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Glover G, Metaxa V, Ostermann M. Intensive Care Unit Without Walls. Crit Care Clin 2024; 40:549-560. [PMID: 38796227 DOI: 10.1016/j.ccc.2024.03.002] [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] [Indexed: 05/28/2024]
Abstract
Critical illness is a continuum with different phases and trajectories. The "Intensive Care Unit (ICU) without walls" concept refers to a model whereby care is adjusted in response to the patient's needs, priorities, and preferences at each stage from detection, escalation, early decision making, treatment and organ support, followed by recovery and rehabilitation, within which all healthcare staff, and the patient are equal partners. The rapid response system incorporates monitoring and alerting tools, a multidisciplinary critical care outreach team and care bundles, supported with education and training, analytical and governance functions, which combine to optimise outcomes of critically ill patients, independent of location.
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Affiliation(s)
- Guy Glover
- Department of Critical Care, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Victoria Metaxa
- Department of Critical Care, King's College Hospital, Denmark Hill, SE5 9RS, London, UK
| | - Marlies Ostermann
- Department of Critical Care, Guy's & St Thomas' NHS Foundation Trust, London, UK.
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Le Lagadec MD, Massey D, Byrne AL, Connor J, Flenady T. Nurse by numbers: The impact of early warning systems on nurses' higher-order thinking, a quantitative study. J Adv Nurs 2024. [PMID: 38733070 DOI: 10.1111/jan.16235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/27/2024] [Accepted: 04/29/2024] [Indexed: 05/13/2024]
Abstract
AIM To evaluate registered nurses' perceptions of whether the mandated use of the early warning system vital signs tool impacts the development of nurses' higher-order thinking skills. DESIGN A concurrent mixed methods study design. METHOD Using an online survey, registered nurses' perceptions were elucidated on whether early warning system algorithmic tools affected the development of their higher-order thinking. Likert-type matrix questions with additional qualitative fields were used to obtain information on nurse's perceptions of the tool's usefulness, clinical confidence in using the tool, compliance with escalation protocols, work environment and perceived compliance barriers. RESULTS Most of the 305 (91%) participants included in the analysis had more than 5 years of nursing experience. Most nurses supported the early warning tool and were happy to comply with escalation protocols if the early warning score concurred with their assessment of the patient (63.6%). When the score and the nurse's higher-order thinking did not align, some had the confidence to override the escalation protocol (40.0%), while others omitted (69.4%) or inaccurately documented vital signs (63.3%) to achieve the desired score. Very few nurses (3.6%) believe using early warning tools did not impede the development of higher-order thinking. CONCLUSION Although experienced nurses appreciate the support of early warning tools, most value patient safety above the tools and rely on their higher-order thinking. The sustained development and use of nurses' higher-order thinking should be encouraged, possibly by adding a critical thinking criterion to existing algorithmic tools. IMPACT The study has implications for all nurses who utilize algorithmic tools, such as early warning systems, in their practice. Relying heavily on algorithmic tools risks impeding the development of higher-order thinking. Most experienced nurses prioritize their higher-order thinking in decision-making but believe early warning tools can impede higher-order thinking. PATIENT OR PUBLIC CONTRIBUTION Registered nurses participated as survey respondents.
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Affiliation(s)
| | - Deb Massey
- Edith Cowan University, Joondalup, New South Wales, Australia
| | - Amy-Louise Byrne
- School of Nursing Midwifery and Social Sciences, CQUniversity, Rockhampton, Queensland, Australia
| | - Justine Connor
- School of Nursing Midwifery and Social Sciences, CQUniversity, Rockhampton, Queensland, Australia
| | - Tracy Flenady
- School of Nursing Midwifery and Social Sciences, CQUniversity, Rockhampton, Queensland, Australia
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Le Lagadec MD, Flenady T, Cleary M. Finally, a new Early Warning Score supporting critical thinking. J Adv Nurs 2024; 80:1241-1242. [PMID: 38018021 DOI: 10.1111/jan.16001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 11/19/2023] [Indexed: 11/30/2023]
Affiliation(s)
| | - Tracy Flenady
- School of Nursing Midwifery and Social Sciences, CQUniversity, Rockhampton, Queensland, Australia
| | - Michelle Cleary
- School of Nursing Midwifery and Social Sciences, CQUniversity, Rockhampton, Queensland, Australia
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Sigvardt E, Grønbaek KK, Jepsen ML, Søgaard M, Haahr L, Inácio A, Aasvang EK, Meyhoff CS. Workload associated with manual assessment of vital signs as compared with continuous wireless monitoring. Acta Anaesthesiol Scand 2024; 68:274-279. [PMID: 37735843 DOI: 10.1111/aas.14333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/28/2023] [Accepted: 09/12/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Vital sign monitoring is considered an essential aspect of clinical care in hospitals. In general wards, this relies on intermittent manual assessments performed by clinical staff at intervals of up to 12 h. In recent years, continuous monitoring of vital signs has been introduced to the clinic, with improved patient outcomes being one of several potential benefits. The aim of this study was to determine the workload difference between continuous monitoring and manual monitoring of vital signs as part of the National Early Warning Score (NEWS). METHODS Three wireless sensors continuously monitored blood pressure, heart rate, respiratory rate, and peripheral oxygen saturation in 20 patients admitted to the general hospital ward. The duration needed for equipment set-up and maintenance for continuous monitoring in a 24-h period was recorded and compared with the time spent on manual assessments and documentation of vital signs performed by clinical staff according to the NEWS. RESULTS The time used for continuous monitoring was 6.0 (IQR 3.2; 7.2) min per patient per day vs. 14 (9.7; 32) min per patient per day for the NEWS. Median difference in duration for monitoring of vital signs was 9.9 (95% CI 5.6; 21) min per patient per day between NEWS and continuous monitoring (p < .001). Time used for continuous monitoring in isolated patients was 6.6 (4.6; 12) min per patient per day as compared with 22 (9.7; 94) min per patient per day for NEWS. CONCLUSION The use of continuous monitoring was associated with a significant reduction in workload in terms of time for monitoring as compared with manual assessment of vital signs.
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Affiliation(s)
- Emilie Sigvardt
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Katja Kjaer Grønbaek
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Mia Lind Jepsen
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Marlene Søgaard
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Louise Haahr
- Department of Anesthesiology, Center of Organ and Cancer Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Ana Inácio
- University of Porto, Faculty of Medicine, Porto, Portugal
| | - Eske Kvanner Aasvang
- Department of Anesthesiology, Center of Organ and Cancer Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christian Sylvest Meyhoff
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Zhao F, Zhao J, Liu H. Commentary: Predicting patient deterioration by nurse intuition: the development and validation of the Nurse Intuition Patient Deterioration Scale. Front Med (Lausanne) 2024; 11:1259449. [PMID: 38333664 PMCID: PMC10850264 DOI: 10.3389/fmed.2024.1259449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 01/05/2024] [Indexed: 02/10/2024] Open
Affiliation(s)
- Feng Zhao
- School of Nursing, Qingdao University, Qingdao, Shandong, China
| | - Jihu Zhao
- Department of Neurosurgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Heng Liu
- School of Nursing, Qingdao University, Qingdao, Shandong, China
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Chua WL, Wee LPC, Lim JYG, Yeo MLK, Jones D, Tan CK, Khan FA, Liaw SY. Automated rapid response system activation-Impact on nurses' attitudes and perceptions towards recognising and responding to clinical deterioration: Mixed-methods study. J Clin Nurs 2023; 32:6322-6338. [PMID: 37087695 DOI: 10.1111/jocn.16734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 02/12/2023] [Accepted: 04/05/2023] [Indexed: 04/24/2023]
Abstract
AIM To explore general ward nurses' attitudes and perceptions towards recognising and responding to clinical deterioration in a hospital with automated rapid response system activation. BACKGROUND There is growing interest in deploying automated clinical deterioration notification systems to reduce delayed or failed recognition and response to clinical deterioration of ward patients. However, little is known about its impact on ward nurses' perspectives and work patterns. DESIGN A mixed-methods study. METHODS Online survey of 168 registered nurses and individual interviews with 10 registered nurses in one acute hospital in Singapore. The study adhered to the STROBE checklist for cross-sectional studies and the COREQ guidelines for qualitative studies. RESULTS Many nurses (38.1%) rarely performed patient assessments or observations other than vital signs assessment to assess for early signs of clinical deterioration. About 30% were worried about being criticised for calling the primary team doctors. Four themes emerged from the qualitative analysis: automated rapid response system activation as a safety net, being more cautious with vital signs monitoring, the NEWS2 alone is inadequate, and ward nurses as the 'middleman' between the intensive care unit outreach nurse and primary team doctors. CONCLUSIONS Although nurses value the automated rapid response system activation as a safety net to minimise delays in accessing urgent critical care resources, it does not address the sociocultural barriers inherent in escalation of care. Although the automated system led nurses to be more cautious with vital signs monitoring, it does not encourage them to perform comprehensive patient assessments to detect early signs of deterioration. RELEVANCE TO CLINICAL PRACTICE Nurse education on assessing for clinical deterioration should focus on the use of broader patient assessment skills other than vital signs. Sociocultural barriers to escalation of care remain a key issue that needs to be addressed by hospital management. NO PATIENT OR PUBLIC CONTRIBUTION No patients, service users, care-givers or members of the public were involved in the study.
