FUNDAMENTAL PRINCIPLES
Recognition of the Learning objectives
critically ill patient and After reading this article, you should be able to:
escalation of therapy C describe a logical and systematic approach to the assessment
of critically ill patients
C discuss the clinical importance of early warning scoring systems
Amy Brown in the recognition of the critically ill patient and the role of rapid
Apoorva Ballal response systems
C discuss the importance of timely involvement of the critical care
Mo Al-Haddad
team in making decisions regarding the most appropriate
environment to care for acutely unwell patients
Abstract
Critical illness often involves multiple organ failures and is associated
with significant morbidity and mortality. In the vast majority of pa-
tients, there is a recognizable period of physiological deterioration Introduction
which heralds the development of organ failure and critical illness. Critical illness carries a significant burden of morbidity and risk
Despite efforts to improve the detection and management of critical of mortality. It can rapidly evolve into multiple organ failure
illness, signs of deterioration are often missed and decisions to (MOF). Early recognition of at-risk patients and preventative
move patients to critical care units are delayed. Standardized ap- measures are the most effective approaches to managing this
proaches which implement an effective ‘chain of response’ are now patient group, considering that up to 40% of ICU admissions are
utilized worldwide. They focus on attempting to reduce the incidence avoidable.1 Ineffective management or failure to intervene in a
of serious adverse events (SAEs) such as in-hospital cardiac arrest timely fashion can lead to adverse outcomes as the number of
and unplanned intensive care unit (ICU) admission using organ systems involved increases.2
preventative measures. These systems should include: accurate Occasionally, the onset of life-threatening illness is acute and
recording and documentation of vital signs, recognition and interpre- catastrophic, but more commonly it is insidious. Early in-
tation of abnormal values, rapid bedside patient assessment by dicators of critical illness are often missed by healthcare pro-
trained teams and appropriate interventions. Early warning systems fessionals.3 Signs and symptoms can be unreliable, and patients
(EWS) are an important part of this and can help identify patients at may compensate for abnormal changes in their measured
risk of deterioration and SAEs. Assessment of the critically ill patient physiological parameters for a long time (Figure 1). Hence, the
should be undertaken by an appropriately trained clinician and follow gradually deteriorating patient on a hospital ward may go un-
a structured ABCDE (airway, breathing, circulation, disability and noticed until severe organ failure is established. The ‘chain of
exposure) format. This facilitates correction of life-threatening prob- response’ requires accurate recording and documentation of
lems by priority and provides a standardized approach between pro- vital signs, recognition and interpretation of abnormal values
fessionals. Lastly, timely support and input from members of the and appropriate patient assessment and intervention. Systems
critical care team are vital to ensure optimal outcomes for critically to standardize the ‘chain of response’ within a hospital are
ill patients. referred to as rapid response systems (RRS). As part of an RRS,
Keywords Assessment; critical care outreach services (CCOS); the use of early warning scoring systems can highlight subtle
critical illness; early warning systems; medical emergency teams physiological derangements (Table 1). An abnormal score
(METs); outcomes; prediction; rapid response system (RRS); signs; should prompt assessment by an appropriately qualified pro-
track and trigger systems (TTS) fessional or team.
A systematic ABCDE approach should be utilized in the
Royal College of Anaesthetists CPD Matrix: 2C01, 2C04 assessment of acutely unwell patients. This standardized rapid
bedside approach prioritizes clinical assessment and correction
of life-threatening problems of immediate risk to the patient. It
also aids communication between professionals by creating a
‘common language’ and reduces the risk of error. Ideally,
multidisciplinary input at the bedside should facilitate rapid
Amy Brown MBChB is a Clinical Teaching Fellow in Critical Care at assessment with concurrent resuscitation and life-saving
the Queen Elizabeth University Hospital in Glasgow, Scotland, UK. interventions.
Conflicts of interest: none declared. The critical care team should be involved in the early recog-
Apoorva Ballal MBChB BSc (Hons) is a Clinical Research Fellow in nition, review and escalation of management of critically unwell
Critical Care at the Queen Elizabeth University Hospital in Glasgow, patients throughout the hospital environment. In addition, this
Scotland, UK. Conflicts of interest: none declared. team plays an active role in the decision to admit patients to
critical care units and supporting patients thereafter. Prompt
Mo Al-Haddad MBChB FRCA FFICM EDIC MSc is a Consultant in
Anaesthesia and Intensive Care at the Queen Elizabeth University input from critical care services and efficient transfer to a critical
Hospital in Glasgow, Scotland, UK. Conflicts of interest: none care area, when appropriate, has a favourable effect on patient
declared. outcomes.
