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Briggs J, Kostakis I, Meredith P, Dall'ora C, Darbyshire J, Gerry S, Griffiths P, Hope J, Jones J, Kovacs C, Lawrence R, Prytherch D, Watkinson P, Redfern O. Safer and more efficient vital signs monitoring protocols to identify the deteriorating patients in the general hospital ward: an observational study. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2024; 12:1-143. [PMID: 38551079 DOI: 10.3310/hytr4612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Background The frequency at which patients should have their vital signs (e.g. blood pressure, pulse, oxygen saturation) measured on hospital wards is currently unknown. Current National Health Service monitoring protocols are based on expert opinion but supported by little empirical evidence. The challenge is finding the balance between insufficient monitoring (risking missing early signs of deterioration and delays in treatment) and over-observation of stable patients (wasting resources needed in other aspects of care). Objective Provide an evidence-based approach to creating monitoring protocols based on a patient's risk of deterioration and link these to nursing workload and economic impact. Design Our study consisted of two parts: (1) an observational study of nursing staff to ascertain the time to perform vital sign observations; and (2) a retrospective study of historic data on patient admissions exploring the relationships between National Early Warning Score and risk of outcome over time. These were underpinned by opinions and experiences from stakeholders. Setting and participants Observational study: observed nursing staff on 16 randomly selected adult general wards at four acute National Health Service hospitals. Retrospective study: extracted, linked and analysed routinely collected data from two large National Health Service acute trusts; data from over 400,000 patient admissions and 9,000,000 vital sign observations. Results Observational study found a variety of practices, with two hospitals having registered nurses take the majority of vital sign observations and two favouring healthcare assistants or student nurses. However, whoever took the observations spent roughly the same length of time. The average was 5:01 minutes per observation over a 'round', including time to locate and prepare the equipment and travel to the patient area. Retrospective study created survival models predicting the risk of outcomes over time since the patient was last observed. For low-risk patients, there was little difference in risk between 4 hours and 24 hours post observation. Conclusions We explored several different scenarios with our stakeholders (clinicians and patients), based on how 'risk' could be managed in different ways. Vital sign observations are often done more frequently than necessary from a bald assessment of the patient's risk, and we show that a maximum threshold of risk could theoretically be achieved with less resource. Existing resources could therefore be redeployed within a changed protocol to achieve better outcomes for some patients without compromising the safety of the rest. Our work supports the approach of the current monitoring protocol, whereby patients' National Early Warning Score 2 guides observation frequency. Existing practice is to observe higher-risk patients more frequently and our findings have shown that this is objectively justified. It is worth noting that important nurse-patient interactions take place during vital sign monitoring and should not be eliminated under new monitoring processes. Our study contributes to the existing evidence on how vital sign observations should be scheduled. However, ultimately, it is for the relevant professionals to decide how our work should be used. Study registration This study is registered as ISRCTN10863045. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/05/03) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 6. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Jim Briggs
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, UK
| | - Ina Kostakis
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, UK
| | - Paul Meredith
- Research Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | | | - Julie Darbyshire
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Stephen Gerry
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | | | - Jo Hope
- Health Sciences, University of Southampton, Southampton, UK
| | - Jeremy Jones
- Health Sciences, University of Southampton, Southampton, UK
| | - Caroline Kovacs
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, UK
| | | | - David Prytherch
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, UK
| | - Peter Watkinson
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Oliver Redfern
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Gustad LT, Bangstad IL, Torsvik M, Rise MB. Nurses' and Physicians' Experiences After Implementation of a Quality Improvement Project to Improve Sepsis Awareness in Hospitals. J Multidiscip Healthc 2024; 17:29-41. [PMID: 38192738 PMCID: PMC10773249 DOI: 10.2147/jmdh.s439017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/27/2023] [Indexed: 01/10/2024] Open
Abstract
Purpose Previous research has explored nurses´ experience with the implementation of early detection alert systems, and nurses and physicians' perceptions of sepsis management and use of sepsis triage. As one of the first, this study aims to investigate the perceived usefulness of an interdisciplinary quality improvement project including standardized sepsis patient pathway to improve the early identification and treatment of sepsis patients. Participants and Methods This study was a qualitative study that employed semi-structured interviews with thirteen ward nurses and five ward physicians recruited by convenience and respondent-driven sampling, respectively. The interviews explored the perceived usefulness of mutual training in sepsis care in medical hospital wards. We applied Systematic Text Condensation to analyze the experiences and knowledge of professional identification and cooperation in early identification of sepsis patients. Results The results revealed three main themes: Awareness of sepsis, collaboration between nurses and physicians, and clinical assessment and judgement. The findings highlighted the positive impact of the project in terms of raising awareness, improving communication, and enhancing the ability to detect and treat sepsis. The study also identified the importance of repetition and reminders to maintain awareness, the need for ongoing training for new healthcare professionals, and the challenges of collaboration and decision-making processes. Conclusion The sepsis intervention seemed successful in improving awareness of sepsis and enhancing interprofessional collaboration between nurses and physicians. Health professionals continued to rely on their clinical judgment but increased the use of objective measurements and communication of vital signs. Continuous repetition and education for new colleagues were identified as important factors for the sustainability of the intervention. Overall, the study highlights the importance of standardized protocols and training for early detection and management of sepsis in healthcare settings.
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Affiliation(s)
- Lise Tuset Gustad
- Faculty of Nursing and Health Sciences, Nord University, Levanger, Norway
- Nord-Trøndelag Hospital Trust, Department of Medicine, Levanger Hospital, Levanger, Norway
| | | | - Malvin Torsvik
- Faculty of Nursing and Health Sciences, Nord University, Levanger, Norway
| | - Marit By Rise
- Regional Centre for Child and Youth Mental Health and Child Welfare (RKBU Central Norway), Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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Monge García MI, Jiménez López I, Lorente Olazábal JV, García López D, Fernández López AR, Pérez Carbonell A, Ripollés Melchor J. Postoperative arterial hypotension: the unnoticed enemy. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:575-579. [PMID: 37652202 DOI: 10.1016/j.redare.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 10/17/2022] [Indexed: 09/02/2023]
Abstract
Postoperative hypotension is a frequently underestimated health problem associated with high morbidity and mortality and increased use of health care resources. It also poses significant clinical, technological, and human challenges for healthcare. As it is a modifiable and avoidable risk factor, this document aims to increase its visibility, defining its clinical impact and the technological challenges involved in optimizing its management, taking clinical-technological, humanistic, and economic aspects into account.
