What is ABCDE and why is it important?
Assessing patients, identifying swiftly those whose condition is deteriorating and prioritising interventions is an essential part of safe healthcare.
One well-established way to carry out assessments is to use the ABCDE approach, which stands for:
- Airway
- Breathing
- Circulation
- Disability
- Exposure
This approach is taught on preregistration nursing programmes and by the Resuscitation Council UK as part of its advanced life-support courses.
ABCDE prioritises life-saving interventions, in a similar way as the national early warning score (NEWS2) assesses patient deterioration.
Using your senses and clinical judgement
Cardiff University lecturer in adult nursing Andy Parry, says ABCDE allows healthcare professionals to pick up subtle changes in a person’s condition that may not be revealed through a significant score on an early warning score chart until later.
Most of the ABCDE approach involves using the senses, clinical judgement and a minimum of equipment, with the focus on feeling the patient’s hands, checking capillary refill time, counting and considering the quality of breathing, and manually monitoring the pulse for rate and quality, he says.
Andy Parry
Andy Parry
‘ABCDE is the gold standard, and we should be using it to assess all patients physically. I always tell students you shouldn’t become overly reliant on equipment, you need your senses and your clinical skill.’
Mr Parry says ABCDE is a quick but thorough assessment he can complete in under four minutes. It should be used in all patients in all settings, he says.
‘We don’t know when patients are going to deteriorate, so if we use this all the time, we have a baseline to be able to recognise in the very early stages when someone is deteriorating,’ Mr Parry says. ‘The earlier you can recognise a patient is becoming acutely unwell, the quicker you can address it and escalate it, and the better the outcome.’
Some underlying principles of ABCDE
- Complete an initial assessment and re-assess regularly
- Treat life-threatening problems before moving to the next part of assessment
- Recognise when you will need extra help. Call for appropriate help early
- Communicate effectively: use the Situation, Background, Assessment, Recommendation (SBAR) or Reason, Story, Vital signs, Plan (RSVP) approach
- The aim of the initial treatment is to keep the patient alive, and achieve some clinical improvement. This will buy time for further treatment and to make a diagnosis
Source:
Resuscitation Council UK
A is for Airway
Is the patient’s airway obstructed?
The first step is to check for an airway obstruction, which is an emergency. The airway is the passage between the lips and trachea.
The Resuscitation Council UK says airway obstruction should be escalated immediately. Untreated, it risks damage to the brain, kidneys and heart, cardiac arrest and death.
Speak to the patient, asking an open question such as ‘How are you?’. If the person responds by speaking normally, they have an unobstructed airway.
‘The approach is quick to use – if a patient is talking to me, I know their airway is good’
When concern persists, look for the signs of airway obstruction including paradoxical chest and abdominal movements (see-saw respirations). Depressed consciousness often leads to airway obstruction.
In most cases, only simple methods of airway clearance are required, such as airway-opening manoeuvres, airway suction, insertion of an oropharyngeal (Guedel) or nasopharyngeal airway.
Give oxygen at high concentration.
B is for Breathing
Look, listen and feel for the general signs of respiratory distress. These include sweating, central cyanosis, use of the accessory muscles of respiration and abdominal breathing.
Assess the depth of each breath, the pattern and rhythm of respiration and whether chest expansion is equal on both sides.
Count the respiratory rate to see if the patient has a normal rate of 12 to 20 breaths per minute. A high rate of 25 or more, or an increasing respiratory rate, can be a warning that the patient may deteriorate suddenly.
‘I have seen personally and professionally that ABCDE is a simple, straightforward tool that should be used universally’
Listen to the patient’s breath a short distance from their face. Rattling airway noises indicate airway secretions, usually caused by inability to cough sufficiently or to take a deep breath. Stridor or wheeze suggests partial, but significant, airway obstruction.
Look for chest deformities and percuss and auscultate the chest, if competent to do so.
Life-threatening conditions
While assessing breathing, it is vital to diagnose and treat immediately life-threatening conditions, which could include acute severe asthma, pulmonary oedema, tension pneumothorax and massive haemothorax (a collection of blood in the pleural cavity).
Pocket mask ventilation
Pocket mask ventilation
If the patient’s depth or rate of breathing is judged to be inadequate, or absent, use a bag mask or pocket mask ventilation while calling for expert help.
Normal breathing – the respiratory rate is between 12-20 breaths per minute and the chest expands symmetrically
Normal breathing – the respiratory rate is between 12-20 breaths per minute and the chest expands symmetrically
C is for Circulation
Shock and hypovolaemia
Loss of blood or fluid can cause shock. Shock is defined as impaired delivery of oxygen and nutrients to the tissues, which leads, ultimately, to organ dysfunction.
Assess the effect of hypovolaemia by looking at the colour of the hands and extremities to see if they are blue, pink, pale or mottled, and feel them to see if they are cool. In darker skin, areas such as the nail beds may be easier to assess.
Capillary refill
Measure the peripheral capillary refill time by compressing a fingertip for five seconds at heart level, or just above, with enough firm pressure to cause blanching. Time how long it takes for the skin to return to the colour of the surrounding skin after releasing the pressure. A central capillary refill time can also be measured using the upper sternum to assess whether any peripheral compromise is also systemic. The normal time is less than two seconds.
