Expert advice

How to spot the ‘soft signs’ of deterioration in older people attending the ED

Neal Aplin warns against an over-reliance on the National Early Warning Score

Deterioration in patients can be spotted very early on by nurses who are trained to recognise the signs

Why do emergency nurses need to know about the soft signs of deterioration?

Emergency nurses play a vital role in recognising the early signs of deterioration and enabling prompt interventions to improve care for older patients in urgent care settings.

I work as an advanced clinical practitioner on a community ward caring for older people where staff, including therapy staff, have been trained to recognise the soft signs of deterioration. These subtle changes in a patient can have a huge effect on outcomes, yet not all emergency nurses receive training in them.

How is deterioration commonly

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Deterioration in patients can be spotted very early on by nurses who are trained to recognise the signs

When nurses intuitively recognise something is ‘not quite right’ in a patient, it is likely they are picking up on soft signs of deterioration.
Picture: John Houlihan


Why do emergency nurses need to know about the ‘soft signs’ of deterioration?

Emergency nurses play a vital role in recognising the early signs of deterioration and enabling prompt interventions to improve care for older patients in urgent care settings.

I work as an advanced clinical practitioner on a community ward caring for older people where staff, including therapy staff, have been trained to recognise the ‘soft signs’ of deterioration. These subtle changes in a patient can have a huge effect on outcomes, yet not all emergency nurses receive training in them.

How is deterioration commonly assessed and monitored in acute settings?

The National Early Warning Score (NEWS) system is used in acute hospitals in England, Scotland, Wales and Northern Ireland to improve identification of acutely ill patients, including those with sepsis, and detection of deterioration.

The original NEWS was developed by the Royal College of Physicians in 2012, but was updated in 2017 and is now known as NEWS2.

Under the system, patients are assessed on:

  • Breathing rate.
  • Pulse rate.
  • Systolic blood pressure.
  • Temperature.
  • Level of consciousness or new confusion.
  • Oxygen saturation.

The results are plotted on a NEWS2 chart, which gives a score for each measure. The combined number then shows the level of clinical care needed and the risk of deterioration. For example, a low score of 1-4 leads to an assessment by a registered nurse; a medium score of between 5 and 6 would prompt an urgent review from an acute clinician, such as a ward-based doctor; and a high score of 7 or more would see an emergency assessment by a critical care team and a likely patient transfer to a high dependency unit.

Deterioration can increase risk of organ failure and death, so prompt recognition of a patient’s declining health is key to improving outcomes.

What about non-acute settings?

Nurses working in care homes and other community services may be trained to use RESTORE2 – a physical deterioration and escalation tool based on nationally recognised methodologies, including NEWS2 and spotting soft signs.

This tool is also designed to support healthcare professionals and other staff in care homes to recognise when someone may be deteriorating, or at risk of deteriorating, and act appropriately to protect and manage them.

A soft signs only version of RESTORE2 entitled RESTORE2mini is available for care homes and has been adapted for use in settings such as domiciliary and home care. However, RESTORE2 – or specific training on recognition of soft signs – is not routinely provided across all acute trust settings.

How easily can nurses recognise the soft signs of deterioration?

Early recognition – or the soft signs – of deterioration can be challenging to describe. Often early signs of physical unwellness are recognised by nurses who know that something is wrong, but can’t put their finger on a specific problem. When nurses intuitively recognise something is ‘not quite right’ in a patient, it is likely they are picking up on soft signs of deterioration.

Even people without healthcare training, but who are familiar with someone’s usual behaviour and habits, often sense a problem, says the Wessex NHS Academic Health Science Network. This might result in them reporting that the relative, resident or child in their care ‘just isn’t themselves’.

What are the soft signs of deterioration?

  • Change in sleep patterns
  • Subtle changes in a person’s behaviour
  • Reduced interest in personal care
  • Diminished concentration
  • Increasing dependence on others for their care needs
  • Reduced mobility (which is sometimes referred to as ‘off legs’)
  • Decreased appetite
  • Reduced interest in normal activities, such as reading
  • Diminished concentration
  • Becoming more withdrawn
  • New or worsening confusion

What is the significance of understanding soft signs of deterioration?

Ultimately, being able to identify the soft signs of deterioration could improve patient outcomes favourably. Evidence suggests that it is possible to identify physical deterioration through soft signs before any hard physiological signs are present, such as a raised NEWS2, a common indicator for deterioration.

Research shows nursing assistants in a nursing home, trained to recognise behavioural and functional changes, documented soft signs of illness, which preceded chart documentation by an average of five days. This means soft signs of deterioration may precede changes in NEWS2 several days before this protocol would be triggered.

Recognising deterioration, especially in older people, can be challenging as the older person can present atypically. Furthermore, those living with dementia or those with learning disabilities and/or autism may not be able to communicate their needs or concerns effectively.

As recognising soft signs of deterioration in care homes can reduce hospital admissions, so recognition of these early signs of deterioration are also applicable to hospital-based staff.

One home care provider, which cares for people with brain and spinal injuries, genetic and motor neurone disease, developed its own soft signs checklist for staff. It said it had prevented around 25 hospital admissions through its use.

The Health Foundation found that up to 41% of emergency admissions from care homes may be avoidable as they are for conditions that are potentially manageable, treatable or preventable outside of a hospital setting.

What is the key takeaway?

In practice, I’ve witnessed an over-reliance on NEWS2 as an indicator for deterioration. There can be an erroneous belief among healthcare professionals that as the NEWS2 is normal, the patient must be stable and not deteriorating. This is not always the case – especially with older people, and those living with dementia or learning disabilities and/or autism. Soft signs of deterioration can be present several days before ‘hard’ signs.

Although NEWS2 can undoubtedly help save lives and has an important role to play in emergency departments, emergency nurses should also have an understanding of the soft signs of deterioration. They should remember these signs as part of their toolbox when assessing patients to ensure prompt and appropriate escalation.

Soft signs of deterioration may be the initial signs of deterioration, and should not be so ‘soft’ that they are dismissed, thought of as trivial or not recognised as key indicators of decline.


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