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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, Singapore
| | - Li-Phing Clarice Wee
- Department of Nursing Administration, Ng Teng Fong General Hospital, National University Health System, Singapore
| | - Jia Ying Germaine Lim
- Department of Nursing, Ng Teng Fong General Hospital, National University Health System, Singapore
| | - Min Li Kimberly Yeo
- Department of Nursing, Ng Teng Fong General Hospital, National University Health System, Singapore
| | - Daryl Jones
- Intensive Care Unit, Austin Health, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
| | - Chee Keat Tan
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System, Singapore
| | - Faheem Ahmed Khan
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System, Singapore
| | - Sok Ying Liaw
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Longstreth MT, Whiteman K, Stephens K, Swanson-Biearman B, Cartwright-Stroupe LM. Implementing Best Practices for Decreasing Nurse Hesitancy to Call the Rapid Response Team: An Evidence-Based Quality Improvement Initiative. J Contin Educ Nurs 2023; 54:281-288. [PMID: 37253325 DOI: 10.3928/00220124-20230511-09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND Nurses, regardless of experience, sometimes wait for the Modified Early Warning Score to indicate physiological decline before initiating the hospital's Rapid Response Team (RRT). The goal of this quality improvement initiative was to reduce nurse hesitancy to call the RRT, as indicated by the monthly number of proactive calls before the Modified Early Warning Score increased and triggered an automated page. METHOD Education, planned handoff communication, debriefing, and good catch emails were the educational strategies used in the implementation of the quality improvement initiatives, encouraging RRT calls sooner. Increasing RRT knowledge and communication is an evidence-based practice strategy to reduce nurse reluctance to call the RRT. RESULTS After implementation, monthly proactive RRT calls increased (χ2 [1, n = 1,964] = 14.6085, p = .000159). Bedside interventions, unscheduled transfers, and Acute Physiologic and Chronic Health Evaluation scores did not differ. CONCLUSION Education, structured handoff communication, and acknowledging good catches reduced nurses' reluctance to call the RRT proactively. [J Contin Educ Nurs. 2023;54(6):281-288.].
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Haegdorens F, Wils C, Franck E. Predicting patient deterioration by nurse intuition: The development and validation of the nurse intuition patient deterioration scale. Int J Nurs Stud 2023; 142:104467. [PMID: 37068418 DOI: 10.1016/j.ijnurstu.2023.104467] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 02/06/2023] [Accepted: 02/09/2023] [Indexed: 02/25/2023]
Abstract
INTRODUCTION Early warning scores based on vital signs are used in hospitals to estimate patient deterioration and to initiate an adequate and timely response when necessary. These scores show acceptable performance in predicting patient outcomes. However, they tend to generate many false positives leading to an increased workload in clinical practice. Additionally, nurses feel a tension between the application of an early warning score and their own clinical judgement. Nurse intuition is often included as an extra call criterion next to an early warning score. It is therefore important to investigate its predictive value. The aim of this study was to develop and validate a Nurse Intuition Patient Deterioration Scale (NIPDS). METHODS The NIPDS was developed using the latest evidence after which relevant items were selected by an expert panel. The scale was tested in a prospective observational study in 2 surgical and 2 medical wards in a Belgian hospital. Data were collected from December 1st, 2019 until March 31st, 2020. A NIPDS registration was done at each patient admission and whenever the attending nurse felt worried. The studied outcomes were urgent physician assistance call, resuscitation team call, patient death, and unplanned transfer to intensive/medium care. Psychometric analyses and scale optimisation were carried out using Rasch modelling techniques. Finally, the scale's accuracy and an optimal threshold were determined. RESULTS The scale item content validity index is 0.88 indicating that the selected items should be included in the instrument according to the expert panel. Item-total score correlation coefficients range between 0.573 (item 9 - pain) and 0.874 (item 6 - behaviour). The Person Separation Index is 0.814 indicating satisfactory discriminatory power. An overall fit of the NIPDS data to the Rasch model was confirmed. Rasch modelling showed that the item 'pain' signalled misfit. Furthermore, the person-item map showed disordered items which were corrected in the final model. The AUROC to predict an event within 24 h after registration was 0.957 (95% CI 0.932-0.982; p < 0.001) indicating excellent model performance. DISCUSSION The results showed that the NIPDS is a valid and accurate instrument to predict events in surgical and medical patients. It showed better performance compared to an existing score estimating nurse intuition. In practice, the NIPDS could be used by nurses to estimate clinical deterioration in addition to an early warning score. It remains unclear if the combination of NIPDS with an early warning score could reduce workload without losing accuracy and this should be explored in future research. TWEETABLE ABSTRACT Newly developed nurse intuition scale, which uses clinical cues to estimate deterioration in hospitalised patients, is brief and performs well in predicting physician assistance, resuscitation team calls, patient death and unplanned transfer to intensive or medium care.
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Affiliation(s)
- Filip Haegdorens
- Centre for Research and Innovation in Care (CRIC), Department of Nursing and Midwifery Sciences, University of Antwerp, Belgium.
| | | | - Erik Franck
- Centre for Research and Innovation in Care (CRIC), Department of Nursing and Midwifery Sciences, University of Antwerp, Belgium
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van Goor HMR, Breteler MJM, Schoonhoven L, Kalkman CJ, van Loon K, Kaasjager KAH. Interpretation of continuously measured vital signs data of COVID-19 patients by nurses and physicians at the general ward: A mixed methods study. PLoS One 2023; 18:e0286080. [PMID: 37228047 DOI: 10.1371/journal.pone.0286080] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 05/08/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Continuous monitoring of vital signs is introduced at general hospital wards to detect patient deterioration. Interpretation and response currently rely on experience and expert opinion. This study aims to determine whether consensus exist among hospital professionals regarding the interpretation of vital signs of COVID-19 patients. In addition, we assessed the ability to recognise respiratory insufficiency and evaluated the interpretation process. METHODS We performed a mixed methods study including 24 hospital professionals (6 nurses, 6 junior physicians, 6 internal medicine specialists, 6 ICU nurses). Each participant was presented with 20 cases of COVID-19 patients, including 4 or 8 hours of continuously measured vital signs data. Participants estimated the patient's situation ('improving', 'stable', or 'deteriorating') and the possibility of developing respiratory insufficiency. Subsequently, a semi-structured interview was held focussing on the interpretation process. Consensus was assessed using Krippendorff's alpha. For the estimation of respiratory insufficiency, we calculated the mean positive/negative predictive value. Interviews were analysed using inductive thematic analysis. RESULTS We found no consensus regarding the patient's situation (α 0.41, 95%CI 0.29-0.52). The mean positive predictive value for respiratory insufficiency was high (0.91, 95%CI 0.86-0.97), but the negative predictive value was 0.66 (95%CI 0.44-0.88). In the interviews, two themes regarding the interpretation process emerged. "Interpretation of deviations" included the strategies participants use to determine stability, focused on finding deviations in data. "Inability to see the patient" entailed the need of hospital professionals to perform a patient evaluation when estimating a patient's situation. CONCLUSION The interpretation of continuously measured vital signs by hospital professionals, and recognition of respiratory insufficiency using these data, is variable, which might be the result of different interpretation strategies, uncertainty regarding deviations, and not being able to see the patient. Protocols and training could help to uniform interpretation, but decision support systems might be necessary to find signs of deterioration that might otherwise go unnoticed.
