Management of the Deteriorating Patient Policy
Version
Version 2
Name of responsible (ratifying)
committee
Patient Safety Working Group
Date ratified
19th December 2013
Document Manager (job title)
Resuscitation Manager
Date issued
10th January 2014
Review date
19th December 2016 (unless requirements change)
Electronic location
Clinical Policies
Related Procedural Documents
Cardiopulmonary Resuscitation Policy
Procedural Documents Development And Management
Policy
Generic Competency Framework for Registered and
Unregistered Practitioners
Modified Early Obstetric Warning (MEOWs) – Guideline
Key Words (to aid with searching)
early warning score; early warning system; EWS;
medical emergency; response; deteriorating patient;
critically ill; VitalPAC; escalation protocol; vital signs;
ViEWS; MEOWs; PEWS; NEWS; heart rate; respiration
rate; temperature; oxygen saturation; systolic blood
pressure; level of consciousness; AVPU; monitoring;
physiological observations; risk of deterioration; track
and trigger; graded response strategy; clinical
deterioration; professional staff; health professionals;
patients; audit; clinical guidelines; transfer
Version Tracking
Version Date Ratified
1
15th Dec 2011
2
19th Dec 2013
Brief Summary of Changes

Author
Resuscitation
Manager
References updated including the reference to
NHSLSA removed and the National Early Warning
System added
Management of the Deteriorating Patient Policy. Version 2 Issued 10/01/2014
(Review date 19th December 2016 (unless requirements change)
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CONTENTS
1.
2.
3.
4.
5.
6.
7.
8.
9.
QUICK REFERENCE GUIDE....................................................................................................... 3
INTRODUCTION.......................................................................................................................... 4
PURPOSE ................................................................................................................................... 4
SCOPE ........................................................................................................................................ 5
DEFINITIONS .............................................................................................................................. 5
DUTIES AND RESPONSIBILITIES .............................................................................................. 6
PROCESS ................................................................................................................................... 7
TRAINING REQUIREMENTS ...................................................................................................... 9
REFERENCES AND ASSOCIATED DOCUMENTATION .......................................................... 10
MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL
DOCUMENTS ............................................................................................................................ 10
APPENDICES:
APPENDIX 1: VitalPAC Early Warning Score (ViEWS) parameters from April 2010….……………...12
APPENDIX 2: ViEWS Escalation Protocol from April 2010 ..…………………………………………… 13
APPENDIX 3: Modified Early Obstetric Warning System (MEOWS) ………………………………….14
APPENDIX 4: Paediatric Early Warning System (PEWS)...………………………………… ………….16
APPENDIX 5: NICE CG50 Audit Tool……………………….………………………………… ………….18
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QUICK REFERENCE GUIDE
This policy must be followed in full to ensure that all patients within Portsmouth Hospitals NHS Trust
(PHT), who are acutely ill or at risk of physical deterioration, are identified and responded to promptly
and appropriately at all times.
For quick reference the guide below is a summary of actions required. This does not negate the need
for all staff to be aware of and follow the detail of this policy.
All patients admitted to PHT will:
1. Have physiological observations recorded at the time of admission or initial assessment,
immediately prior to transfer to another healthcare setting, for example ward to ward transfers, and
within 15mins of arrival in the new healthcare setting;
2. Have a clear written monitoring plan in the patient’s notes that specifies which physiological
observations should be recorded, and how often;
3. Have physiological observations recorded at least every 12 hours and the frequency increased if
abnormal physiology is detected. A rationale for deviation from this standard must be recorded in the
patient’s notes by a senior doctor;
4. Be monitored using a relevant physiological track and trigger system (Appendix 1, 2, 3 & 4). The
track and trigger system will identify the appropriate graded response to abnormal physiological
observations recorded or guide clinicians who are concerned;
5. Receive a graded response if they become acutely ill or are at risk of physical deterioration as per
appropriate escalation protocol (Appendix 2, 3 & 4). The healthcare professional who has recognised
a response is required must record their actions, related to the escalation, in the patient’s notes using
the ViEWS Escalation Sticker;
6. The communication tool ‘RSVP’ should be used to ensure effective communication occurs
between healthcare professionals (see Section 6.3)
7. The healthcare professional responding must document their actions and management plan
clearly in the patient’s notes;
8. The most senior doctor available should refer to Critical Care. The decision to admit to Critical
Care will be made by consultant in critical care in consultation with the referring team;
9. The responsible consultant for the referring team should be aware and have agreed for the need
for critical care referral;
Any patient transfers from critical care to general ward areas:
1. Should occur as early as possible during the day and whenever possible, be avoided between
22.00-07.00;
2. Should involve both a clear verbal handover and agreed written care plan to promote continuity of
care;
