Why it is hard to see

Fever is a poor guide in residential care. A guideline for evaluating infection in long-term care residents notes that a fever, as usually defined, is absent in more than half of residents with a serious infection ⁸. The national sepsis standard makes the same point about older people in general: the commonly recognised signs are often absent, and hypothermia, delirium and falls are more likely ².

Many residents cannot describe what is wrong because of dementia, hearing loss or speech difficulty. That shifts the work onto observation, and the question that matters most is what has changed compared with this person’s usual self.

Changes worth reporting

None of these proves a particular illness. Each is a reason to look more closely and to tell the registered nurse.

New confusion, drowsiness or agitation. A change in mental state can be the first sign of infection in an older person ². In a US nursing home study, it was one of three features linked with a confirmed urinary infection ¹⁵.
A new fall, or several in a short time. The sepsis standard lists falls in frail people among the ways serious infection may show itself ².
Eating or drinking less. Missing drinks between meals was one of the few signs with any value for detecting dehydration in a Cochrane review, although no single sign was reliable on its own ²³.
Needing more help than usual. More help to stand, walk, eat or get to the toilet than the resident needed last week.
Breathing, colour and temperature. Faster or more laboured breathing, a new cough, looking pale or grey, or feeling unusually hot or cold. A low temperature can also be a sign of serious infection in older people ².
Family or carer concern. The sepsis standard treats a high level of family or carer concern as a reason to investigate ². The delirium standard notes that family members and carers are often the best source of information about acute changes in thinking or behaviour ³.

Early warning scores in residential care

Hospitals use early warning scores, which combine routine observations into a single number that prompts a response. Some care homes overseas have adopted the National Early Warning Score (NEWS, now NEWS2).

In four English care homes with 276 residents, higher NEWS scores were linked with hospital admission. Staff said the score improved their communication and decision-making, but also that it could not act as a diagnostic tool on its own, because residents’ existing conditions are complex ⁹. This was an observational study.

A cluster randomised trial in 21 Norwegian nursing homes showed that a structured implementation program made staff use NEWS2 far more often. It did not report whether residents did better ¹⁰. No randomised trial found for this page has shown that an early warning score improves outcomes for residents of residential aged care.

Tools for spotting deterioration: the evidence

Graded on randomised evidence for resident outcomes in nursing homes or residential aged care.

Early warning scores (NEWS or NEWS2)

Uncertain / conflicting

Linked with hospital admission in observational data. No trial has shown better outcomes for residents.

The evidence

An English observational study found higher scores were associated with admission ⁹. A Norwegian cluster randomised trial increased use of the score but did not measure resident outcomes ¹⁰.

In practice

A score gives structure to a phone call. Staff in the English study said it did not replace clinical judgement ⁹.

Staff training in an acute-change and transfer-avoidance toolkit (INTERACT)

Not supported

Training and implementation support did not reduce hospital admissions or emergency department visits.

The evidence

In 85 US nursing homes with 36,717 residents, there was no significant change in admissions, readmissions or emergency visits. A reduction in potentially avoidable admissions did not survive correction for multiple comparisons ¹¹.

In practice

The trial tested training and support for the program, not each of its tools separately ¹¹.

Sources cited on this page

1 Australian Government Department of Health, Disability and Ageing. Strengthened Aged Care Quality Standards (November 2025; implemented 1 November 2025). Outcome 3.2, Actions 3.2.4 and 3.2.5; Outcome 3.3, Action 3.3.3; Outcome 5.2, Actions 5.2.1 and 5.2.2; Outcome 5.4, Actions 5.4.2 and 5.4.5. View source
2 Australian Commission on Safety and Quality in Health Care. Sepsis Clinical Care Standard. Sydney: ACSQHC; June 2022. (Primary settings are ambulance services, hospitals and urgent care centres; also listed as relevant to aged care homes and general practice.) View source
3 Australian Commission on Safety and Quality in Health Care. Delirium Clinical Care Standard. Sydney: ACSQHC; first released 2016, revised September 2021. (Written mainly for hospitals; states it can be adapted for residential aged care.) View source
8 High KP, Bradley SF, Gravenstein S, et al. Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America. J Am Geriatr Soc. 2009;57:375–94. (US guideline; checked at abstract level.) View source
9 Hodgson P, Greaves J, Cook G, Fraser A, Bainbridge L. A study to introduce National Early Warning Scores (NEWS) in care homes: influence on decision-making and referral processes. Nurs Open. 2022;9:519–26. (Observational mixed-methods study; 276 residents in four English care homes.) View source
10 Graverholt B, Espehaug B, Ciliska D, Potrebny T. The effectiveness of a knowledge translation intervention on the implementation of NEWS2 in nursing homes, a pragmatic cluster RCT. Implement Sci. 2024;19:64. (21 Norwegian nursing homes; outcome was use of NEWS2, not resident outcomes.) View source
11 Kane RL, Huckfeldt P, Tappen R, et al. Effects of an intervention to reduce hospitalizations from nursing homes: a randomized implementation trial of the INTERACT program. JAMA Intern Med. 2017;177:1257–64. (85 US nursing homes, 36,717 residents.) View source
15 Juthani-Mehta M, Quagliarello V, Perrelli E, Towle V, Van Ness PH, Tinetti M. Clinical features to identify urinary tract infection in nursing home residents: a cohort study. J Am Geriatr Soc. 2009;57:963–70. (Prospective observational cohort; 551 residents without catheters in five US nursing homes.) View source
23 Hooper L, Abdelhamid A, Attreed NJ, et al. Clinical symptoms, signs and tests for identification of impending and current water-loss dehydration in older people. Cochrane Database Syst Rev. 2015;(4):CD009647. (Diagnostic accuracy review; people aged 65 or more.) View source

See every source cited across the deteriorating resident section →

Written by Dr Josh Hatch, FRACGP. General information only, reflecting his reading of the published evidence as at November 2026. It is not individual medical advice, does not create a doctor–patient relationship, and must not be used to start, stop or change any treatment, and it does not set escalation rules for any facility. Antibiotic choices and doses follow current prescribing guidelines and local advice. Evidence, Australian regulatory requirements and local services change — always confirm current advice with the treating GP and the facility’s own procedures.

This is general education, not a clinical protocol. The doctors who practise with Umbrella Aged Care are independent general practitioners, and each makes their own clinical decisions with the resident and family. Your GP’s advice for an individual may differ from what is written here. If it does, please ask them to talk it through with you.

Recognising deterioration in a resident