Background

The global population is ageing. An estimated 2 billion people will be 65 or older, and 400 million 80 or older, by 2050 [1]. An anticipated consequence is an increase in the number of older adults living with multiple long-term conditions (MLTCs), age-related diseases and frailty [2]. This will lead to sustained and increased demand for care services, including care homes [3].

Care homes are long-term care facilities, with or without nursing support, which are homes to people requiring 24-h care to support activities of daily living. Most residents live with MLTCs and frailty, many live with dementia, cancer, stroke and heart disease [4]. Consequently, care home residents are at high risk of experiencing acute deterioration [5, 6]. Acute deterioration describes a sudden decompensation of physiological and/or mental status [7]. It can result from acute illness, or exacerbation of a chronic condition. It is potentially avoidable and treatable if recognised and responded to promptly [6, 8,9,10].

Signs and symptoms of acute deterioration may include, but are not limited to, changes in respiratory rate, oxygen saturation, heart rate or rhythm, blood pressure, mental state, skin perfusion, urine output, or temperature [6, 8, 11]. In hospital, early warning score (EWS) assessment tools have been developed and are widely used to identify patients with acute deterioration [12, 13]. These use physiological observations and aggregate scoring systems; with a higher score indicating greater clinical risk of adverse outcomes including injury and death [12]. Systematic implementation of early warning scores has been associated with reduced mortality in hospital and pre-hospital settings [14, 15].

More recently, improvement projects have incorporated EWS systems into care homes [16, 17]. However, it is unclear whether these assessment tools work as well in these settings. The physiological frailty, disability and cognitive impairment of care home residents may mean they manifest acute deterioration in different ways, whilst differing skills and competencies of care home staff may influence the sensitivity and specificity of such approaches [18]. Additionally, changes to care home processes and routines as a result of implementing hospital approaches may have unintended adverse consequences, including depersonalisation of the care setting and opportunity cost for staff who are faced with the choice of prioritising observations or person-centred care [19].

In preparation for work to develop care home specific ways of recognising and responding to deterioration, we set out to identify research, policy, guidelines and protocol papers outlining how care home staff recognise and respond to acute deterioration in residents.

Objectives

To identify published primary research and grey literature including policies, guidelines, and protocols regarding how care home staff:

  1. i.

    identify an acutely deteriorating resident

  2. ii.

    respond to an acutely deteriorating resident

  3. iii.

    use protocols or tools to help deliver care to an acutely deteriorating resident

Method

We conducted a systematic scoping review in accordance with Joanna Briggs Institute (JBI) methodology and used the PRISMA-SCR reporting checklist [20]. The review was registered with JBI Evidence Synthesis, and the full protocol published [21].

Preliminary searches were conducted in January 2019 to identify any existing reviews and locate any relevant clinical guidelines or protocols relating to acute deterioration in care homes. The following electronic platforms were searched: PROSPERO, the Cochrane Library JBI evidence-based practice database, Google Scholar, CINAHL and MEDLINE using the terms “deterioration” and “care homes”. This search yielded few responses in relation to acute deterioration in care homes. No current scoping or systematic reviews were identified. However, two systematic reviews were identified [11, 22] which considered care home deterioration from context of acute secondary care. Additionally, care home stakeholders who were part of the study steering group were asked to recommend any care home specific resources used to support the management of acute deterioration in residents. Stakeholders suggested the Gold Standard Framework [23] and the Enhanced Health in Care Homes [24, 25]. These were excluded as they are resources to manage the care of older people entering the end stages of their lives/were not specific to acute deterioration in care homes.

Search strategy

The search strategy was developed with an information scientist to ensure index and key terms were captured and that searches were conducted in consistent ways across multiple databases [26]. The following electronic databases were searched: CINAHL (EBSCOhost), EMCARE (OVID), MEDLINE (OVID), and HMIC (OVID). To reflect the reconfiguration of healthcare services to explicitly focus on acute deterioration following the Royal College of Physicians’ launch of the National Early Warning Score (NEWS) [13] and our published protocol [21], a time filter was applied to database searches from January 2009 – February 2023. Snowball searches were conducted using the reference lists of included studies.

