Recognising clinical deterioration in emergency department patients

Exploring the nurses' experiences in recognising and managing clinical deterioration in emergency patients: A qualitative study

BACKGROUND

Emergency Department (ED) patients are particularly at a high risk of deterioration. The frontline nurses are key players in identifying and responding to deterioration events; however, few studies have sought to explore the whole process of recognition and management of clinical deterioration by emergency nurses.

OBJECTIVES

The aim of this study was to explore the experiences of emergency nurses and provide a whole picture of how they recognise and manage clinical deterioration.

METHODS

A qualitative descriptive study involving 11 senior nurses and seven junior nurses was conducted in the ED of a 3000-bed tertiary general hospital using semistructured interviews. The interviews were transcribed and thematically analysed.

FINDINGS

Four salient themes emerged from the data analysis. The first, 'early recognition and response', revealed the importance of vital signs assessment in recognising and responding to clinical deterioration. The second, 'information transfer', depicted the skills and difficulties of transferring information in escalations of care. The third, 'abilities, education, and training', presented the abilities that emergency nurses should have and their perspectives on training. The fourth, 'support culture', described the major role of senior nurses in collaboration with colleagues in the ED.

CONCLUSIONS

This study explored the experiences of emergency nurses in recognising and managing clinical deterioration. The findings illuminate the need to support the critical role of emergency nurses, with an emphasis on their abilities and continuous interprofessional collaboration training to improve the recognition and management of clinical deterioration.

Systems for recognition and response to deteriorating emergency department patients: a scoping review

Background

Assessing and managing the risk of clinical deterioration is a cornerstone of emergency care, commencing at triage and continuing throughout the emergency department (ED) care. The aim of this scoping review was to assess the extent, range and nature of published research related to formal systems for recognising and responding to clinical deterioration in emergency department (ED) patients.

Materials and methods

We conducted a scoping review according to PRISMA-ScR guidelines. MEDLINE complete, CINAHL and Embase were searched on 07 April 2021 from their dates of inception. Human studies evaluating formal systems for recognising and responding to clinical deterioration occurring after triage that were published in English were included. Formal systems for recognising and responding to clinical deterioration were defined as: i) predefined patient assessment criteria for clinical deterioration (single trigger or aggregate score), and, or ii) a predefined, expected response should a patient fulfil the criteria for clinical deterioration. Studies of short stay units and observation wards; deterioration during the triage process; system or score development or validation; and systems requiring pathology test results were excluded. The following characteristics of each study were extracted: author(s), year, design, country, aims, population, system tested, outcomes examined, and major findings.

Results

After removal of duplicates, there were 2696 publications. Of these 33 studies representing 109,066 patients were included: all were observational studies. Twenty-two aggregate scoring systems were evaluated in 29 studies and three single trigger systems were evaluated in four studies. There were three major findings: i) few studies reported the use of systems for recognising and responding to clinical deterioration to improve care of patients whilst in the ED; ii) the systems for recognising clinical deterioration in ED patients were highly variable and iii) few studies reported on the ED response to patients identified as deteriorating.

Conclusion

There is a need to re-focus the research related to use of systems for recognition and response to deteriorating patients from predicting various post-ED events to their real-time use to improve patient safety during ED care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00882-6.

The implementation of an emergency nursing framework (HIRAID) reduces patient deterioration: A multi-centre quasi-experimental study

INTRODUCTION

Timely recognition and treatment of acutely ill patients at appropriate levels of the health system are fundamental to the quality and safety of healthcare. This study determines if the implementation of an emergency nursing framework HIRAID (History, Identify Red flags, Assessment, Interventions, Diagnostics, communication and reassessment) improves patient safety.

METHODS

A quasi-experimental cohort study was conducted in two emergency departments in [Anonymised], Australia. HIRAID was implemented using a multi-pronged behaviour change intervention. Data of 920 patients (374 pre and 546 post) who deteriorated within 72-hours of ED departure were collected. Statistical tests were conducted as two-sided, with a 95% confidence interval to determine pre/post cohort association.

RESULTS

Patients in the post group had more comorbidities, but experienced less deterioration associated with care delivered in the ED (27% to 13%). There was a reduction in treatment delays [ 28.3% to 15.1%, p = 0.041, 95% CI (1.1%-25.3%)], and delay or failure to escalate care when abnormal vital signs were identified [20.2% to6.9%, p = 0.014, 95% CI (3.5%-23.1%)]. Isolated nursing-related causal factors decreased from 20 (21%) to 6 (8%).

