1
|
Considine J, Casey P, Omonaiye O, van Gulik N, Allen J, Currey J. Importance of specific vital signs in nurses' recognition and response to deteriorating patients: A scoping review. J Clin Nurs 2024; 33:2544-2561. [PMID: 38454551 DOI: 10.1111/jocn.17099] [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: 07/31/2023] [Revised: 10/11/2023] [Accepted: 02/28/2024] [Indexed: 03/09/2024]
Abstract
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.
Collapse
Affiliation(s)
- Julie Considine
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
- Centre for Quality and Patient Safety Research-Eastern Health Partnership, Eastern Health, Box Hill, Victoria, Australia
| | - Penelope Casey
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
- Centre for Quality and Patient Safety Research-Eastern Health Partnership, Eastern Health, Box Hill, Victoria, Australia
| | - Olumuyiwa Omonaiye
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
- Centre for Quality and Patient Safety Research-Eastern Health Partnership, Eastern Health, Box Hill, Victoria, Australia
| | - Nantanit van Gulik
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
- Centre for Quality and Patient Safety Research-Eastern Health Partnership, Eastern Health, Box Hill, Victoria, Australia
| | - Joshua Allen
- Department of Nursing, School of Health Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Victoria, Australia
| | - Judy Currey
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
| |
Collapse
|
2
|
Nolan J, Mackay I, Nolan T, de Looze J. Medical Emergency Team call within 24 h of medical admission with a focus on sepsis: a retrospective review. Intern Med J 2024; 54:961-969. [PMID: 38288844 DOI: 10.1111/imj.16337] [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: 06/11/2023] [Accepted: 12/28/2023] [Indexed: 06/18/2024]
Abstract
BACKGROUND AND AIMS Clinical deterioration within the first 24 h of patient admission triggering a Medical Emergency Team (MET) call is a common occurrence. A greater understanding of these events, with a focus on the recognition and management of sepsis, could lead to quality improvement interventions. METHODS A retrospective observational review of general and subspecialty medical admissions triggering a MET call within 24 h of admission at a quaternary Australian hospital. RESULTS 2648 MET calls occurred (47.9/1000 admissions), 527 (20% of total MET events, 9.5/1000 admissions) within 24 h of admission, with the trigger more likely to be hypotension (odds ratio: 1.5, P = 0.0013). There were 263 MET calls to 217 individual medical patients within 24 h of admission, of which 84 (38.7%) were admitted with suspected infection, 69% of which fulfilled sepsis criteria. Of these, 36.2% received antimicrobial therapy within the recommended timeframe and 39.6% received antibiotics in line with hospital guidelines. Sepsis was initially missed in 11% of patients. Afferent limb failure occurred in 29% of patients with 40.5% experiencing a failure of the ward-based response to deterioration prior to MET call. Median hospital length of stay was increased in patients admitted with suspected infection (7 vs 5 days, P = 0.015) and in those with sepsis not receiving antimicrobial therapy within guideline timeframes (9 vs 4 days, P = 0.017). CONCLUSION There is a significant opportunity to improve care for patients who trigger a MET within 24 h of admission. This study supports the implementation of a hospital sepsis management guideline.
Collapse
Affiliation(s)
- James Nolan
- Internal Medicine and Aged Care, The Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Ian Mackay
- Internal Medicine and Aged Care, The Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Timothy Nolan
- The Cairns Hospital, Cairns, Queensland, Australia
- Griffith University, Gold Coast, Queensland, Australia
| | - Julian de Looze
- Internal Medicine and Aged Care, The Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| |
Collapse
|
3
|
Liu Q, Xie C, Tan J, Xu L, Zhou F, Peng L. Exploring the nurses' experiences in recognising and managing clinical deterioration in emergency patients: A qualitative study. Aust Crit Care 2024; 37:309-317. [PMID: 37455210 DOI: 10.1016/j.aucc.2023.06.004] [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: 09/20/2022] [Revised: 05/30/2023] [Accepted: 06/03/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Emergency Department (ED) patients are particularly at a high risk of deterioration. The frontline nurses are key players in identifying and responding to deterioration events; however, few studies have sought to explore the whole process of recognition and management of clinical deterioration by emergency nurses. OBJECTIVES The aim of this study was to explore the experiences of emergency nurses and provide a whole picture of how they recognise and manage clinical deterioration. METHODS A qualitative descriptive study involving 11 senior nurses and seven junior nurses was conducted in the ED of a 3000-bed tertiary general hospital using semistructured interviews. The interviews were transcribed and thematically analysed. FINDINGS Four salient themes emerged from the data analysis. The first, 'early recognition and response', revealed the importance of vital signs assessment in recognising and responding to clinical deterioration. The second, 'information transfer', depicted the skills and difficulties of transferring information in escalations of care. The third, 'abilities, education, and training', presented the abilities that emergency nurses should have and their perspectives on training. The fourth, 'support culture', described the major role of senior nurses in collaboration with colleagues in the ED. CONCLUSIONS This study explored the experiences of emergency nurses in recognising and managing clinical deterioration. The findings illuminate the need to support the critical role of emergency nurses, with an emphasis on their abilities and continuous interprofessional collaboration training to improve the recognition and management of clinical deterioration.