ANAESTHESIA AND INTENSIVE CARE MEDICINE xxx:xxx 1 Ó 2018 Elsevier Ltd. All rights reserved.
Please cite this article as: Brown A et al., Recognition of the critically ill patient and escalation of therapy, Anaesthesia and intensive care medicine,
https://doi.org/10.1016/j.mpaic.2018.11.011
FUNDAMENTAL PRINCIPLES
‘Top five’ early and late signs of physiological deterioration with
the odds ratio (OR) for death
Early sign: OR (95% C.I.) Late sign: OR (95% C.I.)
Unresponsive to voice:
34.8 (10.7–113.0)
Partial airway obstruction:
38.7 (3.9–64.4)
Poor peripheral circulation:
34.4 (6.8–174.0)
pH <7.3 but >7.2: pH 7.2:
29.0 (3.1–268.3) 116.1 (7.1–1906.1)
Base deficit –8 mmol/litre:
Base deficit –5 to –8 mmol/ 29.0 (3.1–268.3)
40.2 (7.7–208.8)
Urine output 200ml in
Drain fluid loss expected:
24 hours:
30.1 (6.1–148.9)
188.6 (30.1–1179.8)
Anuric:
29.0 (3.1–268.3)
Adapted from the SOCCER study
Figure 1
Partial airway obstruction can occur in response to reduced
Common causes of breathlessness based on speed of level of consciousness, infection, foreign bodies or trauma, to
onset4 name a few, and often results in noisy breathing. The hallmark
Minutes Hours Dayseweeks signs of partial airway obstruction are stridor due to turbulent
airflow through a narrowed airway and increased work of
Pneumothorax Asthma Pleural effusion breathing. Hoarseness is another sign and suggests vocal cord
Pulmonary embolism Pneumonia Exacerbation of COPD involvement. These are all worrying signs and require the expert
Pulmonary oedema Pulmonary oedema Pneumonia intervention of Anaesthetists or ENT specialists. Partial airway
Metabolic acidosis obstruction can progress to a complete airway obstruction with a
progressively exaggerated breathing pattern and eventual
Table 1 cardiorespiratory collapse. Medical texts describe the ‘optimal
position’ that conscious patients with airway comprise adopt to
maintain their airway, often sitting upright and leaning forwards.
A Assessment of Airway These patients should be supported in those positions and not be
The basic principles of airway assessment and management are laid flat as it may exacerbate airway compromise.
covered elsewhere (see Anaesthesia & Intensive Care Medicine Cervical spine (c-spine) injury must always be considered in
2016; 27(10): 492e496.) airway management, particularly following trauma, where
Assessment of airway patency is vital. Asking direct ques- manual in line immobilization is essential. Subsequent applica-
tions, for example, ‘How are you?’ or ‘Can you hear me?’ can tion of a c-spine collar should be instituted until injury is ruled
elicit a quick response, determining patency of airway. A legible out. Supplemental high-flow oxygen administration is impera-
response gives an idea of both the patency of airway as well as tive, aiming for saturations of >94%.
adequacy of cerebral perfusion at that stage. The ‘look, listen and Airway compromise requires immediate action and escalation
feel’ approach is effective, observing for chest wall movement, to senior colleagues is key. Certain causes, for example,
hearing breathing sounds and feeling active breathing from the anaphylaxis, burns or epiglottitis can quickly become fatal and
patient. timely senior involvement can be life saving.
ANAESTHESIA AND INTENSIVE CARE MEDICINE xxx:xxx 2 Ó 2018 Elsevier Ltd. All rights reserved.
Please cite this article as: Brown A et al., Recognition of the critically ill patient and escalation of therapy, Anaesthesia and intensive care medicine,
https://doi.org/10.1016/j.mpaic.2018.11.011
FUNDAMENTAL PRINCIPLES
B Assessment of Breathing patient should be fully exposed, maintaining dignity, and
The look, listen and feel approach can be extrapolated to assess examined for any other possible causes of critical illness while
respiratory response. Note that tachypnoea is a useful and sen- avoiding hypothermia.
