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

Successfully initiating an escalation of care in acute ward settings-A qualitative observational study

AIMS

To address knowledge gaps by (i) developing a theoretical understanding of escalation and (ii) identifying escalation success factors.

DESIGN

Non-participant observations were used to examine deteriorating patient escalation events.

METHODS

Escalation event data were collected by a researcher who shadowed clinical staff, between February 16th 2021 and March 17th 2022 from two National Health Service Trusts. Events were analysed using Framework Analysis. Escalation tasks were mapped using a Hierarchical Task Analysis diagram and data presented as percentages, frequency and 95% CI.

RESULTS

A total of 38 observation sessions were conducted, totaling 105 h, during which 151 escalation events were captured. Half of these were not early warning score-initiated and resulted from bleeding, infection, or chest pain. Four communication phenotypes were observed in the escalation events. The most common was Outcome Focused Escalation, where the referrer expected specific outcomes like blood cultures or antibiotic prescriptions. Informative Escalations were often used when a triggering patient's condition was of low clinical concern and ranked as the second most frequent escalation communication type. General Concern Escalations occurred when the referrer did not have predetermined expectations. Spontaneous Interaction Escalations were the least frequently observed, occurring opportunistically in communal workspaces.

CONCLUSION

Half of the events were non-triggering escalations and understanding these can inform the design of systems to support staff better to undertake them. Escalation is not homogenous and differing escalation communication phenotypes exist. Informative Escalations represent an organizational requirement to report triggering warning scores and a targeted reduction of these may be organizationally advantageous. Increasing the frequency of Spontaneous Escalations, through hospital designs, may also be beneficial.

IMPACT STATEMENT

Our work highlights that a significant proportion of escalation workload occurs without a triggering early warning score and there is scope to better support these with designed systems. Further examination of reducing Informative and increasing Spontaneous Escalations is also warranted.

PATIENT AND PUBLIC CONTRIBUTION

Extensive PPIE was completed throughout the lifecycle of this study. PPIE members validated the research questions and overarching aims of the overall study. PPIE members contributed to the design of the study reviewed documents and the final data generated.

Early prediction of intensive care unit admission in emergency department patients using machine learning

BACKGROUND

The timely identification and transfer of critically ill patients from the emergency department (ED) to the intensive care unit (ICU) is important for patient care and ED workflow practices.

OBJECTIVE

We aimed to develop a predictive model for ICU admission early in the course of an ED presentation.

METHODS

We extracted retrospective data from the electronic medical record and applied natural language processing and machine learning to information available early in the course of an ED presentation to develop a predictive model for ICU admission.

RESULTS

We studied 484 094 adult (≥18 years old) ED presentations, amongst which direct admission to the ICU occurred in 3955 (0.82%) instances. We trained machine learning in 323 678 ED presentations and performed testing/validation in 160 416 (70 546 for testing and 89 870 for validation). Although the area under the receiver operating characteristics curve was 0.92, the F1 score (0.177) and Matthews correlation coefficient (0.257) suggested substantial imbalance in the dataset. The strongest weighted variables in the predictive model at the 30-min timepoint were ED triage category, arrival via ambulance, quick Sequential Organ Failure Assessment score, baseline heart rate, and the number of inpatient presentations in the prior 12 months. Using a likelihood of ICU admission of more than 75%, for activation of automated ICU referral, we estimated the model would generate 2.7 triggers per day.

CONCLUSIONS

The infrequency of ICU admissions as a proportion of ED presentations makes accurate early prediction of admissions challenging. Such triggers are likely to generate a moderate number of false positives.

NEWS-2 Accuracy in Predicting Mortality and Severe Morbidity Among Hospitalized COVID-19 Patients: A Prospective Cohort Study