Record the patient’s heart rate and blood pressure to see if it is within the normal range. Look thoroughly for external haemorrhage from wounds or drains, or evidence of concealed haemorrhage.
Check the patient’s blood pressure
Check the patient’s blood pressure
The specific treatment of cardiovascular compromise depends on the cause, but should focus on intravenous fluid replacement, haemorrhage control and restoration of tissue perfusion.
Give prescribed intravenous fluid, which may include blood products in haemorrhage, to any patient with cool peripheries and a fast heart rate, but this must be considered in the context of any pre-existing cardiac condition.
To measure capillary refill time, squeeze the patient’s fingertip firmly for 5 seconds, release, then time how long the skin takes to return to normal colour
To measure capillary refill time, squeeze the patient’s fingertip firmly for 5 seconds, release, then time how long the skin takes to return to normal colour
If the patient is not alert, speak to them to check their level of consciousness
If the patient is not alert, speak to them to check their level of consciousness
D is for Disability
A rapid assessment of the patient’s level of consciousness should be performed, and the Resuscitation Council UK recommends the AVPU tool is used for this:
A – The patient is alert
V – The patient responds to verbal stimulus
P – The patient responds to painful stimulus
U – The patient is unresponsive
Some hospital organisations are adding a C to the end of this check to see if the patient presents with new confusion or delirium.
Nurses should check the patient’s drug chart for reversible drug-induced causes of reduced consciousness, examine pupillary response to light and measure blood glucose to exclude hypo or hyperglycaemia.
E is for Exposure
While respecting dignity and minimising heat loss, a full exposure of the patient’s body is necessary for an overall examination.
Nurses should look for evidence of internal or external bleeding. Internal bleeding can be indicated by swelling of the abdomen or abnormal patterns of bruising on the abdominal wall.
‘If you have done ABCDE, you have all the evidence to fight your case for why a busy doctor should come and see your patient now’
A Nursing Standard article on ABCDE recommends checking the presence and location of rashes or skin changes that may indicate hypersensitivity reaction, and observing for any clinical signs suggestive of deep vein thrombosis, including a hot, painful, swollen calf. Limb deformity could indicate a fracture.
Measure and record the patient’s temperature. An abnormal temperature is a common finding in patients with infections and associated inflammation. A temperature above 38˚C or below 36˚C should raise suspicion of sepsis.
Case studies
Nurses from diverse clinical settings explain why ABCDE is essential to their practice
The emergency call-out
Air ambulance nurse Owen Hammett on how ABCDE is adapted in cases of major trauma
Owen Hammett is a nurse and critical care practitioner who responds to the most serious 999 calls for his job with Dorset and Somerset Air Ambulance.
He attends serious road accidents, major medical emergencies and other call-outs as part of a team on the helicopter, or alone in a rapid-response car.
‘One of the benefits of ABCDE is I know it will be used by paramedics and the hospital emergency team, and that is important’
ABCDE is the first process he carries out on reaching most patients, apart from major trauma, when he follows a slightly modified version. In these cases, he and his colleagues preface the approach with C for catastrophic haemorrhage, with the first priority to stop major bleeding, before moving on to airway and the subsequent stages of ABCDE.
It is a potentially life-saving approach for front-line healthcare staff, he says. ‘ABCDE is vital for medical patients, and CABCDE for our trauma patients. It treats things in the order they will kill you, and that’s why haemorrhage is first in trauma, because there is no point dealing with airway and circulation if there is no blood to carry oxygen to the brain.
‘The approach is quick to use, if a patient is talking to me for example, I know their airway is good.’
A way to structure handover
When patients are handed over to hospital, Mr Hammett uses the ATMIST tool – Age, Time of incident, Mechanism of injury, Injury findings, Signs, Treatment given, which includes a signs section where he runs through the ABCDE findings.
‘When using ABCDE, one of the benefits is that the whole team uses it. I know it will be used by paramedics and the emergency team in the hospital we go to, and that is important,’ he says.
Owen Hammett
Owen Hammett
The acute ward
Lecturer in advanced practice Duncan Smith says ABCDE helps staff structure their thinking when under pressure
On acute wards, identifying deteriorating patients is vitally important but not always easy for often over-stretched staff.
The ABCDE approach is a good tool for busy nurses to use to pick up any problems quickly, says Duncan Smith, lecturer in advanced practice at City, University of London, and honorary charge nurse in the patient emergency response and resuscitation team at University College London Hospitals NHS Foundation Trust.
It provides a quick, structured assessment for nurses in the often hectic ward environment.
‘Collecting observations is task-based; ABCDE is much more about breaking that information down and thinking about it’
‘With ABCDE you are treating problems in order of severity, according to how life-threatening they are, which is why it starts with the airway,’ Mr Smith says. ‘If you structure your assessment using that approach and communicate your findings in that sequence, whoever you are discussing the patient with should understand because it is so widely used.’
