Nurses’ perceptions of accessing a Medical Emergency Team: A qualitative study

Critical care nurses' role in rapid response teams: A qualitative systematic review

AIM

To analyse the qualitative evidence on the role of critical care nurses in rapid response teams.

DESIGN

Qualitative systematic review.

METHODS

This qualitative systematic review employed Bettany-Saltikov and McSherry's guidelines and is reported according to the Enhancing Transparency in Reporting the Synthesis of Qualitative Research checklist. Two pairs of blinded researchers screened the articles. The data were synthesised using a thematic analysis approach.

DATA SOURCES

A systematic literature search was conducted using the CINAHL, Embase and MEDLINE databases.

RESULTS

Seven studies were included, and three main roles were identified: (1) balancing between confidence and fear in clinical encounters, (2) facilitating collaboration and (3) managing challenging power dynamics in decision-making.

CONCLUSION

Critical care nurses possess extensive knowledge and skills in providing critical care to patients experiencing deterioration on general wards. They play a vital role in facilitating collaboration between team members and ward staff. Furthermore, within the rapid response team, critical care nurses assume leadership responsibilities by overseeing the comprehensive coordination of patient care and actively engaging in the decision-making process concerning patient care.

IMPLICATIONS FOR THE PROFESSION

Highlighting the central role of critical care nurses in rapid response teams as well such a team's benefits in healthcare organisations can promote applications for funding to support further quality assurance of rapid response teams and thus enhance patient safety.

IMPACT

Health care organisations can assure the quality of rapid response team by providing economical resources and training. The education providers should facilitate and standardise curriculum for critical care nursing students to achieve necessary knowledge and skills as members in rapid response teams.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

General ward nurses detection and response to clinical deterioration in three hospitals at the Kenyan coast: a convergent parallel mixed methods study

BACKGROUND

In low and middle-income countries like Kenya, critical care facilities are limited, meaning acutely ill patients are managed in the general wards. Nurses in these wards are expected to detect and respond to patient deterioration to prevent cardiac arrest or death. This study examined nurses' vital signs documentation practices during clinical deterioration and explored factors influencing their ability to detect and respond to deterioration.

METHODS

This convergent parallel mixed methods study was conducted in the general medical and surgical wards of three hospitals in Kenya's coastal region. Quantitative data on the extent to which the nurses monitored and documented the vital signs 24 h before a cardiac arrest (death) occurred was retrieved from patients' medical records. In-depth, semi-structured interviews were conducted with twenty-four purposefully drawn registered nurses working in the three hospitals' adult medical and surgical wards.

RESULTS

This study reviewed 405 patient records and found most of the documentation of the vital signs was done in the nursing notes and not the vital signs observation chart. During the 24 h prior to death, respiratory rate was documented the least in only 1.2% of the records. Only a very small percentage of patients had any vital event documented for all six-time points, i.e. four hourly. Thematic analysis of the interview data identified five broad themes related to detecting and responding promptly to deterioration. These were insufficient monitoring of vital signs linked to limited availability of equipment and supplies, staffing conditions and workload, lack of training and guidelines, and communication and teamwork constraints among healthcare workers.

CONCLUSION

The study showed that nurses did not consistently monitor and record vital signs in the general wards. They also worked in suboptimal ward environments that do not support their ability to promptly detect and respond to clinical deterioration. The findings illustrate the importance of implementation of standardised systems for patient assessment and alert mechanisms for deterioration response. Furthermore, creating a supportive work environment is imperative in empowering nurses to identify and respond to patient deterioration. Addressing these issues is not only beneficial for the nurses but, more importantly, for the well-being of the patients they serve.

A Delphi study to obtain consensus on medical emergency team (MET) stand-down decision making

AIM

A medical emergency team (MET) stand-down decision is the decision to end a MET response and hand responsibility for the patient back to ward staff for ongoing management. Little research has explored this decision. This study aimed to obtain expert consensus on the essential elements required to make optimal MET call stand-down decisions and the communication required before MET departure.

DESIGN

A Delphi design was utilised.

METHODS

An expert panel of 10 members were recruited based on their expert knowledge and recent clinical MET responder experience in acute hospital settings. Participants were emailed a consent form and an electronic interactive PDF for each survey. Two rounds were conducted with no attrition between rounds. The CREDES guidance on conducting and reporting Delphi studies was used to report this study.

RESULTS

Consensus by an expert panel of 10 MET responders generated essential elements of MET stand-down decisions. Essential elements comprised of two steps: (1) the stand-down decision that was influenced by both the patient situation and the ward/organisational context; and (2) the communication required before actioning stand-down. Communication after the decision required both verbal discussions and written documentation to hand over patient responsibility. Specific patient information, a management plan and an escalation plan were considered essential.

CONCLUSION

The Delphi surveys reached consensus on the actions and communication required to stand down a MET call. Passing responsibility back to ward staff after a MET call requires both patient and ward safety assessments, and a clearly articulated patient plan for ward staff. Observation of MET call stand-down decision-making is required to validate the essential elements.

IMPLICATION FOR THE PROFESSION AND PATIENT/OR PATIENT CARE

In specifying the essential elements, this study offers clinical and MET staff a process to support the handing over of clinical responsibility from the MET to the ward staff, and clarification of management plans in order to reduce repeat MET calls and improve patient outcomes.

IMPACT

Minimal research has been focussed on the decision to hand responsibility back to ward staff so the MET may leave the ward with safety plan in place. This study provided expert consensus to optimise MET stand-down decision-making and the ultimate decision to end a MET call. Communication of agreed patient treatment and escalation plans is recommended before leaving the ward. This study can be used as a checklist for MET responder staff making these decisions and ward staff responsible for post-MET call care. The aim being to reduce the likelihood of potentially preventable repeat deterioration in the MET patient population.

REPORTING METHOD

The CREDES guidance on conducting and reporting Delphi studies.

PATIENT OR PUBLIC CONTRIBUTION

None.

Detailing experienced nurse decision making during acute patient care simulations

INTRODUCTION

Nurse decision making (DM) is critical for patient safety. Eye-tracking methods can effectively assess nurse DM. The purpose of this pilot study was to use eye-tracking methods to assess nurse DM during a clinical simulation.

MATERIALS AND METHODS

Experienced nurses managed a simulated patient manikin who suffered from a stroke mid-simulation. We assessed nurses' gaze patterns prior to and after the stroke. DM in general was assessed by nursing faculty using a clinical judgement rubric, and dichotomously based on recognition of the stroke or not.

RESULTS

Data from eight experienced nurses was examined. For the nurses who recognized the stroke, visual attention was focused on the vital sign monitor and patient's head, which suggest those locations were consistently examined for correct decision-makers.

