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Sprogis SK, Currey J, Jones D, Considine J. Clinicians' use and perceptions of the pre-medical emergency team tier of one rapid response system: A mixed-methods study. Aust Crit Care 2023; 36:1050-1058. [PMID: 36948918 DOI: 10.1016/j.aucc.2023.01.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 01/09/2023] [Accepted: 01/22/2023] [Indexed: 03/24/2023] Open
Abstract
BACKGROUND The pre-medical emergency team (pre-MET) tier of rapid response systems facilitates early recognition and treatment of deteriorating ward patients using ward-based clinicians before a MET review is needed. However, there is growing concern that the pre-MET tier is inconsistently used. OBJECTIVE This study aimed to explore clinicians' use of the pre-MET tier. METHODS A sequential mixed-methods design was used. Participants were clinicians (nurses, allied health, doctors) caring for patients on two wards of one Australian hospital. Observations and medical record audits were conducted to identify pre-MET events and examine clinicians' use of the pre-MET tier as per hospital policy. Clinician interviews expanded on understandings gained from observation data. Descriptive and thematic analyses were performed. RESULTS Observations identified 27 pre-MET events for 24 patients that involved 37 clinicians (nurses = 24, speech pathologist = 1, doctors = 12). Nurses initiated assessments or interventions for 92.6% (n = 25/27) of pre-MET events; however, only 51.9% (n = 14/27) of pre-MET events were escalated to doctors. Doctors attended pre-MET reviews for 64.3% (n = 9/14) of escalated pre-MET events. Median time between escalation of care and in-person pre-MET review was 30 min (interquartile range: 8-36). Policy-specified clinical documentation was partially completed for 35.7% (n = 5/14) of escalated pre-MET events. Thirty-two interviews with 29 clinicians (nurses = 18, physiotherapists = 4, doctors = 7) culminated in three themes: Early Deterioration on a Spectrum, A Safety Net, and Demands Versus Resources. CONCLUSIONS There were multiple gaps between pre-MET policy and clinicians' use of the pre-MET tier. To optimise use of the pre-MET tier, pre-MET policy must be critically reviewed and system-based barriers to recognising and responding to pre-MET deterioration addressed.
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Affiliation(s)
- Stephanie K Sprogis
- Deakin University, School of Nursing and Midwifery & Centre for Quality and Patient Safety in the Institute for Health Transformation, 1 Gheringhap St, Geelong, Victoria, 3220, Australia.
| | - Judy Currey
- Deakin University, School of Nursing and Midwifery & Centre for Quality and Patient Safety in the Institute for Health Transformation, 1 Gheringhap St, Geelong, Victoria, 3220, Australia.
| | - Daryl Jones
- Department of Intensive Care, Austin Hospital, 145 Studley Rd, Heidelberg, Victoria, 3084, Australia; School of Public Health and Preventive Medicine, Monash University, 533 St Kilda Road, Melbourne, Victoria, 3004, Australia; Department of Surgery, University of Melbourne, Parkville, Victoria, 3010, Australia.
| | - Julie Considine
- Deakin University, School of Nursing and Midwifery & Centre for Quality and Patient Safety in the Institute for Health Transformation, 1 Gheringhap St, Geelong, Victoria, 3220, Australia; Centre for Quality and Patient Safety Research - Eastern Health Partnership, 2/5 Arnold St, Box Hill, Victoria, 3128, Australia.
