An Organisation-wide Document for the Prevention and Management of the Deteriorating Patient
NHS Trust
An Organisation-wide Document for the Prevention
and Management of the Deteriorating Patient
Version:
Ratified by:
Date ratified:
Name of originator/author:
Name of responsible committee/individual:
Name of executive lead:
Date issued:
Review date:
Target audience:
V.4
March 2012
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An Organisation-wide Document for the Prevention and Management of the Deteriorating Patient
Contents
1
Introduction ............................................................................................................. 4
2
Purpose .................................................................................................................... 4
3
Explanation of Terms ............................................................................................... 4
4
Duties ....................................................................................................................... 4
4.1
4.2
5
Duties within the Organisation ............................................................................................... 4
Committees and Groups with Overarching Responsibilities .................................................. 5
Training .................................................................................................................... 6
5.1
6
General Training Recommendations ...................................................................................... 6
Recognition of the Patient at Risk of Deterioration ................................................ 6
6.1
6.2
Monitoring of Patients. ........................................................................................................... 6
Recognition of Deterioration .................................................................................................. 7
7
Actions to be Taken to Minimise or Prevent Further Deterioration in Patients ..... 7
8
Response to the Deterioration in a Patient’s Condition ......................................... 7
9
Equality Impact Assessment .................................................................................... 8
10
10.1
10.2
11
11.1
12
Monitoring Compliance with the Document ....................................................... 8
Process for Monitoring Compliance ....................................................................................... 8
Standards/Key Performance Indicators .................................................................................. 9
References ............................................................................................................ 9
Guidance from Other Organisations ....................................................................................... 9
Associated Documentation .................................................................................. 9
Appendix A - Template Document for the Prevention and Management of the
Deteriorating Patient .................................................................................................... 11
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An Organisation-wide Document for the Prevention and Management of the Deteriorating Patient
Review and Amendment Log
Version No
Type of Change
Date
Description of change
V.4
Annual review
Mar 2012
Update to section 4 ‘Duties’
V.4
Amendment
Mar 2012
Change of document title and update,
especially section 6, 7 and 8 to broaden scope
of document from resuscitation to cover the
deteriorating patient
Please Note the Intention of this Document
This document has been developed with the aim of providing a model document template.
However, any documentation subsequently produced must follow its own rules and include details
of all the requirements set out in sections 1-12, where relevant. The organisation may use this
template and adapt it to reflect procedures within the organisation or alternatively use a document
already in existence. Whichever approach is used the organisation must ensure it is compliant with
the minimum requirements of the relevant National Health Service Litigation Authority (NHSLA) Risk
Management Standards.
a
To assist the organisation, areas have been identified in the margins where the section
within the template document relates to the minimum requirements for the criterion in the
relevant NHSLA Risk Management Standards.
It is important that the document should follow any pre-existing guidance within the organisation in
relation to style and format of documentation. Please note that a template document entitled An
Organisation-wide Document for the Development and Management of Procedural Documents can
be found on the NHSLA website which may provide the organisation with additional guidance.
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March 2012
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An Organisation-wide Document for the Prevention and Management of the Deteriorating Patient
1
Introduction
This section should state the reason the document has been developed in the organisation.
This document provides a template for organisations to address the risks associated with the
management of the deteriorating patient and supports national recommendations for
recognising the acutely ill patient in hospital and guidance published by the Resuscitation
Council (UK) (2004, revised 2008). It has been constructed to promote compliance with the
NHSLA Risk Management Standards.
2
Purpose
Within this section the organisation should provide the rationale for the development of the
document. It should include a description of how the organisation intends to ensure that
processes are in place for the detection, prevention and management of the deteriorating
patient.
The purpose of the document is to provide direction and guidance for the coordinated
approach to identifying any deterioration in patients and the subsequent actions that aim to
prevent further deterioration and possible subsequent cardio-respiratory arrest.
3
Explanation of Terms
This section should list and describe the meaning of the terms used in the context of the
document if considered necessary. For example:

Anaphylaxis
Anaphylaxis is a severe, life-threatening, generalised or systemic hypersensitivity reaction.
This is characterised by rapidly developing life-threatening airway and/or breathing and/or
circulation problems usually associated with skin and mucosal changes.
The following list is a guide only and is not exhaustive:
4