Collapse
Affiliation(s)
- Qingqing Liu
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha, 410008, Hunan, China; National Clinical Research Center for Geriatric Diseases, Xiangya Hospital of Central South University, Changsha, Hunan, China; Orthopedics Department, Xiangya Hospital of Central South University, Changsha, Hunan, China.
| | - Changning Xie
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha, 410008, Hunan, China.
| | - Jianwen Tan
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha, 410008, Hunan, China; Organ Transplantation Center, Xiangya Hospital of Central South University, Changsha, Hunan, China.
| | - Laiyu Xu
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha, 410008, Hunan, China; Orthopedics Department, Xiangya Hospital of Central South University, Changsha, Hunan, China.
| | - Fangyi Zhou
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha, 410008, Hunan, China; Emergency Department, Xiangya Hospital of Central South University, Changsha, Hunan, China.
| | - Lingli Peng
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha, 410008, Hunan, China; National Clinical Research Center for Geriatric Diseases, Xiangya Hospital of Central South University, Changsha, Hunan, China; Orthopedics Department, Xiangya Hospital of Central South University, Changsha, Hunan, China.
| |
Collapse
|
4
|
Munroe B, Curtis K, Fry M, Balzer S, Perara P, Couttie T, Royston K, Yu P, Tidswell N, Considine J. Impact of an emergency department rapid response system on inpatient clinical deterioration: A controlled pre-post study. Australas Emerg Care 2023; 26:333-340. [PMID: 37210333 DOI: 10.1016/j.auec.2023.05.001] [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: 02/01/2023] [Revised: 05/03/2023] [Accepted: 05/03/2023] [Indexed: 05/22/2023]
Abstract
AIM To determine the impact implementation of Emergency Department Clinical Emergency Response System (EDCERS) on inpatient deterioration events and identify contributing causal factors. METHODS EDCERS was implemented in an Australian regional hospital, integrating a single parameter track and trigger criteria for escalation of care, and emergency, specialty and critical care clinician response to patient deterioration. In this controlled pre-post study, electronic medical records of patients who experienced a deterioration event (rapid response call, cardiac arrest or unplanned intensive care admission) on the ward within 72 h of admission from the emergency department (ED) were reviewed. Causal factors contributing to the deteriorating event were assessed using a validated human factors framework. RESULTS Implementation of EDCERS reduced the number of inpatient deterioration events within 72 h of emergency admission with failure or delayed response to ED patient deterioration as a causal factor. There was no change in the overall rate of inpatient deterioration events. CONCLUSION This study supports wider implementation of rapid response systems in the ED to improve management of deteriorating patients. Tailored implementation strategies should be used to achieve successful and sustainable uptake of ED rapid response systems and improve outcomes in deteriorating patients.
Collapse
Affiliation(s)
- Belinda Munroe
- Emergency Services, Illawarra Shoalhaven Local Health District, Australia; Faculty of Science, Medicine and Health, University of Wollongong, Australia.
