‘Changes of concern’ for detecting potential early clinical deterioration: A validation study

A new situation awareness model decreases clinical deterioration in the emergency departments-A controlled intervention study

BACKGROUND

Studies have suggested that adding subjective parameters to early warning score (EWS) systems might prompt more proactive treatment and positively affect clinical outcomes. Hence, the study aimed to investigate effect of a situation awareness model consisting of objective and subjective parameters on clinical deterioration in adult emergency department (ED) patients.

METHODS

This controlled pre-and-post interventional study was carried out in July-December 2016 and November 2017-April 2018. In ED patients ≥ 18 years, we examined if a situation awareness model compared with a conventional EWS system could reduce clinical deterioration. The new model consisted of a regional EWS, combined with skin observation, clinical concern and patients' and relatives' concerns, pain, dyspnea, and team risk assessment. Clinical deterioration was defined as change in vital signs requiring increased observation or physician assessment, that is, increase in early warning score from either 0 or 1 to score ≥2 or an increase from score ≥2 and above. Secondary outcomes were mortality, intensive care unit (ICU) admissions, and readmissions.

RESULTS

We included 34 556 patients. Patients with two or more registered EWS were included in the primary analysis (N = 21 839). Using difference-in-difference regression, we found a reduced odds of clinical deterioration of 21% (OR 0.79 95% CI [0.69; 0.90]) in the intervention groups compared with controls. No impact on mortality, ICU, or readmissions was found.

CONCLUSION

The situation awareness model reduces odds of clinical deterioration, defined as a clinically relevant increase in EWS, in an unselected adult population of ED patients. However, there was no effect on secondary outcomes.

Consensus on predictors of clinical deterioration in emergency departments: A Delphi process study

AIM

The study aim was to determine relevance and applicability of generic predictors of clinical deterioration in emergency departments based on consensus among clinicians.

METHODS

Thirty-three predictors of clinical deterioration identified from literature were assessed in a modified two-stage Delphi-process. Sixty-eight clinicians (physicians and nurses) participated in the first round and 48 in the second round; all treating hospitalized patients in Danish emergency departments, some with pre-hospital experience. The panel rated the predictors for relevance (relevant marker of clinical deterioration) and applicability (change in clinical presentation over time, generic in nature and possible to detect bedside). They rated their level of agreement on a 9-point Likert scale and were also invited to propose additional generic predictors between the rounds. New predictors suggested by more than one clinician were included in the second round along with non-consensus predictors from the first round. Final decisions of non-consensus predictors after second round were made by a research group and an impartial physician.

RESULTS

The Delphi-process resulted in 19 clinically relevant and applicable predictors based on vital signs and parameters (respiratory rate, saturation, dyspnoea, systolic blood pressure, pulse rate, abnormal electrocardiogram, altered mental state and temperature), biochemical tests (serum c-reactive protein, serum bicarbonate, serum lactate, serum pH, serum potassium, glucose, leucocyte counts and serum haemoglobin), objective clinical observations (skin conditions) and subjective clinical observations (pain reported as new or escalating, and relatives' concerns).

CONCLUSION

The Delphi-process led to consensus of 19 potential predictors of clinical deterioration widely accepted as relevant and applicable in emergency departments.

To identify the factors that influence the recognizing and responding to adult patient deterioration in acute hospitals

AIMS

To identify factors that influence recognition and response to adult patient deterioration in acute hospitals.

DESIGN

A mixed-studies systematic review.

DATA SOURCES

CINAHL, Medline, and Web of Science were searched for relevant literature published between 2007 - 2018.

REVIEW METHODS

Studies were critically appraised, data extracted and thematically analysed.

RESULTS

Thirteen papers met the inclusion criteria. Three main themes were identified: (a) Knowledge and understanding of clinical deterioration; (b) Organizational factors; managing deterioration and staffing levels; and (c) Communication; inter-professional relationships and professional-patient communication.

CONCLUSION

Despite national guidelines, the review findings suggest that the recognition and response to adult patient deterioration in acute hospital settings is sub-optimal. A multitude of factors influencing the recognition and response to adult patient deterioration emerged from the findings.