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2
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Hong JQY, Chua WL, Smith D, Huang CM, Goh QLP, Liaw SY. Collaborative practice among general ward staff on escalating care in clinical deterioration: A systematic review. J Clin Nurs 2023; 32:6165-6178. [PMID: 37154497 DOI: 10.1111/jocn.16743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 03/30/2023] [Accepted: 04/20/2023] [Indexed: 05/10/2023]
Abstract
AIM To understand the issues surrounding collaborative practice and collaboration experiences among general ward staff in the escalation of care for clinically deteriorating patients. DESIGN A systematic synthesis without meta-analysis. REVIEW METHODS Seven electronic databases (CINAHL, Cochrane, Embase, PsycINFO, PubMed, Scopus and ProQuest Theses and Dissertations) were searched from their inception to 30 April 2022. Two reviewers independently screened titles, abstracts and full text for eligibility. The critical appraisal skill programme, Joanna Briggs Institute checklist for analytical cross-sectional studies and mixed methods appraisal tool were used to appraise the quality of the included studies. Both quantitative and qualitative research data were extracted, analysed and then synthesised using the data-based convergent qualitative synthesis approach. This review adhered to the Synthesis without meta-analysis (SWiM) reporting guidelines. RESULTS A total of 17 studies were included. Two themes and six sub-themes were generated: (1) intraprofessional factors-inadequate handover, workload and mutual support, raising and acting on concerns, and seeking help from seniors and (2) interprofessional factors-differences in communication styles, and hierarchical approach versus interpersonal relationships. CONCLUSIONS This systematic review highlights the need to address the intra- and interprofessional issues surrounding collaborative practice in escalation of care among general ward staff. IMPLICATIONS FOR THE PROFESSION Findings from this review will inform healthcare leaders and educators on the development of relevant strategies and multi-disciplinary training to foster effective teamwork among nurses and doctors, with the goal of improving the escalation of care for patients with clinical deterioration. NO PATIENT OR PUBLIC CONTRIBUTION This systematic review did not directly involve patient or public contribution to the manuscript.
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Affiliation(s)
- Jordan Qi Yang Hong
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Wei Ling Chua
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Duncan Smith
- Department of Nursing, School of Health and Psychological Sciences, City University of London, London, UK
- Patient Emergency Response & Resuscitation Team (PERRT), University College London Hospitals, NHS Foundation Trust, London, UK
| | - Chi Ming Huang
- Nursing Service, National Healthcare Group, Tan Tock Seng Hospital, Singapore, Singapore
| | - Qin Ling Pearlyn Goh
- Department of Nursing, National Healthcare Group, Khoo Teck Puat Hospital, Yishun Health Campus, Singapore, Singapore
| | - Sok Ying Liaw
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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Forcey DS, Dyer JC, Hopper IK. Clinical concern and the deteriorating patient: a review of rapid response 2018–20. AUST HEALTH REV 2022; 46:679-685. [PMID: 36198474 DOI: 10.1071/ah22045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 09/08/2022] [Indexed: 12/24/2022]
Abstract
Objective To investigate demographics, clinical patterns and outcomes of rapid response reviews in hospital, reviewing indications for and outcomes of rapid response reviews initiated for clinical concern and to understand the role of clinical concern in identifying the deteriorating patient and at-risk patient populations. Method This was a retrospective analysis of General Medical inpatients at Alfred Hospital from 1 January 2018 to 31 July 2020. Data extraction from electronic medical records identified patients who had a rapid response review during admission. Demographic and clinical data, investigations and clinical outcomes from rapid response reviews were investigated. Comparisons were performed using χ 2 or Fisher's exact test where appropriate. Odds ratios and 95% confidence intervals were calculated for factors associated with rapid response reviews for clinical concern and clinical outcomes. Results There were 10 797 admissions of 7409 individual patients. There were 2359 rapid response reviews during the study period, occurring in 13% of admissions. Patients were majority female (50.4%), and the median age was 79 ± 17.6 years. Rapid response reviews were for cardiovascular (46.8%), respiratory (25.3%) and neurological (14.3%) indications. A total of 11% of rapid response reviews (n = 258) were for clinical concern. Inpatient falls accounted for a significant proportion of rapid response reviews for clinical concern. Reviews were more common in older patients, those admitted after-hours, and patients with disabilities. The latter group weremore likely to have rapid response reviews for clinical concern. Rapid response reviews initiated for clinical concern were more likely than those initiated for standard criteria to change patients' clinical status, particularly the withdrawal of active management. Conclusions Rapid response reviews for clinical concern are important triggers to identify clinical deterioration in vulnerable patients. Reviews were initiated for clinical concern were more likely than those initiated for standard criteria to result in a change in patients' resuscitation status and care trajectory. Clinician concern, even when prompting review for parameters outside of standard clinical review criteria, remains an important factor in recognising the deteriorating patient.
