Action 8.4

The health service organisation has processes for clinicians to detect acute physiological deterioration that require clinicians to:

a. Document individualised vital sign monitoring plans

b. Monitor patients as required by their individualised monitoring plan

c. Graphically document and track changes in agreed observations to detect acute deterioration over time, as appropriate for the patient

Intent

Patients with acute physiological deterioration are identified early.

Reflective questions

What systems are in place for documenting vital sign monitoring plans?

What processes are used to ensure that there is enough equipment for patient monitoring?

How does the health service organisation ensure that clinicians have the skills to monitor patients according to their monitoring plan?

What processes are in place for documenting vital sign observations graphically and over time?

Key tasks

  • Implement a system for documenting vital sign monitoring plans
  • Ensure that clinicians have the necessary skills and equipment to monitor patients as required by their individualised monitoring plans
  • Implement an observation chart or other mechanism for graphically documenting vital sign observations and tracking changes over time.

Strategies for improvement

Hospitals

Develop monitoring plans

Develop individualised vital sign monitoring plans to manage the clinical risks and needs of each patient. Work with clinicians to design systems for developing and documenting these plans, and to ensure that the systems align with workflow and effectively meet patients’ needs. Include capacity to document the frequency (times per day), duration (number of days or weeks) and types of vital signs or other physiological parameters.

Monitoring plans may be included in clinical pathways for specific patient groups who have similar clinical risks and needs, but provide prompts for clinicians to consider whether the monitoring plan meets the needs of each patient, and capacity for them to review and modify the monitoring plan.

Describe the minimum expectations for vital sign monitoring in policy. The National Consensus Statement: Essential elements for recognising and responding to acute physiological deterioration1 identifies a core set of six vital signs, and recommends that these should be monitored at least once per eight-hour shift:

  • Respiratory rate
  • Oxygen saturation
  • Heart rate
  • Blood pressure
  • Level of consciousness
  • Temperature.

The frequency of required monitoring may vary between individual patients, and as a patient’s clinical situation, clinical risks and goals of care change. Some patients may not need all the core vital sign observations to be monitored at the same frequency (for example, young children may not need blood pressure monitored as often as respiratory rate and oxygen saturation).

Include the core vital signs in monitoring plans for most patients. Specific groups of patients may have extra monitoring requirements (for example, pain and sedation scores, fluid balance, respiratory distress, capillary refill, or pupil size and reactivity). Patients who are at the end of life may not need their core vital signs to be monitored, but will need monitoring of symptoms associated with the dying process, such as pain, agitation, breathlessness and nausea. Paediatric patients may not be able to be monitored for level of consciousness, but accessory muscle use may be a relevant vital sign. Local guidelines may need to be developed for vital sign monitoring in specialist areas such as emergency departments, post-anaesthetic care units, rehabilitation wards, maternity units and critical care units.

Ensure appropriate skills and equipment

Develop processes to ensure that clinicians are trained to use monitoring equipment correctly, and are competent in measuring and interpreting vital signs accurately. Educate clinicians about the clinical significance of normal and abnormal vital sign observations in the context of acute physiological deterioration. Strategies might include self-directed learning packages, competency-based skills assessment, face-to-face training sessions, simulation and peer review.

Use an audit of vital sign observation charts to evaluate whether vital sign monitoring practices align with policy, and provide feedback to clinicians about their practice. An observation chart audit tool is available on the Commission’s website.

Ensure that equipment for measuring and monitoring vital signs and other physiological parameters is readily available and in good working order. Conduct a risk assessment to determine how much equipment is needed. Set up systems for regular checking and maintenance of monitoring equipment. If possible, provide consistent monitoring equipment across the organisation – this reduces the burden of training required and can help to avoid errors introduced by small differences in correct use of equipment. For example, if multiple types of cardiac monitoring equipment are used across an organisation, it can be more difficult for clinicians to use the equipment and troubleshoot, especially in emergency situations.

Document and track vital signs

Regardless of the type of system used to document vital signs, it should include:

  • The capacity to display documented vital signs graphically
  • The capacity to track changes in vital signs over time
  • Thresholds for each vital sign parameter or combination of parameters that indicate abnormality
  • Information about the response or action needed when thresholds are reached or physiological deterioration is identified
  • The potential to document the normal range for the patient.

