Acute clinical deterioration and consumer escalation in the hospital setting: A literature review

Feasibility and acceptability of implementing an evidence-based ESCALATION system for paediatric clinical deterioration

BACKGROUND

The ESCALATION system is a novel paediatric Early Warning System that incorporates family involvement and sepsis recognition. This study aimed to assess the feasibility and iteratively refine the ESCALATION system in a variety of hospital settings in preparation for full-service implementation.

METHODS

A series of four multi-methods studies using an Implementation Science and co-design approach were conducted. We examined concepts of implementation, context, and mechanisms of action across a variety of hospitals. Data collected included practice and chart audits, surveys (health professionals), interviews (families) and focus groups (health professionals). Quantitative data were analysed descriptively with qualitative findings assessed by content analysis or thematic analysis.

RESULTS

There were 650 audits (Study I-IV), 205 health professional survey responses (Study I), 154 health professionals participated in focus groups (Study II-IV), 13 parents of hospitalised children interviewed (Study I), and 107 parents reported their involvement in the ESCALATION system (Study III-IV). Each of the studies further refined and confirmed the feasibility, specifically the components of family involvement and the sepsis recognition pathway.

CONCLUSION

The Implementation Science evaluation of the ESCALATION system resulted in a uniform approach that was feasible and acceptable to users and appropriate for full-service implementation.

IMPACT

This series of four studies used a co-production approach built on the Medical Research Council framework to understand feasibility and acceptability of an intervention to improve recognition and response to clinical deterioration in children to the point of full-service implementation. We have reported a detailed, systematic approach to assessing feasibility and acceptability of a complex intervention using established methodologies for whole of health system implementation. The ESCALATION System is an evidence based paediatric early warning system that is a highly refined, well accepted and accommodates a health system that has substantial contextual variation.

Listen to me, I really am sick! Patient and family narratives of clinical deterioration before and during rapid response system intervention

AIM

To explore patient and family narratives about their recognition and response to clinical deterioration and their interactions with clinicians prior to and during Medical Emergency Team (MET) activations in hospital.

BACKGROUND

Research on clinical deterioration has mostly focused on clinicians' roles. Although patients and families can identify subtle cues of early deterioration, little research has focused on their experience of recognising, speaking up and communicating with clinicians during this period of instability.

DESIGN

A narrative inquiry.

METHODS

Using narrative interviewing techniques, 33 adult patients and 14 family members of patients, who had received a MET call, in one private and one public academic teaching hospital in Melbourne, Australia were interviewed. Narrative analysis was conducted on the data.

RESULTS

The core story of help seeking for recognition and response by clinicians to patient deterioration yielded four subplots: (1) identifying deterioration, recognition that something was not right and different from earlier; (2) voicing concerns to their nurse or by family members on their behalf; (3) being heard, desiring a response acknowledging the legitimacy of their concerns; and (4) once concerns were expressed, there was an expectation of and trust in clinicians to act on the concerns and manage the situation.

CONCLUSION

Clinical deterioration results in an additional burden for hospitalised patients and families to speak up, seek help and resolve their concerns. Educating patients and families on what to be concerned about and when to notify staff requires a close partnership with clinicians.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Clinicians must create an environment that enables patients and families to speak up. They must be alert to both subjective and objective information, to acknowledge and to act on the information accordingly.

REPORTING METHOD

The consolidated criteria for reporting qualitative research (COREQ) guidelines were used for reporting.

PATIENT OR PUBLIC CONTRIBUTION

The consumer researcher was involved in design, data analysis and publication preparation.

Opinions of Nurses and Physicians on a Patient, Family, and Visitor Activated Rapid Response System in Use Across Two Hospital Settings

BACKGROUND

Early detection of deterioration of hospitalized patients with timely intervention improves outcomes in the hospital. Patients, family members, and visitors (consumers) at the patient's bedside who are familiar with the patient's condition may play a critical role in detecting early patient deterioration. The authors sought to understand clinicians' views on consumer reporting of patient deterioration through an established hospital consumer-initiated escalation-of-care system.

METHODS

A convenience sample of new graduate-level to senior-level nurses and physicians from two hospitals in South Australia was administered a paper survey containing six open-ended questions. Data were analyzed with a matrix-style framework and six steps of thematic analysis.

RESULTS

A total of 244 clinicians-198 nurses and 46 physicians-provided their views on the consumer-initiated escalation-of-care system. Six major themes and subthemes emerged from the responses indicating that (1) clinicians were supportive of consumer reporting and felt that consumers were ideally positioned to recognize deterioration early and raise concerns about it; (2) management support was required for consumer escalation processes to be effective; (3) clinicians' workload could possibly increase or decrease from consumer escalation; (4) education of consumers and staff on escalation protocol is a requirement for success; (5) there is need to build consumer confidence to speak up; and (6) there is a need to address barriers to consumer escalation.

