title: Defining clinical deterioration.
abstract: OBJECTIVE
  To review literature reporting adverse events and physiological instability in order to develop frameworks that describe and define clinical deterioration in hospitalised patients.
  
  
  METHODS
  Literature review of publications from 1960 to August 2012. Conception and refinement of models to describe clinical deterioration based on prevailing themes that developed chronologically in adverse event literature.
  
  
  RESULTS
  We propose four frameworks or models that define clinical deterioration and discuss the utility of each. Early attempts used retrospective chart review and focussed on the end result of deterioration (adverse events) and iatrogenesis. Subsequent models were also retrospective, but used discrete complications (e.g. sepsis, cardiac arrest) to define deterioration, had a more clinical focus, and identified the concept of antecedent physiological instability. Current models for defining clinical deterioration are based on the presence of abnormalities in vital signs and other clinical observations and attempt to prospectively assist clinicians in predicting subsequent risk. However, use of deranged vital signs in isolation does not consider important patient-, disease-, or system-related factors that are known to adversely affect the outcome of hospitalised patients. These include pre-morbid function, frailty, extent and severity of co-morbidity, nature of presenting illness, delays in responding to deterioration and institution of treatment, and patient response to therapy.
  
  
  CONCLUSIONS
  There is a need to develop multiple-variable models for deteriorating ward patients similar to those used in intensive care units. Such models may assist clinician education, prospective and real-time patient risk stratification, and guide quality improvement initiatives that prevent and improve response to clinical deterioration.
authors: DEPM Monash University, Australia. Daryl.Jones@austin.org.au
authors: Daryl
authors: D
authors: Jones
authors: Imogen
authors: I
authors: Mitchell
authors: Ken
authors: K
authors: Hillman
authors: David
authors: D
authors: Story
mesh_terms: D016638:Critical Illness / Q000401:mortality / Q000628:therapy; D061345:Early Medical Intervention / Q000379:methods / Q000592:standards; D006305:Health Status Indicators; D017052:Hospital Mortality; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007297:Inpatients / Q000706:statistics & numerical data*; D007362:Intensive Care Units / Q000592:standards; D008962:Models, Theoretical; D008991:Monitoring, Physiologic / Q000379:methods / Q000706:statistics & numerical data; D018570:Risk Assessment / Q000379:methods; D017751:Safety Management / Q000379:methods / Q000592:standards
keywords: Adverse event; Clinical deterioration; Deteriorating patient; Patient deterioration; Rapid response team; Risk stratification