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5 Boroughs Partnership NHS Trust
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Addenbrooke's NHS Trust
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Aintree Hospitals NHS Trust
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Airedale General Hospital - Acute Trust
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Association for Clinical Biochemistry
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Association for Psychoanalytic Psychotherapy in the NHS (APP)
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Association of Anaesthetists of Great Britain and Ireland
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Association of Clinical Biochemists, The
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Barking Havering & Redbridge Acute Trust
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Barnet & Chase Farm Hospitals Trust
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Barnsley Hospital NHS Foundation Trust
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Bolton Council
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Bolton Hospitals NHS Trust
GL
2.1.3 Rec 6
We feel that oxygen saturation, as a parameter,should not be included in the physiological track andtrigger system. It is felt that the oxygen saturation parameter canoften lead to false reassurances.
Patients still may
have tissue hypoxia in the presence of anacceptable oxygen saturation recording and mayhave inadequate ventilation, again with anacceptable oxygen saturation recording if the patientis on oxygen. Oxygen saturation is also dependent on anadequate peripheral perfusion and is thereforeconsidered much less reliable than the otherphysiological observations suggested for scoringsystems
We have revised the review of the evidence andevidence to recommendations section 1.1.5 to makethe basis for inclusion of oxygen saturation andexclusion of urine output clear. In the evidence reviewwe refer to the Cuthbertson 2007 paper and the Duckit2007 (in press) which show the importance of O2saturation, with a cut point of 95%, as an importantearly predictor of acute deterioration in both medicaland surgical patients.
Bradford & Airedale PCT
This organisation has been approached but did notrespond
n/a
Bradford Hospitals NHS Trust
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n/a
Brighton & Sussex University Hospitals Trust
Gen
This consultation document has been circulated tolead clinicians and personnel for in BSUH for theircomments. The document is very timely in its publication insupporting the ongoing work of the Critical CareOutreach and patient safety team in the care of theacutely ill hospital patient. Our main comments are outlined below
Thank you.
Brighton & Sussex University Hospitals Trust
GL
1.3.3 page 14
Should clinical emergency be defined? Patient not suitable for critical care followingassessment – need to include review ofmanagement plan including resuscitation status –should arrow therefore go back up to monitoringplan Otherwise care pathway looks clear
The GDG considered whether it was possible to offer adefinition of 'clinical emergency' and considered that itwas not appropriate to offer a detailed list of conditionsthat would be included.
Brighton & Sussex University Hospitals Trust
GL
Evidence for including oxygen saturation.Recommendation implies that this
must
be included
- this would represent considerable change to ourexisting T & T MEWS score / and involved changingdocumentation / practice. Need to link withConnecting for Health – CRS our understanding isthat all organisations will be using samedocumentation within next few years - could this beincorporated to development? Would be useful to include examples of T & Tsystem that includes parameters recommended
We have revised the review of the evidence andevidence to recommendations section 1.1.5 to makethe basis for inclusion of oxygen saturation andexclusion of urine output clear. In the evidence reviewwe refer to the Cuthbertson 2007 paper and the Duckit2007 (in press) which show the importance of O2saturation, with a cut point of 95%, as an importantearly predictor of acute deterioration in both medicaland surgical patients. It is intended that the NICEimplementation tools will offer specific examples ofTTS.
Brighton & Sussex University Hospitals Trust
GL
Again clinical emergency should be defined
The GDG did not consider it was possible to offer adetailed definition of types of clinical emergency,although cadiac arrest is now mentioned, as this groupshould be managed differently than the "high risk"group.
Brighton & Sussex University Hospitals Trust
GL
This has always been the aim for ICU discharges(our aim is to transfer patients before 1700 whenparent medical teams are unavailable) howeverthere are occasions when due to capacity/ demandissues within the organisation this occurs
We have reworded this recommendation (1.3.2.14) toensure that it refers to fact decision to transfer hasbeen made and that night transfer "should be avoidedwhenever possible, and should be documented as anadverse incident if it occurs"
Brighton & Sussex University Hospitals Trust
GL
Need to be clear that critical care dischargingmedical team do not have
ongoing
clinical
responsibility for patient although CCOT maycontinue monitoring of patient.
