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Bodlund J, Wimmerdahl A, Honoré A, Härenstam KP, Forsberg D. A retrospective evaluation of SwePEWS use in paediatric patients with COVID-19 and RSV infection. Acta Paediatr 2024. [PMID: 39373306 DOI: 10.1111/apa.17450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 09/16/2024] [Accepted: 09/26/2024] [Indexed: 10/08/2024]
Abstract
AIM As early detection of deterioration is a challenge in children, the Swedish Paediatric Early Warning Score (SwePEWS) is used to systematically assess paediatric patients' clinical state. Here, we aimed to evaluate the use and predictive ability of SwePEWS. METHODS Electronic health records of paediatric patients admitted due to respiratory syncytial virus infection or COVID-19 were reviewed retrospectively. Registered vital signs were compared to the assigned SwePEWS score and monitored vital sign values to identify discrepancies. Additionally, SwePEWS's ability to predict transfer to the paediatric intensive care unit (PICU) was assessed. RESULTS Among 1374 SwePEWS assessments, one-third were either incomplete or contained errors. Incomplete SwePEWS assessments were more frequent during night-time. Single measurements of oxygen saturation presented lower values compared to average saturation from continuous monitoring. SwePEWS's ability to predict PICU transfer was low. CONCLUSION There was a surprisingly high occurrence of underestimated SwePEWS scores. This study provides new insights into pitfalls when developing and implementing paediatric early warning scores for systematic re-evaluations in paediatric patients.
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Affiliation(s)
- Julia Bodlund
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Albin Wimmerdahl
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Antoine Honoré
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Karin Pukk Härenstam
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - David Forsberg
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
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Dwyer T, Flenady T, Signal T, Boyle CM, Connor J, Le Lagadec D, Goodwin B, Browne M. A theoretical framework for identifying sociocultural factors that influence nurses' compliance with early warning systems for acute clinical deterioration: A cross-sectional survey. Int J Nurs Stud 2024; 158:104846. [PMID: 39043112 DOI: 10.1016/j.ijnurstu.2024.104846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 06/06/2024] [Accepted: 06/20/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND Systematic adoption of early warning systems in healthcare settings is dependent on the optimal and reliable application by the user. Psychosocial issues and hospital culture influence clinicians' patient safety behaviours. OBJECTIVE (i) To examine the sociocultural factors that influence nurses' EWS compliance behaviours, using a theory driven behavioural model and (ii) to propose a conceptual model of sociocultural factors for EWS compliance behaviour. DESIGN A cross-sectional survey. SETTING Nurses employed in public hospitals across Queensland, Australia. PARTICIPANTS Using convenience and snowball sampling techniques eligible nurses accessed a dedicated web site and survey containing closed and open-ended questions. 291 nurses from 60 hospitals completed the survey. METHODS Quantitative data were analysed using ANOVA or t-tests to test differences in means. A series of path models based on the theory were conducted to develop a new model. Directed or theory driven content analysis informed qualitative data analysis. RESULTS Nurses report high levels of previous compliance behaviour and strong intentions to continue complying in the future (M=4.7; SD 0.48). Individual compliance attitudes (β 0.29, p<.05), perceived value of escalation (β 0.24, p<.05) and perceived ease or difficulty complying with documentation (β -0.31, p<.05) were statistically significant, predicting 24% of variation in compliance behaviour. Positive personal charting beliefs (β 0.14, p<.05) and subjective norms both explain higher behavioural intent indirectly through personal attitudes. High ratings of peer charting beliefs indirectly explain attitudes through subjective norms (β 0.20, p<.05). Perceptions of control over one's clinical actions (β -0.24, p<.05) and early warning system training (β -0.17, p<.05) directly contributed to fewer difficulties complying with documentation requirements. Prior difficulties when escalating care (β -0.31, p<.05) directly influenced the perceived value of escalating. CONCLUSIONS The developed theory-based conceptual model identified sociocultural variables that inform compliance behaviour (documenting and escalation protocols). The model highlights areas of clinical judgement, education, interprofessional trust, workplace norms and cultural factors that directly or indirectly influence nurses' intention to comply with EWS protocols. Extending our understanding of the sociocultural and system wide factors that hamper nurses' use of EWSs and professional accountability has the potential to improve the compliance behaviour of staff and subsequently enhance the safety climate attitudes of hospitals. TWEETABLE ABSTRACT A newly developed model reports nurse's personal attitudes, peer influence, perceived difficulties encountered documenting and escalation beliefs all predict early warning system compliance behaviour.
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Affiliation(s)
- Trudy Dwyer
- Appleton Institute, CQUniversity Australia, Australia; School of Nursing, Midwifery & Social Studies, CQUniversity Australia, Australia.
| | - Tracy Flenady
- School of Nursing, Midwifery & Social Studies, CQUniversity Australia, Australia.
| | - Tania Signal
- Appleton Institute, CQUniversity Australia, Australia; School of Health, Medical & Applied Sciences, CQUniversity Australia, Australia.
| | | | - Justine Connor
- School of Nursing, Midwifery & Social Studies, CQUniversity Australia, Australia
| | - Danielle Le Lagadec
- School of Nursing, Midwifery & Social Studies, CQUniversity Australia, Australia
| | - Belinda Goodwin
- Centre for Health Research, University of Southern Queensland, Australia
| | - Matthew Browne
- School of Health, Medical & Applied Sciences, CQUniversity Australia, Australia
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3
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Leenen JP, Mondria CL. Variation in nurses' compliance with an Early Warning Score protocol: A retrospective cohort study. Heliyon 2024; 10:e36147. [PMID: 39247370 PMCID: PMC11378878 DOI: 10.1016/j.heliyon.2024.e36147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 07/25/2024] [Accepted: 08/09/2024] [Indexed: 09/10/2024] Open
Abstract
Introduction Early Warning Score (EWS) protocols are based on intermittent vital sign measurements, and aim to detect clinical deterioration in a timely manner. Despite its predictive value, its effectiveness remains suboptimal. An important limitation appears to be poor compliance with the EWS protocol and its variation between general wards. The current research does not yet provide an understanding of EWS compliance and variation in different nursing wards. Aim To explore the variation in nurses' compliance with the EWS protocol among patients with and without complications and between different nursing wards. Methods In a retrospective single-center cohort study, all patient files from three nursing wards of a tertiary teaching hospital in the Netherlands were reviewed over a 1-month period. Compliance was divided into three categories:1) calculation accuracy, 2) monitoring frequency end 3) clinical response. Results The cohort of 210 patients contained 5864 measurements, of which 4125 (70.6 %) included EWS. Significant differences in the measured vital signs within incomplete measurements were found among nursing wards. Compliance to monitoring frequency was higher within EWSs of 0-1 (78.4 %) than within EWSs of ≥2 (26.1 %). The proportion of correct follow-up was significantly higher in patients with complications, as was the correct clinical response to an EWS of ≥3 (84.8 % vs. 55.0; p = .011). Conclusion Our results suggest suboptimal compliance with the EWS protocol, with large variations between patients with and without complications and between different general care wards. Nurses tended to be more compliant with the EWS protocol for patients with complications.
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Affiliation(s)
- Jobbe Pl Leenen
- Connected Care Centre, Isala, Zwolle, the Netherlands
- Research Group IT Innovations in Healthcare, Windesheim University of Applied Sciences, Zwolle, the Netherlands
| | - Chantal L Mondria
- Department Healthcare and Wellbeing, Windesheim University of Applied Sciences, Zwolle, the Netherlands
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Leenen JP, Schoonhoven L, Patijn GA. Wearable wireless continuous vital signs monitoring on the general ward. Curr Opin Crit Care 2024; 30:275-282. [PMID: 38690957 DOI: 10.1097/mcc.0000000000001160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
PURPOSE OF REVIEW Wearable wireless sensors for continuous vital signs monitoring (CVSM) offer the potential for early identification of patient deterioration, especially in low-intensity care settings like general wards. This study aims to review advances in wearable CVSM - with a focus on the general ward - highlighting the technological characteristics of CVSM systems, user perspectives and impact on patient outcomes by exploring recent evidence. RECENT FINDINGS The accuracy of wearable sensors measuring vital signs exhibits variability, especially notable in ambulatory patients within hospital settings, and standard validation protocols are lacking. Usability of CMVS systems is critical for nurses and patients, highlighting the need for easy-to-use wearable sensors, and expansion of the number of measured vital signs. Current software systems lack integration with hospital IT infrastructures and workflow automation. Imperative enhancements involve nurse-friendly, less intrusive alarm strategies, and advanced decision support systems. Despite observed reductions in ICU admissions and Rapid Response Team calls, the impact on patient outcomes lacks robust statistical significance. SUMMARY Widespread implementation of CVSM systems on the general ward and potentially outside the hospital seems inevitable. Despite the theoretical benefits of CVSM systems in improving clinical outcomes, and supporting nursing care by optimizing clinical workflow efficiency, the demonstrated effects in clinical practice are mixed. This review highlights the existing challenges related to data quality, usability, implementation, integration, interpretation, and user perspectives, as well as the need for robust evidence to support their impact on patient outcomes, workflow and cost-effectiveness.
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Affiliation(s)
- Jobbe Pl Leenen
- Connected Care Centre, Isala, Zwolle
- Research Group IT Innovations in Healthcare, Windesheim University of Applied Sciences, Zwolle
| | - Lisette Schoonhoven
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Gijs A Patijn
- Connected Care Centre, Isala, Zwolle
- Department of Surgery, Isala, Zwolle, The Netherlands
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Le Lagadec MD, Dwyer T, Browne M. Indicators of patient deterioration in poorly resourced private hospitals: Which vital sign to watch? A retrospective case-control study. Aust Crit Care 2024; 37:461-467. [PMID: 37391286 DOI: 10.1016/j.aucc.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 05/26/2023] [Accepted: 05/27/2023] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND Patient vital signs are a measure of wellness if monitored regularly and accurately. Staff shortages in poorly resourced regional hospitals often result in inadequate patient monitoring, putting patients at risk of undetected deterioration. OBJECTIVE This study aims to explore the pattern and completeness of vital sign monitoring and the contribution of each vital sign in predicting clinical deterioration events in resource-poor regional/rural hospitals. METHOD Using a retrospective case-control study design, we compared 24 h of vital sign data from deteriorating and nondeteriorating patients from two poorly-resourced regional hospitals. Descriptive statistics, t-tests, and analysis of variance are used to compare patient-monitoring frequency and completeness. The contribution of each vital sign in predicting patient deterioration was determined using the Area Under the Receiver Operator Characteristic curve and binary logistical regression analysis. RESULTS Deteriorating patients were monitored more frequently (9.58 [7.02] times) in the 24-h period than nondeteriorating patients (4.93 [2.66] times). However, the completeness of vital sign documentation was higher in nondeteriorating (85.2%) than in deteriorating patients (57.7%). Body temperature was the most frequently omitted vital sign. Patient deterioration was positively linked to the frequency of abnormal vital signs and the number of abnormal vital signs per set (Area Under the Receiver Operator Characteristic curve: 0.872 and 0.867, respectively). No single vital sign strongly predicts patient outcomes. However, a supplementary oxygen value of >3 L/min and a heart rate of >139 beats/min were the best predictors of patient deterioration. CONCLUSION Given the poor resourcing and often geographical remoteness of small regional hospitals, it is prudent that the nursing staff are made aware of the vital signs that best indicate deterioration for the cohort of patients in their care. Tachycardic patients on supplementary oxygen are at high risk of deterioration.
