Acute care toolkit 6: The medical patient at risk

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All patients admitted to an acute medical unit (AMU) should have their physiological status defined by a validated track- and-trigger tool as part of their reception to the unit. This facilitates the prompt recognition of a subgroup of more severely ill patients needing particular attention.

Key recommendations

  1. All patients should have a National Early Warning Score (NEWS) on admission and as part of every reassessment.
  2. Systems must be in place to ensure timely and appropriate responses to NEWS.
  3. NEWS >5 should trigger an assessment of ceilings of care and Do Not Attempt Cardiopulmonary Ressucitation (DNACPR) status.
  4. Red flag scenarios should be considered at each assessment.
  5. NEWS should be used as an aid to clinical assessment but not as a substitute for competent clinical judgement.
  6. Concern about a patient’s clinical condition should always override the calculated score from NEWS when considering the need to escalate the level of care.
  7. Patients must always be managed in areas appropriate to their clinical needs.
  8. No patient should be transferred from the AMU to a ward which is unable to meet their clinical requirements.
  9. All hospitals managing acutely ill medical patients should have adequate provision of level 1 care – enhanced care.
  10. Enhanced care areas, as distinct from HDUs, should be established as part of AMUs and this must be a top priority.
  11. All patients eligible for level 2 care should have access to HDU or ACCU – acute cardiac care unit beds.

The toolkit contains advice and examples of effective responses to the National Early Warning Score (NEWS) trigger system, including advice on resource and staff implications. However it is also important to recognise that there are certain clinical situations which define a patient at high risk. These include clinical red flags, severe sepsis, acute kidney injury and patients at risk of medical complications, where they may not be associated with altered physiology.

The toolkit also discusses the importance of agreed care escalation plans and has advice on appropriate documentation and staffing considerations.