Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU: 2023

doi:10.1097/CCM.0000000000006072

Practice Guideline

. 2024 Feb 1;52(2):314-330.

doi: 10.1097/CCM.0000000000006072. Epub 2024 Jan 19.

Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU: 2023

Kimia Honarmand^{1

2}, Randy S Wax^{3

4}, Daleen Penoyer⁵, Geoffery Lighthall^{6

7}, Valerie Danesh⁸, Bram Rochwerg^{1

2

9}, Michael L Cheatham¹⁰, Daniel P Davis¹¹, Michael DeVita¹², James Downar¹³, Dana Edelson¹⁴, Alison Fox-Robichaud¹⁵, Shigeki Fujitani¹⁶, Raeann M Fuller¹⁷, Helen Haskell¹⁸, Matthew Inada-Kim¹⁹, Daryl Jones²⁰, Anand Kumar²¹, Keith M Olsen²², Daniel D Rowley²³, John Welch²⁴, Marie R Baldisseri²⁵, John Kellett²⁶, Heidi Knowles²⁷, Jonathan K Shipley²⁸, Philipp Kolb^{29

30}, Sophie P Wax³¹, Jonathan D Hecht³², Frank Sebat³³

Affiliations

¹ Division of Critical Care, Department of Medicine, Mackenzie Health, Vaughan, ON, Canada.
² Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
³ Department of Critical Care Medicine, Faculty of Health Sciences, Queen's University, Kingston, ON, Canada.
⁴ Department of Critical Care, Lakeridge Health, Oshawa, ON, Canada.
⁵ Center for Nursing Research and Advanced Nursing Practice, Orlando Health, Orlando, FL.
⁶ Department of Anesthesia, Pain, and Perioperative Medicine, Stanford University School of Medicine, Palo Alto, CA.
⁷ Veterans Affairs Medical Center, Palo Alto, CA.
⁸ Center for Applied Health Research, Baylor Scott and White Health, Dallas, TX.
⁹ Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.
¹⁰ Division of Surgical Education, Orlando Regional Medical Center, Orlando, FL.
¹¹ Emergency Medical Services, Logan Health, Kalispell, MT.
¹² Columbia Vagelos College of Physicians and Surgeons, Department of Medicine Harlem Hospital Medical Center, New York City, NY.
¹³ Division of Critical Care, Department of Medicine, University Health Network, Toronto, ON, Canada.
¹⁴ Division of Internal Medicine, Department of Medicine, University of Chicago Medical Center, Chicago, IL.
¹⁵ Division of Critical Care, Department of Internal Medicine, Thrombosis and Atherosclerosis Research Institute, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.
¹⁶ Division of Critical Care, Department of Emergency Medicine, Saint Marianna University, Kawasaki, Japan.
¹⁷ Division of Trauma and Critical Care, Department of Emergency Medicine, Advocate Condell Medical Center, Libertyville, IL.
¹⁸ Mothers Against Medical Error, Columbia, SC.
¹⁹ Department of Acute Medicine, Hampshire Hospitals NHS Foundation Trust and University of Southampton, Southampton, United Kingdom.
²⁰ Division of Surgery, Department of Medicine, University of Melbourne, Melbourne, VIC, Australia.
²¹ Division of Critical Care, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada.
²² University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE.
²³ Respiratory Therapy Services, University of Virginia Medical Center, Charlottesville, VA.
²⁴ Critical Care Unit, University College London Hospitals NHS Foundation Trust, London, United Kingdom.
²⁵ Department of Critical Care, University of Pittsburgh Medical Center, Pittsburgh, PA.
²⁶ Department of Emergency Medicine, University of Southern Denmark, Odense, Denmark.
²⁷ Department of Emergency Medicine, John Peter Smith Health Network, Fort Worth, TX.
²⁸ Division of Critical Care, Vanderbilt University Medical Center, Nashville, TN.
²⁹ Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada.
³⁰ Department of Family Medicine, Dalhousie University, Halifax, ON, Canada.
³¹ Faculty of Health Sciences, Queen's University, Kingston, ON, Canada.
³² School of Nursing, The University of Texas at Austin, Austin, TX.
³³ Division of Internal Medicine, Mercy Medical Center, Redding, CA.

PMID: 38240510
DOI: 10.1097/CCM.0000000000006072

Practice Guideline

Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU: 2023

Kimia Honarmand et al. Crit Care Med. 2024.

. 2024 Feb 1;52(2):314-330.

doi: 10.1097/CCM.0000000000006072. Epub 2024 Jan 19.

