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BMJ 2012;345:e5677 doi: 10.1136/bmj.e5677 (Published 24 August 2012)
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Practice
PRACTICE
COMPETENT NOVICE
Early management of acutely ill ward patients
How junior doctors can develop a systematic approach to managing patients with acute illness in
hospital
1
2
Paul J Frost consultant in intensive care medicine clinical senior lecturer , Matt P Wise consultant
1
in intensive care medicine
Critical Care Directorate, University Hospital of Wales, Cardiff CF14 4XW, UK; 2Institute of Medical Education, School of Medicine, Cardiff University,
Cardiff CF14 4XN
1
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.
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.
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
Correspondence to: Dr Paul J Frost, Institute of Medical Education, School of Medicine, Cardiff University, Cardiff CF14 4XN [email protected]
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BMJ 2012;345:e5677 doi: 10.1136/bmj.e5677 (Published 24 August 2012)
Page 2 of 8
PRACTICE
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.
processes (fig 3⇓). The junior doctor can coordinate these
activities by following the steps outlined below (see also case
scenario, part 2).
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
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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.
What are the challenges?
The Royal College of Physicians has highlighted several factors
that may compromise timely, high quality care to acutely ill
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BMJ 2012;345:e5677 doi: 10.1136/bmj.e5677 (Published 24 August 2012)
Page 3 of 8
PRACTICE
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.
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.
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).
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.
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National Confidential Enquiry into Patient Outcome and Death. An acute problem? 2005.
www.ncepod.org.uk/2005report/index.html.
Kause J, Smith G, Prytherch D, Parr M, Flabouris A, Hillman K, et al. A comparison of
antecedents to cardiac arrests, deaths and emergency intensive care admissions in
Australia and New Zealand, and the United Kingdom—the ACADEMIA study. Resuscitation
2004;62:275-82.
National Institute for Health and Clinical Excellence. Acutely ill patients in hospital. (Clinical
guideline 50.) 2007. http://www.nice.org.uk/CG50.
Royal College of Physicians. National early warning score (NEWS). www.rcplondon.ac.
uk/resources/national-early-warning-score-news.
NHS Institute for Innovation and Improvement. SBAR: Situation, background, assessment,
recommendation. www.institute.nhs.uk/quality_and_service_improvement_tools/quality_
and_service_improvement_tools/sbar_-_situation_-_background_-_assessment_-_
recommendation.html.
Turkington PM, Bamford J, Wanklyn P, Elliott MW. Prevalence and predictors of upper
airway obstruction in the first 24 hours after acute stroke. Stroke 2002;33:2037-42.
O’Driscoll BR, Howard LS, Davison AG, British Thoracic Society. BTS guideline for
emergency oxygen use in adult patients. Thorax 2008;63(suppl 6):1-68.
Cecconi M, Parsons AK, Rhodes A. What is a fluid challenge? Curr Opin Crit Care
2011;17:290-5.
Stacpoole PW, Wright EC, Baumgartner TG, Bersin RM, Buchalter S, Curry SH, et al.
Natural history and course of acquired lactic acidosis in adults. DCA-Lactic Acidosis Study
Group. Am J Med 1994;97:47-54.
General Medical Council. Treatment and care towards the end of life. 2010. www.gmcuk.org/static/documents/content/End_of_life.pdf.
Royal College of Physicians. Acute care toolkit 2. High-quality acute care. 2011. www.
rcplondon.ac.uk/sites/default/files/acute-care-toolkit-2-high-quality-acute-care.pdf.
Subbe CP, Kruger M, Rutherford P, Gemmel L. Validation of a modified early warning
score in medical admissions QJM 2001;94:521-6.
Smith T, den Hartog D, Moerman T, Patka P, van Lieshout EM, Schep NW. Accuracy of
an expanded early warning score for patients in general and trauma surgery wards. Br J
Surg 2012;99:192-7.
Gordon CF, Beckett DJ. Significant deficiencies in the overnight use of a standardised
early warning scoring system in a teaching hospital. Scott Med J 2011;56:15-8.
