Responding to medical emergencies: System characteristics under examination (RESCUE). A prospective multi-site point prevalence study

Importance of specific vital signs in nurses' recognition and response to deteriorating patients: A scoping review

AIM(S)

To explore the published research related to nurses' documentation and use of vital signs in recognising and responding to deteriorating patients.

DESIGN

Scoping review of international, peer-reviewed research studies.

DATA SOURCES

Cumulative Index to Nursing and Allied Health Literature Complete, Medline Complete, American Psychological Association PsycInfo and Excerpta Medica were searched on 25 July 2023.

REPORTING METHOD

Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews.

RESULTS

Of 3880 potentially eligible publications, 32 were included. There were 26 studies of nurses' vital sign documentation: 21 adults and five paediatric. The most and least frequently documented vital signs were blood pressure and respiratory rate respectively. Seven studies focused on vital signs and rapid response activation or afferent limb failure. Five studies of vital signs used to trigger the rapid response system showed heart rate was the most frequent and respiratory rate and conscious state were the least frequent. Heart rate was least likely and oxygen saturation was most likely to be associated with afferent limb failure (n = 4 studies).

CONCLUSION

Despite high reliance on using vital signs to recognise clinical deterioration and activate a response to deteriorating patients in hospital settings, nurses' documentation of vital signs and use of vital signs to activate rapid response systems is poorly understood. There were 21studies of nurses' vital sign documentation in adult patients and five studies related to children.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

A deeper understanding of nurses' decisions to assess (or not assess) specific vital signs, analysis of the value or importance nurses place (or not) on specific vital sign parameters is warranted. The influence of patient characteristics (such as age) or the clinical practice setting, and the impact of nurses' workflows of vital sign assessment warrants further investigation.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Three Years of Continuous Vital Signs Monitoring on the General Surgical Ward: Is It Sustainable? A Qualitative Study

Continuous monitoring of vital signs using a wireless wearable device was implemented in 2018 at a surgical care unit of an academic hospital. This study aimed at gaining insight into nurses' and patients' perspectives regarding the use and innovation of a continuous vital signs monitoring system, three years after its introduction. This qualitative study was performed in a surgical, non-intensive care unit of an academic hospital in 2021. Key-user nurses (nurses with additional training and expertise with the device) and patients were selected for semi-structured interviews, and nurses from the ward were selected for a focus group interview using a topic list. Transcripts of the audio tapes were deductively analysed using four dimensions for adoptions of information and communication technologies (ICT) devices in healthcare. The device provided feelings of safety for nurses and patients. Nurses and patients had a few issues with the device, including the size and the battery life. Nurses gained knowledge and skills in using the system for measurement and interpretations. They perceived the system as a tool to improve the recognition of clinical decline. The use of the system could be further developed regarding the technical device's characteristics, nurses' interpretation of the data and the of type of alarms, the information needs of patients, and clarification of the definition and standardization of continuous monitoring. Three years after the introduction, wireless continuous vital signs monitoring is the new standard of care according to the end-users at the general surgical ward.

Vital sign assessment and nursing interventions in medical and surgical patients with rapid response system triggers

AIM(S)

To explore vital sign assessment (both complete and incomplete sets of vital signs), and escalation of care per policy and nursing interventions in response to clinical deterioration.

DESIGN

This cohort study is a secondary analysis of data from the Prioritising Responses of Nurses To deteriorating patient Observations cluster randomised controlled trial of a facilitation intervention on nurses' vital sign measurement and escalation of care for deteriorating patients.

METHODS

The study was conducted in 36 wards at four metropolitan hospitals in Victoria, Australia. Medical records of all included patients from the study wards during three randomly selected 24-h periods within the same week were audited at three time points: pre-intervention (June 2016), and at 6 (December 2016) and 12 months (June 1017) post-intervention. Descriptive statistics were used to summarise the study data, and relationships between variables were examined using chi-square test.

RESULTS

A total of 10,383 audits were conducted. At least one vital sign measurement was documented every 8 h in 91.6% of audits, and a complete set of vital signs was documented every 8 h in 83.1% of audits. There were pre-Medical Emergency Team, Medical Emergency Team or Cardiac Arrest Team triggers in 25.8% of audits. When triggers were present, a rapid response system call occurred in 26.8% of audits. There were 1350 documented nursing interventions in audits with pre-Medical Emergency Team (n = 2403) or Medical Emergency Team triggers (n = 273). One or more nursing interventions were documented in 29.5% of audits with pre-Medical Emergency Team triggers and 63.7% of audits with Medical Emergency Team triggers.

CONCLUSION

When rapid response system triggers were documented, there were gaps in escalation of care per policy; however, nurses undertook a range of interventions within their scope of practice in response to clinical deterioration.

RELEVANCE TO CLINICAL PRACTICE

Medical and surgical ward nurses in acute care wards frequently engage in vital sign assessment. Interventions by medical and nurgical nurses may occur prior to, or in parallel with calling the rapid response system. Nursing interventions are a key but under-recognised element of the organisational response to deteriorating patients.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Nurses engage in a range of nursing interventions to manage deteriorating patients, (aside from rapid response system activation) that are not well understood, nor well described in the literature to date.

IMPACT

This study addresses the gap in the literature regarding nurses' management of deteriorating patients within their scope of practice (aside from RRS activation) in real world settings. When rapid response system triggers were documented, there were gaps in escalation of care per policy; however, nurses undertook a range of interventions within their scope of practice in response to clinical deterioration. The results of this research are relevant to nurses working on medical and surgical wards.

REPORTING METHOD

The trial was reported according to the Consolidated Standards of Reporting Trials extension for Cluster Trials recommendations, and this paper is reported according to the Strengthening the Reporting of Observational Studies in Epidemiology Statement.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

The patient experience of a medical emergency team review: A convergent mixed-methods study

AIMS

The aim of this study was to explore clinician-patient engagement during, and patient experience of, medical emergency team (MET) reviews.

