SIGN 139 • Care of deteriorating patients

Consensus recommendations May 2014

Evidence
Scottish Intercollegiate Guidelines Network

Care of deteriorating patients

Consensus recommendations

May 2014
Care of deteriorating patients

Scottish Intercollegiate Guidelines Network

Gyle Square, 1 South Gyle Crescent
Edinburgh EH12 9EB
www.sign.ac.uk

First published May 2014

ISBN 978 1 909103 26 9

Citation text
Scottish Intercollegiate Guidelines Network (SIGN).
Care of deteriorating patients. Edinburgh: SIGN; 2014.
(SIGN publication no.139). [May 2014]. Available from URL: http://www.sign.ac.uk

SIGN consents to the photocopying of this guideline for the purpose

of implementation in NHSScotland.
 Contents

Contents
1 Introduction.............................................................................................................................................................1
1.1 The need for guidance.................................................................................................................................................................1
1.2 Remit..................................................................................................................................................................................................1
1.3 Statement of intent.......................................................................................................................................................................1
1.4 Review and updating...................................................................................................................................................................1
2 Recommendations..................................................................................................................................................2
2.1 Observation.....................................................................................................................................................................................2
2.2 National Early Warning Score....................................................................................................................................................2
2.3 Sepsis.................................................................................................................................................................................................3
2.4 Limited reversibility......................................................................................................................................................................3
2.5 Graded response............................................................................................................................................................................3
2.5 Communication.............................................................................................................................................................................4
2.6 Data collection................................................................................................................................................................................4
3 Implementing the recommendations.................................................................................................................5
3.1 Implementation strategy............................................................................................................................................................5
3.2 Resource implications of recommendations.......................................................................................................................5
3.3 Auditing current practice ..........................................................................................................................................................5
4 The consensus methodology................................................................................................................................6
4.1 The Delphi process........................................................................................................................................................................6
4.2 The consensus group...................................................................................................................................................................7
4.3 Acknowledgements......................................................................................................................................................................8
4.4 Editorial review...............................................................................................................................................................................8
Abbreviations.......................................................................................................................................................................9
Annexes.................................................................................................................................................................................10
References............................................................................................................................................................................15
Care of deteriorating patients

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 1 • Introduction

1 Introduction
1.1 THE NEED FOR GUIDANCE
The Scottish Patient Safety Programme (SPSP) is co-ordinated by Healthcare Improvement Scotland. Over
the last five years the SPSP has supported improved processes of care, including recognition of deterioration
in patients, by implementation of Early Warning Score (EWS) systems.
In June 2012, the Cabinet Secretary for Health and Wellbeing set new aims for acute adult health care in
NHSScotland including a 20% reduction in Hospital Standardised Mortality Ratios (HSMR) and that 95%
of patients should be free from avoidable harm. While considerable gains have been made in improved
processes to recognise and deliver appropriate treatment to deteriorating patients, there is much work to
be done to implement reliable systems across Scotland.
The Scottish Intercollegiate Guidelines Network (SIGN) has developed these consensus recommendations
to underpin a national approach to care of adult deteriorating patients. They set out the essential elements
for prompt and reliable recognition of and appropriate response to deteriorating patients in Scotland’s acute
healthcare settings.

1.2 REMIT

1.2.1 OVERALL OBJECTIVES

This document provides consensus recommendations based on expert opinion for best practice in the
management of deteriorating adult patients. The recommendations are intended to guide NHSScotland
boards, hospitals and health professionals in the development of local systems that will deliver reliable
recognition and response to the deteriorating patients in their care.

1.2.2 POTENTIAL USERS

This document will be of interest to healthcare professionals involved in the care of deteriorating adult
patients, their families and service commissioners.

1.3 STATEMENT OF INTENT

This statement is intended to describe an appropriate level of response to any adult patient who suffers
physiological deterioration in an acute hospital setting. It is not based on evidence but on the consensus
opinion of a clinical expert group and is not intended to be construed or to serve as a standard of care.
Standards of care are determined on the basis of all clinical data available for an individual case and are
subject to change as scientific knowledge and technology advance and patterns of care evolve. Adherence
to recommendations will not ensure a successful outcome in every case, nor should they be construed as
including all proper methods of care or excluding other acceptable methods of care aimed at the same
results. The ultimate judgement must be made by the appropriate healthcare professional(s) responsible
for clinical decisions regarding a particular clinical procedure or treatment plan. This judgement should only
be arrived at following discussion of the options with the patient, covering the diagnostic and treatment
choices available. It is advised, however, that significant departures from the national consensus statement
or any local guidelines derived from it should be fully documented in the patient’s case notes at the time
the relevant decision is taken.