| | - Kate Curtis
- Emergency Services, Illawarra Shoalhaven Local Health District, Australia; Faculty of Science, Medicine and Health, University of Wollongong, Australia; Susan Wakil School of Nursing and Midwifery, University of Sydney, Australia; George Institute for Global Health, Australia
| | - Margaret Fry
- Susan Wakil School of Nursing and Midwifery, University of Sydney, Australia; University of Technology Sydney, Australia; Northern Sydney Local Health District, Australia
| | - Sharyn Balzer
- Emergency Services, Illawarra Shoalhaven Local Health District, Australia; Shoalhaven Hospital Group, Illawarra Shoalhaven Local Health District, Australia
| | - Panchalee Perara
- Wollongong Hospital, Illawarra Shoalhaven Local Health District, Australia
| | - Tracey Couttie
- Division of Child and Families, Illawarra Shoalhaven Local Health District, Australia
| | - Karlie Royston
- Shoalhaven Hospital Group, Illawarra Shoalhaven Local Health District, Australia
| | - Ping Yu
- Centre for Digital Transformation, University of Wollongong, Australia
| | - Natasha Tidswell
- Emergency Services, Illawarra Shoalhaven Local Health District, Australia
| | - Julie Considine
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia; Centre for Quality and Patient Safety Research - Eastern Health, Box Hill, Victoria, Australia
| |
Collapse
|
5
|
Taveras AN, Clayton LM, Solano JJ, Hughes PG, Shih RD, Alter SM. Sudden Decompensation of Patients Admitted to Non-ICU Settings Within 24 h of Emergency Department Admission. J Intensive Care Med 2023; 38:399-403. [PMID: 36172632 DOI: 10.1177/08850666221129843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patients admitted to the hospital floor (non-intensive care (ICU) settings) from the emergency department (ED) are generally stable. Unfortunately, some will unexpectedly decompensate rapidly. This study explores these patients and their characteristics. METHODS This retrospective, observational study examined patients admitted to non-ICU settings at a community hospital. Patients were identified by rapid response team (RRT) activation, triggered by acute decompensation. ED chief complaint, reason for activation, and vital signs were compared between patients transferred to a higher level of care versus those who were not. RESULTS Throughout 2019, 424 episodes of acute decompensation were identified, 118 occurring within 24 h of admission. A higher rate of ICU transfers was seen in patients with initial ED chief complaints of general malaise (87.5% vs 12.5%, p = 0.023) and dyspnea (70.6% vs 29.4%, p = 0.050). Patients with sudden decompensation were more likely to need ICU transfer if the RRT reason was respiratory issues (47% vs 24%, p = 0.010) or hypertension (9.1% vs 0%, p = 0.019). Patients with syncope as a reason for decompensation were less likely to need transfer (0% vs 10.3%, p = 0.014). Patients requiring ICU transfer were significantly older (74.4 vs 71.8 years, p = 0.016). No differences in admission vital signs, APACHE score, or qSOFA score were found. CONCLUSIONS Patients admitted to the floor with chief complaint of general malaise or dyspnea should be considered at higher risk of having a sudden decompensation requiring transfer to a higher level of care. Therefore, greater attention should be taken with disposition of these patients at the time of admission.
Collapse
Affiliation(s)
- Anabelle N Taveras
- Department of Emergency Medicine, 306688Florida Atlantic University Charles E. Schmidt College of Medicine, 777 Glades Road, BC-71, Boca Raton, Florida 33431, USA.,Department of Emergency Medicine, 21684Bethesda Hospital East, 2815 South Seacrest Boulevard, Boynton Beach, Florida 33435, USA
| | - Lisa M Clayton
- Department of Emergency Medicine, 306688Florida Atlantic University Charles E. Schmidt College of Medicine, 777 Glades Road, BC-71, Boca Raton, Florida 33431, USA.,Department of Emergency Medicine, 21684Bethesda Hospital East, 2815 South Seacrest Boulevard, Boynton Beach, Florida 33435, USA
| | - Joshua J Solano
- Department of Emergency Medicine, 306688Florida Atlantic University Charles E. Schmidt College of Medicine, 777 Glades Road, BC-71, Boca Raton, Florida 33431, USA.,Department of Emergency Medicine, 21684Bethesda Hospital East, 2815 South Seacrest Boulevard, Boynton Beach, Florida 33435, USA
| | - Patrick G Hughes
- Department of Emergency Medicine, 306688Florida Atlantic University Charles E. Schmidt College of Medicine, 777 Glades Road, BC-71, Boca Raton, Florida 33431, USA.,Department of Emergency Medicine, 21684Bethesda Hospital East, 2815 South Seacrest Boulevard, Boynton Beach, Florida 33435, USA
| | - Richard D Shih
- Department of Emergency Medicine, 306688Florida Atlantic University Charles E. Schmidt College of Medicine, 777 Glades Road, BC-71, Boca Raton, Florida 33431, USA
| | - Scott M Alter
- Department of Emergency Medicine, 306688Florida Atlantic University Charles E. Schmidt College of Medicine, 777 Glades Road, BC-71, Boca Raton, Florida 33431, USA.,Department of Emergency Medicine, 21684Bethesda Hospital East, 2815 South Seacrest Boulevard, Boynton Beach, Florida 33435, USA
| |
Collapse
|
6
|
Allen J, Currey J, Jones D, Considine J, Orellana L. Development and Validation of the Medical Emergency Team-Risk Prediction Model for Clinical Deterioration in Acute Hospital Patients, at Time of an Emergency Admission. Crit Care Med 2022; 50:1588-1598. [PMID: 35866655 DOI: 10.1097/ccm.0000000000005621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To develop and validate a prediction model to estimate the risk of Medical Emergency Team (MET) review, within 48 hours of an emergency admission, using information routinely available at the time of hospital admission. DESIGN Development and validation of a multivariable risk model using prospectively collected data. Transparent Reporting of a multivariable model for Individual Prognosis Or Diagnosis recommendations were followed to develop and report the prediction model. SETTING A 560-bed teaching hospital, with a 22-bed ICU and 24-hour Emergency Department in Melbourne, Australia. PATIENTS A total of 45,170 emergency admissions of 30,064 adult patients (≥18 yr), with an inpatient length of stay greater than 24 hours, admitted under acute medical or surgical hospital services between 2015 and 2017. MEASUREMENTS AND MAIN RESULTS The outcome was MET review within 48 hours of emergency admission. Thirty candidate variables were selected from a routinely collected hospital dataset based on their availability to clinicians at the time of admission. The final model included nine variables: age; comorbid alcohol-related behavioral diagnosis; history of heart failure, chronic obstructive pulmonary disease (COPD), or renal disease; admitted from residential care; Charlson Comorbidity Index score 1 or 2, or 3+; at least one planned and one emergency admission in the last year; and admission diagnosis and one interaction (past history of COPD × admission diagnosis). The discrimination of the model was comparable in the training (C-statistics 0.82; 95% CI, 0.81-0.83) and the validation set (0.81; 0.80-0.83). Calibration was reasonable for training and validation sets. CONCLUSIONS Using only nine predictor variables available to clinicians at the time of admission, the MET-risk model can predict the risk of MET review during the first 48 hours of an emergency admission. Model utility in improving patient outcomes requires further investigation.