Patient at risk system

Situation Background Assessment Recommendation (SBAR) (or RSVP – Reason,
Story, Vital signs, Plan)
Duties
Healthcare organisations have an obligation to provide safe and effective care to their
patients.
Give a brief overview of the roles, responsibilities and accountabilities for the
implementation of the organisation’s process. This section should be a brief overview only
and the details of the process for managing this should be incorporated within later sections
of the document. The following list is a guide only and is not exhaustive:
4.1
Duties within the Organisation
Some example responsibilities have been identified below; however, these should
be considered within the context of the individual organisational structure.
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An Organisation-wide Document for the Prevention and Management of the Deteriorating Patient
Chief Executive
This section should state that the chief executive is ultimately accountable for the
implementation of this organisation-wide process.
Outreach/Critical Care Service/Team
Roles and responsibilities of the individuals nominated as part of the outreach team
and their involvement in the prevention and management of the deteriorating
patient within the organisation.
Line Manager(s)
Roles and responsibilities of line manager(s) and their involvement in the prevention
and management of clinical deterioration in patients.
All Staff
This section should define the responsibilities of all staff. It should emphasise the
individual responsibilities of all staff in relation to the detection, prevention and
management of deterioration in patients.
4.2
Committees and Groups with Overarching Responsibilities
Trust Board
For effective implementation of the Organisation-wide Document for the
Management of the Deteriorating Patient there must be active support from the
most senior members of the organisation. Organisations should detail how the chief
executive and the nominated directors are to gain assurance that this document is
being implemented within the organisation. There must be effective cooperation at
all levels of the organisation in order for this process to be successful, and to ensure
that an organisation wide approach is agreed, implemented, and regularly reviewed
within the clinical governance framework (DH HSC 2000/28).
Committees/Groups
This section should identify the committee/group which will have overall
responsibility for the prevention and management of clinical deterioration in
patients. The section should include:
V.4

how this committee/group links with all the other relevant risk management
committees;

the role this committee/group has with ensuring continuous development of
this document;

the role the committee/group has in the analysis of the management of the
prevention of clinical deterioration in patients;

how this committee/group communicates both up to board level, and down
to the local management levels; and

how the committee/group facilitates organisational learning and
improvement as a result of analysis and monitoring of the management of
the prevention of clinical deterioration in patients.
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An Organisation-wide Document for the Prevention and Management of the Deteriorating Patient
It would be considered good practice if the organisation developed terms of
reference for this committee/group including: accountability, responsibility,
authority, membership (including identified co-opted members and deputies),
meeting schedule and quorum, etc. In addition the terms of reference should be
dated and signed.
5
Training
The strategy for training should be led by the responsible committee and should explicitly
include the identification of the deteriorating patient at risk from cardiac arrest and an
approach to implementing preventative measures such as Early Warning Systems.
The organisation should provide sufficient and appropriate training for each staff group
which may incorporate competency based frameworks, and should identify how they will
ensure staff attendance. This section should cross-reference to the organisation’s training
needs analysis.
5.1
General Training Recommendations
All clinical staff should be trained in the identification of the deteriorating/critically
ill patient and the use of physiological observation charts to enhance decision
making and the escalation of care.
The organisation should make sure the training is in line with associated activities
such as cardio-pulmonary resuscitation training, of which the level of training may
be determined by national guidance and professional bodies.
6
Recognition of the Patient at Risk of Deterioration
For some patients in hospital there is a risk of becoming acutely unwell and in this situation,
should their clinical condition deteriorate, it is essential that healthcare staff are equipped to
recognise and manage the deterioration confidently and competently. This section should
identify the standards required in all clinical areas for identifying and managing patients who
deteriorate.
This section may also include specific circumstances where sudden deterioration may occur.
For example:
a

