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Bourke-Matas E, Bosley E, Smith K, Meadley B, Bowles KA. Developing a consensus-based definition of out-of-hospital clinical deterioration: A Delphi study. Aust Crit Care 2024; 37:318-325. [PMID: 37537124 DOI: 10.1016/j.aucc.2023.05.008] [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: 10/03/2022] [Revised: 05/17/2023] [Accepted: 05/31/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Clinical deterioration is a time-critical medical emergency requiring rapid recognition and intervention. Deteriorating patients are seen across various healthcare settings, including the out-of-hospital (OOH) environment. OOH care is an evolving area of medicine where decisions are made regarding priority and timing of clinical interventions, ongoing management, and transport to appropriate care. To date, the literature lacks a standardised definition of OOH clinical deterioration. OBJECTIVE The objective of this study was to create a consensus-based definition of OOH clinical deterioration informed by emergency medicine health professionals. METHODS A Delphi study consisting three rounds was conducted electronically between June 2020 and January 2021. The expert panel consisted of 30 clinicians, including emergency physicians and paramedics. RESULTS A consensus-based definition of OOH clinical deterioration was identified as changes from a patient's baseline physiological status resulting in their condition worsening. These changes primarily take the form of measurable vital signs and assessable symptoms but should be evaluated in conjunction with the history of events and pertinent risk factors. Clinicians should be suspicious that a patient could deteriorate when changes occur in one or more of the following vital signs: respiratory rate, heart rate, blood pressure, Glasgow Coma Scale, oxygen saturation, electrocardiogram, and skin colour. Almost all participants (92%) indicated an early warning system would be helpful to assist timely recognition of deteriorating patients. CONCLUSION The creation of a consensus-based definition of OOH clinical deterioration can serve as a starting point for the development and validation of OOH-specific early warning systems. Moreover, a standardised definition allows meaningful comparisons to be made across health services and ensures consistency in future research. This study has shown recognition of OOH clinical deterioration to be a complex issue requiring further research. Improving our understanding of key factors contributing to deterioration can assist timely recognition and intervention, potentially reducing unnecessary morbidity and mortality.
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Affiliation(s)
- Emma Bourke-Matas
- Department of Paramedicine, School of Primary and Allied Health Care, Monash University, McMahons Rd, Frankston, Victoria, 3199, Australia; Queensland Ambulance Service, Department of Health, Emergency Services Complex, Cnr Park and Kedron Park Rds, Kedron, Queensland, 4031, Australia.
| | - Emma Bosley
- Queensland Ambulance Service, Department of Health, Emergency Services Complex, Cnr Park and Kedron Park Rds, Kedron, Queensland, 4031, Australia
| | - Karen Smith
- Department of Paramedicine, School of Primary and Allied Health Care, Monash University, McMahons Rd, Frankston, Victoria, 3199, Australia; Ambulance Victoria Centre for Research and Evaluation, 31 Joseph Street, Blackburn North, Victoria, 3130, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Prahran, Victoria, 3181, Australia
| | - Ben Meadley
- Department of Paramedicine, School of Primary and Allied Health Care, Monash University, McMahons Rd, Frankston, Victoria, 3199, Australia; Ambulance Victoria Centre for Research and Evaluation, 31 Joseph Street, Blackburn North, Victoria, 3130, Australia
| | - Kelly-Ann Bowles
- Department of Paramedicine, School of Primary and Allied Health Care, Monash University, McMahons Rd, Frankston, Victoria, 3199, Australia
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Jensen CS, Olesen HV, Kirkegaard H, Lisby M. Consensus on patient cases for hospitalised children with a high paediatric track and trigger tool score that raises no mounting concern: a Delphi process study. BMJ Paediatr Open 2022; 6:10.1136/bmjpo-2022-001564. [PMID: 36053613 PMCID: PMC9272132 DOI: 10.1136/bmjpo-2022-001564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 06/25/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Paediatric track and trigger tools (PTTTs) based on vital parameters have been implemented in hospitals worldwide to help healthcare professionals identify signs of critical illness and incipient deterioration in hospitalised children. It has been documented that nurses do not use PTTT as intended, but deviate from PTTT protocols because, in some situations, PTTT observations make little sense to them. The present study aimed to reach consensus on whether automatically generated PTTT scores that are higher than deemed reasonable by healthcare professionals according to their professional experience and clinical expertise may be downgraded. METHODS A two-round modified Delphi technique was used to explore consensus on 14 patient cases for hospitalised children with a high PTTT score that did not raise concerns by systematically collating questionnaire responses. Participants rated their level of agreement on a 9-point Likert scale. IQR and median were calculated for each case. FINDINGS A total of 221 participants completed round 1 and 101 participants completed round 2. Across the two rounds, majority of the participants were from paediatric departments, nurses and women. In round 1, consensus on inclusion was reached on 2 of the 14 cases. In round 2, consensus was reached on one additional patient case. Three of the 11 non-consensus cases remaining after rounds 1 and 2 were included by the research group based on predefined criteria. CONCLUSION In conclusion, a consensus opinion was achieved on six patient cases where the child had a high PTTT score but where the healthcare professionals were not as concerned as indicated by the PTTT score.