CONCLUSION

Clinicians were supportive of consumers acting as first reporters of patient deterioration. Use of interactive, encouraging communication skills with consumers was recognized as critical. Annual updating of clinicians on consumer reporting of deterioration was also recommended.

Hospital Testing of the Effectiveness of Co-Designed Educational Materials to Improve Patient and Visitor Knowledge and Confidence in Reporting Patient Deterioration

BACKGROUND

Co-designed educational materials could significantly improve the likelihood of patients and visitors (consumers) escalating care through hospital systems. The objective was to investigate patients' and visitors' knowledge and confidence in recognizing and reporting patient deterioration in hospitals before and after exposure to educational materials.

METHODS

A multimethod design involved a convenience sample of patients and visitors at a South Australian hospital. Knowledge and confidence of participants to report patient deterioration was assessed using a validated questionnaire. Baseline group was surveyed, and a second group was surveyed after exposure to a poster and on-hold message relating to consumer-initiated escalation-of-care. Nominal data were examined using chi-square analysis, and ordinal data using the Mann-Whitney U test. Open-ended questions were examined using thematic analysis.

RESULTS

A total of 407 participants completed the study, 203 undertook the baseline survey, and 204 the postintervention survey. Respondents exposed to the educational materials reported significantly higher recognition of responsibility to report concerns about patient deterioration compared to controls (86.3% vs. 73.1%; p = 0.007). Respondents exposed to the educational materials also had better ability to identify signs that a patient was becoming sicker compared to controls (77.5% vs. 71.3%, p = 0.012). Four overarching themes emerged from the questions: patient/visitor understanding of key messages, patient/visitor recognition of deterioration, patient/visitor response to deterioration and patient/visitor recommendations.

CONCLUSION

Following educational interventions, patients and visitors report improved awareness of their role in recognizing and responding to clinical deterioration. They advise additional active interventions and caution that the materials should accommodate language, cultural, and disability needs.

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

BACKGROUND

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

AIM

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

METHOD

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

FINDINGS

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

CONCLUSION

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

Acute clinical deterioration and consumer escalation: The understanding and perceptions of hospital staff

Introduction

Consumer escalation systems allow patients and families to escalate concerns about acute clinical deterioration. Hospital staff can impact upon the success of this process. As part of evaluation processes within a Local Health Network, where a consumer escalation system was introduced in accordance with National requirements, we sought to explore clinicians’ understanding and perceptions of consumer escalation.

Methods

Voluntary and anonymous staff surveys pre, and post, system introduction. Quantitative data was analysed using descriptive statistics, chi-square independence, and non-parametric independent samples median tests. Qualitative data was evaluated using content analysis and cross-referenced with quantitative responses.

Results

Respondent’s (pre: 215; post: 89) area of work varied significantly between survey periods. Most agreed that patients/families have a sound knowledge of a patient’s typical health status (pre: 192/215 (89.3%); post 82/88 (93.2%)) and that patients/families should be encouraged to escalate concerns of deterioration to ward staff (pre: 209/212 (98.6%); post: 85/89 (95.5%)). Respondent perceptions of patient/family ability to recognise clinical deterioration varied. Staff agreement towards local response expectations decreased as the degree of clinical requirement increased. Staff concerns of increased workloads (pre: 90/214 (42.1%); post 12/72 (16.7%), p<0.001) and conflict generation (pre: 71/213 (33.3%); post: 7/71 (9.9%), p = 0.001) decreased significantly following system introduction. However, clinician perceptions of positive system effects also decreased (patient-staff rapport pre: 163/213 (76.5%); post: 38/72 (52.8%), p = 0.001; patient centred care pre: 188/214 (87.9%); post: 53/72 (73.6%), p = 0.012; patient safety pre: 173/214 (80.8%); post: 49/72 (68.1%), p = 0.077). Only 53% of respondents (pre: 112/213 (52.6%); post: 48/88 (54.5%)) perceived that patient/family have sufficient confidence to escalate concerns.

Conclusion

Consumer escalation systems require staff support. Staff perceptions may indicate, and act as, barriers to the operation of consumer escalation processes. Further exploration in identifying and managing staff barriers is crucial to the success of consumer escalation.

Clinicians' attitudes towards escalation and management of deteriorating patients: A cross-sectional study

BACKGROUND

Internationally, rapid response systems have been implemented to recognise and categorise hospital patients at risk of deterioration. Whilst rapid response systems have been implemented with a varying amount of success, there remains ongoing concern about the lack of improvement in the escalation, and management of the deteriorating patient. It also remains unclear why some clinicians fail to escalate concerns for the deteriorating patient.