3. Will be reviewed by the Critical Care Outreach.
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1. INTRODUCTION
This policy reflects NICE guidance CG50 (1) and NPSA Guidance (2) relating to all aspects of
the treatment and care of adults who are acutely ill or at risk of physical deterioration
throughout Portsmouth Hospitals NHS Trust (PHT). The key recommendations from the NICE
CG50 form the basis for the structure of this policy.
This policy has also been developed to describe the process for managing and mitigating risks
relating to all aspects of the treatment and care of adults who are acutely ill or at risk of physical
deterioration.
In 2005, the National Patient Safety Agency (2) undertook a detailed analysis of the 1,804
reported serious incidents which resulted in death. There were 576 events in which the death of
the patient was, or might have been directly related to a patient safety incident. Of these
reported incidents, 425 occurred in an acute/general hospital setting.
The analysis found the following themes:
 71 were related to diagnostic errors (dealt with under a separate NPSA review)
 43 involved a problem with resuscitation.
 64 were related to unrecognised physical deterioration (14 – no observations; 30, no
recognition of signs of deterioration or assistance sought; 17 delays in receipt of
medical attention).
On the basis of this review, the key recommendations from the 64 incidents involving
unrecognised patient deterioration are:
 Better recognition of patients at risk or who have deteriorated
 Appropriate monitoring of vital signs
 Accurate interpretation of clinical findings
 Calling for help early and ensuring it arrives
 Training and skills development
 Ensuring appropriate drugs and equipment are available
2. PURPOSE
The aim of this policy is to standardise the processes by which the patients within Portsmouth
Hospitals NHS Trust (PHT), who are acutely ill or at risk of physical deterioration, are identified
and responded to.
All patients admitted to PHT will:





Have physiological observations recorded at the time of admission or initial assessment;
Have a clear written monitoring plan in the health record that specifies which
physiological observations should be recorded, and how often;
Have physiological observations recorded at least every 12 hours and the frequency
increased if abnormal physiology is detected;
Be monitored using a relevant physiological track and trigger system (Appendix 1, 2, 3
& 4). The track and trigger system will identify the appropriate graded response to
abnormal physiological observations recorded or guide clinicians who are concerned;
Receive a graded response if they become acutely ill or are at risk of physical
deterioration as per appropriate escalation protocol (Appendix 2, 3 & 4);
For patients requiring admission to critical care:
 The decision to admit to Critical Care will be made by consultant in critical care in
consultation with the referring team;
Patient transfers from critical care to general ward areas:
 Should occur as early as possible during the day and whenever possible, be avoided
between 22.00-07.00;
 Should involve both a clear verbal handover and agreed written care plan to promote
continuity of care;
 Will be reviewed by the Critical Care Outreach.
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3. SCOPE
This policy applies to the care of paediatric (excluding neonates on NICU) and adult patients
(excluding patients receiving end of life care and those in Critical Care areas who are directly
under the care of Critical Care Consultants) in all of the Trust’s settings, who because of clinical
status/conditions, interventions or procedures are at risk of physical deterioration and ultimately
of suffering a respiratory or cardiopulmonary arrest.
This policy applies to all staff (including voluntary workers, students, locums and agency) of
Portsmouth Hospitals NHS Trust, the MDHU (Portsmouth) and Carillion, whilst
acknowledging for staff other than those of the Trust the appropriate line management or
chain of command will be followed.
In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises
that it may not be possible to adhere to all aspects of this document. In such circumstances,
staff should take advice from their manager and all possible action must be taken to
maintain ongoing patient and staff safety.