This is addressed by revised recommendation(1.3.2.15)
Brighton & Sussex University Hospitals Trust
GL
This could be a breach of patient confidentiality
Noted. We would ask the PPIP to consider whetherthese issues require it to revise the general section ofprinciples of care (1.2) section.
British Association of Art Therapists
Gen
This consultation document has been circulated tolead clinicians and personnel for in BSUH for theircomments.
Thank you.
The BHF recognises these problems as real issuesin the management of acute patients in hospitals. Ittherefore seems appropriate that guidance isinstituted. The 17 recommendations clearly reflect what seemsto us to be a mixture of good basic clinical care andcommon sense.
British Heart Foundation
Gen
There is the recognition in the report that not allpatients who become acutely ill and require criticalcare will survive, therefore perhaps some referenceneeds to be made to the possibility that this is anissue which both staff and patients will need toaddress. We recognise that this may be beyond thescope of this guidance but reference perhaps shouldbe made to other sources of guidance on theprinciples and practice of providing good qualitypalliative and supportive care.
Thank you. We have addressed this important point inrevised recommendation 1.3.2.
British Heart Foundation
Gen
Handover of acutely ill patients from the generalacute wards to critical care teams is inevitable fromtime to time. It is important to stress that handoverand movement of patients from ward to ward shouldbe minimised and only undertaken when the clinicalcondition necessitates such a handover. Thereasons for this are that:
a.
Handovers are associated in breaks in thecontinuity of care and in particular therelationship that builds up between patientclinician and carer.
b.
Frequent moves of the patient can causeconfusion particularly in frail elderlypatients and
c.
There is clearly a risk of spreading hospitalacquired infection
Thank you.
British Heart Foundation
Gen
In order to address the issues raised in the nationalconfidential inquiry the key will be how this isimplemented in the real world of acute hospitalmedicine with all the pressures from staff trainingand education, staffing levels on the wards, bedpressures and high occupancy rates in hospitals.We would therefore support NICE in itscommissioned work from the Clinical AccountabilityService Planning and Evaluation Research Unit andHealth Quality Service to develop audit criteria aspart of the implementation strategy. This wouldusefully inform the audit cycle in the average districtgeneral hospital. However workforce developmenttraining and NHS capacity issues are also importantareas to address.
Thank you.
British Heart Foundation
GL
Rec 1
All adult patients should have appropriate physicalobservations but no mention is made, over andabove the need to make the observations, recordand act upon these by staff trained to do so, for theneed to quality assure the equipment that is used tomonitor patients. This is an important issue toimprove the quality and assure the quality of bedsidephysiological testing.
Noted. This is outside the remit of this work.
British National Formulary (BNF)
This organisation has been approached but did notrespond
n/a
British Psychological Society, The
Gen
We welcome the attention paid to psychologicalaspects of care, especially to communication issues,to the transition from ICU to general medical wardsettings and to the needs and potentialpsychological distress of family members/carers. Amore comprehensive coverage of these issueswould have been achieved through involvement of aclinical health psychologist in the working party.
Thank you. We would stress that we consider that theGDG was appropriately constituted for its core task.Rehabilitation was outside the scope of this guidance.
British Psychological Society, The
GL
We welcome the specific consideration ofpsychological adjustment and morbidity in theseguidelines. In particular, we welcome theconsideration of qualitative data on patientexperiences and preferences alongside quantitativeoutcome data.
Thank you.