1.4 REVIEW AND UPDATING

These recommendations were issued in 2014 and will be considered for review in two years. Any updates to
the recommendations in the interim period will be noted on the SIGN website: www.sign.ac.uk

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Care of deteriorating patients

2 Recommendations
In order to support a national approach to the care of deteriorating adult patients across Scotland a group
of clinical experts (see section 4.2) took part in a modified Delphi process (see section 4.1) to establish good
-practice recommendations. These recommendations should be adopted as an appropriate response
in the care of deteriorating adult patients in an acute hospital setting by NHS boards in Scotland. These
recommendations are based on guidance from the National Institute for Health and Care Excellence
(NICE),1 the Royal College of Physicians2 and the South Australian Government.3 The recommendations do
not appear in order of priority.

2.1 OBSERVATION
1 Physiological observations should be recorded at the time of admission or initial assessment.
2  clear written monitoring plan should specify which physiological observations should be taken
A
and how often.
3  bservations should be performed by staff trained to undertake these procedures and who understand
O
their clinical relevance.
4  egular assessment of staff taking observations should be undertaken, to defined competency
R
standards.
5 As a minimum, observations should include:
yy heart rate
yy respiratory rate
yy blood pressure
yy level of consciousness
yy oxygen saturation including percentage/flow rate of administered oxygen therapy
yy temperature
yy state of hydration (for patients with medium or high NEWS score).

6 In specific situations additional monitoring will be required, eg biochemical analysis, (such as blood
glucose or lactate) or pain assessment.

2.2 NATIONAL EARLY WARNING SCORE

7 Acute hospitals should implement the National Early Warning Score (NEWS).2
8  EWS should be used to monitor all adult patients in acute hospital settings. Maternity specific EWS
N
should be used for pregnant women.
9  EWS should be monitored at least every four hours after admission to hospital unless a decision is
N
made and documented at a senior level to decrease the frequency of monitoring for an individual
patient.
10 The frequency of monitoring should increase if abnormal physiology is detected.
11  protocol which defines increased frequency of observations for patients whose NEWS score triggers
A
action should be implemented and its compliance measured.
12 Any patient whose NEWS score triggers action should be screened for sepsis and delirium.

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 2 • Recommendations

2.3 SEPSIS
13  ll patients who screen positively for sepsis should be started on the Sepsis Six care pathway,4 unless
A
their treatment plan indicates otherwise.
Sepsis Six (within one hour):
yy deliver O2 (94–98% SpO2 or 88–92% in patients with chronic obstructive pulmonary disease)
yy take blood cultures and consider source control
yy give intravenous (IV) antibiotics according to local protocols
yy start IV fluid resuscitation (minimum 500 ml) and reassess
yy check lactate and full blood count
yy commence accurate urine output measurement and consider urinary catheterisation.

2.4 LIMITED REVERSIBILITY

14  process should be in place to identify patients with limited reversibility. Patients identified as
A
deteriorating with limited reversibility should have a written management plan which considers and
includes:
yy key issues
yy anticipated outcomes which acknowledge uncertainty
yy resuscitation status
yy discussions with the multidisciplinary team
yy  iscussion with the patient and family, which may include discussion of uncertain recovery and
d
medical plan, preferred place of care and concerns or wishes
yy standardised and agreed ceilings of care.

2.5 GRADED RESPONSE

15  graded response for patients identified as deteriorating should be agreed, implemented and audited
A
locally.
For example:
Low NEWS score
yy increase the frequency of observations and alert the nurse in charge.

Medium NEWS score

yy respond within 30 minutes
yy make an urgent call to the team with primary medical responsibility for the patient
yy also call the person with core competencies for acute illness.

High NEWS score

yy respond immediately
yy make an emergency call to the team with critical care competencies and diagnostic skills.

16 Patients with a medium or high NEWS score should have:

yy appropriate interventions initiated
yy the response to these interventions assessed at the time of the intervention or at a later time
yy a written management plan that includes location and level of care.

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Care of deteriorating patients

2.5 COMMUNICATION
17 All communication about patients identified as deteriorating should be formalised and include:
yy a daily process for person-centred communication that includes the wishes of the patient and
family
yy a structured handover process which includes all relevant clinical information.