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Affiliation(s)
- Harriët M R van Goor
- Department of Acute Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martine J M Breteler
- Department of Acute Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Digital Health, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lisette Schoonhoven
- Department of Public Health, Healthcare Innovation & Evaluation and Medical Humanities, Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Cor J Kalkman
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Kim van Loon
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Karin A H Kaasjager
- Department of Acute Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
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Rørbech JT, Jensen CS, Dreyer P, Herholdt-Lomholdt SM. Beyond objective measurements: Danish nurses' identification of hospitalized pediatric patients at risk of clinical deterioration - A qualitative study. J Pediatr Nurs 2022; 66:e67-e73. [PMID: 35710888 DOI: 10.1016/j.pedn.2022.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 05/15/2022] [Accepted: 05/22/2022] [Indexed: 11/19/2022]
Abstract
PURPOSE While the use of Pediatric Track and Trigger Tools as a standard to discriminate high level of urgency in pediatric care has received considerable attention, less focus has been given to other important factors such as nurses' clinical observations and judgement. The purpose of this study was to explore nurses' observational practice and focus on which non-measurable signs and symptoms nurses find important when identifying inpatient pediatric patients at risk of clinical deterioration. DESIGN AND METHODS This was an inductive qualitative study based on an interpretive description methodology. Data were obtained through participant observation of experienced nurses working in a Danish pediatric unit and focus group interviews with pediatric nurses. Field notes were taken, and focus group interviews were audio taped and transcribed. A thematic text condensation method was used to analyse data. RESULTS Findings revealed the following four main themes of non-measurable signs and symptoms that nurses find important when identifying children at risk of clinical deterioration: Colour and skin tone; sounds; movement patterns; behavioural signs. CONCLUSIONS This study suggest that pediatric patients show signs and symptoms that go beyond the objective measurements integrated in Pediatric Track and Trigger Tools and they should not be ignored as they are highly valuable to nurses who are responsible for observing inpatient pediatric patients at risk of clinical deterioration. IMPLICATIONS More empirical research on nurses' observational practice is recommended, especially research to identify the signs and symptoms - both measurable and non-measurable - that are significant to nurses at the bedside.
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Affiliation(s)
- Josefine Tang Rørbech
- Department of Paediatrics and Adolescent Medicine, Unit for Research and Development in Nursing for Children and Young People, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark.
| | - Claus Sixtus Jensen
- Department of Paediatrics and Adolescent Medicine, Unit for Research and Development in Nursing for Children and Young People, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Research Centre for Emergency Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark.
| | - Pia Dreyer
- Professor in clinical nursing, Intensive care, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark.
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Chua WL, Smith D, Wee LC, Ting KC, Yeo MLK, Mordiffi SZ, Liaw SY. Development and psychometric evaluation of the Attitudes Towards Recognising Early and Noticeable Deterioration (ATREND) scale. J Clin Nurs 2022; 32:2684-2699. [PMID: 35527356 DOI: 10.1111/jocn.16350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 04/04/2022] [Accepted: 04/19/2022] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES To develop and evaluate the psychometric properties of an instrument that measures nurses' Attitudes Towards Recognising Early and Noticeable Deterioration (ATREND). BACKGROUND General ward nurses play an important role in recognising patient deterioration. However, their attitudes towards early recognition of clinical deterioration have not been adequately explored due to the lack of a valid and reliable scale. DESIGN An instrument development and validation study. METHODS A three-phase structure that followed the STROBE checklist was used: (1) item generation, (2) content and face validity assessment and (3) psychometric properties evaluation. The scale items were developed based on a comprehensive literature review and content validity assessment by 15 international experts from five countries. The psychometric properties of the ATREND scale were tested on 434 registered nurses, with retest evaluations (n = 100) at two hospitals. Exploratory and confirmatory factor analyses were used to examine the factor structure of the scale. The scale was also evaluated for its internal consistency, test-retest reliability and convergent validity. RESULTS The scale's content validity was 0.95. A 3-factor solution was identified from the final 11 items: (1) beliefs about importance of patient observation, (2) use of broader patient assessment skills and (3) confidence in recognising clinical deterioration. The internal consistency reliability of the scale was supported with an acceptable Cronbach's alpha value of 0.745. Test-retest reliability of the scale was excellent, with an intraclass correlation coefficient of 0.825. The ATREND scale shows evidence of good convergent validity. CONCLUSION The final 11-item ATREND scale demonstrates adequate initial evidence of reliability and validity for use in acute ward settings. RELEVANCE TO CLINICAL PRACTICE Nursing educators and clinicians may use this scale to assess ward nurses' attitudes and practices towards early recognition of clinical deterioration and then enhance their competencies and behaviours in the recognition of clinical deterioration.
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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 Singapore City Singapore
| | - Duncan Smith
- School of Health Sciences City University of London London UK
- Patient Emergency Response & Resuscitation Team (PERRT) NHS Foundation Trust University College London Hospitals London UK
| | - Li‐Phing Clarice Wee
- Department of Nursing Administration Ng Teng Fong General Hospital National University Health System Singapore City Singapore
| | - Kit Cheng Ting
- Nursing Department National University Hospital National University Health System Singapore City Singapore
| | - Min Li Kimberly Yeo
- Department of Nursing Ng Teng Fong General Hospital National University Health System Singapore City Singapore
| | - Siti Zubaidah Mordiffi
- Nursing Department National University Hospital National University Health System Singapore City Singapore
| | - Sok Ying Liaw
- Alice Lee Centre for Nursing Studies Yong Loo Lin School of Medicine National University of Singapore Singapore City Singapore
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Nielsen PB, Langkjær CS, Schultz M, Kodal AM, Pedersen NE, Petersen JA, Lange T, Arvig MD, Meyhoff CS, Bestle MH, Hølge-Hazelton B, Bunkenborg G, Lippert A, Andersen O, Rasmussen LS, Iversen KK. Clinical assessment as a part of an early warning score—a Danish cluster-randomised, multicentre study of an individual early warning score. THE LANCET DIGITAL HEALTH 2022; 4:e497-e506. [DOI: 10.1016/s2589-7500(22)00067-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 03/02/2022] [Accepted: 03/29/2022] [Indexed: 10/18/2022]
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Peerboom FBAL, Hafsteinsdóttir TB, Weldam SW, Schoonhoven L. Surgical nurses' responses to worry: A qualitative focus-group study in the Netherlands. Intensive Crit Care Nurs 2022; 71:103231. [PMID: 35396098 DOI: 10.1016/j.iccn.2022.103231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 02/27/2022] [Accepted: 02/28/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Hospital nurses observe and respond to deterioration using the 'National Early Warning Score 2'. Surgical nurses are highly engaged in the early recognition of and response to deterioration. Responses to deterioration are based on deviating vital signs, while nurses also act on subjective indicators like worry. Scientific literature and (inter)national guidelines do not mention any information about acting upon worry. OBJECTIVE To gain an in-depth understanding of the actions nurses on surgical wards undertake to generate an appropriate response to nurses' worry when the 'National Early Warning Score 2' does not indicate deterioration. METHOD A qualitative focus-group study with surgical nurses working at a hospital in the Netherlands. Data was collected by focus-group interviews supported by vignettes and analysed thematically. FINDINGS Four focus-group interviews with a total of 20 participants were conducted between February and April 2020. Two sequential themes emerged: 'Searching for explanation and confirmation' and 'Responding by actively applying nursing interventions'. Nurses gathered additional information about the patient and searched for a reference point to place this information in perspective. Nurses also approached others for co-assessment and verification. However, nurses faced barriers in calling for medical assistance. They felt physicians did not take them seriously. After gathering additional information, nurses responded by applying nursing interventions to comfort the patient. CONCLUSION Nurses mainly try to formalise an in-depth understanding of their feeling of worry to convince a physician to accurately treat the patient. Spending much time on a search to this understanding leads to delays in escalating care.
