Introduction
In the current days, the characteristics and needs of the patients in Australia and the rest of the world keep changing. The hospitals have been receiving an increased number of patients with different ailments and sometimes they get more ill during their stay in the health facility. The warning sighs always show on a patient before the adverse events such as unexpected deaths, admission to the ICUs or even cardiac arrests. It has been noted that, these warning signs are sometimes not identified, hence not acted upon (Adam, Odell, & Welch, 2010).
This study is meant to discuss the case of Mrs. Jones, a 72 year old lady who has been admitted in the ward with increasing confusion and decreasing mobility. Her recent history suggests that she has had Urinary Tract Infection, and she usually has a GCS of 15. Her normal blood pressure always ranges from 140 to 150. During the primary assessment, it is noted that she is not in danger and she opens her eyes when her name is called. She is able to talk and her airway is patent. Her accessory muscle use is increases; her RR is at 22 and SP02 is at 95% on room air. She is also pale and diaphoretic. Her pulses are weak and thread y with the heart rate of 120 and blood pressure of 95/50, GCS at 13/15, temp at 38.5, BGL at 13.2mmol/L and pain in the lower abdomen.
Nurses role in recognizing and responding to clinical deterioration The nurses also have a role of ensuring that the medication that a specific patient is getting provides the best possible results. Any specific medication taken by a patient has the capability of working effectively if the nurse involved is able to efficiently observe and identify any worsening conditions a patient might be having, in order to take the necessary actions to manage the said conditions (Adam, Odell, & Welch, 2010). If a specific nurse fails to take note of different changes happening to a patient, it may affect the recovery path of the said patient, which in turn alters the overall results of the medication. If there is poor recording of vital signals of the patient changes, failure to report of worsening conditions and not checking on the overall condition of the patient result in the below par care of the patient in a health facility. (Odell Victor & Oliver, 2009). Consequently, a nurse who is devoted in noting and acting early signs of complications greatly helps in reducing the negative results of a patient (Australian Commission on safety and quality in healthcare, 2009). It is worth noting that, if the condition of a specific patient worsens in an unanticipated manner, then the main concern can easily be shown on the story surrounding the danger of the patient that might get to harm him including the overall wellbeing of the said patient (Hanneman & Guliano, 2012). This study involves a rationale; a case scenario of a female patient aged 72 with decreasing mobility and increased confusion. The study will highlight the nurse’s role in identifying and preventing deterioration in such a scenario.
The assessment and intervention of a nurse which are meant to reduce the negative outcome of a specific patient are quite essential. There are several reasons that contribute to worsening of a patient which include improper or wrong diagnosis, administration of wrong medication to a patient and poor of inefficient methods of controlling unforeseen complications. In order for a nurse to undertake these interventions and assessments, they must have efficient clinical reasoning(Adam, Odell, & Welch, 2010).. clinical reasoning is the action or a manner in which a specific nurse integrates, and applies various types of knowledge, to evaluate available evidence, critically think about a specific argument and reflect and analyze the process used to arrive at a specific diagnosis.
In order to avoid unexpected deteriorations, a nurse should always review their knowledge and skills in measuring the psychological parameters of blood pressure, body temperature, oxygen saturation levels in the body, the blood glucose levels and finally the neurological function according to Preston and Flynn (2010), the major indicator of clinical deterioration is the respiratory rate of a patient. Furthermore, the nurses should also recognize the importance of psychological compensatory mechanisms that are automatically activated in the process of clinical deteriorations in order to record and report their findings to the doctor in charge. When a nurse provides accurate assessment using a systematic approach, it greatly helps in detecting deterioration on time hence enabling intervention which helps in stabilizing the condition of the said patient. stabilization of an individual who had a deteriorating health helps in preventing multi- organ failure or sometimes organ dysfunction or further deterioration that may come about, hence reducing mortality rates or the number of patients in the intensive care units patient (Australian Commission on safety and quality in healthcare, 2009).
Monitoring
Accurate monitoring of a patient’s condition is quite essential in preventing deterioration. Vital signs such as blood pressure and heart rate usually reveal deterioration process. If the patient is not monitored effectively, the nurse involved might miss these essential signs therefore causing the patient to deteriorate(Adam, Odell, & Welch, 2010). Early identification of a problem is important in reducing morbidity, mortality rates and even the duration of a stay in the health facility, thus saving on healthcare costs.
The nurse should always use regular measurements to a patient and document the result of a physiological observation. These observations should be taken frequently i.e., every eight hours or as stated in the monitoring plan. The main minimum physiological observations that should always be performed on a patient includes the respiratory rate (RR),the patient’s heart rate, his body temperature including his oxygen saturation, blood pressure and the level of consciousness of a patient.