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Affiliation(s)
- Marie Danielle Le Lagadec
- School of Nursing, Midwifery and Social Sciences, Central Queensland, University, 6 University Dr, Branyan, Bundaberg, Queensland, 4670, Australia.
| | - Trudy Dwyer
- School of Nursing, Midwifery and Social Sciences, Central Queensland, University, 554-700 Yaamba Rd, Norman Gardens Rockhampton, Queensland, 4701, Australia.
| | - Matthew Browne
- School of Health, Medical and Applied Sciences Central Queensland, University, 6 University Dr, Branyan, Bundaberg Queensland, 4670, Australia.
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Robben N, Dierick-van Daele ATM, Bouwman ARA, van Loon FHJ. Worry as Important "Feelers" in Clinical Anesthesia Practice: A Mixed-Methods Study. J Perianesth Nurs 2024:S1089-9472(24)00011-X. [PMID: 38691073 DOI: 10.1016/j.jopan.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 01/08/2024] [Accepted: 01/08/2024] [Indexed: 05/03/2024]
Abstract
PURPOSE Worry is an intuitive sense that goes beyond logical reasoning and is valuable in situations where patients' conditions are rapidly changing or when objective data may not fully capture the complexity of a patient's situation. Nurse anesthetists' subjective reasons for worry are quite vague as they are valued inconsistently and not accurately expressed. This study aimed to identify factors playing a role in the emergence of worry during anesthesia practice to clarify its concept. DESIGN Mixed-methods design consisting of quantitative online surveys followed by qualitative focus group interviews including Dutch nurse anesthetists. METHODS Both quantitative and qualitative thematic analyses were performed, followed by data and methodological triangulation to enhance the validity and credibility of findings and mitigate the presence of bias. FINDINGS Surveys (N = 102) were analyzed, and 14 nurse anesthetists participated in the focus group interviews. A total of 89% of the survey respondents reported that at least once have had the feeling of worry, of which 92% use worry during clinical anesthesia practice. Worry was mentioned to be a vital element during anesthesia practice that makes it possible to take precautionary actions to change the anesthetic care plan in a changing situation or patient deterioration. CONCLUSIONS While a clear definition of worry could not be given, it is a valuable element of anesthesia practice as it serves as a catalyst for critical thinking, problem-solving, clinical reasoning, and decision-making. Use of the feeling of worry alongside technological systems to make an informed decision is crucial. Technology has significantly improved the ability of health care providers to detect and respond to patient deterioration promptly, but it is crucial for nurse anesthetists to use their feeling of worry or intuition alongside technological systems and evidence-based practice to ensure quick assessments or judgments based on experience, knowledge, and observations in clinical practice.
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Affiliation(s)
- Noa Robben
- Department of Anesthesiology, Catharina Hospital, Eindhoven, North-Brabant, The Netherlands
| | - Angelique T M Dierick-van Daele
- Institute of People and Health Sciences, Fontys University of Applied Sciences, Eindhoven, North-Brabant, The Netherlands; Research Department, Catharina Hospital, Eindhoven, North-Brabant, The Netherlands
| | - Arthur R A Bouwman
- Department of Anesthesiology, Catharina Hospital, Eindhoven, North-Brabant, The Netherlands; Department of Signal Processing Systems and Electrical Engineering, TU/e University of Technology, Eindhoven, North-Brabant, The Netherlands
| | - Fredericus H J van Loon
- Department of Anesthesiology, Catharina Hospital, Eindhoven, North-Brabant, The Netherlands; Department of Perioperative Care and Technology of the Institute of People and Health Sciences, Fontys University of Applied Sciences, Eindhoven, North-Brabant, The Netherlands.
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7
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Woodward M, Dixon-Woods M, Randall W, Walker C, Hughes C, Blackwell S, Dewick L, Bahl R, Draycott T, Winter C, Ansari A, Powell A, Willars J, Brown IAF, Olsson A, Richards N, Leeding J, Hinton L, Burt J, Maistrello G, Davies C, van der Scheer JW. How to co-design a prototype of a clinical practice tool: a framework with practical guidance and a case study. BMJ Qual Saf 2024; 33:258-270. [PMID: 38124136 PMCID: PMC10982632 DOI: 10.1136/bmjqs-2023-016196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 11/20/2023] [Indexed: 12/23/2023]
Abstract
Clinical tools for use in practice-such as medicine reconciliation charts, diagnosis support tools and track-and-trigger charts-are endemic in healthcare, but relatively little attention is given to how to optimise their design. User-centred design approaches and co-design principles offer potential for improving usability and acceptability of clinical tools, but limited practical guidance is currently available. We propose a framework (FRamework for co-dESign of Clinical practice tOols or 'FRESCO') offering practical guidance based on user-centred methods and co-design principles, organised in five steps: (1) establish a multidisciplinary advisory group; (2) develop initial drafts of the prototype; (3) conduct think-aloud usability evaluations; (4) test in clinical simulations; (5) generate a final prototype informed by workshops. We applied the framework in a case study to support co-design of a prototype track-and-trigger chart for detecting and responding to possible fetal deterioration during labour. This started with establishing an advisory group of 22 members with varied expertise. Two initial draft prototypes were developed-one based on a version produced by national bodies, and the other with similar content but designed using human factors principles. Think-aloud usability evaluations of these prototypes were conducted with 15 professionals, and the findings used to inform co-design of an improved draft prototype. This was tested with 52 maternity professionals from five maternity units through clinical simulations. Analysis of these simulations and six workshops were used to co-design the final prototype to the point of readiness for large-scale testing. By codifying existing methods and principles into a single framework, FRESCO supported mobilisation of the expertise and ingenuity of diverse stakeholders to co-design a prototype track-and-trigger chart in an area of pressing service need. Subject to further evaluation, the framework has potential for application beyond the area of clinical practice in which it was applied.
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Affiliation(s)
- Matthew Woodward
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Mary Dixon-Woods
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | | | | | | | | | - Louise Dewick
- Royal College of Obstetricians and Gynaecologists, London, UK
| | - Rachna Bahl
- Royal College of Obstetricians and Gynaecologists, London, UK
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Tim Draycott
- Royal College of Obstetricians and Gynaecologists, London, UK
- North Bristol NHS Trust, Westbury on Trym, UK
| | | | - Akbar Ansari
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Alison Powell
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Janet Willars
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Imogen A F Brown
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Annabelle Olsson
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Natalie Richards
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Joann Leeding
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Lisa Hinton
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jenni Burt
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | | | | | - Jan W van der Scheer
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Briggs J, Kostakis I, Meredith P, Dall'ora C, Darbyshire J, Gerry S, Griffiths P, Hope J, Jones J, Kovacs C, Lawrence R, Prytherch D, Watkinson P, Redfern O. Safer and more efficient vital signs monitoring protocols to identify the deteriorating patients in the general hospital ward: an observational study. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2024; 12:1-143. [PMID: 38551079 DOI: 10.3310/hytr4612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Background The frequency at which patients should have their vital signs (e.g. blood pressure, pulse, oxygen saturation) measured on hospital wards is currently unknown. Current National Health Service monitoring protocols are based on expert opinion but supported by little empirical evidence. The challenge is finding the balance between insufficient monitoring (risking missing early signs of deterioration and delays in treatment) and over-observation of stable patients (wasting resources needed in other aspects of care). Objective Provide an evidence-based approach to creating monitoring protocols based on a patient's risk of deterioration and link these to nursing workload and economic impact. Design Our study consisted of two parts: (1) an observational study of nursing staff to ascertain the time to perform vital sign observations; and (2) a retrospective study of historic data on patient admissions exploring the relationships between National Early Warning Score and risk of outcome over time. These were underpinned by opinions and experiences from stakeholders. Setting and participants Observational study: observed nursing staff on 16 randomly selected adult general wards at four acute National Health Service hospitals. Retrospective study: extracted, linked and analysed routinely collected data from two large National Health Service acute trusts; data from over 400,000 patient admissions and 9,000,000 vital sign observations. Results Observational study found a variety of practices, with two hospitals having registered nurses take the majority of vital sign observations and two favouring healthcare assistants or student nurses. However, whoever took the observations spent roughly the same length of time. The average was 5:01 minutes per observation over a 'round', including time to locate and prepare the equipment and travel to the patient area. Retrospective study created survival models predicting the risk of outcomes over time since the patient was last observed. For low-risk patients, there was little difference in risk between 4 hours and 24 hours post observation. Conclusions We explored several different scenarios with our stakeholders (clinicians and patients), based on how 'risk' could be managed in different ways. Vital sign observations are often done more frequently than necessary from a bald assessment of the patient's risk, and we show that a maximum threshold of risk could theoretically be achieved with less resource. Existing resources could therefore be redeployed within a changed protocol to achieve better outcomes for some patients without compromising the safety of the rest. Our work supports the approach of the current monitoring protocol, whereby patients' National Early Warning Score 2 guides observation frequency. Existing practice is to observe higher-risk patients more frequently and our findings have shown that this is objectively justified. It is worth noting that important nurse-patient interactions take place during vital sign monitoring and should not be eliminated under new monitoring processes. Our study contributes to the existing evidence on how vital sign observations should be scheduled. However, ultimately, it is for the relevant professionals to decide how our work should be used. Study registration This study is registered as ISRCTN10863045. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/05/03) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 6. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Jim Briggs
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, UK
| | - Ina Kostakis
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, UK
| | - Paul Meredith
- Research Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | | | - Julie Darbyshire
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Stephen Gerry
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | | | - Jo Hope
- Health Sciences, University of Southampton, Southampton, UK
| | - Jeremy Jones
- Health Sciences, University of Southampton, Southampton, UK
| | - Caroline Kovacs
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, UK
| | | | - David Prytherch
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, UK
| | - Peter Watkinson
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Oliver Redfern
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Chua WL, Wee LPC, Lim JYG, Yeo MLK, Jones D, Tan CK, Khan FA, Liaw SY. Automated rapid response system activation-Impact on nurses' attitudes and perceptions towards recognising and responding to clinical deterioration: Mixed-methods study. J Clin Nurs 2023; 32:6322-6338. [PMID: 37087695 DOI: 10.1111/jocn.16734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 02/12/2023] [Accepted: 04/05/2023] [Indexed: 04/24/2023]
Abstract
AIM To explore general ward nurses' attitudes and perceptions towards recognising and responding to clinical deterioration in a hospital with automated rapid response system activation. BACKGROUND There is growing interest in deploying automated clinical deterioration notification systems to reduce delayed or failed recognition and response to clinical deterioration of ward patients. However, little is known about its impact on ward nurses' perspectives and work patterns. DESIGN A mixed-methods study. METHODS Online survey of 168 registered nurses and individual interviews with 10 registered nurses in one acute hospital in Singapore. The study adhered to the STROBE checklist for cross-sectional studies and the COREQ guidelines for qualitative studies. RESULTS Many nurses (38.1%) rarely performed patient assessments or observations other than vital signs assessment to assess for early signs of clinical deterioration. About 30% were worried about being criticised for calling the primary team doctors. Four themes emerged from the qualitative analysis: automated rapid response system activation as a safety net, being more cautious with vital signs monitoring, the NEWS2 alone is inadequate, and ward nurses as the 'middleman' between the intensive care unit outreach nurse and primary team doctors. CONCLUSIONS Although nurses value the automated rapid response system activation as a safety net to minimise delays in accessing urgent critical care resources, it does not address the sociocultural barriers inherent in escalation of care. Although the automated system led nurses to be more cautious with vital signs monitoring, it does not encourage them to perform comprehensive patient assessments to detect early signs of deterioration. RELEVANCE TO CLINICAL PRACTICE Nurse education on assessing for clinical deterioration should focus on the use of broader patient assessment skills other than vital signs. Sociocultural barriers to escalation of care remain a key issue that needs to be addressed by hospital management. NO PATIENT OR PUBLIC CONTRIBUTION No patients, service users, care-givers or members of the public were involved in the study.
