First published in Great Britain in 1999 by the Royal College of Surgeons of England

Second edition 2003

on d
Third edition 2010

si n
This fourth edition published in 2017 by

is la
The Royal College of Surgeons of England
35-43 Lincoln’s Inn Fields,
London, WC2A 3PE


m ng
www.rcseng.ac.uk

©2017 The Royal College of Surgeons of England

er f E
All rights reserved. Apart from any use permitted under UK copyright law, this publication may
only be reproduced, stored or transmitted, in any form, or by any means with prior permission in

tp o
writing of the publishers or in the case of reprographic production in accordance with the terms of
licences issued by the Copyright Licensing Agency.

ou ns
In the United Kingdom such licences are issued by the Copyright Licensing Agency: Saffron
House, 6-10 Kirby Street, London EC1N 8TS.

ith o
Whilst the advice and information in this book are believed to be true and accurate at the date of
w rge
going to press, neither the author[s] nor the publisher can accept any legal responsibility or liability
for any errors or omissions that may be made. In particular (but without limiting the generality
of the preceding disclaimer) every effort has been made to check drug dosages; however, it is
ce Su
still possible that errors have been missed. Furthermore, dosage schedules are constantly being
revised and new side-effects recognized. For these reasons the reader is strongly urged to consult
the drug companies’ printed instructions before administering any of the drugs recommended in
this book.
du of

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library
ro e
ep eg

Library of Congress Cataloging-in-Publication Data

A catalogue record for this book is available from the Library of Congress
t r oll

ISBN 978-1-904096-32-0

Typeset by Prepress Projects Ltd

no C
o al
D oy
R
©
 ©
R
D oy
o al
no C
t r oll
ep eg
ro e
du of

xxii
ce Su
w rge
ith o
ou ns
tp o
er f E
m ng
1

Introduction is la
si n
on d
 Chapter 1  Introduction

Why have CCrISP?

To the non-medical population, surgeons are doctors who perform operations
of varying complexity under general or regional anaesthesia. Much of the initial

on d
motivation for people like you who enter surgical specialties focuses on an interest in

si n
anatomy and pride in the technical skill of operating and how surgery can qualitatively

is la
and quantitatively improve people’s lives. In isolation these motivations form only

m ng
part of the role of a surgeon working within the multidisciplinary environment of
perioperative medical care. Regardless of whether an operation is a technical

er f E
success, the majority of complaints made by patients and their families relate to either
poor communication or real or perceived inadequacies in ward-based care rather

tp o
than the nature of the surgery and technical skill of the operator. In other words, as

ou ns
a surgeon, you are only as good as the team around you (Box 1.1). Therefore, it is
imperative that surgeons and those looking after surgical patients are aware of the

ith o
interactions between these factors and have the skills to deal with them.
w rge
Increasingly, surgical patients are likely to have prolonged inpatient stays, as they are
ce Su

elderly, have undergone major surgery or are emergency admissions. Out-of-hours

duty arrangements may mean that the initial medical responder is not immediately
from the base specialty and may be a doctor, nurse or allied health professional from
du of
ro e

Box 1.1  Risk and stress factors in surgical care

ep eg

• Ageing population
t r oll

• Concomitant chronic disease processes (often severe and associated with

no C

several years of functional decline)

• Expectations: patients', relatives', staff's, society's
o al

• Increasing complexity and specialisation of surgery

D oy

• Greater number of postoperative interventions and therapies

R

• Higher standards of monitoring

©

• Shortage of permanent and experienced nurses

• Altered patterns of doctors’ duty hours

1
 Care of the Critically Ill Surgical Patient®

a medical response or hospital at-night team. As a trainee surgeon, you must be

aware of this and your ability to respond and plan patient care in order to minimise the
rate and severity of complications is vital.