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Affiliation(s)
- Dana S Forcey
- General Medicine Department, The Alfred Hospital, Alfred Health, 55 Commercial Road, Prahran, Vic. 3181, Australia
| | - Jessamy C Dyer
- General Medicine Department, The Alfred Hospital, Alfred Health, 55 Commercial Road, Prahran, Vic. 3181, Australia
| | - Ingrid K Hopper
- General Medicine Department, The Alfred Hospital, Alfred Health, 55 Commercial Road, Prahran, Vic. 3181, Australia; and School of Population Health, Monash University, Vic., Australia
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4
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Ito A, Sato K, Yumoto Y, Sasaki M, Ogata Y. A concept analysis of psychological safety: Further understanding for application to health care. Nurs Open 2021; 9:467-489. [PMID: 34651454 PMCID: PMC8685887 DOI: 10.1002/nop2.1086] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/23/2021] [Accepted: 09/02/2021] [Indexed: 12/14/2022] Open
Abstract
AIM To clarify the concept of psychological safety in a healthcare context and to provide the first theoretical framework for improving interpersonal relationships in the workplace to better patient care. DESIGN A Rodgers' concept analysis. METHODS The concept analysis was conducted using a systematic search strategy on PubMed, CINAHL, PsycINFO and Ichushi-Web. RESULTS An analysis of 88 articles studying psychological safety in health care identified five attributes: perceptions of the consequences of taking interpersonal risks, strong interpersonal relationships, group-level phenomenon, safe work environment for taking interpersonal risks and non-punitive culture. The antecedents included structure/system factors, interpersonal factors and individual factors. The four consequences included performance outcomes, organizational culture outcomes, and psychological and behavioural outcomes.
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Affiliation(s)
- Ayano Ito
- Department of Gerontological Nursing and Healthcare Systems Management, Graduate School of Health Care Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Kana Sato
- Department of Gerontological Nursing and Healthcare Systems Management, Graduate School of Health Care Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Yoshie Yumoto
- Department of Gerontological Nursing and Healthcare Systems Management, Graduate School of Health Care Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Miki Sasaki
- Department of Gerontological Nursing and Healthcare Systems Management, Graduate School of Health Care Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Yasuko Ogata
- Department of Gerontological Nursing and Healthcare Systems Management, Graduate School of Health Care Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
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Vatn L, Dahl BM. Interprofessional collaboration between nurses and doctors for treating patients in surgical wards. J Interprof Care 2021; 36:186-194. [PMID: 33980107 DOI: 10.1080/13561820.2021.1890703] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Interprofessional collaboration will be one of the main factors in the effort to increase patient safety in the coming years. Research has identified several challenges to interprofessional collaboration between nurses and doctors, where fragmentation of both education and clinical practice contributes to a strong affiliation to one's own profession with little emphasis on collaboration. The aim of this study was to generate more knowledge about how nurses and doctors experience interprofessional collaboration in observation and treatment of patients on a surgical ward. The study was conducted in 2018 and used an explorative qualitative design that was based on four semi-structured focus group interviews. The respondents were 11 nurses and seven doctors with experience from different surgical specialties and employed in three different surgical wards in a Norwegian hospital. The data were analyzed using systematic text-condensation. The following three main categories, each with two subcategories, emerged: 1) Organization and culture: a lack of interprofessional meeting places and experience-based hierarchy; 2) Communication: use of communication tools and little room for professional discussions; and 3) Trust and respect: dependence and recognition and a blurred distribution of responsibility. Both nurses and doctors wished for closer interprofessional collaboration in observation and treatment in the surgical ward; however, organizational limitations with few interprofessional meeting places and time pressure made this difficult.
