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Sutton E, Ibrahim M, Plath W, Booth L, Sujan M, McCulloch P, Mackintosh N. Understanding the enablers and barriers to implementing a patient-led escalation system: a qualitative study. BMJ Qual Saf 2024:bmjqs-2024-017132. [PMID: 38902021 DOI: 10.1136/bmjqs-2024-017132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 05/05/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND The management of acute deterioration following surgery remains highly variable. Patients and families can play an important role in identifying early signs of deterioration but effective contribution to escalation of care can be practically difficult to achieve. This paper reports the enablers and barriers to the implementation of patient-led escalation systems found during a process evaluation of a quality improvement programme Rescue for Emergency Surgery Patients Observed to uNdergo acute Deterioration (RESPOND). METHODS The research used ethnographic methods, including over 100 hours of observations on surgical units in three English hospitals in order to understand the everyday context of care. Observations focused on the coordination of activities such as handovers and how rescue featured as part of this. We also conducted 27 interviews with a range of clinical and managerial staff and patients. We employed a thematic analysis approach, combined with a theoretically focused implementation coding framework, based on Normalisation Process Theory. RESULTS We found that organisational infrastructural support in the form of a leadership support and clinical care outreach teams with capacity were enablers in implementing the patient-led escalation system. Barriers to implementation included making changes to professional practice without discussing the value and legitimacy of operationalising patient concerns, and ensuring equity of use. We found that organisational work is needed to overcome patient fears about disrupting social and cultural norms. CONCLUSIONS This paper reveals the need for infrastructural support to facilitate the implementation of a patient-led escalation system, and leadership support to normalise the everyday process of involving patients and families in escalation. This type of system may not achieve its goals without properly understanding and addressing the concerns of both nurses and patients.
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Affiliation(s)
| | - Mudathir Ibrahim
- Department of General Surgery, Maimonides Medical Center, Brooklyn, New York, USA
| | - William Plath
- Nuffield Department of Surgery, Oxford University, Oxford, UK
| | | | - Mark Sujan
- Human Factors Everywhere, Woking, UK
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Peter McCulloch
- Nuffield Department of Surgery, Oxford University, Oxford, UK
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King L, Minyaev S, Grantham H, Clark RA. Opinions of Nurses and Physicians on a Patient, Family, and Visitor Activated Rapid Response System in Use Across Two Hospital Settings. Jt Comm J Qual Patient Saf 2024; 50:269-278. [PMID: 38296749 DOI: 10.1016/j.jcjq.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 12/30/2023] [Accepted: 01/03/2024] [Indexed: 02/02/2024]
Abstract
BACKGROUND Early detection of deterioration of hospitalized patients with timely intervention improves outcomes in the hospital. Patients, family members, and visitors (consumers) at the patient's bedside who are familiar with the patient's condition may play a critical role in detecting early patient deterioration. The authors sought to understand clinicians' views on consumer reporting of patient deterioration through an established hospital consumer-initiated escalation-of-care system. METHODS A convenience sample of new graduate-level to senior-level nurses and physicians from two hospitals in South Australia was administered a paper survey containing six open-ended questions. Data were analyzed with a matrix-style framework and six steps of thematic analysis. RESULTS A total of 244 clinicians-198 nurses and 46 physicians-provided their views on the consumer-initiated escalation-of-care system. Six major themes and subthemes emerged from the responses indicating that (1) clinicians were supportive of consumer reporting and felt that consumers were ideally positioned to recognize deterioration early and raise concerns about it; (2) management support was required for consumer escalation processes to be effective; (3) clinicians' workload could possibly increase or decrease from consumer escalation; (4) education of consumers and staff on escalation protocol is a requirement for success; (5) there is need to build consumer confidence to speak up; and (6) there is a need to address barriers to consumer escalation. CONCLUSION Clinicians were supportive of consumers acting as first reporters of patient deterioration. Use of interactive, encouraging communication skills with consumers was recognized as critical. Annual updating of clinicians on consumer reporting of deterioration was also recommended.