on d
si n
Many of these patients can deteriorate rapidly when their chronic disease processes

is la
combine with a perioperative complication to cause a massive imbalance in oxygen
demand, oxygen delivery and oxygen utilisation. The subsequent development of

m ng
multiorgan dysfunction is likely to precipitate critical care referral and admission,

er f E
with in-hospital mortality rates in excess of 50%. Furthermore, an absolute failure to
recognise and manage an acute deterioration in the perioperative period can result in

tp o
cardiorespiratory arrest, the nature of which is frequently asystole or PEA (pulseless
electrical activity), which carries a mortality rate of > 85%. Even if the patient survives

ou ns
to hospital discharge, there are likely to be significant rehabilitation consequences,
which can in turn be catastrophic for patients and their families. This phenomenon

ith o
w rge
is often described as failure to rescue (FTR) and is recognised throughout multiple
healthcare systems. Early recognition is vital for effective care. In most cases it can
save lives and reduce perioperative complication rates and hospital length of stay,
ce Su

and in a minority of circumstances may save a dying patient from futile, torturous
treatments (Figure 1.1)
du of

Well
ro e

Ward
ep eg
t r oll
no C

Critical Care Admission

o al
D oy

Good Death
R

Bad Death
©

Death
Time
Figure 1.1  Physiological derangement (timely intervention vs. failure to rescue).
CCrISP®, RCS Eng.

2
 Chapter 1  Introduction

At ward level, efforts to reduce FTR have included marrying standard nursing
observations to illness severity or so-called early warning scores, eg in the NHS
the National Early Warning Score (NEWS) has been introduced to enable rapid

on d
measurement and scoring of baseline, bedside clinical measurements. The

si n
measurements (respiratory rate, heart rate, blood pressure, oxygen saturation,

is la
temperature, consciousness level, urine output and the presence of supplementary
oxygen) reflect oxygen delivery and oxygen utilisation, and are easily reproducible

m ng
and documented in a numeric and colour-coded score designed to illicit a so-called

er f E
graded track and trigger response according to severity (Figure 1.2).

tp o
Increasingly, the response to the deteriorating patient is being used as a quality
indicator for healthcare. However, although observation charts encompassing early

ou ns
warning scores have become best practice, the systems are designed as safety nets
in the first stages of preventing FTR – they are not substitutes for good medical and

ith o
w rge
nursing care. Therefore, the challenge for surgeons like you is to use them in
processes that deal with patients who may become critically ill, thereby developing
your practice and interpretation skills to allow early identification and correction of
ce Su

complications. This comes not only through direct application of care but also through
education, training and leadership of others in the principles of dealing with the
du of

acutely ill (Box 1.2). The strategies outlined are complementary, applied in differing
proportions to different patient groups and in modern surgical practice they are
ro e

arguably more important than heroic last-ditch efforts to rescue the patient in
ep eg

extremis.
t r oll

Box 1.2  Complementary approaches to critical care

no C

• Prediction: identifying an at-risk population

o al

• Prevention
D oy

• Prompt identification and early adequate treatment

R
©

Aims of training in surgical critical care

The beginnings of critical illness are detectable and treatable long before a patient
arrives in the critical care unit, with the majority of abnormal clinical signs being
measureable at the bedside. In the UK the three most common abnormalities in the

3
 Care of the Critically Ill Surgical Patient®

NEWS KEY
0 1 2 3 NAME: D.O.B. ADMISSION DATE:
DATE DATE
TIME TIME
≥25 3 ≥25
RESP. 21-24 2 21-24
12-20 12-20
RATE

on d
9-11 1 9-11
≤8 3 ≤8

si n
≥96 ≥96
Sp02 94-95 1 94-95
92-93 2 92-93

is la
≤91 3 ≤91
Inspired 02% % 2 %

2
≥39° ≥39°

m ng
38°
1 38°
TEMP 37° 37°
36° 36°
≤35°
1 ≤35°
3

er f E
230 230
3
220 220
210 210
200 200
190 190
180 180

tp o
NEW SCORE 170 170
uses Systolic 160 160
BP 150 150
140 140

ou ns
130 130
BLOOD 120 120
PRESSURE 110 110
1
100 100
2

ith o
90 90
80 80
70 70
w rge 60
50

>140
130
3

3
60
50

140
130
120 2 120
110 110
ce Su
100 1 100
HEART
90 90
RATE
80 80
70 70
60 60
50 50
40
1 40
du of