British Psychological Society, The
GL
We strongly support the recommendation (2.3.4.1)that the hand-over of care include structuredfeedback on the particular psychological andemotional needs of the patient, the recommendation(2.3.4.2) regarding the involvement of patients in thedecision-making, with the support of individualisedinformation, and the recommendation for specifictraining of staff in this area (2.3.4.2). Clinical experience suggests that it is difficult for staffworking towards the priorities of an acute medicalenvironment to attend to complex, confusing anddistressing emotional experiences of patients,particularly those with complex needs (Bennun,1999,
J Family Therapy
, 21, 96-112). We would
argue for the provision of dedicated psychologicalinput for that function over and above specifictraining for all staff. In addition, we would suggest that the emotionalneeds of staff working in critical care services arecarefully considered. We see this as an importantcomponent of maintaining a high quality clinicalservice, and we would urge inclusion of suchconsiderations in the guidelines. Dedicatedpsychological input for staff training could alsoinclude the functions of staff support andconsultation.
Thank you. The need to support critical care staff isoutside the scope of this guidance.
written or other. To be fully amenable to audit thisplan would have to be written or documented in thepatient health record.
CASPE Research
1.3.1 Rec 11
This recommendation suggests that the gradedresponse strategy should be
agreed and delivered
locally. To be fully amenable to audit it may beuseful to add ‘documented’ into this paragraph.
This will be addressed by the accompanying auditcriteria
CASPE Research
The schematic found in this section provides a veryuseful overview of the recommendations, and hencecould provide a useful reference in terms of audit.As the audit criteria are linked to the key priorities forimplementation, it may be useful to provide areference to the aforesaid diagram in the keypriorities section.
Noted, thank you.
Chartered Society of Physiotherapy (CSP)
GL
2.1.3.6para 2
The CSP welcomes such specificity with regard tophysiological measurement parameters. This will beof help to physiotherapists working within themultidisciplinary team to use a guideline applicableto all healthcare staff in order to improve patientcare.
Thank you.
Chartered Society of Physiotherapy (CSP)
GL
We welcome the fact that physical and rehabilitationneeds are identified as important at the acute/criticalstage or care.
Thank you.
Chartered Society of Physiotherapy (CSP)
GL
2.3.4.5para 3
The fact that patients have reported that nurses mayhave unrealistic expectations of a patient’s physicalability highlights the need for adequate numbers ofphysiotherapists to be available. Physiotherapistsare the key professionals with expertise in theholistic assessment of physical movement,functioning and ability and identifying appropriaterehabilitation. Patients themselves have clearlyidentified a need for a greater diversity ofprofessionals with appropriate skills to care for them.
Noted
Chartered Society of Physiotherapy (CSP)
GL
Given the comment in section 2.3.2.1 above shouldthere not be research recommendation that states“what is an effective intervention to improve healthoutcomes for patients discharged from critical careareas.”
This has been addressed with the researchrecommendation regarding the clinical and costeffectiveness of CCOS compared with usual care oreducational outreach in improving health outcomes forpatients who clinically deteriorate in general hospitalward settings.
Chartered Society of Physiotherapy (CSP)
Gen
The CSP welcomes this guideline as it will be usefulto respiratory care-, critical care- and medical- &surgical - physiotherapists working in a variety ofacute care settings including medical assessmentunits, high dependency and intensive care areasand general wards.
Thank you.
Chelsea & Westminster Acute Trust
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Chephalon Ltd
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n/a
City Hospitals Sunderland NHS Trust
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n/a
Clatterbridge Centre for Oncology NHS Trust
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Clinical Practice Research Unit
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College of Emergency Medicine
Gen
The use of physicologic measures and triggers systems for the detection of ill patients is logical andsupported by the literature and is practiced variablyby different hospitals. My only comment from the Emergency Medicineperspective is that your document recommends thestarting monitoring within the EmergencyDepartment after the decision to admit the patienthas been made. It would be a golden opportunity toinsist that all opportunity to insist that all patientscoming to the Emergency by ambulance for examplehave their physiological observations made onarrival and that a trigger system be in place. Indeeda number of departments have this as standardpractice using MEWS. There is some evidence (Nurs Stand. 2002 May 8-14;16(34):33-7. Physiological observations ofpatients admitted from A&E. Alcock K, Clancy M,Crouch R.) of the poor recording of physiologicalobservations within Emergency Departments and adocument such as yours could be a means to set astandard. It would make sense that the same logicthat indicates that monitoring is of use for in patientsis extended to Emergency Department patients ontheir arrival.
