Recognising the Deteriorating Patient

Introduction

Most in-hospital cardiac arrests and unplanned intensive care admissions are not sudden, unheralded events. Retrospective review consistently finds clear physiological abnormalities - an elevated respiratory rate, falling saturations, a rising heart rate - documented in the hours beforehand. The recurring failure is not that deterioration was unpredictable, but that it was recognised late, or recognised but not acted upon quickly enough.¹

This article covers the systems built to catch deterioration early - track-and-trigger scoring and outreach teams - and the human factors that determine whether those systems actually work in practice. The clinical assessment and immediate management of an acutely unwell patient (ABCDE) is covered in detail separately; this article is about noticing the problem in time to use it.

Track-and-trigger systems

A track-and-trigger system converts routine observations into a score that standardises the language of deterioration and defines an expected response, removing reliance on individual judgement alone to decide when a patient needs review.

NEWS2

The National Early Warning Score 2 is the standard UK system, scoring respiratory rate, oxygen saturation, air or supplemental oxygen, systolic blood pressure, pulse rate, level of consciousness and temperature, then summing them into an aggregate score.²

Scale 2 for chronic hypercapnic respiratory failure

Patients with a known risk of hypercapnic respiratory failure (some patients with severe COPD) have a different normal range - a saturation of 88-92% is their target, not a warning sign - so NEWS2 is scored against an alternative reference range (Scale 2) specifically for this group, used only when clearly indicated and prescribed, to avoid both under- and over-treatment with oxygen.

Critical care outreach

Critical care outreach teams (sometimes called medical emergency teams or rapid response teams) extend critical care expertise onto general wards, supporting ward staff in assessing and managing a deteriorating patient, helping decide whether escalation to a higher level of care is needed, and following up patients discharged from critical care who remain at risk of relapse. They are activated by a NEWS2 trigger, a specific clinical concern, or simply because a member of staff is worried, and calling them early is a sign of good practice, not failure.

Human factors in failure to rescue

'Failure to rescue' describes a patient who deteriorates and dies despite the problem being detectable, because recognition or escalation failed somewhere along the chain. This is well studied, and several recurring human factors are worth knowing explicitly, since being aware of them is part of what prevents them.

• Normalisation of deviance - repeatedly tolerating a mildly abnormal finding without action gradually shifts what feels 'normal', until a genuinely dangerous trend is missed because each individual step looked only slightly worse than the last
• Hierarchy and reluctance to escalate - a junior team member who is worried may hesitate to call a senior colleague, particularly after a previous dismissive response, and structured tools (SBAR, an explicit 'worried' trigger) exist specifically to lower this barrier
• Diffusion of responsibility - in a busy ward, an abnormal observation can be seen by several people without any one of them acting, each assuming someone else has it in hand
• Anchoring - once a diagnosis or explanation is fixed in mind, new evidence of a different or worsening problem can be discounted rather than prompting reassessment
• Poor handover - deterioration flagged by one team is lost if it is not explicitly and clearly communicated to the next

Communication tools

Recognising deterioration is only useful if it is communicated clearly and acted on - several structured tools exist specifically to make that communication reliable under pressure.

• SBAR (Situation, Background, Assessment, Recommendation) - a structured handover format for escalation calls, ensuring the responder gets the critical information first and a clear ask at the end
• Closed-loop communication - an instruction is repeated back by the person receiving it and confirmed by the person who gave it, so that in a fast-moving situation nothing is assumed to have been heard or actioned when it was not
• Graded assertiveness (for example the PACE framework: Probe, Alert, Challenge, Emergency) - a structured way of escalating concern up a hierarchy when an initial, gentle prompt is not acted on, giving junior staff a legitimate, rehearsed way to insist on review without needing to rely on confidence alone
• Documentation of the trigger and response - recording what score or concern prompted a call, and what was done about it, both supports continuity of care and allows the system itself to be reviewed and improved after the event

Approach to the deteriorating patient

1. Assess using ABCDE, treating problems as they are found, as in any acutely unwell patient
2. Review the trend, not just the current observation set - a NEWS2 of 4 that was 0 an hour ago is more concerning than a stable NEWS2 of 4
3. Review the notes, drug chart and recent results - a new medication, a recent procedure, or a subtle trend in bloods can point directly to the cause
4. Check the ceiling of care - resuscitation status and any treatment escalation plan should be reviewed early, since they change what escalation and treatment are appropriate, without ever being used to justify skipping a proper assessment
5. Escalate using SBAR, giving the responder enough information to prioritise the call and arrive prepared
6. Reassess after every intervention, and escalate further if the patient does not improve as expected

Groups at higher risk of unrecognised deterioration

• Older patients, who can present atypically - confusion or a fall rather than fever or pain - and whose baseline observations may already be different from a young adult's normal range
• Immunosuppressed patients, who may mount a blunted physiological response (a lower fever, a less dramatic tachycardia) to a serious underlying problem
• Patients reviewed less frequently, including overnight and at weekends, when staffing and senior review are often reduced
• Patients recently stepped down from critical care, who remain at higher risk of relapse than their current observations might suggest

Common causes of ward deterioration

• Sepsis, from a new or progressing infection
• Bleeding, overt or occult, particularly post-operatively or in an anticoagulated patient
• Pulmonary embolism, particularly in an immobile or post-operative patient
• Cardiac events - arrhythmia, ischaemia, decompensated heart failure
• Adverse drug reactions or medication errors
• Fluid overload or, conversely, under-recognised hypovolaemia
• A missed surgical or procedural complication

Red flags

Prognosis

Outcome for a deteriorating ward patient depends far more on how quickly the problem is recognised and escalated than on the underlying diagnosis alone - the same reversible cause treated an hour earlier or later can be the difference between a ward-based recovery and an unplanned intensive care admission or cardiac arrest. This is precisely why hospitals invest in track-and-trigger systems, outreach teams and training in the human factors that determine whether those systems are actually used.