30 3 30

Level of Alert Alert

Consciousness V / P / U 3 V/ P / U
ro e

BLOOD SUGAR Bl’d Sugar

TOTAL NEW SCORE TOTAL

ep eg

SCORE
Parameters
Additional

Pain Score Pain Score

t r oll

Urine Output Urine Output

Monitoring Frequency Monitor Freq
Escalation Plan Y/N n/a Escal Plan
no C

Initials Initials
National Early Warning Score: July 2012

National Early Warning Minimum frequency of

o al

© Royal College ofScore

Physicians 2012 monitoring Clinical response
0 12-hourly observations Continue routine NEWS monitoring
with every set of observations
D oy

Total: 1–4 4-hourly observations Inform registered nurse, who must

assess the patient

Registered nurse to decide if

R

increased frequency of monitoring

and/or escalation of critical care is
required
©

Total: 5 or more or 3 in Hourly observations NEWS responder

one parameter
Response time 30 minutes

Total; 7 or more or 3 in Continuous observations Senior NEWS responder and outreach

two parameters
Response time 10 minutes

Stop. Think. Why has my patient triggered?

Figure 1.2  National Early Warning Score (NEWS).

Newcastle upon Tyne Hospitals NHS Foundation Trust, November 2014

4
 Chapter 1  Introduction

90

80

70

on d
60

si n
Percent abnormal

50

is la
40

m ng
30

er f E
20

10

tp o
0
Na K Hb GCS Temp Creat MAP pH WBC RR Oxygenation HR

ou ns
Parameter

Figure 1.3  Abnormal parameters in the 24 hours before intensive care admission.

ith o
Quarterly Journal of Medicine 2001; 94: 507–510
w rge
British Journal of Anaesthesia 2004; 92: 882–884
ce Su

24 hours before emergency admission to intensive care are abnormalities in heart

rate, oxygen saturation and respiratory rate (Figure 1.3), all easily measureable and
recognisable. The objective of CCrISP, therefore, is to equip you to predict and
du of

prevent deterioration, and to treat deteriorating patients in a timely and effective

ro e

manner so that they have the best chance of a good recovery if complications occur.
ep eg

The course offers you an opportunity to practise and develop your management skills
for ward and critical care practice.
t r oll

When you come to the course, the faculty will help you combine your clinical skills and
no C

professional behaviours to identify at-risk patients and take the necessary steps to
prevent complications (Box 1.3).
o al
D oy

Many adverse episodes can be terminated by the immediate provision of simple

support (eg oxygen or intravenous fluids) and by the early attainment of a diagnosis
R

enabling early definitive treatment (eg antibiotics, provision of usual cardiac

©

medications or drainage of an abscess). The course will ensure that the basics are
done properly every time, because they are important.

5
 Care of the Critically Ill Surgical Patient®

Box 1.3  Objectives of the CCrISP course

Clinical skills

on d
si n
• Identify at-risk patients

is la
• Manage critically ill surgical patients:

m ng
– marry theory to practice
– clinical assessment

er f E
• Prevent the ‘complications cascade’ and minimise ‘failure to rescue’

tp o
• Learn to play your part in surgical critical care, understanding your role and the

ou ns
roles of others in the multidisciplinary team

ith o
Professional behaviours
w rge
• Lead the ward team in surgical critical care
• Organise and communicate:
ce Su

– colleagues: own specialty/other specialties

– patients and relatives
du of

• Assume increasing responsibility

ro e

• Be aware of limitations:
ep eg

– others’ and yours

– treatments.
t r oll
no C

• Avoidable problems occur either because simple measures are not taken or
o al

because their effectiveness and adequacy is not checked, eg failure to ensure

D oy

effective support for a postoperative woman with retained sputum on a quick

Saturday morning ward round by following through that the patient has actually had
R

physiotherapy and is improving at the end of your shift may result in that patient
having established pneumonia by the time you return on Monday morning. Patient
©

survival will be threatened and her length of stay certainly prolonged. Implementing
simple interventions such as humidified oxygen and physiotherapy can be life
saving, if not very glamorous, and requires the same skills and professional
behaviours necessary for instituting more complex treatments at consultant
level. They include clinical examination, judicious investigation, formulating and

