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Recognising and responding to clinical deterioration

6th Oct 2022

It is always a tragedy when a child dies in the emergency department (ED), but what if that death could have been prevented? What if that child’s deterioration went unnoticed for hours despite desperate pleas from worried parents? This was the scenario faced by at least three parents in the past 18 months in Australia, whose cases have been highlighted in the media. Cases like these emphasise that health care providers and nurses are responsible and accountable for delivering safe and high-quality care, by recognising and responding to clinical deterioration and meeting all medico-legal requirements for documentation.

A seven-year-old girl died from sepsis in an ED after waiting two hours to be seen by a doctor. The ED was understaffed and busy, and the patient was placed in the waiting room prior to a proper assessment being conducted. The patient’s high temperature of 38.5°C was treated with medication, but not escalated to medical staff. Parental concern was given a score of zero as the nurse felt she had allayed the parents’ concerns, despite the parents approaching staff five times in two hours while in the waiting room. The child was eventually seen by staff and taken to the resuscitation bay, where she went into cardiac arrest and died.[i]

An eight-year-old girl died after she was brought to the ED with stomach pains, vomiting and fever. Her parents had taken her to hospital for suspected appendicitis on the advice of their GP. After waiting two hours to be seen, an abdominal scan was performed but the finding was not consistent with appendicitis, and the parents were told it was likely gastroenteritis. The patient was given IV fluids and soon after developed breathing problems. Despite frequent expressions of concern from the child’s mother to nursing staff, it took six hours for doctors to order a blood test. The child was still having difficulty breathing and three hours later, staff realised the child was in a critical condition, but she went into cardiac arrest and died.[ii]

A five-year-old girl presented to the ED on the advice of their GP, with several days of flu-like symptoms and lethargy. She waited with her parents for almost four hours, at one stage being told by nursing staff that there was a long wait, and they could go home if she wasn’t too unwell. The child was offered an oral rehydration solution but continued vomiting. The following morning, she was diagnosed with Influenza A and inflammation of the heart muscles (myocarditis), requiring transfer to a major hospital by air. While waiting hours for transport, the child went into cardiac arrest and died.[iii]

In light of these tragic deaths, we need to examine the way nursing staff recognise and respond to a deteriorating patient. The early identification and accurate documentation of clinical deterioration, followed by prompt and effective action, is vital to prevent serious adverse outcomes, such as cardiac arrest and unexpected death, as these events are often preceded by observable physiological and clinical abnormalities.

Endorsed by Health Ministers in April 2010, the first edition of the National Consensus Statement: Essential Elements for Recognising and Responding to Clinical Deterioration (Consensus Statement) provides a consistent national framework ‘for recognising and responding to physiological deterioration in Australian hospitals.’ [iv] The Consensus Statement informed the development of the National Safety and Quality Health Service’s Recognising and Responding to Acute Deterioration Standard, which 'aims to ensure that a person's acute deterioration is recognised promptly and appropriate action is taken’.

The warning signs of clinical deterioration are not always recognised or acted on in a timely or appropriate manner, and this can be influenced by organisational and workforce factors such as:

• ‘Not monitoring physiological observations consistently, or not understanding changes in physiological observations
• Lack of knowledge of signs and symptoms that could signal deterioration
• Lack of awareness of the potential for a person’s mental state to deteriorate
• Lack of awareness of delirium, and the benefits of early recognition and treatment
• Lack of formal systems for responding to deterioration
• Lack of skills to manage patients who are deteriorating
• Failure to communicate clinical concerns, including in handover situations.’[v]

The Consensus Standard led to the development and implementation of a range of early-warning tools for documentation, such as the Observation and Response Chart, which has colour-coded zones to trigger escalation, and the Child Early Warning Tool (CEWT) which has age-appropriate ‘track and trigger’ observation charts with trigger limits for escalating care.

Nurses are the primary caregivers for deteriorating patients, and they play a pivotal role in providing a timely and consistent response, in line with hospital policies and procedures, to ensure the best outcomes for their patients. Failure to comply with the Standard can result in serious injury and death for the patient, and the risk of litigation for the health care provider and nursing staff.

The ALA thanks Kristi Gilbert for this contribution.

Kristi Gilbert CCRN is a Registered Nurse with over 25 years’ experience in critical care, anaesthetics, management and aeromedical retrieval, and provides expert nursing opinion for legal issues.

Tags: Kristi Gilbert emergency department clinical deterioration Registered Nurse