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

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.

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:

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.

1. 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.
2. 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.
3. Basic life support: If the patient is unconscious or unresponsive, initiate basic life support measures, such as cardiopulmonary resuscitation, while waiting for further assistance.
4. 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.
5. Prepare for intervention: Assemble necessary equipment and medications in anticipation of medical interventions, ensuring everything is at hand for quick access.
6. 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	Vital Signs: Trainers should teach staff to interpret the data collected from conducting a head-to-toe assessment accurately and confidently. Environmental: Staff must be able to identify potential hazards and rectify them promptly.
Communication Skills	Verbal Reporting: Effective verbal communication ensures that all healthcare team members know the patient's condition and the following action plan. Documentation: Accurate and detailed recording of observations and actions is essential for ongoing care.
Clinical Judgement	Data Analysis: Staff must be able to interpret different data sources, including clinical history and current clinical presentation, to form a comprehensive understanding of the patient's condition. Decision-making: Healthcare workers and clinicians must be able to make decisions based on the available data, balancing risks and benefits. Advance Care Directive: Advance care directives are legal documents that outline their preferences for medical treatment and care in situations where they may be unable to communicate their decisions.
Technical Skills (Staff require appropriate training for this area)	Emergency Procedures: In-depth knowledge of cardiopulmonary resuscitation, medication administration, and use of equipment. Advanced Clinical Skills: More complicated cases may require skills like advanced airway management.
Professional Skills	Empathy: By understanding the patient's emotional state, the staff in the room can provide more effective care. Teamwork: Collaborative skills are essential, as different disciplines deliver healthcare. Respect is a fundamental value that involves acknowledging the worth and dignity of every person, listening attentively, and treating others with courtesy.

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.

Based on the results - "technical" skills require action.

Quarter	Topics	Resources
Q1	Technical skills	Causes of Acute Neurological Deterioration Clinical Deterioration: Renal Clinical Deterioration: Cardiac Palliative Care: Recognising the Deteriorating Patient Clinical Deterioration: Respiratory Timely, Appropriate Referrals and Responding to Deterioration in Community and Residential Care How To Assess a Deteriorating / Critically Ill Patient (ABCDE Assessment)

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Staff Competency Assessment for Patient Deterioration - Example

The survey below will help you identify your staff's competency levels in recognising patient deterioration.

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'

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