Anaphylaxis

Adverse Drug reactions including blood transfusion
6.1
Monitoring of Patients.
This section needs to describe the requirement for a documented plan which should
include vital signs monitoring, including:
V.4

the variables that are to be measured;

the frequency of measurement.
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An Organisation-wide Document for the Prevention and Management of the Deteriorating Patient
6.2
Recognition of Deterioration
Prevention of in-hospital cardiac arrest requires:
b

staff education;

monitoring of patients;

recognition of patient deterioration;

a system to call for help; and

an effective response.
The organisation should have an early warning system established and details of
how this system works should be included here. It is advised that there is a
reference to the use of an early warning chart, which should be included as an
appendix.
Guidance on how to complete the early warning system and when and where to
record observations should be included as a minimum.
All clinical staff should be trained in the identification of the deteriorating/critically
ill patient and the use of physiological observation charts to enhance decision
making and care escalation.
c
7
Actions to be Taken to Minimise or Prevent Further Deterioration in Patients
The organisation should have clear mechanisms in place that support the communication
and escalation of care and treatment amongst all healthcare professionals.
This section should identify what actions are expected to minimise or prevent further
deterioration in patients. This should cover the process throughout all care areas and the
organisation is advised to include:
8

the escalation process between healthcare professionals;

the use of a structured communication tool to ensure the effective handover of
information between staff such as SBAR - Situation-Background-AssessmentRecommendation; RSVP - Reason, Story, Vital signs, Plan;

the use of traffic light system, or score could be discussed;

the process for escalation in and out of hours; and

use of an organisation outreach service and/or appropriate emergency teams, which
should be orientated to respond to medical emergencies in addition to cardiorespiratory arrest.
Response to the Deterioration in a Patient’s Condition
This section should describe the possible outcomes for patients and the organisational
response.
For example:
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An Organisation-wide Document for the Prevention and Management of the Deteriorating Patient

d
e

9
Resuscitation strategy which should include:

Do not attempt Cardio-pulmonary resuscitation

Manual handling

Cross infection

Resuscitation equipment (checked, stocked and fit for use)

Defibrillation

Post resuscitation care
Transfer arrangements
Equality Impact Assessment
The organisation should identify who will undertake the Equality Impact Assessment which is
required to consider the needs and assess the impact of this document in accordance with
the Organisation-wide Document for the Development and Management of Procedural
Documents. The Equality Impact Assessment Tool found at Appendix E of the Organisationwide Document for the Development and Management of Procedural Documents could be
completed and form part of the body of the document, but as a minimum a statement
should be included within the document to demonstrate that an Equality Impact Assessment
has been carried out and that the document does not discriminate, highlighting any areas of
good practice or risk areas requiring attention.
f
10
Monitoring Compliance with the Document
Patient safety incidents should be reported and followed up using the local reporting
system. Patient safety incidents should also be reported to the National Reporting and
Learning System (NRLS).
10.1
Process for Monitoring Compliance
This section should identify how the organisation plans to monitor compliance with
the Organisation-wide Document for the Prevention and Management of the
Deteriorating Patient.
As a minimum it should include the review/monitoring of all the minimum
requirements within the NHSLA Risk Management Standards. The following list is a
guide to issues which could be considered within this section and should be added
to where appropriate:
V.4

Who will perform the monitoring?

When will the monitoring be performed?

How are you going to monitor?

What will happen if any shortfalls are identified?

Where will the results of the monitoring be reported?

How will the resulting action plan be progressed and monitored?
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An Organisation-wide Document for the Prevention and Management of the Deteriorating Patient

10.2
How will learning take place?
Standards/Key Performance Indicators
This section could contain auditable standards and/or key performance indicators
(KPIs) which may assist the organisation in the process for monitoring compliance.
11
References
This section should contain the details of any reference materials reviewed in the
development of the procedural document.
Listed below are some useful sources of reference material:
12
11.1
Guidance from Other Organisations

British Medical Association, the Resuscitation Council (UK) and the Royal College of
Nursing (2007) Decisions relating to cardiopulmonary resuscitation London: BMA

Department of Health (2009) Competencies for Recognising and responding to
acutely ill patients in hospital London DH

National Confidential Enquiry into Patient Outcome and Death (NCEPOD)
(2007)Emergency admissions: A journey in the right direction London: NCEPOD

National Institute for Health and Clinical Excellence (NICE) (2007) CG50 Acutely Ill
Patients in Hospital London: NICE

National Patient Safety Agency (NPSA) (2004) Patient Safety Alert 2004/02.
Establishing a Standard Crash Call Telephone Number in Hospitals NPSA