2.6 DATA COLLECTION

18  cute hospitals should collect data on a monthly basis that measures the number and rate of cardiac
A
arrests (with chest compressions and/or defibrillation).
19 Acute hospitals should consider the introduction of electronic track, trigger and alert systems.

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 3 • Implementing the recommendations

3 Implementing the recommendations

3.1 IMPLEMENTATION STRATEGY
Implementation of these consensus recommendations is the responsibility of each NHS board and is an
essential part of clinical governance. Mechanisms should be in place to review care provided against the
recommendations. The reasons for any differences should be assessed and addressed where appropriate.
Local arrangements should then be made to implement the recommendations in individual hospitals, units
and practices.
Implementation of these recommendations will be encouraged and supported by Healthcare Improvement
Scotland. The national implementation strategy for these consensus recommendations includes the Acute
Adult Scottish Patient Safety Programme which will support NHS boards to test and implement processes
to provide a structured response and review for deteriorating patients.

3.2 RESOURCE IMPLICATIONS OF RECOMMENDATIONS

Training: there will be a requirement to ensure adequate training for healthcare workers in the detection of
and response to deteriorating patients, as well as monitoring continuing competency.
Staffing: there will be a requirement to ensure adequate levels of appropriately qualified staff to detect and
respond to deteriorating patients.
National Early Warning Score: implementation of a National Early Warning Score is a desired future state
for acute adult care in NHSScotland.
Electronic track, trigger and alert systems: there are likely to be resource implications in introducing new
electronic systems.

3.3 AUDITING CURRENT PRACTICE

A first step in implementing any new recommendation is to gain an understanding of current clinical practice.
Audit tools designed around recommendations can assist in this process. Audit tools should be comprehensive
but not time consuming to use. Successful implementation and audit of new recommendations requires
good communication between staff and multidisciplinary team working.

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Care of deteriorating patients

4 The consensus methodology

4.1 THE DELPHI PROCESS
SIGN is a collaborative network of clinicians, other healthcare professionals and patient organisations and
is part of Healthcare Improvement Scotland. These consensus recommendations were developed by a
multidisciplinary group of practicing healthcare professionals using a modified Delphi process. The Delphi
process is a methodology designed to reach a group opinion or consensus without the drawbacks inherent
within a face-to-face group processes. Delphi has been shown to be more accurate than focus groups,
conferences, group discussions and other traditional interactive group processes.5 The modified Delphi
process used was a multistaged survey which fed back group results at each stage in the process. Consensus
was deemed to have been reached when 70% of the group either agreed or disagreed on a question.

4.1.1 PROCESS OVERVIEW

Recruitment SIGN Council and Directors of Nursing consulted for group membership nominations
and volunteers
Proposed group members invited to participate
Declaration of interests obtained from each participant
Phase 1 Questionnaire 1 sent to participants. Views sought on NICE guidelines on acutely ill
(see Annex 1) patients in hospital,1 the National Early Warning System2 and the South Australian
Government’s national consensus statement on deteriorating patients.3
Two week response time
Reminder sent with one week extension
Data collated and fed back to participants
Prepared phase 2 questionnaire
Phase 2 Questionnaire 2 sent asking participants to score each statement on a 5 point Likert
(see Annex 2) scale. Views also sought on related issues.
Three week response time
Reminder sent with one week extension
Data collated and analysed
Consensus reached
Data fed back to participants
Editorial phase Consensus statement and recommandations drafted based on phase 2 outcomes
Circulated to consensus group participants for comment
Ammended based on feedback
Reviewed by SIGN Editorial Group
Recommendations finalised

4.1.2 PARTICIPATION AND RESPONSE RATE

Potential participants were identified by inviting nominations and volunteers from SIGN Council, the Scottish
Executive Nurse Directors group and snowball sampling. To ensure the independence of the responses, group
membership was not disclosed to participants during the Delphi process. Email communications were dealt
with in a way that ensured no group member saw the email address of another group member and written
responses to questionnaires were anonymised when fed back to the group.
Twenty nine participants were invited to take part in the modified Delphi process. Twenty two invitees agreed
to take part, with eighteen responding to the first survey and sixteen responding to the second survey. Two
participants did not respond to either survey.

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 4 • The consensus methodology

It was anticipated that after a scoping stage two or three phases of survey would follow . However, consensus
was reached after only one round of survey after scoping. The results of phase 1 and 2 can be found in
Annexes 1 and 2 respectively.