CONCLUSIONS

Dwell time on general AOIs was associated with poorer DM, which may reflect poorer pattern recognition. Eye-tracking metrics may be effective to objectively assess nurse DM.

Exploration of Ward-Based Nurses' Perspectives on Their Preparedness to Recognize Clinical Deterioration: A Scoping Review

BACKGROUND

Despite initiatives in the early recognition of clinical deterioration, the incidence of failure to recognize clinical deterioration in patients continues to occur contributing to the ongoing rise of in-hospital mortality and morbidity.

OBJECTIVE

The aim of the study was to explore and appraise the research evidence that related to ward-based nurses' preparedness to recognize the clinically deteriorating patient.

METHODS

A scoping review was undertaken as this approach enabled the researchers to investigate the breadth of the available evidence through broad inclusion criteria. A comprehensive database search was conducted through the Cochrane Library; Cumulative Index to Nursing and Allied Health Literature; MEDLINE; ProQuest; PubMed; and Wiley Online Library. Each article was critically appraised and analyzed using a critical appraisal tool and thematic analysis, respectively. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews checklist.

RESULTS

Twelve primary sources of literature met the eligibility criteria. Through thematic analyses 6 primary themes were identified: implication of experience on preparedness; interprofessional and intraprofessional relationships; knowledge of calling criteria, process and procedures; requirement for a supportive system and culture; existence of hierarchy within healthcare impacting care; and clinical deterioration as an education opportunity.

CONCLUSIONS

This review identified central issues that impacted on ward-based nurses' preparedness. Further development of collaborative, supportive professional relationships across-and-within disciplines is needed. Effective use of clinical deterioration situations as educational opportunities would also assist nurses' preparedness through skill and knowledge development. However, more research evidence will be needed because of the limited data available on the topic.

A practical approach to establishing a critical care outreach service: An expert panel research design

BACKGROUND

For over two decades, nurse-led critical care outreach services have improved the recognition, response, and management of deteriorating patients in general hospital wards, yet variation in terms, design, implementation, and evaluation of such services continue. For those establishing a critical care outreach service, these factors make the literature difficult to interpret and translate to the real-world setting.

AIM

The aim of this study was to provide a practical approach to establishing a critical care outreach service in the hospital setting.

METHOD

An international expert panel of clinicians, managers, and academics with experience in implementing, developing, operationalising, educating, and evaluating critical care outreach services collaborated to synthesise evidence, experience, and clinical judgment to develop a practical approach for those establishing a critical care outreach service. A rapid review of the literature identified publications relevant to the study. A modified Delphi technique was used to achieve expert panel consensus particularly in areas where insufficient published literature or ambiguities existed.

FINDINGS

There were 502 publications sourced from the rapid review, of which 104 were relevant and reviewed. Using the modified Delphi technique, the expert panel identified five key components needed to establish a critical care outreach service: (i) approaches to service delivery, (ii) education and training, (iii) organisational engagement, (iv) clinical governance, and (v) monitoring and evaluation.

CONCLUSION

An expert panel research design successfully synthesised evidence, experience, and clinical judgement to provide a practical approach for those establishing a critical care outreach service. This method of research will likely be valuable in other areas of practice where terms are used interchangeably, and the literature is diverse and lacking a single approach to practice.

Improving Communication and Response to Clinical Deterioration to Increase Patient Safety in the Intensive Care Unit

BACKGROUND

In the critical care setting, early recognition of clinical decompensation is imperative to trigger prompt intervention and optimize patient outcomes.

LOCAL PROBLEM

In a 20-bed surgical intensive care unit of an urban academic medical center, cases of clinical deterioration that highlighted opportunities to improve the communication process prompted a reassessment of health care provider roles and responsibilities.

METHODS

A quality improvement initiative was implemented to enhance communication among intensive care unit clinical staff members, improve the timeliness of reporting clinical deterioration, and ensure implementation of timely, appropriate interventions to eliminate adverse outcomes.

INTERVENTIONS

Nurses were surveyed to determine their perceptions of communication and collaboration among providers. Education was provided that focused on familiarizing nurses with clinical conditions necessitating direct notification of the attending surgical intensivist and included review of a case in which escalation of care did not occur. Multidisciplinary rounds were expanded to engage night-shift nurses in clinical discussions and decision-making. A template was created to document episodes of escalation in the electronic health record.

RESULTS

Since implementation of the quality improvement interventions, no incidents of patient harm or death related to failure to escalate have occurred to date. A total of 16 episodes of escalation for clinical deterioration were documented in the electronic health record. Most nurses reported an increased level of confidence in understanding when to escalate concerns about clinical deterioration.

CONCLUSION

Implementing a multimodal program to empower nurses to escalate clinical concerns directly to the attending physician eliminated adverse events related to failure to escalate.

Midwives' recognition and response to maternal deterioration: A national cross-sectional study

BACKGROUND

Early warning systems (EWS) are used across health care settings as a tool for the early identification of clinical deterioration and to determine the need to escalate care. Early detection of clinical deterioration and appropriate escalation of care in maternity settings is critical to the safety of pregnant women and infants; however, underutilization of EWS tools and reluctance to escalate care have been consistently reported. Little is known about midwives' use of EWS in the Australian context.

METHODS

Using a cross-sectional approach, we elicited the attitudes, beliefs, and behaviors of a purposive sample of Australian midwives (n = 87) with respect to the Maternal Early Warning Trigger Tool (MEWT). Participants answered a 25-question Likert scale survey and one open-ended question. Qualitative answers were analyzed using consensus coding.

RESULTS

Midwives reported positive attitudes toward the MEWT, describing it as a valuable tool for identifying clinical deterioration, especially when used as an adjunct to clinical judgment. However, midwives also identified training gaps; 25% had received no training, and only half of those who had received training felt it was effective. In addition, professional tension can create a significant barrier to the effective use of the MEWT. Midwives also reported feeling influenced by their peers in their decision-making with respect to use of the MEWT and being afraid they would be chastised for escalating care unnecessarily.

CONCLUSIONS

Although the MEWT is valued by Australian midwives as a useful tool, barriers exist to its effective use. These include a lack of adequate, ongoing training and professional tension. Improving interdisciplinary collaboration could enhance the use of this tool for the safety of birthing women and their infants.

Frequency and nature of medical emergency team afferent limb failure in patients with documented vital sign abnormalities: A retrospective point prevalence study

BACKGROUND

Medical emergency team (MET) afferent limb failure is the presence of MET triggers and the absence of a documented MET call.

OBJECTIVES

The aim of this study was to measure and understand the frequency and nature of MET afferent limb failure in patients with documented vital sign abnormalities in an Australian major teaching hospital.