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Affiliation(s)
- F B A L Peerboom
- Nursing Sciences, Program in Clinical Health Sciences, University of Medical Center Utrecht, Utrecht University, P.O. Box 85500, 3508GA Utrecht, The Netherlands; Zuyderland Medical Center, Department of Surgery, 6419PC Heerlen, The Netherlands.
| | - T B Hafsteinsdóttir
- Nursing Sciences, Program in Clinical Health Sciences, University of Medical Center Utrecht, Utrecht University, P.O. Box 85500, 3508GA Utrecht, The Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, STR 6.131, P.O. Box 85500, 3508GA Utrecht, The Netherlands.
| | - S W Weldam
- Nursing Sciences, Program in Clinical Health Sciences, University of Medical Center Utrecht, Utrecht University, P.O. Box 85500, 3508GA Utrecht, The Netherlands; University Medical Center Utrecht, Division Heart and Lungs. P.O. Box 85500, 3508GA Utrecht, The Netherlands.
| | - L Schoonhoven
- Nursing Sciences, Program in Clinical Health Sciences, University of Medical Center Utrecht, Utrecht University, P.O. Box 85500, 3508GA Utrecht, The Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, STR 6.131, P.O. Box 85500, 3508GA Utrecht, The Netherlands; School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, UK.
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14
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Gleason KT, Jones R, Rhodes C, Greenberg P, Harkless G, Goeschel C, Cahill M, Graber M. Evidence That Nurses Need to Participate in Diagnosis: Lessons From Malpractice Claims. J Patient Saf 2021; 17:e959-e963. [PMID: 32217927 PMCID: PMC7893643 DOI: 10.1097/pts.0000000000000621] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES There is a pressing need for nurses to contribute as equals to the diagnostic process. The purpose of this article is twofold: (a) to describe the contributing factors in diagnosis-related and failure-to-monitor malpractice claims in which nurses are named the primary responsible party and (b) to describe actions healthcare leaders can take to enhance the role of nurses in diagnosis. METHODS We conducted a review of the Controlled Risk Insurance Company Strategies' repository of malpractice claims, which contain approximately 30% of United States claims. We analyzed the malpractice claims related to diagnosis (n = 139) and physiologic monitoring (n = 647) naming nurses as the primary responsible party from 2007 to 2016. We used logistic regression to determine the association of contributing factors to likelihood of death, indemnity, and expenses incurred. RESULTS Diagnosis-related cases listing communication among providers as a contributing factor were associated with a significantly higher likelihood of death (odds ratio [OR] = 3.01, 95% confidence interval [CI] = 1.50-6.03). Physiologic monitoring cases listing communication among providers as a contributing factor were associated with significantly higher likelihood of death (OR = 2.21, 95% CI = 1.49-3.27), higher indemnity incurred (U.S. $86,781, 95% CI = $18,058-$175,505), and higher expenses incurred (U.S. $20,575, 95% CI = $3685-$37,465). CONCLUSIONS Nurses are held legally accountable for their role in diagnosis. Raising system-wide awareness of the critical role and responsibility of nurses in the diagnostic process and enhancing nurses' knowledge and skill to fulfill those responsibilities are essential to improving diagnosis.
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Affiliation(s)
| | - Rebecca Jones
- Pennsylvania Patient Safety Authority, Harrisburg, Pennsylvania
| | | | | | | | | | - Maureen Cahill
- National Council of State Boards of Nursing, Chicago, Illinois
| | - Mark Graber
- Society to Improve Diagnosis in Medicine, Chicago, IL
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15
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Jensen CS, Lisby M, Kirkegaard H, Loft MI. Signs and symptoms, apart from vital signs, that trigger nurses' concerns about deteriorating conditions in hospitalized paediatric patients: A scoping review. Nurs Open 2021; 9:57-65. [PMID: 34761544 PMCID: PMC8685853 DOI: 10.1002/nop2.1105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 09/10/2021] [Accepted: 10/14/2021] [Indexed: 11/17/2022] Open
Abstract
Aim This scoping review aimed to identify and map the signs and symptoms—apart from vital signs—that trigger nurses’ concerns about the deteriorating conditions of hospitalized paediatric patients. Design A scoping review was conducted in accordance with the Joanna Briggs Institute methodology. Methods Six databases, including MEDLINE, CINAHL, Embase, Scopus, Swemed and ProQuest Dissertations and Theses databases, were searched systematically. Of 5795 citations, seven matched the inclusion criteria. Results Objective observations, such as the patient's colour, pain‐level changes, and behavioural observations, were identified as signs that would trigger nurses’ concerns. Nurse's intuitive feelings or gut feelings when seeing a patient was also identified as an important factor for identifying a deteriorating paediatric patient. A “gut feeling” was described as both a reaction to patient signs and a feeling based on the nurse's intuition gained through experience. The signs or symptoms that would trigger this “gut feeling” were not identified.
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Affiliation(s)
- Claus Sixtus Jensen
- Research Centre for Emergency Medicine, Emergency Department, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Marianne Lisby
- Research Centre for Emergency Medicine, Emergency Department, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Hans Kirkegaard
- Research Centre for Emergency Medicine, Emergency Department, Aarhus University Hospital, Aarhus, Denmark
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16
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Gill FJ, Cooper A, Falconer P, Stokes S, Leslie GD. Development of an evidence-based ESCALATION system for recognition and response to paediatric clinical deterioration. Aust Crit Care 2021; 35:668-676. [PMID: 34711495 DOI: 10.1016/j.aucc.2021.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 09/15/2021] [Accepted: 09/21/2021] [Indexed: 10/20/2022] Open
Abstract
AIM The aim of this study was to develop an evidence-based paediatric early warning system for infants and children that takes into consideration a variety of paediatric healthcare contexts and addresses barriers to escalation of care. METHODS A three-stage intervention development framework consisted of Stage 1: evidence review, benchmarking, stakeholder (health professionals, decision-makers, and health consumers) engagement, and consultation; Stage 2: planning and coproduction by the researchers and stakeholders using action research cycles; and Stage 3: prototyping and testing. RESULTS A prototype evidence-based system incorporated human factor principles, used a structured approach to patient assessment, promoted situational awareness, and included family as well as clinician concern. Family involvement in detecting changes in their child's condition was supported by posters and flyers codesigned with health consumers. Five age-specific observation and response charts included 10 weighted variables and one unweighted variable (temperature) to convey a composite early warning score. The escalation pathway was supported by a targeted communication framework (iSoBAR NOW). CONCLUSION The development process resulted in an agreed uniform ESCALATION system incorporating a whole-system approach to promote critical thinking, situational awareness for the early recognition of paediatric clinical deterioration as well as timely and effective escalation of care. Incorporating family involvement was a novel component of the system.