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Affiliation(s)
- M I Monge García
- Hospital Universitario SAS Jerez, Jerez de la Frontera, Cádiz, Spain.
| | | | | | - D García López
- Hospital Universitario Marqués de Valdecilla, Santander, Spain
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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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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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Kayser SA, Williamson R, Siefert G, Roberts D, Murray A. Respiratory rate monitoring and early detection of deterioration practices. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2023; 32:620-627. [PMID: 37410682 DOI: 10.12968/bjon.2023.32.13.620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
BACKGROUND Growing evidence points to respiratory rate (RR) being the most important vital sign for early detection of patient deterioration. However, RR is the vital sign most likely to be inaccurate or missed. AIMS To measure prevalence of early detection of deterioration protocols, examine whether RR was perceived as the leading indicator of deterioration, and understand RR monitoring practices used by nurses around the world. METHODS A double-blinded survey of nurses in Asia Pacific, Middle East, and Western Europe. FINDINGS 161 nurses responded. Most (80%) reported having an initiative for early detection of patient deterioration; 12% indicated RR was the most important indicator of deterioration, 27% captured RR for all medical/surgical patients, and 56% take 60 seconds or longer to measure RR. CONCLUSION Nurses across all regions generally underestimated the importance of capturing an accurate RR for all patients' multiple times per day. This study reinforces the need to enhance international nursing education regarding the importance of RR.
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Affiliation(s)
- Susan A Kayser
- Health Economist, Baxter International, Batesville, Indiana, USA
| | - Rachel Williamson
- Director, Global Strategic Marketing, Baxter International, Batesville, Indiana, USA
| | - Gabriela Siefert
- Associate Director of Strategy, Baxter International, Omaha, Nebraska, USA
| | - Dan Roberts
- Health Economist, Baxter International, Scottsville, Virginia, USA
| | - Angela Murray
- Senior Director of Health Economics, Baxter International, Chicago, Illinois, USA
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Treacy M, Wong G, Odell M, Roberts N. Understanding the use of the National Early Warning Score 2 in acute care settings: a realist review protocol. BMJ Open 2022; 12:e062154. [PMID: 35803636 PMCID: PMC9272106 DOI: 10.1136/bmjopen-2022-062154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Failure to recognise and respond to patient deterioration in an appropriate and timely manner has been highlighted as a global patient safety concern. Early Warning Scores (EWSs) using vital signs were introduced to address this concern, with the aim of getting the patient timely and appropriate treatment. The National Early Warning Score 2 (NEWS2) is in use across the NHS, and many other settings globally. While patient improvements have been shown, research has identified that the NEWS2 is not always used as intended. Therefore, this review will use a realist approach to understand what the mechanisms are that influence appropriate use (or not) of the NEWS2 in acute care settings, how, for whom and in which contexts. The findings will inform clinicians of what helps and/or hinders appropriate use of the NEWS2 in clinical practice, thus helping to facilitate successful implementation. METHODS AND ANALYSIS Our realist review will follow Pawson's iterative six step process: (1) Development of initial programme theory. (2) Searching the literature; an information scientist will develop, pilot and refine the search strategy. A systematic search will be completed, based on subject relevancy on the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Embase (OvidSP), Web of Science (Science Citation Index and Social Science Citation), Cochrane Database of Systematic Reviews, Joanna Briggs Institute, Ethos, Proquest Dissertations and Theses Global, and Google Scholar for documents dating from 1997 (date of the first published EWS) to present. To retrieve additional relevant data 'snowballing' (finding references and authors by hand, contacting authors, searching reference lists and citation-tracking using Google Scholar) will be used. Inclusion criteria include all documents (including grey literature) that relate to the use of EWSs/NEWS2 in the English language only. Documents set in the paediatric, maternity and primary care settings will be excluded. (3) Selecting documents and quality appraisal. (4) Extracting and organising the data. (5) Synthesising the data. (6) Disseminating the findings. We will recruit a group of stakeholders comprised of experienced clinicians who use the NEWS2 as part of their clinical practice to provide feedback throughout the review. Step 1 has already begun with the development of an initial programme theory. This initial programme theory presents how the NEWS2 is supposed to work (or not), it will now be developed, tested and refined. ETHICS AND DISSEMINATION Ethical approval is not required for this study as it is secondary research. Dissemination will include a peer-reviewed publication and conference presentations. Findings will also be amplified through social media platforms with user friendly summaries. Our stakeholder group will also contribute to dissemination of findings in their clinical areas and among existing networks. PROSPERO REGISTRATION NUMBER CRD42022304497.
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Affiliation(s)
- Michelle Treacy
- Department for Continuing Education, Oxford University, Oxford, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Mandy Odell
- Critical Care, Royal Berkshire NHS Foundation Trust, London Rd, Reading, UK
| | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, UK, Oxford, UK
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Four consecutive yearly point-prevalence studies in Wales indicate lack of improvement in sepsis care on the wards. Sci Rep 2021; 11:16222. [PMID: 34376757 PMCID: PMC8355110 DOI: 10.1038/s41598-021-95648-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 07/22/2021] [Indexed: 12/15/2022] Open
Abstract
The ‘Sepsis Six’ bundle was promoted as a deliverable tool outside of the critical care settings, but there is very little data available on the progress and change of sepsis care outside the critical care environment in the UK. Our aim was to compare the yearly prevalence, outcome and the Sepsis Six bundle compliance in patients at risk of mortality from sepsis in non-intensive care environments. Patients with a National Early Warning Score (NEWS) of 3 or above and suspected or proven infection were enrolled into four yearly 24-h point prevalence studies, carried out in fourteen hospitals across Wales from 2016 to 2019. We followed up patients to 30 days between 2016–2019 and to 90 days between 2017 and 2019. Out of the 26,947 patients screened 1651 fulfilled inclusion criteria and were recruited. The full ‘Sepsis Six’ care bundle was completed on 223 (14.0%) occasions, with no significant difference between the years. On 190 (11.5%) occasions none of the bundle elements were completed. There was no significant correlation between bundle element compliance, NEWS or year of study. One hundred and seventy (10.7%) patients were seen by critical care outreach; the ‘Sepsis Six’ bundle was completed significantly more often in this group (54/170, 32.0%) than for patients who were not reviewed by critical care outreach (168/1385, 11.6%; p < 0.0001). Overall survival to 30 days was 81.7% (1349/1651), with a mean survival time of 26.5 days (95% CI 26.1–26.9) with no difference between each year of study. 90-day survival for years 2017–2019 was 74.7% (949/1271), with no difference between the years. In multivariate regression we identified older age, heart failure, recent chemotherapy, higher frailty score and do not attempt cardiopulmonary resuscitation orders as significantly associated with increased 30-day mortality. Our data suggests that despite efforts to increase sepsis awareness within the NHS, there is poor compliance with the sepsis care bundles and no change in the high mortality over the study period. Further research is needed to determine which time-sensitive ward-based interventions can reduce mortality in patients with sepsis and how can these results be embedded to routine clinical practice. Trial registration Defining Sepsis on the Wards ISRCTN 86502304 https://doi.org/10.1186/ISRCTN86502304 prospectively registered 09/05/2016.