METHODS

A retrospective point prevalence study was conducted at a 600-bed teaching hospital in Melbourne, Australia. Data were collected for all adult inpatients (aged ≥18 years) on 13 wards (three general medicine, three surgical, and seven specialist wards) during a randomly selected 24-h period. Data were extracted from the electronic medical record.

RESULTS

There were 357 patients included in the study, with a median age of 72 y. Of the 9716 vital sign measures extracted, 0.9% fulfilled patient-specific MET activation criteria. There were 93 MET triggers documented in 36 patients: 25 patients experienced MET afferent limb failure. The major issues related to MET afferent limb failure were MET trigger modification processes, resolution of vital sign abnormalities, alternative escalation of care, and limitations of medical treatment orders without specific modifications to MET triggers.

CONCLUSIONS

Mandating MET activation for one aberrant vital sign at a single point in time warrants further assessment: lack of timely vital sign resolution may be a more appropriate trigger for MET calls and should be formally tested in future research. The frequency and effectiveness of alternative escalation pathways and local management of patients with MET triggers also warrant further investigation.

Development and psychometric evaluation of the Attitudes Towards Recognising Early and Noticeable Deterioration (ATREND) scale

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.

User interface approaches implemented with automated patient deterioration surveillance tools: protocol for a scoping review

INTRODUCTION

Early identification of patients who may suffer from unexpected adverse events (eg, sepsis, sudden cardiac arrest) gives bedside staff valuable lead time to care for these patients appropriately. Consequently, many machine learning algorithms have been developed to predict adverse events. However, little research focuses on how these systems are implemented and how system design impacts clinicians' decisions or patient outcomes. This protocol outlines the steps to review the designs of these tools.

METHODS AND ANALYSIS

We will use scoping review methods to explore how tools that leverage machine learning algorithms in predicting adverse events are designed to integrate into clinical practice. We will explore the types of user interfaces deployed, what information is displayed, and how clinical workflows are supported. Electronic sources include Medline, Embase, CINAHL Complete, Cochrane Library (including CENTRAL), and IEEE Xplore from 1 January 2009 to present. We will only review primary research articles that report findings from the implementation of patient deterioration surveillance tools for hospital clinicians. The articles must also include a description of the tool's user interface. Since our primary focus is on how the user interacts with automated tools driven by machine learning algorithms, electronic tools that do not extract data from clinical data documentation or recording systems such as an EHR or patient monitor, or otherwise require manual entry, will be excluded. Similarly, tools that do not synthesise information from more than one data variable will also be excluded. This review will be limited to English-language articles. Two reviewers will review the articles and extract the data. Findings from both researchers will be compared with minimise bias. The results will be quantified, synthesised and presented using appropriate formats.

ETHICS AND DISSEMINATION

Ethics review is not required for this scoping review. Findings will be disseminated through peer-reviewed publications.

Proactive rounding: Perspectives and experiences of nurses and midwives working in a large metropolitan hospital

BACKGROUND

Rounding by the Rapid Response team (RRT) is an integral part of safety and quality care of the deteriorating patient. Rounding enables Intensive Care Units (ICU) liaison nurses to proactively identify deteriorating patients in the general wards and minimize the time spent by general nursing staff to call for assistance.

OBJECTIVE

The study examined nurses' and midwives' experiences of proactive rounding by a RRT/ICU Liaison service, including the impact on workflow and patient care as well as enablers and barriers to utilization of the service.

METHOD

A mixed method approach was used: an online survey and semi-structured interviews with nurses and midwives in an acute care setting.

RESULTS

52 respondents completed the online survey and 6 participated in a semi-structured interviews. The majority of survey respondents found the service useful and indicated that rounding by the ICU Liaison service improves patient care. Participants also believed that pro-active rounding increases staff confidence and builds rapport when utilizing the ICU Liaison service. Barriers to use of the service included the lack of out of normal business hours support and obtaining prompt support.

CONCLUSION

Proactive rounding was perceived by nurses and midwives to be beneficial for both themselves and patients, and ensured that deteriorating patients were identified.

Measuring the safety climate in an Australian emergency department

BACKGROUND

There are numerous intricate human, system and cultural factors that can impact upon the safe and effective implementation of patient safety systems (e.g. rapid response systems). Safety climate is one of these factors and is a measure of frontline healthcare workers' shared perceptions, behaviours, beliefs and attitudes towards the organisation's culture of safety. Safety climate scores are also associated with the frequency of errors and adverse events in the healthcare setting. However, there is little evidence regarding the relationships between attitudes to patient safety and staff characteristics such as emergency care expertise and experience. The aims of this study were to measure perceptions of the safety climate in an Australian metropolitan Emergency Department and examine relationships between safety climate perceptions and staff characteristics.

METHODS

The Victorian Managed Insurance Authority Safety Climate Survey was administered to all doctors (n = 44) and nurses (n = 119) at an Australian emergency department.

RESULTS

Completed surveys were received from 127 (78%) respondents, 25 (52%) doctors and 100 (84%) nurses. Reliability analysis showed very good internal consistency of all 43-items of the survey (α = 0.94). With the exception of stress recognition, nurses rated the organisation's commitment to patient safety higher than doctors in all remaining attitudinal domains (p < 0.05). Both groups acknowledge that fatigue, increased workload and stress recognition negatively impacts upon patient safety. There was a significant trend for declining safety climate ratings related to participants' clinical competence level and experience across all domains except stress recognition (p < 0.05).

CONCLUSIONS

The Safety Climate Survey appears to be a reliable measure of patient safety climate for use in Emergency Departments. Emergency doctors and nurses did not perceive there to be a strong organisational commitment to patient safety in an Australian Emergency Department. Emergency Departments can provide a safer environment through genuine commitment to safety culture improvement which capitalises on the insights, intrinsic strengths and behaviours characteristic of the ED team's expertise and experience. This kind of commitment can positively influence the effectiveness of actions taken to minimise risk to patient safety and improve ED staff job satisfaction and effectiveness.

Ward nurses' experiences and perceptions of the critical care outreach service: A qualitative study undertaken in a large teaching hospital in the West of Ireland

BACKGROUND

The critical care outreach service (CCOS) was established in a large teaching hospital in the West of Ireland in 2014 to provide an extension of CCOS between the intensive care unit (ICU) and the wards outside ICU. With the ever-increasing pressure on ICU resources, CCOS seems to offer an additional service to patients who are critically ill and deteriorating in hospital wards.

AIM

The aim of this study is to explore ward nurses' experiences and perceptions of the CCOS.

STUDY DESIGN

A qualitative descriptive methodology aimed to obtain a descriptive account of ward nurses' experiences of the CCOS. Data were collected using semi-structured interviews. Twelve nurses from the West of Ireland participated in the study. Braun and Clarke's six-step thematic analysis was used to analyse the data.