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Affiliation(s)
- Wei Ling Chua
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Li-Phing Clarice Wee
- Department of Nursing Administration, Ng Teng Fong General Hospital, National University Health System, Singapore
| | - Jia Ying Germaine Lim
- Department of Nursing, Ng Teng Fong General Hospital, National University Health System, Singapore
| | - Min Li Kimberly Yeo
- Department of Nursing, Ng Teng Fong General Hospital, National University Health System, Singapore
| | - Daryl Jones
- Intensive Care Unit, Austin Health, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
| | - Chee Keat Tan
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System, Singapore
| | - Faheem Ahmed Khan
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System, Singapore
| | - Sok Ying Liaw
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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10
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Xu L, Tan J, Chen Q, Luo Z, Song L, Liu Q, Peng L. Development and validation of an instrument for measuring junior nurses' recognition and response abilities to clinical deterioration (RRCD). Aust Crit Care 2023; 36:754-761. [PMID: 36376190 DOI: 10.1016/j.aucc.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 09/20/2022] [Accepted: 09/20/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Nurses of all levels are expected to be competent in managing clinical deterioration. Given their limited experience and basic-level knowledge, there is a concern about junior nurses' clinical and patient management skills. However, junior nurses' abilities to recognise and respond to clinical deterioration have not been adequately explored because of the absence of a comprehensive tool. OBJECTIVES The aim of this study was to develop a new self-assessment scale to assess the junior nurses' recognition and response abilities to clinical deterioration and to examine its reliability and validity. METHODS Scale items were based on literature reviews and interviews. The preliminary scale was generated through two rounds of expert review. A panel of five experts evaluated content validity. After a pilot study, the questionnaire was distributed to 168 junior nurses via convenience sampling. Subsequent statistical analysis of results included construct validity, internal consistency, and test-retest reliability. RESULTS Six factors were included, and 69.310% of the total variance was explained by the 25 items comprising the scale. The Cronbach's alpha coefficient was 0.905 (95% confidence interval [CI]: 0.812-0.979) for the overall scale and 0.655-0.838 for its subscales. The Guttman split-half reliability was 0.856 (95% CI: 0.806-0.894). The test-retest reliability of the scale was 0.878 (95% CI: 0.836-0.911). CONCLUSION We developed a scale for measuring the abilities of junior nurses to recognise and respond to clinical deterioration and confirmed its reliability and validity. More experimental studies are needed to further evaluate this instrument.
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Affiliation(s)
- Laiyu Xu
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jianwen Tan
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Qirong Chen
- Xiangya Nursing School, Central South University, Changsha, Hunan, China
| | - Zhen Luo
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Lili Song
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Qingqing Liu
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Lingli Peng
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University, Changsha, Hunan, China.
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11
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Langkjaer CS, Bundgaard K, Bunkenborg G, Nielsen PB, Iversen KK, Bestle MH, Bove DG. How nurses use National Early Warning Score and Individual Early Warning Score to support their patient risk assessment practice: A fieldwork study. J Adv Nurs 2023; 79:789-797. [PMID: 36541263 PMCID: PMC10107488 DOI: 10.1111/jan.15547] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 12/02/2022] [Accepted: 12/11/2022] [Indexed: 12/24/2022]
Abstract
AIM To explore and describe how the National Early Warning Score (NEWS) and Individual Early Warning Score (I-EWS) are used and how they support nurses' patient risk assessment practice. DESIGN A qualitative observational fieldwork study drawing on ethnographical principles was performed in six hospitals in two regions of Denmark in 2019. METHODS Data were generated from participant observations and informal interviews with 32 nurses across 15 different wards in the hospitals. A total of 180 h of participant observation was performed. The observations lasted between 1.5 and 8 h and were conducted during day or evening shifts. RESULTS NEWS and I-EWS supported nurses' observations of patients, providing useful knowledge for planning patient care, and prompting critical thinking. However, the risk assessment task was sometimes delegated to less experienced staff members, such as nursing students and healthcare assistants. The Early Warning Score (EWS) systems were often adapted by nurses according to contextual aspects, such as the culture of the speciality in which the nurses worked and their levels of competency. In some situations, I-EWS had the effect of enhancing nurse autonomy and responsibility for decision-making in relation to patient care. CONCLUSIONS EWS systems support nurses' patient risk assessment practice, providing useful information. I-EWS makes it easier to factor the heterogeneity of patients and the clinical situation into the risk assessments. The delegation of risk assessment to other, less experienced staff members pose a risk to patient safety, which needs to be addressed in the ongoing debate regarding the shortage of nurses. IMPACT The findings of this study can help ward nurses, hospital managers and policymakers to develop and improve strategies for improved person-centred nursing care.
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Affiliation(s)
- Caroline S Langkjaer
- Department of Emergency Medicine, Copenhagen University Hospital - North Zealand, Copenhagen, Denmark
| | - Karin Bundgaard
- Clinical Nursing Research Unit, Aalborg University Hospital, Aalborg, Denmark.,Clinic for Neuro-, Head- and Orthopaedic Diseases, Aalborg University Hospital, Aalborg, Denmark.,Department of Public Health, Nursing, Health Faculty, Aarhus University, Aarhus C, Denmark
| | - Gitte Bunkenborg
- Department of Anesthesiology, Copenhagen University Hospital - Holbaek, Holbaek, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense C, Denmark
| | - Pernille B Nielsen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark.,Department of Emergency Medicine, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Kasper K Iversen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark.,Department of Emergency Medicine, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Morten H Bestle
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Anaesthesia and Intensive Care, Copenhagen University Hospital - North Zealand, Copenhagen, Denmark
| | - Dorthe G Bove
- University College Absalon, Centre for Nursing, Roskilde, Denmark
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12
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Li W, Yu H, Li B, Zhang Y, Fu M. The transcultural adaptation and validation of the Chinese version of the Attitudes Toward Recognizing Early and Noticeable Deterioration scale. Front Psychol 2022; 13:1062949. [PMID: 36562070 PMCID: PMC9765647 DOI: 10.3389/fpsyg.2022.1062949] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 11/14/2022] [Indexed: 12/12/2022] Open
Abstract
Background In China, clinical deterioration events present a real problem for every clinical nurse. Patient deterioration is determined in part by nurses' attitudes toward early recognition of clinical deterioration. However, research on attitudes toward the early identification of clinical deterioration is still in its infancy, and even less research has been done on ward nurses' attitudes toward the early identification of clinical deterioration. To drive behavioral change and improve the care of deteriorating patients, nurses need comprehensive, valid, and reliable tools to assess their attitudes toward early identification of deterioration. Objective In this study, we aimed to translate the Attitudes Toward Recognizing Early and Noticeable Deterioration (ATREND) scale into Chinese and to assess its validity and reliability tests. Methods From March 2022 to July 2022, the ATREND scale was translated, back-translated, and cross-culturally adapted into the Chinese version using a modified Brislin translation model. Then, 460 ward nurses were recruited from tertiary Grade A general hospitals in two cities: Shenyang and Jinzhou in Liaoning Province, China. Reliability analyses were conducted using internal consistency, split-half, and test-retest reliability. We convened a committee of experts to determine the validity of the content. Tests of the structural validity of the scale were conducted using exploratory and validation factor analyses. Results The Cronbach's α value of the Chinese version of the ATREND scale was 0.804, and the Cronbach's α value of the dimensions ranged from 0.782 to 0.863. The split-half reliability and test-retest reliability were 0.846 and 0.711, respectively. Furthermore, the scale has an index of content validity of 0.922, indicating a high level of content validity. In exploratory factor analysis, eigenvalues, total variance explained, and scree plot supported a three-factor structure. The three-factor model supported by this study was confirmed by confirmatory factor analysis (CFA). Moreover, the model fitting indexes (e.g., χ 2/DF = 1.498, GFI = 0.954, RMSEA = 0.047) were all within acceptable limits based on the CFA. Conclusion The Chinese version of the scale is reliable and valid among ward nurses. Nursing educators and clinicians will be able to develop targeted educational programs to enhance the competence and behaviors of Chinese ward nurses in recognizing clinical deterioration. It will be based on the developed scale to assess Chinese nurses' attitudes and practices regarding early recognition of clinical deterioration. As a result, it is necessary to consider the Chinese scale's three-factor structure. The developed three-factor structured scale will assess Chinese ward nurses' attitudes and practices toward patient observation and vital sign-monitoring empowerment, enlightening them on the importance of patient observation, encouraging ward nurses to use a wider range of patient assessment techniques to capture early signs of clinical deterioration, and helping ward nurses to develop clinical confidence to monitor clinical deterioration.