DESIGN

This study involved a convergent mixed-methods design.

METHODS

This three-phase study was conducted at two hospitals of one Australian health service. Reviews by the MET were observed for clinician-patient engagement behaviours; medical records were audited to confirm patient demographics and clinical characteristics; and patients who received a MET review were interviewed. Quantitative data were analysed using descriptive statistics, and thematic analysis of qualitative interview data was conducted.

RESULTS

In total, 26 MET reviews were observed for 22 patients (median age = 81.5 years and 68.2% females). Between 8 and 13 clinicians and other staff members were present during each review, with a total of 209 clinicians present during the 26 reviews. Clinicians were not observed to speak directly or indirectly to the patient about their care in 38.5% (n = 10/26) of the MET reviews, and 58.3% (n = 56/96) of interventions were performed without explanation. Four themes were identified from the interviews: An unexpected event; A lack of understanding; In good hands, and What happens next?

CONCLUSION

Clinician-patient engagement was infrequent during and after MET reviews. Patients experienced surprise from the sudden arrival of clinicians in their room and had poor levels of understanding about the review. However, most patients felt supported and safe. MET reviews are frequent safety-critical events, and this study identified the patient experience of these events. Clinicians should be aware that patients expressed they were surprised and shocked by the review and that an explanation of what was being done by the clinical team was rarely offered. These findings can be used to inform strategies to improve their patient-engagement behaviours and patient-centred care.

Prioritising Responses Of Nurses To deteriorating patient Observations (PRONTO): a pragmatic cluster randomised controlled trial evaluating the effectiveness of a facilitation intervention on recognition and response to clinical deterioration

BACKGROUND

Most hospitals use physiological signs to trigger an urgent clinical review. We investigated whether facilitation could improve nurses' vital sign measurement, interpretation, treatment and escalation of care for deteriorating patients.

METHODS

In a pragmatic cluster randomised controlled trial, we randomised 36 inpatient wards at four acute hospitals to receive standard clinical practice guideline (CPG) dissemination to ward staff (n=18) or facilitated implementation for 6 months following standard dissemination (n=18). Expert, hospital and ward facilitators tailored facilitation techniques to promote nurses' CPG adherence. Patient records were audited pre-intervention, 6 and 12 months post-intervention on randomly selected days. Escalation of care as per hospital policy was the primary outcome at 6 and 12 months after implementation. Patients, nurses and assessors were blinded to group assignment. Analysis was by intention-to-treat.

RESULTS

From 10 383 audits, improved escalation as per hospital policy was evident in the intervention group at 6 months (OR 1.47, 95% CI (1.06 to 2.04)) with a complete set of vital sign measurements sustained at 12 months (OR 1.22, 95% CI (1.02 to 1.47)). There were no significant differences in escalation of care as per hospital policy between study groups at 6 or 12 months post-intervention. After adjusting for patient and hospital characteristics, a significant change from T0 in mean length of stay between groups at 12 months favoured the intervention group (-2.18 days, 95% CI (-3.53 to -0.82)).

CONCLUSION

Multi-level facilitation significantly improved escalation as per hospital policy at 6 months in the intervention group that was not sustained at 12 months. The intervention group had increased vital sign measurement by nurses, as well as shorter lengths of stay for patients at 12 months. Further research is required to understand the dose of facilitation required to impact clinical practice behaviours and patient outcomes.

TRIAL REGISTRATION NUMBER

ACTRN12616000544471p.

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.

Recognising and Responding to Clinical Deterioration in Adult Patients in Isolation Precautions for Infection Control: A Retrospective Cohort Study

BACKGROUND

Patient isolation is widely used as a strategy for prevention and control of infection but may have unintended consequences for patients. Early recognition and response to acute deterioration is an essential component of safe, quality patient care and has not been explored for patients in isolation. Primary aims of this study were to: i) describe the timing, frequency, and nature of clinical deterioration during hospital admission for patients with isolation precautions for infection control and ii) compare the characteristics of patients who did and did not deteriorate during their initial period of isolation precautions for infection control.

METHODS

This retrospective cohort study was conducted across three sites of a large Australian health service. The study sample were adult patients (≥18 years) admitted into isolation precautions within 24-hours of admission from 1 July to 31 December 2019.

RESULTS

There were 634 patients who fulfilled the study inclusion criteria. One in eight patients experienced at least one episode of clinical deterioration during their time in isolation with most episodes of deterioration occurring within the first two days of admission. Timely Medical Emergency Team calls occurred in almost half the episodes of deterioration; however, the same proportion (47.2%) of deterioration episodes resulted in no Medical Emergency Team activation (afferent limb failure). In the 24-hours preceding each episode of clinical deterioration (n=180), 81.6% (n=147) of episodes were preceded by vital signs fulfilling pre-Medical Emergency Team criteria.Patients who deteriorated during isolation for infection control were older (median age 74.0 vs 71.0 years, P=0.042); more likely to live in a residential care facility (21.0% vs 7.2%, P=0.006); had a longer initial period of isolation (4.0 vs 2.9 days, P=<000.1) and hospital length of stay (median 4.9 vs 3.2 days, P=<0.001) and were more likely to die in hospital (12.3% vs 4.3%, P<0.001).

CONCLUSION

Patients in isolation precautions experienced high Medical Emergency Team afferent limb failure and most fulfilled pre-Medical Emergency Team criteria in the 24-hours preceding episodes of deterioration. Timely recognition and response to clinical deterioration continue to be essential in providing safe, quality patient care regardless of the hospital-care environment.

Using an early warning score for nurse shift patient handover: Before-and-after study

PURPOSE

This study aimed to examine the impact of using an early warning score for shift patient handover on nurse and patient outcomes.

