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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
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 (*).
Adult patients in acute hospital settings, including patients in the emergency department for whom a clinical decision to admit has been made, should have:
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:*
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:*
No specific service configuration can be recommended as a preferred response strategy because robust evidence of clinical and cost effectiveness is lacking.
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.
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
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).
Key areas of uncertainty identified as needing further research:
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.
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.