Early management of acutely ill ward patientsBMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e5677 (Published 24 August 2012) Cite this as: BMJ 2012;345:e5677
- Paul J Frost, consultant in intensive care medicine1, clinical senior lecturer2,
- Matt P Wise, consultant in intensive care medicine1
- 1Critical Care Directorate, University Hospital of Wales, Cardiff CF14 4XW, UK
- 2Institute of Medical Education, School of Medicine, Cardiff University, Cardiff CF14 4XN
- Correspondence to: Dr Paul J Frost, Institute of Medical Education, School of Medicine, Cardiff University, Cardiff CF14 4XN
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 Physicians has recently launched a standardised system of national early warning scores (NEWS) for rollout across the National Health Service. This scoring system is based on aggregate scores, derived from points (0-3) that are given to increasing deviations from the normal range in six physiological variables (with an additional score of 2 for the patients receiving supplemental oxygen).4 The Royal College of Physicians has recommended a graded response strategy: a registered nurse will see and assess patients with a low (1-4) score and junior doctors will review patients with a medium (5-6) or high (≥7) score or with a score of 3 in one variable (fig 2⇓). Alternatively, nurses may use their clinical acumen to alert junior doctors to patients who they suspect are developing acute illness, even though the routine physiological observations are normal. Although there is little published evidence to support this approach, we recommend that junior doctors heed these requests as they are often well grounded (case scenario, part 1). In addition, the physiological manifestations of acute illness may wax and wane in response to treatment (such as increasing oxygen concentrations or intravenous fluid) or be masked by drugs such as β blockers.
Case scenario: part 1
A 62 year old man had been admitted to a general medical ward 12 hours earlier with right lower lobe pneumonia. A rapid response system was in place and national early warning scores (NEWS) were being calculated every four hours. His pulse rate was 52 beats/min, and although the national early warning scores did not mandate urgent medical review, his nurse was sufficiently concerned about him to request that you (junior doctor) attend immediately.
The NHS Institute for Innovation and Improvement has recommended that nurses use the situation, background, assessment, and recommendation (SBAR) approach when referring acutely ill patients (table 1⇓).5 The doctor may supplement this information with a brief review of the medical notes before accompanying the nurse to the bedside. The doctor should ask the nurse to remain at the bedside as a chaperone and to help with the physical examination and any necessary interventions. At night, bedside lighting must be adequate, even if this means disturbing other patients. Assessment should be done using the airway, breathing, circulation, disability, and exposure (ABCDE) approach (table 2⇓). Diagnostic synthesis and the ABCDE approach are complementary and simultaneous processes (fig 3⇓). The junior doctor can coordinate these activities by following the steps outlined below (see also case scenario, part 2).
Case scenario: part 2
You introduce yourself with a handshake and begin your ABCDE assessment. The patient is too breathless to complete a sentence but manages to tell you he is pain free but cannot get his breath. He is cold to touch and is peripherally cyanosed and you notice that the pulse oximeter is not detecting a signal. You start giving high concentration oxygen via a reservoir mask as you believe the patient is critically ill. Initially you are surprised to find that the pulse is just 52 beats/min as the blood pressure is 90/40 mm Hg, but then you discover that the patient has been taking a β blocker for hypertension. You establish venous access and administer a fluid challenge, a few minutes after which the blood pressure improves to 100/45 mm Hg. You complete your examination and find bronchial breath sounds over the right lower lobe. Your clinical impression is that the patient has septic shock secondary to pneumonia.
You discover that, although the appropriate antibiotics were prescribed in the medical admissions unit, the patient was transferred to the ward before they could be administered. You ask for these drugs to be given immediately.
Ten minutes after the first fluid bolus, the patient’s blood pressure has fallen again and you start a further bolus. You also ask for a urinary catheter to be inserted to monitor urinary output.
You organise urgent chest radiography and take blood for arterial blood gas and blood lactate measurements; you also take a venous sample for a full blood count, urea and electrolytes, and blood cultures.
Step 1: Immediate assessment
Offering a handshake is a good way to start your assessment, as this will provide not only information about consciousness level, safety of the airway, and peripheral perfusion, but also reassurance, and will establish a rapport with a potentially distressed and frightened patient. Spend a few moments observing the patient (see “Unsafe features” in table 2⇑), inspect the observation charts, and take a brief history—this will allow you to form an overall impression of the severity of illness and the requirement for urgent interventions and senior assistance. For example, it may be immediately obvious that the patient is moribund and that the cardiac arrest team should be summoned. Do not exhaust a patient by taking a complete history, as much of this can be obtained from other sources; instead, target your questions to ascertain the likely aetiology of the physiological disturbance. For example, if the patient is hypotensive consider causes of infection, hypovolaemia, and heart failure. Additionally, ask the patient directly about the presence and characteristics of any pain, as this is often a cardinal diagnostic symptom and needs to be relieved.
Step 2: Assessment of airway
In acutely ill ward patients a completely obstructed airway—for example, secondary to a food bolus—is rare, but a partially obstructed airway is quite common (see the features listed in table 2⇑). The usual cause is a depressed level of consciousness. In this situation not only is effective ventilation compromised, but the patient is also vulnerable to pulmonary aspiration. In patients with stroke this may lead to repetitive episodes of hypoxaemia with deleterious effects on the cerebral circulation.6 Generally, if the patient is able to talk normally then the airway is safe; conversely, if the patient is unresponsive (U on the AVPU (alert, voice, pain, unresponsive) scale) or has a Glasgow coma score of <8 then the airway is compromised. Management is a challenging proposition, so ask for anaesthetic help urgently. Meanwhile do a simple airway opening manoeuvre (such as a jaw thrust or chin lift), carefully suction away excessive oropharyngeal secretions, remove any obvious (and easily accessible) foreign body, and consider using an oropharyngeal airway. If there is any evidence or risk of vomiting, place the patient in the recovery position.