RESULTS

Three core themes identified in this study included clinical support and decision-making; sharing knowledge and skills, and communication. All 12 nurses identified the positive impacts that they felt the current outreach service provided to them on a daily basis.

CONCLUSIONS

Study findings indicate that nurses value the role of the CCOS in supporting the care of the critically ill and deteriorating patients at ward level. The CCOS has become invaluable to the ward nurses in their daily practice especially at a time when resources are lacking and patient acuity is on the rise.

A clinical competence approach to examine British and Finnish nurses' attitudes towards the rapid response system model: A study in two acute hospitals

BACKGROUND

Nurses' clinical competence involves an integration of knowledge, skills, attitudes, thinking ability, and values, which strongly affects how deteriorating patients are managed.

OBJECTIVES

The aim of the study was to examine nurses' attitudes as part of clinical competence towards the rapid response system in two acute hospitals with different rapid response system models.

METHODS

This is a comparative cross-sectional correlational study. A modified "Nurses' Attitudes Towards the Medical Emergency Team" tool was distributed among 388 medical and surgical registered nurses in one acute hospital in the UK and one in Finland. A total of 179 nurses responded. Statistical analyses, including exploratory factor analysis, Mann-Whitney U tests, Kruskal-Wallis tests, chi-square tests, and univariate and multivariate regression analyses, were used.

FINDINGS

Generally, nurses had positive attitudes towards rapid response systems. British and Finnish nurses' attitudes towards rapid response system activation were divided when asked about facing a stable (normal vital signs) but worrisome patient. Finnish nurses relied more on intuition and were more likely to activate the rapid response system. Approximately half of the nurses perceived the physician's influence as a barrier to rapid response system activation. The only sociodemographic factor that was associated with nurses activating the rapid response system more freely was work experience ≥10 years.

CONCLUSIONS

The findings are beneficial in raising awareness of nurses' attitudes and identifying attitudes that could act as facilitators or barriers in rapid response system activation. The study suggests that nurses' attitudes towards physician influence and intuition need to be improved through continuing development of clinical competence. When the system model included "worrisome" as one of the defined parameters for activation, nurses were more likely to activate the rapid response system. Future rapid response system models may need to have clear evidence-based instructions for nurses when they manage stable (normal vital signs) but worrisome patients and should acknowledge nurses' intuition and clinical judgement.

Human factors in escalating acute ward care: a qualitative evidence synthesis

Background

Identifying how human factors affect clinical staff recognition and managment of the deteriorating ward patient may inform process improvements. We systematically reviewed the literature to identify (1) how human factors affect ward care escalation (2) gaps in the current literature and (3) critique literature methodologies.

Methods

We undertook a Qualitative Evidence Synthesis of care escalation studies. We searched MEDLINE, EMBASE and CINHAL from inception to September 2019. We used the Critical Appraisal Skills Programme and the Grading of Recommendations Assessment-Development and Evaluation and Confidence in Evidence from Reviews of Qualitative Research tool to assess study quality.

Results

Our search identified 24 studies meeting the inclusion criteria. Confidence in findings was moderate (20 studies) to high (4 studies). In 16 studies, the ability to recognise changes in the patient’s condition (soft signals), including skin colour/temperature, respiratory pattern, blood loss, personality change, patient complaint and fatigue, improved the ability to escalate patients. Soft signals were detected through patient assessment (looking/listening/feeling) and not Early Warning Scores (eight studies). In contrast, 13 studies found a high workload and low staffing levels reduced staff’s ability to detect patient deterioration and escalate care. In eight studies quantifiable deterioration evidence (Early Warning Scores) facilitated escalation communication, particularly when referrer/referee were unfamiliar. Conversely, escalating concerning non-triggering patients was challenging but achieved by some clinical staff (three studies). Team decision making facilitated the clinical escalation (six studies).

Conclusions

Early Warning Scores have clinical benefits but can sometimes impede escalation in patients not meeting the threshold. Staff use other factors (soft signals) not captured in Early Warning Scores to escalate care. The literature supports strategies that improve the escalation process such as good patient assessment skills.

PROSPERO registration number

CRD42018104745.

Why do healthcare professionals fail to escalate as per the early warning system (EWS) protocol? A qualitative evidence synthesis of the barriers and facilitators of escalation

Background

Early warning systems (EWSs) are used to assist clinical judgment in the detection of acute deterioration to avoid or reduce adverse events including unanticipated cardiopulmonary arrest, admission to the intensive care unit and death. Sometimes healthcare professionals (HCPs) do not trigger the alarm and escalate for help according to the EWS protocol and it is unclear why this is the case. The aim of this qualitative evidence synthesis was to answer the question ‘why do HCPs fail to escalate care according to EWS protocols?’ The findings will inform the update of the National Clinical Effectiveness Committee (NCEC) National Clinical Guideline No. 1 Irish National Early Warning System (INEWS).

Methods

A systematic search of the published and grey literature was conducted (until February 2018). Data extraction and quality appraisal were conducted by two reviewers independently using standardised data extraction forms and quality appraisal tools. A thematic synthesis was conducted by two reviewers of the qualitative studies included and categorised into the barriers and facilitators of escalation. GRADE CERQual was used to assess the certainty of the evidence.

Results

Eighteen studies incorporating a variety of HCPs across seven countries were included. The barriers and facilitators to the escalation of care according to EWS protocols were developed into five overarching themes: Governance, Rapid Response Team (RRT) Response, Professional Boundaries, Clinical Experience, and EWS parameters. Barriers to escalation included: Lack of Standardisation, Resources, Lack of accountability, RRT behaviours, Fear, Hierarchy, Increased Conflict, Over confidence, Lack of confidence, and Patient variability. Facilitators included: Accountability, Standardisation, Resources, RRT behaviours, Expertise, Additional support, License to escalate, Bridge across boundaries, Clinical confidence, empowerment, Clinical judgment, and a tool for detecting deterioration. These are all individual yet inter-related barriers and facilitators to escalation.

Conclusions

The findings of this qualitative evidence synthesis provide insight into the real world experience of HCPs when using EWSs. This in turn has the potential to inform policy-makers and HCPs as well as hospital management about emergency response system-related issues in practice and the changes needed to address barriers and facilitators and improve patient safety and quality of care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00403-9.