6
 Chapter 1  Introduction

communicating a plan of action, reviewing it and, if necessary, invoking greater

degrees of timely support. Workload and the ability to prioritise can also have a
bearing on patient outcome and you should learn to recognise when you may need

on d
assistance, so that patient care is not compromised (see case scenario 1.1, below).

si n
is la
Case scenario 1.1 

m ng
A 68-year-old man (with mild chronic obstructive airways disease smoking 20

er f E
cigarettes per day) underwent a robotically assisted laparoscopic cystectomy
and ileal conduit formation for transitional cell carcinoma of the bladder on a

tp o
Thursday. By Friday he was mobilising but becoming breathless. No formal

ou ns
request for physiotherapy had been made and the on-call team was informed
that he was ‘progressing’. At 10pm on Friday evening he complained of

ith o
abdominal pain and was noted to have a NEWS of 7 (respiratory rate (RR) 33/min,
w rge
HR 103 bpm, urine output < 30 ml/h).

The foundation year 2 (FY2) doctor covering urology was informed and told the
ce Su

nursing staff to ‘check the PCA’, saying that she would review the patient when
she had a chance but was currently being trained (in emergency theatre) to insert
du of

a ureteric stent. The nursing staff informed the FY2 that ‘the PCA had been taken
down and the patient was drinking and taking oral analgesia’. The FY2 asked the
ro e

nursing team to contact the pain team, unaware that the pain team (out-of-hours)
ep eg

is represented by the anaesthetic specialty trainee currently anaesthetising the

patient with ureteric obstruction, who afterwards had to join his consultant in the
t r oll

A&E resuscitation room. The FY2 said that she would ‘review the patient when
she got a chance’. The FY2 did not communicate any specifics to the anaesthetic
no C

specialty trainee throughout the case. The anaesthetic specialty trainee made no
o al

further enquiries.
D oy

The ureteric stent insertion was difficult, taking a further 90 minutes. The urology
specialty trainee went home and the FY2 completed reviewing an 18-year-
R

old male with testicular pain. During this time the 68-year-old man developed
pyrexia (39.1oC) and hypotension; his pain and tachypnoea worsened. He was
©

reviewed at 3am on Saturday and after oxygen, intravenous fluids and antibiotics
he underwent computerised tomography (CT) and was found to have a rectal
perforation. He had an emergency laparotomy and Hartmann’s procedure and
spent 10 days in intensive care and a further 2 weeks in hospital.

7
 Care of the Critically Ill Surgical Patient®

Learning points 
• New breathlessness on initial mobilisation should be queried and investigated.

on d
• New or worsening abdominal pain 24–48 hours after major surgery requires

si n
early review and possible investigation, particularly where pain control was

is la
previously good.

m ng
• When problems arise out of hours and resources are more stretched, extra
care must be taken to ensure details are communicated appropriately.

er f E
• Improved communications could have led to an earlier assessment and,

tp o
although subsequent emergency surgery and intensive care admission
may have been unavoidable, the severe consequences of rectal perforation

ou ns
and intra-abdominal sepsis could have been minimised and length of stay

ith o
reduced.
w rge
ce Su

Practice points 
• Prompt, simple actions save lives and prevent complications.
du of

• Reassess your treatment plan. Has your intervention been effective?

• Further prompt and simple actions (or more advanced ones) may be
ro e
ep eg

necessary.
t r oll

Patients to be considered at risk

no C

Patients and practices associated with increased risk are summarised in Box 1.4 and
o al

the patients affected fall into three broad categories:

D oy

n the elective preoperative patient;

R

n the emergency admission;

©

n the postoperative ward patient.