4. DEFINITIONS
Cardiopulmonary Resuscitation (CPR)
Cardiopulmonary Resuscitation is a combination of artificial ventilation, chest compressions,
drug therapy and defibrillation.
Classification of Critical Care Patients (3)
Level 0
Level 1
Level 2
Level 3
Patients whose needs can be met through normal ward care in an acute hospital
Patients at risk of their condition deteriorating, or those recently relocated from
higher levels of care, whose needs can be met on an acute ward with additional
advice and support from a critical care team.
Patients requiring more detailed observation or intervention including support for a
single failing organ system or post operative care, or those stepping down form
higher levels of care.
Patients requiring advance respiratory support alone or basic respiratory support
together with support of at least 2 organ systems, includes all complex patients
requiring support for multi organ failure.
Clinical Staff
A member of staff whose duties involve elements of direct patient care.
Critical Care Outreach
A multidisciplinary approach to the identification of patients at risk of developing critical illness
and those patients recovering from a period of critical illness to enable early intervention or
transfer (if appropriate) to an area suitable for care for that patient’s individual needs.
Escalation Protocol for use with ViEWS
Once the ViEWS has been completed the escalation protocol will prompt staff to take action
depending on the ViEWS score. (See Appendix 2)
High Dependency
Patients requiring observation, care and treatment interventions at Level 2.
Monitoring plan
This should detail in the patients notes which physiological observations should be recorded,
and how often. In addition it should specify the management of the patient and when they will
be reviewed by nursing and medical staff.
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Portsmouth Hospitals NHS Trust Hospital Inpatient Areas
Wards at Queen Alexandra Hospital
Community Birthing Unit at St Mary’s Community Hospital
Community Birthing Unit and Cedar Ward at Petersfield Community Hospital
Community Birthing Unit and Ark Royal Ward at Gosport War Memorial Hospital.
RSVP – A communication tool used by all clinical staff to structure communication when
handing on information to a clinical colleague about a deteriorating patient. The RSVP
communication tool is Reason, Story, Vital signs and Plan. (4)
VitalPAC – An electronic track and trigger system that provides a recording mechanism for
patient’s vital signs and essential screening tools. The data entered generates an Early
Warning Score (EWS) and when appropriate prompts the clinical practitioner to escalate the
patient’s condition appropriately. The system also alerts the practitioner if a set of vital signs are
overdue.
The recorded vital signs can be reviewed by authorised staff, along with EWS and laboratory
data, to enable an accurate overview and prioritisation of patient assessment, treatment and
discharge planning.
VitalPAC Early Warning System (ViEWS)
ViEWS is a tool for bedside evaluation incorporated into VitalPAC. It is based on six
physiological parameters: pulse; temperature; systolic blood pressure; respiratory rate; AVPU
(the level to which the patient responds), oxygen saturation, plus the patient’s inspired oxygen
requirements. A ViEWS score should be recorded for every adult patient observation as
detailed in Appendix 1. This has been adapted for the Maternity Dept Appendix 3 and
Paediatric Dept Appendix 4.
N.B ViEWS has the same physiological parameters and escalation criteria as the National Early
Warning System (NEWS) launched in July 2012 (10). Therefore PHT is compliant with NEWS.
Vital Signs/ Physiological observations
Measures of various statistics taken by health professionals or their assistants in order to
assess fundamental physiological functions. For the purposes for ViEWS this is pulse,
temperature, systolic blood pressure, respiratory rate, AVPU (the level to which the patient
responds) and oxygen saturation, plus the patient’s inspired oxygen requirements.
2222 is the emergency number for fast bleeping an individual or calling the Cardiac Arrest
Team at Queen Alexandra Hospital (QAH).
5. DUTIES AND RESPONSIBILITIES
Patient Safety Working Group
The Patient Safety Working Group is responsible, through the receipt of quarterly reports from
the Deteriorating Patient Group, for monitoring that there is continuous and measurable
improvement in the quality of the services provided.
Deteriorating Patient Group
The Deteriorating Patient Group is responsible for ensuring that:
 This procedural document is up to date, technically accurate, is in line with evidencebased best practice and has been produced following consultation with stakeholders
(5).