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Affiliation(s)
- Line Vatn
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
| | - Berit Misund Dahl
- Department of Health Sciences in Ålesund, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Ålesund, Norway
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Sprogis SK, Currey J, Jones D, Considine J. Use of the pre-medical emergency team tier of rapid response systems: A scoping Review. Intensive Crit Care Nurs 2021; 65:103041. [PMID: 33795182 DOI: 10.1016/j.iccn.2021.103041] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/12/2021] [Accepted: 03/16/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The aim of this review was to explore use of the pre-Medical Emergency Team (pre-MET) tier of Rapid Response Systems to recognise and respond to adult ward patients experiencing early clinical deterioration. METHODS A scoping review of studies published in English reporting on use of a pre-MET tier in adult ward patients was conducted. Three databases were searched (Medline, CINAHL, EMBASE) for studies published between January 1995 and September 2020. Two researchers independently performed screening and quality assessments. Findings were synthesised thematically. Reporting of the review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. RESULTS Six of 1669 studies were included in this review. All were single-site studies of single-parameter Rapid Response Systems in Australian hospitals. Five were quantitative studies; one had a qualitative design. Studies fulfilled 50-100% of quality criteria. Two themes were constructed: Afferent processes - Recognising and escalating pre-MET events; and Efferent processes - Pre-MET reviews and associated interventions. There was disparity between clinical practice and pre-MET escalation protocols, and reports of nurse-initiated management of early deterioration. Prospective methods and exploration of multidisciplinary perspectives were notable research gaps. CONCLUSION Use of the pre-MET tier of Rapid Response Systems is under-researched. Further research is needed to understand barriers and facilitators influencing use of pre-MET strategies to address patient deterioration.
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Affiliation(s)
- Stephanie K Sprogis
- Deakin University: School of Nursing and Midwifery & Centre for Quality and Patient Safety in the Institute for Health Transformation, 1 Gheringhap St, Geelong, Victoria 3220, Australia. https://twitter.com/@Steph_Sprogis
| | - Judy Currey
- Deakin University: School of Nursing and Midwifery & Centre for Quality and Patient Safety in the Institute for Health Transformation, 1 Gheringhap St, Geelong, Victoria 3220, Australia; Deakin University: Deakin Learning Futures, Office of the Deputy Vice Chancellor (Education), 1 Gheringhap St, Geelong, Victoria 3220, Australia. https://twitter.com/@Judy_Currey
| | - Daryl Jones
- Department of Intensive Care, Austin Hospital, 145 Studley Rd, Heidelberg, Victoria, 3084, Australia; School of Public Health and Preventive Medicine, Monash University, Wellington Rd, Clayton, Victoria 3800, Australia; Department of Surgery, University of Melbourne, Parkville, Victoria 3010, Australia. https://twitter.com/@jones_daza
| | - Julie Considine
- Deakin University: School of Nursing and Midwifery & Centre for Quality and Patient Safety in the Institute for Health Transformation, 1 Gheringhap St, Geelong, Victoria 3220, Australia; Centre for Quality and Patient Safety Research - Eastern Health Partnership, 2/5 Arnold St, Box Hill, Victoria 3128, Australia. https://twitter.com/@Julie_Considine
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7
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Ede J, Petrinic T, Westgate V, Darbyshire J, Endacott R, Watkinson PJ. Human factors in escalating acute ward care: a qualitative evidence synthesis. BMJ Open Qual 2021; 10:bmjoq-2020-001145. [PMID: 33637554 PMCID: PMC7919590 DOI: 10.1136/bmjoq-2020-001145] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 01/07/2021] [Accepted: 02/04/2021] [Indexed: 11/07/2022] Open
Abstract