Many state and territory health departments, and private hospital groups have developed and implemented track-and-trigger observation charts. Specialist vital sign observation charts have been developed for use in a range of populations, including children of different age groups, obstetric patients and adults. Use these as required by the state, territory or private hospital group.

Electronic systems for tracking vital sign observations may be used, and may improve the detection of deterioration and escalation of care.2 When implementing these systems, organisations need to:

  • Test usability from both the clinical and human factors perspectives
  • Develop strategies for mitigating the risk of human errors associated with issues such as workarounds arising from slow data entry processes3 or alarm fatigue from frequent automatic alerts4,5
  • Provide training to ensure that electronic systems are used correctly
  • Set up processes to evaluate the safety and quality of electronic systems as they are implemented.

Although many electronic systems have automatic triggering of alarms or message prompts when thresholds indicating acute deterioration are reached, human factors testing of paper charts shows that clinicians’ ability to detect vital sign trends that indicate deterioration improves when vital signs are presented graphically.6-8 Set the default display of electronic vital sign monitoring systems so that clinicians can document and review vital sign observations graphically.

If the organisation is planning and implementing electronic systems (for example, electronic vital sign monitoring and escalation systems), ensure that these systems are consistent with the principles underlying paper-based processes and protocols. Also ensure that appropriate clinical and organisational governance experts inform the development of electronic systems for recognising and responding to acute deterioration, and are involved in ongoing monitoring of the safety and quality of these systems.

Day Procedure Services

Develop monitoring plans

Develop individualised vital sign monitoring plans to address the clinical risks and needs of each patient. Work with clinicians to design systems for developing and documenting these plans, and to ensure that the systems align with workflow and effectively meets patients’ needs. Include capacity to document the frequency, duration and types of vital signs or other physiological parameters.

Monitoring plans may be included in clinical pathways for specific patient groups who have similar clinical risks and needs, but provide prompts for clinicians to consider whether the monitoring plan meets the needs of each patient, and capacity for them to review and modify the monitoring plan.

Describe the minimum expectations for vital sign monitoring in policy. The National Consensus Statement: Essential elements for recognising and responding to acute physiological deterioration9 identifies a core set of six vital signs, and recommends that these be monitored at least once per eight-hour shift:

  • Respiratory rate
  • Oxygen saturation
  • Heart rate
  • Blood pressure
  • Level of consciousness
  • Temperature.

The frequency of required monitoring may vary between individual patients, and as a patient’s clinical situation, clinical risks and goals of care change. For example, patients who have received sedation or general anaesthesia will require more frequent and prolonged monitoring than those who received local anaesthetic only. Some patients may not need all the core vital signs to be monitored at the same frequency (for example, young children may not need blood pressure monitored as often as respiratory rate and oxygen saturation).

Include the core vital signs in monitoring plans for most patients. Specific groups of patients may have extra monitoring requirements (for example, Aldrete scores or the Post Anaesthetic Discharge Scoring System, respiratory distress, capillary refill, pupil size and reactivity).

Work with clinicians to make a clinical risk assessment and reduce the monitoring requirements for some groups of patients (such as young, otherwise healthy patients having a simple procedure such as mole removal). Develop guidelines for these patients specifying alternative criteria for recognising clinical deterioration and escalating care, and indications to commence core vital sign monitoring.

Ensure appropriate skills and equipment

Develop processes to ensure that clinicians are trained to use monitoring equipment correctly, and are competent in measuring and interpreting vital signs accurately. Educate clinicians about the clinical significance of normal and abnormal vital sign observations in the context of acute physiological deterioration. Strategies might include self-directed learning packages, competency-based skills assessment, face-to-face training sessions, simulation and peer review.

Use an audit of vital sign observation charts to evaluate whether vital sign monitoring practices align with policy, and provide feedback to clinicians about their practice. An observation chart audit tool is available on the Commission’s website.

Ensure that equipment for measuring and monitoring vital signs and other physiological parameters is readily available and in good working order. Conduct a risk assessment to determine how much equipment is needed. Set up systems for regular checking and maintenance of monitoring equipment. If possible, provide consistent monitoring equipment across the organisation – this reduces the burden of training required and can help to avoid errors introduced by small differences in correct use of equipment. For example, if multiple types of cardiac monitoring equipment are used across an organisation, it can be more difficult for clinicians to use the equipment and troubleshoot, especially in emergency situations.