 Through the Chair, assurance on the effectiveness of this policy and the Trust’s
procedures for the identification and management of the deteriorating patient, is
provided through the receipt of quarterly reports to the Patient Safety Working Group,
including any necessary recommendations to address identified deficits;
 Processes are in place to enable an annual audit of compliance using the audit tool
from the NICE Clinical Guideline 50 (Appendix 5) and that the actions identified as a
result of those audits are implemented.
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Line Managers
Line Managers are responsible for:
 Ensuring all clinical staff receive training in the use of VitalPAC on local induction to the
clinical areas.
 Monitoring data from VitalPAC to ensure there is a local plan to address any areas for
improvement such as number of overdue flags.
 Ensuring that the clinical staff they are responsible for are aware of and apply this policy
into clinical practice.
6. PROCESS
6.1 Identification of patients at risk of deterioration
6.1.1 The Trust uses an Early Warning Scoring (EWS) and graded response system to
detect and monitor patients who are acutely ill or at risk of physical deterioration.
During an adult in-patient episode all patient observations are recorded and scored as
per ViEWS systems detailed in Appendix 1. For Maternity the adapted MEOWS
system (Appendix 3) will be used and in Paediatrics the adapted PEWS system
(Appendix 4) will be used.
6.1.2 All physiological observations must be recorded and acted upon by staff that have
been trained to undertake these procedures and understand their clinical relevance.
Registered and unregistered nursing staff caring for adult patients will undertake the
relevant competency assessment (6, 7 & 8)
6.1.3 All patients must have physiological observations recorded at the time of admission or
initial assessment, including patients in the Emergency Department.
6.1.4 All patients must have a clear written monitoring plan in their health record that
specifies which physiological observations should be recorded, and how often. In
addition it should specify the management of the patient and when they will be
reviewed by nursing and medical staff.
6.1.5 All patients must have physiological observations recorded at least every 12 hours
and the frequency should increase if abnormal physiology is detected as per
escalation protocol (Appendix 2, 3 & 4).
The exception to this will be individual patients who, following senior medical review,
have the frequency of observations decreased. The rationale for this change in
frequency must be documented in the patient’s notes.
6.2 Escalation Protocol and graded response
6.2.1 All patients will be monitored using the appropriate physiological track and trigger
system (Appendix 2, 3 & 4). The track and trigger system will identify the appropriate
graded response to abnormal physiological observations recorded or guide clinicians
who are concerned.
6.2.2 By using the appropriate escalation protocol (Appendix 2, 3 & 4) as a framework it will
ensure that a clinician with the expertise to respond is called and asked to attend
within a specified timeframe. This will make sure that patients who are acutely ill or at
risk of physical deterioration receive prompt care and decisions are made in a timely
manner.
6.2.2 The person recording the vital signs and triggering an escalation response must
document their actions in the patient’s notes using the ViEWS escalation sticker.
6.2.3 The person responding must document their actions and management plan in the
patient’s notes.
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6.3 Communicating Deterioration (RSVP)
6.3.1 To improve communication it is recommended that the person calling for help uses a
structured communication tool. The Reason-Story-Vital Signs-Plan system (4) is easy
to remember in an emergency and ensures the essential information is communicated
enabling an appropriate timely response.
Reason:
It’s ……………….on ward………………
I’m calling about (patient’s name)
The reason I’m calling is………………..
Story:
Reason for admission
Relevant history
Immediately preceding events
Vital Signs:
Heart rate…..BP…….. RR……. CRT……...
SaO2………. FiO2………. AVPU……….. Temp…….
ViEWS…………Urine Output…………. Gluc………...
Plan:
My plan is ……….
What investigations?
How often to monitor?
Parameters for action?
6.4 Patient transfers
6.4.1 The member of staff responsible for patient care prior to transfer to a new location,
must ensure a complete set of vital signs and an early warning score has been
recorded immediately prior to transfer.
The escalation protocol must be followed and if the nurse in charge or doctor have
been informed of an increased EWS score (>3) they must assess the patient to
determine if the transfer should be delayed for clinical reasons.
6.4.2
The member of staff responsible for patient care in the new location must complete
set of vital signs and an early warning score within 15 minutes of the patient’s arrival
in the new locality.