Background Identifying how human factors affect clinical staff recognition and managment of the deteriorating ward patient may inform process improvements. We systematically reviewed the literature to identify (1) how human factors affect ward care escalation (2) gaps in the current literature and (3) critique literature methodologies. Methods We undertook a Qualitative Evidence Synthesis of care escalation studies. We searched MEDLINE, EMBASE and CINHAL from inception to September 2019. We used the Critical Appraisal Skills Programme and the Grading of Recommendations Assessment-Development and Evaluation and Confidence in Evidence from Reviews of Qualitative Research tool to assess study quality. Results Our search identified 24 studies meeting the inclusion criteria. Confidence in findings was moderate (20 studies) to high (4 studies). In 16 studies, the ability to recognise changes in the patient’s condition (soft signals), including skin colour/temperature, respiratory pattern, blood loss, personality change, patient complaint and fatigue, improved the ability to escalate patients. Soft signals were detected through patient assessment (looking/listening/feeling) and not Early Warning Scores (eight studies). In contrast, 13 studies found a high workload and low staffing levels reduced staff’s ability to detect patient deterioration and escalate care. In eight studies quantifiable deterioration evidence (Early Warning Scores) facilitated escalation communication, particularly when referrer/referee were unfamiliar. Conversely, escalating concerning non-triggering patients was challenging but achieved by some clinical staff (three studies). Team decision making facilitated the clinical escalation (six studies). Conclusions Early Warning Scores have clinical benefits but can sometimes impede escalation in patients not meeting the threshold. Staff use other factors (soft signals) not captured in Early Warning Scores to escalate care. The literature supports strategies that improve the escalation process such as good patient assessment skills. PROSPERO registration number CRD42018104745.
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Affiliation(s)
- Jody Ede
- Adult Intensive Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK .,Plymouth University, Plymouth, UK
| | - Tatjana Petrinic
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Verity Westgate
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Julie Darbyshire
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Ruth Endacott
- Plymouth University, Plymouth, UK.,School of Nursing & Midwifery, Monash University, Clayton, Victoria, Australia
| | - Peter J Watkinson
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, Oxfordshire, UK
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Evaluation of nurses' experiences of a post education program promoting recognition and response to patient deterioration: Phase 2, clinical coach support in practice. Nurse Educ Pract 2020; 46:102835. [PMID: 32778370 DOI: 10.1016/j.nepr.2020.102835] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 11/19/2019] [Accepted: 07/02/2020] [Indexed: 11/23/2022]
Abstract
Front-line nurses providing around the clock care are pivotal to the identification, recognition, and response to patient deterioration. However, there is growing evidence that patient deterioration indicators are poorly managed and not escalated to rapid response teams (RRTs), contributing to adverse outcomes. Access to effective educational programs has been cited as vital in optimising nurses' recognition and response to deteriorating patients. Several studies evaluated educational programs, but have not explored nurses' experiences of engaging in patient deterioration events post attendance. Participants in a multimodal education program (DeTER) were invited to attend a series of focus groups three months post workshop as phase two of an overall study. A convenience sample of 22 acute care nurses was recruited. A qualitative descriptive design incorporating focus groups and thematic analysis was used to evaluate participants' experiences of engaging with the RRT during patient deterioration events and whether clinical coach support in practice influenced their recognition and response. Four themes were identified within the data, categorised as enhanced confidence, effective communication, supportive culture, and early response. The importance of an educational model using multimodal strategies, underpinned by coach support and guidance post workshop, was clearly demonstrated to optimise nurses' management of patient deterioration events.
