Deteriorating Patient at Peripheral Hospitals - Standard Operating Procedure

Publication: 13/09/2021  
Next review: 13/09/2023  
Standard Operating Procedure
ID: 7162 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2021  


This Standard Operating Procedure is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Standard Operating Procedure - Deteriorating Patient at Peripheral Hospitals


Patients who are admitted to hospital expect that they are entering a place of safety, where they, and their families and carers, have a right to believe that they will receive the best possible care. They feel confident that, should their condition deteriorate, they are in the best place for prompt and effective treatment.

The National Institute for Health and Care Excellence (NICE) have identified that Patients who are, or become, acutely unwell in hospital may receive suboptimal care. This may be because their deterioration is not recognised or because – despite indications of clinical deterioration – it is not appreciated, or not acted upon appropriately.

The provision of specialist care, in relation to the deteriorating patient, at LTH peripheral sites differs from cover at Leeds General Infirmary (LGI) and St James University Hospital (SJUH), therefore, a clear process is required to ensure early detection of deterioration and initiation of timely interventions to prevent further deterioration and where applicable, transfer from peripheral sites to LGI or SJUH.

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Process of Escalation

Patients should have clearly documented recommendations for emergency treatment, and these are most appropriately recorded in a ReSPECT document.
Patient observations should be recorded at a minimum of 12 hourly; however, the frequency of observations must be increased in response to a patient’s abnormal observations and Early Warning Score, in line with the NEWS2 graded response algorithm. 
Observations must include as a minimum;

  • Pulse
  • Blood pressure
  • Respiratory rate
  • Temperature
  • Oxygen saturations
  • Oxygen support
  • Level of consciousness (ACVPU)

Staff caring for the deteriorating patient should follow the following escalation process;

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Process for Inter-Facility Transfer

To arrange an Inter-facility transfer to LGI or SJUH:

Call 0300 330 0276

Response times will be dependent on risk stratification using the following algorithm.

It is the intention of YAS to maintain the highest level of care to the public of Yorkshire including times when it is experiencing capacity pressures and periods of high demand.  As such, during situations of excessive call volume or reduction in staff numbers, which results in the supply of ambulance service resources being insufficient to meet the clinical demand of patients, response times may vary commensurate with the Yorkshire Ambulance Service Demand Management Plan.

In the event of a Cardiorespiratory Arrest event a 999 call should be made and the clinical staff on site should commence CPR until the ambulance crew arrive.

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Record: 7162

The purpose of this document is to provide direction and guidance for the coordinated approach to identified clinical deterioration in patients at LTHT peripheral sites.  It sets out the escalation actions that aim to prevent further clinical deterioration and possible subsequent cardiac arrest, including the process for Inter-facility transfers via Yorkshire Ambulance Service (YAS).  The term peripheral sites will be used throughout this document to refer to Chapel Allerton, Wharfedale and Seacroft Hospitals and will include the Nightingale Hub if operational.

This document should be read in conjunction with;

LTHT Policy for the Prevention and Management of the Deteriorating Patient, Version 3, April 2021.

LTHT Guideline: Recording and Acting upon Physiological Observations in Adult in-Patients.

Standard Operating Procedure: Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) including Cardiopulmonary Resuscitation (Adults)

Clinical condition:
Target patient group:
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

LTHT Policy for the Prevention and Management of the Deteriorating Patient Version 3, approved April 2021.

Acutely ill adults in hospital: recognising and responding to deterioration, NICE CG50, July 2007.

Yorkshire Ambulance Service Demand Management Plan. Version 5.2.1. March 2020.

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.1

Related information

Not supplied

Equity and Diversity

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