6.4.3
Patient transfers from critical care to general ward areas should occur as early as
possible during the day and whenever possible be avoided between 22.00-07.00.
6.4.4
The critical care area transferring team and the receiving ward team should work
together to ensure the patient is transferred safely. They should jointly ensure there
is continuity of care through a formal structured handover of care from critical care
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area staff to ward staff (including both medical and nursing staff). This must be
supported by a written plan and the receiving ward, with support from Critical Care
Outreach if required, to ensure the ward can deliver the agreed plan.
6.5 Referral to Critical Care Outreach
A referral to Critical Care Outreach should be 'considered' for:
 Any acutely ill or deteriorating ward in-patient who is causing concern (excludes the
Emergency Department, Obstetrics, NICU and Paediatrics);
 As prompted by the ViEWS escalation protocol (Appendix 2).
Critical Care Outreach can be contacted between the hours of 07.00 - 20.30 via Bleep 1676.
6.6 Referral to Critical Care
For patients requiring admission to critical care:
 For urgent help bleep the critical care registrar on 1987;
 If the critical care registrar is uncontactable or referral does not require an immediate
response, please phone extension 5752 (if engaged alternatives are 6035 / 6385 / 6852
/ 6853).
 State you wish to make a referral and ask to speak to the critical care registrar. If
unavailable you will be passed on to another member of the team
 The referral should be made by the most appropriate senior doctor involved in the
patient care at that time.
 The decision to admit to Critical Care will be made by consultant in critical care in
consultation with the referring team;
 The responsible consultant for the referring team should be aware and have agreed for
the need for critical care referral.
All relevant patient information will be required by critical care including:
- referring clinicians name and grade
- patients name and hospital number
- patient’s location
- relevant patient history
- current vital signs and ViEWS score
- recent important investigations and treatment should be at hand when you make the call.
6.7 Patients discharged from Critical Care
All patients discharged from Critical Care will be reviewed by the Critical Care Outreach team
to monitor progress and provide support to the ward staff.
After the decision to transfer a patient from a critical care area to the general ward has been
made, the patient should be transferred as early as possible during the day. Transfer from
critical care areas to the general ward between 22.00 and 07.00 should be avoided whenever
possible, and should be documented as an adverse incident if it occurs.
7. TRAINING REQUIREMENTS
7.1 An introduction to VitalPAC and all Early Warning Systems is included on Trust Induction.
7.2 All Line Managers have a responsibility to ensure that following induction all clinical staff
received additional training relevant to their role, level of responsibility and clinical area. For
areas using VitalPAC, this must include recording vital signs, responding to the escalation
prompts appropriately and care and maintenance of the equipment.
7.3 All Registered and Unregistered Practitioners caring for adult patients must undertake
competency assessments in the taking, recording and assessment of vital signs in Adults
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and Assessing the Physical Well-being of an Adult Patient as per current Generic
Competency Framework for Registered and Unregistered Practitioners
7.4 All Trust Resuscitation Training embodies the statements and guidelines published by the
Resuscitation Council (UK). This recommends that resuscitation training incorporates the
identification of patients at risk of deterioration, ViEWS and the escalation protocol. All
clinical staff must be trained annually in cardiopulmonary resuscitation to a level appropriate
to their clinical roles and responsibilities, which will include an annual update in aspects of
care of the deteriorating patient and calling for help, including the relevant Early warning
System.
8. REFERENCES AND ASSOCIATED DOCUMENTATION
1. NICE Clinical Guideline 50. Acutely ill patients in hospital. Recognition of and response to
acute illness in adults in hospital. July 2007.