Background: Early risk stratification tools for COVID-19 patients have been indicated yet there are few data about their ability to effectively detect clinical deterioration among COVID-19 patients. Objectives: To evaluate the NEWS-2 to predict severe morbidity and mortality for COVID-19 patients admitted to hospitals. Methods: We conducted a prospective cohort study among adult COVID-19 patients with a confirmed diagnosis who were admitted to the inpatient units at COVID-19 Martyrs Medical Military Complex Hospital, from 1 March 2022, until 29 February 2023. NEWS-2 scores were measured at admission and 6, 12, 24, and 48 h after their admission to the hospital using receiver operating characteristic (ROC) curves. Results: Overall, 192 adult COVID-19 patients aged 25-94 years (mean = 62.1, SD = 13.9) were enrolled. Of those, 49.0% were males, 47.4% were vaccinated, and 53.6% had diabetes. The 192 enrolled patients were classified into NEWS-2 score categories, with almost 13% (12.5%) falling into the high-risk category already upon admission. The mean NEWS-2 scores were excellent predictors of mechanical ventilation, admission to the ICU, and mortality, as indicated by an AUROC of 0.94 (95% CI: 0.88-1.00, p < 0.001), 0.91 (95% CI: 0.87-0.96, p < 0.001), and 0.96 (95% CI: 0.92-1.00, p < 0.001), respectively. Significant differences in mean NEWS-2 scores were found between the participating patients, both with and without comorbidity in the course of the patient's stay in the ICU, and mortality (p = 0.004, p = 0.043, respectively). Positive correlations of the high NEWS-2 scores were revealed using a multiple linear regression model, indicating the necessity of administering non-invasive ventilatory assistance (p = 0.013), hospitalization for a minimum of six days (p = 0.013), and admission to the ICU (p = 0.006). Nonetheless, there was a negative association between mortality and the NEWS-2 score (p < 0.001). Conclusions: The NEWS-2 had moderate sensitivity and specificity in predicting the deterioration of patients with COVID-19 whereas there was high sensitivity and specificity in predicting the mortality for patients with COVID-19, both with and without comorbidity. Our findings support the utility of NEWS-2 monitoring as a sensitive approach for initially assessing COVID-19 patients. It could be helpful to enhance the accuracy of predictive performance by supplementing the score parameters by adding biological parameters in addition to clinical judgment.

Pilot study for the development of an automatically generated and wearable-based early warning system for the detection of deterioration of hospitalized patients of an acute care hospital

BACKGROUND

Acute deteriorations of health status are common in hospitalized patients and are often preceded by changes in their vital signs. Events such as heart attacks, death or admission to the intensive care unit can be averted by early detection, therefore so-called Early Warning Scores (EWS) such as the National Early Warning Score 2 (NEWS2), including basic vital parameters such as heart rate, blood pressure, respiratory rate, temperature and level of consciousness, have been developed for a systematic approach. Although studies have shown that EWS have a positive impact on patient outcomes, they are often limited by issues such as calculation errors, time constraints, and a shortage of human resources. Therefore, development of tools for automatic calculation of EWS could help improve quality of EWS calculation and may improve patient outcomes. The aim of this study is to analyze the feasibility of wearable devices for the automatic calculation of NEWS2 compared to conventional calculation using vital signs measured by health care professionals.

METHODS

We conducted a prospective trial at a large tertiary hospital in Switzerland. Patients were given a wristband with a photoplethysmogram (PPG) sensor that continuously recorded their heart rate and respiratory rate for 3 consecutive days. Combined with data from the electronic health record (EHR), NEWS2-score was calculated and compared to NEWS2 score calculated from vital parameters in the EHR measured by medical staff. The main objective of our study was to assess the agreement between NEWS2 scores calculated using both methods. This analysis was conducted using Cohen's Kappa and Bland-Altman analysis. Secondary endpoints were compliance concerning the medical device, patient acceptance, data quality analysis and data availability and signal quality for all time stamps needed for accurate calculation.

RESULTS

Of 210 patients enrolled in our study, NEWS2 was calculated in 904 cases, with 191 cases being directly compared to conventional measurements. Thirty-three of these measurements resulted in a NEWS2 ≥ 5, 158 in a NEWS2 < 5. Comparing all 191 measurements, accordance was substantial (K = 0.76) between conventional and automated NEWS2. No adverse effects due to the device were recorded. Patient acceptance was high.

CONCLUSIONS

In conclusion, the study found strong agreement between automated and conventional NEWS2 calculations using wearable devices, with high patient acceptance despite some data quality challenges. To maximize the potential of continuous monitoring, further research into fully automated EWS calculations without relying on spot measurements is suggested, as this could provide a reliable alternative to traditional methods.

TRIAL REGISTRATION

January 26, 2023, NCT05699967.

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.

Implementation evaluation of a rapid response system in a regional emergency department: a dual-methods study using the behaviour change wheel

BACKGROUND

Failure to recognise and respond to clinical deterioration is a major cause of high mortality events in emergency department (ED) patients. Whilst there is substantial evidence that rapid response teams reduce hospital mortality, unplanned intensive care admissions, and cardiac arrests on in-patient settings, the use of rapid response teams in the ED is variable with poor integration of care between emergency and specialty/intensive care teams.