Authors

Affiliations

¹ Division of Critical Care, Department of Medicine, Mackenzie Health, Vaughan, ON, Canada.
² Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
³ Department of Critical Care Medicine, Faculty of Health Sciences, Queen's University, Kingston, ON, Canada.
⁴ Department of Critical Care, Lakeridge Health, Oshawa, ON, Canada.
⁵ Center for Nursing Research and Advanced Nursing Practice, Orlando Health, Orlando, FL.
⁶ Department of Anesthesia, Pain, and Perioperative Medicine, Stanford University School of Medicine, Palo Alto, CA.
⁷ Veterans Affairs Medical Center, Palo Alto, CA.
⁸ Center for Applied Health Research, Baylor Scott and White Health, Dallas, TX.
⁹ Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.
¹⁰ Division of Surgical Education, Orlando Regional Medical Center, Orlando, FL.
¹¹ Emergency Medical Services, Logan Health, Kalispell, MT.
¹² Columbia Vagelos College of Physicians and Surgeons, Department of Medicine Harlem Hospital Medical Center, New York City, NY.
¹³ Division of Critical Care, Department of Medicine, University Health Network, Toronto, ON, Canada.
¹⁴ Division of Internal Medicine, Department of Medicine, University of Chicago Medical Center, Chicago, IL.
¹⁵ Division of Critical Care, Department of Internal Medicine, Thrombosis and Atherosclerosis Research Institute, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.
¹⁶ Division of Critical Care, Department of Emergency Medicine, Saint Marianna University, Kawasaki, Japan.
¹⁷ Division of Trauma and Critical Care, Department of Emergency Medicine, Advocate Condell Medical Center, Libertyville, IL.
¹⁸ Mothers Against Medical Error, Columbia, SC.
¹⁹ Department of Acute Medicine, Hampshire Hospitals NHS Foundation Trust and University of Southampton, Southampton, United Kingdom.
²⁰ Division of Surgery, Department of Medicine, University of Melbourne, Melbourne, VIC, Australia.
²¹ Division of Critical Care, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada.
²² University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE.
²³ Respiratory Therapy Services, University of Virginia Medical Center, Charlottesville, VA.
²⁴ Critical Care Unit, University College London Hospitals NHS Foundation Trust, London, United Kingdom.
²⁵ Department of Critical Care, University of Pittsburgh Medical Center, Pittsburgh, PA.
²⁶ Department of Emergency Medicine, University of Southern Denmark, Odense, Denmark.
²⁷ Department of Emergency Medicine, John Peter Smith Health Network, Fort Worth, TX.
²⁸ Division of Critical Care, Vanderbilt University Medical Center, Nashville, TN.
²⁹ Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada.
³⁰ Department of Family Medicine, Dalhousie University, Halifax, ON, Canada.
³¹ Faculty of Health Sciences, Queen's University, Kingston, ON, Canada.
³² School of Nursing, The University of Texas at Austin, Austin, TX.
³³ Division of Internal Medicine, Mercy Medical Center, Redding, CA.

PMID: 38240510
DOI: 10.1097/CCM.0000000000006072

Abstract

Rationale: Clinical deterioration of patients hospitalized outside the ICU is a source of potentially reversible morbidity and mortality. To address this, some acute care hospitals have implemented systems aimed at detecting and responding to such patients.

Objectives: To provide evidence-based recommendations for hospital clinicians and administrators to optimize recognition and response to clinical deterioration in non-ICU patients.

Panel design: The 25-member panel included representatives from medicine, nursing, respiratory therapy, pharmacy, patient/family partners, and clinician-methodologists with expertise in developing evidence-based Clinical Practice Guidelines.

Methods: We generated actionable questions using the Population, Intervention, Control, and Outcomes (PICO) format and performed a systematic review of the literature to identify and synthesize the best available evidence. We used the Grading of Recommendations Assessment, Development, and Evaluation Approach to determine certainty in the evidence and to formulate recommendations and good practice statements (GPSs).

Results: The panel issued 10 statements on recognizing and responding to non-ICU patients with critical illness. Healthcare personnel and institutions should ensure that all vital sign acquisition is timely and accurate (GPS). We make no recommendation on the use of continuous vital sign monitoring among unselected patients. We suggest focused education for bedside clinicians in signs of clinical deterioration, and we also suggest that patient/family/care partners' concerns be included in decisions to obtain additional opinions and help (both conditional recommendations). We recommend hospital-wide deployment of a rapid response team or medical emergency team (RRT/MET) with explicit activation criteria (strong recommendation). We make no recommendation about RRT/MET professional composition or inclusion of palliative care members on the responding team but suggest that the skill set of responders should include eliciting patients' goals of care (conditional recommendation). Finally, quality improvement processes should be part of a rapid response system.

