One of the most exciting initiatives our hospital has developed is the Early Recognition of the Deteriorating Patient (ERDP) program.

The program is delivered as COMPASS, a set of tools that assist the bedside nurse in the early recognition of deteriorating patients, and empower them to initiate an appropriate medical review and timely medical management well before they crash and burn.

This project arose from evidence in the existing literature that there is a failure to recognise and appropriately manage deteriorating patients on the general ward. This is evidenced by delays in admission to the intensive care unit (ICU), unexpected referrals to intensive care and unexpected deaths often being preceded by significant physiological disturbances .
The ability to detect early deterioration in patients allows early appropriate intervention. Early intervention can reduce unplanned admissions to the intensive care unit and unexpected deaths .

And to their credit the award winning1 COMPASS team has now released the entire program for free download.
Once you have completed a short registration you can access:

  • a new observation chart tool.
  • a track and trigger system.
  • a locally developed COMPASS education package.

After the initial pilot of this program was run on 4 wards at 2 hospitals during 2006, there was a decrease in unplanned ICU admissions (21 to 5, p=0.005) and cardiac arrests (4 to 0, p=0.03). Medical emergency team reviews increased from 27 to 51 (p<0.001) and the number of hospital deaths decreased from 35 to 16 (2.9% to 1.6% of all first admissions, p=0.05).

I highly recommend this program (particularly the education package) to everyone from nursing students to consultants to nursing unit managers, as a tool to  increase both the quality of care delivery and reduce the morbidity and mortality of patients.

You (or your hospital)  might like to check it out.

  1. National Australian Institute of Project Management Awards 2008: Community Service and/or Development Project of the Year []

11 Responses to “early recognition of the deteriorating patient.”

  1. I agree with Cathy. The COMPASS education package is a good program for staff and the observation chart with the MEWS tool works well in combination with clinical judgement. Scoring observations is not a new concept – look at APGAR and GCS – and I don’t really understand why people believe the tool/protocol/guidelines can’t be successfully used in conjunction with good assessment skills. By the way – the people who developed COMPASS specifically looked at variations in normal BP so Dr Disillusioned’s little old lady would have scored a MET call on their chart.

    Nursing is becoming more speciallized every day yet it is still policy, in most hospitals, to send nurses relieving in unfamiliar areas and to outlie patients where ever there is a bed. Unfortunately, patients frequently deteriorate in our wards without anyone noticing – we know that from the data which has been gathered. Developing tools to assist in assessment is a good idea – as anyone who has ever done an RCA will tell you. Very little education is available for ward nurses but they make up the majority of our work force and look after the majority of our patients. I think the ACT team have done a fantastic job with there medical escalation protocol, observation chart, COMPASS education package etc etc etc. We have introduced a similiar program in SA and the nurses love it here too (different hospital from Cathy). Go COMPASS =)

  2. We are implementing this in my hospital in SA. Im familiar with similar models in the UK, and I think its great. I wonder, if we were to suggest removing the ASA score, the APACHE score, POSSUM, Braden and falls risk assessments, what would the reaction be? These are tools / scores that allow us to monitor trends or support, guide or prompt clinical decision making. I was hospital trained, that has nothing to do with it. The fact is we are not routinely taught to recognise patient deterioration, but when someone suggest we might possibly do a better job instead of reflecting, we get defensive. What really happens is our patients deteriorate, we watch what other nurses / doctors do, and we copy that. Doesnt it make more sense to be taught to anticipate, then detect and manage deterioration? i like COMPASS, and I think the best thing is that it is so freely shared. We now run regular sessions where we reflect on the management of specific patients, it works really well, the nurses love it, and we talk to them about blood results, and WHY this patient has a low BP, almost all of them could not have articulated this at the start of the education programme. Go COMPASS =)

  3. Hi everyone, was surfing for info regarding MAP and metabolic and respiarory acidosis/alkalosis and happened to hit this site….just wanted to say that this is really cool and helpful after all…. By the way I am a student nurse as well…If I have any queries regarding any care I’ll post it because I believe that the experience of qualified staff is very usefull for us students :)

  4. With regard to the above:

    1. Low pH, yes. High bicarb, NO… unless the acidosis is chronic and well compensated. Someone with an acute metabolic acidosis will have a low-normal or low bicarbonate. CO2 may be low, if they have the respiratory and cardiovascular reserve to drive it down to compensate for the acidosis, however many (particulalrly elderly) patients with reduced physiologic reserve who have septic shock will have difficulty with this and will often have a normal or low-normal CO2. (E.g. Mr X in ED a day or two ago, with pH 7.26, pCO2 41, HCO3- 18). [HCO3- = bicarbonate]

    2. Yup, any approximately isotonic crystalloid OTHER THAN DEXTROSE is just fine. Feel free to use colloid if it gives you a warm fuzzy feeling, too, but there is no added benefit in doing so.