METHODS

A before-and-after study was conducted with nurses and patients in three general wards in a tertiary teaching hospital. A short-time nurse education on the National Early Warning Score 2 and the use of a checklist for score calculation were performed from June 4, 2019 to June 30, 2019. Outcomes of nurse response (safety competency, handover quality, teamwork, safety climate, and documentation of vital signs and clinical concerns), patient response (deterioration occurrence post-admission, hospitalization length, and discharge status), and adverse events (mortality, cardiopulmonary arrest, and unplanned intensive care unit admission) were measured using questionnaires and medical record reviews. Data from 89 nurses and 388 patients were analyzed.

RESULTS

Regarding nurse outcomes, handover quality (p <.001), teamwork (p = .004), safety climate (p = .018), and recordings of vital signs (p = .047) and clinical concerns (p = .008) increased after early warning score use. However, no significant change in the safety competency scores was observed. Regarding patient outcomes, there were no significant changes in the occurrence of deterioration, hospitalization length, discharge status, and occurrence of adverse events between pre-and-post intervention.

CONCLUSION

Despite no significant changes in patient outcomes, using a simple, evidence-based early warning score for patient handover enhanced socio-cultural factors for patient safety, with improved patient monitoring. The findings provide evidence that supports the active implementation of an early warning score to improve patient safety.

Early warning systems and rapid response systems for the prevention of patient deterioration on acute adult hospital wards

BACKGROUND

Early warning systems (EWS) and rapid response systems (RRS) have been implemented internationally in acute hospitals to facilitate early recognition, referral and response to patient deterioration as a solution to address suboptimal ward-based care. EWS and RRS facilitate healthcare decision-making using checklists and provide structure to organisational practices through governance and clinical audit. However, it is unclear whether these systems improve patient outcomes. This is the first update of a previously published (2007) Cochrane Review.

OBJECTIVES

To determine the effect of EWS and RRS implementation on adults who deteriorate on acute hospital wards compared to people receiving hospital care without EWS and RRS in place.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two trial registers on 28 March 2019. We subsequently ran a MEDLINE update on 15 May 2020 that identified no further studies. We checked references of included studies, conducted citation searching, and contacted experts and critical care organisations.

SELECTION CRITERIA

We included randomised trials, non-randomised studies, controlled before-after (CBA) studies, and interrupted time series (ITS) designs measuring our outcomes of interest following implementation of EWS and RRS in acute hospital wards compared to ward settings without EWS and RRS.

DATA COLLECTION AND ANALYSIS

Two review authors independently checked studies for inclusion, extracted data and assessed methodological quality using standard Cochrane and Effective Practice and Organisation of Care (EPOC) Group methods. Where possible, we standardised data to rates per 1000 admissions; and calculated risk differences and 95% confidence intervals (CI) using the Newcombe and Altman method. We reanalysed three CBA studies as ITS designs using segmented regression analysis with Newey-West autocorrelation adjusted standard errors with lag of order 1. We assessed the certainty of evidence using the GRADE approach.

MAIN RESULTS

We included four randomised trials (455,226 participants) and seven non-randomised studies (210,905 participants reported in three studies). All 11 studies implemented an intervention comprising an EWS and RRS conducted in high- or middle-income countries. Participants were admitted to 282 acute hospitals. We were unable to perform meta-analyses due to clinical and methodological heterogeneity across studies. Randomised trials were assessed as high risk of bias due to lack of blinding participants and personnel across all studies. Risk of bias for non-randomised studies was critical (three studies) due to high risk of confounding and unclear risk of bias due to no reporting of deviation from protocol or serious (four studies) but not critical due to use of statistical methods to control for some but not all baseline confounders. Where possible we presented original study data which reported the adjusted relative effect given these were appropriately adjusted for design and participant characteristics. We compared outcomes of randomised and non-randomised studies reported them separately to determine which studies contributed to the overall certainty of evidence. We reported findings from key comparisons. Hospital mortality Randomised trials provided low-certainty evidence that an EWS and RRS intervention may result in little or no difference in hospital mortality (4 studies, 455,226 participants; results not pooled). The evidence on hospital mortality from three non-randomised studies was of very low certainty (210,905 participants). Composite outcome (unexpected cardiac arrests, unplanned ICU admissions and death) One randomised study showed that an EWS and RRS intervention probably results in no difference in this composite outcome (adjusted odds ratio (aOR) 0.98, 95% CI 0.83 to 1.16; 364,094 participants; moderate-certainty evidence). One non-randomised study suggests that implementation of an EWS and RRS intervention may slightly reduce this composite outcome (aOR 0.85, 95% CI 0.72 to 0.99; 57,858 participants; low-certainty evidence). Unplanned ICU admissions Randomised trials provided low-certainty evidence that an EWS and RRS intervention may result in little or no difference in unplanned ICU admissions (3 studies, 452,434 participants; results not pooled). The evidence from one non-randomised study is of very low certainty (aOR 0.88, 95% CI 0.75 to 1.02; 57,858 participants). ICU readmissions No studies reported this outcome. Length of hospital stay Randomised trials provided low-certainty evidence that an EWS and RRS intervention may have little or no effect on hospital length of stay (2 studies, 21,417 participants; results not pooled). Adverse events (unexpected cardiac or respiratory arrest) Randomised trials provided low-certainty evidence that an EWS and RRS intervention may result in little or no difference in adverse events (3 studies, 452,434 participants; results not pooled). The evidence on adverse events from three non-randomised studies (210,905 participants) is very uncertain.