Conclusions: The panel provided guidance to inform clinicians and administrators on effective processes to improve the care of patients at-risk for developing critical illness outside the ICU.

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Conflict of interest statement

Funding for these guidelines was provided solely by the Society of Critical Care Medicine. Panel members disclosed all potential financial and intellectual conflicts of interest according to the American College of Critical Care Medicine/Society of Critical Care Medicine Standard Operating Procedures. Refer to Supplemental Digital Contents 1 and 2 (http://links.lww.com/CCM/H434) for details. Dr. Penoyer received funding from Ivenix, Inc, Avanos, ICU Medical, and BD. Dr. Davis disclosed he is a consultant for Zoll and Healthstream and is Chief Executive Officer of Medical X Technologies. Dr. Edelson disclosed that she is president and co-founder of AgileMD and received equity interest, she is an employee of the National Institutes of Health, and received a research grant from BARDA (ARCD.P0535US). Dr. Rowley received funding from Draeger, STIMIT, and Vyaire. Dr. DeVita disclosed that he is a consultant for Hill Rom. Dr. Welch disclosed that he is an advisor in a one-off Becton, Dickinson and Co. Adult and Specialist Critical Care Advisory Board. Dr. Kellett disclosed that he is the founder and major shareholder of Tapa Healthcare DAC. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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References

1. Nates JL, Nunnally M, Kleinpell R, et al.: ICU admission, discharge, and triage guidelines: A framework to enhance clinical operations, development of institutional policies, and further research. Crit Care Med. 2016; 44:1553–1602
1. Guyatt GH, Oxman AD, Schunemann HJ, et al.: GRADE guidelines: A new series of articles in the Journal of Clinical Epidemiology. J Clin Epidemiol. 2011; 64:380–382
1. Andrews J, Guyatt G, Oxman AD, et al.: GRADE guidelines: 14. Going from evidence to recommendations: The significance and presentation of recommendations. J Clin Epidemiol. 2013; 66:719–725
1. Guyatt GH, Schunemann HJ, Djulbegovic B, et al.: Guideline panels should not GRADE good practice statements. J Clin Epidemiol. 2015; 68:597–600
1. Stites M, Surprise J, McNiel J, et al.: Continuous capnography reduces the incidence of opioid-induced respiratory rescue by hospital rapid resuscitation team. J Patient Saf. 2021; 17:e557–e561

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[1] Nates JL, Nunnally M, Kleinpell R, et al.: ICU admission, discharge, and triage guidelines: A framework to enhance clinical operations, development of institutional policies, and further research. Crit Care Med. 2016; 44:1553–1602

[2] Nates JL, Nunnally M, Kleinpell R, et al.: ICU admission, discharge, and triage guidelines: A framework to enhance clinical operations, development of institutional policies, and further research. Crit Care Med. 2016; 44:1553–1602

[3] Guyatt GH, Oxman AD, Schunemann HJ, et al.: GRADE guidelines: A new series of articles in the Journal of Clinical Epidemiology. J Clin Epidemiol. 2011; 64:380–382

[4] Guyatt GH, Oxman AD, Schunemann HJ, et al.: GRADE guidelines: A new series of articles in the Journal of Clinical Epidemiology. J Clin Epidemiol. 2011; 64:380–382

[5] Andrews J, Guyatt G, Oxman AD, et al.: GRADE guidelines: 14. Going from evidence to recommendations: The significance and presentation of recommendations. J Clin Epidemiol. 2013; 66:719–725

[6] Andrews J, Guyatt G, Oxman AD, et al.: GRADE guidelines: 14. Going from evidence to recommendations: The significance and presentation of recommendations. J Clin Epidemiol. 2013; 66:719–725

[7] Guyatt GH, Schunemann HJ, Djulbegovic B, et al.: Guideline panels should not GRADE good practice statements. J Clin Epidemiol. 2015; 68:597–600

[8] Guyatt GH, Schunemann HJ, Djulbegovic B, et al.: Guideline panels should not GRADE good practice statements. J Clin Epidemiol. 2015; 68:597–600

[9] Stites M, Surprise J, McNiel J, et al.: Continuous capnography reduces the incidence of opioid-induced respiratory rescue by hospital rapid resuscitation team. J Patient Saf. 2021; 17:e557–e561

[10] Stites M, Surprise J, McNiel J, et al.: Continuous capnography reduces the incidence of opioid-induced respiratory rescue by hospital rapid resuscitation team. J Patient Saf. 2021; 17:e557–e561

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Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU: 2023

Affiliations

Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU: 2023

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