CONCLUSIONS

Implementing a standardised emergency nursing framework is associated with a reduction in clinical deterioration related to emergency care.

Translation of evidence into policy to improve clinical practice: the development of an emergency department rapid response system

BACKGROUND

Undetected clinical deterioration is a major cause of high mortality events in Emergency Department (ED) patients. Yet, there is no known model to guide the recognition and response to clinical deterioration in the ED, integrating internal and external resources.

METHODS

An integrative review was firstly conducted to identify the critical components of recognising and responding to clinical deterioration in the ED. Components identified from the review were analysed by clinical experts and informed the development of an ED Clinical Emergency Response System (EDCERS).

RESULTS

Twenty four eligible studies were included in the review. Eight core components were identified: 1) vital sign monitoring; 2) track and trigger system; 3) communication plan; 4) response time; 5) emergency nurse response; 6) emergency physician response; 7) critical care team response; and 8) specialty team response. These components informed the development of the EDCERS protocol, integrating responses from staff internal and external to the ED.

CONCLUSIONS

EDCERS was based on the best available evidence and considered the cultural context of care. Future research is needed to determine the useability and impact of EDCERS on patient and health outcomes.

The prevalence and management of deteriorating patients in an Australian emergency department

BACKGROUND

Complex human and system factors impact the effectiveness of Rapid Response Systems (RRS). Emergency Department (ED) specific RRS are relatively new and the factors associated with their effectiveness are largely unknown. This study describes the period prevalence of deterioration and characteristics of care for deteriorating patients in an Australia ED and examine relationships between system factors and escalation of care.

METHODS

A retrospective medical record audit of all patients presenting to an Australian ED in two weeks.

RESULTS

Period prevalence of deterioration was 10.08% (n=269). Failure to escalate care occurred in nearly half (n=52, 47.3%) of the patients requiring a response (n=110). Appropriate escalation practices were associated with where the patient was being cared for (p=0.01), and the competence level of the person documenting deterioration (p=0.005). Intermediate competence level nurses were nine times more likely to escalate care than novices and experts (p=0.005). While there was variance in escalation practice related to system factors, these associations were not statistically significant.

CONCLUSION

The safety of deteriorating ED patients may be improved by informing care based on the escalation practices of staff with intermediate ED experience and competence levels.

Predicting cardiac arrest in the emergency department

In-hospital cardiac arrest remains a leading cause of death: roughly 300,000 in-hospital cardiac arrests occur each year in the United States, ≈10% of which occur in the emergency department. ED-based cardiac arrest may represent a subset of in-hospital cardiac arrest with a higher proportion of reversible etiologies and a higher potential for neurologically intact survival. Patients presenting to the ED have become increasingly complex, have a high burden of critical illness, and face crowded departments with thinly stretched resources. As a result, patients in the ED are vulnerable to unrecognized clinical deterioration that may lead to ED-based cardiac arrest. Efforts to identify patients who may progress to ED-based cardiac arrest have traditionally been approached through identification of critically ill patients at triage and the identification of patients who unexpectedly deteriorate during their stay in the ED. Interventions to facilitate appropriate triage and resource allocation, as well as earlier identification of patients at risk of deterioration in the ED, could potentially allow for both prevention of cardiac arrest and optimization of outcomes from ED-based cardiac arrest. This review will discuss the epidemiology of ED-based cardiac arrest, as well as commonly used approaches to predict ED-based cardiac arrest and highlight areas that require further research to improve outcomes for this population.

Emergency nurses' perceptions of their role in responding to escalations of care for clinical deterioration

BACKGROUND

Clinical leadership is fundamental to patient safety. The Emergency Department (ED) nurse-in-charge is a key leadership role; however, few studies have explored the management of clinical deterioration from the ED nurse-in-charge perspective. The aim of this study was to explore ED nurses-in-charge' perceptions of their role in responding to episodes of escalation of care for clinical deterioration of ED patients.

METHODS

A prospective exploratory descriptive design was used to address the study aims. The study was conducted in an urban ED in Melbourne, Australia. Senior emergency nurses who fulfilled the role of being in charge of the ED were invited to participate. In-depth semi-structured interviews were conducted between December 2015 and March 2016. Interview transcripts were analysed using thematic analysis.

RESULTS

Two major themes, each with two subthemes were identified. The first major theme of Clinical Risk Management comprised sub-themes of Clinical Skills and Confidence. The second major theme of Resource Management comprised sub-themes of Human Resource Management and Logistical Resource Management.

