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BMJ. 2007 August 4; 335(7613): 258–259.
PMCID: PMC1939787
NICE guidelines

Recognising and responding to acute illness in adults in hospital: summary of NICE guidance

Mary Armitage, consultant physician,1 Jane Eddleston, consultant in intensive care medicine,2 and Tim Stokes, associate director, centre for clinical practice3, Guideline Development Group

Why read this summary?

Patients in hospital are at risk of becoming acutely ill due to their underlying diagnosis, associated comorbidities, and increasing age and the increasing complexity of care delivered in our hospitals. The recognition of deteriorating health by clinical staff is often delayed or managed inappropriately, resulting in late referral to critical care, avoidable intensive care admissions, and many unnecessary patient deaths.1 This article summarises the most recent guidance from the National Institute for Health and Clinical Excellence (NICE) on improving the recognition and response to acute illness in adults in hospital.2

Recommendations

NICE recommendations are based on systematic reviews of best available evidence. When minimal evidence is available, a range of consensus techniques is used to develop recommendations. In this summary, recommendations derived primarily from consensus techniques are indicated with an asterisk (*).

Initial assessment

Adult patients in acute hospital settings, including patients in the emergency department for whom a clinical decision to admit has been made, should have:

  • Physiological observations recorded at the time of their admission or initial assessment.*
  • A clear, written monitoring plan that specifies which physiological observations should be recorded and how often.* The plan should take account of the:
    • - Patient's diagnosis
    • - Presence of comorbidities
    • - Agreed treatment plan.

Staff undertaking these procedures should be trained to record these observations, understand their clinical relevance, and act upon them.*

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.

Routine monitoring

  • Use physiological “track and trigger” systems to monitor all adult patients in acute hospital settings. (Such systems comprise the periodic observation of selected basic physiological signs (tracking) with predetermined calling or response criteria (trigger) for requesting the attendance of staff who have specific competencies in the management of acute illness and/or critical care.)
  • Monitor physiological observations at least every 12 hours, unless it has been decided at senior level to increase or decrease the frequency for an individual patient.*
  • Use multiple parameter scoring systems or aggregate weighted scoring systems that allow a graded response. The systems should:
    • - Define the parameters to be measured and frequency of observations
    • - State the parameters, cut-off points, or scores that should trigger a response
    • - Monitor heart rate; respiratory rate; systolic blood pressure; level of consciousness; oxygen saturation; temperature
    • - Depending on clinical circumstances, consider monitoring hourly urine output; biochemistry (for example, lactate, blood glucose, base deficit, arterial pH); pain.*
  • Provide education and training so that staff have the necessary competencies in monitoring, interpreting measurements, and prompt response to acutely ill patients, appropriate to the level of care they are providing. Assess staff to ensure they can demonstrate these competencies.*

Response strategy

Agree on and deliver a local graded response strategy for patients identified as being at risk of clinical deterioration by “track and trigger” score or clinical concern. This response strategy should consist of three levels:*

Low score group:

  • Increase frequency of observations and alert the nurse in charge.

Medium score group:

  • Urgent call to:
    • - Patient's primary medical team
    • - Locally agreed personnel with core competencies for acute illness. These competencies can be delivered by various local models, such as a critical care outreach team, a hospital at night team, or a specialist trainee in an acute medical or surgical specialty.

High score group:

  • Emergency call to team with critical care competencies and diagnostic skills. The team should:
    • - Include a medical practitioner skilled in assessing the critically ill patient and who has advanced airway management and resuscitation competencies
    • - Provide an immediate response.

No specific service configuration can be recommended as a preferred response strategy because robust evidence of clinical and cost effectiveness is lacking.

Transfer to and from critical care

  • If the team caring for the patient considers that admission to a critical care area is clinically indicated, then the decision to admit should involve both the consultant caring for the patient on the ward and the consultant in critical care.*
  • After the decision to transfer a patient from a critical care area to the general ward has been made, the transfer should occur as early as possible during the day. Avoid such transfers between 22 00 and 07 00 whenever possible. Document as an adverse incident.
  • The critical care area discharging team and the receiving ward team should take shared responsibility for the care of the patient being discharged. They should jointly ensure that:*
    • - There is continuity of care through a formal structured handover of care from critical care area staff to ward staff (including both medical and nursing staff), supported by a written plan
    • - The receiving ward, with support from critical care if required, can deliver the agreed plan.
  • The formal structured handover of care should include:*
    • - A summary of critical care stay, including diagnosis and treatment
    • - A monitoring and investigation plan
    • - A plan for ongoing treatment, including drugs and therapies, nutrition plan, infection status, and any agreed limitations of treatment
    • - Physical and rehabilitation needs
    • - Psychological and emotional needs
    • - Specific communication or language needs.