4.2 THE CONSENSUS GROUP

The consensus group consisted of a representative sample of experts made up of doctors, nurses and other
relevant allied health professionals.
Group membership was anonymous to allow each participant an equal voice and to encourage the broadest
possible opinion.

Dr Daniel Beckett Consultant Acute Physician, NHS Forth Valley

Professor Derek Bell Professor of Acute Medicine, Imperial College, London
Ms Helen Carnochan Advanced Nurse Practitioner, NHS Dumfries and Galloway
Dr Wendy Craig General Surgeon, NHS Grampian
Dr Peter Curry Consultant Anaesthetist, NHS Fife
Mr Eddie Docherty Nurse Consultant, NHS Ayrshire and Arran
Dr Claire Gordon Consultant Acute Physician, NHS Lothian
Dr Ailsa Howie Consultant Acute Physician, NHS Lothian
Dr Rajan Madhok Consultant Rheumatologist, NHS Greater Glasgow and Clyde
Ms Ruth Malcolm Charge Nurse, NHS Highland
Ms Louise McKessock Nurse Manager, NHS Grampian
Mr Robert Morton Advanced Clinical Pharmacist, NHS Tayside
Professor Kevin Rooney Professor of Care Improvement, University of the West of Scotland,
Paisley
Ms Judith Roulston Senior Charge Nurse, Critical Care Transfer Service, NHS Greater
Glasgow and Clyde
Mr Charles Sinclair Associate Director of Nursing, NHS Fife
Mr Mark Smith Night Nurse Practitioner, NHS Highland
Dr Stephen Stott Consultant in Intensive Care and Anaesthesia, NHS Grampian
Ms Helen Stirton Nurse Lead, NHS Greater Glasgow and Clyde
Dr Ivan Tonna Consultant Acute Physician, NHS Grampian
Dr John Wilson Consultant Physician, Vice President of the Royal College of Physicians
of Edinburgh

The membership of the consensus group was confirmed following consultation with the
member organisations of SIGN. All members of the consensus group made declarations of
interest. A register of interests is available in the supporting material section for this guidance at
www.sign.ac.uk
Support and facilitation were provided by the SIGN Executive. All members of the SIGN Executive make
yearly declarations of interest. A register of interests is available on the contacts page of the SIGN website
www.sign.ac.uk

Lesley Forsyth Events Co-ordinator

Karen Graham Patient Involvement Officer
Gemma Hardy Distribution and Office Co-ordinator
Stephen Heller-Murphy Programme Manager
Stuart Neville Publications Designer

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Care of deteriorating patients

4.3 ACKNOWLEDGEMENTS
SIGN is grateful to the following who have contributed to the development of the consensus recommendations.

Ms Alison Hunter Improvement Advisor, Healthcare Improvement Scotland, Glasgow

Dr Wayne Wrathall Clinical Director for Anaesthesia, Dumfries and Galloway Royal
Infirmary

4.4 EDITORIAL REVIEW

As a final quality control check, the guidance is reviewed by an editorial group comprising the relevant
specialty representatives on SIGN Council. The editorial group for this guidance was as follows. All members
of SIGN Council make yearly declarations of interest. A register of interests is available on the SIGN Council
Membership page of the SIGN website www.sign.ac.uk

Professor John Kinsella Chair of SIGN; Co-Editor

Dr Roberta James SIGN Programme Lead; Co-Editor
Dr Sara Twaddle Director of SIGN; Co-Editor

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 Abbreviations

Abbreviations

EWS Early Warning Score

HSMR Hospital Standardised Mortality Ratios
IV intravenous
NEWS National Early Warning Score
NICE National Institute for Health and Care Excellence
SIGN Scottish Intercollegiate Guidelines Network
SPSP Scottish Patient Safety Programme

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Care of deteriorating patients

Annex 1
Phase 1 scoping results

Care of deteriorating patients phase 1 scoping

1. Are the NICE guidelines sufficient for the current Scottish context?
Response percent Response count
Yes 38.9% 7
No 61.1% 11
2. Are the South Australian guidelines sufficient for the current Scottish context?
Response percent Response count
Yes 33.3% 6
No 66.7% 12
3. Is NEWS sufficient in the current Scottish context?
Response percent Response count
Yes 50.0% 9
No 50.0% 9
4. Given your answers above, is a consensus statement adopting one, two or all of the above documents, in whole
or in part, sufficient?
Response percent Response count
Yes 44.4% 8
No 55.6% 10
5. Given your answers above, do we need a new guideline on managing deterioration of acutely ill patients?
Response percent Response count
Yes 61.1% 11
No 28.9% 7
6. If you think we should develop new guidelines for this patient group, what are the gaps in the three existing
documents, taken as a whole, that need to be addressed?
Response count
14