    3. In septic shock, the first line pressor agent of choice is noradrenaline (norepinephrine for those who don’t speak English). The peripheral alpha agonist effect is what you’re after, increasing systemic vascular resistance and thereby increasing the MAP. There is a small beta effect on the heart which can/could increase heart rate, however the reflex bradycardia induced by the higher MAP and improved right heart filling usually compensates for this almost perfectly. Phosphodiesterase inhibitors (such as milrinone, amrinone etc.) are of limited benefit and should not be used in this setting. There are old-fashioned arguments about “protective” low doses of dopamine as a second agent (at low doses dopamine selectively dilates the renal, mesenteric and cerebral vessels) but no good evidence to show it has any impact whatsoever on morbidity and mortality at the end of the day. Dobutamine typically should not be used in septic shock; it will increase heart rate and tend to reduce systemic vascular resistance. Some argue for its use as a secondary agent in this setting, however there is little evidence that it is a good idea. If you haven’t got a central line in yet then metaraminol (Aramine) is a useful intermediate, providing almost pure alpha agonism and increasing systemic vascular resistance, and can be given peripherally. Ephedrine is also an option for the anaesthetists out there. ;-) As helva points out, the aim is to improve the MAP to something that will adequately perfuse the brain, kidneys, etc., and thus hopefully stave off further metabolic derangement and eventual multi-organ failure.

    Yes… I know…. I have no life… :-)

  5. Bachelor Party:
    1. Metabolic acidosis will show a pH less than 7.35, a bicarb greater than 26, and the CO2 will most probably be low (to try and compensate for the high bicarb). ABG interpretation is a foundation skill that all nurses should at least be familiar with if not know well, and there are a lot of great resources out there to master this skill. Ian has a few up his sleeve, and will perhaps share.
    2. Isotonic solution is the fluid of choice here (9%NS, LR a.k.a. Hartmann’s).
    3. Inotropes: In this case drugs that cause a positive inotropic response. (Dopamine, Dobutamine, Epi (adrenalin), isoproterenol, Amrinone, and as a last resort noradrenalin (norepinephrine) are the common drugs used (mainly in this order) in the ER bag of tools, but the choice is dependent on the patient (cause, hx, co-morbidities) and the mood the Dr is in (or which drug company he’s got stock ;-) (just being a bit cheeky)). Basically, anything that will bring the BP back up to something that can sustain life.

  6. Call, me silly, but 4.5 yrs of studying to be a nurse and 2 days of exams with the sole purpose of giving me the knowledge to know what is normal and abnormal and assessing this knowledge was so that I could I.D. a sick patient. COMPASS is a late solution to the real problem, nurses not learning in school what they should know before facing the real deal. I’m a bit insulted b/c I had to learn these before I could call myself a nurse.

  7. I am a nursing student who will be tested on this and need to ask a few questions

    1. severe metabolic acidosis – what would the ABG analysis result look like and is this always a common rule for a decompensated reaction to septic shock?
    2. A few almost instantaneous liters of fluid – which type of fluid?
    3. some inotropes later – would these be ‘vaso acitve’ drugs?

    I have also never seen anyone being haemodynamically monitored with the cannula in the arm etc.. how often does this happen?

  8. Yeah, they just need to lower the price of the newly invented Retrospectoscope to be in line with say, a new MRI machine, and we’d be in business. ;)

  9. You are both exactly right.
    And in fact the COMPASS program is not a protocol, but is an educational package that teaches the importance of relationship between changing vital signs and the physiological responses to shock.
    The goal is for staff understand the clinical importance of observations rather than just diligently documenting them as often happens.
    The problem is, and this is made evident time and time again during reviews of adverse incidents, that the painfully obvious only becomes painful in retrospect.

  10. Absolutely,Dr Disillusioned…Look and Listen…Don’t rely on some protocol to get your answers…use your brain and THINK !!!!

  11. A logical extension of the original MET idea, which was demonstrated widely to save lives/arrests/unplanned ICU admissions, the COMPASS program would appear to have improved on those same parameters.

    Just as an aside, however, the existence of a cookbook protocol should not detract from one’s willingness to bang a few brain cells together and actually _think_…

    A random example from an unnamed ED: 89yo lady with LLL pneumonia with a HR of 90 and a BP of 95 systolic left simmering quietly until she decompensated, dropped her BP to 70 with a severe metabolic acidosis.

    A HR of 90 and BP of 95 might be fine in the mythical 70kg fit young adult patient. The same is most certainly not true of an 89yo whose normal BP is 160 on a good day, and who is maximally beta-blocked.

    A few almost instantaneous litres of fluid, a central line and some inotropes later, she and her biochemistry were looking a wee tad better as she was transferred to ICU.

    Septic shock, relative hypotension and beta-blockade are not rocket science, and I realise most people would view it as a trivial example. However, that in itself is almost the entire point.

    Moral of the story… guidelines, protocols and rules of thumb are good for standardisation and making institutional statistics look better, but considering all relevant factors relating to the context in which (and the patient to whom) you are applying these rules is crucially important if you wish to avoid adding to the decreasing, but still significant, number of adverse outcomes (otherwise known as dead patients) caused by overlooking the painfully obvious.

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