Introduction to Standard 9:
Recognising and Responding to Clinical
Deterioration in Acute Health Care
Nicola Dunbar
Program Director
April 2013
The Standard

Standard:
• Health service organisations establish and maintain
systems for recognising and responding to clinical
deterioration. Clinicians and other members of the
workforce use the recognition and response systems.

Intent:
• To ensure that a patient’s deterioration is recognised
promptly and appropriate action is taken

Context:
• To be applied in conjunction with Standard 1: Governance
for Safety and Quality and Standard 2: Partnering with
Consumers
• Does not apply to deterioration in a patient’s mental state
2
Rationale for the Standard

Evidence base:
• deterioration is not always recognised or acted on
• there are early warning signs
• early intervention can improve outcomes for patients
• there are well-established strategies that can be
implemented

Processes of recognising and responding to clinical
deterioration are relevant across the hospital – therefore
need a systems approach to address
3
Criteria to achieve the Standard
1.
Establishing recognition and response systems
•
2.
Recognising clinical deterioration and escalating care
•
3.
Patients whose condition is deteriorating are recognised and
appropriate action is taken to escalate care
Responding to clinical deterioration
•
4.
Organisation-wide systems consistent with the National Consensus
Statement are used to support and promote recognition of, and
response to, patients whose condition deteriorates in an acute health
care facility
Appropriate and timely care is provided to patients whose condition is
deteriorating
Communicating with patients and carers
•
Patients, families and carers are informed of recognition and
response systems and can contribute to the processes of escalating
care
4
Definitions

Recognition and response systems:
• Formal systems to support staff to promptly and reliably recognise
patients who are deteriorating and to respond appropriately to stabilise
the patient

Track and trigger system:
• Tracks changes in physiological parameters over time, includes
thresholds for each parameter that indicates abnormality, and
describes the response or action when deterioration occurs

Escalation protocol:
• Protocol that sets out the organisational response required for different
levels of physiological abnormality or other deterioration

Rapid response system:
• System for providing emergency assistance to patients whose
condition is deteriorating (such as medical emergency team)
5
Developmental and not applicable actions

Developmental:
• Action 9.3.1: use of a general observation chart that has
specified characteristics
• Item 9.7: informing patients, families and carers
• Item 9.8: advance care plans and treatment-limiting
orders
• Item 9.9: patient and family escalation

Not applicable:
• Standard 9 not applicable for specialist, non-acute,
mothercraft hospitals or services (meets requirements
under Action 1.8.3)
• Items 9.7-9.9 may not be applicable for day procedure
services
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Context

National Consensus Statement endorsed by Health
Ministers in 2010:
• sets out essential elements for recognising and
responding to clinical deterioration:
•
•
•
•
•
•
•
•
measurement and documentation of observations
escalation of care
rapid response systems
clinical communication
organisational supports
education
evaluation, audit and feedback
technological systems and solutions
• relates to situations where a patient’s physical condition is
deteriorating
• applies to all patients in an acute healthcare facility
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Context

Flexible standardisation:
• Standardisation of processes is an important way of improving
safety and quality
• Needs to reflect context of the health service
• Contextual issues that will affect the systems that are put in
place to meet Standard 9 include:
•
•
•
•

type and size of health service – small or large hospital, day procedure
nature of services provided – ICU, no ICU
nature and skill mix of workforce – are doctors on site 24/7?
existing policies and programs – eg. Between the Flags, Compass, RMDP
etc
Don’t need to have separate processes and systems for each
action in the Standard – consider how activities fit together to
coordinate evidence and outcomes
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Structure of Standard 9
9.3, 9.4 Recognising
clinical deterioration and
escalating care
9.5, 9.6 Responding
to clinical
deterioration
9.7-9.9
Communicating with
patients and carers
9.1, 9.2 Organisation-wide systems for
recognising and responding to clinical
deterioration
Put the system
in place
Audit / review performance
of or compliance with the
system
Make improvements
based on the results of
the audit
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Organisation-wide systems for recognising
and responding to clinical deterioration

Recognition and response systems are relevant across
the whole hospital:
• overarching governance and policy framework should exist
at an organisation-wide level
• there may also be local (department / ward) policies in
place about local recognition and response processes
• examples of where responsibility can sit:
• senior executive clinical leaders (both medical and nursing)
• clinical governance and/or quality committees
• emergency response / resuscitation committees

Need a systematic approach:
• embedded into clinical governance arrangements
• tailored to local circumstances
• covering all essential elements in Consensus Statement
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Observation charts

Action 9.3.1 relates to general observation charts:
• does not include charts for specific clinical areas – such as
neurovascular, cardiothoracic etc
• for specialist hospitals – these may require specialist paediatric
and obstetric charts

