Early warning signs of patient deterioration8 | Late warning signs of patient deterioration9 |
Partial airway obstruction (excluding snoring) | Airway obstruction or stridor |
SpO2 90–95% | Sp02 < 90% |
Respiratory rate 5–9 bpm or 30–40 bpm | Respiratory rate < 5 bpm or > 40 bpm |
Pulse rate 40–50 or 120–140 | Pulse rate < 40 or > 140 |
Systolic BP 80–100 mmHg or 180–240 mmHg | Systolic BP < 80 or > 240 mmHg |
Urine output < 200 mL over eight hours | Urine output < 200 mL in 24 hours or anuria |
Greater than expected drainage fluid loss | Excess blood loss not controlled by ward staff |
A drop in GCS of 2 points or GCS < 12 or any seizure | Unresponsive to verbal command or GCS < 8 |
ABGs Pa02 50–60, PCO2 50–60, pH 7.2–7.3, BE –5 to –8 mmol/L | ABGs Pa02 < 50, PCO2 > 60, pH < 7.2, BE < –7 |
BSL 1–3 mmol/L | BSL < 1 mmol/L |
Poor peripheral circulation | |
New or uncontrolled pain (including chest pain) |
Used with permission from: Clinical Excellence Commission - Between the Flags
The ACQSHC National Consensus Statement: Essential elements for recognising and responding to clinical deterioration require eight important clinical processes to be in place at all healthcare services:
In managing a deteriorating patient in all health services, the Consensus Statement provides clear guidelines on the development and governance of rapid response systems.