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9
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Bingham G, Fossum M, Hughes L, Digby R, Bucknall T. The pre-Medical Emergency Team response: Nurses' decision-making escalating deterioration to treating teams using urgent review criteria. J Adv Nurs 2020. [PMID: 32432363 DOI: 10.1111/jan.14433] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 03/24/2020] [Accepted: 05/04/2020] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
| | - Mariann Fossum
- Alfred Health, Melbourne, Vic., Australia.,Centre for Caring Research - Southern Norway, Faculty of Health and Sport Sciences, University of Agder, Grimstad, Norway
| | | | - Robin Digby
- Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Faculty of Health, Deakin University, Geelong, Vic., Australia
| | - Tracey Bucknall
- Alfred Health, Melbourne, Vic., Australia.,Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Faculty of Health, Deakin University, Geelong, Vic., Australia
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10
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Wood C, Chaboyer W, Carr P. How do nurses use early warning scoring systems to detect and act on patient deterioration to ensure patient safety? A scoping review. Int J Nurs Stud 2019; 94:166-178. [DOI: 10.1016/j.ijnurstu.2019.03.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 03/17/2019] [Accepted: 03/18/2019] [Indexed: 10/27/2022]
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Foley C, Dowling M. How do nurses use the early warning score in their practice? A case study from an acute medical unit. J Clin Nurs 2018; 28:1183-1192. [PMID: 30428133 DOI: 10.1111/jocn.14713] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 10/04/2018] [Accepted: 11/03/2018] [Indexed: 12/26/2022]
Abstract
AIMS AND OBJECTIVES This study aimed to describe how nurses use the early warning score (EWS) in an acute medical ward and their compliance with the EWS and explore their views and experiences of the EWS. BACKGROUND early warning score systems have been implemented in response to upward trends in mortality rates. Nurses play a central role in the use of EWS systems. However, barriers to their use have been identified and include behavioural, cultural and organisational approaches to adherence. Improvement strategies including education and training and electronic devices have assisted in compliance with the system. DESIGN A holistic single descriptive case study design was used. METHODS Data triangulation was used including non-participant observation, semi-structured interviews with nurses and document analysis. Nurses were observed using EWS and were subsequently interviewed. Data analysis was guided by systematic text condensation (STC), an approach underpinned by Giorgi's phenomenological method, where meaning units and themes are identified. The study adhered to the consolidated criteria for reporting qualitative research (COREQ) guidelines. RESULTS Three themes with associated meaning units were found. Protocol Adherence vs. Clinical Judgement addresses nurses' knowledge, skill and experience and patient assessment. Parameter Adjustment and Escalation included parameters not being adjusted or reviewed, junior doctors not being authorised to set parameters and escalation. The final theme Culture highlighted a task-driven approach and deficient communication processes. CONCLUSION This study highlights the need for ongoing training, behavioural change and a cultural shift by healthcare professionals and organisations to ensure adherence with EWS escalation protocols. RELEVANCE TO CLINICAL PRACTICE Improvements in education and training into recognition, management and communication of a deteriorating patient are required. Also, a cultural shift is needed to improve compliance and adherence with EWS practice. The potential use of electronic data should be explored.
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Affiliation(s)
- Claire Foley
- Nurse Practice Development, Midland Regional Hospital, Tullamore, Co. Offaly, Ireland
| | - Maura Dowling
- School of Nursing and Midwifery, National University of Ireland, Galway, Ireland
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12
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The impact of a multimodal education strategy (the DeTER program) on nurses' recognition and response to deteriorating patients. Nurse Educ Pract 2018; 31:130-135. [PMID: 29879637 DOI: 10.1016/j.nepr.2018.05.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 01/22/2018] [Accepted: 05/21/2018] [Indexed: 11/21/2022]
Abstract
Nurses are ideally positioned to recognise and respond to patient deterioration. However, premonitory signs of patient deterioration are often overlooked, not managed, or not communicated in a timely fashion. Education programs aimed at improving nurses' technical and non-technical skills have been developed, however, the outcomes of these educational strategies remain unclear. A quasi-experimental time series design was used in this study to evaluate the impact of a multi-modal education program (DeTER) on acute care nurses' technical and non-technical skill development and recognition and response to patient deterioration. Participants were asked to complete a survey on four occasions: one month prior to commencement of the DeTER program, immediately prior and post workshop attendance and two-three months' post workshop completion. Pre-intervention, data were collected on participants' demographic profile and their responses to the Clinical Emergency Recognition and Response Survey designed by (Buckley and Gordon, 2011). Post intervention these data were collected again and, in addition, respondents were asked to report on their recent experiences of deteriorating patients and report on their confidence in managing these incidents. Sixty staff consented to participate in the study and all completed the surveys at time 2 and 3. In total 32 staff (45%) responded at all time points. Participants included registered nurses (n = 51; 85%), and enrolled nurses (n = 9; 15%), on average they had worked for 10.4 years (sd = 11.1). Participants rated patient advocacy and assertiveness skills as the most useful aspects of the workshop. Recognition and response to deteriorating patients by ward nurses is a multifaceted process influenced by many factors. Our study supports the importance of multimodal educational strategies in sustaining changes to ward nurses' technical and non-technical skills over time.