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Affiliation(s)
- Wenbo Li
- Department of Nursing, Jinzhou Medical University, Jinzhou, China
| | - Hongyu Yu
- Department of Nursing, Jinzhou Medical University, Jinzhou, China,*Correspondence: Hongyu Yu,
| | - Bing Li
- Department of Dermatology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yanli Zhang
- Department of Nursing, Jinzhou Medical University, Jinzhou, China
| | - Mingshu Fu
- Department of Neurosurgery, The First Affiliated Hospital of China Medical University, Shenyang, China
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13
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Bucknall TK, Considine J, Harvey G, Graham ID, Rycroft-Malone J, Mitchell I, Saultry B, Watts JJ, Mohebbi M, Bohingamu Mudiyanselage S, Lotfaliany M, Hutchinson A. Prioritising Responses Of Nurses To deteriorating patient Observations (PRONTO): a pragmatic cluster randomised controlled trial evaluating the effectiveness of a facilitation intervention on recognition and response to clinical deterioration. BMJ Qual Saf 2022; 31:818-830. [PMID: 35450936 PMCID: PMC9606509 DOI: 10.1136/bmjqs-2021-013785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 03/01/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Most hospitals use physiological signs to trigger an urgent clinical review. We investigated whether facilitation could improve nurses' vital sign measurement, interpretation, treatment and escalation of care for deteriorating patients. METHODS In a pragmatic cluster randomised controlled trial, we randomised 36 inpatient wards at four acute hospitals to receive standard clinical practice guideline (CPG) dissemination to ward staff (n=18) or facilitated implementation for 6 months following standard dissemination (n=18). Expert, hospital and ward facilitators tailored facilitation techniques to promote nurses' CPG adherence. Patient records were audited pre-intervention, 6 and 12 months post-intervention on randomly selected days. Escalation of care as per hospital policy was the primary outcome at 6 and 12 months after implementation. Patients, nurses and assessors were blinded to group assignment. Analysis was by intention-to-treat. RESULTS From 10 383 audits, improved escalation as per hospital policy was evident in the intervention group at 6 months (OR 1.47, 95% CI (1.06 to 2.04)) with a complete set of vital sign measurements sustained at 12 months (OR 1.22, 95% CI (1.02 to 1.47)). There were no significant differences in escalation of care as per hospital policy between study groups at 6 or 12 months post-intervention. After adjusting for patient and hospital characteristics, a significant change from T0 in mean length of stay between groups at 12 months favoured the intervention group (-2.18 days, 95% CI (-3.53 to -0.82)). CONCLUSION Multi-level facilitation significantly improved escalation as per hospital policy at 6 months in the intervention group that was not sustained at 12 months. The intervention group had increased vital sign measurement by nurses, as well as shorter lengths of stay for patients at 12 months. Further research is required to understand the dose of facilitation required to impact clinical practice behaviours and patient outcomes. TRIAL REGISTRATION NUMBER ACTRN12616000544471p.
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Affiliation(s)
- Tracey K Bucknall
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Faculty of Health, Deakin University, Burwood, Victoria, Australia
- Centre for Quality and Patient Safety Research - Alfred Health Partnership, Alfred Health, Melbourne, Victoria, Australia
| | - Julie Considine
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Faculty of Health, Deakin University, Burwood, Victoria, Australia
- Centre for Quality and Patient Safety Research - Eastern Health Partnership, Eastern Health, Box Hill, Victoria, Australia
| | - Gillian Harvey
- Caring Futures Institute, Flinders University College of Nursing and Health Sciences, Bedford Park, South Australia, Australia
| | - Ian D Graham
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Faculty of Health, Deakin University, Burwood, Victoria, Australia
- School of Epidemiology and Public Health and School of Nursing, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Imogen Mitchell
- Australian National University Medical School, Canberra, Australian Capital Territory, Australia
| | - Bridey Saultry
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Faculty of Health, Deakin University, Burwood, Victoria, Australia
- Centre for Quality and Patient Safety Research - Alfred Health Partnership, Alfred Health, Melbourne, Victoria, Australia
| | - Jennifer J Watts
- School of Health and Social Development, Deakin Health Economics, Institute for Health Transformation, Faculty of Health, Deakin University, Burwood, Victoria, Australia
| | - Mohammadreza Mohebbi
- Biostatistics Unit, Faculty of Health, Deakin University, Burwood, Victoria, Australia
| | - Shalika Bohingamu Mudiyanselage
- School of Health and Social Development, Deakin Health Economics, Institute for Health Transformation, Faculty of Health, Deakin University, Burwood, Victoria, Australia
| | - Mojtaba Lotfaliany
- Biostatistics Unit, Faculty of Health, Deakin University, Burwood, Victoria, Australia
| | - Alison Hutchinson
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Faculty of Health, Deakin University, Burwood, Victoria, Australia
- Centre for Quality and Patient Safety Research - Monash Health Partnership, Monash Health, Clayton, Victoria, Australia
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14
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Choi A, Chung K, Chung SP, Lee K, Hyun H, Kim JH. Advantage of Vital Sign Monitoring Using a Wireless Wearable Device for Predicting Septic Shock in Febrile Patients in the Emergency Department: A Machine Learning-Based Analysis. SENSORS (BASEL, SWITZERLAND) 2022; 22:7054. [PMID: 36146403 PMCID: PMC9504566 DOI: 10.3390/s22187054] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 09/02/2022] [Accepted: 09/13/2022] [Indexed: 06/16/2023]
Abstract
Intermittent manual measurement of vital signs may not rapidly predict sepsis development in febrile patients admitted to the emergency department (ED). We aimed to evaluate the predictive performance of a wireless monitoring device that continuously measures heart rate (HR) and respiratory rate (RR) and a machine learning analysis in febrile but stable patients in the ED. We analysed 468 patients (age, ≥18 years; training set, n = 277; validation set, n = 93; test set, n = 98) having fever (temperature >38 °C) and admitted to the isolation care unit of the ED. The AUROC of the fragmented model with device data was 0.858 (95% confidence interval [CI], 0.809−0.908), and that with manual data was 0.841 (95% CI, 0.789−0.893). The AUROC of the accumulated model with device data was 0.861 (95% CI, 0.811−0.910), and that with manual data was 0.853 (95% CI, 0.803−0.903). Fragmented and accumulated models with device data detected clinical deterioration in febrile patients at risk of septic shock 9 h and 5 h 30 min earlier, respectively, than those with manual data. Continuous vital sign monitoring using a wearable device could accurately predict clinical deterioration and reduce the time to recognise potential clinical deterioration in stable ED patients with fever.
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Affiliation(s)
- Arom Choi
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea
| | - Kyungsoo Chung
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea
| | - Kwanhyung Lee
- AITRICS, 28 Hyoryeong-ro 77-gil, Seocho-gu, Seoul 06627, Korea
| | - Heejung Hyun
- AITRICS, 28 Hyoryeong-ro 77-gil, Seocho-gu, Seoul 06627, Korea
| | - Ji Hoon Kim
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea
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15
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Treacy M, Wong G, Odell M, Roberts N. Understanding the use of the National Early Warning Score 2 in acute care settings: a realist review protocol. BMJ Open 2022; 12:e062154. [PMID: 35803636 PMCID: PMC9272106 DOI: 10.1136/bmjopen-2022-062154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Failure to recognise and respond to patient deterioration in an appropriate and timely manner has been highlighted as a global patient safety concern. Early Warning Scores (EWSs) using vital signs were introduced to address this concern, with the aim of getting the patient timely and appropriate treatment. The National Early Warning Score 2 (NEWS2) is in use across the NHS, and many other settings globally. While patient improvements have been shown, research has identified that the NEWS2 is not always used as intended. Therefore, this review will use a realist approach to understand what the mechanisms are that influence appropriate use (or not) of the NEWS2 in acute care settings, how, for whom and in which contexts. The findings will inform clinicians of what helps and/or hinders appropriate use of the NEWS2 in clinical practice, thus helping to facilitate successful implementation. METHODS AND ANALYSIS Our realist review will follow Pawson's iterative six step process: (1) Development of initial programme theory. (2) Searching the literature; an information scientist will develop, pilot and refine the search strategy. A systematic search will be completed, based on subject relevancy on the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Embase (OvidSP), Web of Science (Science Citation Index and Social Science Citation), Cochrane Database of Systematic Reviews, Joanna Briggs Institute, Ethos, Proquest Dissertations and Theses Global, and Google Scholar for documents dating from 1997 (date of the first published EWS) to present. To retrieve additional relevant data 'snowballing' (finding references and authors by hand, contacting authors, searching reference lists and citation-tracking using Google Scholar) will be used. Inclusion criteria include all documents (including grey literature) that relate to the use of EWSs/NEWS2 in the English language only. Documents set in the paediatric, maternity and primary care settings will be excluded. (3) Selecting documents and quality appraisal. (4) Extracting and organising the data. (5) Synthesising the data. (6) Disseminating the findings. We will recruit a group of stakeholders comprised of experienced clinicians who use the NEWS2 as part of their clinical practice to provide feedback throughout the review. Step 1 has already begun with the development of an initial programme theory. This initial programme theory presents how the NEWS2 is supposed to work (or not), it will now be developed, tested and refined. ETHICS AND DISSEMINATION Ethical approval is not required for this study as it is secondary research. Dissemination will include a peer-reviewed publication and conference presentations. Findings will also be amplified through social media platforms with user friendly summaries. Our stakeholder group will also contribute to dissemination of findings in their clinical areas and among existing networks. PROSPERO REGISTRATION NUMBER CRD42022304497.
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Affiliation(s)
- Michelle Treacy
- Department for Continuing Education, Oxford University, Oxford, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Mandy Odell
- Critical Care, Royal Berkshire NHS Foundation Trust, London Rd, Reading, UK
| | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, UK, Oxford, UK
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16
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Carter B, Saron H, Siner S, Preston J, Peak M, Mehta F, Lane S, Lambert C, Jones D, Hughes H, Harris J, Evans L, Dee S, Eyton-Chong CK, Sefton G, Carrol ED. Health professionals' initial experiences and perceptions of the acceptability of a whole-hospital, pro-active electronic paediatric early warning system (the DETECT study): a qualitative interview study. BMC Pediatr 2022; 22:365. [PMID: 35751050 PMCID: PMC9233392 DOI: 10.1186/s12887-022-03411-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 06/08/2022] [Indexed: 11/23/2022] Open
Abstract
Background Paediatric early warning systems (PEWS) alert health professionals to signs of a child’s deterioration with the intention of triggering an urgent review and escalating care. They can reduce unplanned critical care transfer, cardiac arrest, and death. Electronic systems may be superior to paper-based systems. The objective of the study was to critically explore the initial experiences and perceptions of health professionals about the acceptability of DETECT e-PEWS, and what factors influence its acceptability. Methods A descriptive qualitative study (part of The DETECT study) was undertaken February 2020–2021. Single, semi-structured telephone interviews were used. The setting was a tertiary children’s hospital, UK. The participants were health professionals working in study setting and using DETECT e-PEWS. Sampling was undertaken using a mix of convenience and snowballing techniques. Participants represented two user-groups: ‘documenting vital signs’ (D-VS) and ‘responding to vital signs’ (R-VS). Perceptions of clinical utility and acceptability of DETECT e-PEWS were derived from thematic analysis of transcripts. Results Fourteen HPs (12 nurses, 2 doctors) participated; seven in D-VS and seven in the R-VS group. Three main themes were identified: complying with DETECT e-PEWS, circumventing DETECT e-PEWS, and disregarding DETECT e-PEWS. Overall clinical utility and acceptability were deemed good for HPs in the D-VS group but there was diversity in perception in the R-VS group (nurses found it more acceptable than doctors). Compliance was better in the D-VS group where use of DETECT e-PEWS was mandated and used more consistently. Some health professionals circumvented DETECT e-PEWS and fell back into old habits. Doctors (R-VS) did not consistently engage with DETECT e-PEWS, which reduced the acceptability of the system, even in those who thought the system brought benefits. Conclusions Speed and accuracy of real-time data, automation of triggering alerts and improved situational awareness were key factors that contributed to the acceptability of DETECT e-PEWS. Mandating use of both recording and responding aspects of DETECT e-PEWS is needed to ensure full implementation. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-022-03411-1.