Document and track vital signs

For patients whose monitoring plans indicate that vital sign observations are not required (as determined by the risk assessment process described above), this action is not applicable.

For all other patient groups, put a system in place to document and track vital signs. Regardless of the type of system used to document vital signs, it should include:

  • The capacity to display documented vital signs graphically
  • The capacity to track changes in vital signs over time
  • Thresholds for each vital sign parameter or combination of parameters that indicate abnormality
  • Information about the response or action needed when thresholds are reached or physiological deterioration is identified
  • The potential to document the normal range for the patient.

Many Local Hospital Networks, state and territory health departments, and private hospital groups have developed and implemented track-and-trigger observation charts. Specialist vital sign observation charts have been developed for use in a range of populations, including children of different age groups, obstetrics and adults.

Electronic systems for tracking vital sign observations may be used, and may improve the detection of deterioration and escalation of care.8 When implementing these systems, organisations need to:

  • Test usability from both the clinical and human factors perspectives
  • Develop strategies for mitigating the risk of human errors associated with issues such as workarounds arising from slow data-entry processes3 and alarm fatigue from frequent automatic alerts4,5
  • Provide training to ensure that the electronic systems are used correctly
  • Establish processes to evaluate the safety and quality of the electronic systems as they are implemented.

Although many electronic systems have automatic triggering of alarms or message prompts when thresholds indicating acute deterioration are reached, human factors testing of paper charts shows that clinicians’ ability to detect vital sign trends that indicate deterioration improves when vital signs are presented graphically.6-8 Set the default display of electronic vital sign monitoring systems so that clinicians can document and review vital sign observations graphically.

If the organisation is planning and implementing electronic systems (for example, electronic vital sign monitoring and escalation systems), ensure that these systems are consistent with the principles underlying paper-based processes and protocols. Also ensure that appropriate clinical and organisational governance experts inform the development of electronic systems for recognising and responding to acute deterioration, and are involved in ongoing monitoring of the safety and quality of these systems.

Examples of evidence

Select only examples currently in use:

  • Policy documents that align with the National Consensus Statement: Essential elements for recognising and responding to acute physiological deterioration9 and describe the minimum requirements for
    • development and documentation of individualised monitoring plans
    • frequency of monitoring for core vital signs
    • vital sign documentation
  • Training documents about using monitoring equipment, monitoring and documenting vital signs, and developing and documenting monitoring plans
  • Documented protocols that outline the requirements of monitoring plans for different patient groups (for example, patients in an inpatient surgical ward are likely to have different monitoring requirements from patients in an outpatient chemotherapy unit)
  • Audit results of compliance with monitoring policies, procedures or protocols
  • Maintenance logs and checklists for equipment used for monitoring vital signs
  • Results of skills and competency evaluation for detecting acute physiological deterioration
  • Examples of completed monitoring plans, track-and-trigger observation charts, and clinical pathways that are appropriate for the setting
  • Local guidelines for vital sign monitoring in specialist areas.
MPS & Small Hospitals

MPSs or small hospitals that are part of a local health network or private hospital group should adopt or adapt and use the established processes for detecting acute physiological deterioration.

Small hospitals that are not part of a local health network or private hospital group should:

  • Implement a system for documenting vital sign monitoring plans
  • Ensure that clinicians have the necessary skills and equipment to monitor patients as required by their individualised monitoring plans
  • Implement an observation chart or other mechanism for graphically documenting vital sign observations and tracking changes over time.

Develop monitoring plans

Develop individualised vital sign monitoring plans to manage the clinical risks and needs of each patient. Work with clinicians to design systems for developing and documenting these plans, and to ensure that the systems align with workflow and effectively meet patients’ needs. Include capacity to document the frequency (times per day), duration (number of days or weeks) and types of vital signs or other physiological parameters.

Describe the minimum expectations for vital sign monitoring in policy. The National Consensus Statement: Essential elements for recognising and responding to acute physiological deterioration1 identifies a core set of six vital signs, and recommends that these should be monitored at least once per eight-hour shift:

  • Respiratory rate
  • Oxygen saturation
  • Heart rate
  • Blood pressure
  • Level of consciousness
  • Temperature.

