Introduction to ABCDE Assessment

Week 1

 Context

Critically ill patients in hospital sometimes receive suboptimal care, either because staff have not recognised that they are ill and are deteriorating or because, despite indications of clinical deterioration, staff do not appreciate or act upon them in a sufficiently timely manner (National Institute for Health and Clinical Excellence (NICE), 2007). All health care workers can find themselves in a situation where they are the first to recognise that a patient is deteriorating, and this might occur in any health care setting, not just an Accident & Emergency department. It is important, therefore, that all health care workers understand what to look out for, how to assess at the condition of a patient in a systematic way, and how to communicate what they find in a clear and effective way. How much of an assessment you carry out will depend on your level of knowledge and experience, although everyone should use the standard ABCDE approach.

Why the ABCDE Approach

The ABCDE approach is recommended by:

• Resuscitation Guidelines 2015
• National Institute for Health and Care Excellence (NICE)
• Royal College of Physicians (RCP), Royal College of Paediatrics and Child Health (RCPCH)

It is applicable to all clinical areas and it can be used without any equipment in a first aid situation

Content

Starting the Assessment

• Consider safety first
• Infection Control
• Communication
• Visual assessment of the patient
• Consider privacy and dignity

Airway: Is the airway patent? (this is covered at both universal and advanced level in Week 3) Patent: If the patient is talking, or responds in a normal voice, and in normal sentences, then the airway is patent. Partially Obstructed Airway: Signs of a partially obstructed airway include a changed voice, being able to speak only in phrases or words, noisy breathing (eg, stridor), and an increased breathing effort. Completely Obstructed Airway: With a completely obstructed airway, there is no respiration despite great effort. A reduced level of consciousness is a common cause of airway obstruction, partial or complete. A common sign of partial airway obstruction in the unconscious state is snoring. Remember an untreated airway obstruction leads to cardiac arrest
	Breathing: Is the breathing sufficient? (this is covered at both universal and advanced level in Week 4) In all settings, it is possible to determine the respiratory rate, inspect movements of the chest for symmetry, and use of accessory muscles. If a patient is already on oxygen (O2), or on a monitor then remember to record all of this for when you escalate concerns (see SBAR below).
Circulation: Is the circulation sufficient? (this is covered at both universal and advanced level in Week 5) A rapid or increasing pulse rate, as well as changes in skin colour, sweating, and a decreased level of consciousness are all signs of insufficient circulation. If the patient is on any form of cardiac monitor then remember to record this for when you escalate concerns (see SBAR below).
	Disability: What is the level of consciousness? (this is covered at both universal and advanced level in Week 6) The level of consciousness can be rapidly assessed using the AVPU Links to an external site. method, where the patient is graded as alert (A), voice responsive (V), pain responsive (P), or unresponsive (U). Alternatively, the Glasgow Coma Score Links to an external site. can be used. If a patient is unresponsive, you need to get help from personnel qualified to secure the patient's airway.
Exposure: any clues to explain the patient’s condition? (this is covered at both universal and advanced level in Week 7) If you feel a patient's condition is deteriorating, look for signs of trauma, bleeding, skin reactions (rashes), needle marks, or anything else that might be the cause. Bearing the dignity of the patient in mind, and where you are when carrying out the assessment, clothing can be moved to allow a better examination. Body temperature can be estimated by feeling the skin or using a thermometer when available.

 

What Next

Having carried out an ABCDE assessment (even a very quick one) and decided that the patient you are with is deteriorating, you will need to escalate your concerns. Inadequate communication is recognised as a being the most common root cause of serious errors – both clinically and organisationally. There are some fundamental barriers to communication across different disciplines and levels of staff. These include hierarchy, gender, ethnic background and differences in communication styles between disciplines and individuals. Communication is more effective in teams where there are standard structures of communication in place. The recommended structure to use is SBAR. 

 References and Further Reading

Haig, KM.; Sutton, S; Whittington, J. (2006) SBAR: A Shared Mental Model for Improving Communication Between Clinicians. Joint Commission Journal on Quality and Patient Safety, Volume 32, Number 3, March 2006, pp. 167-175

National Health Service Wales (2011) Improving Clinical Communication using SBAR Links to an external site.. National Health Service Wales

National Institute for Health and Clinical Excellence (2007) Acutely Ill Patients in Hospital: Recognition of and Response to Acute Illness in Adults in Hospital [Clinical Guideline 50]. NICE, London