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Honarmand K, Wax RS, Penoyer D, Lighthall G, Danesh V, Rochwerg B, Cheatham ML, Davis DP, DeVita M, Downar J, Edelson D, Fox-Robichaud A, Fujitani S, Fuller RM, Haskell H, Inada-Kim M, Jones D, Kumar A, Olsen KM, Rowley DD, Welch J, Baldisseri MR, Kellett J, Knowles H, Shipley JK, Kolb P, Wax SP, Hecht JD, Sebat F. Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU: 2023. Crit Care Med 2024; 52:314-330. [PMID: 38240510 DOI: 10.1097/ccm.0000000000006072] [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: 01/23/2024]
Abstract
RATIONALE Clinical deterioration of patients hospitalized outside the ICU is a source of potentially reversible morbidity and mortality. To address this, some acute care hospitals have implemented systems aimed at detecting and responding to such patients. OBJECTIVES To provide evidence-based recommendations for hospital clinicians and administrators to optimize recognition and response to clinical deterioration in non-ICU patients. PANEL DESIGN The 25-member panel included representatives from medicine, nursing, respiratory therapy, pharmacy, patient/family partners, and clinician-methodologists with expertise in developing evidence-based Clinical Practice Guidelines. METHODS We generated actionable questions using the Population, Intervention, Control, and Outcomes (PICO) format and performed a systematic review of the literature to identify and synthesize the best available evidence. We used the Grading of Recommendations Assessment, Development, and Evaluation Approach to determine certainty in the evidence and to formulate recommendations and good practice statements (GPSs). RESULTS The panel issued 10 statements on recognizing and responding to non-ICU patients with critical illness. Healthcare personnel and institutions should ensure that all vital sign acquisition is timely and accurate (GPS). We make no recommendation on the use of continuous vital sign monitoring among unselected patients. We suggest focused education for bedside clinicians in signs of clinical deterioration, and we also suggest that patient/family/care partners' concerns be included in decisions to obtain additional opinions and help (both conditional recommendations). We recommend hospital-wide deployment of a rapid response team or medical emergency team (RRT/MET) with explicit activation criteria (strong recommendation). We make no recommendation about RRT/MET professional composition or inclusion of palliative care members on the responding team but suggest that the skill set of responders should include eliciting patients' goals of care (conditional recommendation). Finally, quality improvement processes should be part of a rapid response system. CONCLUSIONS The panel provided guidance to inform clinicians and administrators on effective processes to improve the care of patients at-risk for developing critical illness outside the ICU.
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Affiliation(s)
- Kimia Honarmand
- Division of Critical Care, Department of Medicine, Mackenzie Health, Vaughan, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Randy S Wax
- Department of Critical Care Medicine, Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
- Department of Critical Care, Lakeridge Health, Oshawa, ON, Canada
| | - Daleen Penoyer
- Center for Nursing Research and Advanced Nursing Practice, Orlando Health, Orlando, FL
| | - Geoffery Lighthall
- Department of Anesthesia, Pain, and Perioperative Medicine, Stanford University School of Medicine, Palo Alto, CA
- Veterans Affairs Medical Center, Palo Alto, CA
| | - Valerie Danesh
- Center for Applied Health Research, Baylor Scott and White Health, Dallas, TX
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, Mackenzie Health, Vaughan, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Michael L Cheatham
- Division of Surgical Education, Orlando Regional Medical Center, Orlando, FL
| | | | - Michael DeVita
- Columbia Vagelos College of Physicians and Surgeons, Department of Medicine Harlem Hospital Medical Center, New York City, NY
| | - James Downar
- Division of Critical Care, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Dana Edelson