We used the following search terms: [‘nursing home’ OR ‘residential home’ OR ‘care facility’ OR ‘residential facilities’ OR ‘assisted living facilities’ OR ‘homes for the aged’ OR ‘residential aged care facility’] AND [‘clinical deterioration’ OR ‘rapid’ OR ‘acute’ OR ‘unwell’ OR ‘deterioration’ OR ‘recognise’ OR ‘identify’ OR ‘response’]. Medical Subject Headings (MeSH) terms were used where available. The full search strategy for MEDLINE can be viewed in Additional file 2: appendix II. The final searches were completed on 22 February 2023.

Data extraction & analysis

The title and abstract of each record were reviewed by two researchers (SH and MA) using the eligibility criteria outlined in Table 1. Data were extracted by the primary author (SH) using a modified JBI data extraction tool (Additional file 1: appendix I) and checked by the second reviewer (MA) for consistency. Study characteristics, population, concept, context and main findings in relation to review objectives were extracted from included articles. Snowball searches of included studies’ reference lists were conducted. Included studies were read in full a minimum of three times. Data were analysed thematically using a hybrid of deductive and inductive coding [27, 28] to identify patterns/themes. The approach consisted of using the review questions as an initial, a priori framework to review the data. The researchers also remained open to patterns within the data pertinent to identifying and managing acute deterioration that fell outside the scope of the review questions. All studies were coded manually by author SH and a log of codes generated. Similar codes were grouped together into subthemes and further grouped into main themes. To ensure methodological rigour in analysis, codes and themes were reviewed by author MA and reflexive discussions took place between researchers.

Table 1 Study eligibility criteria
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Results

The search yielded 399 articles after deduplication. After title and abstract screening, 362 were excluded. The full texts of 42 studies were reviewed and a further 33 were excluded at this stage. A meta-synthesis [29] regarding decisions to transfer residents to hospital was screened. This was excluded to avoid duplicating citations as the relevant sourced articles (n = 2) were included. A total of n = 11 eligible studies were included. No relevant national policy or guidelines were identified from the searches. A PRISMA diagram is shown in Fig. 1.

Fig. 1
figure 1

PRISMA flow chart of study search and selection process

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Characteristics and key findings of included studies are summarised in Table 2. All were qualitative studies except for one mixed-methods study that utilised quantitative and qualitative approaches [17]. They comprised: semi-structured interviews plus observations [30,31,32]; semi-structured interviews [17, 33,34,35,36]; individual interviews/focus groups [37] and focus groups [38, 39] with care home staff. Five studies focused on decision-making surrounding transferring residents to hospital [32, 34,35,36,37]. Four studies captured clinical decision making/management of acutely unwell residents [30, 31, 33, 39]. One study used qualitative interviews to examine how resident deterioration is managed following introduction of a hospital avoidance programme [38]. One mixed-method study evaluated the introduction of NEWS in care homes – only the qualitative data have been included in this review as only these data met the eligibility criteria of the study [17]. Studies were conducted in Australia n = 5; UK n = 3; USA n = 1; South Korea n = 1 and Singapore n = 1.

Table 2 Charted data of study characteristics and key findings
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Thematic analysis results

Four main themes, comprising 34 codes (Table 3), were identified: identifying residents with acute deterioration; managing acute deterioration; care home policies and procedures; and factors affecting recognition and response to acute deterioration.

Table 3 Review questions, codes and themes
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Identifying residents with acute deterioration

Reports on how care home staff recognised acute deterioration in residents varied. Central to this theme were descriptions of care home staff relying more on instinct rather than structured tools or guidelines to recognise acute deterioration. Six studies reported ‘knowing the residents’ and their ‘baseline norms’ as enabling them to identify when a resident became unwell [17, 32,33,34, 36, 39]. This was often reported in conjunction with care home staff describing ‘intuition’, a ‘gut feeling’ or ‘just knowing’ when a resident’s health status had deviated from their norm [32, 39]. Furthermore, identification of acute deterioration was reported as care home staff relying on tacit knowledge and their relationship with residents as opposed to conscious logical rationale [31, 34, 39].