We reviewed the evidence on use of TTS in the ED and the view of the GDG was that it was appropriate torestrict TTS use to this subset of ED patients. It is notappropriate to submit all 'walking wounded' and minorillness attendees to routine physiological monitoring.
Commission for Social Care Inspection
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n/a
Connecting for Health
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n/a
ConvaTec
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n/a
Cornwall & Isles of Scilly PCT
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n/a
Department of Health
GL
1.4.1Firstpara:Definitionof Levelsof Care -Level 3
In our view, the definition as given for level 3 care inthe penultimate paragraph is incorrect. The wordingin the Guidelines reflect the original definitions givenon 2000 but these have subsequently beenamended. Would you please consider amending thedefinition to read:-
Level 3
- patients needing monitoring and
support for two or more organ systems
one
of
which may be basic
or
advanced respiratory
support.
This has been addressed in the revised version.
more challenging.
East Kent Hospitals NHS Trust
GL
Surprised that urine measurement not included as acore parameter as it would seem highly likely thatany patient demonstrating physiologicalabnormalities would have a catheter insitu or at thevery least good fluid balance management. It is ourexperience that the development of pre renal failureis a significant risk in this group of patients. Also surprised MAP is not included as this is awelcome addition to the management of poorlypatients especially those with sepsis.
We have revised the review of the evidence andevidence to recommendations section 1.1.5 to makethe basis for exclusion of urine output clear.
East Kent Hospitals NHS Trust
GL
Strongly agree that staff working with acutely illpatients should have necessary competencies forcaring for this group of patients. Must acknowledgethat the reduction in acute hospitals beds has led tomore sick patients being nursed within ward areas.The impact of this is that ward based teams bothnursing and medicine requires further critical caretraining.
Thank you.
East Kent Hospitals NHS Trust
GL
Disappointed that no firm recommendations madefor service delivery re response strategy. Appreciatelack of evidence for individual response services atpresent but evidence would suggest that a robustTrust response is required i.e. teaching, follow-up,response strategy; rehabilitation of critically illpatients is a package of care that would surely bebest delivered by a team approach.
We provide a clear review and summary of theavailable evidence relating to the effectiveness andcost-effectiveness of response strategies (includingCCOS). In the view of the GDG the evidence availableleads to the conclusion that no specific serviceconfiguration can be recommended as a preferredresponse strategy for individuals identified as having adeteriorating clinical condition. It is outside the scope ofthis work to deal with rehabilitation post CCA discharge
East Kent Hospitals NHS Trust
GL
Regarding the needs of discharged ITU patientswould like to see strategies for improvedcommunication links between all members of theMDT who are involved with acutely ill patients. Poorcommunication appears to be the main trigger inmany cases for poor care.
Noted. We would consider the guidelinerecommendations take account of this.
General Chiropractic Council
This organisation has been approached but did notrespond
n/a
Gloucestershire Acute Trust
This organisation has been approached but did notrespond
n/a
Good Hope Hospitals NHS Trust
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n/a
Greater Manchester Critical Care Network
GL
The guidance is generally well accepted bycolleagues within the Network as a pragmatic viewon the best practices available to all medicalpractitioners on the recognition and response topatients with developing acute illness. The relevanceof excellent communication between healthcareprofessionals cannot be over stated and indeed isseen within the Network as the area where carewill/does fail.
Thank you.
Greater Manchester Critical Care Network
GL
The Care pathway makes very clear the process for recognition and response and is welcomed withinthe consultation.
Thank you.
Greater Manchester Critical Care Network
GL
The Network supports the recommendation for theuse of physiological “Track and Trigger” warningsystems and the evidence used to support therecommendations.
Thank you.
Greater Manchester Critical Care Network
GL
It is recognised that the consultation is essentially forthe measurement of non invasive physiologicalparameters, but we would welcome the inclusion ofspecific markers for patients with possible SevereSepsis/ Septic shock eg the measurement andrecording of Serum lactate.
