Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU

Kimia Honarmand, MD; Frank Sebat, MD, FCCM; Randy S. Wax, MD, MEd, FRCPC, FCCM

Published: 1/5/2024

Honarmand K, Wax RS, Penoyer D, et al. Society of Critical Care Medicine guidelines on recognizing and responding to clinical deterioration outside the ICU: 2023. Crit Care Med. 2024 Feb;52(2):314-330.

Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU

Citation: Honarmand K, Wax RS, Penoyer D, et al. Society of Critical Care Medicine guidelines on recognizing and responding to clinical deterioration outside the ICU: 2023. Crit Care Med. 2024 Feb;52(2):314-330.

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RATIONALE: Clinical deterioration of patients hospitalized outside the intensive care unit (ICU) is a source of potentially reversible morbidity and mortality. To address this issue, some acute care hospitals have implemented systems aimed at detecting and responding to such patients.

OBJECTIVES: To provide evidence-based recommendations for hospital clinicians and administrators to optimize recognition and response to clinical deterioration in non-ICU patients

PANEL DESIGN: The 25-member panel included representatives from medicine, nursing, respiratory therapy, pharmacy, patient/family partners, and clinician-methodologists with expertise in developing evidence-based clinical practice guidelines.

METHODS: The panel generated actionable questions using the population, intervention, comparison, outcome (PICO) format and performed a systematic review of the literature to identify and synthesize the best available evidence. The panel used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to determine certainty in the evidence and to formulate recommendations and good practice statements.

RESULTS: The panel issued ten statements on recognizing and responding to non-ICU patients with critical illness. Healthcare personnel and institutions should ensure that all vital sign acquisition is timely and accurate. We make no recommendation on the use of continuous vital sign monitoring among unselected patients. We suggest focused education for bedside clinicians on signs of clinical deterioration, and we also suggest that patient, family, and care partner concerns be included in decisions to obtain additional opinions and help (both conditional recommendations). We recommend hospital-wide deployment of a rapid response team (RRT) or medical emergency team (MET) with explicit activation criteria (strong recommendation). We make no recommendation about RRT/MET professional composition or inclusion of palliative care members on the responding team but suggest that the skill set of responders should include eliciting patients’ goals of care (conditional recommendation). Finally, quality improvement processes should be part of a rapid response system (RRS).

CONCLUSIONS: The panel provided guidance to inform clinicians and administrators on effective processes to improve the care of patients at risk for developing critical illness outside the ICU.

KEYWORDS: clinical deterioration; guidelines; Grading of Recommendations Assessment, Development, and Evaluation; medical emergency teams; rapid response system

Guideline Type: Clinical

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Ward staff caring for hospitalized patients should strive to acquire a complete and accurate set of vital signs when ordered and when there is additional cause for concern and to escalate the reporting of significant abnormalities to the appropriate clinicians in an urgent manner.

Vital sign measurement Vital signs

We make no recommendation regarding the routine use of continuous vital sign monitoring to recognize early clinical deterioration in unselected non-ICU patients.

Vital sign monitoring Vital signs

We suggest focused education of direct-care non-ICU hospital clinicians on recognizing early clinical deterioration.
Quality of evidence: Low

Focused education Conditional Recognizing deterioration

Patients, families, and care partners of hospitalized patients are able to recognize subtle differences in clinical status that may signify deterioration and should be empowered to alert appropriate personnel, including the RRS.

Early warning system Good practice statement Rapid response

We suggest that patient, family, and care partner concerns be incorporated into hospital early warning systems.
Quality of evidence: Low

Early warning system Conditional Early warning systems

We recommend hospital-wide deployment of an RRS(e.g., RRT/MET) for non-ICU patients that includes explicit activation criteria for obtaining help from a designated response team.

Explicit activation criteria Insufficient evidence RRS

We make no recommendation regarding (1) whether an RRT/MET should be led by a prescribing clinician versus a nonprescribing clinician and (2) whether an RRT/MET should be led by a physician as compared to another clinician.

Rapid response team RRS

We make no recommendation about involvement of palliative care trained personnel as part of an RRT/MET.

Palliative care Palliative care

We suggest ensuring that responding clinicians have expertise on eliciting patients’ goals of care and establishing treatment plans that best reflect their wishes and prognoses.
Quality of evidence: Low

Palliative care Conditional Treatment plans

A process for quality improvement should be part of an RRS.

RRS quality improvement RRS quality improvement

MET = medical emergency team, RRS = rapid response system, RRT = rapid response team.

Kimia Honarmand, MD

Kimia Honarmand, MD, is an intensive care physician and clinical epidemiologist at Mackenzie Health in Toronto, Ontario, Canada. She served as the lead methodologists for the Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU.

Frank Sebat, MD, FCCM

Frank Sebat, MD, FCCM, is director of Kritikus Foundation and internal medicine faculty of the Family Practice Program at Mercy Medical Center in Redding, California, USA. He served as cochair of the Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU.

Randy S. Wax, MD, MEd, FRCPC, FCCM

Randy S. Wax, MD, MEd, FRCPC, FCCM, is regional director and an associate professor at Queen’s University in Oshawa, Ontario, Canda. He served as cochair of the Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU.

A complete list of the guidelines authors and contributors is available within the published manuscript.