Practice Competent Novice

Early management of acutely ill ward patients

BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e5677 (Published 24 August 2012) Cite this as: BMJ 2012;345:e5677
  1. Paul J Frost, consultant in intensive care medicine1, clinical senior lecturer2,
  2. Matt P Wise, consultant in intensive care medicine1
  1. 1Critical Care Directorate, University Hospital of Wales, Cardiff CF14 4XW, UK
  2. 2Institute of Medical Education, School of Medicine, Cardiff University, Cardiff CF14 4XN
  1. Correspondence to: Dr Paul J Frost, Institute of Medical Education, School of Medicine, Cardiff University, Cardiff CF14 4XN frostp2{at}cf.ac.uk

How junior doctors can develop a systematic approach to managing patients with acute illness in hospital

Junior doctors can expect to manage previously stable ward patients who have abruptly deteriorated and become acutely ill. These patients have typically developed life threatening, neurological, or cardiorespiratory instability, usually as a result of their presenting condition. In these situations the key priorities are to stabilise the patient, diagnose the underlying problem, and deliver definitive treatment. A report from the National Confidential Enquiry into Patient Outcome and Death described numerous deficiencies in the care of such patients. These included prolonged periods of physiological instability before the admission to intensive care unit, and in a high proportion of cases, very poor management of airway, breathing, and circulation, and monitoring and oxygen therapy. The report recommended that junior doctors should develop a systematic approach to acute illness and seek senior advice more readily.1

How best to do it?

The clinical signs of life threatening acute illness may be readily identified, even though the underlying disease may not be. These signs include coma; seizures; agitation and confusion; tachycardia or bradycardia; hypotension; cold peripheries; cyanosis; tachypnoea or bradypnoea; and oliguria. These signs are usually detected during simple routine observations by ward nurses (fig 1). A large, multicentre, prospective, observational study found that 60% of hospital deaths, cardiac arrests, and unanticipated admissions to intensive care units were preceded by serious physiological abnormalities, the most common of which were hypotension and a fall in the Glasgow coma score.2 In the United Kingdom, the National Institute for Health and Clinical Excellence (NICE) recommended the use of physiological track and trigger systems to monitor adult patients in acute hospital settings.3 These systems use early warning scores to identify patients at risk of deterioration and to trigger an appropriate response. The Royal College of …

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