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Gardner AJ, Kristensen SR. A multivariable analysis to predict variations in hospital mortality using systems-based factors of healthcare delivery to inform improvements to healthcare design within the English NHS. PLoS One 2024; 19:e0303932. [PMID: 38968314 PMCID: PMC11226030 DOI: 10.1371/journal.pone.0303932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 05/03/2024] [Indexed: 07/07/2024] Open
Abstract
Over the last decade, the strain on the English National Health Service (NHS) has increased. This has been especially felt by acute hospital trusts where the volume of admissions has steadily increased. Patient outcomes, including inpatient mortality, vary between trusts. The extent to which these differences are explained by systems-based factors, and whether they are avoidable, is unclear. Few studies have investigated these relationships. A systems-based methodology recognises the complexity of influences on healthcare outcomes. Rather than clinical interventions alone, the resources supporting a patient's treatment journey have near-equal importance. This paper first identifies suitable metrics of resource and demand within healthcare delivery from routinely collected, publicly available, hospital-level data. Then it proceeds to use univariate and multivariable linear regression to associate such systems-based factors with standardised mortality. Three sequential cross-sectional analyses were performed, spanning the last decade. The results of the univariate regression analyses show clear relationships between five out of the six selected predictor variables and standardised mortality. When these five predicators are included within a multivariable regression analysis, they reliably explain approximately 36% of the variation in standardised mortality between hospital trusts. Three factors are consistently statistically significant: the number of doctors per hospital bed, bed occupancy, and the percentage of patients who are placed in a bed within four hours after a decision to admit them. Of these, the number of doctors per bed had the strongest effect. Linear regression assumption testing and a robustness analysis indicate the observations have internal validity. However, our empirical strategy cannot determine causality and our findings should not be interpreted as established causal relationships. This study provides hypothesis-generating evidence of significant relationships between systems-based factors of healthcare delivery and standardised mortality. These have relevance to clinicians and policymakers alike. While identifying causal relationships between the predictors is left to the future, it establishes an important paradigm for further research.
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Affiliation(s)
- Andrew J. Gardner
- Centre for Health Policy, Imperial College London, London, United Kingdom
- William Harvey Research Institute, Critical Care and Perioperative Medicine Research Group, Queen Mary University of London, London, United Kingdom
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Gawronski O, Parshuram CS, Cecchetti C, Tiozzo E, Szadkowski L, Ciofi Degli Atti ML, Dryden-Palmer K, Dall'Oglio I, Raponi M, Joffe AR, Tomlinson G. Evaluating associations between patient-to-nurse ratios and mortality, process of care events and vital sign documentation on paediatric wards: a secondary analysis of data from the EPOCH cluster-randomised trial. BMJ Open 2024; 14:e081645. [PMID: 38964797 PMCID: PMC11227805 DOI: 10.1136/bmjopen-2023-081645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 06/11/2024] [Indexed: 07/06/2024] Open
Abstract
OBJECTIVE To describe the associations between patient-to-nurse staffing ratios and rates of mortality, process of care events and vital sign documentation. DESIGN Secondary analysis of data from the evaluating processes of care and outcomes of children in hospital (EPOCH) cluster-randomised trial. SETTING 22 hospitals caring for children in Canada, Europe and New Zealand. PARTICIPANTS Eligible hospitalised patients were aged>37 weeks and <18 years. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was all-cause hospital mortality. Secondary outcomes included five events reflecting the process of care, collected for all EPOCH patients; the frequency of documentation for each of eight vital signs on a random sample of patients; four measures describing nursing perceptions of care. RESULTS A total of 217 714 patient admissions accounting for 849 798 patient days over the course of the study were analysed. The overall mortality rate was 1.65/1000 patient discharges. The median (IQR) number of patients cared for by an individual nurse was 3.0 (2.8-3.6). Univariate Bayesian models estimating the rate ratio (RR) for the patient-to-nurse ratio and the probability that the RR was less than one found that a higher patient-to-nurse ratio was associated with fewer clinical deterioration events (RR=0.88, 95% credible interval (CrI) 0.77-1.03; P (RR<1)=95%) and late intensive care unit admissions (RR=0.76, 95% CrI 0.53-1.06; P (RR<1)=95%). In adjusted models, a higher patient-to-nurse ratio was associated with lower hospital mortality (OR=0.77, 95% CrI=0.57-1.00; P (OR<1)=98%). Nurses from hospitals with a higher patient-to-nurse ratio had lower ratings for their ability to influence care and reduced documentation of most individual vital signs and of the complete set of vital signs. CONCLUSIONS The data from this study challenge the assumption that lower patient-to-nurse ratios will improve the safety of paediatric care in contexts where ratios are low. The mechanism of these effects warrants further evaluation including factors, such as nursing skill mix, experience, education, work environment and physician staffing ratios. TRIAL REGISTRATION NUMBER EPOCH clinical trial registered on clinical trial.gov NCT01260831; post-results.