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Byrne G, Ennis S, Barnes AM, Morrison P, Connors S, Quirke MB. Triggers and Interventions of Patients Who Require Medical Emergency Team Reviews: A Cross-Sectional Analysis of Single Versus Multiple Reviews. Crit Care Nurse 2021; 41:e1-e10. [PMID: 34333613 DOI: 10.4037/ccn2021407] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Medical emergency teams constitute part of the escalation protocol of early warning systems in many hospitals. The literature indicates that medical emergency teams may reduce hospital mortality and cardiac arrest. A greater understanding of pathways of patients who experience multiple medical emergency team reviews will inform clinical decision-making. OBJECTIVES To explore differences between patients who require a single medical emergency team review and those who require multiple reviews, and to identify any differences between patients who were reviewed only once during admission and patients who required multiple reviews. METHODS Data for this retrospective cross-sectional review, including demographic data, call triggers, outcomes, and interventions, were routinely collected from January 2013 through December 2015. The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) collaborative's cross-sectional studies checklist (version 4). RESULTS Of 54 787 admitted patients, 1274 (2%) required a call to a medical emergency team; of those, 260 patients (20%) needed multiple calls. Patients requiring multiple calls demonstrated higher mortality (odds ratio, 1.49 [95% CI, 1.12-1.98]). A logistic regression model identified surgical patients and those receiving antibiotics and respiratory interventions at the first medical emergency team review as being more likely to require multiple reviews. Patients transferred to a higher level of care after the first review were less likely to require another review. CONCLUSIONS Patients requiring multiple medical emergency team reviews have higher mortality. Surgical patients have a higher risk of requiring multiple reviews. Hospitals need to include more details on surgical patients when auditing medical emergency team activation.
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Affiliation(s)
- Gobnait Byrne
- Gobnait Byrne is Director, Trinity Centre for Practice and Health-care Innovation, and an assistant professor, School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Shauna Ennis
- Shauna Ennis is Head of Learning and Development, Tallaght University Hospital, Dublin, Ireland
| | - Anne Marie Barnes
- Anne Marie Barnes is the Emergency Response System Coordinator, Tallaght University Hospital
| | - Patricia Morrison
- Patricia Morrison is the Assistant Director of Nursing and Lead Assistant Director of Nursing for the Perioperative Directorate, Tallaght University Hospital
| | - Siobhan Connors
- Siobhan Connors is a critical care outreach nurse, Tallaght University Hospital
| | - Mary B Quirke
- Mary B. Quirke is a research fellow, Trinity Centre for Practice and Healthcare Innovation, School of Nursing and Midwifery, Trinity College Dublin
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Chua WL, Rahim NRBA, McKenna L, Ho JTY, Liaw SY. Intraprofessional collaboration between enrolled and registered nurses in the care of clinically deteriorating ward patients: A qualitative study. Aust Crit Care 2021; 35:81-88. [PMID: 33926789 DOI: 10.1016/j.aucc.2021.01.009] [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] [Received: 10/10/2020] [Revised: 01/06/2021] [Accepted: 01/11/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Nurses' role in vital signs monitoring places them in an ideal position to recognise and respond to clinical deterioration in general wards. However, enrolled nurses (ENs) and registered nurses (RNs) do not always work collaboratively, and this can lead to delays in recognition and escalation of clinical deterioration in general wards. OBJECTIVES The aim of the study was to explore the collaboration experiences between ENs and RNs in recognising and responding to clinical deterioration in general ward settings. METHODS A qualitative descriptive study involving 12 ENs and 11 RNs was conducted in a 1250-bed tertiary hospital in Singapore using semistructured interviews. Interviews were transcribed and thematically analysed. FINDINGS Three main themes emerged from the data analysis. The first, "reaching a collective understanding of patients' conditions', identifies nursing shift handover as the primary method of obtaining patient information essential for ENs and RNs to work collaboratively to deliver safe patient care. However, the dissociation of ENs during the handover process created information gaps on patients at risk of clinical deterioration. The second, "role expectations of each other", describes expectations that both groups of nurses had for each other's functions and responsibilities and the importance of mutual support in the nursing teamwork process. The third, "lacking in shared decision-making", depicts a top-down approach in decision-making, wherein ENs were often not engaged in the decision-making process related to patient care. CONCLUSIONS A less-than-optimal collaborative EN-RN relationship was observed in this study, which sometimes caused delays in recognising and responding to deteriorating ward patients. This study illuminates the need for intraprofessional learning opportunities in prelicensure nursing programmes and the workplace to foster effective EN-RN collaborative practice. Nurse managers and educators are instrumental in fostering EN-RN collaboration and providing ongoing education on nursing teamwork skills and competencies.