2. NPSA. PSO/5. Safer care for the acutely ill patient: learning from serious incidents (2007)
3. Comprehensive Critical Care. A Review of Adult Critical Care Services. DoH. (2000)
4. Featherstone P, Chalmers T, Smith GB. RSVP: a system for communication of deterioration
in hospital patients. Br J Nursing. 2008;17(13):860-64
5. Procedural Documents Development And Management Policy
http://pht/PoliciesGuidelines/Pages/default.aspx
6. Current Nursing and Midwifery Competency for Taking, recording and assessment of vital
signs in Adults. http://www.phtlearningzone.org.uk/index.php?page=generic-nursing-andmidwifery-competency-framework
7. Current Nursing and Midwifery Competency for Assessing the Physical Well-being of an
Adult Patient. http://www.phtlearningzone.org.uk/index.php?page=generic-nursing-andmidwifery-competency-framework
8. Current Generic Competency Framework for Registered and Unregistered Practitioners
http://pht/PoliciesGuidelines/NursingandMidwiferyPolicies/default.aspx?PageView=Shared
9. Resuscitation Guidelines (UK) 2010. http://www.resus.org.uk/pages/guide.htm
10. National Early Warning Score (NEWS) | Royal College of Physicians
9. EQUALITY IMPACT ASSESSMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably
practicable, the way we provide services to the public and the way we treat our staff reflects
their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly
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10. MONITORING COMPLIANCE
This policy will be monitored to ensure it is effective and to assure compliance
Minimum requirement to be
monitored
Implementation of NICE Clinical
Guideline 50
Lead
Chair of
Deteriorating
Patient
Group
Tool
NICE Clinical
Guideline 50 audit
tool (Appendix 5)
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Frequency
Annually
Reporting arrangements
Results of audit will be presented
to the Deteriorating Patient Group
and Patient Safety Working Group.
Information on status of action
planning and learning, as a result
of the audit will be reported
quarterly to the Patient Safety
Working Group
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Acting on recommendations
and Lead(s)
Chair of the Deteriorating
Patient Group
Appendix 1
VitalPAC Early Warning Score (ViEWS) parameters for Adult patients at October 2013
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Appendix 2
Escalation Protocol for the ViEWS for Adult patients at October 2013. Used on Queen Alexandra Hospital Site
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Appendix 3
Modified Early Obstetric Warning System (MEOWS)
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Appendix 3 (cont)
Modified Early Obstetric Warning System (MEOWS)
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Appendix 4
PHT Paediatric Early Warning Score (PEWS)
Example of PEWS Vital Signs Chart
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PEWS Instructions
 Score 1 point for every observation in shaded area
 Score an extra point for any of the additional factors






Temp. above 38C in baby 0-3months
Temp. above 39C in baby3-6months
Temp. above 38.5C in immunosuppressed (e.g. oncology) patient
Requiring Oxygen (or increase in O2 dependant babies)
Capillary refill time greater than 2
Increasing pain which is causing distress
PEWS score = sum of entries in shaded areas plus 1 point each for any of the additional
features present
Actions for a new or increasing PEWS score
PEWS score
0-1
2
3
4
5 & above
Action
Continue monitoring
Nurse in charge & SHO review
Registrar review, must complete Action Plan
Inform Consultant
Consultant to attend if not already present
A PEWS score of 3 should trigger a Registrar review within 1 hour.
If Nursing staff are concerned that the child’s condition requires more urgent attention,
regardless of the PEWS score, they should be asked to attend sooner.
If the Registrar is unable to attend the consultant must be informed.
Note
All patients should be reviewed by the doctors of the team responsible for their care, however if
nursing staff have significant medical concerns or there is a major delay in the attendance of
the team, the Nurse in Charge may call the paediatric team to review.
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Appendix 5
Title: Acutely ill patients in hospital NICE clinical guideline 50
Audit criteria: These are the audit criteria developed by NICE to support the implementation of this guideline. Users can cut and paste these into
their own programmes or they can use this template
Criterion
no.
Criterion
Exceptions
Definition of terms and/or general guidance
Data source
1
Physiological observations in acute hospital settings
None.
As a minimum, the following physiological observations
should be recorded at the initial assessment and as part of
routine monitoring:

heart rate

respiratory rate

systolic blood pressure

level of consciousness

oxygen saturation

temperature.
Patient health
record.
Percentage of patients who have had their physiological
observations recorded at the time of admission or initial
assessment.
(Acute hospital settings)
(Standard = 100%)
2
Physiological observations in acute hospital settings
None.
(Standard = 100%)
Patient health
record.
None.
(Standard = 100%)
Patient health
record.