IMPACT

Patients are receiving sub-optimal care due to failure in recognizing and responding to patient deterioration in an appropriate and timely manner. Nurses lack knowledge and understanding of deterioration. Organizational factors contribute to inadequate care and communication among professionals was highlighted as challenging. The factors that influence the recognizing and responding to patient deterioration in acute hospitals are multi-faceted, however this review highlights immediate recommendations for professionals in the acute care setting.

Insight into hospital ward nurses' concerns about patient health and the corresponding Medical Emergency Team nurse response

AIM

This study aims to understand the concerns of nurses when making MET calls which did not fulfil the vital sign criteria, and the MET nurses subsequent responses to these calls.

METHODS

This was a retrospective report-based study. Research material included nursing reports and MET forms related to MET calls made due to nurses' concern. Inductive content analysis was used to identify observations, which were then quantified based on the research material.

FINDINGS

From a total of 546 MET calls, 39 visits (7%) were due to nurses' concern. In these 39 visits, the vital sign criteria did not reach the alert threshold, but nurses made the call due to subjective worry. In 13% of visits, the alert concern was inadequate contact with the doctor. MET nurses responded to the alert by providing clinical and indirect nursing; more specifically, they performed examinations and nursing interventions and collaborated with other professionals.

CONCLUSION

A nurse's worry is influenced by subjective changes in the patient's condition or an inadequate doctor's response rather than objective physiological measurements. A MET nurse's ability to assess patient condition, respond to nurses' calls, and acknowledge justified alerts help MET nurses support concerned nurses and encourage them to contact the MET if necessary.

How do nurses use the early warning score in their practice? A case study from an acute medical unit

AIMS AND OBJECTIVES

This study aimed to describe how nurses use the early warning score (EWS) in an acute medical ward and their compliance with the EWS and explore their views and experiences of the EWS.

BACKGROUND

early warning score systems have been implemented in response to upward trends in mortality rates. Nurses play a central role in the use of EWS systems. However, barriers to their use have been identified and include behavioural, cultural and organisational approaches to adherence. Improvement strategies including education and training and electronic devices have assisted in compliance with the system.

DESIGN

A holistic single descriptive case study design was used.

METHODS

Data triangulation was used including non-participant observation, semi-structured interviews with nurses and document analysis. Nurses were observed using EWS and were subsequently interviewed. Data analysis was guided by systematic text condensation (STC), an approach underpinned by Giorgi's phenomenological method, where meaning units and themes are identified. The study adhered to the consolidated criteria for reporting qualitative research (COREQ) guidelines.

RESULTS

Three themes with associated meaning units were found. Protocol Adherence vs. Clinical Judgement addresses nurses' knowledge, skill and experience and patient assessment. Parameter Adjustment and Escalation included parameters not being adjusted or reviewed, junior doctors not being authorised to set parameters and escalation. The final theme Culture highlighted a task-driven approach and deficient communication processes.

CONCLUSION

This study highlights the need for ongoing training, behavioural change and a cultural shift by healthcare professionals and organisations to ensure adherence with EWS escalation protocols.

RELEVANCE TO CLINICAL PRACTICE

Improvements in education and training into recognition, management and communication of a deteriorating patient are required. Also, a cultural shift is needed to improve compliance and adherence with EWS practice. The potential use of electronic data should be explored.

Nurses' role in recognising and responding to clinical deterioration in surgical patients

AIM AND OBJECTIVES

To explore nurse' role in recognising and responding to deteriorating post-operative patients.

BACKGROUND

Clinical deterioration is a significant problem in acute care settings. Nurses play a vital role in post-operative patient monitoring; however, there is limited understanding of the nurses' role in recognising and responding to clinical deterioration in surgical patients.

METHODS

This qualitative exploratory study was conducted at a metropolitan teaching hospital in Melbourne, Australia. Data were collected through focus groups from 1 September to 31 October 2014. Four focus groups of 2-5 surgical nurses (n = 14) were conducted to explore the nurses' perception of their role in managing deterioration over the first 72 hr postoperatively. Qualitative data were recorded, transcribed and key themes identified.

