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558 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

Research vignette, Continued
without LS were examined as predictors of death. Global modified could be expensive in terms of demand with limited benefit, at
early warning scores (GMEWS) were calculated. least in reduction in mortality. So whilst this study further indenti-
fies both early and late signs of deterioration that will allow for
Results
ES with LS, plus LS only, had higher odds ratios than ES alone. Four more refined calling criteria, it does fail to deliver the definitive set
combinations of ES were strongly associated with death: cardiovas- of calling criteria for clinical emergency response systems. Weak-
cular plus respiratory with decrease in urinary output, cardiovascu- nesses include the retrospective nature of the review and the reli-
lar plus respiratory with a decrease in consciousness, respiratory ance on charted records. The original sample is now over 10 years
with decrease in urinary output, and cardiovascular plus respira- old and care practices may have moved on since then. It does
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tory. In other combinations, recordings of SpO 2 90–95%, systolic acknowledge the MERIT study, the only large-scale prospective
blood pressure 80–100 mmHg or decrease in urinary output in turn assessment of the MET system in Australia but does not discuss in
occurring with one or more disturbed blood gas variable were detail why this research failed to show a difference where a MET
associated with death. Compared with admissions whose GMEWS system was in place.
were 0–2, admissions with GMEWS 5–15 were 27.1 times more Of note, parameters in the cardiovascular category most consis-
likely to die while those with GMEWS 3–4 were 6.5 times more tently feature in the combination of signs closely associated with
likely. clinical deterioration. This emphasises both the value and the
Conclusions importance of these measures in defining clinical deterioration in
The results support the inclusion of early signs of a deteriorating patients, and provides a strong message for all clinicians working
clinical condition in sets of call criteria. in acute care as to the risks of ignoring these signs or failing to fully
assess patients on a regular basis. Many other signs not listed spe-
Critique cifically as cardiovascular are not mutually exclusive, with changes
It has long been recognised that vital signs falling out of ‘normal in mentation, urine output and blood pH inextricably linked to
ranges’ are associated with adverse events for patients. This large perfusion of specific organ systems and tissues as a whole. It is also
scale study reviewed the case notes of 3160 patients from five NSW clear that as the patient in shock deteriorates, the chances of suc-
hospitals in late 2000 for early and late physiological signs of clini- cessful intervention and recovery are reduced.
cal deterioration. It is considered a landmark Australian study given The SOCCER study continues to support the value of close, fre-
the magnitude of the review and the rigorous application of cat- quent clinical observation and the linking of signs and symptoms
egories to define patient deterioration. Twenty-six early signs and within the patient’s overall physiologic system that provides the
symptoms and 21 late signs and symptoms were defined prior to astute clinician with numerous indicators of the health or other-
the review that was initially carried out by two ICU trained nurses wise of the cardiovascular system and the impending shock syn-
and then verified by two of the investigators. The participant hos- drome. It also supports less-experienced clinicians in seeking help
pitals were chosen for their representativeness of ‘typical’ acute to interpret the patient’s clinical state and gaining support to avoid
case mix and excluded those with do not resuscitate orders, under deterioration to the point where late signs become an all-too-
14 years of age, day only admissions, non admitted ED patients, obvious message of imminent patient mortality.
deaths in O.R. prior to ward transfer, ICU patients (whilst in ICU) and
specific specialties such as palliative care or psychiatry. The care- Although there are more signs included in the SOCCER study than
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fully selected sites for investigation and exclusion criteria all con- would be available on a standard bedside observation chart,
tributed to ensuring the findings were both representative and research such as this has led to initiatives to standardise observa-
generalisable to the broader Australian and international context. tion charts and highlight appropriate calling criteria and escalation
procedures. Standardisation in this way supports organisations to
Early signs of deterioration included, but were not limited to, SBP
80–100 mmHg, heart rate 40–49 or 121–140 b/min, respiratory rate provide equitable service to patients. In NSW there has been state-
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5–9 or 31–40 b/min, SPO 2 90–95%, altered mentation, GCS 9–11 or wide implementation of the ‘Between the Flags’ program which
fall >2, urine output <200 mL in 8 hrs, amongst others. Likewise, includes a colour-coded chart, escalation procedure and indepth
late signs include cardiac arrest, SBP <80 mmHg, GCS ≤8, PaO 2 <50 online training modules. This program enables clinicians to respond
mmHg, pH <7.2, along with others. An ‘other’ category was appropriately and communicate effectively when patients deterio-
included. rate. The Australian Commission on Safety and Quality in Health-
care has also developed a program to support organisations in
Not surprisingly, early signs, when combined with late signs, were increasing structures for hospital patients to receive comprehen-
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more strongly predictive than early signs alone of risk of death. sive care regardless of location and time of day. These are impor-
Having noted this, many of the early signs listed did not result in tant initiatives to combat avoidable in-hospital complications and
death so any system of response based on the early signs alone deaths.

Learning activities
The following reflective questions prompt analysis of the systems areas for improvement. After reading the case study consider the
in place where you work, to reinforce appropriate care and identify following questions: