Assessment and escalation: ABCDE, NEWS2 and SBAR

Amara Let us do the assessment station, because this is where most of the marks live. ABCDE.

Nadia Airway, breathing, circulation, disability, exposure. Assessed and treated in order, with reassessment after each intervention. And the word I want you to hold on to is order. You do not skip ahead to the interesting problem.

Amara Talk me through it as you would say it in the room.

Nadia Airway. Is it patent. Is the patient talking to me in full sentences, because if they are, the airway is open and I have learned something about breathing too. Breathing: rate, saturations, work of breathing, and oxygen if hypoxic. Circulation: pulse, blood pressure, capillary refill, fluid status, access. Disability: level of consciousness using ACVPU, blood glucose, pupils. Exposure: temperature, skin, wounds, calves, and while I do that I am protecting dignity.

Amara What gets forgotten?

Nadia Reassessment. Candidates give oxygen and move straight on to circulation. Say the sentence out loud: I am going to reassess after that intervention. It is explicitly looked for and it disappears under time pressure.

Amara NEWS2. Give me the numbers that matter.

Nadia Seven parameters aggregated into one score. Respiratory rate, oxygen saturation, air or oxygen, systolic blood pressure, pulse, consciousness on ACVPU, temperature. Then the thresholds. Five or more, or any single parameter scoring three, means urgent review. Seven or more means an emergency response.

Amara Which parameter do people get wrong?

Nadia Respiratory rate, by a very wide margin. It is the most sensitive early indicator of deterioration and it is the one most often invented.

Amara Invented is a strong word.

Nadia It is the right one. Somebody glances, writes eighteen, and moves on. Count for a full sixty seconds, and do not tell the patient you are doing it, because as soon as somebody knows you are counting their breathing, they change it.

Amara Anything else about NEWS2?

Nadia New confusion scores, and it is a red flag rather than a soft sign. And Scale 2 for saturations is only for patients with confirmed hypercapnic respiratory failure and a prescribed target, usually eighty eight to ninety two per cent. Using Scale 2 without that documented decision is an error.

Amara One more thing on scores. What if the number is low but I am worried?

Nadia Then you escalate on your concern. Say it in exactly those words. The score is three but I am concerned about this patient. Clinical concern is a legitimate trigger in its own right, and it saves lives that scores miss.

Amara SBAR. Everybody knows the letters.

Nadia Everybody knows the letters and almost everybody fluffs the last one. Situation, background, assessment, recommendation.

Amara What goes wrong with the R?

Nadia People describe a patient beautifully and then stop. They leave the doctor on the other end of the phone to work out what is actually being asked for.

Amara So what should it sound like?

Nadia Specific and time bound. I need you to review him within the next fifteen minutes. Or, I am asking for an urgent medical review and I would like a fluid bolus prescribed now. Say what you want and say when you want it.

Amara Last topic, and the most serious. Sepsis.

Nadia A person with suspected infection who has signs of organ dysfunction. Deteriorating NEWS2. New confusion. Low blood pressure. Reduced urine output. Mottled or ashen skin. A non blanching rash.

Amara And the response?

Nadia Time critical and bundled. Oxygen if indicated. Blood cultures before antibiotics where that does not delay them. Intravenous antibiotics. Intravenous fluids. Lactate. Monitor urine output. And escalate immediately, saying out loud that you are escalating.

Amara Is there one thing that makes the difference?

Nadia Saying the word. Say sepsis out loud. Both in an exam and on a real ward. A patient who is described accurately but whose suspicion is never named does not get the pathway started. Naming it is what starts the clock.