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Affiliation(s)
- Orsola Gawronski
- Professional Development, Continuing Education and Nursing Research Unit, Bambino Gesù Children's Hospital, IRCCS, Roma, Lazio, Italy
| | - Christopher S Parshuram
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Corrado Cecchetti
- Critical Care, Bambino Gesù Children's Hospital, IRCCS, Roma, Lazio, Italy
| | - Emanuela Tiozzo
- Professional Development, Continuing Education and Nursing Research Unit, Bambino Gesù Children's Hospital, IRCCS, Roma, Lazio, Italy
| | - Leah Szadkowski
- Biostatistics Research Unit, Toronto General Hospital, Toronto, Ontario, Canada
| | | | - Karen Dryden-Palmer
- Paediatric Intensive Care Unit, Hospital for Sick Children, Barrie, Ontario, Canada
| | - Immacolata Dall'Oglio
- Professional Development, Continuing Education and Nursing Research Unit, Bambino Gesù Children's Hospital, IRCCS, Roma, Lazio, Italy
| | - Massimiliano Raponi
- Medical Directorate, Bambino Gesù Children's Hospital, IRCCS, Roma, Lazio, Italy
| | - Ari Robin Joffe
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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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, Dwyer T, Browne M. Indicators of patient deterioration in poorly resourced private hospitals: Which vital sign to watch? A retrospective case-control study. Aust Crit Care 2024; 37:461-467. [PMID: 37391286 DOI: 10.1016/j.aucc.2023.05.006] [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: 11/26/2022] [Revised: 05/26/2023] [Accepted: 05/27/2023] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND Patient vital signs are a measure of wellness if monitored regularly and accurately. Staff shortages in poorly resourced regional hospitals often result in inadequate patient monitoring, putting patients at risk of undetected deterioration. OBJECTIVE This study aims to explore the pattern and completeness of vital sign monitoring and the contribution of each vital sign in predicting clinical deterioration events in resource-poor regional/rural hospitals. METHOD Using a retrospective case-control study design, we compared 24 h of vital sign data from deteriorating and nondeteriorating patients from two poorly-resourced regional hospitals. Descriptive statistics, t-tests, and analysis of variance are used to compare patient-monitoring frequency and completeness. The contribution of each vital sign in predicting patient deterioration was determined using the Area Under the Receiver Operator Characteristic curve and binary logistical regression analysis. RESULTS Deteriorating patients were monitored more frequently (9.58 [7.02] times) in the 24-h period than nondeteriorating patients (4.93 [2.66] times). However, the completeness of vital sign documentation was higher in nondeteriorating (85.2%) than in deteriorating patients (57.7%). Body temperature was the most frequently omitted vital sign. Patient deterioration was positively linked to the frequency of abnormal vital signs and the number of abnormal vital signs per set (Area Under the Receiver Operator Characteristic curve: 0.872 and 0.867, respectively). No single vital sign strongly predicts patient outcomes. However, a supplementary oxygen value of >3 L/min and a heart rate of >139 beats/min were the best predictors of patient deterioration. CONCLUSION Given the poor resourcing and often geographical remoteness of small regional hospitals, it is prudent that the nursing staff are made aware of the vital signs that best indicate deterioration for the cohort of patients in their care. Tachycardic patients on supplementary oxygen are at high risk of deterioration.
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Affiliation(s)
- Marie Danielle Le Lagadec
- School of Nursing, Midwifery and Social Sciences, Central Queensland, University, 6 University Dr, Branyan, Bundaberg, Queensland, 4670, Australia.
| | - Trudy Dwyer
- School of Nursing, Midwifery and Social Sciences, Central Queensland, University, 554-700 Yaamba Rd, Norman Gardens Rockhampton, Queensland, 4701, Australia.
| | - Matthew Browne
- School of Health, Medical and Applied Sciences Central Queensland, University, 6 University Dr, Branyan, Bundaberg Queensland, 4670, Australia.