Recognition
The main importance of a nurse is to recognize the early warning signs in a patient and utilizing the information to better the health of the said individual. The use of Modified Early Warning Score (MEWS) to record the patient observation is an easy to use tool but highly useful in predicting a worse in-hospital result and greatly helps in identifying the patients in danger of clinical adverse effects such as intracranial pressure or cardiac arrest patient (Australian Commission on safety and quality in healthcare, 2009).
If a case of clinical deterioration is not reported or responded to, assessing or recognizing the vital signs is deemed useless. Lack of response may come about due to several reasons such as ineffective communication where a nurse involved may not be clear in communicating the information in a manner to convince the doctor involved of the urgency of the situation., failure by doctors to accept the nurse’s judgment or when the less experienced nurse not being confident enough to report the matter to the senior staff.
Systems to Support Early Identification Of Clinical Deterioration (Track and Trigger)
Based on the relationship between physiological abnormalities and the occurrence of serious adverse events systems have been developed to support the early identification of clinical deterioration. normally these specific systems are referred to as “track and trigger” systems that rely on periodic measurement of vital signs (tracking), with a predetermined calling or response criteria (trigger) when a certain threshold is reached
There are four main types of track and trigger systems used by different facilities which include: * Single parameter system: this is the periodic type of observation where the vital organs are selected and compared with a simple set of criteria with predefined verge, where a response algorithm is activated when any criterion is met. The most common type of single parameter system in Australia is the calling criteria for a medical emergency team (MET). * Multiple parameter system: response algorithm requires more than one criterion to be met, or differs according to the number of criteria met. This is could be a variant on the MET calling criteria that requires abnormalities for two different physiological parameters. * Aggregate scoring system: weighted scores are assigned to physiological values and compared with predefined trigger thresholds. The Modified Early Warning Score (MEWS) tool is one of the most common scoring system * Combination system: this involves the use of single or multiple parameter systems used in combination with aggregate weighted scoring systems.
For this study, the most effective method to use on Mrs. Jones, which is also mostly used in Australia, is the single parameter system. A chart will be drawn recording all her parameters which includes the heart rate, respiratory rate (RR), blood pressure (BP), consciousness, temperature, urine output and oxygen saturation. The chart will include a cutoff point which is used to trigger immediate response also including the aggregate scoring systems such as the early warning scores.

Display of information
The purpose of the said observation chart is to assist in monitoring the rate of deterioration of Mrs. Jones. Information about physiological, including other measures will also be displayed in a manner that will support early and easy identification of deterioration process.

Physiological measurements and scoring algorithms included in track and trigger systems
There is a large difference in the type and number of physiological measures that are usually included in the track and trigger systems. Though there is a core set of parameters that are mostly used in the majority of the systems , that include pulse rate, BP, RR, temperature, urine output etc ; some systems are usually more complex and involve many parameters which in most cases never get to be measured in the general ward. Such as blood oxygen or carbon dioxide pressure patient (Australian Commission on safety and quality in healthcare, 2009).
There is also difference involving the track and trigger systems in the cut off points that are usually used to trigger a specific response and for aggregate scoring systems which include systems such as the early warning scores, variations in the weighting and measures and scoring algorithms.
Usefulness of the track and trigger systems
A review concerning the track and trigger systems has found out that the performance of most of these systems is quite poor and do not provide evidence of validity, utility or even reliability. The systems were found to contain low sensitivities and positive predictive values and hence would easily miss patients requiring immediate assistance if the said methods are used alone. The said review also suggested that, it is actually possible to increase the sensitivity of the said systems if the trigger thresholds could be increased. With the increase of the trigger threshold, the workload would also increase due to the increased number of patients that would be identified a needing attention. Due to the great difference in the available track and trigger systems, it is sometimes difficult to compare these systems in order to make decisions about the best one to use.
Types of observation charts
There are different kinds of observation charts to be used in such a process which includes: * Colour-coded charts that incorporate a track and trigger system. The different colors in the charts reflect levels of physiological abnormality and are linked to weighted scores in aggregate scoring systems, or specific triggers in single or multiple parameter systems. * Charts that incorporate a track and trigger system without the using the colors. The charts use shading or colored lines to indicate when there is physiological abnormality and a trigger is required. * Charts that do not incorporate a track and trigger system. While these charts sometimes indicate normal values, they do not highlight physiological abnormalities or prompt a trigger if an abnormality is observed.
These charts generally use graphical recording (ie. use symbols) for core vital signs such as pulse, temperature and blood pressure. Some also use this form of recording for other parameters such as respiratory rate and oxygen saturation. For other charts the numerical values of these and other parameters are recorded.