O’Neill et al.’s., (2017) study examining nursing home staff’s perceptions of managing acute deterioration following the introduction of a ‘sub-acute program’ reported on a hospital style approach to identifying and managing acute deterioration [38]. The sub-acute program included training on signs and symptoms of acute deterioration, associated illnesses/diagnoses, and use of equipment to manage acute deterioration in residents. Even with this additional knowledge and training, participants still reported a ‘sense of knowing’ when a resident was unwell. Explicit examples of how acute deterioration was identified following the implementation of the sub-acute program were not provided and it remains unclear how/if the intervention improved identification of residents with acute deterioration or if care home staff relied on their knowledge of the resident to detect changes in health. The study also found that detection of acute deterioration was increased because of raised awareness of signs and symptoms and increased confidence in clinical intuition. However, staff reported being competent at recognising when a resident was unwell prior to the programme being implemented. The assertion that the subacute programme increased recognition is not grounded in evidence and it unclear how the authors knew this or how the fact staff were “good” was objectively established [38]. Similar findings were reported in Hodgson et al.’s., (2021) study evaluating the introduction of NEWS in care homes. Staff were interviewed from two care homes, and they reported knowing their residents remained the ‘main source’ of identifying a possible acute deterioration rather than using NEWS [17].

Studies collectively reported reliance on unregistered care staff to identify acute deterioration [31, 32, 36, 37, 39]. Registered Nurses (RNs) were reported as having limited interactions with residents, with most day-to-day contact from Enrolled Nurses (ENs) and Personal Care Assistants (PCAs). RNs had less opportunity to identify acute deterioration because of limited resident contact and the need to work through intermediaries with varying skills and experience. Four studies reported RNs concerns about relying on unregistered staff to identify acute deterioration as early clinical indicators might be missed due to PCAs’ lack of clinical acumen or training [31, 36, 38, 39].

Overall, these concerns reflected a lack of confidence amongst RNs about delegating and/or relying on unregistered staff to identify acutely unwell residents. Countervailing against this was evidence about the importance of PCAs and how they are nurses’ ‘eyes and ears’, best placed to notice changes in residents [31].

Managing acute deterioration

Central to this theme were the common listed actions/series of events undertaken by care home staff to manage acute deterioration and the support available from external healthcare providers (Table 4).

Table 4 Responses to acute deterioration reported in included studies
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Five studies reported on resident transfer to hospital as part of the management plan of a resident but also as an outcome of acute deterioration [32, 34,35,36,37]. Care home staff were reported as aspiring to keep residents in their home because hospitals were considered ‘traumatic’ for residents and staff worried they would not receive high quality and holistic care. Hospital transfers were described as a ‘last resort’ which happened due to lack of adequate resources to manage the condition in the home, emergency scenarios that ‘threatened life’, or family/resident requests. The same issues were reported in studies that had additional services in place to help manage acute deterioration and avoid hospital transfer [17, 37, 38]. O’Neill et al., (2017) found their sub-acute program provided structure for care home staff to assess and provide care for residents in situ in the event of deterioration [38]. Participants stated that their responsibilities had increased however, their time was used differently – focus was directed to providing care to a resident that had deteriorated instead of organising a hospital transfer. Whether the sub-acute programme made it more likely that staff would ask for help and escalate care or, if it prevented hospital admissions was unreported.

Amadoru et al., (2018) reported care homes having access to a purpose-designed ‘rapid-in-reach service’ that could provide assistance for residents with acute deterioration [37]. The RiR service comprised nurse specialists and geriatricians and provided ‘sub-acute care’ to residents in the care home. The study reported RNs/ENs frequent use of the services, especially when access to usual GPs or other health professionals was limited. Not only did this help care home staff, the RiR reduced GP workload, and helped residents who might not be able to access GPs during busy times when they had competing clinical priorities. Outside of the RiR service hours, the study reported problems with accessing timely care for residents and this increased likelihood of residents being sent to hospital.

Registered nurses were considered the highest-ranking figure when managing a resident with acute deterioration within the care home. RNs were described as having overall responsibility and decision-making authority in these scenarios despite having infrequent interactions with residents [31,32,33, 35]. A recurrent pattern identified was RN and PCA role boundaries and how this interfered with managing acute deterioration. On some occasions, this was considered to have a negative impact on resident care and potentially contributed to delayed responses to acutely deteriorating residents [31, 37].