Collapse
Affiliation(s)
- Joshua Allen
- Deakin University, School of Nursing and Midwifery and Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Geelong, VIC, Australia
| | - Judy Currey
- Deakin University, School of Nursing and Midwifery and Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Geelong, VIC, Australia
| | - Daryl Jones
- DEPM Monash University, Level 6 The Alfred Centre (Alfred Hospital), Melbourne, VIC, Australia
| | - Julie Considine
- Deakin University, School of Nursing and Midwifery and Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Geelong, VIC, Australia
- Centre for Quality and Patient Safety Research-Eastern Health Partnership, VIC, Australia
| | - Liliana Orellana
- Biostatistics Unit, Faculty of Health, Deakin University, Geelong, VIC, Australia
| |
Collapse
|
7
|
Kim SW, Kim YW, Min YH, Lee KJ, Choi HJ, Kim DW, Jo YH, Lee DK. Development and Validation of Simple Age-Adjusted Objectified Korean Triage and Acuity Scale for Adult Patients Visiting the Emergency Department. Yonsei Med J 2022; 63:272-281. [PMID: 35184430 PMCID: PMC8860940 DOI: 10.3349/ymj.2022.63.3.272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 11/10/2021] [Accepted: 11/12/2021] [Indexed: 11/27/2022] Open
Abstract
PURPOSE The study aimed to develop an objectified Korean Triage and Acuity Scale (OTAS) that can objectively and quickly classify severity, as well as a simple age-adjusted OTAS (S-OTAS) that reflects age and evaluate its usefulness. MATERIALS AND METHODS A retrospective analysis was performed of all adult patients who had visited the emergency department at three teaching hospitals. Sex, systolic blood pressure, diastolic blood pressure, pulse rate, respiratory rate, body temperature, O2 saturation, and consciousness level were collected from medical records. The OTAS was developed with objective criterion and minimal OTAS level, and S-OTAS was developed by adding the age variable. For usefulness evaluation, the 30-day mortality, the rates of computed tomography scan and emergency procedures were compared between Korean Triage and Acuity Scale (KTAS) and OTAS. RESULTS A total of 44402 patients were analyzed. For 30-day mortality, S-OTAS showed a higher area under the curve (AUC) compared to KTAS (0.751 vs. 0.812 for KTAS and S-OTAS, respectively, p<0.001). Regarding the rates of emergency procedures, AUC was significantly higher in S-OTAS, compared to KTAS (0.807 vs. 0.830, for KTAS and S-OTAS, respectively, p=0.013). CONCLUSION S-OTAS showed comparative usefulness for adult patients visiting the emergency department as a triage tool compared to KTAS.
Collapse
Affiliation(s)
- Seung Wook Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yong Won Kim
- Department of Emergency Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Yong Hun Min
- Department of Emergency Medicine, Pohang St. Mary's Hospital, Pohang, Korea
| | - Kui Ja Lee
- Department of Emergency Medical Services, Kyungdong University, Wonju, Korea
| | - Hyo Ju Choi
- Department of Emergency Medical Services, Kyungdong University, Wonju, Korea
| | - Dong Won Kim
- Department of Emergency Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea.