AUTHORS' CONCLUSIONS

Given the low-to-very low certainty evidence for all outcomes from non-randomised studies, we have drawn our conclusions from the randomised evidence. This evidence provides low-certainty evidence that EWS and RRS may lead to little or no difference in hospital mortality, unplanned ICU admissions, length of hospital stay or adverse events; and moderate-certainty evidence of little to no difference on composite outcome. The evidence from this review update highlights the diversity in outcome selection and poor methodological quality of most studies investigating EWS and RRS. As a result, no strong recommendations can be made regarding the effectiveness of EWS and RRS based on the evidence currently available. There is a need for development of a patient-informed core outcome set comprising clear and consistent definitions and recommendations for measurement as well as EWS and RRS interventions conforming to a standard to facilitate meaningful comparison and future meta-analyses.

Modifications to medical emergency team activation criteria and implications for patient safety: A point prevalence study

BACKGROUND

Medical emergency team (MET) activation criteria are sometimes modified to minimise unnecessary MET calls in patients who have chronic physiological derangements, have limitation of medical treatment orders in place, or have recently received treatment for clinical deterioration. However, the safety implications of modifying MET activation criteria are poorly understood.

OBJECTIVES

The aim of the study was to examine the safety of modifying MET activation criteria. Specifically, we aimed to examine the frequency and nature of modifications to MET activation criteria and compare characteristics and outcomes of patients with and without modifications to MET activation criteria.

METHODS

This was a point prevalence study using a retrospective medical record audit. Patients admitted to 14 wards on November 7, 2018, at two acute-care hospitals of one health service in Melbourne, Australia, were included (N = 430). Data were analysed using descriptive and inferential statistics. The main outcome measures included frequency and nature of modifications to MET activation criteria on a specified date, MET calls, intensive care unit admission, in-hospital cardiac arrest, and in-hospital death.

RESULTS

Amongst 430 inpatients, there were 30 modifications to MET activation criteria in 26 (6.0%) patients. All modifications were intended to trigger METs at more extreme levels of physiological derangement. Most modifications pertained to tachypnoea (26.7%; n = 8/30) and bradycardia (23.3%; n = 7/30). Patients with modifications were more likely to have documented physiological deterioration that fulfilled MET (47.8%, n = 11; p < 0.001) or pre-MET (87.0%, n = 20; p < 0.001) criteria in the preceding 24-h period than patients without modifications. Of patients with modifications, none were admitted to an intensive care unit, had a cardiac arrest, or died in the hospital. There were no differences in hospital length of stay or discharge destination between patients with and without modifications.

CONCLUSIONS

In this point prevalence study, modifications to MET activation criteria were infrequent and not associated with negative patient safety outcomes.

Vital sign abnormalities as predictors of clinical deterioration in subacute care patients: A prospective case-time-control study

BACKGROUND

Emergency interhospital transfers from inpatient subacute care to acute care occur in 8% to 17.4% of admitted patients and are associated with high rates of acute care readmission and in-hospital mortality. Serious adverse events in subacute care (rapid response team or cardiac arrest team calls) and increased nursing surveillance are the strongest known predictors of emergency interhospital transfer from subacute to acute care hospitals. However, the epidemiology of clinical deterioration across sectors of care, and specifically in subacute care is not well understood.

OBJECTIVES

To explore the trajectory of clinical deterioration in patients who did and did not have an emergency interhospital transfer from subacute to acute care; and develop an internally validated predictive model to identify the role of vital sign abnormalities in predicting these emergency interhospital transfers.

DESIGN

This prospective, exploratory cohort study is a subanalysis of data derived from a larger case-time-control study.

SETTING

Twenty-two wards of eight subacute care hospitals in five major health services in Victoria, Australia. All subacute care hospitals were geographically separate from their health services' acute care hospitals.

PARTICIPANTS

All patients with an emergency transfer from inpatient rehabilitation or geriatric evaluation and management unit to an acute care hospital within the same health service were included. Patients receiving palliative care were excluded.

METHODS

Study data were collected between 22 August 2015 and 30 October 2016 by medical record audit. The Cochran-Mantel-Haenszel test and bivariate logistic regression analysis were used to compare cases with controls and to account for health service clustering effect.

RESULTS

Data were collected on 603 transfers (557 patients) and 1160 controls. Adjusted for health service, ≥2 vital sign abnormalities in subacute care (adjusted odds ratio=8.81, 95% confidence intervals:6.36-12.19, p<0.001) and serious adverse events during the first acute care admission (adjusted odds ratio=1.28, 95% confidence intervals:1.08-1.99, p=0.015) were the clinical factors associated with increased risk of emergency interhospital transfer. An internally validated predictive model showed that vital sign abnormalities can fairly predict emergency interhospital transfers from subacute to acute care hospitals.

CONCLUSION

Serious adverse events in acute care should be a key consideration in decisions about the location of subacute care delivery. During subacute care, 15.7% of cases had vital signs fulfilling organisational rapid response team activation criteria, yet missed rapid response team activations were common suggesting that further consideration of the criteria and strategies to optimise recognition and response to clinical deterioration in subacute care are needed.

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.

Self-confidence in the care of critically ill patients: before and after a simulated intervention

OBJECTIVE

To evaluate the self-confidence of nurses in the care of critically ill patients, before and after a simulated intervention.

METHOD

A quasi-experimental study was carried out with 103 nurses who participated in a workshop on the care of critically ill patients in the first semester of 2016. A clinical simulation pedagogical instrument was used throughout the event, and self-confidence was assessed by the Portuguese version of the Self-confidence Scale (SCSvp).

RESULTS

Most participants reported not being prepared to provide first care to critically ill patients, which was carried out during care practice. The participants presented a significant increase in self-confidence after the simulated intervention (p<0.001) in the cardiac, neurological, and respiratory dimensions.

CONCLUSION

Simulation has proved to be an effective strategy for the development of individuals' self-confidence, which contributes to the improvement of skills required for professional practice.