Percentage of patients for whom a clear written monitoring
plan that specifies which physiological observations should
be recorded, and how often, is present in the health record.
(Acute hospital settings)
3
Identifying patients whose clinical condition is
deteriorating or is at risk of deterioration
Percentage of patients monitored using a physiological track
and trigger system.
Local policy
and
procedure
documents.
(Acute hospital settings)
4
Identifying patients whose clinical condition is
deteriorating or is at risk of deterioration
For 4a: Individual
patients for whom
the decision to
For those patients monitored using a physiological track and
increase or
trigger system:
decrease the
a) the percentage whose physiological observations were
monitoring
monitored at least every 12 hours
frequency has
b) the percentage of patients for whom there is evidence of
been made at a
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For 4b: The frequency of monitoring should increase as
outlined in the recommendation on locally agreed and
delivered graded response strategies.
(Standard = 100% in each case)
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Patient health
record.
Criterion
no.
5
Criterion
Exceptions
increased frequency of monitoring in response to the
detection of abnormal physiology.
(Acute hospital settings)
senior level.
Graded response strategy
None.
There is an agreed and locally delivered graded response
strategy in place for patients identified as being at risk of
clinical deterioration.
Definition of terms and/or general guidance
Data source
Further information, and a description of the recommended
graded response strategy, can be found on page 14 of the
NICE guideline document (section 1.2.2.10).
Local policy
and
procedure
documents.
(Standard = 100%)
(Acute hospital settings)
6
Graded response strategy
None.
(Standard = 100%)
Patient health
record.
None.
Transfer from critical care areas to the general ward
between 22.00 and 07.00 should be avoided whenever
possible.
Patient health
record.
For those patients admitted to a critical care area, the
percentage of patients for whom there is evidence that the
decision to admit was made by both the consultant caring
for the patient on the ward and the consultant in critical care.
(Acute hospital settings)
7
Transfer of patients from critical care areas to general
wards
For those patients transferred from a critical care area back
to a general ward, the percentage for whom this transfer
occurred between 22.00 and 07.00.
(Standard = 0%)
(Acute hospital settings)
8
Transfer of patients from critical care areas to general
wards
None.
For those patients transferred from a critical care area back
to a general ward between 22.00 and 07.00, the percentage
where this transfer was documented as an adverse incident.
Transfer from critical care areas to the general ward
between 22.00 and 07.00 should be avoided whenever
possible, and should be documented as an adverse
incident if it occurs.
(Standard = 100%)
(Acute hospital settings)
Management of the Deteriorating Patient Policy. Version 2 Issued 10/01/2014
(Review date 19th December 2016 (unless requirements change)
Page 19 of 20
Patient health
record.
Adverse
incident
reports.
Criterion
no.
Criterion
9
Care on the general ward following transfer
Exceptions
Patients who have
not been
Percentage of patients for whom there is a formal structured
transferred from a
handover of care from critical care area staff to ward staff
critical care area to
(including both medical and nursing staff), supported by a
a general ward.
written plan.
Definition of terms and/or general guidance
Data source
The critical care area transferring team and the receiving
ward team should take shared responsibility for the care of
the patient being transferred.
Patient health
record.Writte
n care plan
that details
the formal
structured
handover of
care.
(Standard = 100%)
(Acute hospital settings)
10
Care on the general ward following transfer
Percentage of patients for whom the formal structured
handover of care (supported by a written plan) includes:
c) a summary of the critical care stay, including diagnosis
and treatment
d) a monitoring and investigation plan
e) a plan for ongoing treatment, including drugs and
therapies, nutrition plan, infection status and any agreed
limitations of treatment
f) physical and rehabilitation needs
g) psychological and emotional needs
h) specific communication or language needs.
Patients who have (Standard = 100% in each case)
not been
transferred from a
critical care area to
a general ward.
(Acute hospital settings)
No. of
criterion
replaced
Local alternatives to above criteria (to be used where other data
addressing the same issue are more readily available)
Management of the Deteriorating Patient Policy. Version 2 Issued 10/01/2014
(Review date 19th December 2016 (unless requirements change)
Page 20 of 20
Patient health
record.
Written care
plan that
details the
formal
structured
handover of
care.