What chart to use:
• for jurisdictions that have a state-wide chart, use of this chart is
acceptable:
• NSW, Qld, ACT, WA (SA coming soon...)
• the Commission has developed four charts that can be
customised for local use – these are acceptable
• also have a chart that has been developed for and trialed in day procedure
hospitals
• for other charts – sites need to demonstrate how they have
tested the chart to ensure its safety

Fact sheets available on the Commission’s web site
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Escalation protocols

Escalation policies and protocols that contain information
about what to do if deterioration occurs reduce the risk of
delays in providing appropriate care

Escalation protocol needs to:
• be tailored to the facility – size, location, skill mix,
resources
• included a graded response – different types of responses
depending on the level of abnormality
• include an option for emergency assistance
• include an option for clinicians to escalate care based only
their concern for the patient
• be regularly reviewed
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Escalation protocols

Developing triggers and responses for an escalation
protocol:
• How many levels of abnormality?
• What physiological observation thresholds trigger
abnormality?
• What actions/treatments are required?
• Who can provide this treatment?
• Responsibilities of responding clinicians?
• How will the system operate?

Planning tool on the Commission’s web site
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Rapid response systems

Need a system to provide appropriate emergency
assistance in a timely way when severe deterioration
occurs

Rapid response systems have been shown to reduce
cardiac arrests, unplanned ICU admissions, and deaths

Models for rapid response systems:
• medical emergency teams / rapid response teams
• ICU liaison / critical care outreach
• nursing and medical staff trained in advanced life support
– ED, anaesthetics etc
• advanced practice nursing roles
• local GPs or VMOs
• local ambulance
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Clinical workforce that can respond

Everyone needs to know how to call for emergency
assistance

All clinicians should be able to implement basic life
support while waiting for emergency assistance:
• includes nurses, allied health providers, doctors

Non-technical skills also important – leadership, team
work, communication, task management

A system needs to be in place to ensure access at all
times to at least one clinician who can practice advanced
life support

Need to maintain competency – Commission does not
specify how this should occur
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Communicating with patients and carers

Why is this important?
• patients, families and carers are part of the healthcare team and
can help ensure best understanding of clinical circumstances
• patients, families and carers generally want to know when
deterioration is occurring

Communication with families and carers about:
• the importance of communicating concerns and signs/symptoms
of deterioration
• how they can raise their concerns
• local systems for responding to deterioration

Opportunities for communication:
• on presentation in acute care
• at regularly scheduled intervals during admission
• during healthcare team rounds
• during bedside handover
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Advance care plans and treatment-limiting orders

Advance care preferences and treatment-limiting
decisions need to be considered when deterioration
occurs

Most states and territories have legislation and policy
regarding advanced care directives that will need to be
reflected in local policies and processes

Standard covers both advanced care plans and other
treatment-limiting orders - e.g. NFR, DNR etc
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Family and patient escalation of care

Patients experience delays in treatment despite
reporting concerns about deterioration

Families and carers are well placed to identify signs of
deterioration

New models of family escalation now being introduced:
• what are the triggers for families to escalate care
• how will the response be activated
• what will the response be
• how to inform about the new system
18
Family and patient escalation of care

More than existing processes for calling for assistance –
such as the call bell

Is a formal process that acts in a similar way to
escalation protocols triggered by health professionals

Patient, family member or carer can escalate care
directly to request review / emergency assistance

Should be built into existing recognition and response
system
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Data collection processes

Collection of feedback from clinical workforce (9.2.1):
• surveys, focus groups to get information from a number of
people
• peer review processes such as morbidity and mortality meetings
to get feedback on individual events

Review of cardiac arrests and deaths without a treatment-limiting
order (9.2.2):
• routine reviews of in-hospital cardiac arrests
• reviews of unexpected deaths to identify failures of escalation
and systems issues
• identification of patients with and without a treatment-limiting
order

Completion of observation charts (9.3.2):
• audits of observation charts against local policy and monitoring
plan
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Data collection processes

Use of escalation processes, including failures to call and calls for
emergency assistance (9.4.2, 9.5.2):
• audit of observation charts to identify triggers for escalation and
actions taken
• number and circumstances of rapid response calls
• outcomes measures such as cardiac arrests, unplanned
admissions to ICU, deaths

Performance of family escalation processes (9.9.3):
• surveys, interviews, focus groups to get information about
knowledge and views of patients, families and carers, and
workforce
• records of family escalation calls
• clinical record regarding circumstances of calls

Quality measures and audit tools are on the Commission’s web site
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Resources

Safety and Quality Improvement Guide for Standard 9

National Consensus Statement – and supporting
implementation guides

Observation charts

Fact sheets, planning and audit tools

Jurisdictional programs
22
Summary

Recognising patients whose condition is deteriorating
and responding to their needs in an appropriate and
timely way are essential components of safe and high
quality care

Purpose of the Standard is to improve outcomes for
patients by ensuring that there is a systematic approach
in place for recognising and responding to clinical
deterioration

Outcomes to be achieved are clear – methods to get
there will vary depending on context
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