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Affiliation(s)
- Wei Ling Chua
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 3, Clinical Research Centre, Block MD11, 10 Medical Drive, 117597, Singapore.
| | | | - Lisa McKenna
- School of Nursing and Midwifery, La Trobe University, Plenty Rd & Kingsbury Dr, Bundoora (Melbourne), Victoria, 3086, Australia
| | - Jasmine Tze Yin Ho
- National University Hospital, 5 Lower Kent Ridge Road, 119074, Singapore
| | - Sok Ying Liaw
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 3, Clinical Research Centre, Block MD11, 10 Medical Drive, 117597, Singapore
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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: 13] [Impact Index Per Article: 4.3] [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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12
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Smith D, Cartwright M, Dyson J, Hartin J, Aitken LM. Patterns of behaviour in nursing staff actioning the afferent limb of the rapid response system (RRS): A focused ethnography. J Adv Nurs 2020; 76:3548-3562. [PMID: 32996620 DOI: 10.1111/jan.14551] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/09/2020] [Accepted: 07/29/2020] [Indexed: 12/17/2022]
Abstract
AIM To improve understanding of afferent limb behaviour in acute hospital ward settings, to define and specify who needs to do what differently and to report what afferent limb behaviours should be targeted in a subsequent multi-phase, theory-based, intervention development process. DESIGN Focused ethnography was used including direct observation of nursing staff enacting afferent limb behaviours and review of vital signs charts. METHODS An observation guide focused observation on "key moments" of the afferent limb. Descriptions of observations from between 7 January 2019-18 December 2019 were recorded in a field journal alongside reflexive notes. Vital signs and early warning scores from charts were reviewed and recorded. Field notes were analysed using structured content analysis. Observed behaviour was compared with expected (policy-specified) behaviour. RESULTS Observation was conducted for 300 hr. Four hundred and ninety-nine items of data (e.g., an episode of observation or a set of vital signs) were collected. Two hundred and eighty-nine (58%) items of data were associated with expected (i.e. policy-specified) afferent limb behaviour; 210 (42%) items of data were associated with unexpected afferent limb behaviour (i.e. alternative behaviour or no behaviour). Ten specific behaviours were identified where the behaviour observed deviated (negatively) from policy or where no action was taken when it should have been. One further behaviour was seen to expedite the assessment of a deteriorating patient by an appropriate responder and was therefore considered a positive deviance. CONCLUSION Afferent limb failure has been described as a problem of inconsistent staff behaviour. Eleven potential target behaviours for change are reported and specified using a published framework. IMPACT Clear specification of target behaviour will allow further enquiry into the determinants of these behaviours and the development of a theory-based intervention that is more likely to result in behaviour change and can be tested empirically in future research.
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Affiliation(s)
- Duncan Smith
- School of Health Sciences, City University of London, London, UK.,University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Judith Dyson
- School of Health Sciences, City University of London, London, UK
| | - Jillian Hartin
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Leanne M Aitken
- School of Health Sciences, City University of London, London, UK.,School of Nursing and Midwifery, Griffith University, Nathan, QLD, Australia
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13
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Dall'Ora C, Griffiths P, Hope J, Barker H, Smith GB. What is the nursing time and workload involved in taking and recording patients' vital signs? A systematic review. J Clin Nurs 2020; 29:2053-2068. [PMID: 32017272 DOI: 10.1111/jocn.15202] [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: 07/04/2019] [Revised: 12/18/2019] [Accepted: 01/10/2020] [Indexed: 11/29/2022]
Abstract
AIMS AND OBJECTIVES To synthesise evidence regarding the time nurses take to monitor and record vital signs observations and to calculate early warning scores. BACKGROUND While the importance of vital signs' monitoring is increasingly highlighted as a fundamental means of maintaining patient safety and avoiding patient deterioration, the time and associated workload involved in vital signs activities for nurses are currently unknown. DESIGN Systematic review. METHODS A literature search was performed up to 17 December 2019 in CINAHL, Medline, EMBASE and the Cochrane Library using the following terms: vital signs; monitoring; surveillance; observation; recording; early warning scores; workload; time; and nursing. We included studies performed in secondary or tertiary ward settings, where vital signs activities were performed by nurses, and we excluded qualitative studies and any research conducted exclusively in paediatric or maternity settings. The study methods were compliant with the PRISMA checklist. RESULTS Of 1,277 articles, we included 16 papers. Studies described taking vital signs observations as the time to measure/collect vital signs and time to record/document vital signs. As well as mean times being variable between studies, there was considerable variation in the time taken within some studies as standard deviations were high. Documenting vital signs observations electronically at the bedside was faster than documenting vital signs away from the bed. CONCLUSIONS Variation in the method(s) of vital signs measurement, the timing of entry into the patient record, the method of recording and the calculation of early warning scores values across the literature make direct comparisons of their influence on total time taken difficult or impossible. RELEVANCE TO CLINICAL PRACTICE There is a very limited body of research that might inform workload planning around vital signs observations. This uncertainty means the resource implications of any recommendation to change the frequency of observations associated with early warning scores are unknown.
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Affiliation(s)
- Chiara Dall'Ora
- School of Health Sciences, University of Southampton, Southampton, UK.,National Institute for Health Research Applied Research Collaboration (NIHR ARC) Wessex, Southampton, UK
| | - Peter Griffiths
- School of Health Sciences, University of Southampton, Southampton, UK.,National Institute for Health Research Applied Research Collaboration (NIHR ARC) Wessex, Southampton, UK.,Division of Innovative Care Research, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Joanna Hope
- School of Health Sciences, University of Southampton, Southampton, UK.,National Institute for Health Research Applied Research Collaboration (NIHR ARC) Wessex, Southampton, UK
| | - Hannah Barker
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Gary B Smith
- Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, UK
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14
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The association between nurse staffing levels and a failure to respond to patients with deranged physiology: A retrospective observational study in the UK. Resuscitation 2020; 149:202-208. [PMID: 31945427 DOI: 10.1016/j.resuscitation.2020.01.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 12/24/2019] [Accepted: 01/04/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Responding to abnormalities in patients' vital signs is a fundamental aspect of nursing. However, failure to respond to patient deterioration is common and often leads to adverse patient outcomes. This study aimed to determine the association between Registered Nurse (RN) and Nursing Assistant (NA) staffing levels and the failure to respond promptly to patients' abnormal physiology. METHODS This retrospective, observational study used routinely collected patients' vital signs and administrative data, including nursing staffing, from 32 general wards of an acute hospital in England between April 2012 and March 2015. Mixed-effects binomial regression was used to model the relationship between nurse staffing, measured as 'Hours per Patient Day' (HPPD), and a composite primary outcome representing failure to respond for patients with National Early Warning Score (NEWS) values ≥ 6 and ≥ 7. RESULTS There were 189,123 NEWS values ≥ 6 and 114,504 NEWS values ≥ 7, affecting 28,098 patients. For patients with NEWS values ≥ 7, failure to respond was significantly associated with levels of RN HPPD ((IRR 0.98, 95% CI 0.96-0.99, p = 0.0001) but not NA HPPD (((IRR 0.99, 95%CI 0.96-1.01, p = 0.238). For patients with NEWS values ≥ 6, no such relationship existed. CONCLUSIONS RN, but not NA, staffing levels influence the rates of failure to respond for patients with the most abnormal vital signs (NEWS values ≥ 7). These findings offer a possible explanation for the increasingly reported association between low RN staffing and an increased risk of patient death during a hospital admission.
