Recognition of the critically ill patient and escalation of therapy Amy Brown Apoorva Ballal Mo Al-Haddad Abstract Critical illness often involves multiple organ failures and is associated with significant morbidity and mortality. In the vast majority of pa- tients, there is a recognizable period of physiological deterioration which heralds the development of organ failure and critical illness. Despite efforts to improve the detection and management of critical illness, signs of deterioration are often missed and decisions to move patients to critical care units are delayed. Standardized ap- proaches which implement an effective ‘chain of response’ are now utilized worldwide. They focus on attempting to reduce the incidence of serious adverse events (SAEs) such as in-hospital cardiac arrest and unplanned intensive care unit (ICU) admission using preventative measures. These systems should include: accurate recording and documentation of vital signs, recognition and interpre- tation of abnormal values, rapid bedside patient assessment by trained teams and appropriate interventions. Early warning systems (EWS) are an important part of this and can help identify patients at risk of deterioration and SAEs. Assessment of the critically ill patient should be undertaken by an appropriately trained clinician and follow a structured ABCDE (airway, breathing, circulation, disability and exposure) format. This facilitates correction of life-threatening prob- lems by priority and provides a standardized approach between pro- fessionals. Lastly, timely support and input from members of the critical care team are vital to ensure optimal outcomes for critically ill patients. Keywords Assessment; critical care outreach services (CCOS); critical illness; early warning systems; medical emergency teams (METs); outcomes; prediction; rapid response system (RRS); signs; track and trigger systems (TTS) Royal College of Anaesthetists CPD Matrix: 2C01, 2C04 Introduction Critical illness carries a significant burden of morbidity and risk of mortality. It can rapidly evolve into multiple organ failure (MOF). Early recognition of at-risk patients and preventative measures are the most effective approaches to managing this patient group, considering that up to 40% of ICU admissions are avoidable. 1 Ineffective management or failure to intervene in a timely fashion can lead to adverse outcomes as the number of organ systems involved increases. 2 Occasionally, the onset of life-threatening illness is acute and catastrophic, but more commonly it is insidious. Early in- dicators of critical illness are often missed by healthcare pro- fessionals. 3 Signs and symptoms can be unreliable, and patients may compensate for abnormal changes in their measured physiological parameters for a long time (Figure 1). Hence, the gradually deteriorating patient on a hospital ward may go un- noticed until severe organ failure is established. The ‘chain of response’ requires accurate recording and documentation of vital signs, recognition and interpretation of abnormal values and appropriate patient assessment and intervention. Systems to standardize the ‘chain of response’ within a hospital are referred to as rapid response systems (RRS). As part of an RRS, the use of early warning scoring systems can highlight subtle physiological derangements (Table 1). An abnormal score should prompt assessment by an appropriately qualified pro- fessional or team. A systematic ABCDE approach should be utilized in the assessment of acutely unwell patients. This standardized rapid bedside approach prioritizes clinical assessment and correction of life-threatening problems of immediate risk to the patient. It also aids communication between professionals by creating a ‘common language’ and reduces the risk of error. Ideally, multidisciplinary input at the bedside should facilitate rapid assessment with concurrent resuscitation and life-saving interventions. The critical care team should be involved in the early recog- nition, review and escalation of management of critically unwell patients throughout the hospital environment. In addition, this team plays an active role in the decision to admit patients to critical care units and supporting patients thereafter. Prompt input from critical care services and efficient transfer to a critical care area, when appropriate, has a favourable effect on patient outcomes. Learning objectives After reading this article, you should be able to: C describe a logical and systematic approach to the assessment of critically ill patients C discuss the clinical importance of early warning scoring systems in the recognition of the critically ill patient and the role of rapid response systems C discuss the importance of timely involvement of the critical care team in making decisions regarding the most appropriate environment to care for acutely unwell patients Amy Brown MBChB is a Clinical Teaching Fellow in Critical Care at the Queen Elizabeth University Hospital in Glasgow, Scotland, UK. Conflicts of interest: none declared. Apoorva Ballal MBChB BSc (Hons) is a Clinical Research Fellow in Critical Care at the Queen Elizabeth University Hospital in Glasgow, Scotland, UK. Conflicts of interest: none declared. Mo Al-Haddad MBChB FRCA FFICM EDIC MSc is a Consultant in Anaesthesia and Intensive Care at the Queen Elizabeth University Hospital in Glasgow, Scotland, UK. Conflicts of interest: none declared. FUNDAMENTAL PRINCIPLES ANAESTHESIA AND INTENSIVE CARE MEDICINE xxx:xxx 1 Ó 2018 Elsevier Ltd. All rights reserved. Please cite this article as: Brown A et al., Recognition of the critically ill patient and escalation of therapy, Anaesthesia and intensive care medicine, https://doi.org/10.1016/j.mpaic.2018.11.011