Recommendation 6 (1.3.2.6) does mention the role ofspecific markers in specific clinical circumstances
Greater Manchester Critical Care Network
GL
There is a view that oxygen saturation, as aparameter, should not be included in thephysiological track and trigger system. It is felt that the oxygen saturation parameter canoften lead to false reassurances Patients still may have tissue hypoxia in thepresence of an acceptable oxygen saturationrecording and may have inadequate ventilation,again with an acceptable oxygen saturationrecording if the patient is on oxygen. Oxygen saturation is also dependent on anadequate peripheral perfusion and is thereforeconsidered much less reliable than the otherphysiological observations suggested for scoringsystems
In the review of TTS we do address the question ofwhat TTS should be used, including what physiologicalobservations should be recorded. The GDG used theinformation in this review, including the evidence tablesin the appendix, to make recommendations on whatthey considered to be minimum physiologicalobservations that should be undertaken. We haverevised the review of the evidence and evidence torecommendations section 1.1.5 to make the basis forinclusion of oxygen saturation and exclusion of urineoutput clear. In the evidence review we refer to theCuthbertson 2007 paper and the Duckit 2007 (in press)which show the importance of O2 saturation, with a cutpoint of 95%, as an important early predictor of acutedeterioration in both medical and surgical patients.
Greater Manchester Critical Care Network
GL
The use of track and trigger is well supported
by
the Network. Some concern exists on the minimummonitoring frequency of 12 hour and there is a beliefthat this should be at 8 hours.
Stakeholder comments were evenly spread betweenthose supporting 12 hourly monitoring and thosefavouring more frequent monitoring. Therecommendation 1.3.2.3 has been re-worded to state"physiological observations should be monitored atleast every 12 hours". The recommendation also notesthat on occasion it will not be necessary to use TTsystems to monitor certain groups of patients (e.g.,those in receipt of palliative care). It should beemphasised that at this point the patients beingmonitored have not been defined as "acutely ill".
Greater Manchester Critical Care Network
GL
The Network hospitals generally use a multi-parameter TT system and feel that this option is thebest option for use in the acute hospital setting.
It is set out clearly in the evidence statements andevidence to recommendations section why amultiple/aggregate TTS should be recommended asopposed to a single parameter system (1.1.4). Asnoted, SPS - do not allow a patient’s progress to betracked - do not allow a graded response strategy. Inaddition, we received a range of SH comments onwhether a single or multiple/aggregate weighting TTSshould be recommended and the large majority were in
Hampshire PCT
This organisation has been approached but did notrespond
n/a
Health and Safety Executive
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n/a
Health Commission Wales
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n/a
Healthcare Commission
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n/a
Heart of England Acute Trust
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n/a
Heatherwood and Wexham Park Hospitals Trust
GL
This list does not include urinary output. On theother hand oxygen saturation is added. There mightbe evidence that such a list is better. Opinions mightdiffer.
In the review of TTS we do address the question ofwhat TTS should be used, including what physiologicalobservations should be recorded. The GDG used theinformation in this review, including the evidence tablesin the appendix, to make recommendations on whatthey considered to be minimum physiologicalobservations that should be undertaken. We haverevised the review of the evidence and evidence torecommendations section 1.1.5 to make the basis forinclusion of oxygen saturation and exclusion of urineoutput clear. In the evidence review we refer to theCuthbertson 2007 paper and the Duckit 2007 (in press)which show the importance of O2 saturation, with a cutpoint of 95%, as an important early predictor of acutedeterioration in both medical and surgical patients.
Heatherwood and Wexham Park Hospitals Trust
GL
Good idea to call these additional as they are notreadily accessible
Thank you.
Heatherwood and Wexham Park Hospitals Trust
GL
‘clinical emergency’
This should best be
referenced. Who will identify etc.
The GDG did not consider it was possible to offer adetailed definition of types of clinical emergency,although cadiac arrest is now mentioned, as this groupshould be managed differently than the "high risk"group.