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15
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Succeeding with rapid response systems – a never-ending process: A systematic review of how health-care professionals perceive facilitators and barriers within the limbs of the RRS. Resuscitation 2019; 144:75-90. [DOI: 10.1016/j.resuscitation.2019.08.034] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 08/15/2019] [Accepted: 08/24/2019] [Indexed: 11/24/2022]
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16
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Performance of the Afferent Limb of Rapid Response Systems in Managing Deteriorating Patients: A Systematic Review. Crit Care Res Pract 2019; 2019:6902420. [PMID: 31781390 PMCID: PMC6874970 DOI: 10.1155/2019/6902420] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 05/31/2019] [Accepted: 06/26/2019] [Indexed: 11/18/2022] Open
Abstract
Introduction The clinical components of the rapid response system (RRS) are the afferent limb, to ensure identification of in-hospital patients who deteriorate and activation of a response, and the efferent limb, to provide the response. This review aims to evaluate the factors that influence the performance of the afferent limb in managing deteriorating ward patients and their effects on patient outcomes. Methods A systematic review was performed for the years 1995–2017 by employing five electronic databases. Articles were included assessing the ability of the ward staffs to monitor, recognize, and escalate care to patient deterioration. The findings were summarized using a narrative approach. Results Thirty-one studies met the inclusion criteria. The analysis revealed major themes enclosing several factors affecting management of patients having sudden deterioration. The monitoring and recognition process was conditioned by the lack of recording of physiological parameters, the influence of facilitators, including staff education and training, and barriers, including human and environmental factors, and poor compliance with the calling criteria. The escalation of care process highlighted the influence of cultural barriers and personal judgment on RRS activation. Mainly, delayed team calls were factors strongly associated with the increased risk of unplanned admissions to the intensive care unit and length of stay, hospital length of stay and mortality, and 30-day mortality. Conclusions A combination of factors affects the timely identification and response to sudden deterioration by general ward staffs, leading to suboptimal care of patients, delayed or failed activation of RRS teams, and increased risks of worsening outcomes. The research efforts and clinical involvement to improve the governance of the factors limiting the performance of the afferent limb may ensure proper management of hospitalized patients showing physiological deterioration.
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17
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Jensen JK, Skår R, Tveit B. Hospital nurses' professional accountability while using the National Early Warning Score: A qualitative study with a hermeneutic design. J Clin Nurs 2019; 28:4389-4399. [PMID: 31408561 DOI: 10.1111/jocn.15021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 08/04/2019] [Indexed: 11/27/2022]
Abstract
AIM To explore general hospital ward nurses' experiences with the National Early Warning Score and to determine its impacts on their professionalism. BACKGROUND The National Early Warning Score has broad appeal; it is a patient safety initiative designed to ensure early identification of and response to deteriorating patients in hospitals. However, it is still unclear how the tool impacts nurses' professionalism. METHODS A qualitative study with a hermeneutic design was conducted in autumn 2017; the study consisted of semi-structured, in-depth interviews with 14 hospital nurses. The data were analysed thematically to understand and interpret the nurses' experiences. Methods are reported using COREQ guidelines (see Appendix S1). RESULTS The study examined nurses' experience with the National Early Warning Score and its perceived impact on their professionalism. Four themes were identified: (a) the National Early Warning Score and clinical judgement in patient assessment, (b) responding to the National Early Warning Score standard, (c) involving the professional community and (d) adjusting the tool. CONCLUSION The National Early Warning Score may impact nurses' professionalism in diverse ways. Nurses are aware of the importance of incorporating all of their professional competence, comprising clinical judgement, discretion and accountability, with the National Early Warning Score to accurately assess patients' conditions. Findings indicated that the National Early Warning Score was beneficial to nurses' professional practice; however, accountability to this standard alone does not ensure quality care and patient safety. RELEVANCE TO CLINICAL PRACTICE A greater understanding of the role of nurses' professional accountability when using the National Early Warning Score is needed to improve practice and ensure patient safety.
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Affiliation(s)
| | - Randi Skår
- Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Bodil Tveit
- Faculty of Health Studies, VID Specialized University, Oslo, Norway
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18
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Smith D, Sekhon M, Francis JJ, Aitken LM. How actionable are staff behaviours specified in policy documents? A document analysis of protocols for managing deteriorating patients. J Clin Nurs 2019; 28:4139-4149. [PMID: 31327164 DOI: 10.1111/jocn.15005] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/22/2019] [Accepted: 06/21/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND To optimise care of deteriorating patients, healthcare organisations have implemented rapid response systems including an "afferent" and "efferent" limb. Afferent limb behaviours include monitoring vital signs and escalating care. To strengthen afferent limb behaviour and reduce adverse patient outcomes, the National Early Warning Score was implemented in the UK. There are no published reports of how National Early Warning Score guidance has translated into trust-level deteriorating patient policy and whether these documents provide clear, actionable statements guiding staff. AIM To identify how deteriorating patient policy documents provide "actionable" behavioural instruction for staff, responsible for actioning the afferent limb of the rapid response system. DESIGN A structured content analysis of a national guideline and local policies using a behaviour specification framework. METHODS Local deteriorating patient policies were obtained. Statements of behaviour were extracted from policies; coded using a behaviour specification framework: Target, Action, Context, Timing and Actor and scored for specificity (1 = present, nonspecific; 2 = present, specific). Frequencies and proportions of statements containing elements of the Target, Action, Context, Timing and Actor framework were summarised descriptively. Reporting was guided by the COREQ checklist. RESULTS There were more statements related to monitoring than escalation behaviour (65% vs 35%). Despite high levels of clear specification of the action (94%) and the target of the behaviour (74%), context, timing and actor were poorly specified (37%, 37% and 33%). CONCLUSION Delay in escalating deteriorating patients is associated with adverse outcomes. Some delay could be addressed by writing local protocols with greater behavioural specificity, to facilitate actionability. RELEVANCE TO CLINICAL PRACTICE Numerous clinical staff are required for an effective response to patient deterioration. To mitigate role confusion, local policy writers should provide clear specification of the actor. As the behaviours are time-sensitive, clear specification of the time frame may increase actionability of policy statements for clinical staff.