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King L, Belan I, Clark RA, Young T, Grantham H, Thornton K, Kidd MR. Hospital Testing of the Effectiveness of Co-Designed Educational Materials to Improve Patient and Visitor Knowledge and Confidence in Reporting Patient Deterioration. Jt Comm J Qual Patient Saf 2024; 50:116-126. [PMID: 37821325 DOI: 10.1016/j.jcjq.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 08/31/2023] [Accepted: 09/01/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Co-designed educational materials could significantly improve the likelihood of patients and visitors (consumers) escalating care through hospital systems. The objective was to investigate patients' and visitors' knowledge and confidence in recognizing and reporting patient deterioration in hospitals before and after exposure to educational materials. METHODS A multimethod design involved a convenience sample of patients and visitors at a South Australian hospital. Knowledge and confidence of participants to report patient deterioration was assessed using a validated questionnaire. Baseline group was surveyed, and a second group was surveyed after exposure to a poster and on-hold message relating to consumer-initiated escalation-of-care. Nominal data were examined using chi-square analysis, and ordinal data using the Mann-Whitney U test. Open-ended questions were examined using thematic analysis. RESULTS A total of 407 participants completed the study, 203 undertook the baseline survey, and 204 the postintervention survey. Respondents exposed to the educational materials reported significantly higher recognition of responsibility to report concerns about patient deterioration compared to controls (86.3% vs. 73.1%; p = 0.007). Respondents exposed to the educational materials also had better ability to identify signs that a patient was becoming sicker compared to controls (77.5% vs. 71.3%, p = 0.012). Four overarching themes emerged from the questions: patient/visitor understanding of key messages, patient/visitor recognition of deterioration, patient/visitor response to deterioration and patient/visitor recommendations. CONCLUSION Following educational interventions, patients and visitors report improved awareness of their role in recognizing and responding to clinical deterioration. They advise additional active interventions and caution that the materials should accommodate language, cultural, and disability needs.
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Khan N. Martha's Rule: what does it mean for general practice? Br J Gen Pract 2023; 73:504-505. [PMID: 37884361 PMCID: PMC10617944 DOI: 10.3399/bjgp23x735381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Affiliation(s)
- Nada Khan
- Nada is an Exeter-based National Institute for Health and Care Research Academic Clinical Fellow in general practice, GPST4/Registrar, and an Associate Editor at the BJGP.
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Haskell H. Martha's rule presents a unique opportunity for improving patient care. BMJ 2023; 383:2331. [PMID: 37813468 DOI: 10.1136/bmj.p2331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
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Cooksley T, Astbury S, Holland M. Martha's rule and patients' rights to a second opinion. BMJ 2023; 383:2221. [PMID: 37783488 DOI: 10.1136/bmj.p2221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Affiliation(s)
| | | | - Mark Holland
- School of Clinical and Biomedical Sciences, University of Bolton, Bolton, UK
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Shahrestanaki SK, Rafii F, Najafi Ghezeljeh T, Farahani MA, Majdabadi Kohne ZA. Patient safety in home health care: a grounded theory study. BMC Health Serv Res 2023; 23:467. [PMID: 37165357 PMCID: PMC10171141 DOI: 10.1186/s12913-023-09458-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 04/27/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND The home environment is designed for living, not for professional care. For this reason, safe patient care is one of the most important challenges of home health care. Despite abundant research on safe care, there is still little understanding of safety issues in home care. DESIGN The aim of the present study was to explain the process of safe patient care in home health care. A qualitative, grounded theory study was conducted based on the approach proposed by Corbin & Strauss in 2015. METHOD In total, 22 interviews were conducted with 16 participants including 9 home care nurses, 2 home care nursing assistants, 1 home care inspector, 1 home care physician and 3 family caregivers in Tehran, Iran. Four observation sessions were conducted in different homes. Purposeful sampling was used followed by theoretical sampling from August 2020-July 2022. Data analysis was carried out based on the approach proposed by Corbin & Strauss in 2015. RESULTS The results showed that the healthcare members (nurses, family caregivers, patients and home care centers) used the model of safe patient care in home health care based on four assessment methods, i.e. prevention, foresight, establishment of safety and verification. The core variable in this process is foresight-based care. CONCLUSION The results of this study showed that the key to safe patient care in home health care, which helps to maintain patient safety and prevent threats to safe care, is the foresight of healthcare members, which is essential for identifying threats to safe care considering the many risks of home health care.