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Affiliation(s)
- Fenella J Gill
- School of Nursing, Faculty of Health Sciences, Curtin University, GPO Box U1987 Perth, Western Australia 6845, Australia; Perth Children's Hospital, Child & Adolescent Health Services, Western Australia, Australia.
| | - Alannah Cooper
- School of Nursing, Faculty of Health Sciences, Curtin University, GPO Box U1987 Perth, Western Australia 6845, Australia; Perth Children's Hospital, Child & Adolescent Health Services, Western Australia, Australia.
| | - Pania Falconer
- School of Nursing, Faculty of Health Sciences, Curtin University, GPO Box U1987 Perth, Western Australia 6845, Australia; Perth Children's Hospital, Child & Adolescent Health Services, Western Australia, Australia.
| | - Scott Stokes
- Kimberley Regional Paediatric Service, Broome Hospital, Western Australia, Australia.
| | - Gavin D Leslie
- School of Nursing, Faculty of Health Sciences, Curtin University, GPO Box U1987 Perth, Western Australia 6845, Australia.
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17
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Tygesen GB, Lisby M, Raaber N, Rask MT, Kirkegaard H. A new situation awareness model decreases clinical deterioration in the emergency departments-A controlled intervention study. Acta Anaesthesiol Scand 2021; 65:1337-1344. [PMID: 34028009 DOI: 10.1111/aas.13929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 05/05/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Studies have suggested that adding subjective parameters to early warning score (EWS) systems might prompt more proactive treatment and positively affect clinical outcomes. Hence, the study aimed to investigate effect of a situation awareness model consisting of objective and subjective parameters on clinical deterioration in adult emergency department (ED) patients. METHODS This controlled pre-and-post interventional study was carried out in July-December 2016 and November 2017-April 2018. In ED patients ≥ 18 years, we examined if a situation awareness model compared with a conventional EWS system could reduce clinical deterioration. The new model consisted of a regional EWS, combined with skin observation, clinical concern and patients' and relatives' concerns, pain, dyspnea, and team risk assessment. Clinical deterioration was defined as change in vital signs requiring increased observation or physician assessment, that is, increase in early warning score from either 0 or 1 to score ≥2 or an increase from score ≥2 and above. Secondary outcomes were mortality, intensive care unit (ICU) admissions, and readmissions. RESULTS We included 34 556 patients. Patients with two or more registered EWS were included in the primary analysis (N = 21 839). Using difference-in-difference regression, we found a reduced odds of clinical deterioration of 21% (OR 0.79 95% CI [0.69; 0.90]) in the intervention groups compared with controls. No impact on mortality, ICU, or readmissions was found. CONCLUSION The situation awareness model reduces odds of clinical deterioration, defined as a clinically relevant increase in EWS, in an unselected adult population of ED patients. However, there was no effect on secondary outcomes.
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Affiliation(s)
- Gitte B. Tygesen
- Department of Emergency Medicine Horsens Regional Hospital Horsens Denmark
- Research Centre for Emergency Medicine Aarhus University Aarhus Denmark
| | - Marianne Lisby
- Research Centre for Emergency Medicine Aarhus University Aarhus Denmark
- Department of Emergency Medicine Aarhus University Hospital Aarhus Denmark
| | - Nikolaj Raaber
- Department of Emergency Medicine Aarhus University Hospital Aarhus Denmark
| | - Mette T. Rask
- The Research Clinic for Functional Disorders and Psychosomatics Aarhus University Hospital Aarhus Denmark
| | - Hans Kirkegaard
- Research Centre for Emergency Medicine Aarhus University Aarhus Denmark
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18
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Flanagan JM, Read C, Shindul-Rothschild J. Factors Associated With the Rate of Sepsis After Surgery. Crit Care Nurse 2021; 40:e1-e9. [PMID: 33000139 DOI: 10.4037/ccn2020171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Sepsis is a critical illness that requires early detection and intervention to prevent disability and/or death. OBJECTIVE To analyze the association between various hospital-related factors and rates of sepsis after surgery in Massachusetts hospitals. METHODS The sample consisted of 53 hospitals with intensive or critical care units and 25 hospitals with step-down units. Hospital characteristics, staffing levels, and health care-acquired conditions were examined using publicly available data. Analysis of variance and linear regression were performed to explore the relationship between nurse and physician staffing levels and sepsis rates. RESULTS Sepsis rates were significantly lower when nurses cared for fewer patients (P < .001) and when intensivist hours were greater (P = .03). Linear regression for nurse staffing revealed that higher rates of catheter-associated urinary tract infection (P = .001) and higher numbers of step-down patients cared for by nurses (P = .001) were associated with a significantly higher rate of sepsis (P < .001). Linear regression for physician staffing revealed that higher rates of catheter-associated urinary tract infection (P < .001) and wound dehiscence after surgery (P < .001), greater hospitalist hours (P = .001), and greater physician hours (P = .05) were associated with a significantly higher sepsis rate, while greater intensivist hours were associated with a lower sepsis rate (P = .002). CONCLUSION In this study, greater nurse staffing and intensivist hours were associated with significantly lower rates of sepsis, whereas greater physician staffing and hospitalist hours were associated with significantly higher rates. Further research is needed to understand the roles of the various types of providers and the reasons for their differing effects on sepsis rates.
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Affiliation(s)
- Jane M Flanagan
- Jane M. Flanagan is an associate professor, Boston College, Chestnut Hill, Massachusetts
| | - Catherine Read
- Catherine Read is an associate professor, Boston College
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19
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Soar J, Böttiger BW, Carli P, Couper K, Deakin CD, Djärv T, Lott C, Olasveengen T, Paal P, Pellis T, Perkins GD, Sandroni C, Nolan JP. [Adult advanced life support]. Notf Rett Med 2021; 24:406-446. [PMID: 34121923 PMCID: PMC8185697 DOI: 10.1007/s10049-021-00893-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2021] [Indexed: 12/19/2022]
Abstract
These European Resuscitation Council Advanced Life Support guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the prevention of and ALS treatments for both in-hospital cardiac arrest and out-of-hospital cardiac arrest.
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Affiliation(s)
- Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, Großbritannien
| | - Bernd W. Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, Universitätsklinikum Köln, Köln, Deutschland
| | - Pierre Carli
- SAMU de Paris, Center Hospitalier Universitaire Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, and Université Paris Descartes, Paris, Frankreich
| | - Keith Couper
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
- Warwick Medical School, University of Warwick, Coventry, Großbritannien
| | - Charles D. Deakin
- University Hospital Southampton NHS Foundation Trust, Southampton, Großbritannien
- South Central Ambulance Service NHS Foundation Trust, Otterbourne, Großbritannien
| | - Therese Djärv
- Dept of Acute and Reparative Medicine, Karolinska University Hospital, Stockholm, Schweden
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Schweden
| | - Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
| | - Theresa Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norwegen
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Österreich
| | - Tommaso Pellis
- Department of Anaesthesia and Intensive Care, Azienda Sanitaria Friuli Occidentale, Pordenone, Italien
| | - Gavin D. Perkins
- Warwick Medical School and University Hospitals Birmingham NHS Foundation Trust, University of Warwick, Coventry, Großbritannien
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rom, Italien
- Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rom, Italien
| | - Jerry P. Nolan
- Warwick Medical School, Coventry, Großbritannien, Consultant in Anaesthesia and Intensive Care Medicine Royal United Hospital, University of Warwick, Bath, Großbritannien
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20
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Hogervorst VM, Buurman BM, De Jonghe A, van Oppen JD, Nickel CH, Lucke J, Blomaard LC, Thaur A, Mooijaart SP, Banerjee J, Wallace J, de Groot B, Conroy SP. Emergency department management of older people living with frailty: a guide for emergency practitioners. Emerg Med J 2021; 38:724-729. [PMID: 33883216 DOI: 10.1136/emermed-2020-210014] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 03/09/2021] [Accepted: 03/31/2021] [Indexed: 11/04/2022]
Abstract
Emergency Departments (EDs) are increasingly seeing more seriously unwell older people living with frailty. In the context of limited resources and increasing demand it's the ED practitioner's challenge to unpick this constellation of physical, psychological, functional and social issues.To properly assess older people living with frailty at the ED it is crucial to use an holistic approach. This consists of triage with algorithms sensitive to the higher risk of older people living with frailty, a frailty assessment, and an assessment with the help of the principles of Comprehensive Geriatric Assessment. Multi-disciplinary care, a tailor-made treatment plan, based on what the person values most, will help the ED practitioner to deliver appropriate and valuable care during the ED stay, but also in transition from hospital to home.