Improving student nurses' confidence in managing the acutely ill patient

AIM

the Acute Illness Management (AIM) course was introduced into NHS trusts across Greater Manchester in 2002/03 for registered nurses. In preparation for the transition from student to registered nurse, the AIM course was then included in the final year of the undergraduate nursing programme. The aim of this study was to evaluate the impact of the AIM course on student nurses' confidence in managing the acutely ill patient.

METHOD

a quantitative approach was adopted. Ethical approval was granted by the Research and Ethics committee at the University of Salford.

RESULTS

a total of 192 student nurses attended the AIM course; 94% of the students completed a pre-course questionnaire and 100% completed the post-course questionnaire.

CONCLUSION

the evidence suggests a significant increase in the student nurses' confidence in recognising, responding and managing an acutely ill patient following the one-day course.

Patient acceptability of wearable vital sign monitoring technologies in the acute care setting: A systematic review

AIMS AND OBJECTIVES

To examine patient acceptability of wearable vital sign monitoring devices in the acute setting.

BACKGROUND

Wearable vital sign monitoring devices may improve patient safety, yet hospital patients' acceptability of these devices is largely unreported.

DESIGN

A systematic review.

METHODS

Cumulative Index to Nursing and Allied Health Literature Complete, MEDLINE Complete and EMBASE were searched, supplemented by reference list hand searching. Studies were included if they involved adult hospital patients (≥18 years), a wearable monitoring device capable of assessing ≥1 vital sign, and measured patient acceptability, satisfaction or experience of wearing the device. No date restrictions were enforced. Quality assessments of quantitative and qualitative studies were undertaken using the Downs and Black Checklist for Measuring Study Quality and the Critical Appraisal Skills Programme Qualitative Research Checklist, respectively. Meta-analyses were not possible given data heterogeneity and low research quality. Reporting adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and a Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist was completed.

RESULTS

Of the 427 studies screened, seven observational studies met the inclusion criteria. Six studies were of low quality and one was of high quality. In two studies, patient satisfaction was investigated. In the remaining studies, patient experience, patient opinions and experience, patient perceptions and experience, device acceptability, and patient comfort and concerns were investigated. In four studies, patients were mostly accepting of the wearable devices, reporting positive experiences and satisfaction relating to their use. In three studies, findings were mixed.

CONCLUSION

There is limited high-quality research examining patient acceptability of wearable vital sign monitoring devices as an a priori focus in the acute setting. Further understanding of patient perspectives of these devices is required to inform their continued use and development.

RELEVANCE TO CLINICAL PRACTICE

The provision of patient-centred nursing care is contingent on understanding patients' preferences, including their acceptability of technology use.

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%.

Effect of a newly designed observation, response and discharge chart in the Post Anaesthesia Care Unit on patient outcomes: a quasi-expermental study in Australia

OBJECTIVES

This study aimed to evaluate whether use of a discharge criteria tool for nursing assessment of patients in Post Anaesthesia Care Unit (PACU) would enhance nurses' recognition and response to patients at-risk of deterioration and improve patient outcomes.

METHODS

A prospective non-randomised pre-post intervention study was conducted in three hospitals in Australia. Participants were adults undergoing elective surgery before (n=723) and after (n=694) implementation of the Post-Anaesthetic Care Tool (PACT).

RESULTS

Nursing response to patients at-risk of deterioration was higher using PACT, with more medical consultations initiated by PACU nurses (19% vs 30%, P<0.001) and more patients with Medical Emergency Team activation criteria modified by an anaesthetist while in PACU (6.5% vs 13.8%, P<0.001). There were higher rates of analgesia administration (37.3% vs 54.2%, P=0.001), nursing assessment of pain and documentation of ongoing analgesia prior to discharge (55% vs 85%, P<0.001). More adverse events were recorded in PACU after introduction of the PACT (8.3% vs 16.7%, P<0.001). The rate of adverse events after discharge from PACU remained constant (16.5%), but the rate of cardiac events (5.1% vs 2.6%, P=0.021) and clinical deterioration (8.7% vs 4.3%, P=0.001) following PACU discharge significantly decreased, using the PACT. Despite the increased number of patients with adverse events in phase 2, healthcare costs did not increase significantly. Length of stay in PACU and length of hospital admission for those patients who had an adverse event in PACU were significantly reduced after implementation of the PACT.

CONCLUSION

This study found that using a structured discharge criteria tool, the PACT, enhanced nurses' recognition and response to patients who experienced clinical deterioration, reduced length of stay for patients who experienced an adverse event in PACU and was cost-effective.

Prioritising Responses Of Nurses To deteriorating patient Observations (PRONTO) protocol: testing the effectiveness of a facilitation intervention in a pragmatic, cluster-randomised trial with an embedded process evaluation and cost analysis

BACKGROUND

Vital signs are the primary indicator of physiological status and for determining the need for urgent clinical treatment. Yet, if physiological signs of deterioration are missed, misinterpreted or mismanaged, then critical illness, unplanned intensive care admissions, cardiac arrest and death may ensue. Although evidence demonstrates the benefit of early recognition and management of deteriorating patients, failure to escalate care and manage deteriorating patients remains a relatively frequent occurrence in hospitals.

METHODS/DESIGN

A pragmatic cluster-randomised controlled trial design will be used to measure clinical effectiveness and cost of a facilitation intervention to improve nurses' vital sign measurement, interpretation, treatment and escalation of care for patients with abnormal vital signs. A cost consequence analysis will evaluate the intervention cost and effectiveness, and a process evaluation will determine how the implementation of the intervention contributes to outcomes. We will compare clinical outcomes and costs from standard implementation of clinical practice guidelines (CPGs) to facilitated implementation of CPGs. The primary outcome will be adherence to the CPGs by nurses, as measured by escalation of care as per organisational policy. The study will be conducted in four Australian major metropolitan teaching hospitals. In each hospital, eight to ten wards will be randomly allocated to intervention and control groups. Control wards will receive standard implementation of CPGs, while intervention wards will receive standard CPG implementation plus facilitation, using facilitation methods and processes tailored to the ward context. The intervention will be administered to all nursing staff at the ward level for 6 months. At each hospital, two types of facilitators will be provided: a hospital-level facilitator as the lead; and two ward-level facilitators for each ward.

