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Part 1
Assessment![]()
Chapter 1
The deteriorating patient
Contents
Introduction
Staffing levels
Levels of care
Microphysiology
Adverse events
Fundamental care
āAcuteā versus āchronicā
A note on this using book
Implications for practice
Summary
Further reading
Clinical scenario
Introduction
Significant avoidable morbidity and mortality occurs in acute hospitals (NICE, 2007; NPSA, 2007a; Yoon et al., 2014). In recent years, average acuity of patients in acute hospitals has increased (Needleman, 2013), placing all acute hospital patients at potential risk of deterioration. This book aims to help readers recognise the deteriorating patient, and identify what interventions may help avoid or reduce avoidable mortality.
Healthcare has faced many challenges and changes over the last quarter century. While 25 years may seem a long perspective, many buildings in which acute hospitals function are older, and many structures of, and expectations from, healthcare delivery predate these changes.
Arguably, the most significant change in acute care coincided with the new millennium: in 2000 the Department of Health (DOH) published Comprehensive Critical Care. Among the reportās many recommendations, all of which were accepted in full, was the expectation to replace āthe existing division into high dependency and intensive care based on beds . . . by a classification that focuses on the level of care that individual patients need, regardless of locationā (paragraph 16). From a patient-centred perspective, this appears desirable. However, most general wards were not designed, equipped or staffed to provide high dependency or intensive care, and most ward staff had little or no experience of those specialities. The expectations of Comprehensive Critical Care therefore placed significant pressures on acute hospitals and their staff.
The challenges would have been significant had expectations been matched by increased funding, staffing and resources. But publication of Comprehensive Critical Care coincided with multiple other internal and external pressures, including
- ā year-on-year budget restrictions encouraging cost-saving reductions in numbers of staff (Francis, 2013; Aiken et al., 2014);
- ā national and international directives and legislation, such as the European Union working time directives;
- ā society moving from a duty-based ethic to a rights-based one;
- ā promotion of evidence-based practice (Stevens, 2013).
Recent years have seen much turbulence within healthcare, potentially destabilising practice and confidence. An example of this turbulence is the number of relatively recently created national organisations which, having highlighted many of the issues discussed in this book, have now been disbanded, such as the NHS Modernisation Agency, and the National Patient Safety Agency (transferred to the NHS Commissioning Board Special Health Authority).
Staffing levels
Maintaining safety is fundamental to healthcare (Nightingale, 1859/1980; Roper et al., 1996). Staffing costs, and especially nursing staff, form the largest part of the NHS budget, so financial prioritisation has sometimes encouraged reduction of staffing levels (Francis, 2013). But this may be a false economy: lower staffing levels increase
- ā mortality (Aiken et al., 2014; Needleman et al., 2011);
- ā pressure ulcer rates (Twigg et al., 2010);
- ā incidence of falls (RCN, 2012);
- ā medication errors (Twigg et al., 2010);
- ā readmission rates (McHugh and Chenjuan, 2013);
and many other causes of morbidity and mortality. Many nurses feel unable to provide safe care due to excessive work pressures. The Royal College of Nursing (RCN, 2012), and many other organisations have proposed that the UK should, like some other countries, adopt minimum staffing levels. In the wake of Francis (2013), NHS England (2014) published guidance for nurse staffing levels, and now requires Trusts to publish data on the internet.
Levels of care
Comprehensive Critical Care defined four levels of care for hospitalised patients (see Table 1.1), level 2 patients being what were previously called āhigh dependencyā. This book focuses of level 2 patients, although aspects are also relevant to patients needing other levels of care. Level 1 was later (AUKUH, 2007) subdivided into 1a (sicker) and 1b (less sick), although this division tends to be used more for administration than ward-level care.
Table 1.1 Levels of Care (DOH, 2000; ICS, 2009)
Level 0:
Patients whose needs can be met through normal ward care in an acute hospital |
Level 1:
Patients at risk of their condition deteriorating, or those recently relocated from higher levels of care, whose needs can be met on an acute ward with additional advice and support from the critical care team |
Level 2:
Patients requiring more detailed observation or intervention including support for a single failing organ system or post-operative care and those āstepping downā from higher levels of care |
Level 3:
Patients requiring advanced respiratory support alone or basic respiratory support together with support of at least two organ systems. This level includes all complex patients requiring support for multi-organ failure |
The 2007 document further specified level 2 as patients
- ā with single organ system monitoring and support (not advanced respiratory support);
- ā needing preoperative optimisation: invasive monitoring and treatment to improve organ function;
- ā needing extended post-operative care: including short term (less than 24 hours), routine post-operative ventilation with no other organ dysfunction (e.g. fast track cardiac surgery patients);
- ā needing greater degree of observation and monitoring;
- ā moving to step-down care;
- ā major uncorrected physiological abnormalities.
Previously, the Intensive Care Society (ICS, 2002) had listed examples of level 2 patients as those
- ā needing more than 50% oxygen;
- ā with haemodynamic instability due to hypovolaemia/haemorrhage/sepsis;
- ā with acute impairment of renal, electrolyte or metabolic function;
- ā having undergone major elective surgery;
- ā with tachycardia above 120 bpm;
- ā with hypotension (systolic below 80 mmHg for more than one hour);
- ā with Glasgow Coma Scale (GCS) score below 10 and at risk of acute deterioration.
A 2009 update of this ICS document includes further examples. However, the shorter 2002 list illustrates that most general wards do have level 2 patients.
Microphysiology
Many acute pathologies will be outlined in later chapters, focusing on major organs and body systems. The human body is made up of more than 100 trillion (100,000,000,000, 000) cells (Maczulak, 2010). While visible organs may be easier to conceptualise, microscopic cells, cell function and dysfunction are fundamental to health. When sufficient cells fail, the organ/system fails. Crude mortality risk is approximately 25% per org...