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Keon Lee
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea.
| |
Collapse
|
8
|
Wijesundera P, See EJ, Robbins R, Crosthwaite A, Smallwood D, Jones D, Bellomo R. Features, risk factors, and outcomes of older internal medicine patients triggering a medical emergency team call. Acta Anaesthesiol Scand 2022; 66:392-400. [PMID: 34875110 DOI: 10.1111/aas.14014] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 10/07/2021] [Accepted: 11/09/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Information about the epidemiology of older Internal Medicine patients receiving medical emergency team (MET) calls is limited. We assessed the prevalence, characteristics, risk factors, and outcomes of this vulnerable group. METHODS Internal Medicine patients aged >75 years who were admitted via the Emergency Department to a tertiary hospital between January 2015 to December 2018 and who activated a MET call were compared to patients without MET call activation during the same time period. Outcome measures included management post-MET call, Intensive Care Unit (ICU) admission rates, discharge disposition, length of hospital stays (LOS), and in-patient mortality. RESULTS There were 10,803 Internal Medical admissions involving 10,423 patients; median age 85 (IQR 81-89) years. Of these, 995 (10%) patients received at least one MET call. MET call patients had greater physiological instability in the Emergency Department and higher median Charlson comorbidity index values (2, IQR 1-3 vs. 1, IQR 0-2; p < .0001) than non-MET call patients. Overall, 10% of MET call patients were admitted to ICU. MET patients had a longer median length of stay (9 [IQR 5-14] vs. 4 days [IQR 2-7]; p < .001) and higher in-hospital mortality (29% vs. 7%; p < .001). However, mortality of MET call patients without treatment limitations was 48/357 (13%). CONCLUSION One in ten Internal Medicine patients aged >75 years and admitted via ED had a MET call. Physiological instability in ED and comorbidities were key risk factors. Mortality in MET patients approached 30%. These data can help predict at-risk patients for improving goals of care and pre-MET interventions.
Collapse
Affiliation(s)
- Piyumi Wijesundera
- Department of General Medicine Austin Hospital Melbourne Victoria Australia
| | - Emily J. See
- Intensive Care Unit Austin Hospital Melbourne Victoria Australia
| | - Raymond Robbins
- Data Analytics Research and Evaluation (DARE) Centre Austin Hospital Melbourne Victoria Australia
| | - Amy Crosthwaite
- Department of General Medicine Austin Hospital Melbourne Victoria Australia
| | - David Smallwood
- Department of General Medicine Austin Hospital Melbourne Victoria Australia
| | - Daryl Jones
- Intensive Care Unit Austin Hospital Melbourne Victoria Australia
| | - Rinaldo Bellomo
- Intensive Care Unit Austin Hospital Melbourne Victoria Australia
- Data Analytics Research and Evaluation (DARE) Centre Austin Hospital Melbourne Victoria Australia
| |
Collapse
|
9
|
Batterbury A, Douglas C, Coyer F. The illness severity of patients reviewed by the medical emergency team: A scoping review. Aust Crit Care 2021; 34:496-509. [PMID: 33509705 DOI: 10.1016/j.aucc.2020.11.006] [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: 07/10/2020] [Revised: 11/16/2020] [Accepted: 11/22/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Medical emergency teams (METs) are internationally used to manage hospitalised deteriorating patients. Although triggers for MET review and hospital outcomes have previously been widely reported, the illness severity at the point of MET review has not been reported. As such, levels of clinical acuity and patient dependency representing the risk of exposure to short-term adverse clinical outcomes remain largely unknown. OBJECTIVE This scoping review sought to understand the illness severity of MET review recipients in terms of acuity and dependency. METHODS This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. The published and grey literature since 2009 was searched to identify relevant articles reporting illness severity scores associated with hospitalised adult inpatients reviewed by a MET. After applying the inclusion and exclusion criteria, 17 articles (16 quantitative studies, one mixed-methods study) were reviewed, summarised, collated, and reported. RESULTS A total of 17 studies reported clinical acuity metrics for patients reviewed by a MET. No studies described an integrated risk score encompassing acuity, patient dependency, or wider parameters that might be associated with increased patient risk or the need for intervention. Multi-MET review, the use of specialist interventions, and delayed/transfer to the intensive care unit were associated with a greater risk of clinical deterioration, higher clinical acuity score, and predicted mortality risk. A single dependency metric was not reported although organisational levels of care, the duration of MET review, MET interventions, chronic illness, and frailty were inferred proxy measures. CONCLUSION Of the 17 studies reviewed, no single study provided an integrated assessment of illness severity from which to stratify risk or support patient management processes. Patients reviewed by a MET have variable and rapidly changing health needs that make them particularly vulnerable. The lack of high-quality data reporting acuity and dependency limits our understanding of true clinical risk and subsequent opportunities for pathway development.