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Affiliation(s)
- Vera M Hogervorst
- Department of Geriatric Medicine, Tergooi Hospital, Hilversum, The Netherlands .,Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands
| | - Bianca M Buurman
- Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands
| | | | - James David van Oppen
- Department of Health Sciences, University of Leicester, Leicester, UK.,Emergency & Specialist Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Jacinta Lucke
- Department of Emergency Medicine, Spaarne Gasthuis, Haarlem, The Netherlands
| | - Laura C Blomaard
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Arjun Thaur
- Department of Emergency Medicine, Guy's and Saint Thomas' NHS Foundation Trust, London, London, UK
| | - Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Jay Banerjee
- Department of Health Sciences, University of Leicester, Leicester, UK.,Department of Emergency Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - James Wallace
- Department of Emergency Medicine, Warrington and Halton Teaching Hospitals NHS Foundation Trust, Warrington, UK
| | - Bas de Groot
- Department of Emergency Medicine, Leids Universitair Medisch Centrum, Leiden, The Netherlands
| | - Simon Paul Conroy
- Department of Health Sciences, University of Leicester, Leicester, UK
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21
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Soar J, Böttiger BW, Carli P, Couper K, Deakin CD, Djärv T, Lott C, Olasveengen T, Paal P, Pellis T, Perkins GD, Sandroni C, Nolan JP. European Resuscitation Council Guidelines 2021: Adult advanced life support. Resuscitation 2021; 161:115-151. [PMID: 33773825 DOI: 10.1016/j.resuscitation.2021.02.010] [Citation(s) in RCA: 433] [Impact Index Per Article: 144.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
These European Resuscitation Council Advanced Life Support guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the prevention of and ALS treatments for both in-hospital cardiac arrest and out-of-hospital cardiac arrest.
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Affiliation(s)
- Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, UK.
| | - Bernd W Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Pierre Carli
- SAMU de Paris, Centre Hospitalier Universitaire Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, and Université Paris Descartes, Paris, France
| | - Keith Couper
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Warwick Medical School, University of Warwick, Coventry,UK
| | - Charles D Deakin
- University Hospital Southampton NHS Foundation Trust, Southampton, UK; South Central Ambulance Service NHS Foundation Trust, Otterbourne,UK
| | - Therese Djärv
- Dept of Acute and Reparative Medicine, Karolinska University Hospital, Stockholm, Sweden, Department of Medicine Solna, Karolinska Institutet,Stockholm, Sweden
| | - Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-Universitaet Mainz, Germany
| | - Theresa Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Tommaso Pellis
- Department of Anaesthesia and Intensive Care, Azienda Sanitaria Friuli Occidentale, Italy
| | - Gavin D Perkins
- University of Warwick, Warwick Medical School and University Hospitals Birmingham NHS Foundation Trust, Coventry, UK
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy; Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jerry P Nolan
- University of Warwick, Warwick Medical School, Coventry, CV4 7AL; Royal United Hospital, Bath, UK
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22
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Boier Tygesen G, Kirkegaard H, Raaber N, Trøllund Rask M, Lisby M. Consensus on predictors of clinical deterioration in emergency departments: A Delphi process study. Acta Anaesthesiol Scand 2021; 65:266-275. [PMID: 32941660 DOI: 10.1111/aas.13709] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 09/03/2020] [Accepted: 09/09/2020] [Indexed: 12/21/2022]
Abstract
AIM The study aim was to determine relevance and applicability of generic predictors of clinical deterioration in emergency departments based on consensus among clinicians. METHODS Thirty-three predictors of clinical deterioration identified from literature were assessed in a modified two-stage Delphi-process. Sixty-eight clinicians (physicians and nurses) participated in the first round and 48 in the second round; all treating hospitalized patients in Danish emergency departments, some with pre-hospital experience. The panel rated the predictors for relevance (relevant marker of clinical deterioration) and applicability (change in clinical presentation over time, generic in nature and possible to detect bedside). They rated their level of agreement on a 9-point Likert scale and were also invited to propose additional generic predictors between the rounds. New predictors suggested by more than one clinician were included in the second round along with non-consensus predictors from the first round. Final decisions of non-consensus predictors after second round were made by a research group and an impartial physician. RESULTS The Delphi-process resulted in 19 clinically relevant and applicable predictors based on vital signs and parameters (respiratory rate, saturation, dyspnoea, systolic blood pressure, pulse rate, abnormal electrocardiogram, altered mental state and temperature), biochemical tests (serum c-reactive protein, serum bicarbonate, serum lactate, serum pH, serum potassium, glucose, leucocyte counts and serum haemoglobin), objective clinical observations (skin conditions) and subjective clinical observations (pain reported as new or escalating, and relatives' concerns). CONCLUSION The Delphi-process led to consensus of 19 potential predictors of clinical deterioration widely accepted as relevant and applicable in emergency departments.
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Affiliation(s)
- Gitte Boier Tygesen
- Department of Emergency Medicine Horsens Regional Hospital Horsens Denmark
- Research Centre for Emergency Medicine Aarhus University Aarhus Denmark
| | - Hans Kirkegaard
- Research Centre for Emergency Medicine Aarhus University Aarhus Denmark
| | - Nikolaj Raaber
- Department of Emergency Medicine Aarhus University Hospital Aarhus Denmark
| | - Mette Trøllund Rask
- The Research Clinic for Functional Disorders and Psychosomatics Aarhus University Hospital Aarhus Denmark
| | - Marianne Lisby
- Research Centre for Emergency Medicine Aarhus University Aarhus Denmark
- Department of Emergency Medicine Aarhus University Hospital Aarhus Denmark
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23
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Jensen CS, Lisby M, Kirkegaard H, Loft MI. Signs and symptoms that trigger nurses' concerns about deteriorating conditions in hospitalized pediatric patients: a scoping review protocol. JBI Evid Synth 2020; 18:1594-1601. [PMID: 32813400 DOI: 10.11124/jbisrir-d-19-00220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE The objective of this scoping review is to identify and map the signs and symptoms that trigger nurses' concerns about the deteriorating conditions of hospitalized pediatric patients. INTRODUCTION Standardized observations and risk assessments of hospitalized pediatric patients are important in modern health systems. The Pediatric Early Warning Score (PEWS) is based on objective criteria, such as vital parameters, but does not include subjective criteria, such as nurses' worry. A Dutch study has shown that adding indicators for "worry" or "concern" to an early warning system based on vital signs improves the prediction of unplanned adult admissions to intensive care units. However, this has not been studied in a pediatric population. Clarifying the signs and symptoms that trigger nurses' concerns about pediatric patients' conditions could possibly help them take actions based on their intuitive feelings and obtain medical support for pediatric patients in the early stages of deterioration. INCLUSION CRITERIA This review will consider studies that include nurses working in hospital settings who care for pediatric patients (up to 18 years of age). Specifically, this scoping review will explore the signs and symptoms that underlie nurses' concerns about a pediatric patient's condition when the patient's vital signs are not a cause of worry. METHODS This scoping review will be conducted in accordance with the JBI methodology for scoping reviews. The review will search MEDLINE (via PubMed), CINAHL, Embase, Scopus and Swemed databases. The review will also search for unpublished PhD dissertations using the ProQuest Dissertations and Theses.