8
 Chapter 1  Introduction

Box 1.4  At-risk patients

At-risk patients

on d
si n
• Emergencies

is la
• Elderly patients

m ng
• Patients with coexisting disease
• Non-progressing patients

er f E
• Severity of acute illness (including shock) or magnitude of surgery (including

tp o
re-bleeding and the need for massive transfusion)

ou ns
• Failure/delay in diagnosis and treatment

ith o
Practices that increase risk
w rge
• Incomplete or infrequent assessment
• Failure to act on abnormal findings
ce Su

• Failure to check on outcomes of interventions

• Failure of continuity of care (poor communication)
du of

• Failure of nursing support: insufficient numbers, wrong ward, etc.

ro e
ep eg

The elective preoperative patient

t r oll

The presence of coexisting disease (and treatments of such disease) can play a
no C

significant role in the development of postoperative complications and optimisation is

necessary (see case scenario 1.2, below). Careful specialist preoperative assessment
o al

should occur (see Chapter 16). This may include active testing of functional status, eg
D oy

cardiopulmonary exercise testing (CPET), postoperative planning and (especially) in

high-risk patients a discussion of risk via a shared decision-making process.
R
©

9
 Care of the Critically Ill Surgical Patient®

Case scenario 1.2 

A male patient presents on the day of surgery for elective repair of an inguinal

on d
hernia. He describes himself as being fit and well but ECG shows left bundle

si n
branch block. He smokes 20 cigarettes a day, admits to drinking in excess of 20

is la
units of alcohol per week and has occasional nocturia.

m ng
Does this man need a plan for his surgical care?

er f E
If anaesthesia and surgery proceed without further investigation and planning,
a predictable chain of minor events could occur that have the potential to

tp o
prove fatal. For example, a simple hernia repair can lead to urinary retention;

ou ns
a subsequent urinary tract infection could contribute to an acute confusional
state (exacerbated by alcohol withdrawal). The patient fails to cough adequately,

ith o
leading to atelectasis and pneumonia, and subsequent hypoxaemia compounds
w rge
coronary artery perfusion.
ce Su

Learning points 
• It is crucial to predict and prevent problems.
du of

• Consider the pros and cons of surgery on a case-by-case basis. Elective

patients need to have plans for their perioperative care.
ro e
ep eg

• Review comorbidities and their potential impact in the perioperative period.

• Optimise appropriately if surgery is essential.
t r oll
no C

The emergency admission

o al

Emergency admissions present with a variety of underlying diseases and

D oy

comorbidities that may be unrecognised (eg occult ischaemic heart disease) or

recognised but with significant surgical implications (eg anticoagulant therapies). Many
R

of these patients may also be inherently unstable and at risk of further complications.
Prompt and effective resuscitation can reduce this, but the consequences of
©

general anaesthesia in the shocked patient must also be considered, ie the risks of
vasodilation and reduced contractility. Simultaneous resuscitation and surgery may
be necessary. Furthermore, emergency surgery frequently takes place out of hours,

10
 Chapter 1  Introduction

taxing organisational and communication skills and professional behaviours rather

than clinical skills.

on d
The ward patient

si n
is la
On business ward rounds, many apparently stable patients will need to be reviewed

m ng
quickly: this is potentially one of the most effective ways of practising good critical
care by conducting systematic and thorough reviews using the CCrISP approach.

er f E
A standardised approach like this can identify many problems, allowing them to be
corrected before significant upset occurs.

tp o
When ward patients develop complications, the major pitfall is usually a failure to take

ou ns
further prompt action when initial interventions have proved insufficient to rescue

ith o
the patient. Therefore, clear plans that are communicated and followed up are very
important. w rge
More difficult ward patients to deal with are those ‘who fail to progress’. In such
ce Su

circumstances there is a high probability of an underlying problem eluding detection,

especially if you are unfamiliar with the usual postoperative time course for the
du of

surgical procedure. These types of patients are often elderly and failure to progress
can be easy to miss either because changes in their clinical and laboratory indices
ro e

are subtle and/or because they have associated delirium. Thorough assessment with
ep eg

subsequent investigation and follow-up can prevent major problems occurring, so

your level of clinical suspicion must be high unless you use a system like CCrISP to
t r oll

ensure that you do not cut corners and miss things.

