Strand 3. Supporting early recognition of, and response to, deterioration
Getting to know patients makes a huge difference – not using bank nurses." Service provider
In Recognising and Responding to Acute Deterioration in Mental State: A Scoping Review, published in 2014, Craze L et al identify deterioration as ‘changes in a person’s mental state that indicate the need for more frequent review and for the introduction, change or up-scaling of therapeutic interventions’.
Ward systems and activities should be structured to facilitate early recognition and response and adopting a multidisciplinary approach is essential to the delivery of safe, efficient and effective care, support and treatment. A range of social and relational factors can contribute to deterioration and should therefore be taken into account:
- the patient’s circumstances and the experiences that surround their hospital admission
- the patient’s environment – the design, nature and focus of ward structure and routines
- the therapeutic milieu of the ward and its ethos, such as trauma-informed as opposed to custodial care, and the use of restrictive practices
- the presence of familiar, skilled, competent and caring staff
- the ward team’s workload, communication skills and approach to teamwork
- the degree of anticipatory care planning and personalised assessment that has been addressed to enable early recognition, intervention, support and treatment
Putting guidance into practice
For patients potentially deteriorating or at risk of harm, their care, treatment and safety plan should show details of personalised forward planning, aligned to wider clinical needs. This may involve increasing nursing or allied healthcare contact (occupational therapy, physiotherapy, activity coordination) to support engagement in new activities. Facilitated self-help activities (personal goal setting, reading, occupational activities) can be undertaken alongside a member of staff but without direct engagement if the patient finds this too difficult or distressing.
Ward staff should
- record an early intervention personalised action plan during the ward safety huddle or safety briefing discussion for patients with signs of deterioration or at risk of harm
- temporarily increase the frequency of interventions or meaningful activity (or forward plan to do so imminently) where potential or actual deterioration is apparent to enhance patient engagement and benefit – this may mean prescribing a deteriorating patient a number of specific interventions, contacts or activities per day within their care, treatment and safety plan and following up or reviewing progress
- consider the views of the patient themselves, and/or their carer, when developing interventions – this is just as important at times of potential deterioration or crisis and it must not be assumed that the patient cannot or does not want to engage
- think ‘out of the box’ to develop meaningful activities that may be indirect or non-invasive for patients who find it difficult to engage directly with staff – remember that it’s rare for an individual’s purpose of admission to either necessitate, or benefit from, prolonged periods of isolation or disengagement
- ensure that the nature, frequency and intensity of interventions are personalised and therefore responsive to the patient’s reason for admission, clinical needs, preferences and/or advance statement – not solely on the presence or lack of risk
For more information, please refer to our From Observation to Intervention (PDF) guidance document.