The frequency of required monitoring may vary between individual patients, and as a patient’s clinical situation, clinical risks and goals of care change. Some patients may not need all the core vital sign observations to be monitored at the same frequency (for example, young children may not need blood pressure monitored as often as respiratory rate and oxygen saturation).

Long-term aged care residents of MPSs who are mostly healthy and well may need to have their vital signs monitored less often than a patient with an acute health issue.

Include the core vital signs in monitoring plans for most patients. Specific groups of patients may have extra monitoring requirements (for example, pain and sedation scores, fluid balance, respiratory distress, capillary refill, or pupil size and reactivity). Patients who are at the end of life may not need their core vital signs to be monitored, but will need monitoring of symptoms associated with the dying process, such as pain, agitation, breathlessness and nausea. Paediatric patients may not be able to be monitored for level of consciousness, but accessory muscle use may be a relevant vital sign. Local guidelines may need to be developed for vital sign monitoring in specialist areas such as emergency departments, post-anaesthetic care units, rehabilitation wards, maternity units and critical care units.

Ensure appropriate skills and equipment

Develop processes to ensure that clinicians are trained to use monitoring equipment correctly, and are competent in measuring and interpreting vital signs accurately. Educate clinicians about the clinical significance of normal and abnormal vital sign observations in the context of acute physiological deterioration. Strategies might include self-directed learning packages, competency-based skills assessment, face-to-face training sessions, simulation and peer review.

Use an audit of vital sign observation charts to evaluate whether vital sign monitoring practices align with policy, and provide feedback to clinicians about their practice. An observation chart audit tool is available on the Commission’s website.

Ensure that equipment for measuring and monitoring vital signs and other physiological parameters is readily available and in good working order. Conduct a risk assessment to determine how much equipment is needed. Set up systems for regular checking and maintenance of monitoring equipment. If possible, provide consistent monitoring equipment across the organisation – this reduces the burden of training required and can help to avoid errors introduced by small differences in correct use of equipment. For example, if multiple types of cardiac monitoring equipment are used across an organisation, it can be more difficult for clinicians to use the equipment and troubleshoot, especially in emergency situations.

Document and track vital signs

Regardless of the type of system used to document vital signs, it should include:

  • The capacity to display documented vital signs graphically
  • The capacity to track changes in vital signs over time
  • Thresholds for each vital sign parameter or combination of parameters that indicate abnormality
  • Information about the response or action needed when thresholds are reached or physiological deterioration is identified
  • The potential to document the normal range for the patient.

Many state and territory health departments, Local Hospital Networks and larger hospitals have developed and implemented track-and-trigger observation charts. Use these as required by the state or territory health department or Local Hospital Network.

Action 8.5

The health service organisation has processes for clinicians to recognise acute deterioration in mental state that require clinicians to:

a. Monitor patients at risk of acute deterioration in mental state, including patients at risk of developing delirium

b. Include the person’s known early warning signs of deterioration in mental state in their individualised monitoring plan

c. Assess possible causes of acute deterioration in mental state, including delirium, when changes in behaviour, cognitive function, perception, physical function or emotional state are observed or reported

d. Determine the required level of observation

e. Document and communicate observed or reported changes in mental state

Intent

Adverse outcomes relating to acute deterioration in a person’s mental state are prevented through early recognition and effective response.

Reflective questions

How does the health service organisation ensure that clinicians are trained to be alert for the signs of acute deterioration in a person’s mental state?

How does this apply to people who have not been identified as being at high risk of deterioration in mental state?

Key tasks

  • Use comprehensive care plans to guide monitoring of people who are at risk of acute deterioration in mental state, incorporating knowledge from the person, and their carers and families about individual early warning signs
  • Ensure that members of the workforce are alert to signs of deterioration in a person’s mental state, including for people who have not been previously identified as being at high risk
  • Ensure that members of the workforce are alert to the signs of delirium
  • Ensure that members of the workforce can implement an initial response and keep the person safe until arrangements are made for specialist review.

Strategies for improvement

Hospitals

Be alert for signs of deterioration in a person’s mental state

Initial screening should identify people who are at risk of acute deterioration in their mental state, including patients at risk of developing delirium.

If screening identifies risk of deterioration in a person’s mental state, conduct a complete mental state examination. Mental health workers complete these routinely. Undertaking a mental state examination also forms part of the curriculum for all members of the clinical workforce.