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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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Mbuthia N, Kagwanja N, Ngari M, Boga M. General ward nurses detection and response to clinical deterioration in three hospitals at the Kenyan coast: a convergent parallel mixed methods study. BMC Nurs 2024; 23:143. [PMID: 38429750 PMCID: PMC10905788 DOI: 10.1186/s12912-024-01822-2] [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: 02/27/2023] [Accepted: 02/22/2024] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND In low and middle-income countries like Kenya, critical care facilities are limited, meaning acutely ill patients are managed in the general wards. Nurses in these wards are expected to detect and respond to patient deterioration to prevent cardiac arrest or death. This study examined nurses' vital signs documentation practices during clinical deterioration and explored factors influencing their ability to detect and respond to deterioration. METHODS This convergent parallel mixed methods study was conducted in the general medical and surgical wards of three hospitals in Kenya's coastal region. Quantitative data on the extent to which the nurses monitored and documented the vital signs 24 h before a cardiac arrest (death) occurred was retrieved from patients' medical records. In-depth, semi-structured interviews were conducted with twenty-four purposefully drawn registered nurses working in the three hospitals' adult medical and surgical wards. RESULTS This study reviewed 405 patient records and found most of the documentation of the vital signs was done in the nursing notes and not the vital signs observation chart. During the 24 h prior to death, respiratory rate was documented the least in only 1.2% of the records. Only a very small percentage of patients had any vital event documented for all six-time points, i.e. four hourly. Thematic analysis of the interview data identified five broad themes related to detecting and responding promptly to deterioration. These were insufficient monitoring of vital signs linked to limited availability of equipment and supplies, staffing conditions and workload, lack of training and guidelines, and communication and teamwork constraints among healthcare workers. CONCLUSION The study showed that nurses did not consistently monitor and record vital signs in the general wards. They also worked in suboptimal ward environments that do not support their ability to promptly detect and respond to clinical deterioration. The findings illustrate the importance of implementation of standardised systems for patient assessment and alert mechanisms for deterioration response. Furthermore, creating a supportive work environment is imperative in empowering nurses to identify and respond to patient deterioration. Addressing these issues is not only beneficial for the nurses but, more importantly, for the well-being of the patients they serve.
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Affiliation(s)
- Nickcy Mbuthia
- Department of Medical Surgical Nursing, School of Health Sciences, Kenyatta University, Nairobi, Kenya.
| | - Nancy Kagwanja
- KEMRI Wellcome Trust Research Programme, KEMRI Centre for Geographic Medicine Research Coast, Kilifi, Kenya
| | - Moses Ngari
- KEMRI Wellcome Trust Research Programme, KEMRI Centre for Geographic Medicine Research Coast, Kilifi, Kenya
| | - Mwanamvua Boga
- KEMRI Wellcome Trust Research Programme, KEMRI Centre for Geographic Medicine Research Coast, Kilifi, Kenya
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Carter C, Notter J. Undertaking a neurological assessment. Nurs Stand 2024; 39:45-50. [PMID: 37927224 DOI: 10.7748/ns.2023.e12173] [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] [Accepted: 07/05/2023] [Indexed: 11/07/2023]
Abstract
Neurological observations are an essential aspect of assessment in patients with altered mental status and require the nurse to collect and analyse information using a validated assessment tool. Assessing a patient's pupil size and response is also an important element of a neurological assessment. This article summarises the pathophysiology of raised intracranial pressure and lists some of the conditions that may contribute to an alteration in a patient's mental status. The article details the use of two commonly used neurological assessment tools and the assessment of a patient's pupil size and response. The author also considers the challenges related to accurate recording of neurological observations.
