Managing acute physical deterioration through the ‘prevention, identification, escalation, response’ (PIER) approach

What is the PIER approach?

The new PIER approach will enable the effective management of acute physical deterioration in health and care and will apply to all conditions, clinical settings and specialities.

The new PIER approach views deterioration as a whole pathway which is supported by systems rather than only advocating a single strategy for identification.

Acute physical deterioration is the rapid worsening of a patient’s condition. It can be identified from changes in physiology, such as respiratory rate, blood pressure or consciousness, or more subtle signs, such as not eating and a patient or their family’s concerns and observations around wellness, mental status or behaviour.

Deterioration can occur in any health and care setting and is the common pathway in all emergency admissions, prolonged illnesses and deaths.

PIER stands for:

  • prevention: planning ahead of any episode of deterioration to stop what is preventable, considering indicators of risk and patient choice
  • identification: tools and methods to identify when deterioration is occurring in a standardised way
  • escalation: timely escalation of care when deterioration has been identified using standardised communication tools
  • response: timely, appropriate and effective response to escalation of the deteriorating patient/person.


Supporting the NHS to manage acute physical deterioration not only saves lives and prevents patients from becoming increasingly unwell but can also reduce the length of a hospital stay allowing resources to be available to benefit other patients.

Implementing the PIER approach

In Summer 2024, following a variety of testing with colleagues, we will produce a PIER toolkit, containing a range of resources to support integrated care boards (ICBs) to introduce the PIER approach across their local systems.

The toolkit will support and guide ICBs with pathway/system thinking for deterioration management that is system led. This suite of resources will help ICBs to use an improvement approach to design and implement a deterioration improvement plan that follows 7 key phases:

  1. set up
  2. building the ICB vision
  3. mapping the ICB
  4. improvement planning
  5. operationalising
  6. improvement action
  7. evaluation and sustainability.

What does each aspect of PIER mean from a system perspective?

P – prevention

Developing systems and processes that support the design of reliable and safe care pathways that include continuous assessment to help monitor or reduce individual risk, prevent deterioration where prevention is clinically expected, and ensure care is personalised and reflects what matters to the person.

Key points to consider when reviewing prevention:

  • An individual’s vital sign baseline is understood, and a range of risk assessment tools and methods are used to identify, monitor and mitigate their risk of physical deterioration. Risk is documented and communicated, and appropriate mitigating actions are taken.
  • Key information about planning for the event of acute deterioration is recorded in a patient’s personalised care and support plan (PCSP); this ensures what matters most to the person is respected, key people are aware of these plans (including family/carers), and these sharable plans inform escalation and response should they deteriorate.

I – identification

Tools and methods for the standardised and timely recognition of physical acute deterioration through the reliable monitoring, identification and assessment of people.

Key points to consider when reviewing identification:

  • Training in, and the reliable adoption of, a standardised approach to identifying acute physical deterioration across care settings that is well communicated and incorporates both vital sign monitoring and recognised soft signs of deterioration.
  • Where not already embedded in early warning systems, additional methods capture the voice of the patient/family/carer and staff concerns to personalise/individualise a patient’s monitoring and assessment, in line with Martha’s Rule.

E – escalation

The principles of escalation should ideally be the same whether this takes place within an organisation or across a system; however, when multiple care providers are involved, this will inevitably become more complex. Integrated care boards should consider how appropriate escalation takes place within and between providers and help define clear escalation protocols and reliable processes that are regularly monitored and reviewed. Tools such as ‘situation, background, assessment, recommendation’ (SBARD) or ‘age, time, mechanism, injury, signs, treatment’ (ATMIST) have been shown to improve the reliability of communication and handover and safeguard against safety-critical information being lost between clinical teams.

Key points to consider when reviewing escalation:

  • Where not part of a standardised early warning score/system, use clear protocols/processes that include information and guidance for when, how (using a common language approach) and who to escalate to in the event of acute physical deterioration.
  • Agree escalation processes across sectors. This could be from the community, primary care, virtual wards and specialty hubs into acute services and/or social care. This may include a directory of services.
  • Key elements of Martha’s Rule include the ability for staff, patients, families and carers to be able to raise concerns to a 24/7 critical care outreach team if they are worried about a person’s condition, alongside routine structured capture of a patient’s condition from them or their family at least daily. Martha’s Rule is being piloted in at least 100 acute hospital sites from April 2024, and work will also begin to explore how Martha’s Rule might be applied in other settings such as mental health and community. Martha’s Rule is therefore relevant to the I (identification), E (escalation) and R (response) of improving deterioration management.

R – response

Within a hospital this might be a senior clinician or specialist rapid response team. In a community setting this could be a GP, community nurse or other care professional. The response should be based on agreed parameters of severity and accommodate the patient’s personalised care choices.

Key points to consider when reviewing the response:

  • Where not already included as part of a standardised early warning score/system, use clear protocols/processes that include information and guidance on who should respond, the expected response based on levels of acuity, and the expected timeframes for the initial response.
  • Protocols and processes should also include a mechanism for ongoing monitoring and evaluation of an individual patient with parameters to rapidly re-escalate/de-escalate should an individual’s deterioration worsen or improve.
  • Responses are evidence-based in line with national guidance.

When responding to a patient/family/carer escalation, there should be well defined protocols/processes in place to ensure that the response is well communicated to those who raised it. They should be clear on what they expect to happen next, the timescales for this and who they can contact in the meantime.