CONCLUSIONS

Strong collaboration, logistical and clinical risk management roles were perceived as fundamental to the nurse-in-charge's capacity to respond to escalations of care for clinical deterioration within in a complex team environment such as the ED.

The pre-Medical Emergency Team response: Nurses' decision-making escalating deterioration to treating teams using urgent review criteria

AIM

To describe nurses' decision-making, experiences and perceptions of escalating deteriorating patients to the treating medical team using urgent clinical review criteria.

DESIGN

A qualitative design comprising individual in-depth interviews with nurses from a major Australian metropolitan tertiary teaching hospital.

METHOD

A purposive sample of 30 Registered Nurses from nine surgical and medical wards were interviewed in April 2018 using semi-structured interviews. An inductive thematic analysis was conducted.

RESULTS

Identified themes included: detecting the deterioration; countering the problem; getting a response; and challenges faced in the process of escalation. Nurses reported an important awareness, sense of responsibility, and critical thinking to ensure the safe management and escalation of deteriorating patients. However, barriers to escalation necessitated individual workarounds and organizational structures to mitigate patient risk.

CONCLUSION

This study supports the importance of communication between clinical teams and recognizes that it is crucial to enable a fail-safe experience for patients and families. Recognition of disciplinary contributions to patients' goals of care is required to better understand and address the prevalence of deteriorating patients. Our study is among the first to explore the actual experience of nurses who articulate balancing uncertainty and managing complex team dynamics on wards for patients experiencing deteriorating health status. The information may assist in determining team training strategies and structures to facilitate patient management during deterioration.

IMPACT

This is among the first study to investigate barriers influencing decision-making of RNs prior to escalation using qualitative methods. This study provides a foundation to inform and develop policies and strategies aimed at ensuring escalation occurs for deteriorating patients.

Association of blood pressure documentation with adverse outcomes in an emergency department in Brazil

OBJECTIVE

To associate blood pressure (BP) documentation with adverse outcomes in an emergency department (ED).

METHODS

This is a retrospective observational study, and 642 records of patients admitted to the ED of a tertiary hospital in Brazil were used. We included medical records of patients of both sexes aged over 18 years, who were allocated in general wards in the period December 2015-June 2016. Association between BP measurements with length of stay (LOS), worsening of clinical presentation, unplanned patient transfer, readmission, stroke or transient ischemic attack, cardiorespiratory arrest, and death were investigated.

RESULTS

Association was observed between worsening of clinical presentation and systolic (p = 0.003) or diastolic (p = 0.001) BP values. The association between LOS and worsening of clinical presentation with the number of BP measurements or mean time between BP measurements was statistically significant (p < 0.001). Unplanned patient transfer was associated with an increase in the number of BP measurements (p < 0.001). The mean time between BP measurements was higher among patients who returned to the ED within 48-72 h (p = 0.030).

CONCLUSIONS

The results of this study showed association between BP documentation with adverse outcomes in the ED, reinforcing the need to develop educational strategies regarding nursing records and monitoring of vital signs.

Patient acceptability of wearable vital sign monitoring technologies in the acute care setting: A systematic review

AIMS AND OBJECTIVES

To examine patient acceptability of wearable vital sign monitoring devices in the acute setting.

BACKGROUND

Wearable vital sign monitoring devices may improve patient safety, yet hospital patients' acceptability of these devices is largely unreported.

DESIGN

A systematic review.

METHODS

Cumulative Index to Nursing and Allied Health Literature Complete, MEDLINE Complete and EMBASE were searched, supplemented by reference list hand searching. Studies were included if they involved adult hospital patients (≥18 years), a wearable monitoring device capable of assessing ≥1 vital sign, and measured patient acceptability, satisfaction or experience of wearing the device. No date restrictions were enforced. Quality assessments of quantitative and qualitative studies were undertaken using the Downs and Black Checklist for Measuring Study Quality and the Critical Appraisal Skills Programme Qualitative Research Checklist, respectively. Meta-analyses were not possible given data heterogeneity and low research quality. Reporting adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and a Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist was completed.

RESULTS

Of the 427 studies screened, seven observational studies met the inclusion criteria. Six studies were of low quality and one was of high quality. In two studies, patient satisfaction was investigated. In the remaining studies, patient experience, patient opinions and experience, patient perceptions and experience, device acceptability, and patient comfort and concerns were investigated. In four studies, patients were mostly accepting of the wearable devices, reporting positive experiences and satisfaction relating to their use. In three studies, findings were mixed.