DISCUSSION

This study uses an innovative, networked approach to facilitation to enable uptake of CPGs. Findings will inform the intervention utility and knowledge translation measurement approaches. If successful, the study methodology and intervention has potential for translation to other health care standards.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN12616000544471p.

Safety of intravenous metoprolol use in unmonitored wards: a single-centre observational study

BACKGROUND AND AIM

This study aims to examine and quantify the risks associated with the use of intravenous metoprolol on unmonitored wards.

METHOD

This study was a retrospective single-centre observational study from 1 January 2009 to 31 December 2013. The study hospital was a 415-bed, private hospital in Melbourne, Victoria. The study population was all patients who received intravenous metoprolol on an unmonitored ward. The primary outcome measure was the rate of serious adverse events (SAE), defined as a complication of intravenous metoprolol resulting in transfer to a critical-care environment, a medical emergency team call or death.

RESULTS

Six hundred and nine patients received a total of 8260 doses of intravenous metoprolol. Seven cases were identified with a SAE deemed possibly related to beta-blocker use and there was one death. All SAE were hypotension, giving an overall rate of hypotension of 7/609 or 1.1% (95% confidence interval (CI), 0.5 to 2.4%) with a rate per dose delivered of 0.8/1000 doses (95% CI 0.3 to 1.7). The death occurred in a 94-year-old woman with abdominal sepsis. After case file review, consensus opinion deemed this to be unrelated to intravenous metoprolol.

CONCLUSION

The use of intravenous metoprolol on unmonitored wards appears to be safe. The complication rate was low, suggesting that this may be a sensible approach to the management of in-hospital populations at risk of beta-blocker withdrawal.

Doing the Right Thing at the Right Time: Assessing Responses to Patient Deterioration in Electronic Simulation Scenarios Using Course-of-Action Analysis

International studies indicate that the recognition and management of deteriorating patients in hospitals are poor and that patient assessment is often inadequate. Face-to-face simulation programs have been shown to have an impact on educational and clinical outcomes; however, little is known about performance in contemporary healthcare e-simulation approaches. Using data from an open-access Web-based patient deterioration program (FIRSTACTWeb), the performance of 367 Australian nursing students in identification of treatment priorities and clinical actions was analyzed using a military model of Course of Action Simulation Analysis. Participants' performance in the whole program demonstrated a significant improvement in knowledge and skills (P ≤ .001) with high levels of participant satisfaction. Course of Action Simulation Analysis modeling identified three key participant groupings within which only 18% took the "best course of action" (the right actions and timing), with most (70%) completing the right actions but in the wrong order. The remaining 12% produced incomplete assessments and actions in an incorrect sequence. Contemporary approaches such as e-simulation do enhance educational outcomes. Measurement of performance when combined with Course of Action Simulation Analysis becomes a useful tool in the description of outcomes, an understanding of decision making, and the prediction of future events.

Multi-Tiered Observation and Response Charts: Prevalence and Incidence of Triggers, Modifications and Calls, to Acutely Deteriorating Adult Patients

BACKGROUND

Observation charts are the primary tool for recording patient vital signs. They have a critical role in documenting triggers for a multi-tiered escalation response to the deteriorating patient. The objectives of this study were to ascertain the prevalence and incidence of triggers, trigger modifications and escalation response (Call) amongst general medical and surgical inpatients following the introduction of an observation and response chart (ORC).

METHODS

Prospective (prevalence), over two 24-hour periods, and retrospective (incidence), over entire hospital stay, observational study of documented patient observations intended to trigger one of three escalation responses, being a MER-Medical Emergency Response [highest tier], MDT-Multidisciplinary Team [admitting team], or Nurse-senior ward nurse [lowest tier] response amongst adult general medical and surgical patients.

RESULTS

PREVALENCE

416 patients, 321 (77.2%) being medical admissions, median age 76 years (IQR 62, 85) and 95 (22.8%) Not for Resuscitation (NFR). Overall, 193 (46.4%) patients had a Trigger, being 17 (4.1%) MER, 45 (10.8%) MDT and 178 (42.8%) Nurse triggers. 60 (14.4%) patients had a Call, and 72 (17.3%) a modified Trigger.

INCIDENCE

206 patients, of similar age, of whom 166 (80.5%) had a Trigger, 122 (59.2%) a Call, and 91 (44.2%) a modified Trigger. PREVALENCE and incidence of failure to Call was 33.2% and 68% of patients, respectively, particular for Nurse Triggers (26.7% and 62.1%, respectively). The number of Modifications, Calls, and failure to Call, correlated with the number of Triggers (0.912 [p<0.01], 0.631 [p<0.01], 0.988 [p<0.01]).

CONCLUSION

Within a multi-tiered response system for the detection and response to the deteriorating patient Triggers, their Modifications and failure to Call are common, particularly within the lower tiers of escalation. The number of Triggers and their Modifications may erode the structure, compliance, and potential efficacy of structured observation and response charts within a multi-tiered response system.

