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Acutely ill patients in hospital
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Introduction
This pathway covers the recognition of and response to acute illness in adults in hospital.
Any patient in hospital may become acutely ill. However, the recognition of acute illness is often delayed and its subsequent management may be inappropriate. This may result in late referral and avoidable admissions to critical care, and may lead to unnecessary patient deaths, particularly when the initial standard of care is suboptimal.
Source guidance
The NICE guidance that was used to create the pathway.
Acutely ill patients in hospital. NICE clinical guideline 50 (2007)
Acute upper GI bleeding. NICE clinical guideline 141 (2012)
Quality standards
Quality statements
Effective interventions library
Successful effective interventions library details
Implementation
Commissioning
These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.
Education and learning
NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.
Service improvement and audit
These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.
Pathway information
Information for the public
NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on:
Patient-centred care
Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If someone does not have the capacity to make decisions, healthcare professionals should follow the Department of Health's advice on consent, the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards. In Wales, healthcare professionals should follow advice on consent from the Welsh Government.
If the person is under 16, healthcare professionals should follow the guidelines in Seeking consent: working with children. If a young person is moving between paediatric and adult services their care should be planned and managed according to the best practice guidance described in the Department of Health's Transition: getting it right for young people.
Updates to this pathway
26 February 2013 Minor maintenance updates.
Supporting information
Glossary
Adult patient in acute hospital setting (including emergency department) for whom a clinical decision to admit has been made
Adult patient in acute hospital setting (including emergency department) for whom a clinical decision to admit has been made
At admission
At admission
At admission
Write a clear monitoring plan specifying the physiological observations to be recorded and how often. Take into account:
- diagnosis
- comorbidities
- the agreed treatment plan.
Record at least:
- heart rate
- respiratory rate
- systolic blood pressure
- level of consciousness
- oxygen saturation
- temperature.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeRoutine monitoring and scoring
Routine monitoring and scoring
Routine monitoring and scoring
Use physiological track and trigger systems to monitor patients.
Monitor physiological observations at least every 12 hours, unless decided at a senior level to increase or decrease the frequency for an individual patient.
The frequency of monitoring should increase if abnormal physiology is detected.
Use multiple-parameter or aggregate weighted scoring systems, which allow a graded response. The systems should:
- define the parameters to be measured and the 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.
Set thresholds locally, and review regularly to optimise sensitivity and specificity.
Consider monitoring:
- biochemistry (for example, lactate, blood glucose, base deficit, arterial pH)
- hourly urine output
- pain.
Trigger thresholds for track and trigger systems should be set locally. The threshold should be reviewed regularly to optimise sensitivity and specificity.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeIf the patient's clinical condition is deteriorating or at risk of deteriorating
If the patient's clinical condition is deteriorating or at risk of deteriorating
If the patient's clinical condition is deteriorating or at risk of deteriorating
Follow a locally agreed graded response strategy if:
- alerted by track and trigger score
- there is clinical concern.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeGraded response strategy and patients with a clinical emergency
Graded response strategy and patients with a clinical emergency
Graded response strategy and patients with a clinical emergency
No specific service configuration can be recommended as a preferred response strategy for individuals identified as having a deteriorating clinical condition.
A graded response strategy for patients identified as being at risk of clinical deterioration should be agreed and delivered locally. It should consist of the following three levels.
Low-score group:
Increased frequency of observations and the nurse in charge alerted.
Medium-score group:
Urgent call to team with primary medical responsibility for the patient.
Simultaneous call to personnel with core competencies for acute illness.
These competencies can be delivered by a variety of models at a local level, 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 the assessment of the critically ill patient, who possesses advanced airway management and resuscitation skills. There should be an immediate response.
Clinical emergencies
Patients identified as 'clinical emergency' should bypass the graded response system. With the exception of those with a cardiac arrest, they should be treated in the same way as the high-score group.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeInitiate appropriate interventions, assess response and formulate a management plan, including location and level of care
Initiate appropriate interventions, assess response and formulate a management plan, including location and level of care
Initiate appropriate interventions, assess response and formulate a management plan, including location and level of care
For patients in the high- and medium-score groups, healthcare professionals should:
- initiate appropriate interventions
- assess response
- formulate a management plan, including location and level of care.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodePatient requires admission to critical care
Patient requires admission to critical care
Patient requires admission to critical care
The decision to admit should involve both the patient's consultant and the consultant in critical care.
For information on rehabilitation after a period of critical illness, see the rehabilitation after critical illness pathway.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodePreventing bleeding in acutely ill patients
Preventing bleeding in acutely ill patients
Preventing bleeding in acutely ill patients
Offer acid-suppression therapy (H2-receptor antagonists or proton pump inhibitors) for primary prevention of upper gastrointestinal bleeding in acutely ill patients admitted to critical care. If possible, use the oral form of the drug.
Review the ongoing need for acid-suppression drugs for primary prevention of upper gastrointestinal bleeding in acutely ill patients when they recover or are discharged from critical care.
For more information, see the pathway on acute upper gastrointestinal bleeding.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeTransfer from critical care
Transfer from critical care
Transfer from critical care to ward-based care
Transfers to general wards should be as early in the day as possible.
Avoid transfers between 22.00 and 07.00 wherever possible. Document as an adverse incident if they occur.
The critical care and ward teams have shared responsibility for the patient's care. They should:
- use a formal structured handover (including both medical and nursing staff), supported by a written plan, to ensure continuity of care
- ensure the ward can deliver the plan, with support from critical care if required.
The handover of care should include:
- a summary of the 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.
Staff should offer patients information about their condition and encourage them to participate in decisions that relate to their recovery.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeStaff competencies
Staff competencies
Staff competencies
Physiological observations should be recorded and acted upon by staff specifically trained to undertake them and understand their clinical relevance.
Staff should have competencies, appropriate to the level of care they provide, in:
- monitoring
- measurement
- interpretation
- prompt response.
These should be assessed, and education and training provided.
Ward staff working with patients transferred from critical care areas should be educated to recognise and understand their physical, psychological and emotional needs.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodePaths in this pathway
Pathway created: August 2012 Last updated: February 2013
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