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The deteriorating patient
Recognise it early, escalate it clearly, and don't do it alone. NEWS2 tells you when to worry; an A–E assessment tells you why. Treat what you find, escalate with a clear SBAR call, and know the patient's ceiling of care before 3 am. Built for revision, not live patient decisions.
Settle them, and check the basics
recognise · respondRed flags — what each should make you think
New confusion scores 3 on NEWS2 on its own, and is often the first sign of sepsis, hypoxia or hypoglycaemia. Never put it down to "just dementia" without checking.
The response
- A–EAssess A–E
- 🧪Bedside tests
- 📋Review notes + drug chart
- ☎Escalate with SBAR
- 🔁Reassess
- 📝Document + plan
Understand NEWS2
RCP NEWS2The parameters
- Respiration rate
- Oxygen saturation (Scale 1, or Scale 2 for confirmed hypercapnic respiratory failure, target 88–92%)
- Air or supplemental oxygen
- Systolic blood pressure
- Pulse rate
- Consciousness: ACVPU (new Confusion scores 3)
- Temperature
Thresholds and responses
- 0–4 — ward-based response (registered nurse assessment; minimum 4–6-hourly obs at 1–4)
- A score of 3 in any single parameter — urgent ward-based response
- 5–6 — urgent response: clinician review; key threshold for urgent assessment and suspected sepsis
- 7 or more — emergency response: critical care outreach/team, continuous monitoring
Common causes on the ward
- Sepsis (chest, urine, wounds, lines)
- Bleeding (post-op, GI, anticoagulants)
- PE, MI, arrhythmia
- Respiratory failure, fluid overload
- Opioid or sedative toxicity
- Hypoglycaemia, AKI, electrolyte disturbance
- Delirium (look for its cause)
Work A–E — assess and act as you go
The diagnoses you must not miss
tap to open eachWhat points toward it, what would rule it in, and how to manage it.
Unresponsive, not breathing normally, or rapidly deteriorating.
Clinical.
Call 2222, start CPR/ALS, unless a DNACPR decision is in place.
Infection plus raised NEWS2, new confusion, low BP, high lactate.
Lactate, cultures.
Sepsis bundle within 1 h. See the septic patient page.
Tachycardia, hypotension, drains filling, melaena, falling Hb.
VBG Hb, FBC, clotting.
Fluids/blood, reverse anticoagulation, call surgical team / MHP.
Drowsy, RR low, pinpoint pupils, especially with AKI or after dose increase.
Clinical; drug chart.
Naloxone titrated (e.g. 100–200 microgram IV increments) — avoid precipitating severe pain/withdrawal; review analgesia.
Confusion, drowsiness, seizures, especially on insulin/sulfonylureas.
Capillary glucose.
Oral glucose if able; IV 10% glucose or IM glucagon if not.
Investigate — what to order, when, and what it tells you
test with a question in mindBedside
Bloods
Imaging
How the plan comes together
disposition · handoverSBAR — make the call count
- Situation — who you are, who the patient is, what's wrong now ("NEWS2 7, hypotensive")
- Background — why they're in hospital, relevant history, ceiling of care
- Assessment — your A–E findings and what you've done
- Recommendation — what you need ("please come and review within 15 minutes")
ward + plan
Improving after intervention: clear plan, obs frequency increased, review time set, nurse aware of escalation triggers.
critical care
Not responding, NEWS2 ≥7, organ support needed, or for escalation within the ceiling of care.
Ceilings of care: check the treatment escalation plan/ReSPECT form; discuss with the patient and family when possible.
Martha's Rule
In England, patients and families can request an urgent review (often via critical care outreach) if they're worried a patient is deteriorating and not being listened to. Their concern is a valid reason to escalate.
Trust NEWS2 and the nurse who's worried. Assess A–E, treat what you find, call early with SBAR, and know the ceiling of care. Nicely done getting here.
Clerking template
copy or downloadThe deteriorating patient — documentation structure
A structure and prompt list to help you document and think systematically. It is not a completeness check and cannot guarantee nothing is missed — use your trust's own proforma, your seniors, and your clinical judgement.
Test yourself
active recallCover the answer, say it out loud, then reveal. Retrieval beats re-reading.
0 / 11 knownFrequently asked questions
quick answersWhat are the red flags for the deteriorating ward patient?
- NEWS2 ≥7 — think emergency response — critical care team
- NEWS2 5–6 — think urgent review — think sepsis
- Single parameter scoring 3 — think urgent review
- New confusion — think scores 3 — never ignore
- Unresponsive, not breathing normally — think cardiac arrest — 2222
- Patient or family saying "something is wrong" — think escalate (Martha's Rule)
What is the initial management of the deteriorating ward patient?
- Assess A–E — treat as you go
- Bedside tests — glucose, ABG/VBG, ECG, bladder scan
- Review notes + drug chart — new drugs, missed drugs, fluid balance, recent procedures
- Escalate with SBAR — Situation, Background, Assessment, Recommendation
- Reassess — after each intervention and set a time to review
- Document + plan — including ceiling of care and resuscitation status
Always alongside senior support and your local guideline.
What diagnoses must you not miss in the deteriorating ward patient?
- Peri-arrest / cardiac arrest — call 2222
- Sepsis — NEWS2 ≥5
- Haemorrhage — post-op · GI · anticoagulated
- Opioid toxicity — pinpoint pupils · slow RR
- Hypoglycaemia — confusion · sweating
Open each one in the must-not-miss section for what points toward it, how to rule it in, and how to manage it.
What investigations should a junior doctor order for the deteriorating ward patient?
- Bedside — Always.
- Bloods — FBC, U&E, CRP, LFT, clotting, troponin, cultures.
- Imaging — Respiratory deterioration.
Admit or discharge: how is the plan decided for the deteriorating ward patient?
- Ward + plan — Improving after intervention: clear plan, obs frequency increased, review time set, nurse aware of escalation triggers.
- Critical care — Not responding, NEWS2 ≥7, organ support needed, or for escalation within the ceiling of care.
Is there a clerking template for the deteriorating ward patient?
Yes — there is a free clerking template for the deteriorating ward patient on this page, structured as presenting complaint, red flags asked, history, examination (A–E), investigations, differentials, plan and escalation. You can copy it or download it as a Word document. Jump to the template.
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