Intensive care unit admission in patients following rapid response team activation: call factors, patient characteristics and hospital outcomes

Rapid Response Systems (RRSs) have been widely introduced throughout hospital health systems, yet there is limited research on the characteristics and outcomes of patients admitted to an intensive care unit (ICU) following RRS activation. Using database extraction, this study examined the factors associated with ICU admission and patient outcome in patients receiving RRS activation in a tertiary level hospital between 2009 and 2013. Of 3004 RRS activations, 392 resulted in ICU admissions. Call factors associated with ICU admission and increased hospital mortality included tachypnoea (P <0.001 and P <0.001, respectively), hypoxia (P <0.001 and P <0.001, respectively) and having multiple Medical Emergency Team call triggers breached simultaneously (P <0.001 and P <0.001, respectively). Patients with seizures (P <0.001) and tachycardia (P=0.004) were more likely to survive to hospital discharge. Patient factors associated with ICU admission included young age (P <0.001) and having severe liver disease (P <0.001). Factors associated with increased hospital mortality included delayed RRS activation (P <0.001), increased age (P <0.001) and comorbidities including ischaemic heart disease (P=0.006), congestive heart failure (P <0.001), chronic kidney disease (P <0.001) and severe liver disease (P <0.001). Multiple factors relating to both the nature of the RRS activation call and patient characteristics are associated with ICU admission and hospital mortality post RRS activation. This information may be useful for risk stratification of deteriorating patients and determination of appropriate escalation.

Multisite analysis of the timing and outcomes of unplanned transfers from subacute to acute care

Objective The aim of the present study was to examine the timing and outcomes of patients requiring an unplanned transfer from subacute to acute care. Methods Subacute care in-patients requiring unplanned transfer to an acute care facility within four Victorian health services from 1 January to 31 December 2010 were included in the study. Data were collected using retrospective audit. The primary outcome was transfer within 24 h of subacute care admission. Results In all, 431 patients (median age 81 years) had unplanned transfers; of these, 37.8% had a limitation of medical treatment (LOMT) order. The median subacute care length of stay was 43 h: 29.0% of patients were transferred within 24 h and 83.5% were transferred within 72 h of subacute care admission. Predictors of transfer within 24 h were comorbidity weighting (odds ratio (OR) 1.1, P = 0.02) and LOMT order (OR 2.1, P < 0.01). Hospital admission occurred in 87.2% of patients and 15.4% died in hospital. Predictors of in-hospital mortality were comorbidity weighting (OR 1.2, P < 0.01) and the number of physiological abnormalities in the 24 h preceding transfer (OR 1.3, P < 0.01). Conclusions There is a high rate of unplanned transfers to acute care within 24 h of admission to subacute care. Unplanned transfers are associated with high hospital admission and in-hospital mortality rates. What is known about the topic? Subacute care is becoming a high acuity environment where many patients are at significant risk of clinical deterioration. Systems for recognising and responding to deteriorating patients are well developed in acute care, but still developing in subacute care. What does this paper add? This is the first Australian multisite study of clinical deterioration in patients situated in subacute care facilities. One-third of unplanned transfers occur within 24 h of admission to subacute care. Patients who require unplanned transfer from subacute to acute care have unexpectedly high hospital admission rates and high in-hospital mortality rates. The frequency and completeness of physiological monitoring preceding transfer was low. What are the implications for practitioners? Patients in subacute care require regular physiological assessment and early escalation of care if there are physiological abnormalities. Risk of clinical deterioration should be a factor in the decision to admit patients to subacute care after an acute illness or injury. There is a need to improve systems for recognising and responding to deteriorating patients in subacute care settings.

Ensuring a proactive, evidence-based, patient safety approach to patient assessment

AIMS AND OBJECTIVES

To argue that if all nurses were to adopt the primary survey approach (assessment of airway, breathing, circulation and disability) as the first element of patient assessment, they would be more focused on active detection of clinical deterioration rather than passive collection of patient data.

BACKGROUND

Nurses are the professional group that carry the highest level of responsibility for patient assessment, accurate data collection and interpretation. The timely recognition of, and response to deteriorating patients, is dependent on the measurement and interpretation of pertinent physiological data by nurses.

DESIGN

Discursive paper.

METHODS

Traditionally taught and commonly used approaches to patient assessment such as 'vital signs' and 'body systems' are not evidence-based nor framed in patient safety. The primary survey approach as the first element in patient assessment has three major advantages: (1) data are collected according to clinical importance; (2) data are collected using the same framework as most organisation's rapid response system activation criteria; and (3) the primary survey acts as a patient safety checklist, thereby decreasing the risk of failure to recognise, and therefore respond to, deteriorating patients.

CONCLUSION

The vital signs and body systems approaches to patient assessment have significant limitations in identifying clinical deterioration. The primary survey approach provides nurses with a consistent, evidence-based and sequenced approach to patient assessment in every clinical setting.

RELEVANCE TO CLINICAL PRACTICE

All nurses should use a primary survey approach as the first element of patient assessment in every patient encounter as a patient safety strategy.

Undergraduate nursing students' performance in recognising and responding to sudden patient deterioration in high psychological fidelity simulated environments: an Australian multi-centre study

BACKGROUND

Early recognition and situation awareness of sudden patient deterioration, a timely appropriate clinical response, and teamwork are critical to patient outcomes. High fidelity simulated environments provide the opportunity for undergraduate nursing students to develop and refine recognition and response skills.

OBJECTIVES

This paper reports the quantitative findings of the first phase of a larger program of ongoing research: Feedback Incorporating Review and Simulation Techniques to Act on Clinical Trends (FIRST2ACTTM). It specifically aims to identify the characteristics that may predict primary outcome measures of clinical performance, teamwork and situation awareness in the management of deteriorating patients.

DESIGN

Mixed-method multi-centre study.

SETTING

High fidelity simulated acute clinical environment in three Australian universities.

PARTICIPANTS

A convenience sample of 97 final year nursing students enrolled in an undergraduate Bachelor of Nursing or combined Bachelor of Nursing degree were included in the study.