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Affiliation(s)
| | | | - Sarah Siner
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | | | - Matthew Peak
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Fulya Mehta
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | | | - Caroline Lambert
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK.,University of Liverpool, Liverpool, UK
| | - Dawn Jones
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Hannah Hughes
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Jane Harris
- Liverpool John Moores University, Liverpool, UK
| | - Leah Evans
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Sarah Dee
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | | | - Gerri Sefton
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Enitan D Carrol
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK.,University of Liverpool, Liverpool, UK
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17
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Smith D, Cartwright M, Dyson J, Hartin J, Aitken LM. Selecting intervention content to target barriers and enablers of recognition and response to deteriorating patients: an online nominal group study. BMC Health Serv Res 2022; 22:766. [PMID: 35689227 PMCID: PMC9186287 DOI: 10.1186/s12913-022-08128-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 05/23/2022] [Indexed: 12/02/2022] Open
Abstract
Background Patients who deteriorate in hospital wards without appropriate recognition and/or response are at risk of increased morbidity and mortality. Track-and-trigger tools have been implemented internationally prompting healthcare practitioners (typically nursing staff) to recognise physiological changes (e.g. changes in blood pressure, heart rate) consistent with patient deterioration, and then to contact a practitioner with expertise in management of acute/critical illness. Despite some evidence these tools improve patient outcomes, their translation into clinical practice is inconsistent internationally. To drive greater guideline adherence in the use of the National Early Warning Score tool (a track-and-trigger tool used widely in the United Kingdom and parts of Europe), a theoretically informed implementation intervention was developed (targeting nursing staff) using the Theoretical Domains Framework (TDF) version 2 and a taxonomy of Behaviour Change Techniques (BCTs). Methods A three-stage process was followed: 1. TDF domains representing important barriers and enablers to target behaviours derived from earlier published empirical work were mapped to appropriate BCTs; 2. BCTs were shortlisted using consensus approaches within the research team; 3. shortlisted BCTs were presented to relevant stakeholders in two online group discussions where nominal group techniques were applied. Nominal group participants were healthcare leaders, senior clinicians, and ward-based nursing staff. Stakeholders individually generated concrete strategies for operationalising shortlisted BCTs (‘applications’) and privately ranked them according to acceptability and feasibility. Ranking data were used to drive decision-making about intervention content. Results Fifty BCTs (mapped in stage 1) were shortlisted to 14 (stage 2) and presented to stakeholders in nominal groups (stage 3) alongside example applications. Informed by ranking data from nominal groups, the intervention was populated with 12 BCTs that will be delivered face-to-face, to individuals and groups of nursing staff, through 18 applications. Conclusions A description of a theory-based behaviour change intervention is reported, populated with BCTs and applications generated and/or prioritised by stakeholders using replicable consensus methods. The feasibility of the proposed intervention should be tested in a clinical setting and the content of the intervention elaborated further to permit replication and evaluation. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08128-6.
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Affiliation(s)
- Duncan Smith
- School of Health Sciences, City, University of London, Northampton Square, London, EC1V 0HB, UK. .,Patient Emergency Response & Resuscitation Team (PERRT), University College London Hospitals NHS Foundation Trust, Euston Road, London, NW1 2BU, UK.
| | - Martin Cartwright
- School of Health Sciences, City, University of London, Northampton Square, London, EC1V 0HB, UK
| | - Judith Dyson
- Reader in Implementation Science, Birmingham City University, Westbourne Road, Edgbaston, Birmingham, B15 3TN, UK
| | - Jillian Hartin
- Patient Emergency Response & Resuscitation Team (PERRT), University College London Hospitals NHS Foundation Trust, Euston Road, London, NW1 2BU, UK
| | - Leanne M Aitken
- School of Health Sciences, City, University of London, Northampton Square, London, EC1V 0HB, UK.,School of Nursing and Midwifery, Griffith University, Nathan, QLD, 4111, Australia
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18
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Chua WL, Smith D, Wee LC, Ting KC, Yeo MLK, Mordiffi SZ, Liaw SY. Development and psychometric evaluation of the Attitudes Towards Recognising Early and Noticeable Deterioration (ATREND) scale. J Clin Nurs 2022; 32:2684-2699. [PMID: 35527356 DOI: 10.1111/jocn.16350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 04/04/2022] [Accepted: 04/19/2022] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES To develop and evaluate the psychometric properties of an instrument that measures nurses' Attitudes Towards Recognising Early and Noticeable Deterioration (ATREND). BACKGROUND General ward nurses play an important role in recognising patient deterioration. However, their attitudes towards early recognition of clinical deterioration have not been adequately explored due to the lack of a valid and reliable scale. DESIGN An instrument development and validation study. METHODS A three-phase structure that followed the STROBE checklist was used: (1) item generation, (2) content and face validity assessment and (3) psychometric properties evaluation. The scale items were developed based on a comprehensive literature review and content validity assessment by 15 international experts from five countries. The psychometric properties of the ATREND scale were tested on 434 registered nurses, with retest evaluations (n = 100) at two hospitals. Exploratory and confirmatory factor analyses were used to examine the factor structure of the scale. The scale was also evaluated for its internal consistency, test-retest reliability and convergent validity. RESULTS The scale's content validity was 0.95. A 3-factor solution was identified from the final 11 items: (1) beliefs about importance of patient observation, (2) use of broader patient assessment skills and (3) confidence in recognising clinical deterioration. The internal consistency reliability of the scale was supported with an acceptable Cronbach's alpha value of 0.745. Test-retest reliability of the scale was excellent, with an intraclass correlation coefficient of 0.825. The ATREND scale shows evidence of good convergent validity. CONCLUSION The final 11-item ATREND scale demonstrates adequate initial evidence of reliability and validity for use in acute ward settings. RELEVANCE TO CLINICAL PRACTICE Nursing educators and clinicians may use this scale to assess ward nurses' attitudes and practices towards early recognition of clinical deterioration and then enhance their competencies and behaviours in the recognition of clinical deterioration.
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Affiliation(s)
- Wei Ling Chua
- Alice Lee Centre for Nursing Studies Yong Loo Lin School of Medicine National University of Singapore Singapore City Singapore
| | - Duncan Smith
- School of Health Sciences City University of London London UK
- Patient Emergency Response & Resuscitation Team (PERRT) NHS Foundation Trust University College London Hospitals London UK
| | - Li‐Phing Clarice Wee
- Department of Nursing Administration Ng Teng Fong General Hospital National University Health System Singapore City Singapore
| | - Kit Cheng Ting
- Nursing Department National University Hospital National University Health System Singapore City Singapore
| | - Min Li Kimberly Yeo
- Department of Nursing Ng Teng Fong General Hospital National University Health System Singapore City Singapore
| | - Siti Zubaidah Mordiffi
- Nursing Department National University Hospital National University Health System Singapore City Singapore
| | - Sok Ying Liaw
- Alice Lee Centre for Nursing Studies Yong Loo Lin School of Medicine National University of Singapore Singapore City Singapore
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19
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Burke C, Conway Y. Factors that influence hospital nurses' escalation of patient care in response to their early warning score: A qualitative evidence synthesis. J Clin Nurs 2022; 32:1885-1934. [PMID: 35338540 DOI: 10.1111/jocn.16233] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 01/18/2022] [Accepted: 01/19/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The Early Warning Score (EWS) is a validated tool that has improved patient outcomes internationally. This scoring system is used within the hospital setting to identify potentially deteriorating patients, thus expediting referral to appropriate medical personnel. It is increasingly recognised that there are other influencing factors along with EWS, which impact on nurses' decisions to escalate care. AIM The aim of this review was to identify and synthesise data from qualitative studies, which examined factors influencing nurses' escalation of care in response to patients' EWS. METHODS The systematic search strategy and eligibility criteria were guided by the SPIDER (Sample Phenomenon of Interest Design Evaluation Type of Research) framework. Eleven databases and five grey literature databases were searched. Titles and abstracts were independently screened in line with pre-established inclusion and exclusion criteria using the cloud-based platform, Rayyan. The selected studies underwent quality appraisal using CASP (Critical Appraisal Skills Programme, 2017, https://www.casp-uk.net/casp-toolschecklists) and subsequently synthesised using Thomas and Harden's thematic analysis approach. GRADE-CERQual (Grading of Recommendations Assessment Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research) was used to assess confidence in results. The EQUATOR listed guideline ENTREQ (Tong et al., 2012, BMC Medical Research Methodology, 12) was used to synthesise and report findings. RESULTS Eighteen studies from seven countries including 235 nurses were identified. Following synthesis, four analytical themes were generated with eighteen derived consequent findings. The four themes identified were as follows: 1) Marrying nurses' clinical judgement with EWS 2) SMART communication 3) EWS Protocol: Blessing and a Curse 5) Hospital Domain. CONCLUSION Nurses strive to find balance by simultaneously navigating within the boundaries of both the EWS protocol and the hospital domain. They view the EWS as a valid essential component in the system but one that does not give a definitive answer and absolute direction. They value the protocols' ability to identify deteriorating patients and convey the seriousness of a situation to their multidisciplinary colleagues but also find it somewhat restrictive and frustrating and wish to have credence given to their own intuition and clinical judgement.