Quels sont le fonctionnement, les caractéristiques, les effets et les modalités d’implantation des équipes d’intervention rapide ? Une revue de la littérature

Introduction&#160;: Hospitalized patients are at risk of unrecognized clinical deterioration that may lead to adverse events.Context&#160;: Rapid Response Teams (RRTs) exist around the world as a strategy to improve patient safety.Objective&#160;: To explore how RRTs work, their characteristics, impacts, and methods of implementation.Design&#160;: Literature review.Method&#160;: Consultation of the databases CINAHL, MEDLINE, PUBMED, COCHRANE library, SCOPUS, and PROQUEST Dissertations and Theses. Keywords&#160;: &#8220;health care team&#8221; and &#8220;rapid response team&#8221;.Results&#160;: 121 articles were included. The collected data were divided into five categories&#160;: 1) composition and operation of RRTs, 2) benefits and limitations of RRTs, 3) perceptions of RRTs by health care teams, organizations, and patients, 4) implementation strategies, and 5) facilitators and barriers to implementation.Discussion&#160;: Although there are many articles related to RRTs, it appears that&#160;: 1) few studies analyze the difference in outcomes in hospitalized patients related to the composition of RRTs, 2) few studies describe how RRTs should work, 3) more studies are needed on the impacts of RRTs on hospitalized patients, 4) organizations&#8217; and patients&#8217; perceptions of RRTs are not well studied, and 5) more studies are needed on the best way to implement an RRT.Conclusion&#160;: The results show that there is a lack of studies on the difference in outcomes in hospitalized patients related to the composition of RRTs, on how RRTs should work, on the impacts of RRTs on hospitalized patients, on organizations&#8217; and patients&#8217; perceptions of RRTs, and on the factors that influence the success or failure of the implementation of an RRT.

Identifying barriers and facilitators to recognition and response to patient clinical deterioration by clinicians using a behaviour change approach: A qualitative study

BACKGROUND

Failure of clinicians to recognise and respond to patient clinical deterioration is associated with increased hospital mortality. Emergency response teams are implemented throughout hospitals to support direct-care clinicians in managing patient deterioration, but patient clinical deterioration is often not identified or acted upon by clinicians in ward settings. To date, no studies have used an integrative theoretical framework in multiple sites to examine why clinicians' delay identification and action on patients' clinical deterioration.

AIM

To identify barriers and facilitators that influence clinicians' absent or delayed response to patient clinical deterioration using the Theoretical Domains Framework.

METHODS

The Theoretical Domains Framework guided: (a) semi-structured interviews with clinicians, health consumers and family members undertaken at two sites; (b) deductive analyses of inductive themes to identify barriers and facilitators to optimal care. This study complied with the COREQ research guidelines.

FINDINGS

Seven themes identified: (a) information transfer; (b) ownership of patient care; (c) confidence to respond; (d) knowledge and skills; (e) culture; (f) emotion; and (g) environmental context and resources.

DISCUSSION

The Theoretical Domains Framework identified traditional social and professional hierarchies and limitations due to environmental contexts and resources as contributors to diminished interprofessional recognition and impediments to the development of effective relationships between professional groups. Communication processes were impacted by these restraints and further confounded by inadequate policy development and limited access to regular effective team-based training. As a result, patient safety was compromised, and clinicians frustrated.

CONCLUSIONS

These results inform the development, implementation and evaluation of a behaviour change intervention and increase knowledge about barriers and facilitators to timely response to patient clinical deterioration.

RELEVANCE TO CLINICAL PRACTICE

Results contribute to understanding of why clinicians delay responding to patient clinical deterioration and suggest key recommendations to identify and challenge traditional hierarchies and practices that prevent interdisciplinary collaboration and decision-making.

The development and psychometric evaluation of the Clinicians' Attitudes towards Responding and Escalating care of Deteriorating patients scale

BACKGROUND

Validated measures of ward nurses' safety cultures in relation to escalations of care in deteriorating patients are lacking.

OBJECTIVES

This study aimed to develop and evaluate the psychometric properties of the Clinicians' Attitudes towards Responding and Escalating care of Deteriorating patients (CARED) scale for use among ward nurses.

METHODS

The study was conducted in two phases: scale development and psychometric evaluation. The scale items were developed based on a systematic literature review, informant interviews, and expert reviews (n = 15). The reliability and validity of the scale were examined by administering the scale to 617 registered nurses with retest evaluations (n = 60). The factor structure of the CARED scale was examined in a split-half analysis with exploratory and confirmatory factor analyses. The internal consistency, test-retest reliability, convergent validity, and known-group validity of the scale were also analysed.

RESULTS

A high overall content validity index of 0.95 was obtained from the validations of 15 international experts from seven countries. A three-factor solution was identified from the final 22 items: 'beliefs about rapid response system', 'fears about escalating care', and 'perceived confidence in responding to deteriorating patients'. The internal consistency reliability of the scale was supported with a good Cronbach's alpha value of 0.86 and a Spearman-Brown split-half coefficient of 0.87. An excellent test-retest reliability was demonstrated, with an intraclass correlation coefficient of 0.92. The convergent validity of the scale was supported with an existing validated scale. The CARED scale also demonstrated abilities to discriminate differences among the sample characteristics.

CONCLUSIONS

The final 22-item CARED scale was tested to be a reliable and valid scale in the Singaporean setting. The scale may be used in other settings to review hospitals' rapid response systems and to identify strategies to support ward nurses in the process of escalating care in deteriorating ward patients.

Evaluation of nurses' experiences of a post education program promoting recognition and response to patient deterioration: Phase 2, clinical coach support in practice

Front-line nurses providing around the clock care are pivotal to the identification, recognition, and response to patient deterioration. However, there is growing evidence that patient deterioration indicators are poorly managed and not escalated to rapid response teams (RRTs), contributing to adverse outcomes. Access to effective educational programs has been cited as vital in optimising nurses' recognition and response to deteriorating patients. Several studies evaluated educational programs, but have not explored nurses' experiences of engaging in patient deterioration events post attendance. Participants in a multimodal education program (DeTER) were invited to attend a series of focus groups three months post workshop as phase two of an overall study. A convenience sample of 22 acute care nurses was recruited. A qualitative descriptive design incorporating focus groups and thematic analysis was used to evaluate participants' experiences of engaging with the RRT during patient deterioration events and whether clinical coach support in practice influenced their recognition and response. Four themes were identified within the data, categorised as enhanced confidence, effective communication, supportive culture, and early response. The importance of an educational model using multimodal strategies, underpinned by coach support and guidance post workshop, was clearly demonstrated to optimise nurses' management of patient deterioration events.