no C
o al

Why the CCrISP method of approach works

D oy

As you progress in seniority throughout your career, your role changes as your
responsibilities develop. The requirement to make decisions that have a direct bearing
R

on patient management and outcome increases. Using the skills and approaches
©

developed on the CCrISP course assists you in this process and encourages
reflection that further aids the development of decision-making. All clinicians find the
management of emergencies stressful and will have experienced occasions when
the stress has been compounded by limited information, disorganisation and a lack
of appreciation of the severity of the situation. CCrISP provides templates for trainee

11
 Care of the Critically Ill Surgical Patient®

surgeons to deal with these dilemmas by rapidly assessing the situation and the
patient, responding to the immediate problem and initiating treatment. The CCrISP
algorithm (Figure 1.4) and simple immediate thoughts can help set your assessment

on d
off on the right foot (Box 1.5).

si n
is la
What the CCrISP course is not

m ng
The main ethos of the course is the prevention of further deterioration through

er f E
accurate and prompt ASSESSMENT and TREATMENT, minimising the need for, or
impact of, critical care admission. CCrISP takes a practical, management-orientated

tp o
approach to surgical critical care. The manual is not designed as a comprehensive

ou ns
textbook for intensive care and will not teach candidates on the CCrISP course to
become specialists in intensive care medicine. There is overlap between surgical

ith o
care and the principles applied day to day by the intensive care team, and surgeons
w rge
should therefore be aware of the nature and principles of intensive care, the support
it provides, when such support should be sought and what the limitations of that
The may CCrISP ®
system ofofassessment
ce Su

support be. They should also be aware the support and advice that intensive
du of

Immediate management
Investigations
Airway | Breathing | Circulation | Dysfunction of CNS | Exposure
Blood | X-ray
ro e

Specialist opinion
ep eg

Full patient assessment

Nutrition
Chart review | History and systematic examination | Available results
Requirement | Route
t r oll

Fluid balance prescription

no C

Decide and plan

Oral intake
Unstable/unsure Stable

Drugs and analgesia

o al

Treat condition | Prophylaxis | Comorbid disease

D oy

Diagnosis required
Daily management plan Physiotherapy
Chest | Mobility
R

Drains and tubes removal

©

Move to a lower level of care

Medical | Surgical | Radiological

Figure 1.4  The CCrISP algorithm.

CCrISP 4th edition © Royal College of Surgeons of England 2017 All rights reserved Registered Charity No. 212808 www.rcseng.ac.uk 4th edition
CCrISP®, RCS Eng.

12
 Chapter 1  Introduction

Box 1.5  Thinking on the run

• Think early: when the phone call comes

on d
– Instructions to the caller

si n
– What do I know about?

is la
– What will I do when I arrive?

m ng
• Think basics: when I arrive

er f E
– Check and secure ABCs
– What system has failed?

tp o
– What observations are available?

ou ns
– What observations can I make quickly?

• Think simply

ith o
w rge
– How quickly must I act?
– Do I have a diagnosis?
- How will I get the diagnosis safely
ce Su

- What help do I need?

du of
ro e

Box 1.6  Basic summary of levels of patient care

ep eg

• Level 3: invasive organ support (nurse–patient ratio of 1:1)

t r oll

• Level 2: no invasive respiratory support required (nurse–patient ratio of 1:2)

• Level 1: ward levels of care
no C

• Level 0: self-caring patients

o al
D oy

care requires from them and the impact of intensive care on patients that survive. Use
R

the course as an opportunity to explore this interface and your role as a surgeon in
patient care on an HDU or ICU.
©

13
 Care of the Critically Ill Surgical Patient®

Increasing surgical input

Surgical ward

on d
si n
is la
Intensive care input Surgical input

m ng
Critical care

er f E
Increasing intensive care input

tp o
Figure 1.5  Interplay between intensive care and surgical care.

ou ns
CCrISP®, RCS Eng.

