Team Role in Recognising Deterioration

The acronym DETECT can be used to assist in identifying and managing deteriorating patients and to guide staff as to when to escalate assessment and intervention or activate a rapid response team if available at the health service.9

There are a range of parameters that should be taken into consideration when deciding if escalation of care is required.

Many institutions now advocate for escalation and clinical review even if the only criteria met is that staff are concerned about the patient.

This may be without markedly abnormal observations and no added differential diagnosis.  Further communication may assist in identifying acute changes in the patient’s condition.

The activation of local resources may include contributions from pre-hospital team members such as emergency response personnel, secondment of in-house staff to assist or the recall of off-duty staff. The potentially challenging circumstances of managing a deteriorating patient requires leadership and early planning. It should also include nominating a skilled staff member to supervise and guide assessment and intervention.

Importantly, the lead of the response team should remain, where possible, dedicated to this single role, and not become involved in direct intervention. This may be limited by the need to assist in managing the patient as advanced skills of the leader may be required; however, they should return to the supervisory role as soon as possible to manage overarching supervision, continuously scoping for changes in the patient’s condition and indications for further intervention.  

For health services with limited capacity, communication with ARV contributes to the team assessment and management of a deteriorating trauma patient.
This additional communication with experienced staff may provide the required clinical support to improve patient care and offer staff assurance that the patient is being appropriately managed under difficult circumstances.

The DETECT algorithm (see table below), promotes the use of a systematised process to detect Deterioration, Evaluate, Treat, Escalate and Communicate with your Team. This system promotes a ‘concern, communicate and care for’ approach for these patients to ensure they receive simple, early intervention to reverse deterioration.

DDetect deterioration
•Recognise that you have a problem by gathering information relating to your patient
•Use the ABCDEFG algorithm (look, listen, feel)
•Identify early and late warning signs
Trauma examples
Altered conscious state, note ongoing revealed blood loss, increasing heart rate, falling blood pressure and pallor, decreased urine output, increasing respiratory rate
•Likely causes of deterioration
•Whether your skills and the skills of those around you will meet the patient’s needs
•If and when to call for help
•The urgency of the response
•Continue to constantly re-evaluate
Evolving head injury and changing conscious state where the cause appears obvious but need to exclude concealed haemorrhage and complications of chest trauma compromising ventilation
Consider early communication of any problems identified
•Prioritise interventions using the ABCDEFG algorithm to guide your decision making
•Commence simple treatments such as oxygen, positioning your patient and establishing IV access
•Call for help if you can’t manage
Begin basic life support if required, check oxygen administration, ensure large-bore IV access and administer resuscitation fluids, position patient as needed (for example, left lateral/sit up) check point of care/formal blood tests, prepare equipment for interventions such as intubation
•Be aware of signs of further deterioration, or failure to reverse deterioration
•Know how and who to call for more assistance
•Know when the patient’s clinical management requires advanced skills
Notify the senior doctor/nurse in charge, activate local protocols, re-contact ARV, use internal and/or external resources where capacity exists
CCommunicating in Teams
•Provide leadership where appropriate
•Coordinate activities within the team
•Use the ISBAR algorithm to communicate clearly
•Document clearly the patient’s outcome in the healthcare record
Revise, prepare and communicate the patient’s care plan, assess outcomes of intervention, designate a team leader and other roles to the response team members, consider tele/video conferenced support from ARV

Used with permission from:  Used with permission from: Clinical Excellence Commission - Between the Flags

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The DETECT algorithm, ‘detect deterioration’ uses the ABCDEFG10 format to ensure effective assessment of the patient is undertaken including collecting important information that may indicate the patient is heading down the ‘slippery slope’ and for effectively communicating the patient’s status.

ABCDEFG for deteriorating patients