Heatherwood and Wexham Park Hospitals Trust
GL
Sensitivity reduces and specificity increases as thenumber of abnormal variables increase.
Is this
correct? Is sensitivity indeed lower in multiplevariable systems? How about Negative predictivevalue?
This is correct.
Heatherwood and Wexham Park Hospitals Trust
Table 1
Current evidence suggested that the system has lowsensitivity, low PPV but high specificity. This couldpotentially cause increased triggers that are notrelated to an adverse event. Does it make sense? Would lower Sensibility notmean higher neg Predictive value
This is incorrect. A low sensitivity and high specificitymeans that when the system is triggered it is likely tobe related to abnormal physiology.
Herts & Beds Critical Care Network
GL
Rec 1
The importance of adequate documentation ishighlighted which is crucial in setting managementplan for patients. Staff setting the “right” monitoringplan is dependent on their own ability to identifythose patients whom are at risk and clarify what
Noted. We have addressed this by changing therecommendation to require a "clear written monitoringplan"
measures are then required to ensure that thesepatients are adequately assessed and monitored.Medics and nursing staff do not routinely receive thistype of training as is not provided by Trusts, andalthough our critical care network provides andpromotes these skills/education are not resourced toimpact this deficit at the level required. Across thenetwork we have observed adequate documentationof physiological observations, however with noactions initiated as staff did not have the necessarycompetencies to identify and diagnose the criticalcondition of the patient. Until these skills are evidentin ward nurses and medics at the extent required,surly within Acute trusts it is prudent to access andutilise these staff which already have these skills inensuring the safety of this group of patients who areso clearly at risk.
Herts & Beds Critical Care Network
GL
Rec 3
“Physiological Track and Trigger systems should beused to monitor all adult patients…”
It is known that
deterioration
of
physiological
parameters
identify
patients at risk of clinical deterioration. The purposeof such a system is to reliably identify those at riskso that a response strategy may be initiated. Thesystem is useless unless there is a specific personor team to be notified of the deterioration. We havestrong evidence that response on a local ward basisdoes not work – even though the deterioration maybe
detected.
Often
no
action
is
initiated
or
it
is
ineffective. Appropriate structure must be in place to supportthis.
We agree. Recommendation 1.3.2.10 outlines theresponse strategy.
Herts & Beds Critical Care Network
GL
Rec 11
This recommendation describes a graded-responsestrategy (3 grades of low – medium – high). Thehigh response requires an
“emergency call to a team
with critical care competencies and diagnostic skills”. There should be an
“immediate response”.
The ward
nursing and medical teams do not have these skills.The response required will only be guaranteed by adedicated team whom have the skills and are ablealso to maintain this competence, to ensure the saferetrieval and/or start of the necessary therapies.
Noted.
Herts & Beds Critical Care Network
GL
Rec 15
“No
specific
service
configuration
can
be
recommended as a preferred response strategy forindividuals
identified
as
having
a
deteriorating
clinical condition”
- i.e. we have to tailor our system
to our own patient mix/skill mix situation.
It is clear
that this framework leaves the door wide open forpatients to fall through the net as are not supported
We provide a clear review and summary of theavailable evidence relating to the effectiveness andcost-effectiveness of response strategies (includingCCOS). In the view of the GDG the evidence availableleads to the conclusion that no specific serviceconfiguration can be recommended as a preferredresponse strategy for individuals identified as having a
Huntleigh Healthcare
This organisation has been approached but did notrespond
n/a
ICUsteps
GL
Recommendation 3: We understand that 12 hourlyis an absolute minimum for observations but areconcerned some trusts may interpret the guidelineas a green light to reduce the frequency of obs tothis level.
Noted. This issue is outside the scope of the guideline.
ICUsteps
GL
Recommendation 8: Should be offered is not strongenough. We understand this cannot be mandatory,this at least ‘MUST be offered’
We have reworded to "should be provided", which isconsistent with NICE style guidance.