10 |
 Annexes

Annex 2
Phase 2 survey results

Please indicate on the tables below your level of agreement with the following statements:
Neither agree Strongly
Strongly agree Agree Disagree
or disagree disagree
Physiological
observations are
recorded at the time 93.8% (15) 6.3% (1) 0.0% (0) 0.0% (0) 0.0% (0)
of admission or initial
assessment

There is a clear
written monitoring
plan that specifies
50.0% (8) 31.3% (5) 6.3% (1) 6.3% (1) 6.3% (1)
which physiological
observations should be
taken and how often

Observations should
be performed by
staff who have been
trained to undertake 75.0% (12) 12.5% (2) 12.5% (2) 0.0% (0) 0.0% (0)
these procedures and
understand their clinical
significance

Regular assessments
of competency of staff
56.3% (9) 37.5% (6) 0.0% (0) 6.3% (1) 0.0% (0)
taking observations
should be undertaken
As a minimum, observations should include:
Heart rate 93.8% (15) 6.3% (1) 0.0% (0) 0.0% (0) 0.0% (0)
Respiratory rate 87.5% (14) 12.5% (2) 0.0% (0) 0.0% (0) 0.0% (0)
Systolic blood pressure 93.8% (15) 6.3% (1) 0.0% (0) 0.0% (0) 0.0% (0)
Level of consciousness 87.5% (14) 6.3% (1) 0.0% (0) 6.3% (1) 0.0% (0)
Oxygen saturation 87.5% (14) 6.3% (1) 0.0% (0) 6.3% (1) 0.0% (0)
Temperature 87.5% (14) 6.3% (1) 0.0% (0) 6.3% (1) 0.0% (0)
In specific situation, additional monitoring will be required:
Urine output 87.5% (14) 6.3% (1) 0.0% (0) 6.3% (1) 0.0% (0)

Biochemical analysis, eg
81.3% (13) 12.5% (2) 6.3% (1) 0.0% (0) 0.0% (0)
blood glucose or lactate

Pain assessment 56.3% (9) 25.0% (4) 12.5% (2) 6.3% (1) 0.0% (0)

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Care of deteriorating patients

Neither agree Strongly

Strongly agree Agree Disagree
or disagree disagree

Early warning scores

(EWS) should be used to
87.5% (14) 12.5% (2) 0.0% (0) 0.0% (0) 0.0% (0)
monitor all adult patients
in acute hospital settings

EWS should be
monitored at least every 81.3% (13) 6.3% (1) 0.0% (0) 12.5% (2) 0.0% (0)
12 hours

A decision to monitor a
patient less frequently
that 12 hours should be 68.8% (11) 25.0% (4) 0.0% (0) 6.3% (1) 0.0% (0)
made at a senior level
and documented

The frequency of
monitoring should
93.8% (15) 6.3% (1) 0.0% (0) 0.0% (0) 0.0% (0)
increase if abnormal
physiology is detected

Any patient whose EWS

score triggers action,
56.3% (9) 25.0% (4) 18.8% (3) 0.0% (0) 0.0% (0)
should be screened for
sepsis

All patients who

trigger EWS and screen
positively for sepsis
should be started on the
75.0% (12) 18.8% (3) 0.0% (0) 6.3% (1) 0.0% (0)
Sepsis Six care pathway/
protocol, unless their
treatment plan indicates
otherwise

A protocol which defines

increased frequency of
observations for patients
whose EWS score 75.0% (12) 18.8% (3) 6.3% (1) 0.0% (0) 0.0% (0)
triggers action should
be implemented and its
compliance measured

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 Annexes

Neither agree Strongly

Strongly agree Agree Disagree
or disagree disagree

A process is in place to identify patients with limited reversibility and as such any patient identified as
deteriorating with limited reversibility should have a written management plan which considers and includes:

Key issues 62.5% (10) 37.5% (6) 0.0% (0) 0.0% (0) 0.0% (0)
Anticipated outcomes
which acknowledges 62.5% (10) 37.5% (6) 0.0% (0) 0.0% (0) 0.0% (0)
uncertainty
Resuscitation status 93.8% (15) 6.3% (1) 0.0% (0) 0.0% (0) 0.0% (0)
Discussions with the
50.0% (8) 43.8% (7) 0.0% (0) 0.0% (0) 6.3% (1)
multidisciplinary team