Collapse
Affiliation(s)
- Anthony Batterbury
- Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia; School of Nursing/Centre for Healthcare Transformation, Queensland University of Technology, Victoria Park Rd, Kelvin Grove, QLD, 4059, Australia.
| | - Clint Douglas
- School of Nursing/Centre for Healthcare Transformation, Queensland University of Technology, Victoria Park Rd, Kelvin Grove, QLD, 4059, Australia; Metro North Hospital and Health Service, Herston, QLD, 4029, Australia.
| | - Fiona Coyer
- Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia; School of Nursing/Centre for Healthcare Transformation, Queensland University of Technology, Victoria Park Rd, Kelvin Grove, QLD, 4059, Australia.
| |
Collapse
|
10
|
Haegdorens F, Monsieurs KG, De Meester K, Van Bogaert P. The optimal threshold for prompt clinical review: An external validation study of the national early warning score. J Clin Nurs 2020; 29:4594-4603. [PMID: 32920891 DOI: 10.1111/jocn.15493] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 08/07/2020] [Accepted: 08/29/2020] [Indexed: 12/21/2022]
Abstract
AIMS AND OBJECTIVES The aim of this study was to determine the optimal threshold for national early warning score in clinical practice. BACKGROUND The national early warning score is an aggregate early warning score aiming to predict patient mortality. Studies validating national early warning score did not use standardised patient outcomes or did not always include clinical workload in their results. Since all patients with a positive national early warning score require a clinical workup, it is crucial to determine the optimal threshold to limit false-positive alerts. DESIGN An external validation study using retrospectively collected data of patient admissions in six Belgian hospitals. METHODS We adhered to the STARD guideline for reporting. Two sample groups were selected: the cross-sectional sample (admitted patients, 1 day every 4 months) and the serious adverse event sample (all patients with unexpected death, cardiac arrest and unplanned admission to the intensive care unit). The maximum registered national early warning score value was collected in both groups. Predictive values were used as estimates for clinical workload. RESULTS We collected 1,523 in the cross-sectional sample and 390 patients in the serious adverse event sample. A national early warning score ≥5 had a predictive value of 6.8% and a negative predictive value of 99.5% to predict unexpected death, cardiac arrest with cardiopulmonary resuscitation or unplanned admission to intensive care (AUROC 0.841). The performance of national early warning score differed between outcome measures. Considering the predictive value, the optimal threshold for national early warning score is ≥5. CONCLUSIONS We validated national early warning score to be applied in general hospital wards and confirmed the optimal threshold (≥5). RELEVANCE TO CLINICAL PRACTICE When a patient has a national early warning score <5, we may assume that in the next 24 hr this patient is less likely to die unexpectedly, receive cardiopulmonary resuscitation or be transferred to the ICU. Because of the significant number of false positives when national early warning score is ≥5, hospitals should create workable guidelines for clinical practice.
Collapse
Affiliation(s)
- Filip Haegdorens
- Department of Nursing and Midwifery Sciences, Centre for Research and Innovation in Care (CRIC), University of Antwerp, Wilrijk, Belgium
| | - Koenraad G Monsieurs
- Department of Emergency Medicine, Antwerp University Hospital, University of Antwerp, Edegem, Belgium
| | - Koen De Meester
- Department of Nursing and Midwifery Sciences, Centre for Research and Innovation in Care (CRIC), University of Antwerp, Wilrijk, Belgium
| | - Peter Van Bogaert
- Department of Nursing and Midwifery Sciences, Centre for Research and Innovation in Care (CRIC), University of Antwerp, Wilrijk, Belgium
| |
Collapse
|
11
|
Munroe B, Curtis K, Balzer S, Roysten K, Fetchet W, Tucker S, Pratt W, Morris R, Fry M, Considine J. Translation of evidence into policy to improve clinical practice: the development of an emergency department rapid response system. Australas Emerg Care 2020; 24:197-209. [PMID: 32950439 DOI: 10.1016/j.auec.2020.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 08/18/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Undetected clinical deterioration is a major cause of high mortality events in Emergency Department (ED) patients. Yet, there is no known model to guide the recognition and response to clinical deterioration in the ED, integrating internal and external resources. METHODS An integrative review was firstly conducted to identify the critical components of recognising and responding to clinical deterioration in the ED. Components identified from the review were analysed by clinical experts and informed the development of an ED Clinical Emergency Response System (EDCERS). RESULTS Twenty four eligible studies were included in the review. Eight core components were identified: 1) vital sign monitoring; 2) track and trigger system; 3) communication plan; 4) response time; 5) emergency nurse response; 6) emergency physician response; 7) critical care team response; and 8) specialty team response. These components informed the development of the EDCERS protocol, integrating responses from staff internal and external to the ED. CONCLUSIONS EDCERS was based on the best available evidence and considered the cultural context of care. Future research is needed to determine the useability and impact of EDCERS on patient and health outcomes.