Comprehensive assessment should differentiate among potential causes for the person’s deterioration in mental state.

Delirium can occur at any age and can be prevented. Patients aged 65 years or over, and patients with cognitive impairment (such as dementia), severe medical illness or a hip fracture are considered to be at greatest risk.10

People who have not been identified as being at high risk can also experience deterioration in their mental state. Be alert for changes in mental state in all patients.

Use comprehensive care plans to manage patients at risk

If a person has been identified as being at high risk of acute deterioration in their mental state, conduct a comprehensive assessment as outlined in the Comprehensive Care Standard. The comprehensive care plan can incorporate information from a person’s advance care plan. When a person is experiencing deterioration in their mental state, they may be able to self-report this to members of the workforce. Similarly, carers or family members may recognise the specific signs that they know indicate the person’s mental state is deteriorating. Integrate this information into the comprehensive care plan, and engage the person – and, with permission, their carers and family – in decision-making.

Ensure that all members of the workforce involved in a person’s care are aware of the contents of the comprehensive care plan and are alert to changes that have been identified as individual markers indicating a deterioration in the person’s mental state.

For all patients at risk of delirium, this plan should include tailored delirium prevention interventions, regular monitoring and reassessment for delirium with any changes.10

Monitor patients at risk

Develop systems to routinely monitor patients at risk of deterioration in mental state, including12:

  • Prompts for assessment
  • Identification of the clinician responsible for assessment, documentation and communication processes
  • Actions to be taken, including level of nursing observation
  • Regular review and feedback processes.

If delirium is identified as a cause of deterioration in the person’s mental state, use indicators from the Delirium Clinical Care Standard for local review and feedback mechanisms.10,11

Patients with dementia may experience deteriorating behaviour and mental state (such as agitation, aggression or psychosis) during a stay in a health service organisation. Although these may be viewed as behavioural and psychological symptoms of dementia, a comprehensive assessment is required to rule out possible delirium, pain and other physical problems.12

Assess observed or reported changes

With possible delirium, diseases can have atypical presentations in older people, so do not dismiss a family member’s non-specific concerns (for example, the person ‘is not usually like this’) and assess the person for delirium.4

Incorporate this information into shared decision making. A tool has been developed to capture and track a person’s self-reported mental state daily in inpatient settings.13 Good outcomes have been reported, and further research will assess the tool’s broader applicability.

Engagement with carers and families can help maintain safety for the person experiencing deterioration in their mental state and others, while arrangements for specialist intervention are under way.

Use tools and resources

No tool currently sets out objective criteria for tracking deterioration in a person’s mental state equivalent to observation charts for physiological deterioration. Nonetheless, there are parameters that can indicate deterioration in a person’s mental state, and these can be used to develop individualised monitoring plans in collaboration with the person, and their carers and families.

These parameters are based on the mental state examination, which is integrated into clinical assessment protocols in most states and territories. Training about mental state examination is available throughout the Mental Health Professional Online Development website.

In addition, a mental health triage tool was developed to augment the Australasian Triage Scale used in emergency departments. It provides a set of structured and defined terms that can be used to assess a person’s mental state. The tool also provides the workforce with language to describe and communicate their observations.3

The tool uses an ABC mnemonic to align with the airway, breathing, circulation parameters for identifying physiological health status. For mental health, these are described as:

  • Appearance
  • Behaviour
  • Conversation.

Guidelines for using the mental health triage tool are available in the Emergency Triage Education Kit.

The Vanderbilt ICU Delirium and Cognitive Impairment Study Group website13 includes resources for monitoring and managing delirium in intensive care units as part of a bundle of measures for prevention and safety.

Day Procedure Services

Although there is low prevalence of episodes of acute deterioration in a person’s mental state in day procedure services, members of the healthcare workforce need to be alert to signs indicating that a person may be experiencing acute deterioration in mental state, and know what to do when they recognise these signs.

The health service organisation needs to ensure that, if a person does experience acute deterioration in their mental state, members of the workforce have the skills to initiate an immediate response to ensure safety, and communicate their concerns to relevant parties.

Engagement with families and carers can help to maintain safety for the person experiencing deterioration in their mental state and others, while arrangements for specialist intervention are in train.

