Recognising and responding to acute illness in patients in hospital

The recognition of and response to potentially life threatening acute illness on hospital wards is of increasing concern. Changes in the type and availability of staff combined with the need to manage patients with increasingly complex problems have highlighted this concern.

Patients who develop severe organ failure often have abnormal physiological signs, sometimes for hours before their final “collapse.” Attempts to improve how we identify and manage these patients disregarded the lack of robust evidence,1 and national policies and initiatives promoting new models of care were issued in England (critical care outreach services),2 3 the United States (rapid response teams),4 and Australia (medical emergency teams).5

In their paper in this week’s BMJ, Buist and colleagues report their experience of a model that incorporates a method to improve the recognition of acute illness (medical emergency team calling criteria) with skilled personnel (the medical emergency team) to ensure a timely and appropriate response. The model is underpinned by an ongoing programme of education and support, both formal (an orientation programme for interns and a professional development course for medical registrars) and informal (introduction of an intensive care liaison nurse).6

During the last six years of a 10 year implementation period, they found a sustained reduction in the incidence of in-hospital calls for cardiac arrest (used as a proxy for delayed or suboptimal clinical management) of 24% each year. If we assume that these results do not reflect a dilution effect from the increasing denominator of hospital admissions (of 25% over the six year period), or a more general decline in the incidence of in-hospital cardiac arrest in the hospital population, then they may indicate that the clinical management of these patients improved. This may have occurred either through a genuine reduction in cardiac arrests or more appropriate use of “do not attempt resuscitation” orders.

What can we learn from these results for our own healthcare systems, hospitals, and practices? And what gaps in our knowledge should be a priority for research in this area?

Buist and colleagues’ experience indicates that leadership, culture change, education, support, and regular auditing of activity are important. Leadership was clearly important for ensuring successful implementation—the authors themselves showed such leadership. A culture change was needed and changing culture takes time—in Buist and colleagues’ experience, 10 years. A formal and informal education and support programme was needed to reinforce the need for periodic, appropriate documentation of physiological observations; to educate staff about the importance and interpretation of abnormal physiological observations; to empower the more junior staff to make the call to the medical emergency team; and to reinforce the need for a non-negotiable obligation from more senior, experienced staff to attend the patient’s bedside.

The importance of these lessons is supported by other research. The only multicentre randomised controlled trial of this model of care (MERIT) cites its short time frame for implementation of medical emergency teams as one reason for its failure to find an effect.7 Other reasons, which were also noted in Buist and colleagues’ study, included failure to make the call to the medical emergency team and delay in, or absence of, response.

Our recently completed qualitative study (122 in-depth interviews with relevant stakeholders in eight acute National Health Service hospitals)—part of a mixed methods evaluation of critical care outreach services in the NHS—highlighted the importance of leadership and the need for an “organisational entrepreneur” to ensure successful and sustained implementation.8 Critical care outreach services created an important change in culture by facilitating connectivity, reducing communication difficulties, and enhancing the delivery of care across organisational, professional, and specialty boundaries. The importance of training, particularly informal training (reassuring ward staff was most often highlighted), and factors related to implementation including documentation, authority, communication, resistance, and delay were also highlighted (D Baker-McClearn, S Carmel, personal communication, 2007).

The biggest gaps in our knowledge relate to the best way to identify deterioration, the most appropriate staff to respond to deterioration, the level of education and support needed, and the overall cost effectiveness of this model of care.

Buist and colleagues use one of several physiological “track and trigger” warning systems for detecting patients who are deteriorating. A recent systematic review identified at least 25 of these warning systems; none met the requirements for a level 1 clinical decision rule and little rigorous evidence existed for their validity, reliability, usefulness, or diagnostic accuracy.9 An assessment of 15 of these warning systems showed less than optimal diagnostic accuracy and provided no clear evidence of which method was best. Buist and colleagues provide no details of the diagnostic accuracy of their system but recognise that it could be improved.

Medical emergency teams and rapid response teams are staffed mainly by doctors, whereas critical care outreach services are staffed mainly by senior nurses. The optimum composition of a team or service, the best personnel to respond, and whether responses should be graded by the severity of the trigger are all unknown. Optimal diagnostic accuracy, grading of response, and an appropriate level of education and support will be essential for managing the workload and costs of delivering this model of care in the future.

The original objectives for the national policies and initiatives were the timely recognition of patients with potential or established critical illness followed by rapid attendance and initial management from skilled staff in an equitable manner across all acute hospital settings. To achieve this, we need to develop outcome measures for early identification of acute deterioration that can be used to evaluate and identify the most appropriate track and trigger warning system.