CONCLUSION

There is limited high-quality research examining patient acceptability of wearable vital sign monitoring devices as an a priori focus in the acute setting. Further understanding of patient perspectives of these devices is required to inform their continued use and development.

RELEVANCE TO CLINICAL PRACTICE

The provision of patient-centred nursing care is contingent on understanding patients' preferences, including their acceptability of technology use.

Interprofessional Practice in the Emergency Service: specific and shared assignments of nurses

ABSTRACT Objective: To map and categorize, according to the Nursing Interventions Classification (NIC), the specific assignments of the nurses and to identify the assignments shared with doctors and physiotherapists in the Emergency Service. Method: Descriptive exploratory study, carried out in two phases: first, the analysis of dissertations /theses from the database of the Center for Studies and Research of the Brazilian Nursing Association; Second, the use of the Delphi Technique to reach the consensus about which assignments were specific to the nurse and which were shared with physiotherapists and doctors. Results: The results were 45.7% for specific to the nurses, 14.2% for shared with physiotherapists and/or doctors, and in 40% (n=42) there was no consensus about the sharing of assignments. Conclusion: The sharing of actions among professionals shows an increase in the scope of the practice of professions and the constitution of a common sphere of work, but the high number of assignments with no consensus among specialists can be a potential factor in conflicts due to the lack of definition of these assignments.

Use of medical emergency call data as a marker of quality of emergency department care in the post-National Emergency Access Target era

Objectives Any new model of care should always be accompanied by rigorous monitoring to ensure that there are no negative consequences, especially any that impact upon patient safety. In 2013, ‘THERMoSTAT’ (Two- Hour Evaluation and Referral Model for Shorter Turnaround Times), an emergency department model of care developed by Royal Brisbane and Women’s Hospital staff was launched to gain efficiencies and improve hospital National Emergency Access Target (NEAT) compliance. The aim of this study was to trial the use of medical emergency call data as a novel marker of the quality of care delivered by our emergency department. Methods Incidence of medical emergency calls for hospital emergency admission patients for the 2 years pre- and 1 year post-THERMoSTAT were compared after standardising for overall hospital activity. Results During the study period, hospital activity increased 10%, and the emergency department experienced a total of 222 645 presentations, 68 000 (30.5%) of which converted into an admission. THERMoSTAT improved NEAT compliance by 17% (from 57.7% to 74.9%) with no change in any patient-safety indicators. A total of 8432 medical emergency calls were made on 5930 patients, 2831 of whom were emergency admissions. After adjusting for hospital activity, there was no change in the average number of patients per week who triggered a medical emergency call after the introduction of THERMoSTAT. These results were reproduced when data was analysed for: total number of inpatients triggering calls; emergency admission patients; and emergency admission patients within the first 24 h or first 4 h of admission. Conclusions This is the first report to investigate the correlation between inpatient medical emergency call incidence and emergency department model of care. Medical emergency call data showed significant promise as a measure of morbidity and as a more direct, objective, simple, quantitative and meaningful measure of patient safety. What is known about the topic? It is well established that extended emergency department lengths of stay are associated with poorer patient outcomes. The corollary of this is not always true however; shorter emergency department length of stay does not automatically translate into better care. Although the underlying philosophy of NEAT is to enhance patient care, there is a risk of negative consequences if NEAT is seen as an end in itself. Many of the commonly used emergency department key performance indicators focus on the timeliness of care and there is a scarcity of easily quantifiable markers that reliably reflect the quality of that care. What does this paper add? This study builds on the concept of medical emergency call incidence as a marker of safety and quality. It explores the utility of using the number of medical emergency calls made in the first few hours of an emergency admission as an indicator of the quality of care delivered by the emergency department. This is significant because it introduces a measure that has a focus that embraces more than the timeliness of care only. What are the implications for practitioners? If medical emergency call incidence in early emergency admissions can be proven to accurately reflect emergency department quality of care then it would provide an easily monitored, objective, quantitative and prompt measure that evaluates dimensions other than timeliness.

Explaining transgression in respiratory rate observation methods in the emergency department: A classic grounded theory analysis

BACKGROUND

Abnormal respiratory rates are one of the first indicators of clinical deterioration in emergency department(ED) patients. Despite the importance of respiratory rate observations, this vital sign is often inaccurately recorded on ED observation charts, compromising patient safety. Concurrently, there is a paucity of research reporting why this phenomenon occurs.