- Division of Internal Medicine, Department of Medicine, University of Chicago Medical Center, Chicago, IL
| | - Alison Fox-Robichaud
- Division of Critical Care, Department of Internal Medicine, Thrombosis and Atherosclerosis Research Institute, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Shigeki Fujitani
- Division of Critical Care, Department of Emergency Medicine, Saint Marianna University, Kawasaki, Japan
| | - Raeann M Fuller
- Division of Trauma and Critical Care, Department of Emergency Medicine, Advocate Condell Medical Center, Libertyville, IL
| | | | - Matthew Inada-Kim
- Department of Acute Medicine, Hampshire Hospitals NHS Foundation Trust and University of Southampton, Southampton, United Kingdom
| | - Daryl Jones
- Division of Surgery, Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Anand Kumar
- Division of Critical Care, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Keith M Olsen
- University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE
| | - Daniel D Rowley
- Respiratory Therapy Services, University of Virginia Medical Center, Charlottesville, VA
| | - John Welch
- Critical Care Unit, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Marie R Baldisseri
- Department of Critical Care, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - John Kellett
- Department of Emergency Medicine, University of Southern Denmark, Odense, Denmark
| | - Heidi Knowles
- Department of Emergency Medicine, John Peter Smith Health Network, Fort Worth, TX
| | - Jonathan K Shipley
- Division of Critical Care, Vanderbilt University Medical Center, Nashville, TN
| | - Philipp Kolb
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Family Medicine, Dalhousie University, Halifax, ON, Canada
| | - Sophie P Wax
- Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
| | - Jonathan D Hecht
- School of Nursing, The University of Texas at Austin, Austin, TX
| | - Frank Sebat
- Division of Internal Medicine, Mercy Medical Center, Redding, CA
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Augutis W, Flenady T, Le Lagadec D, Jefford E. How do nurses use early warning system vital signs observation charts in rural, remote and regional health care facilities: A scoping review. Aust J Rural Health 2023. [PMID: 36802114 DOI: 10.1111/ajr.12971] [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: 09/07/2022] [Revised: 12/08/2022] [Accepted: 02/03/2023] [Indexed: 02/21/2023] Open
Abstract
INTRODUCTION Physiological signs of clinical deterioration are known to occur in the hours preceding a serious adverse event. As a result, track and trigger systems known as early warning systems (EWS) were introduced and routinely implemented as patient observation tools to trigger an alert in the presence of abnormal vital signs. OBJECTIVE The objective aimed to explore the literature pertaining to EWS and their utilisation in rural, remote and regional health care facilities. DESIGN The Arksey and O'Malley's methodological framework was used to guide the scoping review. Only studies reporting on rural, remote and regional health care settings were included. All four authors participated in the screening, data extraction and analysis process. FINDINGS Our search strategy yielded 3869 peer-reviewed articles published between 2012 and 2022, with six studies ultimately included. Collectively, the studies included in this scoping review examined the complex interaction between patient vital signs observation charts and recognition of patient deterioration. DISCUSSION Whilst rural, remote and regional clinicians use EWS to recognise and respond to clinical deterioration, noncompliance dilutes the tool's effectiveness. This overarching finding is informed by three contributing factors: documentation, communication and challenges specific to the rural context. CONCLUSION The success of EWS relies on accurate documentation and effective communication within the interdisciplinary team to support appropriate responses to clinical patient decline. More research is required to understand the nuances and complexities of rural and remote nursing and to address challenges associated with the use of EWS in rural health care settings.