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Affiliation(s)
- Catherine Burke
- St Johns Hospital Urgent Care Center St Johns Hospital St Johns Square, Limerick, Ireland
| | - Yvonne Conway
- Department of Nursing, Health Sciences and Integrated Care, Galway Mayo Institute of Technology, Galway, Ireland
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20
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Qualls BW, Bode AM, Hopkins KR. Deviation in Medical Record Documentation Prevents Calculation of the Modified Early Warning System Score. Prof Case Manag 2022; 27:100-104. [PMID: 35099426 DOI: 10.1097/ncm.0000000000000557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Brandon W Qualls
- Brandon W. Qualls, MPA, is the Coordinator of the Clinical Nursing Research Center and a PhD student at the Margaret Warner Graduate School of Education and Human Development at the University of Rochester, Rochester, NY. Brandon received both his undergraduate and master's degrees from The College at Brockport, State University of New York (SUNY)
- Angela M. Bode, BSN, CMSRN , is a clinical resource administrator at Highland Hospital and a family nurse practitioner student at St. John Fisher College, Highland Hospital, Rochester, NY
- Kathryn R. Hopkins, BSN, RN, is a staff nurse, Cardiovascular Intensive Care Unit, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Angela M Bode
- Brandon W. Qualls, MPA, is the Coordinator of the Clinical Nursing Research Center and a PhD student at the Margaret Warner Graduate School of Education and Human Development at the University of Rochester, Rochester, NY. Brandon received both his undergraduate and master's degrees from The College at Brockport, State University of New York (SUNY)
- Angela M. Bode, BSN, CMSRN , is a clinical resource administrator at Highland Hospital and a family nurse practitioner student at St. John Fisher College, Highland Hospital, Rochester, NY
- Kathryn R. Hopkins, BSN, RN, is a staff nurse, Cardiovascular Intensive Care Unit, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Kathryn R Hopkins
- Brandon W. Qualls, MPA, is the Coordinator of the Clinical Nursing Research Center and a PhD student at the Margaret Warner Graduate School of Education and Human Development at the University of Rochester, Rochester, NY. Brandon received both his undergraduate and master's degrees from The College at Brockport, State University of New York (SUNY)
- Angela M. Bode, BSN, CMSRN , is a clinical resource administrator at Highland Hospital and a family nurse practitioner student at St. John Fisher College, Highland Hospital, Rochester, NY
- Kathryn R. Hopkins, BSN, RN, is a staff nurse, Cardiovascular Intensive Care Unit, Thomas Jefferson University Hospital, Philadelphia, PA
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21
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Pankhurst T, Sapey E, Gyves H, Evison F, Gallier S, Gkoutos G, Ball S. Evaluation of NEWS2 response thresholds in a retrospective observational study from a UK acute hospital. BMJ Open 2022; 12:e054027. [PMID: 35135770 PMCID: PMC8830252 DOI: 10.1136/bmjopen-2021-054027] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE Use of National Early Warning Score 2 (NEWS2) has been mandated in adults admitted to acute hospitals in England. Urgent clinical review is recommended at NEWS2 ≥5. This policy is recognised as requiring ongoing evaluation. We assessed NEWS2 acquisition, alerting at key thresholds and patient outcomes, to understand how response recommendations would affect clinical resource allocation. SETTING Adult acute hospital in England. DESIGN Retrospective observational cohort study. PARTICIPANTS 100 362 consecutive admissions between November 2018 and July 2019. OUTCOME Death or admission to intensive care unit within 24 hours of a score. METHODS NEWS2 were assembled as single scores from consecutive 24-hour time frames, (the first NEWS2 termed 'Index-NEWS2'), or as all scores from the admission (termed All-NEWS2). Scores were excluded when a patient was in intensive care, in the presence of a decision not to attempt cardiopulmonary resuscitation, or on day 1 of elective admission. RESULTS A mean of 4.5 NEWS2 were acquired per patient per day. The outcome rate following an Index-NEWS2 was 0.22/100 patient-days. The sensitivity of outcome prediction at Index-NEWS2 ≥5=0.46, and number needed to evaluate (NNE)=52. At this threshold, a mean of 37.6 alerts/100 patient-days would be generated, occurring in 12.3% of patients on any single day. Threshold changes to increase sensitivity by 0.1, would result in a twofold increase in alert rate and 1.5-fold increase in NNE. Overall, NEWS2 classification performance was significantly worse on Index-scores than All-scores (c-statistic=0.78 vs 0.85; p<0.001). CONCLUSIONS The combination of low event-rate, high alert-rate and low sensitivity, in patients for cardiopulmonary resuscitation, means that at current NEWS2 thresholds, resource demand would be sufficient to meaningfully compete with other pathways to clinical evaluation. In analyses that epitomise in-patient screening, NEWS2 performance suggests a need for re-evaluation of current response recommendations in this population.
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Affiliation(s)
- Tanya Pankhurst
- Renal Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Elizabeth Sapey
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- PIONEER Hub, University of Birmingham, Birmingham, UK
| | - Helen Gyves
- Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Felicity Evison
- Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Suzy Gallier
- Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- PIONEER Technical Director, University of Birmingham, Birmingham, UK
| | | | - Simon Ball
- Better Care, Health Data Research, London, UK
- Chief Medical Officer, University Hospitals Birmingham NHS Founation Trust, Birmingham, UK
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22
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Mølgaard RR, Jørgensen L, Christensen EF, Grønkjaer M, Voldbjerg SL. Ambivalence in nurses' use of the early warning score: A focussed ethnography in a hospital setting. J Adv Nurs 2021; 78:1461-1472. [PMID: 34841561 DOI: 10.1111/jan.15118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 10/12/2021] [Accepted: 11/04/2021] [Indexed: 11/29/2022]
Abstract
AIM This study describes and explores the influences in registered nurses' use of early warning scores to support clinical decisions in a hospital setting. DESIGN A focussed ethnography allowed for the investigation of registered nurses' clinical practices in two wards in a Danish University Hospital. The study adhered to the 'Standards for Reporting Qualitative Research'. METHODS Participant observation and ethnographic interviews were conducted from March 2019 to August 2019. Ten registered nurses were observed and interviewed, and four physicians were interviewed. Data were analysed using LeCompte and Schensul's ethnographic analysis. FINDINGS The findings show the registered nurses' ambivalence towards the early warning score as a decision support system. Early warning score monitoring created a space for registered nurses to identify and initiate optimized care. However, when early warning scores contradicted registered nurses' clinical judgments, the latter were given priority in decisions even though elevated scores were not always accounted for in the situation. Moreover, we found unspoken expectations in the collaboration between physicians and registered nurses, which influenced the registered nurses' workloads and decisions regarding early warning scores. CONCLUSION Registered nurses' clinical judgment is essential to clinical decisions on the care and safety of patients if used combined with the early warning score. Interprofessional collaboration between registered nurses and physicians about the early warning score is challenged. Future research may address this challenge to explore how it should be operated as a collaboration tool. IMPACT The study adds knowledge to the evidence base of registered nurses' use of early warning score and the advantages and challenges associated with the use of these scoring systems. The study may provide valuable knowledge for the future development of policies or implementation strategies.
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Affiliation(s)
- Rikke R Mølgaard
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Clinical Nursing Research Unit, Aalborg University Hospital, Aalborg, Denmark.,Department of Nursing, University College of Northern Denmark, Hjorring, Denmark
| | - Lone Jørgensen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Clinical Nursing Research Unit, Aalborg University Hospital, Aalborg, Denmark.,Clinic for Surgery and Cancer Treatment, Aalborg University Hospital, Aalborg, Denmark
| | - Erika F Christensen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Center for Prehospital and Emergency Research, Aalborg University Hospital, Aalborg, Denmark
| | - Mette Grønkjaer
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Clinical Nursing Research Unit, Aalborg University Hospital, Aalborg, Denmark
| | - Siri L Voldbjerg
- Clinical Nursing Research Unit, Aalborg University Hospital, Aalborg, Denmark.,Department of Nursing, University College of Northern Denmark, Hjorring, Denmark
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23
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Bunkenborg G, Nydahl P. Early Warning Score systems: Their predictive ability and their clinical usefulness when drawing a complete picture of the patient at risk of an adverse event and escalating care. Intensive Crit Care Nurs 2021; 67:103129. [PMID: 34391626 DOI: 10.1016/j.iccn.2021.103129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Gitte Bunkenborg
- Department of Regional Health Research, University of Southern Denmark and Department of Anesthesiology, Holbæk Hospital, Denmark.
| | - Peter Nydahl
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Schleswig-Holstein, Kiel, Germany.
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24
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Langkjaer CS, Bove DG, Nielsen PB, Iversen KK, Bestle MH, Bunkenborg G. Nurses' Experiences and Perceptions of two Early Warning Score systems to Identify Patient Deterioration-A Focus Group Study. Nurs Open 2021; 8:1788-1796. [PMID: 33638617 PMCID: PMC8186715 DOI: 10.1002/nop2.821] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 12/29/2020] [Accepted: 01/31/2021] [Indexed: 11/07/2022] Open
Abstract
AIMS To explore Registered Nurses' experiences and perceptions with National Early Warning Score and Individual Early Warning Score to identify patient deterioration. DESIGN A qualitative exploratory design. METHODS Six focus groups were conducted at six Danish hospitals from February to June 2019. Registered Nurses from both medical, surgical and emergency departments participated. The focus groups were analysed using content analysis. RESULTS One theme and four categories were identified. Theme: Meaningful in identifying patient deterioration but causing frustration due to lack of flexibility. Categories: (a) Inter-professional collaboration strengthened through the use of Early Warning Score systems, (b) Enhanced professional development and communication among nurses when using Early Warning Score systems, (c) Detecting patient deterioration by integrating nurses' clinical gaze with Early Warning Score systems and (d) Modification and fear of making mistakes when using Early Warning Score systems.
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Affiliation(s)
- Caroline S. Langkjaer
- Department of Emergency MedicineNordsjaellands HospitalUniversity of CopenhagenHilleroedDenmark
| | - Dorthe G. Bove
- Department of Emergency MedicineNordsjaellands HospitalUniversity of CopenhagenHilleroedDenmark
| | - Pernille B. Nielsen
- Department of CardiologyHerlev and Gentofte HospitalUniversity of CopenhagenHerlevDenmark
- Department of Emergency MedicineHerlev and Gentofte HospitalUniversity of CopenhagenHerlevDenmark
| | - Kasper K. Iversen
- Department of CardiologyHerlev and Gentofte HospitalUniversity of CopenhagenHerlevDenmark
- Department of Emergency MedicineHerlev and Gentofte HospitalUniversity of CopenhagenHerlevDenmark
- Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
| | - Morten H. Bestle
- Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
- Department of Anaesthesiology and Intensive careNordsjaellands HospitalUniversity of CopenhagenHilleroedDenmark
| | - Gitte Bunkenborg
- Department of AnesthesiologyHolbaek HospitalHolbaekDenmark
- Department of Regional Health ResearchUniversity of Southern DenmarkOdenseDenmark
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25
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Sprogis SK, Currey J, Jones D, Considine J. Use of the pre-medical emergency team tier of rapid response systems: A scoping Review. Intensive Crit Care Nurs 2021; 65:103041. [PMID: 33795182 DOI: 10.1016/j.iccn.2021.103041] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/12/2021] [Accepted: 03/16/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The aim of this review was to explore use of the pre-Medical Emergency Team (pre-MET) tier of Rapid Response Systems to recognise and respond to adult ward patients experiencing early clinical deterioration. METHODS A scoping review of studies published in English reporting on use of a pre-MET tier in adult ward patients was conducted. Three databases were searched (Medline, CINAHL, EMBASE) for studies published between January 1995 and September 2020. Two researchers independently performed screening and quality assessments. Findings were synthesised thematically. Reporting of the review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. RESULTS Six of 1669 studies were included in this review. All were single-site studies of single-parameter Rapid Response Systems in Australian hospitals. Five were quantitative studies; one had a qualitative design. Studies fulfilled 50-100% of quality criteria. Two themes were constructed: Afferent processes - Recognising and escalating pre-MET events; and Efferent processes - Pre-MET reviews and associated interventions. There was disparity between clinical practice and pre-MET escalation protocols, and reports of nurse-initiated management of early deterioration. Prospective methods and exploration of multidisciplinary perspectives were notable research gaps. CONCLUSION Use of the pre-MET tier of Rapid Response Systems is under-researched. Further research is needed to understand barriers and facilitators influencing use of pre-MET strategies to address patient deterioration.