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Affiliation(s)
| | - Forough Rafii
- Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran
| | - Tahereh Najafi Ghezeljeh
- Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran
- Cardiovascular Nursing Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mansoureh Ashghali Farahani
- Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran
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Williams G, Pirret A, Credland N, Odell M, Raftery C, Smith D, Winterbottom F, Massey D. A practical approach to establishing a critical care outreach service: An expert panel research design. Aust Crit Care 2023; 36:151-158. [PMID: 35341667 DOI: 10.1016/j.aucc.2022.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 12/18/2021] [Accepted: 01/18/2022] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Ged Williams
- School of Nursing & Midwifery, Griffith University, Australia; South Metropolitan Health Service, Perth, Australia.
| | - Alison Pirret
- Critical Care Complex, Middlemore Hospital, Auckland, New Zealand; Massey University, Auckland, New Zealand
| | - Nicki Credland
- Reader in Critical Care Education, University of Hull, United Kingdom; Chair British Association of Critical Care Nurses (BACCN), United Kingdom
| | - Mandy Odell
- Critical Care, Royal Berkshire Hospital, NHS FT, Reading, United Kingdom
| | - Chris Raftery
- School of Nursing, Queensland University of Technology, Australia; Gold Coast Health, Queensland, Australia
| | - Duncan Smith
- City, University of London, Northampton Square, London, UK; Honorary Charge Nurse - Patient Emergency Response & Resuscitation Team, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | | | - Debbie Massey
- Southern Cross University, Australia; Intensive Care Unit John Flynn Hospital, Tugun, Australia
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Carter B, Saron H, Blake L, Eyton-Chong CK, Dee S, Evans L, Harris J, Hughes H, Jones D, Lambert C, Lane S, Mehta F, Peak M, Preston J, Siner S, Sefton G, Carrol ED. Clinical utility and acceptability of a whole-hospital, pro-active electronic paediatric early warning system (the DETECT study): A prospective e-survey of parents and health professionals. PLoS One 2022; 17:e0273666. [PMID: 36107953 PMCID: PMC9477367 DOI: 10.1371/journal.pone.0273666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 08/11/2022] [Indexed: 11/18/2022] Open
Abstract
Background Paediatric early warning systems (PEWS) are a means of tracking physiological state and alerting healthcare professionals about signs of deterioration, triggering a clinical review and/or escalation of care of children. A proactive end-to-end deterioration solution (the DETECT surveillance system) with an embedded e-PEWS that included sepsis screening was introduced across a tertiary children’s hospital. One component of the implementation programme was a sub-study to determine an understanding of the DETECT e-PEWS in terms of its clinical utility and its acceptability. Aim This study aimed to examine how parents and health professionals view and engage with the DETECT e-PEWS apps, with a particular focus on its clinical utility and its acceptability. Method A prospective, closed (tick box or sliding scale) and open (text based) question, e-survey of parents (n = 137) and health professionals (n = 151) with experience of DETECT e-PEWS. Data were collected between February 2020 and February 2021. Results Quantitative data were analysed using descriptive and inferential statistics and qualitative data with generic thematic analysis. Overall, both clinical utility and acceptability (across seven constructs) were high across both stakeholder groups although some challenges to utility (e.g., sensitivity of triggers within specific patient populations) and acceptability (e.g., burden related to having to carry extra technology) were identified. Conclusion Despite the multifaceted nature of the intervention and the complexity of implementation across a hospital, the system demonstrated clinical utility and acceptability across two key groups of stakeholders: parents and health professionals.