Overcoming barriers

Effective implementation of this guideline will require the education and training of a wide range of healthcare staff in conducting and interpreting physiological observations and in recognising and responding to patients who become acutely unwell in hospital. In England and Wales, often such educational programmes are the primary responsibility of critical care outreach teams, with success measured by improvements in knowledge and clinical skills. The outstanding challenge now is to deliver a graded response strategy to patients with deteriorating health. An effective strategy will be one that matches the competencies of doctors and nurses to an individual patient's needs in a clearly defined time frame. For critically ill patients who need to be admitted to a critical care area, the process should be seamless and consultant led. Such fundamental changes within acute hospitals should benefit all adult inpatients.

NICE has developed tools to help organisations implement the guidance (see www.nice.org.uk). Further information about the guidance is available on bmj.com.

Background

This short clinical guideline aims to improve the care of acutely ill patients in hospital by giving evidence based recommendations on the best way to identify and manage this group of patients. It is also intended to tackle current shortcomings in care identified by the NCEPOD report.3

Methods

This is the first short clinical guideline to be developed by NICE. In 2006 NICE established a “short” clinical guideline programme for the rapid (9-11 month) development of clinical guidelines concerned with the part of a care pathway for which the NHS requires guidance rapidly. Short clinical guidelines are developed by an internal NICE technical team to the same rigorous methods as existing clinical guidelines (see www.nice.org.uk/page.aspx?o=114219) developed by NICE's national collaborating centres.

The NICE Short Clinical Guidelines Technical Team convened a group of healthcare professionals and patient representatives to oversee the work and to help develop the recommendations.

The group conducted a systematic review of the literature, assessed the quality of the literature, and qualitatively synthesised the included evidence. It was not possible to develop a suitably comprehensive de novo economic model, owing in large part to inadequacies in the effectiveness data available, although a relevant unpublished economic analysis on critical care outreach services was identified and made available to the guidelines development group.

The guideline went through an external consultation with stakeholders. The development group then assessed stakeholders' comments, reanalysed the data where necessary, and modified the guideline.

NICE has produced three different versions of the guideline: a full version, a quick reference guide, and a version for patients and the public. All these versions are available from the NICE website (www.nice.org.uk).

Research recommendations

Key areas of uncertainty identified as needing further research:

  • What is the clinical and cost effectiveness of a structured educational programme to improve recognition of and response to acute illness in general hospital wards, compared with no structured programme?
  • What is the clinical and cost effectiveness of automated (electronic) monitoring systems compared with manual recording systems, in identifying people at risk of clinical deterioration in general hospital ward settings?
  • Is it possible to recommend a specific service configuration to deliver the response strategy? The Department of Health's 2000 report Comprehensive Critical Care identified dedicated hospital teams, termed critical care outreach services, as an important component of future critical care services in the NHS. These services aim to ensure appropriate admission to critical care, enable discharges from critical care, and share skills with ward and community staff. In spite of the widespread uptake of such critical care outreach services since then, our guideline highlights the lack of robust evidence of their effectiveness or cost effectiveness. Research is urgently needed to tackle this evidence “gap.”

Guideline development group

The guideline development group comprised: Sheila Adam, Mary Armitage (chair), Peter Brewer, Brian Cuthbertson, Jane Eddleston (clinical adviser), Peter Gibb, Paul Glynne, David Goldhill, John Hindle, Paul Jenkins, Simon McKenzie, Patrick Nee, Brian Rowlands, and Kirsty Ward. We note with sadness the death of Peter Brewer during the development of the guidance. In addition David Harrison and Gary Smith acted as expert advisers. The NICE Short Guidelines Technical team comprised: Michael Heath, Francis Ruiz, Tim Stokes (NICE lead), and Toni Tan.

Notes

Contributors: TS drafted the summary and MA and JE reviewed its contents. It is based on the full guideline (reference 1).

Funding: This summary was written by the Centre for Clinical Practice (Short Clinical Guidelines technical team) at the National Institute for Health and Clinical Excellence.

Competing interests: JE is an advisor to the Department of Health on adult critical care.

Provenance and peer review: Commissioned, not peer reviewed.

References

1. National Institute for Health and Clinical Excellence. Acutely ill patients in hospital : recognition of and response to acute illness in adults in hospital 2007. (NICE clinical guideline No 50.) www.nice.org.uk/CG050 [PubMed]
2. Department of Health. Comprehensive critical care: a review of adult critical care services London: DH, 2000. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4006585
3. National Confidential Enquiry into Patient Outcome and Death. An acute problem? A report of the national confidential enquiry into patient outcome and death (NCEPOD) London: NCEPOD, 2005. www.ncepod.org.uk/2005.htm [PubMed]

Articles from The BMJ are provided here courtesy of BMJ Publishing Group