Use screening processes to identify patients with cognitive impairment or at risk of delirium to trigger strategies to keep the patient safe and minimise potential distress (see Action 5.29).

Examples of evidence

Select only examples currently in use:

  • Policy documents about recognising, documenting and observing acute deterioration in mental state
  • Screening and assessment policies and procedures for mental health in line with the Comprehensive Care Standard
  • Training documents about recognising acute deterioration in mental state and how to deal with reports of deterioration from the patient, carer or family
  • Documentation of patient involvement in developing individualised monitoring plans
  • Audit results of compliance with the monitoring plan systems for mental state.
MPS & Small Hospitals

MPSs or small hospitals that are part of a local health network or private hospital group should adopt or adapt and use the established processes for detecting acute deterioration in mental health.

Small hospitals that are not part of a local health network or private hospital group should:

  • Use comprehensive care plans to guide monitoring of people who are at risk of acute deterioration in mental state, incorporating knowledge from the person, and their carers and families about individual early warning signs
  • Ensure that members of the workforce are alert to signs of deterioration in a person’s mental state, including for people who have not been previously identified as being at high risk
  • Ensure that members of the workforce are alert to the signs of delirium
  • Ensure that members of the workforce can implement an initial response and keep the person safe until arrangements are made for specialist review.

Be alert for signs of deterioration in a person’s mental state

Initial screening should identify people who are at risk of acute deterioration in their mental state, including patients at risk of developing delirium.

If screening identifies risk of deterioration in a person’s mental state, conduct a complete mental state examination.

In the absence of on-site mental health expertise, arrange specialist care through transfer to other services or consultation. The workforce should know how to gain access to these services, and management should set up partnerships with these organisations to enable patient referral or transfer.

Clinicians need to be able to recognise signs of deterioration early, and communicate these signs effectively to receiving clinicians when care is transferred.

Comprehensive assessment should differentiate among potential causes for the person’s deterioration in mental state.

Delirium can occur at any age and can be prevented. Patients aged 65 years or over, and patients with cognitive impairment (such as dementia), severe medical illness or a hip fracture are considered to be at greatest risk.10

People who have not been identified as being at high risk can also experience deterioration in their mental state. Be alert for changes in mental state in all patients.

Use comprehensive care plans to manage patients at risk

If a person has been identified as being at high risk of acute deterioration in their mental state, conduct a comprehensive assessment as outlined in the Comprehensive Care Standard. The comprehensive care plan can incorporate information from a person’s advance care plan. When a person is experiencing deterioration in their mental state, they may be able to self-report this to members of the workforce. Similarly, carers or family members may recognise the specific signs that they know indicate the person’s mental state is deteriorating. Integrate this information into the comprehensive care plan, and engage the person – and, with permission, their carers and family – in decision-making.

Ensure that all members of the workforce involved in a person’s care are aware of the contents of the comprehensive care plan and are alert to changes that have been identified as individual markers indicating a deterioration in the person’s mental state.

For all patients at risk of delirium, this plan should include tailored delirium prevention interventions, regular monitoring and reassessment for delirium with any changes.10

Monitor patients at risk

Develop systems to routinely monitor patients at risk of deterioration in mental state, including15:

  • Prompts for assessment
  • Identification of the clinician responsible for assessment, documentation and communication processes
  • Actions to be taken, including level of nursing observation
  • Regular review and feedback processes.

If delirium is identified as a cause of deterioration in the person’s mental state, use indicators from the Delirium Clinical Care Standard for local review and feedback mechanisms.10,16

Patients with dementia may experience deteriorating behaviour and mental state (such as agitation, aggression or psychosis) during a stay in a health service organisation. Although these may be viewed as behavioural and psychological symptoms of dementia, a comprehensive assessment is required to rule out possible delirium, pain and other physical problems.12

Assess observed or reported changes

With possible delirium, diseases can have atypical presentations in older people, so do not dismiss a family member’s non-specific concerns (for example, the person ‘is not usually like this’) and assess the person for delirium.18

Incorporate this information into shared decision making. A tool has been developed to capture and track a person’s self-reported mental state daily in inpatient settings.17 Good outcomes have been reported, and further research will determine the tool’s broader applicability.

Engagement with carers and families can help maintain safety for the person experiencing deterioration in their mental state and others, while arrangements for specialist care are under way.