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Affiliation(s)
- Bernie Carter
- Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, United Kingdom
- * E-mail:
| | - Holly Saron
- Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, United Kingdom
| | - Lucy Blake
- Department of Social Sciences, University of West of England, Bristol, United Kingdom
| | - Chin-Kien Eyton-Chong
- Department of General Paediatrics, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Sarah Dee
- High Dependency Unit, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Leah Evans
- High Dependency Unit, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Jane Harris
- Faculty of Health, Public Health Institute, Liverpool John Moores University, United Kingdom
| | - Hannah Hughes
- Oncology Unit, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Dawn Jones
- Clinical Research Division, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Caroline Lambert
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
- Department of Infectious Diseases, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Steven Lane
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Fulya Mehta
- Department of General Paediatrics, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Matthew Peak
- NIHR Alder Hey Clinical Research Facility, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Jennifer Preston
- Department of Women’s and Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Sarah Siner
- Clinical Research Division, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Gerri Sefton
- Paediatric Intensive Care Unit, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Enitan D. Carrol
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
- Department of Infectious Diseases, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
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Yu S, Thornton K, King L. Consumers’ views on reporting of patient deterioration before the development of a consumer-activated response service. Collegian 2022. [DOI: 10.1016/j.colegn.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Thiele L, Flabouris A, Thompson C. Acute clinical deterioration and consumer escalation: The understanding and perceptions of hospital staff. PLoS One 2022; 17:e0269921. [PMID: 35709173 PMCID: PMC9202900 DOI: 10.1371/journal.pone.0269921] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 05/31/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction Consumer escalation systems allow patients and families to escalate concerns about acute clinical deterioration. Hospital staff can impact upon the success of this process. As part of evaluation processes within a Local Health Network, where a consumer escalation system was introduced in accordance with National requirements, we sought to explore clinicians’ understanding and perceptions of consumer escalation. Methods Voluntary and anonymous staff surveys pre, and post, system introduction. Quantitative data was analysed using descriptive statistics, chi-square independence, and non-parametric independent samples median tests. Qualitative data was evaluated using content analysis and cross-referenced with quantitative responses. Results Respondent’s (pre: 215; post: 89) area of work varied significantly between survey periods. Most agreed that patients/families have a sound knowledge of a patient’s typical health status (pre: 192/215 (89.3%); post 82/88 (93.2%)) and that patients/families should be encouraged to escalate concerns of deterioration to ward staff (pre: 209/212 (98.6%); post: 85/89 (95.5%)). Respondent perceptions of patient/family ability to recognise clinical deterioration varied. Staff agreement towards local response expectations decreased as the degree of clinical requirement increased. Staff concerns of increased workloads (pre: 90/214 (42.1%); post 12/72 (16.7%), p<0.001) and conflict generation (pre: 71/213 (33.3%); post: 7/71 (9.9%), p = 0.001) decreased significantly following system introduction. However, clinician perceptions of positive system effects also decreased (patient-staff rapport pre: 163/213 (76.5%); post: 38/72 (52.8%), p = 0.001; patient centred care pre: 188/214 (87.9%); post: 53/72 (73.6%), p = 0.012; patient safety pre: 173/214 (80.8%); post: 49/72 (68.1%), p = 0.077). Only 53% of respondents (pre: 112/213 (52.6%); post: 48/88 (54.5%)) perceived that patient/family have sufficient confidence to escalate concerns. Conclusion Consumer escalation systems require staff support. Staff perceptions may indicate, and act as, barriers to the operation of consumer escalation processes. Further exploration in identifying and managing staff barriers is crucial to the success of consumer escalation.
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Affiliation(s)
- Lisa Thiele
- Faculty of Health and Medical Sciences, Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- * E-mail:
| | - Arthas Flabouris
- Faculty of Health and Medical Sciences, Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Campbell Thompson
- Faculty of Health and Medical Sciences, Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- General Medicine Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Clinicians' attitudes towards escalation and management of deteriorating patients: A cross-sectional study. Aust Crit Care 2022; 36:320-326. [PMID: 35490110 DOI: 10.1016/j.aucc.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 02/23/2022] [Accepted: 03/01/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Internationally, rapid response systems have been implemented to recognise and categorise hospital patients at risk of deterioration. Whilst rapid response systems have been implemented with a varying amount of success, there remains ongoing concern about the lack of improvement in the escalation, and management of the deteriorating patient. It also remains unclear why some clinicians fail to escalate concerns for the deteriorating patient. OBJECTIVE The objective of this study was to explore clinicians' attitudes towards the escalation, and management of the deteriorating patient. METHODS A cross-sectional online survey of conveniently sampled clinicians from the acute care sector in a regional health district in Australia was conducted. The Clinicians' Attitudes towards Responding and Escalating care of Deteriorating patients scale, was used to explore attitudes towards the escalation and management of the deteriorating patient. RESULTS Survey responses were received from medical officers (n = 43), nurses (n = 677), allied health clinicians (n = 60), and students (n = 57). Years of experience was significantly associated with more confidence responding to deteriorating patients (p < .001) and significantly less fears about escalating care (p < .001). Nurses (M = 4.16, SD = .57) and students (M = 4.11, SD = .55) in general had significantly greater positive beliefs that the rapid response system would support them to respond to the deteriorating patient than allied health (M = 3.67, SD = .64) and medical (M = 3.87, SD = .54) clinicians, whilst nurses and medical clinicians had significantly less fear about escalating care and greater confidence in responding to deteriorating patients than allied health clinicians and healthcare students (p < .001). CONCLUSION Nurses and medical officers have less fear to escalate care and greater confidence responding to the deteriorating patient than allied health clinicians and students. Whilst the majority of participants had positive perceptions towards the rapid response system, those with less experience lacked the confidence to escalate care and respond to the deteriorating patient.