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Affiliation(s)
- Claus Sixtus Jensen
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus N, Denmark .,Research Center for Emergency Medicine, Aarhus University and Aarhus University Hospital, Aarhus N, Denmark
| | - Hanne Vebert Olesen
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Hans Kirkegaard
- Research Center for Emergency Medicine, Aarhus University and Aarhus University Hospital, Aarhus N, Denmark
| | - Marianne Lisby
- Research Center for Emergency Medicine, Aarhus University and Aarhus University Hospital, Aarhus N, Denmark
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Tygesen GB, Lisby M, Raaber N, Rask MT, Kirkegaard H. A new situation awareness model decreases clinical deterioration in the emergency departments-A controlled intervention study. Acta Anaesthesiol Scand 2021; 65:1337-1344. [PMID: 34028009 DOI: 10.1111/aas.13929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 05/05/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Studies have suggested that adding subjective parameters to early warning score (EWS) systems might prompt more proactive treatment and positively affect clinical outcomes. Hence, the study aimed to investigate effect of a situation awareness model consisting of objective and subjective parameters on clinical deterioration in adult emergency department (ED) patients. METHODS This controlled pre-and-post interventional study was carried out in July-December 2016 and November 2017-April 2018. In ED patients ≥ 18 years, we examined if a situation awareness model compared with a conventional EWS system could reduce clinical deterioration. The new model consisted of a regional EWS, combined with skin observation, clinical concern and patients' and relatives' concerns, pain, dyspnea, and team risk assessment. Clinical deterioration was defined as change in vital signs requiring increased observation or physician assessment, that is, increase in early warning score from either 0 or 1 to score ≥2 or an increase from score ≥2 and above. Secondary outcomes were mortality, intensive care unit (ICU) admissions, and readmissions. RESULTS We included 34 556 patients. Patients with two or more registered EWS were included in the primary analysis (N = 21 839). Using difference-in-difference regression, we found a reduced odds of clinical deterioration of 21% (OR 0.79 95% CI [0.69; 0.90]) in the intervention groups compared with controls. No impact on mortality, ICU, or readmissions was found. CONCLUSION The situation awareness model reduces odds of clinical deterioration, defined as a clinically relevant increase in EWS, in an unselected adult population of ED patients. However, there was no effect on secondary outcomes.
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Affiliation(s)
- Gitte B. Tygesen
- Department of Emergency Medicine Horsens Regional Hospital Horsens Denmark
- Research Centre for Emergency Medicine Aarhus University Aarhus Denmark
| | - Marianne Lisby
- Research Centre for Emergency Medicine Aarhus University Aarhus Denmark
- Department of Emergency Medicine Aarhus University Hospital Aarhus Denmark
| | - Nikolaj Raaber
- Department of Emergency Medicine Aarhus University Hospital Aarhus Denmark
| | - Mette T. Rask
- The Research Clinic for Functional Disorders and Psychosomatics Aarhus University Hospital Aarhus Denmark
| | - Hans Kirkegaard
- Research Centre for Emergency Medicine Aarhus University Aarhus Denmark
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