sitive marker of illness severity. Other indicators of respiratory
compromise include inability to complete sentences, use of Early warning systems and the ‘chain of response’
accessory muscles of respiration, intercostal recession, altered
In the majority of patients, there is a detectable period of phys-
mental status and the late sign of cyanosis. Pulse oximetry is a
iological deterioration prior to in-hospital death, in-hospital car-
valuable bedside tool. Significant desaturation is often a late
diac arrest or unplanned ICU admission.5 For the past two
feature of ventilatory abnormalities, potentially resulting in false
decades there has been much focus on standardizing the recog-
reassurance in the early stages. Arterial blood gas analysis is
nition of patients at risk of critical illness and optimizing in-
vital for further evaluation and management. Respiratory failure
hospital response to avoid such adverse events.6
occurs when the respiratory system can no longer meet the
Rapid response systems (RRS) have been implemented inter-
metabolic demands of the body and can be divided into type 1
nationally as the standard structure for recognizing and man-
and type 2 respiratory failures. Hypoxaemic or type 1 respiratory
aging deteriorating patients. The components of an RRS can be
failure (PaO2 <8 kPa or 60 mmHg with a low/normal PaCO2).
classified into one of two groups or ‘limbs’. The afferent limb is
Hypercapnic or type II respiratory failure is hypoxia (PaO2 <8
concerned with recognizing the deteriorating and potentially
kPa or 60 mmHg) in addition to hypercarbia (PaCO2 >6 kPa or
critically ill patient and the efferent limb with responding to these
45 mmHg). Type I respiratory failure can progress to type II
patients and managing them appropriately.7 Poor compliance
respiratory failure as compensatory mechanisms fail with
with RRSs is associated with adverse patient outcomes.8
worsening hypoxia, acidosis and fatigue. Absence of an abnor-
The first objective in the RRS process is to create an afferent
mality in oxygenation in a breathless patient should prompt a
limb system which is sensitive enough to detect potentially
search for non-respiratory causes such as metabolic acidosis or
deteriorating patients. The system must also be efficient as it
sepsis.
needs to be utilized at optimum intervals in order to observe
Management of respiratory failure involves treating the un-
trends in patient physiology over time but avoid creating extra
derlying causes in addition to increasing inspired oxygen con-
workload for staff. Such systems, often referred to as track and
centration. Non-invasive or invasive ventilation may be required
trigger systems (TTS), can either take the form of (a) single or (b)
in severe cases. The decision to ventilate patients if increases in
multi-parameter systems or (c) aggregate-weighted track and
FiO2 and continuous positive airway pressure are unsuccessful
trigger systems (AWTTS). Here, a score is calculated that reflects
should involve senior clinicians. In some cases, the decision to
an aggregated number of physiological parameters out with
ventilate patients can be straightforward, for example in a patient
predetermined targets. In AWTTS, the score generated is referred
who remains hypoxic despite high inspired oxygen or a patient
to as an early warning score or EWS. The National Early Warning
who is unconscious secondary to hypercapnia. In other cases the
Score (NEWS) is currently the gold standard AWTTS in the UK. It
decision can be complex. Several factors should be taken into
is recommended by NHS England, NHS Improvement and the
account such as the severity of respiratory failure, adequacy of
Scottish Intercollegiate Guideline Network (SIGN).9,10 The cur-
compensation and the patient’s cardiopulmonary reserve.
rent system measures respiratory rate, peripheral oxygen satu-
C Assessment of Circulation ration, supplemental oxygen flow rate, pulse rate, systolic blood
The basics of the assessment of the circulation will not be pressure, temperature and conscious level using the AVPU score
covered here. The management of circulatory failure, i.e. shock (see Figure 2). The aggregate weighted scores then trigger an
is covered in these articles (see Anaesthesia & Intensive Care appropriate response as outlined in Figure 3.