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Affiliation(s)
- Duncan Smith
- School of Health Sciences, City, University of London, London, UK.,Patient Emergency Response & Resuscitation Team (PERRT), University College London Hospitals NHS Foundation Trust, London, UK
| | - Mandeep Sekhon
- Department of Population Health Sciences, Faculty of Life Sciences and Medicine, School of Population Health & Environmental Sciences, King's College London, London, UK
| | - Jill J Francis
- School of Health Sciences, City, University of London, London, UK
| | - Leanne M Aitken
- School of Health Sciences, City, University of London, London, UK.,Menzies Health Institute Queensland, Griffith University, Nathan, Qld, Australia
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19
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Jensen JK, Skår R, Tveit B. Introducing the National Early Warning Score - A qualitative study of hospital nurses' perceptions and reactions. Nurs Open 2019; 6:1067-1075. [PMID: 31367432 PMCID: PMC6650757 DOI: 10.1002/nop2.291] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 03/13/2019] [Accepted: 04/04/2019] [Indexed: 11/05/2022] Open
Abstract
AIM The aim of this study was to explore hospital nurses' perceptions and reactions to the National Early Warning Score during an introduction programme. DESIGN A qualitative case study approach with participatory observations was used for this study. METHODS In total, nine seminars and 23 simulation sessions attended by nurses were observed. An activity theory system analysis was applied to interpret the material. RESULTS The findings revealed four tensions related to the working context: (a) tension between using a standardized tool and relying on clinical judgement (the tool could be either an aid or a barrier to patient assessment); (b) tension in the community of practice (the tool could be beneficial or increase stress and anxiety); (c) tension related to rules and compliance (the tool could be perceived as optional or compulsory); and (d) tension related to the division of labour (nurses feared more work).
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Affiliation(s)
| | - Randi Skår
- Dean Faculty of Health and Social SciencesWestern Norway University of Applied SciencesBergenNorway
| | - Bodil Tveit
- Faculty of Health StudiesVID Specialized UniversityOsloNorway
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20
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Smith D, Francis JJ, Aitken LM. DEveloping a Complex Intervention for DEteriorating patients using theoretical modelling (DECIDE study): Study protocol. J Adv Nurs 2019; 75:2024-2035. [DOI: 10.1111/jan.14076] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 04/09/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Duncan Smith
- School of Health Sciences, City University of London London UK
- University College London Hospitals NHS Foundation Trust London UK
| | - Jill J. Francis
- School of Health Sciences, City University of London London UK
| | - Leanne M. Aitken
- School of Health Sciences, City University of London London UK
- School of Nursing and Midwifery Griffith University Nathan Qld Australia
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21
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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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22
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Incidence, Severity, and Detection of Blood Pressure Perturbations after Abdominal Surgery. Anesthesiology 2019; 130:550-559. [DOI: 10.1097/aln.0000000000002626] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
Intraoperative and postoperative hypotension are associated with myocardial and kidney injury and 30-day mortality. Intraoperative blood pressure is measured frequently, but blood pressure on surgical wards is usually measured only every 4 to 6 h, leaving long intervals during which hypotension and hypertension may be undetected. This study evaluated the incidence and severity of postoperative hypotension and hypertension in adults recovering from abdominal surgery and the extent to which serious perturbations were missed by routine vital-sign assessments.
Methods
Blood pressure was recorded at 1-min intervals during the initial 48 h in adults recovering from abdominal surgery using a continuous noninvasive monitor. Caregivers were blinded to these measurements and depended on routine vital-sign assessments. Hypotension and hypertension were characterized as time under and above various mean arterial pressure thresholds.
Results
Of 502 available patients, 312 patients with high-quality records were analyzed, with a median measurement time of 48 [interquartile range: 41, 48] postoperative hours. Nearly a quarter experienced an episode of mean arterial pressure of less than 70 mm Hg lasting at least 30 min (24%; 95% CI, 20%, 29%), and 18% had an episode of mean arterial pressure of less than 65 mm Hg lasting at least 15 min. Nearly half the patients who had mean arterial pressure of less than 65 mm Hg for at least 15 min (47%; 95% CI, 34%, 61%) were undetected by routine vital-sign assessments. Episodes of mean arterial pressure greater than 110 mm Hg lasting at least 30 min were observed in 42% (95% CI, 37%, 48%) of patients; 7% had mean arterial pressure greater than 130 mm Hg for at least 30 min, 96% of which were missed by routine assessments. Episodes of mean arterial pressure less than 65 mm Hg and mean arterial pressure greater than 110 mm Hg captured by routine vital-sign assessments but not by continuous monitoring occurred in 34 and 8 patients, respectively.
Conclusions
Postoperative hypotension and hypertension were common, prolonged, profound, and largely undetected by routine vital-sign assessments in a cohort of adults recovering from abdominal surgery. Frequent or continuous blood pressure monitoring may detect hemodynamic perturbations more effectively and potentially facilitate treatment.
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23
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Loftus NW, Smith D. Investigating ward nurses' responses to deteriorating patients. Nurs Stand 2019; 34:76-82. [PMID: 31468928 DOI: 10.7748/ns.2019.e11020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2018] [Indexed: 11/09/2022]
Abstract
Deteriorating patients often present with suboptimal vital signs. If these are not recognised by healthcare staff, the patient's condition can deteriorate further, potentially leading to serious complications and even death. Despite efforts to improve ward nurses' recognition of, and responses to, deteriorating patients, this aspect of care has been found to be suboptimal. AIM To identify factors that influence ward nurses' responses to deteriorating patients. METHOD A literature review was undertaken, based on the research question 'What factors influence the trigger component of ward-based registered nurses' afferent response to deteriorating patients?' Several electronic databases were searched electronically to identify relevant articles, alongside hand-searching. Inclusion and exclusion criteria were set to determine which articles should be included in the literature review. FINDINGS Nine studies were identified for inclusion in the literature review. Four main themes that influenced ward nurses' responses to deteriorating patients emerged: communication, diurnal and weekend variation, knowledge and attitudes, and nurse staffing levels. CONCLUSION Effective communication was identified as an important factor in improving ward nurses' responses to deteriorating patients, as was improved knowledge of 'do not attempt cardiopulmonary resuscitation' (DNACPR) orders. It was also identified that increased ward nurse numbers improved responses to deteriorating patients, as did increased availability of senior healthcare staff, which enabled junior staff to escalate care.
