Recognising and Caring for the Critically Unwell Patient

Question 1

Describe the different urgenies of clinical response based on NEWS.

Answer 1

• A low NEW score (1–4) should prompt assessment by a competent registered nurse or equivalent, who should decide whether a change to frequency of clinical monitoring or an escalation of clinical care is required.
• A single red score (3 in a single parameter) is unusual, but should prompt an urgent review by a clinician with competencies in the assessment of acute illness (usually a ward-based doctor) to determine the cause, and decide on the frequency of subsequent monitoring and whether an escalation of care is required.
• A medium NEW score (5–6) is a key trigger threshold and should prompt an urgent review by a clinician with competencies in the assessment of acute illness – usually a ward-based doctor or acute team nurse, who should urgently decide whether escalation of care to a team with critical care skills is required (ie critical care outreach team).
• A high NEW score (7 or more) is a key trigger threshold and should prompt emergency assessment by a clinical team / critical care outreach team with critical care competencies and usually transfer of the patient to a higher- dependency care area.

Question 2

How frequently should patients be reassessed based on NEWS?

Answer 2

• Patients scoring 0, the minimum frequency of monitoring should be 12 hourly.
• Increasing to 4–6 hourly for scores of 1–4, unless more or less frequent monitoring is considered appropriate by a competent clinical decision maker.
• Frequency of monitoring should be increased to a minimum of hourly for those patients with a NEW score of 5–6, or a red score (ie a score of 3 in any single parameter) until the patient is reviewed and a plan of care documented.
• Continuous monitoring and recording of vital signs for those with an aggregate NEW score of 7 or more.

Question 3

When carrying out ABCDE, state which features of the airway assessment would reassure you, which would cause concern and the potential bedside interventions.

Answer 3

Question 4

When carrying out ABCDE, state which features of the breathing assessment would reassure you, which would cause concern and the potential bedside interventions.

Answer 4

Question 5

When carrying out ABCDE, state which features of the circulation assessment would reassure you, which would cause concern and the potential bedside interventions.

Answer 5

Question 6

When carrying out ABCDE, state which features of the disability assessment would reassure you, which would cause concern and the potential bedside interventions.

Answer 6

Question 7

When carrying out ABCDE, state which features of the exposure assessment would reassure you, which would cause concern and the potential bedside interventions.

Answer 7

Question 8

Describe level 0 criteria for critical care.

Answer 8

• Receiving normal ward care

Question 9

Describe the level 1 criteria for critical care.

Answer 9

• Recently discharged from higher level of care.
• Critical care outreach service support required.
• Additional monitoring, clinical input or advice required.
• Care from specialist staff / requiring additional facilities for one or more aspects of critical care on ward.

Question 10

Describe the level 2 criteria for critical care.

Answer 10

• Admissions receiving monitoring and support for one organ due to an acute illness.
• Admissions receiving pre-surgical optimisation requiring invasive monitoring and treatment to improve organ function.
• Admissions receiving extended post-surgical care either because of the procedure and / or the condition of the admission.
• Admissions receiving a greater degree of observation and monitoring than level 1 care.
• Admissions moving to step-down care.
• Admissions with uncorrected physiological abnormalities receiving level 2 care as above.

Question 11

Describe the level 3 criteria for critical care.

Answer 11

• Advanced respiratory support.
• Monitoring and support of 2 or more organs due to an acute illness (one of which may be basic or advanced respiratory support).
• Chronic dysfunction of one or more organs sufficient to restrict daily activities and who receive monitoring and support for one other organ due to an acute illness.

Question 12

What are the potential consequences of an ineffective handover process?

Answer 12

• Life-threatening and other preventable adverse events, which have a detrimental impact on the quality of care provided, patient outcomes and patient experience, for example, incorrect or repeated investigations and treatment.
• Delays in diagnosis and treatment.
• Increased hospital stay and subsequent avoidable healthcare cost.
• Patient safety incidents, complaints, and litigation.

Question 13

Describe SBAR.

Answer 13