Medicine 2017; 18(3): 11e121; 18(3): 122e125; and 2016; 17(2): Much like a TTS, the efferent limb of the response system has
86e91). varying structures with different terminology depending on the
Shock is a state in which there is inadequate blood flow and hospital site. Common examples include rapid response teams
oxygen supply to the organs and tissues to meet their metabolic (RRT), medical emergency teams (MET) and critical care
demands. The different patterns of shock are covered in other outreach services (CCOS). However, in every example the team
articles (see above). must consist of a multi-disciplinary, organized group of trained
Adequate tissue perfusion, heart rate and blood pressure clinicians including those with critical care competencies, airway
should all be assessed. Although shock and hypotension often skills and diagnostic skills. Their objective is to attend to dete-
coexist, hypotension need not be present. Altered consciousness riorating patients in order to provide an emergency review and
level (reduced level of consciousness, agitation, confusion), skin initial management. They also contribute to decisions regarding
mottling, cold peripheries, poor capillary refill (>2 s), oliguria escalation of patient care to critical care areas and establishing
and metabolic acidosis all indicate inadequate tissue perfusion. appropriate ceilings of care. A commitment to hospital staff ed-
ucation and ongoing quality improvement in managing critical
D and E Assessment of Disability and Exposure illness also often fall within the team’s remit. An effective CCOS
The Glasgow Coma Score or Alert, Voice Pain, Unresponsive specifically extends its role to include ongoing care for those
(AVPU) scale can be used to determine the patient’s level of patients recovering after a period of critical illness.11
consciousness. Measuring blood glucose level is essential at this The success of rapid response systems is far from irrefutable,
stage of the assessment in addition to measuring core tempera- however. There remain areas of contention and debate particu-
ture. Pupillary response should be checked frequently. The larly around how human factor elements, such as poor
ANAESTHESIA AND INTENSIVE CARE MEDICINE xxx:xxx 3 Ó 2018 Elsevier Ltd. All rights reserved.
Please cite this article as: Brown A et al., Recognition of the critically ill patient and escalation of therapy, Anaesthesia and intensive care medicine,
https://doi.org/10.1016/j.mpaic.2018.11.011
FUNDAMENTAL PRINCIPLES
Figure 2
communication and stress, as well as pressure on resources may recognized that such systems must be used in the context of
effect such systems. Evidence to date has not always demon- clinical judgement and be supported by sufficient resources.
strated a strong correlation between RRSs and positive patient
outcomes. An RRS is a complex process with multiple steps
The role of the critical care team and early transfer
involving many different multi-disciplinary staff members.
Therefore, there is scope for breaches in this chain that may The concept of ‘intensive care without walls’ is now well
disrupt the process and lead to poorer outcomes than expected. established. It advocates that critical care teams should extend
Human or sociocultural factors such as fear of reprimand, poor their resources and expertise to assisting with the detection,
communication and the general culture amongst ward staff are management and transfer of at-risk patients in the general ward
some of the most common individual factors leading to poor and emergency department (ED). In line with our earlier
compliance with such systems.12 Track and trigger systems comment, 41% of ICU admissions are considered avoidable.
should also be used to increase awareness of potentially deteri- Moreover, 39% of patients admitted to ICU are transferred too
orating patients and not viewed as purely a ‘tick box exercise’ to late in the course of their clinical illness.1
the detriment of employing good clinical skills and judgement.13 The early stage in a patient’s deterioration may present the
Better outcomes are achieved when an RRS is implemented well optimum time for critical care interventions with actions during
with an EWS used alongside good clinical judgement, staff edu- this time window offering the greatest chance of improving
cation and experienced staff.14 In summary, there is reasonable outcome. Delays in care escalation, defined as ‘deterioration to
evidence that RRSs are associated with a reduced rate of door time’, of greater than 4 hours are common and associated
cardiorespiratory arrest and mortality.15 However, it is with an increased incidence of adverse outcomes.16 Similarly, in
Figure 3
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Please cite this article as: Brown A et al., Recognition of the critically ill patient and escalation of therapy, Anaesthesia and intensive care medicine,
https://doi.org/10.1016/j.mpaic.2018.11.011
FUNDAMENTAL PRINCIPLES
one cohort study, prompt ICU admission in under 4 hours 7 Joshi K, Campbell V, Landy M, Anstey C, Gooch R. The effect of
resulted in a 16.2% reduction in 90 day mortality amongst pa- Rapid Response System revision on standard and specific
tients requiring ICU care.17 No consensus statements or stan- intensive care unit outcomes in a regional hospital. Anaesth
dards for maximum time to ICU admission are currently in use, Intensive Care 2017; 45: 369e74.
however the above emphasizes the importance of timely esca- 8 Trinkle RM, Flabouris A. Documenting rapid response system
lation to ICU. afferent limb failure and associated patient outcomes. Resusci-
Factors which may reduce the ‘deterioration to door time’ tation 2011; 82: 810e4.
begin with the detection and initial response to deteriorating 9 The Royal College of Physicians. National early warning score
patients as detailed previously. However, additional issues may (NEWS) 2. Standardising the assessment of acute-illness severity
include: communication with hospital management and bed in the NHS. London: RCP, 2017.
flow, effective handovers, availability of ICU beds, clinician 10 The Scottish Intercollegiate Guidelines Network. Care of deterio-
judgement regarding the appropriate thresholds for ICU admis- rating patients. Edinburgh: SIGN, 2014.