National Patient Safety Agency (NPSA) (2007) Recognising and responding
appropriately to early signs of deterioration in hospitalised patients London: NPSA

Patient Safety First. ‘How to Reduce Harm from Deterioration’ Patient Safety First
website page

The Resuscitation Council (UK) Resuscitation Guidelines 2010 (2010)
Associated Documentation
This section should provide a cross reference to any other related organisational procedural
document(s).
The following list is a guide only and is not exhaustive:
V.4

Resuscitation

Medicines management

Transfusion

Training needs analysis

Prevention and control of infection/decontamination of medical devices
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V.4

Paediatric

Discharge

Handover of care
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An Organisation-wide Document for the Prevention and Management of the Deteriorating Patient
Appendix A - Template Document for the Prevention and Management of
the Deteriorating Patient
NHS Trust
An Organisation-wide Document for the Prevention
and Management of the Deteriorating Patient
Version:
Ratified by:
Date ratified:
Name of originator/author:
Name of responsible committee/individual:
Name of executive lead:
Date issued:
Review date:
Target audience:
V.4
March 2012
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An Organisation-wide Document for the Prevention and Management of the Deteriorating Patient
Contents
1
Introduction ........................................................................................................... 14
2
Purpose .................................................................................................................. 14
3
Explanation of Terms ............................................................................................. 14
4
Duties ..................................................................................................................... 14
4.1
4.2
5
Duties within the Organisation ............................................................................................. 14
Committees and Groups with Overarching Responsibilities ................................................ 14
Training .................................................................................................................. 14
5.1
6
General Training Recommendations .................................................................................... 14
Recognition of the Patient at Risk of Deterioration .............................................. 14
6.1
6.2
Monitoring of Patients .......................................................................................................... 14
Recognition of Deterioration ................................................................................................ 14
7
Actions to be Taken to Minimise or Prevent Further Deterioration in Patients ... 14
8
Response to the Deterioration in a Patient’s Condition ....................................... 14
9
Equality Impact Assessment .................................................................................. 14
10
10.1
10.2
11
11.1
12
Monitoring Compliance with the Document ..................................................... 14
Process for Monitoring Compliance ..................................................................................... 15
Standards/Key Performance Indicators ................................................................................ 15
References .......................................................................................................... 15
Guidance from Other Organisations ..................................................................................... 15
Associated Documentation ................................................................................ 15
Appendix A
Early Warning Score Tool ...................................................................... 15
Appendix B
Plan for Dissemination .......................................................................... 15
Appendix C
Equality Impact Assessment Tool ......................................................... 15
Examples of the Checklist for the Review and Approval of Procedural Documents, Version Control
Sheet, Plan for Dissemination and the Equality Impact Assessment Tool can all be found within the
Organisation-wide Document for the Development and Management of Procedural Documents on
the NHSLA website.
Appendix B in the Organisation-wide Document for the Development and Management of Procedural
Documents contains a flowchart to assist with the process for the creation and implementation of
procedural documents.
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An Organisation-wide Document for the Prevention and Management of the Deteriorating Patient
Review and Amendment Log
Version No
V.4
Type of Change
Date
March 2012
Description of change
Page 13 of 15
An Organisation-wide Document for the Prevention and Management of the Deteriorating Patient
1
Introduction
2
Purpose
3
Explanation of Terms
4
Duties
5
4.1
Duties within the Organisation
4.2
Committees and Groups with Overarching Responsibilities
Training
5.1
6
General Training Recommendations
Recognition of the Patient at Risk of Deterioration
6.1
Monitoring of Patients
6.2
Recognition of Deterioration
7
Actions to be Taken to Minimise or Prevent Further Deterioration in Patients
8
Response to the Deterioration in a Patient’s Condition
9
Equality Impact Assessment
10
Monitoring Compliance with the Document
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11
10.1
Process for Monitoring Compliance
10.2
Standards/Key Performance Indicators
References
11.1
12
V.4
Guidance from Other Organisations
Associated Documentation
Appendix A
Early Warning Score Tool
Appendix B
Plan for Dissemination
Appendix C
Equality Impact Assessment Tool
March 2012
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