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Affiliation(s)
- Stephanie K Sprogis
- Deakin University: School of Nursing and Midwifery & Centre for Quality and Patient Safety in the Institute for Health Transformation, 1 Gheringhap St, Geelong, Victoria 3220, Australia. https://twitter.com/@Steph_Sprogis
| | - Judy Currey
- Deakin University: School of Nursing and Midwifery & Centre for Quality and Patient Safety in the Institute for Health Transformation, 1 Gheringhap St, Geelong, Victoria 3220, Australia; Deakin University: Deakin Learning Futures, Office of the Deputy Vice Chancellor (Education), 1 Gheringhap St, Geelong, Victoria 3220, Australia. https://twitter.com/@Judy_Currey
| | - Daryl Jones
- Department of Intensive Care, Austin Hospital, 145 Studley Rd, Heidelberg, Victoria, 3084, Australia; School of Public Health and Preventive Medicine, Monash University, Wellington Rd, Clayton, Victoria 3800, Australia; Department of Surgery, University of Melbourne, Parkville, Victoria 3010, Australia. https://twitter.com/@jones_daza
| | - Julie Considine
- Deakin University: School of Nursing and Midwifery & Centre for Quality and Patient Safety in the Institute for Health Transformation, 1 Gheringhap St, Geelong, Victoria 3220, Australia; Centre for Quality and Patient Safety Research - Eastern Health Partnership, 2/5 Arnold St, Box Hill, Victoria 3128, Australia. https://twitter.com/@Julie_Considine
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26
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Smith D, Cartwright M, Dyson J, Hartin J, Aitken LM. Barriers and enablers of recognition and response to deteriorating patients in the acute hospital setting: A theory-driven interview study using the Theoretical Domains Framework. J Adv Nurs 2021; 77:2831-2844. [PMID: 33739478 DOI: 10.1111/jan.14830] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 02/02/2021] [Accepted: 03/05/2021] [Indexed: 12/01/2022]
Abstract
AIM To explore barriers and enablers of recognition and response to signs of patient deterioration by nursing staff in an acute hospital. DESIGN A theory-driven interview study underpinned by the Theoretical Domains Framework of behaviour change. METHODS Between 07/01/2019 and 18/12/2019 a purposive sample of registered nurses and healthcare assistants was recruited to participate in a semi-structured (audio-recorded) interview, to explore the determinants of seven specified behaviours of the afferent limb. Anonymised transcripts were deductively coded (using the 14 Theoretical Domains Framework domains as coding categories) and then extracts within each domain were inductively analysed to synthesise belief statements and themes. Prioritisation criteria from published literature were applied. RESULTS Thirty-two semi-structured interviews were conducted. From 1,888 quotes, 184 belief statements and 66 themes were synthesised. One hundred and forty-six belief statements, represented by 58 themes, met prioritisation criteria. Nine domains of the Theoretical Domains Framework were of high importance: Knowledge; Social, Professional Role and Identity; Beliefs about Consequences; Reinforcement; Intentions; Goals; Memory, Attention and Decision Processes; Environment, Context and Resources and Social Influences. CONCLUSIONS Barriers and enablers most likely to impact on nursing staff afferent limb behaviour were identified in nine domains of the Theoretical Domains Framework.
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Affiliation(s)
- Duncan Smith
- School of Health Sciences, City University of London, London, UK.,Patient Emergency Response & Resuscitation Team (PERRT), University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Judith Dyson
- School of Health Sciences, Birmingham City University, Birmingham, UK
| | - Jillian Hartin
- Patient Emergency Response & Resuscitation Team (PERRT), University College London Hospitals NHS Foundation Trust, London, UK
| | - Leanne M Aitken
- School of Health Sciences, City University of London, London, UK.,School of Nursing and Midwifery, Griffith University, Nathan, Qld., Australia
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27
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Low compliance to a vital sign safety protocol on general hospital wards: A retrospective cohort study. Int J Nurs Stud 2021; 115:103849. [DOI: 10.1016/j.ijnurstu.2020.103849] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 11/12/2020] [Accepted: 11/12/2020] [Indexed: 11/20/2022]
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28
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Credland N, Dyson J, Johnson MJ. Do early warning track and trigger tools improve patient outcomes? A systematic synthesis without meta-analysis. J Adv Nurs 2020; 77:622-634. [PMID: 33128308 DOI: 10.1111/jan.14619] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 09/08/2020] [Accepted: 10/06/2020] [Indexed: 12/23/2022]
Abstract
AIM To determine the effect of Early Warning Track and Trigger Tools on patient outcomes. DESIGN A systematic review: synthesis without meta-analysis. DATA SOURCES Electronic databases were searched from 1 January 2013-1 August 2018 and 221 papers identified. REVIEW METHODS A systematic review and narrative synthesis supported the identification of synthesized findings named and reported according to outcome measure. RESULTS Five international papers representing over 74,000 patients were included in the analysis. Seven key findings were identified, the impact of NEWS on: (a) cardiopulmonary arrest; (b) mortality; (c) serious adverse events; (d) length of hospital stay; (e) hospital admissions; (f) observation frequency; and (g) Intensive/High dependency Unit admission. Papers identified statistically significant improvements in mortality, serious adverse events, hospital admissions, observation frequency, and intensive care unit/high dependency unit admission when an Early Warning Track and Trigger protocol is in use. There were conflicting results regarding length of stay and cardiopulmonary arrest data. CONCLUSION Early Warning Track and Trigger Tools can aid recognition of deteriorating patients. Further research is required in relation to hospital length of stay and cardiopulmonary arrests. IMPACT Early warning track and trigger tools have been implemented nationally and to a lesser degree internationally. There is evidence to suggest improved clinical outcomes following their use. Further research needs to combine the use of the National Early Warning Score with an agreed set of measured outcomes, and then subsequent study data could be combined to provide much stronger levels of evidence.
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Affiliation(s)
- Nicola Credland
- Faculty of Health Sciences, School of Health and Social Work, The University of Hull, Hull, UK
| | - Judith Dyson
- City University of London, Northampton Square, London, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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29
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Smith D, Cartwright M, Dyson J, Hartin J, Aitken LM. Patterns of behaviour in nursing staff actioning the afferent limb of the rapid response system (RRS): A focused ethnography. J Adv Nurs 2020; 76:3548-3562. [PMID: 32996620 DOI: 10.1111/jan.14551] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/09/2020] [Accepted: 07/29/2020] [Indexed: 12/17/2022]
Abstract
AIM To improve understanding of afferent limb behaviour in acute hospital ward settings, to define and specify who needs to do what differently and to report what afferent limb behaviours should be targeted in a subsequent multi-phase, theory-based, intervention development process. DESIGN Focused ethnography was used including direct observation of nursing staff enacting afferent limb behaviours and review of vital signs charts. METHODS An observation guide focused observation on "key moments" of the afferent limb. Descriptions of observations from between 7 January 2019-18 December 2019 were recorded in a field journal alongside reflexive notes. Vital signs and early warning scores from charts were reviewed and recorded. Field notes were analysed using structured content analysis. Observed behaviour was compared with expected (policy-specified) behaviour. RESULTS Observation was conducted for 300 hr. Four hundred and ninety-nine items of data (e.g., an episode of observation or a set of vital signs) were collected. Two hundred and eighty-nine (58%) items of data were associated with expected (i.e. policy-specified) afferent limb behaviour; 210 (42%) items of data were associated with unexpected afferent limb behaviour (i.e. alternative behaviour or no behaviour). Ten specific behaviours were identified where the behaviour observed deviated (negatively) from policy or where no action was taken when it should have been. One further behaviour was seen to expedite the assessment of a deteriorating patient by an appropriate responder and was therefore considered a positive deviance. CONCLUSION Afferent limb failure has been described as a problem of inconsistent staff behaviour. Eleven potential target behaviours for change are reported and specified using a published framework. IMPACT Clear specification of target behaviour will allow further enquiry into the determinants of these behaviours and the development of a theory-based intervention that is more likely to result in behaviour change and can be tested empirically in future research.
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Affiliation(s)
- Duncan Smith
- School of Health Sciences, City University of London, London, UK.,University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Judith Dyson
- School of Health Sciences, City University of London, London, UK
| | - Jillian Hartin
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Leanne M Aitken
- School of Health Sciences, City University of London, London, UK.,School of Nursing and Midwifery, Griffith University, Nathan, QLD, Australia
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30
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Martín-Rodríguez F, Sanz-García A, Medina-Lozano E, Castro Villamor MÁ, Carbajosa Rodríguez V, Del Pozo Vegas C, Fadrique Millán LN, Rabbione GO, Martín-Conty JL, López-Izquierdo R. The Value of Prehospital Early Warning Scores to Predict in - Hospital Clinical Deterioration: A Multicenter, Observational Base-Ambulance Study. PREHOSP EMERG CARE 2020; 25:597-606. [PMID: 32820947 DOI: 10.1080/10903127.2020.1813224] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVES Early warning scores are clinical tools capable of identifying prehospital patients with high risk of deterioration. We sought here to contrast the validity of seven early warning scores in the prehospital setting and specifically, to evaluate the predictive value of each score to determine early deterioration-risk during the hospital stay, including mortality at one, two, three and seven- days since the index event. Methods: A prospective multicenter observational based-ambulance study of patients treated by six advanced life support emergency services and transferred to five Spanish hospitals between October 1, 2018 and December 31, 2019. We collected demographic, clinical, and laboratory variables. Seven risk score were constructed based on the analysis of prehospital variables associated with death within one, two, three and seven days since the index event. The area under the receiver operating characteristics was used to determine the discriminant validity of each early warning score. Results: A total of 3,273 participants with acute diseases were accurately linked. The median age was 69 years (IQR, 54-81 years), 1,348 (41.1%) were females. The overall mortality rate for patients in the study cohort ranged from 3.5% for first-day mortality (114 cases), to 7% for seven-day mortality (228 cases). The scores with the best performances for one-day mortality were Vitalpac Early Warning Score with an area under the receiver operating characteristic (AUROC) of 0.873 (95% CI: 0.81-0.9), for two-day mortality, Triage Early Warning Score with an AUROC of 0.868 (95% CI: 0.83-0.9), for three and seven-days mortality the Modified Rapid Emergency Medicine Score with an AUROC of 0.857 (0.82-0.89) and 0.833 (95% CI: 0.8-0.86). In general, there were no significant differences between the scores analyzed. Conclusions: All the analyzed scores have a good predictive capacity for early mortality, and no statistically significant differences between them were found. The National Early Warning Score 2, at the clinical level, has certain advantages. Early warning scores are clinical tools that can help in the complex decision-making processes during critical moments, so their use should be generalized in all emergency medical services.