RESULTS

Nurses demonstrated a high level of awareness of their role in recognising and responding to early signs of deterioration. The themes that arose from the focus group interviews were "struggling with blood pressure," and "we know our patient is sick." The nurses were confident about the clinical indicators of deterioration and the appropriate channels to use to escalate care. Using track and trigger observation charts enabled nurses to identify deteriorating patients prior to the patient fulfilling rapid response system escalation criteria.

CONCLUSIONS

These findings highlight the importance of a collective team approach to preventing, recognising and responding to clinical deterioration across the whole patient journey. Initiatives to ensure accurate written and verbal communication between medical and nursing staff warrants further assessment.

RELEVANCE TO CLINICAL PRACTICE

Nurses working in acute surgical wards are highly engaged in the process of recognising and responding to clinical deterioration in post-operative patients. Many nurses reported being able to anticipate deterioration occurring but are required by current organisational frameworks to escalate care to rapid response systems. How nurses anticipate and manage deterioration prior to the patient fulfilling rapid response system criteria warrants further investigation.

Critical care clinician perceptions of factors leading to Medical Emergency Team review

BACKGROUND

The introduction of rapid response systems has reduced the incidence of in-hospital cardiac arrest; however, many instances of clinical deterioration are unrecognised. Afferent limb failure is common and may be associated with unplanned intensive care admissions, heightened mortality and prolonged length of stay. Patients reviewed by a Medical Emergency Team are inherently vulnerable with a high in-hospital mortality.

OBJECTIVE

To explore perceptions of intensive care unit (ICU) staff who attend deteriorating acute care ward patients regarding current problems, barriers and potential solutions to recognising and responding to clinical deterioration that culminates in a Medical Emergency Team review.

METHODS

A descriptive exploratory design was used. Registered intensive care nurses and medical staff (N=207) were recruited during a professional conference using purposive sampling for experience in attending deteriorating patients. Written response surveys were used to address the study aim. Data were analysed using content analysis.

RESULTS

Four major themes were identified: Governance, Teamwork, Clinical Care Delivery and End of Life Care. Participants perceived there was a lack of sufficient and senior staff with the required theoretical knowledge; and inadequate assessment and critical thinking skills for anticipating, recognising and responding to clinical deterioration. Senior doctors were perceived to inappropriately manage End of Life Care issues and displayed Teamwork behaviours rendering ward clinicians feeling fearful and intimidated. A lack of System and Clinical Governance hindered identification of clinical deterioration.

CONCLUSIONS

To improve patient safety related to recognising and responding to clinical deterioration, suboptimal care due to professionals' knowledge, skills and behaviours need addressing, along with End of Life Care and Governance.

Medical-surgical nurses' experiences as first responders during deterioration events: a qualitative study

AIM AND OBJECTIVE

To explore and understand the experiences of medical-surgical nurses as first responders during clinical deterioration events.

BACKGROUND

Nurses are key players in identifying and responding to deterioration events to escalate the level of care essential to address specific needs of patients. Delays in recognising signs and symptoms of patient deterioration and activation of Rapid Response Teams have been linked to a lack of nontechnical skills (leadership, teamwork, situational awareness) resulting in increased patient morbidity and mortality.

DESIGN

A descriptive, qualitative approach was used.

METHODS

A purposive sample of 28 medical-surgical nurses was recruited and interviewed from an integrated healthcare system located in the USA. Interviews were conducted from October 2014-February 2015. Interviews were audio recorded and transcribed verbatim. Transcripts were entered into MaxQDA. The constant comparative method was used for data analysis.

RESULTS

Three patterns emerged from the data analysis: Recognising and Responding to the Event, Managing the Event and Challenges Encountered during the Event. From the patterns, seven themes emerged. Themes for pattern one, Recognising and Responding, were early warning signs, continuity in patient care assignments and intuition. Themes for pattern two, Managing the Event, were cognitive, technical and behavioural skills. The theme for pattern three, Challenges Encountered during the Event, was work environment complexity.

CONCLUSION

Listening to the stories of medical-surgical nurses provided insight into how they recognised and managed patients experiencing clinical deterioration events. Furthermore, insight into the challenges that medical-surgical nurses encountered in caring for deteriorating patients were identified.