ICUsteps
GL
Recommendation10. Does the phrase ‘informed bypatient case mix’ mean that in busier hospitalspatients will have to be more sick to trigger? Thiswould be unacceptable.
We have reworded this recommendation to make itclear that the threshold set at local level shouldoptimise sensitivity and specificity.
ICUsteps
GL
Recommendation 16. When patients are dischargedbetween 22:00 and 7:00 is this logged and reportedand are additional steps taken to ensure the patientreceives the necessary additional attention on theward?
We have reworded this recommendation to make itclear that such an event should be logged as anadverse incident.
ICUsteps
GL
Recommendation 17: What procedures are going tobe implemented to ensure that the agreed treatmentplan is acted upon and followed through?
This will be taken up by those implementing theguideline, including the NICE implementation team.
ICUsteps
GL
Recommendation 17. If possible the patient shouldbe Involved in the handover process to giveconfidence that they are being transferred to theward in a controlled manner from one team toanother and be reassured that the receiving teamhas been fully briefed on their treatment history andongoing requirements.
This is covered in this and the accompanyingrecommendation.
ICUsteps
GL
It is not appropriate for the monitoring level of apatient just returned to the ward from a critical carearea to be the same as that of a patient showing nophysiological abnormalities. Patients returning tothe ward from critical care should be, by default,monitored more frequently until the staff can beconfident that their condition is improving at whichtime the monitoring frequency could be reduced.
This is made clear in the care pathway
Institute of biomedical Science
This organisation has been approached but did notrespond
n/a
Intensive Care National Audit & Research Centre (ICNARC)
This organisation has been approached but did notrespond
n/a
James Whale Fund for Kidney Cancer
This organisation has been approached but did notrespond
n/a
Kent & Sussex Hospital
This organisation has been approached but did notrespond
n/a
Kent & Medway Critical Care Network
GL
2.1.3.2/3 Rec 2 & 3
The recommendations around physiologicalsurveillance are welcome. Concerns have been expressed around specifying aminimum 12 hourly standard for all patients in acutesettings – this is thought to be too sensitive. Theevidence regarding frequency of observation and
Noted. We have revised recommendation 3 (1.3.2.3) tomake it clear when TT systems may not be necessary.
also the sensitivity of vital signs is equivocal. While observations can benefit patients, patientsalso need rest, and over-observation can both be detrimental to thisaspect of care, and consume nurses' time. There is a particular concernabout the suggestion of 12hrly observations beingthe minimum frequency. Rituals of observation timesmay need to change and some patients in acutehospitals still do not need observations thatfrequently. Consideration needs to be made with regard to thebalance of facilitating sleep and monitoring vitalsigns. It is a belief of some of those commentingthat generally the most important task of nightnursing is to facilitate patients' sleep. The whole setof issues surrounding sensory balance, stressresponses etc that if upset can cause not onlypsychological distress, but all the detrimental effectsof psychosis and stress responses. Many studieshave shown that both short and long-term survival ismarkedly reduced following delirium etc. There is the question of what to observe. Thedocuments has a suggested list which, although by-and-largereasonable, has a few aspects which could be problematic. In particular,thinking especially of patients in shock, measuring the systolic bloodpressure will not always indicate problems. If patients have very wide pulse pressures, severeshock might merely reduce their systolic BP to"normal" parameters. MAP needs to be included, but a lessideal compromise could be diastolic BP. MAP is easilyrecorded from electronic vital sign devices.Temperature - core or oral equivalent should bestated. The importance of accurate fluid balance recordingsand in particular urine output as overall assessmentof acutely unwell patients was thought to be animportant parameter not cited for a chosen scoringsystem. There are pros and cons whether tomeasure as ml/kg or by absolute volumes. Theformer individualises to the patient, but the latter iseasier for staff, and so more likely to be monitored
managing sick patients. What about post registrationeducation? ALERT courses (or equivalent) andward based high dependency courses they all needto be precisely mentioned as in today’s current NHSdeficits, these courses are being scrapped or notgiven priority and the document needs to have morespecifics regarding what education for both pre &post reg. Generally there is much to welcome in thisdocument, and it gives much useful and sensibleguidance. There is a strong welcome identifyingneed for education.