Discussion with the

patient and family
on issues including
uncertain recovery, 62.5% (10) 31.3% (5) 6.3% (1) 0.0% (0) 0.0% (0)
medical plans, preferred
place of care, concerns or
wishes

Standardised and agreed

75.0% (12) 25.0% (4) 0.0% (0) 0.0% (0) 0.0% (0)
ceilings of care

A graded response for patients identified as deteriorating should be agreed, implemented and audited locally:

Low score:
Increase frequency of
observations and alert 62.5% (10) 31.3% (5) 6.3% (1) 0.0% (0) 0.0% (0)
nurse in charge
Medium score:

Response required
80.0% (12) 13.3% (2) 6.7% (1) 0.0% (0) 0.0% (0)
within 30 minutes*

Urgent call to team

with primary medical
73.3% (11) 13.3% (2) 6.7% (1) 6.7% (1) 0.0% (0)
responsibility for
patient*
Simultaneous call
to person with core
37.5% (6) 50.0% (8) 6.3% (1) 6.3% (1) 0.0% (0)
competencies for acute
illness
High score:
Response required
81.3% (13) 12.5% (2) 0.0% (0) 0.0% (0) 0.0% (0)
immediately

Emergency call to
team with critical care
62.5% (10) 25.0% (4) 0.0% (0) 12.5% (2) 0.0% (0)
competencies and
diagnostic skills

*only 15 out of 16 participants answered these two questions

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Care of deteriorating patients

Neither agree Strongly

Strongly agree Agree Disagree
or disagree disagree
Patients with a medium or high score should have:
Appropriate
87.5% (14) 12.5% (2) 0.0% (0) 0.0% (0) 0.0% (0)
interventions initiated

The response to these

93.8% (15) 6.3% (1) 0.0% (0) 0.0% (0) 0.0% (0)
interventions assessed

A written management
plan that includes 93.8% (15) 6.3% (1) 0.0% (0) 0.0% (0) 0.0% (0)
location and level of care

Communication of deteriorating patients is formalised and includes:

A daily process for

person-centred
communication that 56.3% (9) 25.0% (4) 18.8% (3) 0.0% (0) 0.0% (0)
includes the wishes of
the patient and family

A structured handover
process for all
deteriorating patients
87.5% (14) 12.5% (2) 0.0% (0) 0.0% (0) 0.0% (0)
which includes all
relevant clinical
information
Please indicate on the tables below your level of agreement with the following statements:

Acute hospitals have

data that measures
number and rate of
56.3% (9) 31.3% (5) 6.3% (1) 6.3% (1) 0.0% (0)
cardiac arrests (with
chest compressions and/
or artificial ventilation)

Acute hospitals should

implement the National 75.0% (12) 12.5% (2) 6.3% (1) 6.3% (1) 0.0% (0)
Early Warning Score

Acute hospitals should

develop electronic track, 31.3% (5) 56.3% (9) 12.5% (2) 0.0% (0) 0.0% (0)
trigger and alert systems

14 |
 References

References
1. National Institute for Health and Clinical Excellence, Short Clinical Guidelines Technical Team. Acutely
ill patients in hospital: recognition of and response to acute illness in adults in hospital. London: NICE;
2006. (NICE guideline CG50). [cited 17 Apr 2014]. Available from http://guidance.nice.org.uk/CG50/
Guidance
2. Royal College of Physicians. National Early Warning Score (NEWS): Standardising the assessment of
acute illness severity in the NHS. London: RCP; 2012.[cited 17 Apr 2014] Available from http://www.
rcplondon.ac.uk/resources/national-early-warning-score-news
3. Australian Commission on Safety and Quality in Health Care. Safety and Quality Improvement Guide
Standard 9: Recognising and Responding to Clinical Deterioration in Acute Health Care. Sydney:
ACSQHC; 2012. [cited 17 Apr 2014] Available from http://www.safetyandquality.gov.au/wp-content/
uploads/2012/10/Standard9_Oct_2012_WEB.pdf
4. The Sepsis Trust. Survive sepsis: The Sepsis Six. [cited 17 Apr 2014] Available from http://survivesepsis.
org/the-sepsis-six/
5. Keeney S, Hasson F, McKenna H. The Delphi Technique in Nursing and Health Research. Chichester:
John Wiley & Sons; 2011.

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 ISBN 978 1 909103 26 9
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