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Affiliation(s)
- Claus Sixtus Jensen
- 1Research Centre for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark 2Department of Clinical Medicine, Aarhus University, Aarhus, Denmark 3Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark 4Department of Neurology, Rigshospitalet, Glostrup, Denmark
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24
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Hwang JI, Chin HJ. Relationships between the National Early Warning Score 2, clinical worry and patient outcome at discharge: Retrospective observational study. J Clin Nurs 2020; 29:3774-3789. [PMID: 32644226 DOI: 10.1111/jocn.15408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 06/19/2020] [Accepted: 06/27/2020] [Indexed: 11/27/2022]
Abstract
AIMS AND OBJECTIVES To examine the performance of the National Early Warning Score 2 and composite score for clinical worry in identifying patients at risk of clinical deterioration, and to determine relationships between National Early Warning Score 2, clinical worry score and patient outcome at discharge. BACKGROUND The efficacy of early warning systems depends on patient population and care settings. Based on a theoretical framework on factors affecting clinical deterioration and patient outcomes, studies exploring the relationship between early warning systems and patient outcomes at discharge are sparse. DESIGN Retrospective observational study. METHODS A random sample of 732 medical records were reviewed. The area under the receiver operating characteristic curve was calculated to evaluate predictive abilities regarding the events of unanticipated in-hospital mortality, unplanned intensive care unit/ higher dependency bed admission and cardiac arrest. Multiple logistic regression analyses were performed to determine relationships between National Early Warning Score 2, clinical worry score and patient outcome. Reporting followed the STROBE checklist. RESULTS National Early Warning Score 2 and clinical worry score significantly predicted the events within 24 hr of the assessment. After controlling for other patient, treatment and organisational characteristics, National Early Warning Score 2 was a significant factor associated with patient outcome, but clinical worry score was not. Specifically, patients at high risk based on National Early Warning Score 2 were less likely to have improved outcome. CONCLUSIONS National Early Warning Score 2 and clinical worry score performed well for predicting deteriorating condition of patients. National Early Warning Score 2 was significantly associated with patient outcome. It can be used for efficient patient management for safe, quality care. RELEVANCE TO CLINICAL PRACTICE National Early Warning Score 2 can be used for early assessment of not only clinical deterioration but also patient outcome and provide timely intervention, when coupled with clinical worry score.
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Affiliation(s)
- Jee-In Hwang
- College of Nursing Science, Kyung Hee University, Seoul, South Korea
| | - Ho Jun Chin
- Seoul National University College of Medicine and Seoul National University Bundang Hospital, Seongnam-Si, South Korea
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25
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26
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Gerry S, Bonnici T, Birks J, Kirtley S, Virdee PS, Watkinson PJ, Collins GS. Early warning scores for detecting deterioration in adult hospital patients: systematic review and critical appraisal of methodology. BMJ 2020; 369:m1501. [PMID: 32434791 PMCID: PMC7238890 DOI: 10.1136/bmj.m1501] [Citation(s) in RCA: 125] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/25/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To provide an overview and critical appraisal of early warning scores for adult hospital patients. DESIGN Systematic review. DATA SOURCES Medline, CINAHL, PsycInfo, and Embase until June 2019. ELIGIBILITY CRITERIA FOR STUDY SELECTION Studies describing the development or external validation of an early warning score for adult hospital inpatients. RESULTS 13 171 references were screened and 95 articles were included in the review. 11 studies were development only, 23 were development and external validation, and 61 were external validation only. Most early warning scores were developed for use in the United States (n=13/34, 38%) and the United Kingdom (n=10/34, 29%). Death was the most frequent prediction outcome for development studies (n=10/23, 44%) and validation studies (n=66/84, 79%), with different time horizons (the most frequent was 24 hours). The most common predictors were respiratory rate (n=30/34, 88%), heart rate (n=28/34, 83%), oxygen saturation, temperature, and systolic blood pressure (all n=24/34, 71%). Age (n=13/34, 38%) and sex (n=3/34, 9%) were less frequently included. Key details of the analysis populations were often not reported in development studies (n=12/29, 41%) or validation studies (n=33/84, 39%). Small sample sizes and insufficient numbers of event patients were common in model development and external validation studies. Missing data were often discarded, with just one study using multiple imputation. Only nine of the early warning scores that were developed were presented in sufficient detail to allow individualised risk prediction. Internal validation was carried out in 19 studies, but recommended approaches such as bootstrapping or cross validation were rarely used (n=4/19, 22%). Model performance was frequently assessed using discrimination (development n=18/22, 82%; validation n=69/84, 82%), while calibration was seldom assessed (validation n=13/84, 15%). All included studies were rated at high risk of bias. CONCLUSIONS Early warning scores are widely used prediction models that are often mandated in daily clinical practice to identify early clinical deterioration in hospital patients. However, many early warning scores in clinical use were found to have methodological weaknesses. Early warning scores might not perform as well as expected and therefore they could have a detrimental effect on patient care. Future work should focus on following recommended approaches for developing and evaluating early warning scores, and investigating the impact and safety of using these scores in clinical practice. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017053324.
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Affiliation(s)
- Stephen Gerry
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
| | - Timothy Bonnici
- Critical Care Division, University College London Hospitals NHS Trust, London, UK
| | - Jacqueline Birks
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Shona Kirtley
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
| | - Pradeep S Virdee
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
| | - Peter J Watkinson
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Welch J, Thorpe E, Rafferty AM. Recognition of the deteriorating patient — More resources and smarter deployment please. Resuscitation 2020; 149:235-237. [DOI: 10.1016/j.resuscitation.2020.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 02/12/2020] [Indexed: 01/15/2023]
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Early Warning Signs and Rapid Response on the Nursing Floor-Can We Do More? Int Anesthesiol Clin 2020; 57:61-74. [PMID: 30864991 DOI: 10.1097/aia.0000000000000228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Nielsen PB, Schultz M, Langkjaer CS, Kodal AM, Pedersen NE, Petersen JA, Lange T, Arvig MD, Meyhoff CS, Bestle M, Hølge-Hazelton B, Bunkenborg G, Lippert A, Andersen O, Rasmussen LS, Iversen KK. Adjusting Early Warning Score by clinical assessment: a study protocol for a Danish cluster-randomised, multicentre study of an Individual Early Warning Score (I-EWS). BMJ Open 2020; 10:e033676. [PMID: 31915173 PMCID: PMC6955532 DOI: 10.1136/bmjopen-2019-033676] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 11/13/2019] [Accepted: 11/27/2019] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Track and trigger systems (TTSs) based on vital signs are implemented in hospitals worldwide to identify patients with clinical deterioration. TTSs may provide prognostic information but do not actively include clinical assessment, and their impact on severe adverse events remain uncertain. The demand for prospective, multicentre studies to demonstrate the effectiveness of TTSs has grown the last decade. Individual Early Warning Score (I-EWS) is a newly developed TTS with an aggregated score based on vital signs that can be adjusted according to the clinical assessment of the patient. The objective is to compare I-EWS with the existing National Early Warning Score (NEWS) algorithm regarding clinical outcomes and use of resources. METHOD AND ANALYSIS In a prospective, multicentre, cluster-randomised, crossover, non-inferiority study. Eight hospitals are randomised to use either NEWS in combination with the Capital Region of Denmark NEWS Override System (CROS) or implement I-EWS for 6.5 months, followed by a crossover. Based on their clinical assessment, the nursing staff can adjust the aggregated score with a maximum of -4 or +6 points. We expect to include 150 000 unique patients. The primary endpoint is all-cause mortality at 30 days. Coprimary endpoint is the average number of times per day a patient is NEWS/I-EWS-scored, and secondary outcomes are all-cause mortality at 48 hours and at 7 days as well as length of stay. ETHICS AND DISSEMINATION The study was presented for the Regional Ethics committee who decided that no formal approval was needed according to Danish law (J.no. 1701733). The I-EWS study is a large prospective, randomised multicentre study that investigates the effect of integrating a clinical assessment performed by the nursing staff in a TTS, in a head-to-head comparison with the internationally used NEWS with the opportunity to use CROS. TRIAL REGISTRATION NUMBER NCT03690128.