Five studies demonstrated a shift in hierarchy when care home workers requested services from external healthcare providers [31, 32, 35, 37]. The ‘handing over’ of authority and decision making from RNs/ENs/PCAs to attending external healthcare professionals was evident in all studies. This passing of responsibility was not explicit or even conscious. Staff appeared to assume this position when they lacked confidence to lead/manage care of the residents, had litigation concerns, experienced pressure from residents or relatives, and external healthcare professionals undervaluing care home staff’s assessments which was evident in all studies. An exception to this was Hodgson et al., (2021) study which reported the use of NEWS empowered and validated care home staff’s assessments as all involved parties were speaking the same language [17].

Care home protocol and procedures

Scant evidence demonstrated the use or existence of acute deterioration protocols in care homes [17, 30,31,32,33,34,35,36,37,38,39]. However, conditions such as haemorrhage, head injuries, fractures, respiratory distress and falls were protocolised as needing immediate transfer to hospital [31, 34, 36, 37, 39]. Furthermore, care home staff reported occasions where they felt obligated to send residents to hospital regardless of whether this was deemed clinically appropriate. The main reasons for this were described as fear of litigation/disciplinary action, perceived lack of confidence in the ability to perform clinical assessments or as a way of managing other care home pressures such as continuing routine care alongside the demands associated with an acutely unwell resident [34, 36, 37, 39]. A consequence was reported as the potential loss of clinical autonomy and a deskilled of a workforce unable to conduct assessments of unwell residents [31].

Factors affecting recognition and response to acute deterioration

Central to this theme were multiple interrelated factors influencing identification, escalation and management of acutely unwell residents e.g. organisational factors (staffing ratios and skill mix), access to training and equipment, and care home culture (Table 5). These factors were not part of the initial review objectives however, they were prominent in all studies and provided essential context to understanding the management of acute deterioration in care home residents.

Table 5 Factors influencing the care of residents with AD
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The ratio of registered nurses to care home residents had a detrimental impact on early identification and management of acute deterioration. Studies reported RN to resident ratio ranging from 1:30 and 1:150. Two studies found that responses from healthcare professionals was delayed because of low RN to high resident ratios [29, 31]. RNs were unable to review the resident promptly due to competing responsibilities for other residents [30, 36,37,38].

Access to additional support and/or external healthcare providers was described in studies as variable, disjointed and dependent on local service configuration [30, 32, 34, 37,38,39]. The lack of timely multi-disciplinary support appeared to increase the likelihood of residents being admitted to hospital as RNs redirected their focus/care to arranging resident transfer to hospital rather than trying to manage the resident in situ [32, 34, 36, 38, 39].

The fear of litigation was a recurrent pattern identified in the majority of the included studies and directly influenced the management of acute deterioration including decisions to transfer residents to hospital [30,31,32,33,34,35,36,37,38,39]. This was particularly evident for RNs as they were reported as the ‘key individual’ who is accountable for managing any risks to residents. Additionally, nurses were reported as acting like brokers trying to satisfy ‘all sides’ including family, resident and doctor requests [30, 32, 34, 36,37,38]. There were instances reported where family members wanted their relative to receive treatment in hospital despite the nurse’s assessment establishing that this was unnecessary [30, 31, 38]. To help manage resident and relative expectations advanced care plans (ACPs) were described as a useful way to broach discussions around potential deterioration. However, four studies reported that ACPs or ‘emergency care plans’, were inadequate for acute deterioration scenarios and could further complicate decisions about whether to transfer to hospital [30, 32, 34, 37]. Partly, this was due to misunderstandings between ‘for active treatment’ and ‘not for resuscitation (CPR)’ and ACPs not being recognised as a legal document [34]. As a result, staff’s actions to escalate care e.g. calling for an ambulance was a means of managing any uncertainty surrounding the resident’s care and avoid potential litigation issues [30, 35, 36].