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Affiliation(s)
- Chris Carter
- Faculty of Health, Education and Life Sciences, Birmingham City University, Birmingham, England
| | - Joy Notter
- Faculty of Health, Education and Life Sciences, Birmingham City University, Birmingham, England
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Schlosser Metitiri KR, Perotte A. Delay Between Actual Occurrence of Patient Vital Sign and the Nominal Appearance in the Electronic Health Record: Single-Center, Retrospective Study of PICU Data, 2014-2018. Pediatr Crit Care Med 2024; 25:54-61. [PMID: 37966346 PMCID: PMC10842173 DOI: 10.1097/pcc.0000000000003398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
OBJECTIVES Patient vital sign data charted in the electronic health record (EHR) are used for time-sensitive decisions, yet little is known about when these data become nominally available compared with when the vital sign was actually measured. The objective of this study was to determine the magnitude of any delay between when a vital sign was actually measured in a patient and when it nominally appears in the EHR. DESIGN We performed a single-center retrospective cohort study. SETTING Tertiary academic children's hospital. PATIENTS A total of 5,458 patients were admitted to a PICU from January 2014 to December 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We analyzed entry and display times of all vital signs entered in the EHR. The primary outcome measurement was time between vital sign occurrence and nominal timing of the vital sign in the EHR. An additional outcome measurement was the frequency of batch charting. A total of 9,818,901 vital sign recordings occurred during the study period. Across the entire cohort the median (interquartile range [IQR]) difference between time of occurrence and nominal time in the EHR was in hours:minutes:seconds, 00:41:58 (IQR 00:13:42-01:44:10). Lag in the first 24 hours of PICU admission was 00:47:34 (IQR 00:15:23-02:19:00), lag in the last 24 hours was 00:38:49 (IQR 00:13:09-01:29:22; p < 0.001). There were 1,892,143 occurrences of batch charting. CONCLUSIONS This retrospective study shows a lag between vital sign occurrence and its appearance in the EHR, as well as a frequent practice of batch charting. The magnitude of the delay-median ~40 minutes-suggests that vital signs available in the EHR for clinical review and incorporation into clinical alerts may be outdated by the time they are available.
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Affiliation(s)
- Katherine R. Schlosser Metitiri
- Division of Critical Care and Hospital Medicine, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons and NewYork-Presbyterian Morgan Stanley Children’s Hospital
| | - Adler Perotte
- Department of Biomedical Informatics, Columbia University, New York, NY, USA
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Thekkan KR, Genna C, Ferro F, Cecchetti C, Dall'Oglio I, Tiozzo E, Raponi M, Gawronski O. Pediatric vital signs monitoring in hospital wards: Recognition systems and factors influencing nurses' attitudes and practices. J Pediatr Nurs 2023; 73:e602-e611. [PMID: 37977971 DOI: 10.1016/j.pedn.2023.10.041] [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: 07/26/2023] [Revised: 10/31/2023] [Accepted: 10/31/2023] [Indexed: 11/19/2023]
Abstract
AIMS To describe: 1) systems in place for recognition and response to deteriorating children in Italy, 2) attitudes and practices of registered nurses (RN) towards vital signs (VS) monitoring in pediatric wards, 3) the associations of nurses attitudes and pratices with nurses' and organizational characteristics. DESIGN AND METHODS A multicentre cross-sectional correlational study. Data were collected between January-May 2020 using: an adapted version of the 'Survey on Recognition and Response Systems in Australia', and the 'Ped-V Scale'. Descriptive and adjusted linear regression analysis was performed, accounting for clustering. RESULTS Ten Italian hospitals participated, 432 RNs responded to the Ped-V scale (response rate = 52%). Five (50%) hospitals had a VS policy in place, three hospitals (30%) had a Pediatric Early Warning System (PEWS), almost all hospitals had a system in place to respond to deteriorating children. Following multivariate regression analysis, having a PEWS was significantly associated with Ped-V scale 'Workload', 'Clinical competence', 'Standardization' dimensions; gender was associated with 'key indicators' and pediatric surgical ward with 'Clinical competence'. CONCLUSIONS The use of VS policies and PEWS was not consistent across hospitals caring for children in Italy. Nurses' attitudes and practices (i.e., perception of workload, and clinical competence) were significantly lower in hospitals with increased complexity of care/PEWS. Gender was significantly associated with knowledge scores. PRACTICE IMPLICATIONS System strategies to improve nurses' attitudes and practices towards VS monitoring and education are warranted to support effective behaviors towards VS monitoring, their interpretation, and appropriate communication to activate the efferent limb of the rapid response system.
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Affiliation(s)
- Kiara Ros Thekkan
- Professional Development, Continuing Education and Research Unit, Medical Directorate, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Catia Genna
- Professional Development, Continuing Education and Research Unit, Medical Directorate, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Federico Ferro
- Professional Development, Continuing Education and Research Unit, Medical Directorate, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Corrado Cecchetti
- Department of Emergency, Acceptance and General Pediatrics, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Immacolata Dall'Oglio
- Professional Development, Continuing Education and Research Unit, Medical Directorate, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Emanuela Tiozzo
- Professional Development, Continuing Education and Research Unit, Medical Directorate, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | | | - Orsola Gawronski
- Professional Development, Continuing Education and Research Unit, Medical Directorate, Bambino Gesù Children's Hospital IRCCS, Rome, Italy.