ith o
w rge
Following discharge from intensive care, a further range of skills are necessary
to ensure that the patient does not fall into the trap of early deterioration and
re-admission. Much of this relates to the assessment principles of CCrISP, it may
ce Su

also include difficult discussions about the possible futility of further intensive care
treatments and the appropriateness of advanced organ support in a deteriorating
du of

patient. These topics will be dealt with on the course and will contribute towards
making you a better practitioner, marrying clinical skills to professional behaviours.
ro e
ep eg

Summary
t r oll

n Preventing deterioration is more effective than attempting salvage at a later stage.

no C

n Surgical critical care includes prediction and prevention of problems as well as

o al

investigation and intervention in the acutely unwell.

D oy

n There is a continuum in surgical critical care extending from the surgical ward
(prediction, prevention) to critical care and back again.
R

n Simple logical thought and actions utilising systematic guidance will often be
©

effective.

14
 Chapter 1  Introduction

Further reading
American College of Surgeons. Surgical Traits. https://www.facs.org/education/
resources/residency-search/traits (accessed November 2015).

on d
si n
Bismark MM, Spittal MJ, Gurrin LC et al. Identification of doctors at risk of recurrent

is la
complaints: a national study of healthcare complaints in Australia. BMJ Qual Saf

m ng
2013; 22: 532–540.

er f E
Department of Health. A Review of the NHS Hospitals Complaints System: Putting
Patients Back in the Picture. Department of Health, London; 2013.

tp o
ou ns
Department of Health. Comprehensive Critical Care: a Review of Adult Critical Care
Services. Department of Health, London; 2000.

ith o
w rge
Goldhill DR, McNarry AF, Mandersloot G, McGinley A. A physiologically-based early
warning score for ward patients: the association between score and outcome.
ce Su

Anaesthesia 2005; 60: 547–553.

Goldhill DR, McNarry AF. Physiological abnormalities in early warning scores are
du of

related to mortality in adult inpatients. Br J Anaesth 2004; 92: 882–884.

ro e

Health and Social Care Information Centre. NHS Outcomes Framework Indicators.
ep eg

http://www.hscic.gov.uk/nhsof (accessed November 2015).

t r oll

Intensive Care Society and Department of Health. Levels of Critical Care for Adult
no C

Patients. Intensive Care Society and Department of Health, London; 2009.

o al

Nolan JP, Soar J, Smith GB et al. Incidence and outcome of in-hospital cardiac arrest
D oy

in the United Kingdom National Cardiac Arrest Audit. Resuscitation 2014; 85:
987–992.
R

Ou L, Chen J, Hassan A, Hollis SJ et al. Trends and variations in the rates of hospital
©

complications, failure-to-rescue and 30-day mortality in surgical patients in New

South Wales, Australia, 2002–2009. PLoS One 2014; 9: e96164.

15
 Care of the Critically Ill Surgical Patient®

Royal Australian College of Surgeons. Interviews with surgeons. http://www.surgeons.

org/becoming-a-surgeon/surgery-as-a-career/videos/ (accessed November 2015).

on d
Royal College of Anaesthetists. Perioperative Medicine. The Pathway to Better

si n
Surgical Care. Royal College of Anaesthetists, London; 2014.

is la
Royal College of Physicians. National Early Warning Score (NEWS). Royal College of

m ng
Physicians, London; 2012.

er f E
Stringer W, Casaburi R, Older P. Cardiopulmonary exercise testing: does it improve
perioperative care and outcome? Curr Opin Anaesthesiol 2012; 25: 178–184.

tp o
ou ns
Subbe CP, Kruger M, Rutherford P, Gemmel L. Validation of a modified Early Warning
Score in medical admissions. Q J Med 2001; 94: 521–526.

ith o
w rge
ce Su
du of
ro e
ep eg
t r oll
no C
o al
D oy
R
©

16
©
R
D oy
o al
no C
t r oll
ep eg
ro e
du of
ce Su
w rge
ith o
ou ns
tp o
er f E
m ng
is la
si n
on d