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Affiliation(s)
- Wendy Augutis
- School of Nursing & Midwifery, Central Queensland University, Bundaberg, Queensland, Australia
| | - Tracy Flenady
- School of Nursing & Midwifery, Central Queensland University, Rockhampton, Queensland, Australia
| | - Danielle Le Lagadec
- School of Nursing & Midwifery, Central Queensland University, Bundaberg, Queensland, Australia
| | - Elaine Jefford
- Clinical and health Sciences, University of the Sunshine Coast, Adelaide, Queensland, Australia
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4
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Newman D, Hofstee F, Bowen K, Massey D, Penman O, Aggar C. A qualitative study exploring clinicians’ attitudes toward responding to and escalating care of deteriorating patients. J Interprof Care 2022; 37:541-548. [DOI: 10.1080/13561820.2022.2104231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Affiliation(s)
- Deb Newman
- Northern New South Wales Local Health District, Australia
| | - Fran Hofstee
- Northern New South Wales Local Health District, Australia
| | - Karen Bowen
- Northern New South Wales Local Health District, Australia
| | - Deb Massey
- School of Health & Human Sciences Southern Cross Drive, Southern Cross University, Lismore, Australia
| | - Olivia Penman
- School of Health & Human Sciences Southern Cross Drive, Southern Cross University, Lismore, Australia
| | - Christina Aggar
- Northern New South Wales Local Health District, Australia
- School of Health & Human Sciences Southern Cross Drive, Southern Cross University, Lismore, Australia
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Hewitt L, Frohmuller C, Wall J, Okely AD. Clinician and early childhood educator knowledge and advice given to parents regarding physical activity, screen time and sleep. An observational study. J Pediatr Nurs 2022; 66:143-150. [PMID: 35759995 DOI: 10.1016/j.pedn.2022.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 05/19/2022] [Accepted: 06/17/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Global guidelines regarding infant physical activity, screen time and sleep were released by the World Health Organisation in 2019. Clinician and Early Childhood Educator's knowledge and advice given to parents regarding this content is unknown. The aims of this study were to determine the advice given to parents regarding infant care. This will enable a baseline from which future interventions and multidisciplinary professional development can be compared and reviewed. METHODS 80 Clinicians (Medical, Nursing, Allied Health) and Early Childhood Educators from a local health district in NSW Australia completed an online survey. Medical records (N = 272) were also reviewed to determine if the documentation included advice in accordance with guidelines. FINDINGS Staff were aware that infant guidelines contributes to positive health outcomes (all >85%). Nursing entered the most information into the medical record with >80% of files containing general advice about infant physical activity and sleep. Only 30% of entries contained evidence of guideline specific information. Minimal entries from all clinicians contained information about screen time (2%). DISCUSSION The majority of clinicians and Early Childhood Educators were aware of the content of the guidelines and the advice they report to provide is consistent. Medical record documentation regarding the specificity of advice provided is lacking. APPLICATION TO PRACTICE This study provides a baseline from which professional development interventions aimed at increasing compliance to infant guidelines can be compared.
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Affiliation(s)
- Lyndel Hewitt
- Illawarra Shoalhaven Local Health District, Wollongong Hospital, Wollongong, New South Wales, 2500, Australia; Illawarra Health and Medical Research Institute, Wollongong, New South Wales, 2522, Australia; Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, 2522, Australia.
| | - Carolyn Frohmuller
- Illawarra Shoalhaven Local Health District, Wollongong Hospital, Wollongong, New South Wales, 2500, Australia.
| | - Jacinta Wall
- Illawarra Shoalhaven Local Health District, Wollongong Hospital, Wollongong, New South Wales, 2500, Australia.
| | - Anthony D Okely
- Illawarra Health and Medical Research Institute, Wollongong, New South Wales, 2522, Australia; Early Start, Faculty of the Arts, Social Sciences and Humanities, University of Wollongong, Wollongong, New South Wales, 2522, Australia.