Collapse
Affiliation(s)
- Belinda Munroe
- Faculty of Medicine and Health, The University of Sydney Susan Wakil School of Nursing and Midwifery, Mallet St, Camperdown, NSW, Australia; Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia.
| | - Kate Curtis
- Faculty of Medicine and Health, The University of Sydney Susan Wakil School of Nursing and Midwifery, Mallet St, Camperdown, NSW, Australia; Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia
| | - Sharyn Balzer
- Emergency Department, Shoalhaven Memorial District Hospital, Shoalhaven, NSW, Australia
| | - Karlie Roysten
- Clinical Emergency Response, Executive Services, Shoalhaven Hospital Groups, Shoalhaven, NSW, Australia
| | - Wendy Fetchet
- Emergency Department, Shoalhaven Memorial District Hospital, Shoalhaven, NSW, Australia
| | - Simon Tucker
- Emergency Department, Shoalhaven Memorial District Hospital, Shoalhaven, NSW, Australia
| | - William Pratt
- Department of Medicine, Shoalhaven Memorial District Hospital, Shoalhaven, NSW, Australia
| | - Richard Morris
- Intensive Care Unit, Shoalhaven Memorial District Hospital, Shoalhaven, NSW, Australia; Faculty of Medicine, University of NSW
| | - Margaret Fry
- University of Technology Sydney School of Nursing and Midwifery Broadway NSW 2007; Northern Sydney Local Health District
| | - Julie Considine
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, and Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia; Centre for Quality and Patient Safety Research - Eastern Health Partnership, Eastern Health, Box Hill, Victoria, Australia
| |
Collapse
|
12
|
The prognostic value of national early warning scores (NEWS) during transfer of care from community settings to hospital: a retrospective service evaluation. BJGP Open 2020; 4:bjgpopen20X101071. [PMID: 32398345 PMCID: PMC7330211 DOI: 10.3399/bjgpopen20x101071] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 03/23/2020] [Indexed: 11/09/2022] Open
Abstract
Background The National Early Warning Score (NEWS) calculated from physiological observations provides a simple away to identify and respond to the deteriorating patient. There is increasing interest in the application of NEWS to facilitate referrals from the community. Aim To establish whether elevated NEWS are associated with adverse outcomes at 5 and 30 days when obtained in a community setting at the time of transfer to an acute setting. Design & setting A retrospective service evaluation was undertaken using a database of emergency admissions to secondary care from two NHS district general hospitals within the South of England between January 2018 and April 2019. Method The performance of NEWS recorded in a community setting to predict death or critical care admission at 5 and 30 days was calculated using established thresholds. Results 2786 referrals from primary care were analysed. The 5 day and 30 day mortality was 2.2% (1.7 to 2.8) and 7.1% (6.2 to 8.1). The prevalence of the composite outcome was 3.4% (2.8 to 4.2) at 5 days and 8.5% (7.5 to 9.6) at 30 days. The risk of adverse outcomes increased incrementally with increasing NEWS. When calculated at the point of referral from primary care the positive predictive value of death at 5 and 30 days was 15% (95% confidence intervals [CI] = 12 to 19) and 23% (95% CI = 17 to 30) in the high-risk NEWS group. Conclusion Elevated NEWS obtained in the community during the process of emergency admission are associated with adverse outcomes. Communicating NEWS may allow downstream care to be better calibrated to risk.
Collapse
|
13
|
Vital sign abnormalities as predictors of clinical deterioration in subacute care patients: A prospective case-time-control study. Int J Nurs Stud 2020; 108:103612. [PMID: 32473397 DOI: 10.1016/j.ijnurstu.2020.103612] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 01/03/2020] [Accepted: 04/14/2020] [Indexed: 11/21/2022]
Abstract
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.