METHOD

In groups of three, participants proceeded through three phases: (i) pre-briefing and completion of a multi-choice question test, (ii) three video-recorded simulated clinical scenarios where actors substituted real patients with deteriorating conditions, and (iii) post-scenario debriefing. Clinical performance, teamwork and situation awareness were evaluated, using a validated standard checklist (OSCE), Team Emergency Assessment Measure (TEAM) score sheet and Situation Awareness Global Assessment Technique (SAGAT). A Modified Angoff technique was used to establish cut points for clinical performance.

RESULTS

Student teams engaged in 97 simulation experiences across the three scenarios and achieved a level of clinical performance consistent with the experts' identified pass level point in only 9 (1%) of the simulation experiences. Knowledge was significantly associated with overall teamwork (p=.034), overall situation awareness (p=.05) and clinical performance in two of the three scenarios (p=.032 cardiac and p=.006 shock). Situation awareness scores of scenario team leaders were low overall, with an average total score of 41%.

CONCLUSIONS

Final year undergraduate nursing students may have difficulty recognising and responding appropriately to patient deterioration. Improving pre-requisite knowledge, rehearsal of first response and team management strategies need to be a key component of undergraduate nursing students' education and ought to specifically address clinical performance, teamwork and situation awareness.

The epidemiology of adult Rapid Response Team patients in Australia

Rapid Response Teams (RRT) are specialised teams that review deteriorating ward patients in an attempt to prevent morbidity and mortality. Most studies have assessed the effect of implementing an RRT into a hospital. There is much less literature on the characteristics and outcomes of RRT patients themselves. This article reviews the epidemiology of adult RRT patients in Australia and proposes three models of RRT syndromes. The number of RRT calls varies considerably in Australian hospitals from 1.35 to 71.3/1000 hospital admissions. Common causes of RRT calls include sepsis, atrial fibrillation, seizures and pulmonary oedema. Approximately 20% of patients to whom an RRT has responded have more than one RRT call, and up to one-third have issues around end-of-life care. Calls are least common overnight. Between 10 to 25% of patients are admitted to a critical care area after the call. The in-hospital mortality for RRT patients is approximately 25% overall but only 15% in patients without a limitation of medical therapy. RRT syndromes can be conceptually described by the trigger for the call (e.g. hypotension) or the clinical condition causing the call (e.g. sepsis). Alternatively, the RRT call can be described by the major theme of the call: "end-of-life care", "requiring critical care" and "stable enough to initially remain on the ward". Based on these themes, education strategies and quality improvement initiatives may be developed to reduce the incidence of RRT calls, further improving patient outcome.

Recognising clinical deterioration in emergency department patients

BACKGROUND

The use of rapid response systems such as Medical Emergency Team (MET) improves recognition and response to clinical deterioration in in-patient settings. However, few published studies have investigated use of rapid response systems in Australian emergency departments (ED).

AIM

To examine the frequency, nature and outcomes of clinical deterioration in ED patients and compare the utility of hospital MET calling criteria with ED specific Clinical Instability Criteria (CIC) for recognition of deteriorating patients. The outcomes of interest were the prevalence of deterioration in ED patients, the utility of MET versus ED CIC, and the outcomes (MET activation, in-hospital mortality at 30 days) of patients who experienced deterioration during ED care.

METHOD

An exploratory descriptive design was used. Vital sign data were prospectively collected from 200 patients receiving ED care in the general treatment areas of regional, publicly funded health service in Victoria, Australia, during May 2012. Outcome data were collected by follow up medical record audit.

RESULTS

Of the 200 ED patients recruited, 2% fulfilled the study site MET criteria and 7.5% fulfilled ED CIC. The median age of patients fulfilling MET criteria was 85 years compared with a median age of 74 years for patients fulfilling the ED CIC criteria. Of the 136 ED patients admitted to in-patient wards, 5.9% required MET activation during admission and 3.7% of these MET activations occurred within 24h of emergency admission. Five percent of patients died in-hospital within 30 days of ED attendance.

CONCLUSIONS

ED specific criteria for activation of a rapid response system identifies more ED patients at risk of clinical deterioration. The results of this study highlight a need for EDs to implement and evaluate systems to increase recognition of deteriorating patients designed specifically for the emergency care context.

Medical emergency team activation: performance of conventional dichotomised criteria versus national early warning score

BACKGROUND

To activate the hospital's medical emergency team (MET), either conventional dichotomised activation criteria or an early warning scoring system may be used. The relative performance of these different activation patterns to discriminate high risk patients in a heterogenic general ward population after adjustment for multiple confounding factors has not been evaluated. We aimed to evaluate the dichotomised activation criteria used at our institution and the recently published national early warning score (NEWS, United Kingdom).

MATERIALS AND METHODS

Prospective point prevalence study at a university hospital in Finland. On two separate days, the vital signs of all adult patients without treatment limitations were measured. Data on cumulative comorbidity (Charlson comorbidity index), age, gender, admission characteristics and subsequent mortality were collected. Univariate and multivariate logistic regression models were used for unadjusted and adjusted performance testing.

RESULTS

The cohort consisted of 615 patients. The dichotomised activation criteria were not associated with in-hospital serious adverse events (odds ratio 1.87, 95% confidence interval 0.55-6.30) or 30-day mortality (2.13, 0.79-5.72) after adjustments. For a NEWS of seven or more (the suggested trigger level for immediate MET activation), the adjusted odds ratios for the above mentioned outcomes were 7.45 (2.39-23.3) and 11.4 (4.40-29.6), respectively. Unlike the dichotomised activation criteria, NEWS was also independently associated with a higher 60- and 180-day mortality after adjustments.

CONCLUSIONS

NEWS discriminates high risk patients in a heterogenic general ward population independently of multiple confounding factors. The conventional dichotomised activation criteria were not able to detect high risk patients.