OBJECTIVE

To develop a substantive theory explaining ED registered nurses' reasoning when they miss or misreport respiratory rate observations.

DESIGN

This research project employed a classic grounded theory analysis of qualitative data.

PARTICIPANTS

Seventy-nine registered nurses currently working in EDs within Australia. Data collected included detailed responses from individual interviews and open-ended responses from an online questionnaire.

METHODS

Classic grounded theory (CGT) research methods were utilised, therefore coding was central to the abstraction of data and its reintegration as theory. Constant comparison synonymous with CGT methods were employed to code data. This approach facilitated the identification of the main concern of the participants and aided in the generation of theory explaining how the participants processed this issue.

RESULTS

The main concern identified is that ED registered nurses do not believe that collecting an accurate respiratory rate for ALL patients at EVERY round of observations is a requirement, and yet organizational requirements often dictate that a value for the respiratory rate be included each time vital signs are collected. The theory 'Rationalising Transgression', explains how participants continually resolve this problem. The study found that despite feeling professionally conflicted, nurses often erroneously record respiratory rate observations, and then rationalise this behaviour by employing strategies that adjust the significance of the organisational requirement. These strategies include; Compensating, when nurses believe they are compensating for errant behaviour by enhancing the patient's outcome; Minimalizing, when nurses believe that the patient's outcome would be no different if they recorded an accurate respiratory rate or not and; Trivialising, a strategy that sanctions negligent behaviour and occurs when nurses 'cut corners' to get the job done. Nurses' use these strategies to titrate the level ofemotional discomfort associated with erroneous behaviour, thereby rationalising transgression CONCLUSION: This research reveals that despite continuing education regarding gold standard guidelines for respiratory rate collection, suboptimal practice continues. Ideally, to combat this transgression, a culture shift must occur regarding nurses' understanding of acceptable practice methods. Nurses must receive education in a way that permeates their understanding of the relationship between the regular collection of accurate respiratory rate observations and optimal patient outcomes.

Current practices related to family presence during acute deterioration in adult emergency department patients

AIMS AND OBJECTIVES

To explore the characteristics of and interactions between clinicians, patients and family members during management of the deteriorating adult patient in the emergency department.

BACKGROUND

Previous research into family presence during resuscitation has identified many positive outcomes when families are included. However, over the last three decades the epidemiology of acute clinical deterioration has changed, with a decrease in in-hospital cardiac arrests and an increase in acute clinical deterioration. Despite the decrease in cardiac arrests, research related to family presence continues to focus on care during resuscitation rather than care during acute deterioration.

DESIGN

Descriptive exploratory study using nonparticipatory observation.

METHODS

Five clinical deterioration episodes were observed within a 50-bed, urban, Australian emergency department. Field notes were taken using a semistructured tool to allow for thematic analysis.

RESULTS

Presence, roles and engagement describe the interactions between clinicians, family members and patients while family are present during a patient's episode of deterioration. Presence was classified as no presence, physical presence and therapeutic presence. Clinicians and family members moved through primary, secondary and tertiary roles during patients' deterioration episode. Engagement was observed to be superficial or deep. There was a complex interplay between presence, roles and engagement with each influencing which form the other could take.

CONCLUSIONS

Current practices of managing family during episodes of acute deterioration are complex and multifaceted. There is fluid interplay between presence, roles and engagement during a patient's episode of deterioration.

RELEVANCE TO CLINICAL PRACTICE

This study will contribute to best practice, provide a strong foundation for clinician education and present opportunities for future research.

Outcome of adult patients attended by rapid response teams: A systematic review of the literature

BACKGROUND

An abundance of studies have investigated the impact of rapid response teams (RRTs) on in-hospital cardiac arrest rates. However, existing RRT data appear highly variable in terms of both study quality and reported uses of limitations of care, patient survival and patient long-term outcome.

METHODS

A systematic electronic literature search (January, 1990-March, 2016) of the PubMed and Cochrane databases was performed. Bibliographies of articles included in the full-text review were searched for additional studies. A predefined RRT cohort quality score (range 0-17) was used to evaluate studies independently by two reviewers.