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Affiliation(s)
- Pernille B Nielsen
- Department of Emergency Medicine, Herlev-Gentofte Hospital, University of Copenhagen, Herlev, Denmark
- Department of Cardiology, Herlev-Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Martin Schultz
- Department of Emergency Medicine, Herlev-Gentofte Hospital, University of Copenhagen, Herlev, Denmark
- Department of Cardiology, Herlev-Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | | | - Anne Marie Kodal
- Department of Anaesthesiology and Intensive Care, Nordsjaellands Hospital, Hillerod, Denmark
| | - Niels Egholm Pedersen
- Department of Anaesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - John Asger Petersen
- Department of Day Surgery, Amager and Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Theis Lange
- Department of Public Health, Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
- Center for Statistical Science, Peking University, Beijing, China
| | - Michael Dan Arvig
- Department of Emergency Medicine, Slagelse Hospital, Slagelse, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christian Sahlholt Meyhoff
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Morten Bestle
- Department of Anaesthesiology and Intensive Care, Nordsjaellands Hospital, Hillerod, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Bibi Hølge-Hazelton
- Research Support Unit, Zealand University Hospital Roskilde, Roskilde, Denmark
- Department of Regional Studies, University of Southern Denmark, Odense, Denmark
| | - Gitte Bunkenborg
- Department of Anesthesiology, Holbaek Hospital, Holbaek, Denmark
| | - Anne Lippert
- Copenhagen Academy for Medical Education and Simulation, Herlev, Denmark
| | - Ove Andersen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Clinical Research Centre, Amager and Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Lars Simon Rasmussen
- Department of Anaesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Kasper Karmark Iversen
- Department of Emergency Medicine, Herlev-Gentofte Hospital, University of Copenhagen, Herlev, Denmark
- Department of Cardiology, Herlev-Gentofte Hospital, University of Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Kellett J, Nickel CH, Skyttberg N, Brabrand M. Is it possible to quickly identify acutely unwell patients who can be safely managed as outpatients? The need for a "Universal Safe to Discharge Score". Eur J Intern Med 2019; 67:e13-e15. [PMID: 31351762 DOI: 10.1016/j.ejim.2019.07.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 07/15/2019] [Accepted: 07/20/2019] [Indexed: 10/26/2022]
Abstract
If scores or algorithms were developed that quickly identified patients who are bound to have 100% survival, if even only for a few days, more patients could be safely discharged from emergency department, this eliminating the risks of hospitalization for many patients. This hypothesis proposes that it is possible to develop a "Universal Safe to Discharge Score", and suggests how it might be developed and validated.
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Affiliation(s)
- John Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Denmark.
| | | | - Niclas Skyttberg
- Department of Learning, Informatics, Management and Ethics, Health Informatics Centre, Stockholm, Sweden.
| | - Mikkel Brabrand
- Department of Emergency Medicine, Hospital of South West Jutland, Denmark; Department of Emergency Medicine, Odense University Hospital, Denmark.
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Romero-Brufau S, Gaines K, Nicolas CT, Johnson MG, Hickman J, Huddleston JM. The fifth vital sign? Nurse worry predicts inpatient deterioration within 24 hours. JAMIA Open 2019; 2:465-470. [PMID: 32025643 PMCID: PMC6994008 DOI: 10.1093/jamiaopen/ooz033] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 06/17/2019] [Accepted: 07/22/2019] [Indexed: 11/14/2022] Open
Abstract
Introduction Identification of hospitalized patients with suddenly unfavorable clinical course remains challenging. Models using objective data elements from the electronic health record may miss important sources of information available to nurses. Methods We recorded nurses’ perception of patient potential for deterioration in 2 medical and 2 surgical adult hospital units using a 5-point score at the start of the shift (the Worry Factor [WF]), and any time a change or an increase was noted by the nurse. Cases were evaluated by three reviewers. Intensive care unit (ICU) transfers were also tracked. Results 31 159 patient-shifts were recorded for 3185 unique patients during 3551 hospitalizations, with 169 total outcome events. Out of 492 potential deterioration events identified, 380 (77%) were confirmed by reviewers as true deterioration events. Likelihood ratios for ICU transfer were 17.8 (15.2–20.9) in the 24 hours following a WF > 2, and 40.4 (27.1–60.1) following a WF > 3. Accuracy rates were significantly higher in nurses with over a year of experience (68% vs 79%, P = 0.04). The area under the receiver operator characteristic curve (AUROC) was 0.92 for the prediction of ICU transfer within 24 hours. Discussion This is a higher accuracy than most published early warning scores. Conclusion Nurses’ pattern recognition and sense of worry can provide important information for the detection of acute physiological deterioration and should be included in the electronic medical record.
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Affiliation(s)
- Santiago Romero-Brufau
- Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kim Gaines
- Department of Nursing, Mayo Clinic, Rochester, Minnesota, USA
| | - Clara T Nicolas
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew G Johnson
- Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Joel Hickman
- Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeanne M Huddleston
- Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota, USA.,Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Teheux L, Verlaat CW, Lemson J, Draaisma JMT, Fuijkschot J. Risk stratification to improve Pediatric Early Warning Systems: it is all about the context. Eur J Pediatr 2019; 178:1589-1596. [PMID: 31485752 PMCID: PMC6733815 DOI: 10.1007/s00431-019-03446-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 07/31/2019] [Accepted: 08/06/2019] [Indexed: 11/30/2022]
Abstract
Early recognition of critically ill patients is of paramount importance to reduce pediatric mortality and morbidity. We created a risk stratification system combining vital parameters and predefined risk factors aimed at reducing the risk of unrecognized clinical deterioration compared with conventional Pediatric Early Warning Systems (PEWS). This single-center retrospective case cohort study included infants (gestational age ≥ 37 weeks) to adolescents (aged <18 years) with unplanned pediatric intensive care unit (PICU) admission between April 01, 2014, and February 28, 2018. The sensitivity in the 24 h prior to endpoint of the Pediatric Risk Evaluation and Stratification System (PRESS) was compared with that of the conventional PEWS and calculated as the proportion of study patients who received a high-risk score. Seventy-four PICU admissions were included. PRESS and PEWS sensitivities at 2 h prior to endpoint were 0.70 (95%CI 0.59 to 0.80) and 0.30 (95%CI 0.20 to 0.42) respectively (p < 0.001). Excluding patients with seizures, PRESS sensitivity increased to 0.75 (95%CI 0.64 to 0.85). Forty-nine patients (66%) scored positive on at least one high-risk factor, and "worried sign" was scored in 31 patients (42%).Conclusion: Risk stratification seems advantageous for a faster detection of clinical deterioration, providing opportunity for earlier intervention. What is Known: • Prompt detection of clinical deterioration is of essential importance to reduce morbidity and mortality. • Conventional Pediatric Early Warning Systems (PEWS) have limited sensitivity and a short window of detection of 1 to 2 h. What is New: • Risk stratification based on context factors allows earlier identification of patients at risk, well before deviation of vital signs. • Risk stratification combined with continuous monitoring of deteriorating trends in vital signs could lead to the development of next-generation warning systems achieving true patient safety.
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Affiliation(s)
- Lara Teheux
- Radboud Institute for Health Sciences, Amalia Children's Hospital, Department of Pediatrics, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Carin W. Verlaat
- Radboud Institute for Health Sciences, Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Joris Lemson
- Radboud Institute for Health Sciences, Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jos M. T. Draaisma
- Radboud Institute for Health Sciences, Amalia Children’s Hospital, Department of Pediatrics, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Joris Fuijkschot
- Radboud Institute for Health Sciences, Amalia Children’s Hospital, Department of Pediatrics, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, The Netherlands
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Surgical ward nurses’ responses to worry: An observational descriptive study. Int J Nurs Stud 2018; 85:90-95. [DOI: 10.1016/j.ijnurstu.2018.05.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Revised: 05/15/2018] [Accepted: 05/16/2018] [Indexed: 11/24/2022]
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