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Flynn DE, Flynn H, Gifford S, Smith K. Can you hear me? Analysis of a Queensland patient-initiated escalation process and the importance of communication in surgical care. ANZ J Surg 2022; 92:1371-1376. [PMID: 35238154 DOI: 10.1111/ans.17584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 01/17/2022] [Accepted: 02/16/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Ryan's Rule is a three-step escalation process established by Queensland Health whereby patients, their families and carers can escalate concerns if a patient's health is worsening or not improving as expected. This study analysed the incidence, causes and outcomes of Ryan's Rule cases involving patients admitted under various surgical specialties across Queensland. METHODS A retrospective analysis was undertaken of cases wherein Ryan's Rule was invoked by surgical patients between 2016 and 2021. The analysis focused on rationale for invoking Ryan's Rule, clinical actions undertaken, outcomes and patient feedback. RESULTS The study analysed 364 activations of Ryan's Rule among surgical patients admitted across ten Queensland Health hospitals. The common causes for invoking Ryan's Rule were concern or disagreement regarding the management plan (39%), poor understanding of the care plan (32%) and feeling that concerns were not being heard (35%). Less than 1 % of cases (0.8%) met early warning criteria for deterioration, and only 0.5% required admission to ICU. The majority of Ryan's Rule cases (92%) were resolved through discussion between the treating surgical team, the patient and their representatives. In 74% of cases, the management plan did not change following the Ryan's Rule review. CONCLUSION Communication is the overwhelming theme throughout the Ryan's Rule cases invoked by surgical patients. The majority of Ryan's Rules cases were initiated by issues in communication and understanding between clinicians and patients. The vast majority of cases were resolved by surgical teams establishing and maintaining clear communication with patients, their families and carers.
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Affiliation(s)
- David E Flynn
- Department of Vascular Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Hannah Flynn
- Department of Urology, Toowoomba Hospital, Toowoomba, Queensland, Australia
| | - Shaune Gifford
- Queensland Health, Clinical Excellence Queensland (Patient Safety and Quality Improvement Service), Brisbane, Queensland, Australia
| | - Kate Smith
- Queensland Health, Clinical Excellence Queensland (Patient Safety and Quality Improvement Service), Brisbane, Queensland, Australia
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King L, Ullah S, Belan I, Clark RA, Young T, Grantham H, Peacock G, Kidd MR. Development and Validation of an Evaluation Tool of Consumers' Knowledge and Confidence to Report Patient Deterioration in Hospitals. J Patient Saf 2021; 17:e1406-e1412. [PMID: 34508043 DOI: 10.1097/pts.0000000000000895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Studies have shown that many preventable hospital deaths may be reduced through early reporting of deterioration by patients and their visitors to health professionals. Engagement of patients and families for safer health care was recommended by the World Health Organization. As no validated tool was identified, the objective of the study was to develop and validate a tool to measure the impact of messages contained in self-developed educational materials on consumers' knowledge and confidence to report patient deterioration. METHODS A tool was created using consumer-based input. A test-retest methodology was used 2 weeks apart, using 37 participants sourced from consumer groups. Fourteen 5-point Likert scale questionnaire items were categorized into knowledge and confidence components to identify the impact of the materials in both of these areas. RESULTS Test-retest reliability confirmed 10 of the 14 proposed questionnaire items (4 knowledge items and 6 confidence) had at least moderate κ agreement ranging from 0.42 to 0.69 and an intraclass correlation coefficient of 0.66. An exploratory factor analysis of the 10 remaining items indicated a 2-factor solution had the best interpretability accounting for 96.9% of variability. The Cronbach α and factor loadings for the factors, knowledge, and confidence suggested an acceptable level of reliability and validity. CONCLUSIONS The study confirms our tool for assessment of educational materials to be a reliable, context-specific, and validated instrument. The tool is an appropriate instrument to assess the effectiveness of educational materials in public awareness campaigns that focus on consumer reporting of patient deterioration within hospitals.