OBJECTIVES

The aim of this study was to evaluate uptake and impact of a rapid response system on recognising and responding to deteriorating patients in the ED and identify implementation factors and strategies to optimise future implementation success.

METHODS

A dual-methods design was used to evaluate an ED Clinical Emergency Response System (EDCERS) protocol implemented at a regional Australian ED in June 2019. A documentation audit was conducted on patients eligible for the EDCERS during the first 3 months of implementation. Quantitative data from documentation audit were used to measure uptake and impact of the protocol on escalation and response to patient deterioration. Facilitators and barriers to the EDCERS uptake were identified via key stakeholder engagement and consultation. An implementation plan was developed using the Behaviour Change Wheel for future implementation.

RESULTS

The EDCERS was activated in 42 (53.1%) of 79 eligible patients. The specialty care team were more likely to respond when the EDCERS was activated than when there was no activation ([n = 40, 50.6%] v [n = 26, 32.9%], p = 0.01). Six facilitators and nine barriers to protocol uptake were identified. Twenty behaviour change techniques were selected and informed the development of a theory-informed implementation plan.

CONCLUSION

Implementation of the EDCERS protocol resulted in high response rates from specialty and intensive care staff. However, overall uptake of the protocol by emergency staff was poor. This study highlights the importance of understanding facilitators and barriers to uptake prior to implementing a new intervention.

A scoping review of barriers, facilitators and tools to escalation of care processes in the emergency department

INTRODUCTION

Escalation of care is the timely recognition and communication of deterioration in a previously stable patient. Delays in escalating care may lead to unnecessary patient morbidity and mortality. There is currently a paucity of synthesis of work focused on the initiation of escalation of care in the emergency department (ED), where unique challenges may be present. We sought to complete a scoping review to investigate: (1) factors (barriers and/or facilitators) affecting clinicians in escalating care in the ED; and (2) tools that support clinicians in ED escalation of care processes.

METHODS

We conducted a scoping review guided by the Arksey & O'Malley framework, and in accordance with PRISMA Scoping Reviews (PRISMA-ScR) checklist. Searches were conducted in MEDLINE, EMBASE and CINAHL on November 30th, 2020. Extracted data was analyzed via qualitative content analysis. Review and data abstraction were completed by two independent reviewers. Discrepancies were resolved via consensus meetings with a third reviewer.

RESULTS

Of the 4527 unique records identified, 13 studies met our inclusion criteria. Studies described standard escalation practices including detection, reporting, and response. Factors influencing escalation of care were described on individual (confidence, comfort, and expertise), interpersonal (communication and the nurse-physician relationship), organizational (workload and staffing), and environmental (distractions and layout) levels. Four ED-specific tools for escalation of care were also identified.

CONCLUSION

This scoping review identified 13 studies that contained information on processes, factors influencing and/or tools used to facilitate escalation of care in the ED. They may serve as valuable starting points for ED clinicians and administrators who are building or reforming local escalation of care processes.

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.

Effect of National Early Warning Scoring System Implementation on Cardiopulmonary Arrest, Unplanned ICU Admission, Emergency Surgery, and Acute Kidney Injury in an Emergency Hospital, Egypt

Purpose

To evaluate the effect of national early warning scoring system (NEWS) implementation in identifying patients at risk of clinical deterioration at an emergency hospital.

Background

Early warning score has been developed to facilitate early detection of deterioration by categorizing a patients’ severity of illness and prompting nursing staff to request a medical review at specific trigger points.

Patients and Methods

A prospective, control/intervention groups’, quasi-experimental design was utilized. A sample of 364 adult patients were admitted to the inpatient unit at an emergency hospital for six months. The patients were divided into a study group (174 patients) and a control group (190 patients). All study patients were followed up to either death or hospital discharge before and after implementing a new observation chart. The patients’ outcomes were compared and analyzed between both groups.

Results

In the intervention period, compared to the control period, a significant reduction was seen in the number of cardiopulmonary arrest (4.7% vs 1.1%, p = 0.046), unplanned ICU admission (5.3% vs 1.7%, p = 0.049), emergency surgery (6.3% vs 0%, p = 0.001), acute kidney injury (6.8% vs 1.1%, p = 0.006). As well, there was a significant increase in the number of patients receiving medical reviews following clinical deterioration in terms of escalation plan (3.2% vs 26.4%, p = <0.001).

Conclusion

The implementation of NEWS was associated with a significant improvement in patients’ outcomes in hospital wards, increases in the frequency of vital signs measurements, and an increase in the number of medical reviews following clinical instability.

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