OBJECTIVE

The objective of this study was to explore clinicians' attitudes towards the escalation, and management of the deteriorating patient.

METHODS

A cross-sectional online survey of conveniently sampled clinicians from the acute care sector in a regional health district in Australia was conducted. The Clinicians' Attitudes towards Responding and Escalating care of Deteriorating patients scale, was used to explore attitudes towards the escalation and management of the deteriorating patient.

RESULTS

Survey responses were received from medical officers (n = 43), nurses (n = 677), allied health clinicians (n = 60), and students (n = 57). Years of experience was significantly associated with more confidence responding to deteriorating patients (p < .001) and significantly less fears about escalating care (p < .001). Nurses (M = 4.16, SD = .57) and students (M = 4.11, SD = .55) in general had significantly greater positive beliefs that the rapid response system would support them to respond to the deteriorating patient than allied health (M = 3.67, SD = .64) and medical (M = 3.87, SD = .54) clinicians, whilst nurses and medical clinicians had significantly less fear about escalating care and greater confidence in responding to deteriorating patients than allied health clinicians and healthcare students (p < .001).

CONCLUSION

Nurses and medical officers have less fear to escalate care and greater confidence responding to the deteriorating patient than allied health clinicians and students. Whilst the majority of participants had positive perceptions towards the rapid response system, those with less experience lacked the confidence to escalate care and respond to the deteriorating patient.

Aboriginal perspectives on recognising clinical deterioration in their child and communicating concerns to clinicians

AIMS AND OBJECTIVES

To explore the perspectives of family members of Aboriginal children about a) their involvement in recognising clinical deterioration in a hospital setting and b) the effectiveness of a poster designed to promote family involvement.

BACKGROUND

To assist in the early recognition and response to clinical deterioration for hospitalised children, many escalation of care processes now include family involvement. Little is currently known about the perspectives of Australian Aboriginal families in recognising deterioration in their child and raising the alarm, or if current escalation of care systems meet the needs of Aboriginal families.

DESIGN

Qualitative pragmatist approach using semi-structured interviews.

METHODS

Seven interviews were conducted with five mothers and two grandmothers of Aboriginal children who were inpatients at a children's hospital. Thematic analysis was undertaken.

FINDINGS

Two themes were identified: Theme one was: Family role in recognising and responding to clinical deterioration, with two subthemes of knowing when to worry and communicating concerns. Participants reported that some families needed more knowledge to recognise clinical deterioration. Communication barriers between families and clinicians were identified. Theme two was: Effective visual communication with three subthemes of linguistic clarity, visual appeal and content.

CONCLUSIONS

Additional strategies are needed to promote effective communication between clinicians and families of Aboriginal children in hospital. Posters were considered effective, particularly if including a cultural connection, images and simplified language.

PRACTICE IMPLICATIONS

These insights provide important information for health professionals and health service managers to be aware that additional communication strategies are required to support Aboriginal family involvement in recognising clinical deterioration and escalation of care.

Development of an evidence-based ESCALATION system for recognition and response to paediatric clinical deterioration

AIM

The aim of this study was to develop an evidence-based paediatric early warning system for infants and children that takes into consideration a variety of paediatric healthcare contexts and addresses barriers to escalation of care.

METHODS

A three-stage intervention development framework consisted of Stage 1: evidence review, benchmarking, stakeholder (health professionals, decision-makers, and health consumers) engagement, and consultation; Stage 2: planning and coproduction by the researchers and stakeholders using action research cycles; and Stage 3: prototyping and testing.

RESULTS

A prototype evidence-based system incorporated human factor principles, used a structured approach to patient assessment, promoted situational awareness, and included family as well as clinician concern. Family involvement in detecting changes in their child's condition was supported by posters and flyers codesigned with health consumers. Five age-specific observation and response charts included 10 weighted variables and one unweighted variable (temperature) to convey a composite early warning score. The escalation pathway was supported by a targeted communication framework (iSoBAR NOW).

CONCLUSION

The development process resulted in an agreed uniform ESCALATION system incorporating a whole-system approach to promote critical thinking, situational awareness for the early recognition of paediatric clinical deterioration as well as timely and effective escalation of care. Incorporating family involvement was a novel component of the system.

Resuscitation highlights in 2020

BACKGROUND

This review is the latest in a series of regular annual reviews undertaken by the editors and aims to highlight some of the key papers published in Resuscitation during 2020. The number of papers submitted to the Journal in 2020 increased by 25% on the previous year.MethodsHand-searching by the editors of all papers published in Resuscitation during 2020. Papers were selected based on then general interest and novelty and were categorised into general themes.ResultsA total of 103 papers were selected for brief mention in this review.ConclusionsResuscitation science continues to evolve rapidly and incorporate all links in the chain of survival.