions and cardiopulmonary arrests.²²

Within secondary care, scoring systems such as NEWS2 are widely used. These are accompanied by a plan that stipulates specific interventions for each level of NEWS2 score. This plan is termed a ‘standardised clinical response’ and may vary across specific hospital settings.

With the increasing adoption of scoring such as NEWS2 within primary care and community settings, it has been proposed that similar standardised clinical response tools could be adapted for these healthcare settings. Presently, there is a lack of high-quality evidence for such interventions in these settings.

The evidence, consisting of one RCT,²³ a high-quality systematic review,²⁴ a well-conducted cohort study,²⁵ a cross-sectional appraisal²⁶ and a cross-sectional study,²⁷ was inconclusive. In addition, consensus could not be reached on the use of a standardised clinical response tool in primary care.