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Augutis W, Flenady T, Le Lagadec D, Jefford E. How do nurses use early warning system vital signs observation charts in rural, remote and regional health care facilities: A scoping review. Aust J Rural Health 2023. [PMID: 36802114 DOI: 10.1111/ajr.12971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 12/08/2022] [Accepted: 02/03/2023] [Indexed: 02/21/2023] Open
Abstract
INTRODUCTION Physiological signs of clinical deterioration are known to occur in the hours preceding a serious adverse event. As a result, track and trigger systems known as early warning systems (EWS) were introduced and routinely implemented as patient observation tools to trigger an alert in the presence of abnormal vital signs. OBJECTIVE The objective aimed to explore the literature pertaining to EWS and their utilisation in rural, remote and regional health care facilities. DESIGN The Arksey and O'Malley's methodological framework was used to guide the scoping review. Only studies reporting on rural, remote and regional health care settings were included. All four authors participated in the screening, data extraction and analysis process. FINDINGS Our search strategy yielded 3869 peer-reviewed articles published between 2012 and 2022, with six studies ultimately included. Collectively, the studies included in this scoping review examined the complex interaction between patient vital signs observation charts and recognition of patient deterioration. DISCUSSION Whilst rural, remote and regional clinicians use EWS to recognise and respond to clinical deterioration, noncompliance dilutes the tool's effectiveness. This overarching finding is informed by three contributing factors: documentation, communication and challenges specific to the rural context. CONCLUSION The success of EWS relies on accurate documentation and effective communication within the interdisciplinary team to support appropriate responses to clinical patient decline. More research is required to understand the nuances and complexities of rural and remote nursing and to address challenges associated with the use of EWS in rural health care settings.
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Affiliation(s)
- Wendy Augutis
- School of Nursing & Midwifery, Central Queensland University, Bundaberg, Queensland, Australia
| | - Tracy Flenady
- School of Nursing & Midwifery, Central Queensland University, Rockhampton, Queensland, Australia
| | - Danielle Le Lagadec
- School of Nursing & Midwifery, Central Queensland University, Bundaberg, Queensland, Australia
| | - Elaine Jefford
- Clinical and health Sciences, University of the Sunshine Coast, Adelaide, Queensland, Australia
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Li W, Yu H, Li B, Zhang Y, Fu M. The transcultural adaptation and validation of the Chinese version of the Attitudes Toward Recognizing Early and Noticeable Deterioration scale. Front Psychol 2022; 13:1062949. [PMID: 36562070 PMCID: PMC9765647 DOI: 10.3389/fpsyg.2022.1062949] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 11/14/2022] [Indexed: 12/12/2022] Open
Abstract
Background In China, clinical deterioration events present a real problem for every clinical nurse. Patient deterioration is determined in part by nurses' attitudes toward early recognition of clinical deterioration. However, research on attitudes toward the early identification of clinical deterioration is still in its infancy, and even less research has been done on ward nurses' attitudes toward the early identification of clinical deterioration. To drive behavioral change and improve the care of deteriorating patients, nurses need comprehensive, valid, and reliable tools to assess their attitudes toward early identification of deterioration. Objective In this study, we aimed to translate the Attitudes Toward Recognizing Early and Noticeable Deterioration (ATREND) scale into Chinese and to assess its validity and reliability tests. Methods From March 2022 to July 2022, the ATREND scale was translated, back-translated, and cross-culturally adapted into the Chinese version using a modified Brislin translation model. Then, 460 ward nurses were recruited from tertiary Grade A general hospitals in two cities: Shenyang and Jinzhou in Liaoning Province, China. Reliability analyses were conducted using internal consistency, split-half, and test-retest reliability. We convened a committee of experts to determine the validity of the content. Tests of the structural validity of the scale were conducted using exploratory and validation factor analyses. Results The Cronbach's α value of the Chinese version of the ATREND scale was 0.804, and the Cronbach's α value of the dimensions ranged from 0.782 to 0.863. The split-half reliability and test-retest reliability were 0.846 and 0.711, respectively. Furthermore, the scale has an index of content validity of 0.922, indicating a high level of content validity. In exploratory factor analysis, eigenvalues, total variance explained, and scree plot supported a three-factor structure. The three-factor model supported by this study was confirmed by confirmatory factor analysis (CFA). Moreover, the model fitting indexes (e.g., χ 2/DF = 1.498, GFI = 0.954, RMSEA = 0.047) were all within acceptable limits based on the CFA. Conclusion The Chinese version of the scale is reliable and valid among ward nurses. Nursing educators and clinicians will be able to develop targeted educational programs to enhance the competence and behaviors of Chinese ward nurses in recognizing clinical deterioration. It will be based on the developed scale to assess Chinese nurses' attitudes and practices regarding early recognition of clinical deterioration. As a result, it is necessary to consider the Chinese scale's three-factor structure. The developed three-factor structured scale will assess Chinese ward nurses' attitudes and practices toward patient observation and vital sign-monitoring empowerment, enlightening them on the importance of patient observation, encouraging ward nurses to use a wider range of patient assessment techniques to capture early signs of clinical deterioration, and helping ward nurses to develop clinical confidence to monitor clinical deterioration.