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Affiliation(s)
| | - Duncan Smith
- City, University of London, London; honorary charge nurse in the Patient Emergency Response and Resuscitation Team (PERRT), University College London Hospitals NHS Foundation Trust, London, and clinical doctoral research fellow
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24
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Spångfors M, Bunkenborg G, Molt M, Samuelson K. The National Early Warning Score predicts mortality in hospital ward patients with deviating vital signs: A retrospective medical record review study. J Clin Nurs 2019; 28:1216-1222. [PMID: 30516860 DOI: 10.1111/jocn.14728] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 09/07/2018] [Accepted: 11/25/2018] [Indexed: 01/19/2023]
Abstract
AIMS AND OBJECTIVES To evaluate whether the scale used for assessment of hospital ward patients could predict in-hospital and 30-day mortality amongst those with deviating vital signs; that is, that patients classified as medium or high risk would have increased risk of in-hospital and 30-day mortality compared to patients with low risk. BACKGROUND The National Early Warning Score (NEWS) is a widely adopted scale for assessing deviating vital signs. A clinical risk scale that comes with the NEWS divides the risk for critical illness into three risk categories, low, medium and high. DESIGN Retrospective analysis of vital sign data. METHODS Logistic regression models for age-adjusted in-hospital and 30-day mortality were used for analyses of 1,107 patients with deviating vital signs. RESULTS Patients classified as medium or high risk by NEWS experienced a 2.11 or 3.40 increase, respectively, in odds of in-hospital death (95% CI: 1.27-3.51, p = 0.004% and 95% CI: 1.90-6.01, p < 0.001) compared to low-risk patients. Moreover, those with NEWS medium or high risk were associated with a 1.98 or 3.19 increase, respectively, in odds of 30-day mortality (95% CI: 1.32-2.97, p = 0.001% and 95% CI: 1.97-5.18, p < 0.001). CONCLUSION The NEWS risk classification seems to be a reliable predictor of mortality on patients in hospital wards. RELEVANCE TO CLINICAL PRACTICE The NEWS risk classification offers a simple way to identify deteriorating patients and can aid the healthcare staff to prioritise amongst patients.
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Affiliation(s)
- Martin Spångfors
- Department of Clinical Sciences Lund, Anesthesiology and Intensive Care, Faculty of Medicine, Lund University, Lund, Sweden.,Department of Anaesthesiology & Intensive Care, Hospital of Kristianstad, Region Skane, Sweden
| | - Gitte Bunkenborg
- Department of Anaesthesiology, Copenhagen University Hospital, Hvidovre, Denmark.,Department of Clinical Sciences Malmö, Anaesthesiology and Intensive Care Medicine, Lund University, Malmö, Sweden.,Department of Anesthesiology, Holbaek University Hospital, Zealand Region, Denmark
| | - Mats Molt
- Department of Clinical Sciences Lund, Anesthesiology and Intensive Care, Faculty of Medicine, Lund University, Lund, Sweden
| | - Karin Samuelson
- Department of Clinical Sciences Lund, Anesthesiology and Intensive Care, Faculty of Medicine, Lund University, Lund, Sweden.,Department of Health Sciences, Lund University, Lund, Sweden
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25
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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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26
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Trajkovska A, Farooq M, Richardson D. Management of abnormal observations in the emergency department: A review. Emerg Med Australas 2018; 31:569-574. [PMID: 30485904 DOI: 10.1111/1742-6723.13208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 10/19/2018] [Accepted: 10/22/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To assess utility and accuracy of general observation modified early warning score charts; and compare sensitivity and specificity of single- and multiple-parameter-based trigger scores on patient outcomes in the ED. METHODS Retrospective cohort clinical audit of all adult Modified Early Warning Score charts in the ED of a mixed tertiary hospital over 4 weeks. Data extracted included recorded parameters required to calculate Modified Early Warning Score and evidence of response. RESULTS Of 5901 ED presentations, medical records system identified 2482 Modified Early Warning Score; 347 were missing or blank. Of 2135 Modified Early Warning Score charts, 19.5% contained a calculation error, 51.9% had one or more missing parameters and 36.6% did not have usual/target systolic blood pressure recorded; with 25.1% (95% confidence interval [CI] 23.3-27.0) charts correctly completed. Four hundred and forty-three had a single-abnormal parameter of which chart review showed 96.6% (94.5-97.3) were identified as abnormal by nurses with 25.7% (21.9-30.0); only 5.6% (3.9-8.2) had evidence of recognition by medical staff. Modified Early Warning Score sensitivity and specificity for ward admission was 14.7% and 96.1%, respectively. Modelling using the dataset of a single-abnormal parameter suggested sensitivity and specificity of 31.6% and 85.8%, respectively. CONCLUSIONS This study highlights serious deficiencies in documentation of abnormal parameters and emergency response. It has also shown poor accuracy of both single- and multiple-parameter-based trigger scores in predicting patient outcomes within the ED. However, single-parameter-based trigger scores are twice as sensitive as total Modified Early Warning Score for admission and reduces documentation error by 23%.
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Affiliation(s)
- Aleksandra Trajkovska
- Australian National University School of Clinical Medicine Canberra Hospital Campus, Canberra, Australian Capital Territory, Australia.,Emergency Department, Canberra Hospital and Health Services, Canberra, Australian Capital Territory, Australia
| | - Munawar Farooq
- Australian National University School of Clinical Medicine Canberra Hospital Campus, Canberra, Australian Capital Territory, Australia.,Emergency Department, Canberra Hospital and Health Services, Canberra, Australian Capital Territory, Australia
| | - Drew Richardson
- Australian National University School of Clinical Medicine Canberra Hospital Campus, Canberra, Australian Capital Territory, Australia.,Emergency Department, Canberra Hospital and Health Services, Canberra, Australian Capital Territory, Australia
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27
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Loftus NW, Smith D. Investigating ward nurses' responses to deteriorating patients. Nurs Stand 2018:e11020. [PMID: 30226338 DOI: 10.7748/ns.2018.e11020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2018] [Indexed: 11/09/2022]
Abstract
Deteriorating patients often present with suboptimal vital signs. If these are not recognised by healthcare staff, the patient's condition can deteriorate further, potentially leading to serious complications and even death. Despite efforts to improve ward nurses' recognition of, and responses to, deteriorating patients, this aspect of care has been found to be suboptimal. AIM To identify factors that influence ward nurses' responses to deteriorating patients. METHOD A literature review was undertaken, based on the research question 'What factors influence the trigger component of ward-based registered nurses' afferent response to deteriorating patients?' Several electronic databases were searched electronically to identify relevant articles, alongside hand-searching. Inclusion and exclusion criteria were set to determine which articles should be included in the literature review. FINDINGS Nine studies were identified for inclusion in the literature review. Four main themes that influenced ward nurses' responses to deteriorating patients emerged: communication, diurnal and weekend variation, knowledge and attitudes, and nurse staffing levels. CONCLUSION Effective communication was identified as an important factor in improving ward nurses' responses to deteriorating patients, as was improved knowledge of 'do not attempt cardiopulmonary resuscitation' (DNACPR) orders. It was also identified that increased ward nurse numbers improved responses to deteriorating patients, as did increased availability of senior healthcare staff, which enabled junior staff to escalate care.
