Recognising & Responding to a Clinically Deteriorating Patient

  • Recognising Clinical Deterioration

    • A key aspect of healthcare is recognising a patient's deteriorating physiological status to activate appropriate care.

    • Failure to recognise and manage a patient's physiological state contributes to adverse events.

    Between The Flags (BTF) Observation Chart

    • Developed by the Clinical Excellence Commission and clinical experts.

  • Vital signs are documented and analyzed to determine a patient's health status.

  • Aims to detect deterioration and trigger healthcare interventions to prevent further decline.

  • Uses colour-coded criteria and a "track and trigger" format to alert clinicians.

BTF Chart Zones

  • SAGO chart is used in all NSW health services as part of the Deteriorating Patient Safety Net System.

  • Yellow zone: Indicates early warning signs of deterioration; clinical review may be required.

  • Red zone: Indicates late warning signs of deterioration; a rapid response is required.

Standard Adult General Observation Chart Components

  • Alterations to calling criteria (ACC) allow for adjustments based on the patient’s condition, for either acute (up to 8 hours) or chronic conditions.

  • Any alterations MUST be signed by a Medical Officer and confirmed by Attending Medical Officer.

  • Rationale for altering CALLING CRITERIA must be documented in the patient's health care record

  • Yellow Zone Response:

    • Initiate appropriate clinical care.

    • Repeat and increase the frequency of observations.

    • Consult promptly with the NURSE IN CHARGE to decide whether a CLINICAL REVIEW (or other CERS) call should be made.

    • Consider:

      • What is usual for your patent and are there documented ALTERATIONS TO CALLING CRITERIA?

      • Does the trend in observations suggest deterioration?

      • Is there more than one Yellow Zone observation or additional criterion?

      • Are you concerned about your patient?

    • IF A CLINICAL REVIEW IS CALLED:

      • Reassess your patient and escalate according to your local CERS if the call is not attended within 30 minutes or you are becoming more concerned.

      • Document an A-G assessment, reason for escalation, treatment and outcome in your patient's health care record.

      • Inform the Attending Medical Officer that a cat was made as soon as it is practicable

    • Additional YELLOW ZONE Criteria:

      • Increasing oxygen requirement

      • Poor peripheral circulation

      • Excess or increasing blood los

      • Decrease in Level of Consciousness or new onset of confusion

      • Low urine output persistent for 4 hours (<100mls over 4 hours or 0.5mL/kg/hr via an IDC)

      • Polyuria, in the absence of diuretics (urine output>200mL/hr for 2 hours)

      • Greater than expected fluid loss from a drain

      • New, increasing or uncontrolled pain (including chest pain)

      • Blood Glucose Level <4mmol or > 20mmol

      • Ketonaemia > 1.5mmol or Ketonuria 2+ or more

      • Concern by patient or family member

      • Concern by you or any staff member

  • Red Zone Response:

    • Call for a RAPID RESPONSE (as per local CERS) AND

      • Initiate appropriate clinical care

      • Inform the NURSE IN CHARGE that you have called for a RAPID RESPONSE

      • Repeat and increase the frequency of observations, as indicated by your patient's condition

      • Document an A-G assessment, reason for escalation, treatment and outcome in your patients health care record

      • Inform the Attending Medical Officer that a call was made as soon as it is practicable

    • Additional RED ZONE Criteria:

      • Cardiac or respiratory arrest

      • Airway obstruction or stridor

      • Patient unresponsive

      • Deterioration not reversed within 1 hour of Clinical Review

      • Increasing oxygen requirements to maintain oxygen saturation 90%

      • Arterial Blood Gas: Pao2 <60 or Paco2 > 60 or pH < 7.2 or BE < -5

      • Venous Blood Gas PVCO_2 > 65 or pH < 7.2

      • Only responds to Pain (P) on the AVPU scale

      • Sudden decrease in Level of Consciousness (a drop of 2 or more points on the GCS)

      • Seizures

      • Low urine output persistent for 8 hours (<200mL over 8 hours or 0.5mL/kg/hr via an IDC)

      • Blood Glucose Level <4mmol or > 20mmol with a decreased Level of Consciousness

      • Lactate >4mmol

      • Serious concern by any patient or family member

      • Serious concern by you or any staff member

Using the Observation Chart

  • For adult inpatients, observations should be done at least 4 times a day, every 6 hours.

  • Includes respiratory rate, oxygen saturation, heart rate, blood pressure, temperature, level of consciousness, new onset confusion or behavior change, and pain score.

  • Other patient groups may have different frequencies.

  • Yellow zone: Follow instructions on the back of the SAGO chart.

  • Red zone: A rapid response call must be made.

Alterations to Calling Criteria

  • Based on patient assessment and input from patient, carers, and family.

  • Only a medical officer can alter the standard calling criteria.

  • Must be documented on the front of the chart and in the patient's health record.

Early Warning Signs: Adult Deterioration

  • Poor peripheral circulation.

  • Excess or increasing blood loss.

  • Decreased level of consciousness (LOC) or new onset confusion.

  • Low urine output (< 100ml over 4 hours).

  • New or increasing pain.

  • Blood glucose level (BGL) <4mmol or >20mmol.

  • Concern by patient, family member, or staff.

Late Warning Signs: Adult Deterioration

  • All cardiac or respiratory arrests.

  • Airway obstruction or stridor.

  • Unresponsiveness.

  • Any observation in the red zone.

  • Deterioration not reversed within 1 hour of clinical review.

  • Seizures.

  • Serious concern by patient, family member, or staff.

Yellow Zone Response

  • Initiate appropriate clinical care.

  • Repeat and increase frequency of observations.

  • Consult promptly with the nurse in charge to decide whether a clinical review should be made.

Appropriate Clinical Care

  • Consider the A-H algorithm for providing appropriate clinical care.

  • Position patient appropriately.

  • Call for help.

  • Never leave a deteriorating patient without a management plan.

  • Repeat vital signs.

  • If the patient is not responding, not breathing normally, or shows no other sign of life, begin Basic Life Support (BLS).

Basic Life Support (BLS)

  1. Dangers: Check for danger.

  2. Responsiveness: Check for response.

  3. Send: Send for help.

  4. Airway: Open the airway.

  5. Breathing: Check breathing (if not breathing or abnormal breathing).

  6. CPR: Start CPR (30 chest compressions followed by 2 breaths).

  7. Defibrillation: Attach automated external defibrillator.

DRS

  • Danger: Look around for hazards (e.g., spills, electrical cords, aggressive patient).

  • Response: Check if the person responds.

  • Send for help: Call out, press emergency call bell, or phone the emergency number if nearby.

ABC

  • Airway: Open the airway.

  • Breathing: Look, listen, and feel for breathing.

  • CPR: 30 compressions to 2 breaths at a rate of 100/min; deliver 8-10 breaths/min.

Bag Valve Mask

  • Used in clinical settings.

  • Self-inflating bag attached to a non-rebreathing valve and mask.

  • Can be connected to an oxygen supply.

  • Available in different sizes.

Defibrillation

  • Apply electrode pads to dry skin:

    • One pad on the upper right chest near the clavicle.

    • One pad on the lower left chest below the nipple.

  • The device analyzes heart rhythm and delivers a shock if needed.

  • It will not shock a patient who doesn't need it.

  • Follow the prompts.

Following a Critical Incident

  • Document.

  • Debrief.

  • Declutter.