Use tools and resources

No tool currently sets out objective criteria for tracking deterioration in a person’s mental state equivalent to observation charts for physiological deterioration. Nonetheless, there are parameters that can indicate deterioration in a person’s mental state, and these can be used to develop individualised monitoring plans in collaboration with the person, and their carers and families.

These parameters are based on the mental state examination, which is integrated into clinical assessment protocols in most states and territories. Training about mental state examination is available throughout the Mental Health Professional Online Development website.

In addition, a mental health triage tool was developed to augment the Australasian Triage Scale used in emergency departments. It provides a set of structured and defined terms that can be used to assess a person’s mental state. The tool also provides the workforce with language to describe and communicate their observations.19

The tool uses an ABC mnemonic to align with the airway, breathing, circulation parameters for identifying physiological health status. For mental health, these are described as:

  • Appearance
  • Behaviour
  • Conversation.

Guidelines for using the mental health triage tool are available in the Emergency Triage Education Kit.

The Vanderbilt ICU Delirium and Cognitive Impairment Study Group website13 includes resources for monitoring and managing delirium in intensive care units as part of a bundle of measures for prevention and safety.

Last updated 30th May, 2018 at 01:45am
BACK TO TOP
References

Australian Commission on Safety and Quality in Health Care. National consensus statement: essential elements for recognising and responding to acute physiological deterioration. Sydney: ACSQHC; 2017.

Yeung MS, Lapinsky SE, Granton JT, Doran DM, Cafazzo JA. Examining nursing vital signs documentation workflow: barriers and opportunities in general internal medicine units. J Clin Nurs 2012;21(7–8):975–82.

Fidler R, Bond R, Finlay D, Guldenring D, Gallagher A, Pelter M, et al. Human factors approach to evaluate the user interface of physiologic monitoring. J Electrocardiol 2015;48(6):982–7.

Cvach M. Monitor alarm fatigue: an integrative review. Biomed Instrum Technol 2012;46(4):268–77.

Preece MHW, Horswill MS, Hill A, Karamatic R, Hewett D, Watson MO. Heuristic analysis of 25 Australian and New Zealand adult general observation charts. Sydney: Australian Commission on Safety and Quality in Health Care; 2010.

Preece M, Horswill M, Hill A, Watson M. The development of the adult deterioration detection systems (ADDS) chart. Sydney: Australian Commission on Safety and Quality in Health Care; 2010.

Horswill M, Preece M, Hill A, Watson M. Detecting abnormal vital signs on six observation charts: an experimental comparison. Sydney: Australian Commission on Safety and Quality in Health Care; 2010.

Bellomo R, Ackerman M, Bailey M, Beale R, Clancy G, Danesh V, et al. A controlled trial of electronic automated advisory vital signs monitoring in general hospital wards. Crit Care Med 2012 Aug;40(8):2349–61.

Australian Commission on Safety and Quality in Health Care. National consensus statement: essential elements for recognising and responding to clinical deterioration. Sydney: ACSQHC; 2010.

Australian Commission on Safety and Quality in Health Care. Delirium clinical care standard. Sydney: ACSQHC; 2016.

Australian Commission on Safety and Quality in Health Care. Indicator specification: delirium clinical care standard. Sydney: Australian Commission on Safety and Quality in Health Care; 2016.

Royal Australian and New Zealand College of Psychiatrists. Assessment and management of people with behavioural and psychological symptoms of dementia (BPSD): a handbook for NSW clinicians. Sydney: NSW Ministry of Health; 2013.

Johnston M, Arora S, King D, Stroman L, Darzi A. Escalation of care and failure to rescue: a multicenter, multiprofessional qualitative study. Surgery 2014;155(6):989–94.

Health Research & Educational Trust (US). Preventing iatrogenic delirium change package. Chicago (IL): Health Research & Educational Trust; 2016.

Australian Commission on Safety and Quality in Health Care. Indicator specification: delirium clinical care standard. Sydney: ACSQHC; 2016.

Dyer K, Hooke G, Page AC. Development and psychometrics of the five item daily index in a psychiatric sample. J Affect Disord 2014;152-154:409–15.

Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet 2014;383(9920):911–22.

Australian Government Department of Health. Mental health triage tool. Canberra: DoH; 2013.