Smith CM, Perkins GD, Bullock I, Bion JF. Undergraduate training in the care of the acutely
ill patient: a literature review. Intensive Care Med 2007;33:901-7.
Cite this as: BMJ 2012;345:e5677
© BMJ Publishing Group Ltd 2012
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BMJ 2012;345:e5677 doi: 10.1136/bmj.e5677 (Published 24 August 2012)
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PRACTICE
Tables
Table 1| Situation, background, assessment, and recommendation (SBAR): an approach for nursing staff requesting a doctor’s immediate
attention for a patient4
S: situation
Identify yourself (name, role, location); confirm the identity of the person you are speaking to; identify the patient (name, age, sex, and location)
State the reason you are calling and the urgency—such as “this is urgent as the patient has a systolic blood pressure of 60 mm Hg”
B: background
Relate the history (date of admission, diagnosis, and management); describe the current interventions
A: assessment
State what you think is happening—such as “I think the patient has septic shock secondary to pneumonia”
R: recommendation State the request—such as “I need you to see this patient urgently; please come to the ward immediately”
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PRACTICE
Table 2| ABCDE (airway, breathing, circulation, disability, and exposure) assessment of acutely ill ward patients
Component
Safe features
Unsafe features
Potential bedside interventions
Airway
Patient talks normally, no additional Depressed level of consciousness; paradoxical chest Chin lift, jaw thrust, removal of foreign bodies, use of
airway noises
wall movements; snoring, grunting, or drooling; stridor oropharyngeal airway, suction of secretions, recovery
position, endotracheal intubation (expert only)
Breathing
Talking comfortably; respiratory rate Too breathless to talk; respiratory rate ≤8 or ≥25
12-20 breaths/min; oxygen
breaths/min; oxygen saturations ≤91% (supplemental
saturation ≥96% (breathing air)
oxygen); audible wheeze; asymmetrical chest
expansion; tracheal deviation; use of accessory
muscles; pursed lip breathing; cyanosis
High concentration oxygen via reservoir mask (15 L/min);
continuous positive airways pressure; non-invasive
ventilation; invasive ventilation; cough assist device;
intravenous antibiotics if evidence of pneumonia
Circulation
Capillary refill time <2 s; heart rate
51-90 beats/min; systolic blood
pressure 120-140 mm Hg; urine
output >0.5mL/kg/h
Cold peripheries; mottled skin; confusion; heart rate
≤40 or ≥131 beats/min; systolic blood pressure ≤90
or ≥220 mm Hg; raised or invisible jugular venous
pulse; urine output <0.5 mL/kg/h; temperature ≤35
or ≥39.1°C
Fluid bolus (crystalloid or colloid); intravenous antibiotics
if evidence of sepsis; blood transfusion; coronary
revascularisation (thrombolysis); inotropes (only in intensive
care unit unless during periarrest period)
Disability
Normal level of consciousness
Depressed level of consciousness; localising
neurological signs; neck stiffness or other signs of
meningism
Secure airway; treat hypoglycaemia and hyponatraemia;
start antimicrobials if evidence of sepsis
Exposure
Unremarkable physical examination Localising clinical signs, such as peritonism,
meningism, bronchial breath sounds
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Start monitoring (electrocardiography, automated blood
pressure cuff, urinary catheter); chest radiography;
ultrasonography (chest and abdomen); echocardiography;
arterial blood gas and relevant blood tests including blood
cultures
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BMJ 2012;345:e5677 doi: 10.1136/bmj.e5677 (Published 24 August 2012)
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PRACTICE
Figures
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Fig 1 Observation chart for the national early warning score (NEWS) (green=low score; orange=medium score; red=high
score).4 Published with permission from the Royal College of Physicians
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PRACTICE
Fig 2 Clinical responses triggered by national early warning scores (NEWS)
Fig 3 Assessment of acutely ill patients. The ABCDE approach (airway, breathing, circulation, disability, and exposure) and
diagnostic synthesis should be complementary and simultaneous
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