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Affiliation(s)
- Lindy King
- From the College of Nursing and Health Sciences, Flinders University, Adelaide
| | - Shahid Ullah
- College of Medicine and Public Health, Flinders University
| | - Ingrid Belan
- From the College of Nursing and Health Sciences, Flinders University, Adelaide
| | - Robyn A Clark
- College of Nursing and Health Sciences, Caring Futures Institute
| | - Tom Young
- College of Humanities, Arts and Social Sciences, Flinders University, Adelaide, South Australia
| | - Hugh Grantham
- South Australian Ambulance Service/School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia
| | - Guy Peacock
- Division of Mental Health Services, Southern Adelaide Local Health Network (SALHN), Daw Park, South Australia
| | - Michael R Kidd
- The Australian National University, Canberra, Australian Capital Territory, Australia
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Harley A, Schlapbach LJ, Johnston ANB, Massey D. Challenges in the recognition and management of paediatric sepsis - The journey. Australas Emerg Care 2021; 25:23-29. [PMID: 33865753 DOI: 10.1016/j.auec.2021.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 02/25/2021] [Accepted: 03/16/2021] [Indexed: 01/06/2023]
Abstract
Paediatric sepsis remains a leading cause of childhood death. Morbidity is high, with up to one third of children affected developing ongoing, sometimes lifelong sequelae. To address the major burden of sepsis on child health, there is need for a unified approach to care, as outlined in the Australian National Action Plan for sepsis. While the Surviving Sepsis Campaign 2020 guidelines provided evidence-based recommendations for sepsis management in hospital, additional emphasis on families, pre-hospital recognition and post-sepsis care incorporating the multidisciplinary team is paramount to achieve quality patient outcomes. The role of families, paramedics and nurses in recognising and managing paediatric sepsis remains an under-represented area in current literature. The aim of this paper is to critically discuss key challenges surrounding the journey of paediatric sepsis, drawing on contemporary literature to highlight key areas pertinent to recognition and management of sepsis in children. Application of a holistic, patient-centred focus will provide an overview of paediatric sepsis, aiming to inform future development for enhanced healthcare delivery and identify critical areas for further research.
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Affiliation(s)
- Amanda Harley
- School of Nursing, Midwifery and Social Work, The University of Queensland, Brisbane, QLD, Australia; Child Health Research Centre, The University of Queensland, and Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, QLD, Australia; Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, QLD, Australia.
| | - Luregn J Schlapbach
- Child Health Research Centre, The University of Queensland, and Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, QLD, Australia; Department of Intensive Care Medicine and Neonatology, and Children's Research Center, University Children's Hospital Zurich, Switzerland.
| | - Amy N B Johnston
- School of Nursing, Midwifery and Social Work, The University of Queensland, Brisbane, QLD, Australia; Department of Emergency Medicine, Princess Alexandra Hospital, Brisbane, QLD, Australia.
| | - Debbie Massey
- School of Nursing and Midwifery, Southern Cross University, Coolangatta, QLD, Australia.