Perceived Barriers to Rapid Response Team Activation Among Nurses

The purpose of this literature review was to investigate the major barriers nurses face when it is necessary to seek additional assistance and resources by calling the rapid response team (RRT) in order to manage and stabilize a clinically deteriorating patient. A total of 40 articles were reviewed. Eight barriers were identified as having an impact on RRT activation, either causing a delay in activation time or preventing activation altogether: a lack of consistent RRT education among nurses, the established hierarchy in the hospital, an uncertainty about when to call the RRT if clinical deterioration is subtle or gradual rather than abrupt, a perceived need to justify a decision to call the RRT, the increased workload for both the ICU nurse and the medical-surgical nurse, negative past experiences with RRTs, an unsupportive unit culture, and less nursing experience. Suggestions for overcoming these barriers include RRT education for nurses and physicians in addition to fostering a supportive unit culture.

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

AIM

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

DESIGN

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

METHOD

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

RESULTS

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

CONCLUSION

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

IMPACT

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

Staff's Perception of the Intensive Care Outreach Nurse Role: A Multisite Cross-sectional Study

BACKGROUND

Rapid Response Systems are emerging internationally to provide a patient-focused approach to prevent potentially avoidable deaths and serious adverse events.

LOCAL PROBLEM

This study focused on ward nurses in the United Arab Emirates (UAE) government hospitals who were perceived to lack the confidence and knowledge to detect and/or respond to deteriorating patients.

METHOD

A cross-sectional study design was used to evaluate the Intensive Care Outreach Nurse (ICON) role from the perspectives of the ICONs, their managers/educators, and ward-based physicians and nurses. ICONs are intensive care experienced nurses with additional education in the role of rapid responder to the deteriorating patient.

INTERVENTIONS

An ICON role was implemented across 4 hospitals to respond to and support clinicians in the recognition and management of the deteriorating patient on general inpatient wards.

RESULTS

ICON skills perceived as most beneficial by respondents included staff education, respiratory therapy, medication administration, and intravenous access.

CONCLUSIONS

The ICON role is able to support recognition and management of the deteriorating patients.

Optimising paediatric afferent component early warning systems: a hermeneutic systematic literature review and model development

OBJECTIVE

To identify the core components of successful early warning systems for detecting and initiating action in response to clinical deterioration in paediatric inpatients.

METHODS

A hermeneutic systematic literature review informed by translational mobilisation theory and normalisation process theory was used to synthesise 82 studies of paediatric and adult early warning systems and interventions to support the detection of clinical deterioration and escalation of care. This method, which is designed to develop understanding, enabled the development of a propositional model of an optimal afferent component early warning system.

RESULTS

Detecting deterioration and initiating action in response to clinical deterioration in paediatric inpatients involves several challenges, and the potential failure points in early warning systems are well documented. Track and trigger tools (TTT) are commonly used and have value in supporting key mechanisms of action but depend on certain preconditions for successful integration into practice. Several supplementary interventions have been proposed to improve the effectiveness of early warning systems but there is limited evidence to recommend their wider use, due to the weight and quality of the evidence; the extent to which systems are conditioned by the local clinical context; and the need to attend to system component relationships, which do not work in isolation. While it was not possible to make empirical recommendations for practice, the review methodology generated theoretical inferences about the core components of an optimal system for early warning systems. These are presented as a propositional model conceptualised as three subsystems: detection, planning and action.

CONCLUSIONS

There is a growing consensus of the need to think beyond TTTs in improving action to detect and respond to clinical deterioration. Clinical teams wishing to improve early warning systems can use the model to consider systematically the constellation of factors necessary to support detection, planning and action and consider how these arrangements can be implemented in their local context.

PROSPERO REGISTRATION NUMBER

CRD42015015326.

A review of Code Blue activations in a single Regional Australian Healthcare Service: A retrospective descriptive study of RISKMAN data

BACKGROUND

In the case of life-threatening conditions such as respiratory or cardiac arrest, or the clinical deterioration of the patient, a Code Blue activation may be instigated. A Code Blue activation involves a team of advanced trained clinicians attending the emergency needs of the patient.

AIMS AND OBJECTIVES

The aim of the study was to explore the number of cases of Code Blue activations, looking at the timing, clinical ward, diagnosis and activation criteria while noting cases where escalation from a Medical Emergency Team (MET) call occurs in one Regional Healthcare Service in Victoria, Australia, over a six-year period.

METHODS

A quantitative retrospective descriptive study of Code Blue emergencies over a six-year period from June 2010 to June 2016 was conducted. Data collected from the RISKMAN program operating at a single site was imported into SPSS (V 22) for descriptive statistical analysis. A STROBE EQUATOR checklist was used for this study (see File S1).

FINDINGS

The majority of Code Blue activations were male (59%, n = 127) and aged between 70 and 89 years of age (43%, n = 93). A Code Blue activation was more likely to occur at 08:00 hr, 14:00 hr or 22:00 hr, corresponding to the nurses' change in shift, with the majority of Code Blues (27.8%, n = 60) occurring in the emergency department. Cardiac arrest was the main activation criterion with 54.6% (n = 118) cases followed by respiratory arrest (14%, n = 32). Interestingly, 20% (n = 45) of the Code Blue activations were upgraded from a Medical Emergency Team (MET) call.

CONCLUSION

This project has produced several interesting findings surrounding Code Blue activations at one regional healthcare service which are not present in existing literature and is worthwhile for further investigation.

RELEVANCE TO CLINICAL PRACTICE

Understanding Code Blue activation criteria, common timings (month, time of day) and patient demographics ensures clinicians can remain vigilant in watching for the signs of patient deterioration and improve staff preparedness Code Blue events.

Parent escalation of care for the deteriorating child in hospital: A health-care improvement study

OBJECTIVE

To evaluate the implementation of an intervention for parents to escalate care if concerned about their child's clinical condition.

DESIGN

Mixed-methods health-care improvement approach guided by the Theoretical Domains Framework.

METHODS

Implementation of the 'Calling for Help' (C4H) intervention was informed by previously identified barriers and facilitators. Evaluation involved audit, review of clinical deterioration incidents, interviews and focus groups.

SETTING

Australian specialist paediatric hospital.

PARTICIPANTS

Convenience sample of 75 parents from inpatient areas during the audit, interviews with ten parents who had expressed concern about their child's clinical condition; five focus groups with 35 ward nurses.

MAIN OUTCOME MEASURES

Parent awareness and utilization of C4H, parent and nurse views of factors influencing implementation.

RESULTS

Parent awareness of C4H improved to 35% (25/75). Parent concern was documented prior to 21/174 (12%) clinical deterioration events. All interviewed parents and nurses who participated in focus groups were positive about C4H. Parents preferred to be informed about C4H by nurses, but nurses described this as time-consuming and selectively chose parents who they believed would benefit most. Parents and nurses described frustrations with and trepidation in escalating care. Nurses had used C4H to expedite urgent medical review.

