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Patient assessment: do you use your ABCDE?

The pros of the ABCDE approach are accepted, yet ‘doing the obs’ remains common practice
Illustration showing the five elements of the ABCDE approach to assessing deteriorating patients

The pros of the ABCDE approach to assessing deteriorating patients are widely accepted, yet doing the obs remains common practice

In the context of the deteriorating patient, it is accepted (fairly unequivocally) that patient assessment be carried out using an airway, breathing, circulation, disability and exposure (ABCDE) sequence.

This highly systematic and linear approach to patient assessment is often the bedrock of training programmes related to care of the deteriorating patient and/or resuscitation.

An adaptable approach suitable for every healthcare practitioner

Following an ABCDE approach is considered beneficial, as it allows the practitioner to identify potentially life-threatening problems in a timely fashion and in principle by order of severity; severity in this context typically relates to likelihood of inducing further deterioration and/or cardiac arrest.

ABCDE provides a degree of flexibility that allows different practitioners to perform

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The pros of the ABCDE approach to assessing deteriorating patients are widely accepted, yet ‘doing the obs’ remains common practice

Illustration showing the five elements of the ABCDE approach to assessing deteriorating patients
Picture: iStock

In the context of the deteriorating patient, it is accepted (fairly unequivocally) that patient assessment be carried out using an airway, breathing, circulation, disability and exposure (ABCDE) sequence.

This highly systematic and linear approach to patient assessment is often the bedrock of training programmes related to care of the deteriorating patient and/or resuscitation.

An adaptable approach suitable for every healthcare practitioner

Following an ABCDE approach is considered beneficial, as it allows the practitioner to identify potentially life-threatening problems in a timely fashion and – in principle – by order of severity; severity in this context typically relates to likelihood of inducing further deterioration and/or cardiac arrest.

ABCDE provides a degree of flexibility that allows different practitioners to perform varying levels of assessment within each component, according to their own scope of practice, while broadly using the same generic sequence.

For example, a healthcare assistant assessing breathing might look at a patient’s chest to measure respiratory rate, observe work of breathing and measure peripheral oxygen saturations; a registered nurse (in a clinical specialist role) may do all of the above but also add in further physical assessment, such as elements of palpation, percussion and auscultation.

‘It may be more helpful if we change our language and substitute ‘the obs’ for ‘the vital signs’’

The ABCDE approach also permits interventions to be delivered in a targeted and priority-based fashion, making it clear when the needs of the patient exceed the practitioner’s individual capacity to deliver a suitable treatment. This mismatch should signal strongly that escalation is required and that a team approach may be needed to optimise the patient’s care.

At the point of escalation, having assessed the patient systematically, the practitioner should be well positioned to summarise their clinical findings in accordance with the ABCDE structure, which is typically well understood by those who respond to escalation (for example, doctors and members of a critical care outreach team or equivalent).

If we know ABCDE works, why don’t we use it in patient assessments?

Broadly, we seem to have accepted ABCDE assessment as a sensible, useful and suitable approach to assessment of the deteriorating patient. Despite this, I rarely observe nurses actually performing this mode of assessment in clinical practice.

Perhaps this suggests our acceptance of ABCDE as a useful approach to patient assessment is more theoretical than practical.

Are nurses using ABCDE as a framework for organising and making sense of existing clinical cues, rather than using it to gather new clinical data through enacting a series of assessments in a prescribed sequence?

Image showing a someone checking a person's breathing, one of the five elements of the ABCDE approach
For some, aligning vital signs with the
relevant ABCDE – ie, respiratory rate to
breathing – is not intuitive Picture: iStock 

If so, why do nurses not consistently use ABCDE to assess deteriorating patients? What are the barriers to performing a systematic assessment using this approach?

These are, perhaps, questions that warrant further attention and investigation. Arguably, answering these questions is particularly important in view of the increased emphasis placed on clinical assessment in the Nursing and Midwifery Council's 2018 Standards of Proficiency for Registered Nurses.

What nurses refer to in practice as ‘doing the obs’

In practice, carrying out a clinical assessment on a patient appears to be synonymous with ‘doing the obs’. This is a phrase that I hear often in clinical practice when nursing staff are discussing or delegating tasks related to patient monitoring and surveillance.

Recently, I have witnessed very experienced critical care outreach colleagues challenging this use of language, suggesting that ‘doing the obs’ steeps the monitoring of our most vulnerable patients within a task-orientated process, and devalues the overall importance of these episodes of patient assessment.

For starters, it may be more helpful if we change our language and substitute ‘the obs’ for ‘the vital signs’. Given that 60-80% of patients who deteriorate and collapse in hospital have changes in these clinical signs, the case for how very vital they are is strong. Is it time for our language to reflect the importance of these clinical data more explicitly?

A cluster of clinical cues that builds a bigger picture of the patient’s risk

In addition to a change of language, we may need to consider reframing how we view the clinical data that is collected from episodes of patient monitoring.

For some, separating the vital signs and aligning the individual parameters to the relevant ABCDE systems (ie, respiratory rate to breathing, blood pressure to circulation) is not intuitive.

Perhaps we have become so adept at seeing the whole picture of these physiological data and generating aggregates (as in the NEWS2 score) that we have lost some of our focus on the smaller independent units that make up the score – each vital sign – and therefore our ability to pull the vital signs apart and link each measurement back to a system.

It may be helpful to view the vital signs as a cluster of clinical cues that can be combined to build a picture of the patient’s broader level of clinical risk, while also acknowledging that the data should be examined separately to identify discreet physiological changes and alterations over time.

Helpfully, the Royal College of Physicians amended the second version of the National Early Warning Score (NEWS2) to include ABCDE and make the links between ABCDE and vital signs more explicit.


Duncan Smith, lecturer in advanced practice at City, University of LondonDuncan Smith is lecturer in advanced practice at City, University of London, and honorary charge nurse in the patient emergency response & resuscitation team (PERRT) at  University College London Hospitals NHS Foundation Trust 

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