The use of colour-coded and other charts incorporating track and trigger systems appear to be increasing in Australia. While there is some limited evidence about the best design of observation charts to identify patients at risk, anecdotal information suggests that design is largely based on tradition and consensus. There have been no published evaluations regarding the effectiveness of different types of observation chart design in identifying patients who are deteriorating. As part of their Between the Flags project, the Clinical Excellence Commission recommended the use of a specifically designed observation chart as a track and trigger system that met certain minimum standards. In this study, the color coded chart will be used to monitor Mrs. Jones health. This is due to its large and wide use in Australia, and also because of the fact that they are most suitable to be used with the single parameter system, which is being used in this essay.
Display of information and use of observation charts to identify clinical deterioration
In Australia, an intervention at The Canberra Hospital that included the introduction of a new observation chart linked to a track and trigger system, as well a comprehensive education program found improved recording of observations, a decrease in admissions of patients to intensive care and improved hospital outcomes.

Barriers to Escalation In order to reduce instances of escalation, the minimum observation frequency may be varied purely based on variations to the patients’ clinical circumstances. Depending on the patients’ assessment, the least observation frequency of every eight hours should be: * Reduced with the express approval of the medical officer in charge after consultation with the attending medical officer. Such patients that require a reduce frequency in observation include the patients that are awaiting permanent residential care as well as permanent aged care residents * Increased based on expert clinical judgment of the patient’s condition
At a bare minimum, observations must be conducted at least: * Every day in cases of sub acute adult patients * On a monthly basis for aged care residents that stay in a residential care facility for the aged.
The changes in the frequency of the observations have to be clearly documented on the facility’s monitoring plan as well as in the patient’s general medical record. Newborns and infants that are not seen to be at any risk will have their heart rate, respiratory rate and temperature attended to every hour for the next three hours. If their conditions remain normal or stable, the attending will cease. The facility’s clinicians may put in place additional observations like fluid balance and pain that will also be documented on the general monitoring plan.

Escalation Guidelines and Protocol Every facility should have such a protocol that clearly outlines what should take place in cases of abnormal physiological parameters. These have to include time frames by which the patients should be attended to or reviewed.
The protocol should: * Authorize the clinicians to increase care until they are personally satisfied that the response made has been appropriate. In the event that the delegated clinical staff is not able to appropriately respond to the clinical review request, the clinician has the option of escalating it to the next level of escalation. * The protocol has to be specifically tailored to the hospital’s characteristics i.e. role, size, available resources, location and any future potential need for transfer to another health facility. * It should highlight to include the worried criterion that allows all clinicians in the facility to escalate care giving in the absence of all other abnormal physiological measurements * The concerns of the family and patients have to be taken into consideration. The health facilities should have a process by which the family members or the patients themselves can request a clinical review in cases whereby they raise their concerns. * It should include the considerations of the wishes and needs of the patients * These protocols should be widely distributed to increase their accessibility. They should also be included in the education materials for new staff or interns at the facility.
These escalation protocols have to contain: * Physiological parameters that can be termed as abnormal * The appropriate response for any specific abnormal cumulative score or physiological parameters * How to escalate the patient’s care * The personnel that are responsible for escalating the patient’s care * The staff members that will be assigned the primary responsibility for the patient’s care * It has to expressly state the other party or parties that may be contacted when the patient’s care is escalated * The timeframe has to be specified in which the needed care response has to be provided * Any backup options should be outlined in the event the primary response is not available.
The Organizational requirements
Rapid response calls The clinicians that are tasked with the provision of emergency assistance should use the Medical Response call as an ideal educational opportunity for the students and staff members. The clinicians that are providing the required emergency assistance have to provide feedback to the attending medical officer and hi team on the outcome of the call. This may include information that is documented in the individual’s medical record.
Rapid response system This system has to be needs to be appropriate to the role and staffing organization, and the size of the health facility. At various remote sites, this system may be composed of a midwife/nurse that is accredited in advanced life support, general practitioner or a local ambulance service provider. This system has to collect and review the following statistics; rate of deaths; unexpected mortality, unplanned admissions into the Intensive care unit e.t.c.
Conclusion
This study has displayed the facts base and existing resources that are meant support the nurses in contributing to safer care of acutely ill patients. It has realized that, in order to assist precise detection deterioration, nurses working in severe care must recognize the significance of observations and early warning systems in the detection of patients at risk of unfavorable events, and ensure patients are evaluated using a sound comprehension of physiological compensatory mechanisms. It was found that communication tools help nurses when calling for senior assistance and the implementation of a standard tool within acute hospital settings could help to prevent harm from deterioration.
References
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