CONCLUSIONS

There was an improvement in the level of parent awareness of C4H, which was viewed positively by parents and nurses alike. To achieve a high level of parent awareness in a sustainable way, a multifaceted approach is required. Further strategies will be required for parents to feel confident enough to use C4H and to address interprofessional communication barriers.

How actionable are staff behaviours specified in policy documents? A document analysis of protocols for managing deteriorating patients

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.

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.

Nurses' Perceptions of Barriers to Rapid Response System Activation: A Systematic Review

BACKGROUND

The rapid response system (RRS) was designed to identify and intervene on patients exhibiting clinical deterioration in the non-critical-care setting but is not always effectively activated by nurses, leading to adverse patient outcomes.

OBJECTIVES

The objective of this systematic review was to explore nurses' perceived barriers to RRS activation in the acute adult inpatient setting.

METHOD

A systematic review was completed utilizing the Preferred Reporting Items for Systematic Reviews and Meta-analysis checklist. Six different search terms were used in the following electronic databases: Academic Search Premier, the Cumulative Index to Nursing and Allied Health Literature, Healthsource: Nursing/Academic Edition, MEDLINE, and PubMed. Limiters applied to search methods included years 2007 to current, full text, scholarly (peer reviewed), and English language. This review was further limited to quantitative studies in the adult inpatient setting.

RESULTS

The initial electronic database search yielded 149 articles. After duplicate exclusion, 87 article abstracts were reviewed for inclusion and eligibility, and a total of 8 articles were used for this systematic review. Themes to nurses' perceived barriers to RRS activation include RRS activator-responder interaction, physician influence, nurse education, and nurse experience.

DISCUSSION

Nurses play a vital role in patient care by providing continuous surveillance and are the frontline for early detection including prompt intervention should a patient's condition deteriorate. Inconsistent RRS activation has been associated with negative patient outcomes. Exploring nurses' perceived barriers to RRS activation may contribute to interventions that lead to nurses appropriately activating the RRS and potentially decreasing adverse patient outcomes.

Providing a Safe Environment in a Psychiatric Ward: Nurses and Vigilance in Iran

The aim of this study was to explore nurses' use of vigilance in the provision of inpatient psychiatric care. In this qualitative exploratory descriptive design study, 16 nurses working in inpatient psychiatric units were recruited through purposive sampling. Data were collected by semi-structured interviews and fieldwork observations and analysed using conventional content analysis. According to participants, nurses' vigilance is related to synthesising knowledge, experience, communication, and presence. This conclusion was derived from four main themes: understanding the context of the psychiatric ward; continuous monitoring; cognitive assessments; and involving others. The study highlights the significance of education for all mental health staff and provision of appropriate information to all patients and their companions about psychiatric disorders and the side effects of prescribed medications. Of importance is the skill of active listening to the concerns of patients and the demonstration of commitment by nurses to follow-up on reports from stakeholders. Imparting the skills and experiences of senior nurses to novice nurses and their presence alongside other nurses on work-shifts can be effective in promoting vigilance.

Barriers and facilitators to implementing a process to enable parent escalation of care for the deteriorating child in hospital

OBJECTIVE

To identify barriers and facilitators to implementing a parent escalation of care process: Calling for Help (C4H).

DESIGN

Audits, semi-structured interviews and focus groups guided by the Theoretical Domains Framework.

SETTING

Australian paediatric hospital where a parent escalation of care process was introduced in the previous 6 months.

PARTICIPANTS

Four children, 13 parents, 91 nurses and doctors including Medical Emergency Team (MET) members.

MAIN OUTCOME MEASURES

Parent awareness and involvement in escalating care and factors impacting implementation of C4H.

RESULTS

Two audits identified low level of parent awareness (16/88, 19% and 5/85, 6%). Parent involvement in escalation of care was documented in 11/62 (18%) events. The main facilitators included uniformly positive views that C4H was in the child's best interest, acknowledgement that parents had skills to recognize deterioration and would take action. C4H was considered to add to patient safety and being reviewed by the MET was a patient benefit. Key barriers were the low level of awareness, doubt about parent capabilities, concern about parents' information overload, anticipated overuse of resources, staff unease about possible repercussions and anticipated difficulty for parents to question staff with potential negative effects on parent-staff relationships. Overall C4H presents a challenge to traditional hospital hierarchy and culture.

CONCLUSIONS

Although there was a low level of awareness about C4H in practice, there was in-principle support for the concept. Initial strategies had primarily targeted policy change without taking into account the need for practice and organizational behaviour changes. Using a theoretical approach to identify key factors will enable a targeted approach to implementation.

Management of abnormal observations in the emergency department: A review

OBJECTIVE

To assess utility and accuracy of general observation modified early warning score charts; and compare sensitivity and specificity of single- and multiple-parameter-based trigger scores on patient outcomes in the ED.

METHODS

Retrospective cohort clinical audit of all adult Modified Early Warning Score charts in the ED of a mixed tertiary hospital over 4 weeks. Data extracted included recorded parameters required to calculate Modified Early Warning Score and evidence of response.

RESULTS

Of 5901 ED presentations, medical records system identified 2482 Modified Early Warning Score; 347 were missing or blank. Of 2135 Modified Early Warning Score charts, 19.5% contained a calculation error, 51.9% had one or more missing parameters and 36.6% did not have usual/target systolic blood pressure recorded; with 25.1% (95% confidence interval [CI] 23.3-27.0) charts correctly completed. Four hundred and forty-three had a single-abnormal parameter of which chart review showed 96.6% (94.5-97.3) were identified as abnormal by nurses with 25.7% (21.9-30.0); only 5.6% (3.9-8.2) had evidence of recognition by medical staff. Modified Early Warning Score sensitivity and specificity for ward admission was 14.7% and 96.1%, respectively. Modelling using the dataset of a single-abnormal parameter suggested sensitivity and specificity of 31.6% and 85.8%, respectively.

CONCLUSIONS

This study highlights serious deficiencies in documentation of abnormal parameters and emergency response. It has also shown poor accuracy of both single- and multiple-parameter-based trigger scores in predicting patient outcomes within the ED. However, single-parameter-based trigger scores are twice as sensitive as total Modified Early Warning Score for admission and reduces documentation error by 23%.

The art of balance: Preceptors' experiences of caring for deteriorating patients

AIM

To explore nurse preceptors' experiences of caring for deteriorating patients while providing guidance and supervision to a new graduate nurse.

BACKGROUND

Fostering novice nurse development during high-stakes encounters may be challenging for preceptors. Despite myriad preceptor literature, there is limited published research on experience of caring for deteriorating patients while serving as preceptor to a novice nurse.

DESIGN

Qualitative interpretive phenomenological analysis.

