Standard 9:
Recognising and Responding
to Clinical Deterioration in
Acute Health Care
Nicola Dunbar, Accrediting Agencies Surveyor Workshop, 10 July 2012
Why have a Standard about recognising and
responding to clinical deterioration?

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
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
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)
The 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.

Two overarching Standards:
• Standard 1: Governance for Safety and Quality
• Standard 2: Partnering with Consumers
Four criteria
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
1. Establishing recognition and response
systems

9.1: Developing, implementing and regularly reviewing the effectiveness of
governance arrangements and the policies, procedures and/or protocols that
are consistent with the requirements of the National Consensus Statement

Why?
• Systems for recognising and responding to clinical
deterioration need organisational support and executive and
clinical leadership to be successful
• Recognition and response systems need to be embedded
in governance frameworks to ensure that risks are identified
and continuous improvement occurs
1. Establishing recognition and response
systems

What?
• Identify suitable individual / group / committee to take
responsibility for governance of recognition and response
systems (9.1.1)
• Develop / adapt and implement policies and procedures
across the organisation in the areas of (9.1.2):
•
•
•
•
measurement and documentation of observations
escalation of care
establishment of a rapid response system
communication about clinical deterioration
1. Establishing recognition and response
systems

9.2: Collecting information about the recognition and response systems,
providing feedback to the clinical workforce, and tracking outcomes and
changes in performance over time

Why?
• Evaluation of new systems needed to establish efficacy
and determine changes needed to optimise performance
• Ongoing monitoring needed to track changes over time
and ensure that systems operate effectively
1. Establishing recognition and response
systems

What?
• Develop and implement processes for:
• collecting and using information from the workforce about
recognition and response systems (9.2.1)
• reviewing deaths and cardiac arrests in patients without treatmentlimiting orders (9.2.2)
• providing data about recognition and response systems to clinical
workforce in a timely way (9.2.3)
• Use data from recognition and response systems to
improve performance (9.2.4)
2. Recognising clinical deterioration and
escalating care

9.3: Implementing mechanism(s) for recording physiological observations
that incorporate triggers to escalate care when deterioration occurs

Why?
• Including track and trigger systems in observation charts
streamlines identification of deterioration and action
• Charts designed according to human factors principles –
faster and more accurate in identifying deterioration

What?
• Put in place a general observation chart that meets the
criteria specified in the standard (9.3.1)
• Audit completion of observation charts (9.3.2)
• Take action to improve completion of observation charts
(9.3.3)
2. Recognising clinical deterioration and
escalating care

9.4 Developing and implementing mechanisms to escalate care and call for
emergency assistance where there are concerns that a patient’s condition is
deteriorating

Why?
• Escalation policies and protocols that contain information
about what to do if deterioration occurs reduce the risk of
delays in providing appropriate care

What?
• Put in place systems for escalating care and calling for
emergency assistance (9.4.1)
• Develop and implement mechanisms to evaluate
escalation processes (9.4.2)
• Take action to improve escalation processes (9.4.3)
3. Responding to clinical deterioration

9.5 Using the system in place to ensure that specialised and timely care is
available to patients whose condition is deteriorating

Why?
• 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

What?
• Agree on criteria for calling for emergency assistance and
include in escalation protocol (9.5.1)
• Develop and implement mechanisms to review calls for
emergency assistance (9.5.2)
3. Responding to clinical deterioration

9.6 Having a clinical workforce that is able to respond appropriately when a
patient’s condition is deteriorating

Why?
• Treatment of deterioration can be delayed if workforce
cannot identify deterioration and do not know how to
respond

What?
• Develop / adapt / provide access to basic life support
training (9.6.1)
• Develop and implement mechanism that ensure access at
all times to at least one clinician who can practise
advanced life support (9.6.2)
4. Communicating with patients and carers

9.7 Ensuring patients, families and carers are informed about, and are
supported so that they can participate in recognition and response systems
and processes

Why?
• 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

What?
• Develop / adapt mechanisms for informing patients,
families and carers about how to raise potential concerns
about deterioration and the importance of doing so (9.7.1)
4. Communicating with patients and carers

9.8 Ensuring that information about advance care plans and treatmentlimiting orders is in the patient clinical record, where appropriate

Why?
• Advance care preferences and treatment-limiting
decisions need to be considered when responding to
deterioration

What?
• Develop and implement a mechanism for receiving and
preparing advance care plans in partnership with patients,
families and carers (9.8.1)
• Document advance care plans and other treatmentlimiting orders in the clinical record (9.8.2)
4. Communicating with patients and carers

9.9 Enabling patients, families and carers to initiate an escalation of care
response

Why?
• Patients experience delays in treatment despite reporting
concerns about deterioration
• Families and carers are well placed to identify signs of
deterioration

What?
• Put in place systems for patients, families and carers to
independently escalate care (9.9.1)
• Provide information about family escalation of care (9.9.2)
• Review performance of family escalation system (9.9.3)
• Take action to improve family escalation system (9.9.4)
General issues – 1

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
• Documentation could include:
• committee papers and terms of reference
• clinical / organisational governance frameworks
• position descriptions
General issues – 2

Nature of the recognition and response systems can
vary depending on:
• Size and location of the health service
• Nature of health services provided (eg ICU vs no ICU)
• Nature and skill mix of workforce (eg no on-site doctors)