Collapse
|
14
|
Mäkinen M, Castrén M, Huttunen K, Sundell S, Kaartinen J, Ben-Meir M, Renholm M. Assessing the discharge instructing in the emergency department: Patient perspective. Int Emerg Nurs 2019; 43:40-44. [DOI: 10.1016/j.ienj.2018.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 06/19/2018] [Accepted: 07/20/2018] [Indexed: 12/24/2022]
|
15
|
Cross R, Considine J, Currey J. Nursing handover of vital signs at the transition of care from the emergency department to the inpatient ward: An integrative review. J Clin Nurs 2018; 28:1010-1021. [DOI: 10.1111/jocn.14679] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 09/03/2018] [Accepted: 09/13/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Rachel Cross
- School of Nursing and Midwifery Deakin University Burwood Victoria Australia
- School of Nursing and Midwifery La Trobe University Melbourne Victoria Australia
| | - Julie Considine
- Centre for Quality and Patient Safety Research School of Nursing and Midwifery Deakin University Geelong Victoria Australia
- Centre for Quality and Patient Safety Research Eastern Health Partnership Box Hill Victoria Australia
| | - Judy Currey
- Centre for Quality and Patient Safety Research School of Nursing and Midwifery Deakin University Geelong Victoria Australia
| |
Collapse
|
16
|
Clinical significance in nursing research: A discussion and descriptive analysis. Int J Nurs Stud 2017; 73:17-23. [DOI: 10.1016/j.ijnurstu.2017.05.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 05/02/2017] [Accepted: 05/04/2017] [Indexed: 12/19/2022]
|
17
|
Frequency of vital sign assessment and clinical deterioration in an Australian emergency department. ACTA ACUST UNITED AC 2016; 19:217-222. [DOI: 10.1016/j.aenj.2016.09.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 09/07/2016] [Accepted: 09/13/2016] [Indexed: 11/18/2022]
|
18
|
Alberto L, Gillespie BM, Green A, Martínez MDC, Cañete A, Zotarez H, Díaz CA, Enriquez M, Gerónimo M, Chaboyer W. Activities undertaken by Intensive Care Unit Liaison Nurses in Argentina. Aust Crit Care 2016; 30:74-78. [PMID: 27451146 DOI: 10.1016/j.aucc.2016.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 06/22/2016] [Accepted: 06/25/2016] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The Intensive Care Unit Liaison Nurse (ICULN), also known as an outreach nurse, is an advanced practice nursing role that emerged in the late 1990s in Australia and the United Kingdom (UK). Little is known about this role in less developed economies. OBJECTIVE To describe the activities undertaken by ICULNs in Argentina. METHODS Prospective, descriptive, observational, single site study in an Argentinean metropolitan tertiary referral hospital. Adult patients under ICULN follow up were included in the sample. Data on ICULN activities and patients were collected using an established tool developed by The Australian Intensive Care Unit Liaison Nurse Forum. Descriptive statistics were used to summarise the findings. RESULTS Two hundred patients were visited by the ICULNs during the study period. The mean age of patients was 52.5 years (SD 17.7). Cardiovascular disease (n=104, 52%), respiratory disease (n=90, 45%) and diabetes (n=40, 20%) were the most common comorbidities. 110 (55%) patients had surgical procedures. The primary reasons for ICULN visit were follow up post ICU discharge (n=138, 69%) and ward referral (n=46, 23%). 136 (68%) patients received up to 3 visits; the remaining 64 (32%) patients received ≥4 visits. In those patients in need of ≥4 visits ICULNs initiated more non-medical treatments (100%), referred to escalate treatment (35%) and to a higher level of care (13.8%) than in those who were visited up to 3 times. CONCLUSIONS This study is the first to document ICULN activity in Argentina using an international framework and data set. These findings can assist with understanding an advanced practice nursing role in Argentina. It may facilitate future comparisons with other contexts and could help managers implementing the role in similar settings. Further investigation will help develop this practice and document its influence on patient outcomes.
Collapse
Affiliation(s)
- Laura Alberto
- Sanatorio de Alta Complejidad Sagrado Corazón, Ciudad de Buenos Aires, Argentina; Menzies Health Institute Qld (MHIQ), Griffith University, Queensland, Australia; School of Nursing & Midwifery, Griffith University, Queensland, Australia.
| | - Brigid M Gillespie
- Menzies Health Institute Qld (MHIQ), Griffith University, Queensland, Australia; NHMRC Centre for Research Excellence in Nursing, Griffith University, Queensland, Australia
| | - Anna Green
- ICU Liaison Nurse Service, Western Health (1998 - 2015), Victoria, Australia
| | - Maria Del Carmen Martínez
- Sanatorio de Alta Complejidad Sagrado Corazón, Ciudad de Buenos Aires, Argentina; School of Nursing, Universidad de Buenos Aires, Ciudad de Buenos Aires, Argentina
| | - Angel Cañete
- Sanatorio de Alta Complejidad Sagrado Corazón, Ciudad de Buenos Aires, Argentina
| | - Haydee Zotarez
- Sanatorio de Alta Complejidad Sagrado Corazón, Ciudad de Buenos Aires, Argentina
| | - Carlos Alberto Díaz
- Sanatorio de Alta Complejidad Sagrado Corazón, Ciudad de Buenos Aires, Argentina; Economy and Health Management Specialization Program, Universidad ISALUD, Ciudad de Buenos Aires, Argentina
| | - Marcelino Enriquez
- Sanatorio de Alta Complejidad Sagrado Corazón, Ciudad de Buenos Aires, Argentina
| | - Mario Gerónimo
- Sanatorio de Alta Complejidad Sagrado Corazón, Ciudad de Buenos Aires, Argentina
| | - Wendy Chaboyer
- Menzies Health Institute Qld (MHIQ), Griffith University, Queensland, Australia; NHMRC Centre for Research Excellence in Nursing, Griffith University, Queensland, Australia
| |
Collapse
|