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13
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Large C, Aldridge M. Non-technical skills required to recognise and escalate patient deterioration in acute hospital settings. Nurs Manag (Harrow) 2018; 25:24-30. [PMID: 29718603 DOI: 10.7748/nm.2018.e1707] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2018] [Indexed: 11/09/2022]
Abstract
Recognising patient deterioration is a vital nursing role. Observation based on vital signs and early warning scores are mandatory for all adult patients in acute hospital care and are the first steps in identifying deterioration. However, they rely on users' understanding of the significance of the results they find and their ability to escalate to senior colleagues if necessary. This article examines the non-technical skills nurses require to recognise and escalate patient deterioration. Itexplores and analyses the literature on this topic and suggests there is a need for greater focus on situational awareness in nurse training and in healthcare in general, as this is linked to improved patient safety.
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14
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Molloy J, Pratt N, Tiruvoipati R, Green C, Plummer V. Relationship between diurnal patterns in Rapid Response Call activation and patient outcome. Aust Crit Care 2018; 31:42-46. [PMID: 28274779 DOI: 10.1016/j.aucc.2017.01.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 01/28/2017] [Accepted: 01/30/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The Rapid Response Call (RRC) is a system designed to escalate care to a specialised team in response to the detection of patient deterioration. To date, there have been few studies which have explored the relationship between time of day of RRC and patient outcome. OBJECTIVE To examine the relationship between the time of RRC activations and patient outcome. METHOD All adult inpatients with a RRC in non-critical care wards of a metropolitan Australian hospital in 2012 were retrospectively reviewed. RRCs occurring between 18:00-07:59 were defined as 'out of hours'. RESULTS There were 892 RRC during the study period. RRCs out of hours were associated with a higher rate of ICU admissions immediately after the RRC (19.4% vs. 12.3%, p<0.001). Patients experiencing an out-of-hours RRC were more likely to have an in-hospital cardiopulmonary arrest (OR=1.7, p<0.04). In-hospital mortality rate was significantly higher for patients with out-of-hours RRCs (35.5% vs. 25.0%, p=0.014). After adjusting for confounders out-of-hours RRC were independently associated with increased need for ICU admissions and in-hospital mortality. CONCLUSION The diurnal timing of RRCs appears to have significant implications for patient mortality and morbidity, patient outcomes are worse if RRC occurs out of hours. This finding has implications for staffing and resource allocation.
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Affiliation(s)
- Joanne Molloy
- Peninsula Health, 2 Hastings Road (PO Box 52), Frankston, VIC 3199, Australia.
| | - Naomi Pratt
- Peninsula Health, 2 Hastings Road (PO Box 52), Frankston, VIC 3199, Australia.
| | - Ravindranath Tiruvoipati
- Peninsula Health, 2 Hastings Road (PO Box 52), Frankston, VIC 3199, Australia; Monash University, Peninsula Campus, McMahons Road, Frankston, VIC 3199, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria 3800, Australia.
| | - Cameron Green
- Peninsula Health, 2 Hastings Road (PO Box 52), Frankston, VIC 3199, Australia.
| | - Virginia Plummer
- Peninsula Health, 2 Hastings Road (PO Box 52), Frankston, VIC 3199, Australia; Monash University, Peninsula Campus, McMahons Road, Frankston, VIC 3199, Australia.
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