RESULTS

Twenty-nine studies with a total of 157,383 RRT activations were included in this review. The quality of data reporting related to RRT patients was assessed as modest, with a median quality score of 8 (range 2-11). Data from the included studies indicate that a median 8.1% of RRT reviews result in limitations of medical treatment (range 2.1-25%) and 23% (8.2-56%) result in a transfer to intensive care. A median of 29% (6.9-35%) of patients transferred to intensive care died during that admission. The median hospital mortality of patients reviewed by RRT is 26% (12-60%), and the median 30-day mortality rate is 29% (8-39%). Data on long-term survival is minimal. No data on functional outcomes was identified.

CONCLUSIONS

Patients reviewed by rapid response teams have a high and variable mortality rate, and limitations of care are commonly used. Data on the long-term outcomes of RRT are lacking and needed.

Accurate respiratory rates count: So should you!

It is well documented that the respiratory rate is the least accurately recorded vital sign. Despite nurses consistently confirming that they understand the physiological importance of the respiratory rate, more often than not, they estimate a value rather than count for an entire minute. Until recently, little has been known about why this phenomenon perpetuates. However, it has now been established that many emergency department registered nurses believe they are enhancing patients' outcomes by performing tasks other than counting a patient's respiratory rate. This discussion highlights the significance of recording accurate respiratory rates, as opposed to estimating a rate; emphasizing that just four breaths either side of the normal range could be indicative of impending clinical deterioration.

Scoping review: The use of early warning systems for the identification of in-hospital patients at risk of deterioration

INTRODUCTION

Early warning systems (EWS) were developed as a means of alerting medical staff to patient clinical decline. Since 85% of severe adverse events are preceded by abnormal physiological signs, the patient bed-side vital signs observation chart has emerged as an EWS tool to help staff identify and quantify deteriorating patients. There are three broad categories of patient observation chart EWS: single or multiple parameter systems; aggregated weighted scoring systems; or combinations of single or multiple parameter and aggregated weighted scoring systems.

OBJECTIVE

This scoping review is an overview of quantitative studies and systematic reviews examining the efficiency of the adult EWS charts in the recognition of in-hospital patient deterioration.

METHOD

A broad search was undertaken of peer-reviewed publications, official government websites and databases housing research theses, using combinations of keywords and phrases.

DATA SOURCES

CINAHL with full text; MedLine, PsycINFO, MasterFILE Premier, GreenFILE and ScienceDirect. Also, the Cochrane Library database, Department of Health government websites and Ethos, ProQuest and Trove databases were searched.

EXCLUSIONS

Paediatric, obstetric and intensive care studies, studies undertaken at the point of hospital admission or pre-admission, non-English publications and editorials.

RESULTS

Five hundred and sixty five publications, government documents, reports and theses were located of which 91 were considered and 21 were included in the scoping review. Of the 21 publications eight studies compared the efficacy of various EWS and 13 publications validated specific EWS.

CONCLUSIONS

There is low level quantitative evidence that EWS improve patient outcomes and strong anecdotal evidence that they augment the ability of the clinical staff to recognise and respond to patient decline, thus reducing the incidence of severe adverse events. Although aggregated weighted scoring systems are most frequently used, the efficiency of the specific EWS appears to be dependent on the patient cohort, facilities available and staff training and attitude. While the review demonstrates support for EWS, researchers caution that given the contribution of human factors to the EWS decision-making process, patient EWS charts alone cannot replace good clinical judgment.

The effect of a staged, emergency department specific rapid response system on reporting of clinical deterioration

BACKGROUND

Despite emerging evidence regarding clinical deterioration in emergency department (ED) patients, the widespread uptake of rapid response systems (RRS) in EDs has been limited.

AIMS

To evaluate the effect of an ED RRS on reporting of clinical deterioration and determine if there were differences between patients who did, and did not, deteriorate during ED care.

METHODS

A retrospective cross sectional design was used to conduct this single site study in Melbourne, Australia. Stratified random sampling identified 50 patients with shortness of breath, chest pain or abdominal pain per each year studied (2009-2012) giving a total of 600 patients. The intervention was an ED RRS implemented in stages.

RESULTS

The frequency of clinical deterioration was 14.8% (318 episodes/89 patients). Unreported deterioration decreased each year (86.7%; 68.8%; 55.3%; 54.0%, p=0.141). Patients who deteriorated during ED care had a longer median ED length of stay (2.8h; p<0.001), were 31.9% more likely to need hospital admission (p<0.001) and 4.9% more likely to die in hospital (p=0.044).

CONCLUSIONS

A staged ED specific RRS decreased the frequency of unreported clinical deterioration. Controlled multi-site studies of ED specific RRSs are needed to examine the effect of formal ED RRSs on patient outcomes.