But while most nurses are familiar with the protocol, and agree it is a sound approach, it is probably used less on wards than it should be, Mr Smith says.
Duncan Smith
Duncan Smith
This is mainly because it is healthcare assistants, rather than nurses, who tend to be at the coalface of assessing patients, by collecting and recording the observations that are then used to generate an early warning score.
Tools such as the National Early Warning Score 2 – rather than ABCDE – are the primary indicator on many wards that a patient is deteriorating. ‘Collecting observations is a much more task-based approach to identifying deterioration,’ Mr Smith says. ‘ABCDE is much more about breaking that information down and thinking about it.’
Evidence for escalation
He believes a good approach, which is encouraged at his trust, is for nurses to use ABCDE to assess the patient when a NEWS2 warning is triggered. While implementing this approach has not been without challenges, following the model helps nurses to escalate concerns, he says.
‘The reality is that when you call a doctor to come and see a patient, they are very busy and there are probably five to ten things they could be doing at that point. If you have done ABCDE, which is the best-practice approach, you have all the evidence to fight your case for why they should come and see your patient now. This gives the patient the best chance to see a doctor quickly.’
The nursing home
Nurse managing director Anita Astle says ABCDE helps staff reduce hospital admissions
Anita Astle
Anita Astle
Using ABCDE alongside other assessment tools helps nursing homes get the best care in the right place for residents, says Anita Astle, a nursing home managing director.
She and the other nurses at Wren Hall in Selston, Nottinghamshire, use ABCDE to work out what care a resident needs. Having these clinical skills means the home can reduce unnecessary hospital admissions.
‘Homes are now recognising deterioration much more quickly’
There has been a big push to get nursing and residential homes to identify deterioration and sepsis more effectively, Ms Astle says.
‘Homes are now recognising deterioration much more quickly. But the issue with this is that GPs and paramedics whisk people off to hospital, because there is no accepted standard for keeping them in the care home.
‘We know that often, going to hospital is not the best place for residents if we can care for them here. We use ABCDE to structure our assessment, we say this is our assessment of the person, and then we use something like the SBARD – Situation, Background, Assessment, Recommendation, Decision – tool to ensure we communicate clearly with other clinicians, including GPs and paramedics.’
Wren Hall, which has 54 beds, cares for older people who have complex needs. Despite this, it has low admissions to hospital.
Identifying that death is imminent
The ABCDE assessment may indicate that a person is dying, and in that case staying in the home with their family as they wished can be the best outcome, Ms Astle says.
‘That can be identified due to the knowledge and skills of our nursing staff, the confidence that GPs have in our staff, and the fact we communicate effectively with them, the people we care for and their families. This means if there is a need for advance care planning we will have done it.’
The general practice
Nurse Jenny Bishop says ABCDE helps her focus on what’s most important first
Patients with any condition can pass through the front door of a general practice, including those who are dangerously unwell. When confronted by a seriously ill and deteriorating patient, advanced nurse practitioner Jenny Bishop quickly assesses them using ABCDE.
A military and intensive care nursing background means Ms Bishop has a great deal of experience in the value of using ABCDE to assess patients swiftly.
‘ABCDE is useful because it is systematic – I know I have covered all the basics and quickly’
While used much less in primary care, she says she still reaches for the tool occasionally. ‘We deal with everything in primary care, and every now and again we will be caring for a patient who is seriously unwell and deteriorating,’ says Ms Bishop, who works at a general practice in Worcester.
‘Often this will be through serious breathing difficulties, such as one patient I recall who had pneumonia and sepsis.
‘We dial 999 straight away, and while waiting for the ambulance, I run through ABCDE and record it in the notes. I find it useful because it is a systematic approach and focuses your mind on the most important things first, such as airway and breathing, so that I know I have covered all the basics and quickly. You know what you should be doing at that point when you use ABCDE.’
Jenny Bishop
Jenny Bishop
It would be beneficial for more nursing staff in all settings to be comfortable with the ABCDE approach, says Ms Bishop. People with anaphylaxis, myocardial and breathing difficulties, such as asthma attacks, can all present in primary care, she points out.
‘Most of the time we don’t use ABCDE in primary care because it is not an emergency situation, but when it is, it is useful to have the model when time is critical,’ she says. ‘Every nurse in any setting is likely to be involved with an emergency situation at some point.’
A tool that is quick, subtle and systematic – whatever your setting
Nurses who use ABCDE see it is an essential, quick and systematic way to assess unwell patients.
Those who spoke to Nursing Standard said it can and should be implemented in many, if not all, areas of the NHS and independent sector.
Early warning scores are widely used in hospitals and beyond as the front-line assessments for patients. But while these are useful, patients can be deteriorating for some time before triggering a warning because they lack the detail and subtlety of ABCDE, adult nursing lecturer Andy Parry says.
Mr Parry has personal experience of the devastating impact failing to assess patients properly can have. His grandfather died from sepsis after his deteriorating condition was not picked up in hospital.
‘As soon as I saw him it was clear something sinister was happening, there were a lot of red flags, but they were not picked up.
‘I have seen personally and professionally, that ABCDE is a simple, straightforward tool that should be used universally.’
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