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Ede J, Jeffs E, Vollam S, Watkinson P. A qualitative exploration of escalation of care in the acute ward setting. Nurs Crit Care 2020; 25:171-178. [PMID: 31833178 PMCID: PMC7217245 DOI: 10.1111/nicc.12479] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 09/18/2019] [Accepted: 09/24/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND "Failure to Rescue" includes failing to prevent avoidable patient deterioration and death. Despite its use, delays in care escalation still affect patient outcomes. AIMS AND OBJECTIVE The aim of this qualitative service evaluation was to map the barriers and facilitators to the escalation of care in the acute ward setting and identify those that are modifiable. DESIGN A total of 55 hours of qualitative observations were completed to capture care escalation events. These were conducted at two hospital sites in one National Health Service trust. METHODS Observations were iterative, with research team meetings being used to discuss the data and future methods. Field notes were analysed thematically by two researchers, extracting data on barriers and facilitators to escalation of care. RESULTS Clinical nursing staff challenged the sensitivity and specificity of Early Warning Scores, describing tool failings in certain clinical scenarios. Staff did not escalate based on the alerting Early Warning Scores alone but used other clinical factors, such as bleeding, which are not necessarily captured in the scoring systems. Staff frequently did not re-escalate low-level scores. Patient and non-patient factors identified as posing barriers to escalation were complex care needs, patient outlier status, and involvement of multiple care teams. Factors negatively affecting the chain of communication during escalation were team tension, staffing levels, and inadequate handover. CONCLUSION This service evaluation identified barriers and facilitators to the escalation of care in the acute ward setting. Unlike other studies, we found that re-escalation or tracking of deterioration was problematic. Patients identified as being at a higher risk of escalation failure included complex patients, outliers, and patients with multiple care teams. RELEVANCE TO CLINICAL PRACTICE This service evaluation demonstrates continuing health care communication barriers. Patient groups (complex patients and outliers) risk process failures during escalation. This can be applied in clinical practice by staff anticipating problems in these patients, documenting clear escalation pathways.
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Affiliation(s)
- Jody Ede
- Nuffield Department of Clinical NeurosciencesUniversity of OxfordOxfordEngland
| | - Emma Jeffs
- Emergency DepartmentRoyal Children's HospitalMelbourneVictoriaAustralia
| | - Sarah Vollam
- Nuffield Department of Clinical NeurosciencesUniversity of OxfordOxfordEngland
| | - Peter Watkinson
- Nuffield Department of Clinical NeurosciencesUniversity of OxfordOxfordEngland
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Le Lagadec MD, Dwyer T, Browne M. The efficacy of twelve early warning systems for potential use in regional medical facilities in Queensland, Australia. Aust Crit Care 2019; 33:47-53. [PMID: 30979578 DOI: 10.1016/j.aucc.2019.03.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 02/05/2019] [Accepted: 03/06/2019] [Indexed: 10/27/2022] Open
Abstract
AIM Early warning system (EWS) validation studies are conducted predominantly in tertiary metropolitan facilities and are not necessarily applicable to regional hospitals. This study evaluates 12 EWSs for use in regional subcritical hospitals. METHOD This is a retrospective case-control study of patients who experienced severe adverse events (SAEs) in two regional private hospitals. Vital signs collected over 72 h preceding the SAE were applied to 12 EWSs representing three classes of EWSs. The EWS area under the receiver operator characteristic curve (AUROC), sensitivity, specificity, and number of alerts were calculated. RESULTS Data from 159 index and 172 control patients showed no significant differences in demographics, length of stay, and level of comorbidities. Only half of index patients achieved a medical emergency alert threshold score. On average, index patients triggered alerts 20.06 (22.67) hours preceding the SAE and alerted 2.25 (3.87) times over 72 h. The AUROC ranged from 0.628 to 0.747, with a single-parameter EWS having the lowest AUROC and an aggregated weighted EWS, the highest. The sensitivity of the EWS ranges from 0.359 to 0.692. The specificity was greater than 0.9 for all the EWSs tested. CONCLUSIONS Based on the EWS sensitivity and AUROC, there is a lack of conclusive evidence of the efficacy of the 12 EWSs tested. However, because the adoption of the EWS in Australian hospitals is mandatory, the implementation of an aggregated weighted EWS, such as Compass, should be considered in subcritical regional private hospitals. Given that only half of SAE achieved an EWS medical alert threshold score, it is important that good clinical judgement be used with EWS.
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Affiliation(s)
| | - Trudy Dwyer
- CQUniversity Australia, Building 18/G.06 Rockhampton, Bruce Highway, Rockhampton Qld, 4702 Australia.
| | - Matthew Browne
- CQUniversity Australia, University Drive, Building 8/G.47 Bundaberg, Branyan Australia, Qld, 4670, Australia.
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11
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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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