Kent & Medway Critical Care Network
GL
No discharge of patients between 22.00 and 07.00.Ideally, this is wise, but in the real world of lack of beds, includingin ICUs, discharges between these times aresometimes necessary. If this is prevented, and bedcapacity is not increased, the inevitable result will bepeople who need ICU dying because a wardablepatient is not allowed to be discharged from ICU.Sadly there may be a perverse incentive for wards torefuse a transfer on grounds of time by delaying theprocess. The document does not take into account the role ofoutreach for these patients, where services are alsoout of hours. Neither does it take into account thepositive impact Hospital at Night has had on patientsafety. However, in general, the consensus is thatthis is a good recommendation, albeit requiring aflexible approach to ensure it really benefits patients.
We have reworded this recommendation (1.3.2.14) toensure that it refers to fact decision to transfer hasbeen made and that night transfer "should be avoidedwhenever possible, and should be documented as anadverse incident if it occurs"
Kent & Medway Critical Care Network
Gen
Some people commenting were disappointed withthis "fast track" guidance, expecting more meatbehind it. It was not felt to be particularly dynamicwith some of the recommendations. This provides a good meta- analysis of outreach,track & trigger systems etc. and shows us again thatoutreach evidence is equivocal in the research (eventhough people feel it makes a big difference). The fact that the NICE technical guidance usesRCTs as the gold standard for evaluating evidencecan limit valuable evidence generated by different,yet perhaps more appropriate methodologies asbeing less valuable. The real problem here is thatmany methodologies accepted for this guidance andin the main so far used as evidence, do not truly
Noted.
reflect the dynamic and complex processes thatoccur in the clinical setting and affect decision-making, and subsequent outcomes for patients. There are concerns about the wording that there isno evidence that Critical Care Outreach is cost-effective. Of course, inabsolute terms this is true, but as this document will be read byadministrators seeking to trim hospital services further, this wordingis begging to be misinterpreted as "Critical Care Outreach is not cost-effective" and so should be scrapped. There was adisappointment that there were no real statements ofanalysis that outreach is difficult to measure and thatoutreach teams enhance care via other methodseven if its not necessarily related to patient survival. Recruiting outreach teams from ICU or A&E teamsmakes ideal recruiting grounds, but depending howthis is interpreted. We know of some excellentOutreach staff whose clinical backgrounds are fromother areas. Some Trusts include physios onOutreach - would this exclude them? It was also felt that there needs to be moreacknowledgement that more patients will bemanaged in the community so the patient acuity willincrease again on the wards and this needs to beaddressed with staffing and education to reflect this.
Lancashire Teaching Hospitals Acute Trust
Gen
Document very repetitive
The final version will be the subject of professionalediting. There will be a Quick Reference Guide.
Lancashire Teaching Hospitals Acute Trust
GL
2.1.3 Rec 2 or 7
Should a reference be made to monitoring a painscore as well as the other vital signs parameters?
The GDG agrees and this has been added torecommendation 6 (1.3.2.6)
Lancashire Teaching Hospitals Acute Trust
GL
2.1.6 Rec 2 or 7
Should a reference be made to monitoring a painscore as well as the other vital signs parameters?
Pain score has been added to recommendation 6(1.3.2.6)
Lancashire Teaching Hospitals Acute Trust
GL
2.1.7Rec 7
There is no mention of fluid balance monitoring(input as well as output - fluid loss other that justurine output should always be monitored in a patientat risk of deterioration)
We have revised the review of the evidence andevidence to recommendations section 1.1.5 to makethe basis for inclusion of oxygen saturation andexclusion of urine output clear. We refer to theCuthbertson 2007 paper which shows the importanceof O2 saturation as an important early predictor of needfor ITU admission in HDU surgical patients. Fluidbalance is not a TTS parameter.