Step 3: Assessment of breathing and circulation
Most of the breathing assessment can be made by observation alone (table 2⇑).
In any patient with acute respiratory distress the key intervention is to relieve hypoxia as this may lead to brain damage and death. For acute illness, use high concentration oxygen from a reservoir mask (15 L/min). According to expert consensus guidelines, the target oxygen saturation should be 94-98%.7 The same target is recommended for critically ill patients with chronic obstructive pulmonary disease pending the results of blood gases, after which these patients may need controlled oxygen therapy or ventilatory support.7 If severe respiratory failure persists despite high concentration oxygen, and potentially reversible disease is identified, then ventilation may be needed.
After intervention to correct hypoxia, examine the patient’s circulation (table 2⇑). A reduced capillary refill time and cold peripheries may be present in a patient with low cardiac output (for example, after massive pulmonary embolus or myocardial infarction) or with hypovolaemia. These features are usually associated with tachycardia and reduced peripheral pulses. In any shock state the blood pressure will usually be low—but this may not be the case in previously hypertensive individuals. The jugular venous pressure will be raised in obstructive causes of shock (such as massive pulmonary embolus) and usually unseen in hypovolaemic shock. Establish peripheral venous access using a size 18 cannula or larger. A fluid challenge (such as 250 ml normal saline administered over two minutes) will normally identify hypovolaemic patients whose blood pressure and pulse will improve after the bolus.8 Although this manoeuvre is useful diagnostically, it is potentially harmful in cardiogenic shock and should be avoided in this context.
Step 4: Assessment of disability and exposure
Disability refers to neurological status, and exposure is a prompt to complete the physical examination. Do not distress the patient with an exhaustive examination, but rather target the most relevant system.
Step 5 Diagnostic synthesis, investigation, and definitive management
In the context of deterioration, reconsider the original diagnosis and check to ensure that appropriate treatment has been given. Investigations will be needed to confirm the diagnosis and assess illness severity (fig 2⇑). In this context a blood lactate concentration can be informative. One prospective study reported 83% mortality in patients with a blood lactate of ≥5 mmol/L.9
Once a diagnosis is obtained and/or the cause(s) for deterioration understood, definitive treatment can be started. Acutely ill patients will often need closer monitoring or be transferred to a higher care area such as an intensive care unit (case scenario, part 3). Guidance from NICE states that this decision should involve both the consultant caring for the patient on the ward and the consultant in critical care, so you should ensure that these individuals are informed.3 Occasionally decisions on treatment limitation (such as “do not attempt cardiopulmonary resuscitation”) may be needed. In the UK the General Medical Council states that these decisions must be based on the circumstances and wishes of the individual patient. This will involve sensitive discussion with the patient or those close to them, or both (usually by senior doctors).10
Finally you must ensure that all aspects of the management plan are communicated to the healthcare team and the patient (and those close to them) and that this communication is documented.
Case scenario: part 3
Your specialty trainee is busy managing another acutely ill patient so you speak directly to your consultant, who discusses the case with the consultant intensivist.
Forty five minutes after your initial review, the patient is seen by the intensivist, who organises his transfer to the intensive care unit.
You ensure that the patient and his family are fully informed about why the transfer was necessary and that the reasons are also documented in the notes.
You decide that you will follow up this patient during his stay in the intensive care unit, and you visit him there daily.
What are the challenges?
The Royal College of Physicians has highlighted several factors that may compromise timely, high quality care to acutely ill patients; these largely relate to staffing, organisation, and case mix.11 These factors include inadequate consultant cover, particularly out of hours; depletion of ward based junior doctors owing to restricted working hours; reduced clinical experience of junior doctors; and the use of different systems of early warning scores across hospitals. These problems are compounded by an increase in the age, complexity, and comorbidity of acutely ill patients alongside a general increase in societal expectations of care.
Moreover, although early warning scores have been shown to reliably identify medical and surgical patients at risk of deterioration and adverse events,12 13 vital signs, particularly respiratory rate, are often not reliably and consistently measured. Deficiencies in the use of early warning scores—such as the omission of observations or incorrect calculation of scores—have also been reported.14 The Royal College of Physicians has provided an online training facility to support the implementation of the system of national early warning scores.4 Additionally the college has published two acute care toolkits, with recommendations to tackle staffing and organisational matters, such as concerns about the proposals that consultants should have an increased presence on the wards, especially outside normal working hours.
Suboptimal training of undergraduates and junior doctors in acute care skills remains a major problem. A large systematic literature review concluded that undergraduates and junior physicians lack knowledge, confidence, and competence in all aspects of acute care, including the basic task of recognition and management of acutely ill patients.15 Many medical schools have incorporated relevant training into their curriculum (video: https://learningcentral.cf.ac.uk/bbcswebdav/institution/Medic/Undergraduate/Shock/video/shock.swf), and several acute care courses are available to junior doctors. The Ill Medical Patients Acute Care and Treatment (IMPACT) course is designed to enhance the skills of junior doctors dealing with critically ill patients and is endorsed by the Federation of Medical Royal Colleges and the Royal College of Anaesthetists (http://careers.bmj.com/careers/advice/view-article.html?id=2794).
Cite this as: BMJ 2012;345:e5677
This series aims to help junior doctors in their daily tasks and is based on selected topics from the UK core curriculum for foundation years 1 and 2, the first two years after graduation from medical school.
Contributors: Both authors contributed to the planning of this article and to the drafting and revisions. They both gave final approval of the article. PJF is the guarantor.
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; PJF is a member of the Ill Medical Patients Acute Care and Treatment (IMPACT) curriculum group.
Provenance and peer review: Commissioned; externally peer reviewed.