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Flenady T, Dwyer T, Sobolewska A, Lagadec DL, Connor J, Kahl J, Signal T, Browne M. Developing a sociocultural framework of compliance: an exploration of factors related to the use of early warning systems among acute care clinicians. BMC Health Serv Res 2020; 20:736. [PMID: 32782002 PMCID: PMC7422559 DOI: 10.1186/s12913-020-05615-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 08/02/2020] [Indexed: 11/10/2022] Open
Abstract
Background Early warning systems (EWS) are most effective when clinicians monitor patients’ vital signs and comply with the recommended escalation of care protocols once deterioration is recognised. Objectives To explore sociocultural factors influencing acute care clinicians’ compliance with an early warning system commonly used in Queensland public hospitals in Australia. Methods This interpretative qualitative study utilised inductive thematic analysis to analyse data collected from semi-structured interviews conducted with 30 acute care clinicians from Queensland, Australia. Results This study identified that individuals and teams approached compliance with EWS in the context of 1) the use of EWS for patient monitoring; and 2) the use of EWS for the escalation of patient care. Individual and team compliance with monitoring and escalation processes is facilitated by intra and inter-professional factors such as acceptance and support, clear instruction, inter-disciplinary collaboration and good communication. Noncompliance with EWS can be attributed to intra and inter-professional hierarchy and poor communication. Conclusions The overarching organisational context including the hospital’s embedded quality improvement and administrative protocols (training, resources and staffing) impact hospital-wide culture and influence clinicians’ and teams’ compliance or non-compliance with early warning system’s monitoring and escalation processes. Successful adoption of EWS relies on effective and meaningful interactions among multidisciplinary staff.
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Affiliation(s)
- Tracy Flenady
- Central Queensland University, School of Nursing & Midwifery, Building 18, Bruce Highway, Rockhampton, 4702, Australia.
| | - Trudy Dwyer
- Central Queensland University, School of Nursing & Midwifery, Building 18, Bruce Highway, Rockhampton, 4702, Australia
| | - Agnieszka Sobolewska
- Central Queensland University, School of Nursing & Midwifery, Building 18, Bruce Highway, Rockhampton, 4702, Australia
| | - Danielle Le Lagadec
- Central Queensland University, School of Nursing & Midwifery, Building 18, Bruce Highway, Rockhampton, 4702, Australia
| | - Justine Connor
- Central Queensland University, School of Nursing & Midwifery, Building 18, Bruce Highway, Rockhampton, 4702, Australia
| | - Julie Kahl
- Central Queensland Hospital and Health Services, Canning Street, Rockhampton, 4701, Australia
| | - Tania Signal
- Central Queensland University, School of Nursing & Midwifery, Building 18, Bruce Highway, Rockhampton, 4702, Australia
| | - Matthew Browne
- Central Queensland University, School of Nursing & Midwifery, Building 18, Bruce Highway, Rockhampton, 4702, Australia
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Leenen JPL, Leerentveld C, van Dijk JD, van Westreenen HL, Schoonhoven L, Patijn GA. Current Evidence for Continuous Vital Signs Monitoring by Wearable Wireless Devices in Hospitalized Adults: Systematic Review. J Med Internet Res 2020; 22:e18636. [PMID: 32469323 PMCID: PMC7351263 DOI: 10.2196/18636] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/07/2020] [Accepted: 05/14/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Continuous monitoring of vital signs by using wearable wireless devices may allow for timely detection of clinical deterioration in patients in general wards in comparison to detection by standard intermittent vital signs measurements. A large number of studies on many different wearable devices have been reported in recent years, but a systematic review is not yet available to date. OBJECTIVE The aim of this study was to provide a systematic review for health care professionals regarding the current evidence about the validation, feasibility, clinical outcomes, and costs of wearable wireless devices for continuous monitoring of vital signs. METHODS A systematic and comprehensive search was performed using PubMed/MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials from January 2009 to September 2019 for studies that evaluated wearable wireless devices for continuous monitoring of vital signs in adults. Outcomes were structured by validation, feasibility, clinical outcomes, and costs. Risk of bias was determined by using the Mixed Methods Appraisal Tool, quality assessment of diagnostic accuracy studies 2nd edition, or quality of health economic studies tool. RESULTS In this review, 27 studies evaluating 13 different wearable wireless devices were included. These studies predominantly evaluated the validation or the feasibility outcomes of these devices. Only a few studies reported the clinical outcomes with these devices and they did not report a significantly better clinical outcome than the standard tools used for measuring vital signs. Cost outcomes were not reported in any study. The quality of the included studies was predominantly rated as low or moderate. CONCLUSIONS Wearable wireless continuous monitoring devices are mostly still in the clinical validation and feasibility testing phases. To date, there are no high quality large well-controlled studies of wearable wireless devices available that show a significant clinical benefit or cost-effectiveness. Such studies are needed to help health care professionals and administrators in their decision making regarding implementation of these devices on a large scale in clinical practice or in-home monitoring.
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Affiliation(s)
| | | | | | | | - Lisette Schoonhoven
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, United Kingdom
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Hope J, Griffiths P, Schmidt PE, Recio-Saucedo A, Smith GB. Impact of using data from electronic protocols in nursing performance management: A qualitative interview study. J Nurs Manag 2019; 27:1682-1690. [PMID: 31482604 PMCID: PMC6919414 DOI: 10.1111/jonm.12858] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 08/27/2019] [Accepted: 08/29/2019] [Indexed: 01/02/2023]
Abstract
Aim To explore the impact of using electronic data in performance management to improve nursing compliance with a protocol. Background Electronic data are increasingly used to monitor protocol compliance but little is known about the impact on nurses’ practice in hospital wards. Method Seventeen acute hospital nursing staff participated in semi‐structured interviews about compliance with an early warning score (EWS) protocol delivered by a bedside electronic handheld device. Results Before electronic EWS data was used to monitor compliance, staff combined protocol‐led actions with clinical judgement. However, some observations were missed to reduce noise and disruption at night. After compliance monitoring was introduced, observations were sometimes covertly omitted using a loophole. Interviewees described a loss of autonomy but acknowledged the EWS system sometimes flagged unexpected patient deterioration. Conclusions Introducing automated electronic systems to support nursing tasks can decrease nursing burden but remove the ability to record legitimate reasons for missing observations. This can result in covert resistance that could reduce patient safety. Implications for nursing management Providing the ability to log legitimate reasons for missing observations would allow nurses to balance professional judgement with the use of electronic data in performance management of protocol compliance.
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Affiliation(s)
- Joanna Hope
- School of Health Sciences, National Institute for Health Research (NIHR) Collaboration for Applied Health Research and Care (CLAHRC), University of Southampton, Wessex, Southampton, UK
| | - Peter Griffiths
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Paul E Schmidt
- Portsmouth Hospitals NHS Trust, Medical Assessment Unit, Queen Alexandra Hospital, Portsmouth, UK
| | | | - Gary B Smith
- Centre of Postgraduate Medical Research & Education (CoPMRE), Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, Dorset, UK
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Smith D, Sekhon M, Francis JJ, Aitken LM. How actionable are staff behaviours specified in policy documents? A document analysis of protocols for managing deteriorating patients. J Clin Nurs 2019; 28:4139-4149. [PMID: 31327164 DOI: 10.1111/jocn.15005] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/22/2019] [Accepted: 06/21/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND To optimise care of deteriorating patients, healthcare organisations have implemented rapid response systems including an "afferent" and "efferent" limb. Afferent limb behaviours include monitoring vital signs and escalating care. To strengthen afferent limb behaviour and reduce adverse patient outcomes, the National Early Warning Score was implemented in the UK. There are no published reports of how National Early Warning Score guidance has translated into trust-level deteriorating patient policy and whether these documents provide clear, actionable statements guiding staff. AIM To identify how deteriorating patient policy documents provide "actionable" behavioural instruction for staff, responsible for actioning the afferent limb of the rapid response system. DESIGN A structured content analysis of a national guideline and local policies using a behaviour specification framework. METHODS Local deteriorating patient policies were obtained. Statements of behaviour were extracted from policies; coded using a behaviour specification framework: Target, Action, Context, Timing and Actor and scored for specificity (1 = present, nonspecific; 2 = present, specific). Frequencies and proportions of statements containing elements of the Target, Action, Context, Timing and Actor framework were summarised descriptively. Reporting was guided by the COREQ checklist. RESULTS There were more statements related to monitoring than escalation behaviour (65% vs 35%). Despite high levels of clear specification of the action (94%) and the target of the behaviour (74%), context, timing and actor were poorly specified (37%, 37% and 33%). CONCLUSION Delay in escalating deteriorating patients is associated with adverse outcomes. Some delay could be addressed by writing local protocols with greater behavioural specificity, to facilitate actionability. RELEVANCE TO CLINICAL PRACTICE Numerous clinical staff are required for an effective response to patient deterioration. To mitigate role confusion, local policy writers should provide clear specification of the actor. As the behaviours are time-sensitive, clear specification of the time frame may increase actionability of policy statements for clinical staff.
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Affiliation(s)
- Duncan Smith
- School of Health Sciences, City, University of London, London, UK.,Patient Emergency Response & Resuscitation Team (PERRT), University College London Hospitals NHS Foundation Trust, London, UK
| | - Mandeep Sekhon
- Department of Population Health Sciences, Faculty of Life Sciences and Medicine, School of Population Health & Environmental Sciences, King's College London, London, UK
| | - Jill J Francis
- School of Health Sciences, City, University of London, London, UK
| | - Leanne M Aitken
- School of Health Sciences, City, University of London, London, UK.,Menzies Health Institute Queensland, Griffith University, Nathan, Qld, Australia
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Bunkenborg G, Smith‐Hansen L, Poulsen I. Implementing mandatory early warning scoring impacts nurses’ practice of documenting free text notes. J Clin Nurs 2019; 28:2990-3000. [DOI: 10.1111/jocn.14870] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 02/13/2019] [Accepted: 03/23/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Gitte Bunkenborg
- Department of Anesthesiology Copenhagen University Hospital Hvidovre Denmark
- Department of Anesthesiology Holbaek Hospital, part of Copenhagen University Hospital Holbaek Denmark
| | - Lars Smith‐Hansen
- Clinical Research Center Copenhagen University Hospital Hvidovre Denmark
| | - Ingrid Poulsen
- Research Unit on Brain Injury Rehabilitation Copenhagen (RUBRIC) Department of Neurorehabilitation, Traumatic Brain Injury Copenhagen University Hospital Rigshospitalet Denmark
- Section of Nursing Science, Health Aarhus University Aarhus Denmark
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