sion and availability of staff to assist with the transfer. 11 Stenhouse C, Cunningham M. Guidelines for the introduction
Optimum care of the critically ill patient should include a of Outreach services. London: The Intensive Care Society,
prompt review by the critical care team and a decision regarding 2002.
whether or not to transfer to ICU without delay. If queries or 12 Petersen JA. Early warning score challenges and opportu-
doubts arise regarding the appropriateness for ICU admission for nities in the care of deteriorating patients. Danish Med J
a patient, advice should be sought promptly from a senior 2018; 65.
member of the critical care team to avoid delaying the transfer 13 Le Lagadec MD, Dwyer T. Scoping review: the use of early
unnecessarily. If a decision is made not to transfer a patient to the warning systems for the identification of in-hospital patients at risk
ICU, the decision should be clearly documented, conveyed to the of deterioration. Aust Crit Care 2017; 30: 211e8.
patient, next of kin and staff as appropriate. In addition, a clear 14 McGaughey J, O’Halloran P, Porter S, Blackwood B. Early
plan should be made regarding further reviews by the critical warning systems and rapid response to the deteriorating patient in
care team, thresholds for re-referral or establishing an appro- hospital: a systematic realist review. J Adv Nurs 2017; 73:
priate ceiling of care which may include a decision not to attempt 2877e91.
cardio pulmonary resuscitation. A 15 Winters BD, Weaver SJ, Pfoh ER, Yang T, Pham J, Dy SM. Rapid-
response systems as a patient safety strategy: a systematic re-
view. Ann Intern Med 2013; 158: 417e25.
REFERENCES 16 Sankey CB, McAvay G, Siner JM, Barsky CL, Chaudhry SI.
1 McQuillan P, Pilkington S, Allan A, et al. Confidential inquiry into Deterioration to door time: an exploratory analysis of delays in
quality of care before admission to intensive care. BMJ (Clinical escalation of care for hospitalized patients. J Gen Intern Med
research ed) 1998; 316: 1853e8. 2016; 31: 895e900.
2 Zimmerman JE, Knaus WA, Sun X, Wagner DP. Severity stratifi- 17 Harris S, Singer M, Sanderson C, Grieve R, Harrison D, Rowan K.
cation and outcome prediction for multisystem organ failure and Impact on mortality of prompt admission to critical care for
dysfunction. World J Surg 1996; 20: 401e5. deteriorating ward patients: an instrumental variable analysis
3 McGloin H, Adam SK, Singer M. Unexpected deaths and referrals using critical care bed strain. Intensive Care Med 2018; 44:
to intensive care of patients on general wards. Are some cases 606e15.
potentially avoidable? J R Coll Physicians Lond 1999; 33: 255e9.
4 Gomersall C. Basic assessment & support in intensive care. Acute FURTHER READING
respiratory failure. Shatin, Hong Kong: The Chinese Univeristy of Jones C, Radford P. Managing deteriorating patients. Rapid response
Hong Kong, 2017. Table 1: common causes of breathlessness team handbook. 2018, https://rrthandbook.org.
based on speed of onset. The Dept of Anaesthesia & Intensive National Institute for Health and Clinical Excellence. Acutely ill patients
Care. in hospital: recognition of and response to acute illness in adults in
5 Kause J, Smith G, Prytherch D, Parr M, Flabouris A, Hillman K. hospital, 2007. NICE Guideline no. 50.
A comparison of antecedents to cardiac arrests, deaths and National Patient Safety Agency. Recognising and responding appro-
EMergency intensive care admissions in Australia and New Zea- priately to early signs of deterioration in hospitalised patients, 2007.
land, and the United Kingdomdthe ACADEMIA study. Resusci- Ref no. 0683.
tation 2004; 62: 275e82. Smith GB, Osgood VM, Crane S. ALERTTM- a multiprofessional
6 National Institute for Clinical Excellence. Acutely ill adults in training course in the care of the acutely ill adult patient. Resusci-
hospital: recognising and responding to deterioration. NICE, 2007. tation 2002; 52: 281e6.
ANAESTHESIA AND INTENSIVE CARE MEDICINE xxx:xxx 5 Ó 2018 Elsevier Ltd. All rights reserved.
Please cite this article as: Brown A et al., Recognition of the critically ill patient and escalation of therapy, Anaesthesia and intensive care medicine,
https://doi.org/10.1016/j.mpaic.2018.11.011