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McKinney A, Fitzsimons D, Blackwood B, McGaughey J. Patient and family involvement in escalating concerns about clinical deterioration in acute adult wards: A qualitative systematic review. Nurs Crit Care 2020; 26:352-362. [PMID: 33345386 DOI: 10.1111/nicc.12582] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/01/2020] [Accepted: 12/02/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Despite international standards for recognition and response to deterioration, warning signs are not always identified by staff on acute hospital wards. Patient and family-initiated escalation of care schemes have shown some benefit in assisting early recognition, but are not widely used in many clinical practice areas. OBJECTIVES To explore (a) patients' and relatives' experiences of acute deterioration and (b) patients', relatives' and healthcare professionals' perceptions of the barriers or facilitators to patient and family-initiated escalation of care in acute adult hospital wards. METHODS We conducted a qualitative review using Cochrane methodology. Two reviewers independently screened studies, extracted data, and appraised the quality using a qualitative critical appraisal tool. Findings were analysed using thematic synthesis and confidence in findings was assessed using GRADE-CERQual. SEARCH STRATEGY MEDLINE, CINAHL, EMBASE, PsychINFO databases and grey literature from 2005 to August 2019. INCLUSION CRITERIA Any research design that had a qualitative element and focused on adult patients' and relatives' experiences of deterioration and perceptions of escalating care. RESULTS We included five studies representing 120 participants and assessed the certainty of evidence as moderate using GRADE-CERQual. Findings indicated that a number of patients/relatives have the ability to detect acute deterioration, however, various factors act as both barriers and facilitators to being heard. These include personal factors, perceptions of role, quality of relationships with healthcare staff, and organisational factors. Theoretical understanding suggests that patient and relative involvement in escalation is dependent on both inherent capabilities and the factors that influence empowerment. CONCLUSION This review highlights that patient and family escalation of care interventions need to be designed with the aim of improving patient/relative-clinician collaboration and the sharing of responsibility. RELEVANCE TO PRACTICE These factors need to be addressed to promote more active partnerships when designing and implementing patient and family-initiated escalation of care interventions.
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Affiliation(s)
- Aidín McKinney
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Donna Fitzsimons
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Jennifer McGaughey
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
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Thiele L, Flabouris A, Thompson C. Acute clinical deterioration and consumer escalation in the hospital setting: A literature review. Resuscitation 2020; 156:72-83. [PMID: 32858153 DOI: 10.1016/j.resuscitation.2020.08.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 07/23/2020] [Accepted: 08/09/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Consumer escalation systems that allow patients and/or their family/carers to escalate concerns about clinical deterioration have been proposed as a way of enhancing patient safety. However, evidence to guide implementation or to support system effectiveness remains unclear. AIM To critically evaluate the current evidence surrounding consumer escalation within the context of clinical deterioration to identify the strengths, weaknesses and gaps in existing knowledge, essential themes, and directions for further investigation. METHOD Database searches were conducted within Cumulative Index of Nursing and Allied Health Literature, PubMed, and the Cochrane Library for articles directly relating to consumer escalation systems published, in English, within the previous 10 year-period. Titles and abstracts were screened and relevant full-text articles included. Content was examined to identify breadth of knowledge, essential themes, and the effectiveness of current systems. RESULTS 27 articles, containing a mixture of both quantitative and qualitative findings, were identified. Within the context of limitations in the overall depth and quality of current evidence, four key areas (relating to consumer understanding and awareness of clinical deterioration, confidence and ability to escalate concerns, education, and staff attitudes) were identified as potentially critical to the foundation, functioning, and success of consumer escalation systems. Consumer escalation processes may contribute positive effects beyond mortality rates; however, an agreed method of assessing effectiveness remains undetermined. CONCLUSIONS The ability of consumer escalation processes to achieve their underlying goals is still to be adequately assessed. Further research is required to inform how to best implement, support and optimise consumer escalation systems.
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Affiliation(s)
- Lisa Thiele
- The University of Adelaide, Faculty of Health and Medical Sciences, Adelaide Medical School, North Terrace, Adelaide 5000, South Australia, Australia; Registered Nurse, Intensive Care Unit, Royal Adelaide Hospital, Adelaide 5000, South Australia, Australia.
| | - Arthas Flabouris
- Staff Specialist, Intensive Care Unit, Royal Adelaide Hospital, and Clinical Associate Professor, The University of Adelaide, Faculty of Health and Medical Sciences, Adelaide Medical School, North Terrace, Adelaide 5000, South Australia, Australia.
| | - Campbell Thompson
- Consultant, Acute Medical Unit, Royal Adelaide Hospital, and Professor of Medicine, The University of Adelaide, Faculty of Health and Medical Sciences, Adelaide Medical School, Discipline of Medicine, North Terrace, Adelaide 5000, South Australia, Australia.
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