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Affiliation(s)
| | - Duncan Smith
- City, University of London, London; honorary charge nurse in the Patient Emergency Response and Resuscitation Team (PERRT), University College London Hospitals NHS Foundation Trust, London, and clinical doctoral research fellow
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Dalton M, Harrison J, Malin A, Leavey C. Factors that influence nurses' assessment of patient acuity and response to acute deterioration. ACTA ACUST UNITED AC 2018; 27:212-218. [DOI: 10.12968/bjon.2018.27.4.212] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Mark Dalton
- Advanced Nurse Practitioner, Royal Liverpool and Broadgreen Hospital Trust, Final year PhD student/Visiting Senior Lecturer, Liverpool John Moores University
| | - John Harrison
- Senior Lecturer In Mental Health Nursing, Faculty of Education, Health and Community, Liverpool John Moores University
| | - Anitra Malin
- Senior Lecturer in Adult Nursing, Faculty of Education, Health and Community, Liverpool John Moores University
| | - Conan Leavey
- Senior Lecturer in Public Health, Faculty of Education, Health and Community, Liverpool John Moores University
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29
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Padilla RM, Mayo AM. Clinical deterioration: A concept analysis. J Clin Nurs 2018; 27:1360-1368. [PMID: 29266536 DOI: 10.1111/jocn.14238] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2017] [Indexed: 12/01/2022]
Abstract
AIMS AND OBJECTIVES To present a concept analysis of clinical deterioration and introduce an operational definition. BACKGROUND Hospitalised patients who endure cardiopulmonary arrest and unplanned intensive care unit admissions often exhibit physiological signs preceding these events. Clinical deterioration not promptly recognised can result in increased patient morbidity and mortality. A barrier to recognising and responding to clinical deterioration stems from practice variations among healthcare clinicians. DESIGN Concept analysis. METHODS Eight-step method of concept analysis proposed by Walker and Avant. RESULTS Defining attributes include dynamic state, decompensation and objective and subjective determination. Antecedents identified include clinical state, susceptibility, pathogenesis and adverse event. Increased mortality, resuscitation, implementation of higher level of care and prolonged hospital admission were the consequences identified. Defining attributes, antecedents and consequences identified led to an operational definition of clinical deterioration as a dynamic state experienced by a patient compromising hemodynamic stability, marked by physiological decompensation accompanied by subjective or objective findings. CONCLUSIONS Clinical deterioration is a key contributor to inpatient mortality, and its recognition is often underpinned by contextual factors and practice variances. Variation in the uniformity of the concept of clinical deterioration causes a gap in knowledge and necessitated clarification of this phenomenon for nursing research and practice. RELEVANCE TO CLINICAL PRACTICE Identifying and intervening on clinical deterioration plays a vital role in the inpatient setting demonstrated by the dynamic nature of a patients' condition during hospitalisation. It is anticipated that this concept analysis on clinical deterioration will contribute to further identification of clinically modifiable risk factors and accompanying interventions to prevent clinical deterioration in the inpatient setting.
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Affiliation(s)
- Ricardo M Padilla
- Hahn School of Nursing & Health Science, Beyster Institute for Nursing Research, University of San Diego, San Diego, CA, USA
| | - Ann M Mayo
- Hahn School of Nursing & Health Science, Beyster Institute for Nursing Research, University of San Diego, San Diego, CA, USA
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30
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Smith D, Bowden T. Using the ABCDE approach to assess the deteriorating patient. Nurs Stand 2017; 32:51-63. [PMID: 29185642 DOI: 10.7748/ns.2017.e11030] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2017] [Indexed: 12/31/2022]
Abstract
Patients who deteriorate without recognition or timely interventions are at risk of critical care admission and increased morbidity or mortality. This article outlines the systematic ABCDE (airway, breathing, circulation, disability, exposure) approach to patient assessment, which enables healthcare practitioners to identify and respond to life-threatening conditions in order of priority. The patient's vital signs should be measured as part of the ABCDE assessment and recorded using a track and trigger tool to enhance recognition of physiological abnormalities that signal deterioration. To optimise communication and escalation of deteriorating patients, healthcare practitioners should report ABCDE assessment findings using a structured communication tool.
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Affiliation(s)
- Duncan Smith
- Adult nursing, Division of Nursing, School of Health Sciences, City University, London, England
| | - Tracey Bowden
- Cardiac care, Division of Nursing, School of Health Sciences, City University, London, England
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31
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Wong ECK. On being human: reflections on a daily error. BMJ Qual Saf 2017; 27:e4. [PMID: 28971882 DOI: 10.1136/bmjqs-2017-007415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 09/22/2017] [Indexed: 11/03/2022]
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32
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McGaughey J, O'Halloran P, Porter S, Blackwood B. Early warning systems and rapid response to the deteriorating patient in hospital: A systematic realist review. J Adv Nurs 2017; 73:2877-2891. [DOI: 10.1111/jan.13398] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Jennifer McGaughey
- School of Nursing & Midwifery; Medical Biology Centre; Queen's University Belfast; Belfast UK
| | - Peter O'Halloran
- School of Nursing & Midwifery; Queen's University of Belfast; Belfast UK
| | - Sam Porter
- Department of Social Sciences and Social Work; Bournemouth University; Poole UK
| | - Bronagh Blackwood
- School of Medicine, Dentistry & Biomedical Sciences; Centre for Experimental Medicine; Queen's University Belfast; Belfast UK
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