Discussion

In this scoping review, we screened 399 journal articles and included n = 11 studies that featured qualitative data about how acute deterioration recognised and responded to in care home residents. Key findings are that most of the literature focusses on what happens when a resident deteriorates, without investigating how best to harness care home staff’s expertise in identifying deterioration. We found evidence of conflict between organisational policies and clinical judgement, issues around workforce including staffing ratios and skill-mix, and variability in the external support services offered to care homes to help manage acute deterioration and prevent hospital admissions. Finally, very little evidence of acute deterioration protocols or in-house procedures to manage this condition were identified.

The majority of sourced studies focused on resident transfer to hospital and not acute deterioration as the phenomenon of interest. Whilst there may be some overlap, in-depth and contextual nuances may have been missed that could provide valuable insights into how care homes manage this condition.

This literature review considers many contributing factors to hospital admission, including shared decision making, prognostication, advance care plans, the roles of multiple professionals and evaluations of hospital avoidance programmes [22, 40,41,42]. However, it does not consider the cascade of events that lead to care home staff identifying residents at risk of deterioration, or their decision to seek help external to the care home. A lack of data exists exploring how the use of care home observations and physiological observations inform subsequent shared decision-making about escalation and management of acute deterioration.

The review highlighted care home staff’s aspirations to manage the care of residents within the care home. However, due to a lack of adequate resources and infrastructure, hospital admissions were deemed unavoidable. Evidence demonstrates the risks and harms associated with hospital admission for older adults living with frailty, such as deconditioning, trauma, hospital acquired infections and poorer health outcomes [43,44,45]. Despite this, the only option for optimal treatment was hospital admission. In the UK, current services are not fit to support the care needs of older adults living in care homes [46]. This appears to be a global issue as highlighted by resource deficits in the articles (paucity of equipment, adequate training and timely access to sub-acute/acute care) [29, 31,32,33, 37, 40]. This requires greater consideration and restructuring of service provision to ensure the health and well-being of care home residents [46].

Within the UK, the uptake of EWS tools (NEWS/RESTORE) accelerated during the COVID-19 pandemic [47]. However, no evidence was identified detailing how they were being used in care homes and their impact on managing acute deterioration in residents with or without COVID. We still do not know the effect of these interventions, how they are being used to inform care, what is considered an appropriate response and whether they have been embedded into practice [18, 48]. Further research to determine the contextual factors surrounding the recognition and response to acute deterioration is needed, with particular attention to the processes of identification, how acute deterioration tools inform the management of this condition and what infrastructure is required to support care home staff when managing the care of acutely unwell residents.

Strengths & limitations

The scoping review followed Joanna Briggs Institute scoping review methodology to ensure rigorous methods were adopted and minimised reviewer bias. A wide range of database searches were conducted to capture a broad range of data and ensure a comprehensive review. The study has provided an overview of the current available evidence regarding the topic of interest and identified the gaps in knowledge regarding acute deterioration in care homes.

Despite the broad search, the study mainly identified service evaluations and the implementation of acute deterioration tools/interventions in care homes that did not consider how care home workers identified or responded to acute deterioration. Further, the systematic development of the search strategy may have narrowed the number of articles retrieved due to the trade-off between specificity and sensitivity. It is likely that some care homes have in-house polices on the management of this condition that would not have been captured using the search strategy. The body of literature identified was small and the majority of studies conducted in Australia. Whilst there are likely organisational similarities in UK care homes, the findings from the review may not translate or apply as well to care home facilities in different countries. As per scoping review methodology, a critical appraisal of the quality of evidence was not conducted.

Conclusion and implications

Recognising and responding to acute deterioration in care home residents is reliant on a complex and open system that encompasses multiple interrelated components. Currently, care home support services remain disjointed and vary across the country [49]. As the UK moves towards a systemised and integrated health and social care service and a focus on proactive, personalised care for older people in care homes [25], further intervention and evaluation studies are needed to enhance resident safety for this vulnerable group. Additionally, we need to fully understand the phenomenon of acute deterioration in the context of care homes and their residents and, to better outline what resources care homes need to manage this condition. This research should be conducted in different countries to understand how it is managed and to identify any differences/similarities in practice which may aid in the earlier identification and treatment of acutely deteriorating elderly patients.