Some jurisdictions have programs in this area – will
determine nature of recognition and response systems:
• NSW – Between the Flags
• Queensland – Recognition and Management of the
Deteriorating Patient (RMDP)
• ACT – Compass
• WA – Recognising and Responding to Clinical
Deterioration (RRCD)
General issues – 3

The structure of most criteria is to:
• Develop and implement a policy / protocol / process
• Audit / review effectiveness of process
• Undertake improvement processes based on audit results
General issues – 4

Documentation of these steps:
• Development and implementation of policy / protocol /
process:
• policy documents, protocols, tools, templates, materials to inform
workforce and patients
• Audit / review effectiveness of process:
• policies / protocols about audit processes
• evaluation plans and audit schedules
• reports on audits / reviews
• Undertake improvement processes based on audit
results:
•
•
•
•
documentation of quality improvement processes
examples of actions and improvement activities
training and education material and records
feeding back information to workforce
General issues – 5

What data collection processes need to be in place?
• 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 treatmentlimiting 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
General issues – 6

What data collection processes need to be in place?
(cont)
• 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
Specific issues – 1

Policies, procedures and protocols required (9.1.2):
• Measurement and documentation of observations:
• minimum frequencies and duration for core observations in all
acute care areas
• additional observations or assessments for specific patient groups
• process for documenting a monitoring plan for all patients
• observation charts that include a track and trigger system (9.3.1)
Specific issues – 2

Policies, procedures and protocols required (9.1.2)
(cont):
• Escalation of care:
• escalation policy – level of care that can safely be provided, when
care should be escalated to a higher level, location and availability
of services (9.4.1)
• escalation protocol with a graded response system – including
escalation based only on concern (9.4.1)
• processes to individualise triggers and responses for patients with
treatment-limiting orders
• processes for informing patients, families and carers about how to
escalate care (9.7.1)
Specific issues – 3

Policies, procedures and protocols required (9.1.2)
(cont):
• Rapid response systems:
• protocol that outlines use of rapid response system included in
escalation protocol (9.5.1)
• emergency assistance treatment protocols and algorithms
• use of agreed communication processes when deterioration occurs
• Clinical communication:
• roles and responsibilities related to communication included in the
escalation protocol (9.4.1)
• processes for communicating with patients, families and carers
about deterioration
Specific issues – 4

Observation chart that: (i) is designed according to
human factors principles; (ii) includes capacity to record
observations graphically (iii) includes a track and trigger
system (9.3.1):
• Focus is on general observation charts – not charts for
specific clinical areas (such as neurovascular,
cardiothoracic etc)
• For specialist hospitals – these may require paediatric and
obstetric charts
Specific issues – 5

Observation chart that: (i) is designed according to
human factors principles; (ii) includes capacity to record
observations graphically (iii) includes a track and trigger
system (9.3.1):
• 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
ACT
NSW
Qld
WA
Specific issues – 8

Observation chart that: (i) is designed according to
human factors principles; (ii) includes capacity to record
observations graphically (iii) includes a track and trigger
system (9.3.1):
• Demonstration of testing of chart is a complex process
that should:
• involve evaluating performance of alternative versions of the chart
on key functions (such as ability of clinicians to identify abnormal
observations)
• be conducted with appropriate methodology to ensure results are
reliable – specialist advice may be required (Commission has a fact
sheet on the required process)
Specific issues – 9

Clinical workforce trained and proficient in basic life
support (9.6.1):
• All clinicians should be able to implement basic life
support measures – doctors, nurses and allied health
• Does not need to be developed or delivered internally –
there are many external providers
• As well as training records and attendance records,
documentation should also include records of
achievement of competency
Specific issues – 10

Access at all times to at least one clinician who can
practise advanced life support (9.6.2):
• Models for rapid response systems that ensure this kind
of expertise vary depending on context and can include:
• 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
• retrieval services
• Documentation can include:
• records of currency of advanced life support certification
• rosters or evidence that demonstrates 24 hour access to clinician
Specific issues – 11

Providing information to patients, families and carers
(9.7.1):
• Documentation can include:
• material for patients, families and carers about how to raise
concerns about deterioration and the importance of doing so
• policies about processes for involving patients, families and carers
in communication about deterioration, eg during rounds, bedside
handover
Specific issues – 12

Advanced care plans and treatment-limiting orders
(9.8.1, 9.8.2):
• Most states and territories have legislation and policy
regarding advanced care directives that will need to be
reflected in local policies and processes
• Need to demonstrate policies and processes for:
• receiving advanced care plans that have been developed
elsewhere (such as in the community, with a GP)
• developing new advanced care plans within the health service
• involving patients, families and carers in the development of the
advanced care plan
• documenting the advanced care plan in the patient’s clinical record
• Standard covers both advanced care plans and other
treatment-limiting orders - eg NFR, DNR etc
Specific issues – 13

Family escalation of care (9.9.1 – 9.9.4):
• 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
Specific issues – 14

Family escalation of care (9.9.1 – 9.9.4):
• Documentation should include:
• policies and procedures that describe process for family escalation
• information for patients, families and carers about when and how to
escalate care and call for assistance
• evaluation plans and audit schedules for reviewing the
effectiveness of family escalation processes
• data from reviews of family escalation processes – including
reviews of calls and views of patients and families
• training materials for staff about family escalation
• actions taken to improve family escalation processes following
review
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
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