The Nursing Associate's Handbook of Clinical Skills

Table 7.2 An overview of the RSVP escalation method.

A registered nurse is a healthcare professional who has expertise in the delivery of professional nursing care to patients. It is important to remember that registered nurses possess a number of assessment, evaluation and clinical decision‐making skills as well as specific knowledge of disease pathology, pharmacology/medicines management and non‐medical treatments and therapies within the context of compassionate and caring nursing skills.

Registered nurses also maintain accountability for patients under their care, and consequently, a registered nurse should be notified of your assessment of the patient.

The registered nurse may have the ability to manage a patient by putting into place a plan of care which may not necessarily require the patient to be escalated to a physician or other healthcare professional. Registered nurses may have significant experience in the specialism and have developed additional specialist skills and knowledge; they may have access to patient group directives or be non‐medical prescribers, allowing them to administer medications without a direct prescription and as such, and they can be consulted for advice and intervention.

These are registered nurses and sometimes practitioners from other healthcare professions who have advanced training, skills and knowledge which may overlap that of medical practitioners. NPs and ACPs may be able to provide advice, intervene and provide monitoring beyond that of other registered nurses and healthcare professionals.

FY1 doctors are ‘newly qualified’ doctors undergoing a pre‐registration year of experience under very close supervision of a consultant or GP. FY2 doctors have completed the FY1 year and have obtained full registration as a doctor but remain under the supervision of a consultant. When working in a hospital, these are often the first point of contact for concerns about patients.

These are doctors who have completed their foundation training and are now developing in their specialist field of medicine. These doctors are more experienced, and in the later years of training, they are often still referred to as an older term ‘Specialist Registrars’, meaning they are in the final stages of their training to become a consultant.

A consultant is a doctor who has completed speciality training in their specialist medical field. It is rare that consultants provide immediate response to patient concerns; but many are approachable and will often be contacted by more junior doctors for advice and guidance.

Acute hospitals may have a critical care outreach team comprised normally of registered nurses (and sometimes other roles) with significant clinical experience in intensive care or the emergency department and therefore expert at assessing, monitoring and treating unwell and deteriorating patients.

Critical care outreach teams may also provide ongoing monitoring for unwell patients on wards and provide advice and support to nursing and medical staff.

Outreach teams may also carry out other technical roles too, for example, monitoring patient‐controlled analgesia.

A medical emergency team (MET) or ‘Crash Team’ can be contacted on 2222 in an emergency in an acute hospital in the United Kingdom. This team comprises selected on‐call clinicians normally from the on‐call medical team, intensive care teams and critical care outreach teams who respond when called to a medical emergency. The Crash Team is also summoned by calling 2222 and is normally the same clinicians from the MET, although other staff such as resuscitation officers and anaesthetists may also respond to a crash call.

In patient homes, GP surgeries, community hospitals and other community settings, the most appropriate response to a deteriorating patient is the ambulance service; within the United Kingdom, an emergency ambulance is arranged by calling 999.

The first person you speak to will be an operator who will ask you which emergency service you require and will connect you to the ambulance service when asked to. The next person you speak to will be an ambulance service call taker who is not a healthcare professional; therefore, it is important to give clear information about the patient, and this will enable them to complete a triage pathway and arrange the most appropriate response.

They will ask you a set of questions from a protocol which you must answer, even if they seem inappropriate, given your professional role. On arrival of the ambulance, you will normally handover to a clinician such as a paramedic, emergency care practitioner, ambulance technician or registered nurse all of whom have expertise in the management of unwell patients.

The task of passing on important information related to an escalation of concern occurs in every care setting and between care settings (transfers of care) every day, for example, in a person’s own home, the back of ambulances when transferring a patient for place of detention a hospital, community clinics, GP surgeries, to name a few. It is just as important in any of these care settings to ensure that the handover, the escalation of concern, is timely and performed in a systematic manner.

In acute and community inpatient hospitals in the United Kingdom, the use of the National Early Warning Score (NEWS) is now embedded into policies regarding identifying and escalating concerns about patient’s clinical observations, with a scoring system used to identify who should be contacted to provide further assessment of the patient. NEWS is discussed later in the chapter.