Early identification and management of the unstable adult patient in the emergency department

Aims and objectives: The focus of this research was to standardise an emergency observation chart, the Adult Emergency Department Flow Chart, which incorporates elements designed to allow clinicians to more readily recognise the trends of patient deterioration. Background: Patients present to the Emergency Department with some form of instability. Core skills and principles of Emergency Department care are to rapidly and continually assess the clinical condition of the patient, prioritise their care and treat accordingly. Often, however, deterioration of these patients is missed. The incidence of missed deterioration is set within a background of increasing presentations to Emergency Departments, greater complexity of the patient health status, longer length of stay within the Emergency Department and an ageing population. Design: This quantitative research study comprised a retrospective medical record audit. Only those records containing notes relating to an Emergency Department admission were included. Methods: An online data collection tool based on the Adult Emergency Department Flow Chart was developed. A total of 181 medical records were reviewed: 80 during the pre-implementation audit and 101 during the post-implementation audit. Results: The Adult Emergency Department Flow Chart enabled clinicians to better identify deteriorating patients, with a higher number of abnormal vital signs being identified at the post-implementation audit. Identification of pain also dramatically increased at the post-implementation audit. Documentation of notification to Medical Officers also increased, as did documentation of the number of patients receiving medication to help treat the abnormal vital sign. Conclusion: The introduction of the Adult Emergency Department Flow Chart facilitated the essential role of nurses in the identification, documentation and monitoring of the unstable or deteriorating patient in the Emergency Department. Further research is required with larger samples to determine the impact of the Adult Emergency Department Flow Chart on the timely management of abnormal vital signs. Relevance to clinical practice: The Adult Emergency Flow Chart provides a valuable tool for the early identification and subsequent management of an unstable / deteriorating adult in the emergency department, particularly for clinicians with limited experience