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

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.

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.

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.

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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