METHOD

Data were collected through one-on-one, semistructured interviews between August 2016-September 2017 until data saturation occurred. Diekelmann's method was used to analyse the narratives of the purposive sample of 11 nurse preceptors.

RESULTS

The findings reveal the experience of preceptors as they balanced their role as nurse with preceptor role to ensure patient safety and novice nurse development. Supporting the novice to care portrays the ways preceptors facilitated novice nurse development in caring for deteriorating patients. Impacting the preceptor role was remembering their own novice experience. Knowing when to step in was influenced by the preceptor's clinical expertise as they came to know (or not) when it was necessary for them to assume care of the patient. Debriefing: an essential preceptor tool emerged as a critical aspect of the experience to review technical aspects of care, vent emotions and provide evaluative feedback and reassurance to the novice.

CONCLUSION

Preceptors' experiences of caring for deteriorating patients while precepting novice nurses require a balancing of roles to ensure patient safety and novice nurse development. Preceptors' clinical expertise was critical in knowing when to step in and assume care of the patient.

RELEVANCE TO CLINICAL PRACTICE

Caring for deteriorating patients while serving as preceptor to novice nurses requires clinical expertise to ensure patient safety and novice nurse development. Clinical leaders may use the findings from this study to improve preceptor development and support.

Factors influencing the activation of the rapid response system for clinically deteriorating patients by frontline ward clinicians: a systematic review

Purpose

To synthesize factors influencing the activation of the rapid response system (RRS) and reasons for suboptimal RRS activation by ward nurses and junior physicians.

Data sources

Nine electronic databases were searched for articles published between January 1995 and January 2016 in addition to a hand-search of reference lists and relevant journals.

Study selection

Published primary studies conducted in adult general ward settings and involved the experiences and views of ward nurses and/or junior physicians in RRS activation were included.

Data extraction

Data on design, methods and key findings were extracted and collated.

Results of data synthesis

Thirty studies were included for the review. The process to RRS activation was influenced by the perceptions and clinical experiences of ward nurses and physicians, and facilitated by tools and technologies, including the sensitivity and specificity of the activation criteria, and monitoring technology. However, the task of enacting the RRS activations was challenged by seeking further justification, deliberating over reactions from the rapid response team and the impact of workload and staffing. Finally, adherence to the traditional model of escalation of care, support from colleagues and hospital leaders, and staff training were organizational factors that influence RRS activation.

Conclusion

This review suggests that the factors influencing RRS activation originated from a combination of socio-cultural, organizational and technical aspects. Institutions that strive for improvements in the existing RRS or are considering to adopt the RRS should consider the complex interactions between people and the elements of technologies, tasks, environment and organization in healthcare settings.

Factors Influencing Registered Nurses' Decision to Activate an Adult Rapid Response Team in a Community Hospital

BACKGROUND

One factor impacting patient outcomes in the acutely deteriorating patient is a delay by nursing staff to activate a rapid response team (RRT); however, a gap in knowledge exists concerning factors influencing activation of an RRT by nursing staff working in adult areas outside the medical-surgical and telemetry setting.

OBJECTIVES

The purpose of this study was to examine beliefs and behaviors that influence registered nurses' decision to activate an adult rapid response team in a community hospital that includes 3 specialties: medical-surgical and telemetry, peripartum, and psychiatric areas.

METHODS

One hundred sixty-three nurses were surveyed using a 17-item Likert-style instrument to assess registered nurses' beliefs and attitudes on and barriers to utilizing an RRT.

RESULTS

The survey was analyzed yielding 3 factors: RRT barriers, RRT positive/intent to activate, and patient management beliefs. Barriers cited by other research to activate RRT including criticism by the team and perception that the RRT increases workload or reduces skills were not found to be influential considerations. A significant difference was found among the 3 specialty groups related to RRT positive/intent to activate (F2,159 = 6.09, P = .003) and patient management beliefs (F2,159 = 5.87, P = .003). A strong negative correlation was found between years of experience as an RN and RRT barriers (ρ161 = -0.250).

DISCUSSION

Organizations should examine RRT activation delays particularly in the area of calls to covering physicians prior to RRT activations. Differences between specialty groups highlight the need for education across specialties on the recognition of the acutely deteriorating patient. The findings indicate that the inexperienced nurse requires support from experienced colleagues and temporary adjustments to workload during situations of acute deterioration of a patient.

Qualitative study exploring factors influencing escalation of care of deteriorating children in a children's hospital

BACKGROUND

System-level interventions including rapid response teams and paediatric early warning scores have been designed to support escalation of care and prevent severe adverse events in hospital wards. Barriers and facilitators to escalation of care have been rarely explored in paediatric settings.

AIM

This study explores the experiences of parents and healthcare professionals of in-hospital paediatric clinical deterioration events to identify factors associated with escalation of care.

METHODS

Across 2 hospital sites, 6 focus groups with 32 participants were conducted with parents (n=9) and healthcare professionals (n=23) who had cared for or witnessed a clinical deterioration event of a child. Transcripts of audio recording were analysed for emergent themes using a constant comparative approach.

FINDINGS

Four themes and 19 subthemes were identified: (1) impact of staff competencies and skills, including personal judgement of clinical efficacy (self-efficacy), differences in staff training and their impact on perceived nursing credibility; (2) impact of relationships in care focusing on communication and teamwork; (3) processes identifying and responding to clinical deterioration, such as patient assessment practices, tools to support the identification of patients at risk and the role of the rapid response team; and (4) influences of organisational factors on escalation of care, such as staffing, patient pathways and continuity of care.

CONCLUSIONS

Findings emphasise the considerable influence of social processes such as teamwork, communication, models of staff organisation and staff education. Further studies are needed to better understand how modification of these factors can be used to improve patient safety.

Nurses' experiences of managing patient deterioration following a post-registration education programme: A critical incident analysis study

The aim of this study was to explore nurses' experiences assessing and managing deteriorating patients in practice following completion of a relevant post-registration education programme. Recognising the increasing acuity of ward patients, nurses are faced with patients who are at an increased risk of deterioration. Patients who are acutely ill or deteriorating often exhibit periods of physiological deterioration; however there is evidence illustrating that these clinical changes are frequently missed, misinterpreted or mismanaged in practice. In order to prepare nurses to competently assess and manage the deteriorating patient, education as a care initiative is offered to develop the knowledge and skills required. A qualitative study using critical incident analysis was conducted to acquire narrative data from nurses, describing their clinical practice experiences of patient deterioration. Thematic analysis was used to analyse the data. Findings revealed improvements in nurses' abilities to recognise patient deterioration, greater application of the evidence base and an increase in confidence and assertiveness. There was some evidence of applying the knowledge and skills learned, however equally some nurses indicated that they remained ill-prepared to apply the skills in practice.