RELEVANCE TO CLINICAL PRACTICE

Implication for practice in the areas of continuity of patient assignments, formal clinical deterioration education, work environment and team collaboration and communication was presented.

Defining patient deterioration through acute care and intensive care nurses' perspectives

AIM

To explore the variations between acute care and intensive care nurses' understanding of patient deterioration according to their use of this term in published literature.

BACKGROUND

Evidence suggests that nurses on wards do not always recognize and act upon patient deterioration appropriately. Even if resources exist to call for intensive care nurses' help, acute care nurses use them infrequently and the problem of unattended patient deterioration remains.

DESIGN

Dimensional analysis was used as a framework to analyze papers retrieved in a nursing-focused database.

METHOD

A thematic analysis of 34 papers (2002-2012) depicting acute care and intensive care unit nurses' perspectives on patient deterioration was conducted.

FINDINGS

No explicit definition of patient deterioration was retrieved in the papers. There are variations between acute care and intensive care unit nurses' accounts of this concept, particularly regarding the validity of patient deterioration indicators. Contextual factors, processes and consequences are also explored.

CONCLUSIONS

From the perspectives of acute care and intensive care nurses, patient deterioration can be defined as an evolving, predictable and symptomatic process of worsening physiology towards critical illness. Contextual factors relating to acute care units (ACU) appear as barriers to optimal care of the deteriorating patient. This work can be considered as a first effort in modelling the concept of patient deterioration, which could be specific to ACU.

RELEVANCE TO CLINICAL PRACTICE

The findings suggest that it might be relevant to include subjective indicators of patient deterioration in track and trigger systems and educational efforts. Contextual factors impacting care for the deteriorating patient could be addressed in further attempts to deal with this issue.

Nurses' immediate response to the fall of a hospitalized patient: a comparison of actions and cognitions of experienced and novice nurses

BACKGROUND

Falls represent a significant threat to patient safety for hospitalized patients throughout the world. Little is known, however, regarding nurses' immediate responses to the discovery of a fallen patient.

OBJECTIVES

The objective of this study was to perform an experimental examination of experienced and novice nurses' reaction to the discovery of a fallen patient who has sustained a closed head injury.

DESIGN

The study was based upon the expert performance approach, which utilizes a mixed methods approach to determining performance characteristics of individuals performing in a variety of domains.

SETTING

The study was accomplished using a simulated task environment developed specifically for research concerning the performance of health professionals.

PARTICIPANTS

The study included 12 experienced and 10 novice nurses, all of whom were currently employed in critical care settings.

METHODS

The study used directly observed performance, which was quantified through the use of direct coding of clinical behaviors and the analysis of verbal reports of thought.

RESULTS

The data indicate that experienced participants were not only more likely to call for help but that they were more likely to precede this action by checking for responsiveness, and then, after calling for help, establish the effectiveness of the patient's airway, breathing and circulation. These data confirmed that experienced participants were more likely to engage in the appropriate sequence of actions when faced with this unexpected and highly stressful situation.

CONCLUSIONS

Novice nurses' superficial assessment of the situation and subsequent failure to react properly implied an overall pattern of superior performance by the experienced nurses. The results indicated that, compared with novice nurses, experienced nurses are more likely to initiate standard treatment protocols in situations such as the one reported in this study.

Expanding the scope of decision-making research for nursing and midwifery practice

Decision making embedded in clinical situations is studied to inform nursing and midwifery practice and to enhance clinical effectiveness. To date this knowledge has mainly been derived from classical decision-making research approaches that are limited in capturing cognition in rapidly changing 'real-world' clinical environments. A naturalistic decision making approach can strengthen the ecological validity of descriptive investigations in certain dynamic clinical decision situations that include urgency and complexity. This paper presents a discussion about naturalistic decision making, its relevance for studying certain clinical decision situations in the 'real world' of nursing and midwifery practice and its application in a midwifery decision-making situation. In conclusion classical decision-making research approaches can be extended to include the naturalistic decision making approach that can capture decision making in dynamic clinical situations and show the underlying knowledge that distinguishes more experienced clinicians.