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Affiliation(s)
- Wenbo Li
- Department of Nursing, Jinzhou Medical University, Jinzhou, China
| | - Hongyu Yu
- Department of Nursing, Jinzhou Medical University, Jinzhou, China,*Correspondence: Hongyu Yu,
| | - Bing Li
- Department of Dermatology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yanli Zhang
- Department of Nursing, Jinzhou Medical University, Jinzhou, China
| | - Mingshu Fu
- Department of Neurosurgery, The First Affiliated Hospital of China Medical University, Shenyang, China
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Alhmoud B, Melley D, Khan N, Bonicci T, Patel R, Banerjee A. Evaluating a novel, integrative dashboard for health professionals' performance in managing deteriorating patients: a quality improvement project. BMJ Open Qual 2022; 11:e002033. [PMID: 36588306 PMCID: PMC9723858 DOI: 10.1136/bmjoq-2022-002033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 11/10/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The quality of recording and documentation of deteriorating patient management by health professionals has been challenged during the COVID-19 pandemic. Non-adherence to escalation and documentation guidelines increases risk of serious adverse events. Electronic health record (EHR)-integrated dashboards are auditing tools of patients' status and clinicians' performance, but neither the views nor the performance of health professionals have been assessed, relating to management of deteriorating patients. OBJECTIVE To develop and evaluate a real-time dashboard of deteriorating patients' assessment, referral and therapy. SETTINGS Five academic hospitals in the largest National Health Service (NHS) trust in the UK (Barts Health NHS Trust). INTERVENTION The dashboard was developed from EHR data to investigate patients with National Early Warning Score (NEWS2)>5, assessment, and escalation of deteriorating patients. We adopted the Plan, Do, Study, Act model and Standards for Quality Improvement Reporting Excellence framework to evaluate the dashboard. DESIGN Mixed methods: (1) virtual, face-to-face, interviews and (2) retrospective descriptive EHR data analysis. RESULTS We interviewed three nurses (two quality and safety and one informatics specialists). Participants perceived the dashboard as a facilitator for auditing NEWS2 recording and escalation of care to improve practice; (2) there is a need for guiding clinicians and adjusting data sources and metrics to enhance the functionality and usability. Data analysis (2019-2022) showed: (1) NEWS2 recording has gradually improved (May 2021-April 2022) from 64% to 83%;(2) referral and assessment completion increased (n: 170-6800 and 23-540, respectively). CONCLUSION The dashboard is an effective real-time data-driven method for improving the quality of managing deteriorating patients. Integrating health systems, a wider analysis NEWS2 and escalation of care metrics, and clinicians' learning digital solutions will enhance functionality and experience to boost its value. There is a need to examine the generalisability of the dashboard through further validation and quality improvement studies.
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Affiliation(s)
- Baneen Alhmoud
- Institute of Health Informatics, University College London, London, UK
| | - Daniel Melley
- Department of Intensive Care, Barts Health NHS Trust, London, UK
| | - Nadeem Khan
- Department of Intensive Care, Barts Health NHS Trust, London, UK
| | - Timothy Bonicci
- Institute of Health Informatics, University College London, London, UK
- Department of Intensive Care, University College London Hospitals NHS Foundation Trust, London, UK
| | - Riyaz Patel
- Institute of Health Informatics, University College London, London, UK
- Department of Cardiology, University College London Hospitals NHS Trust, London, UK
| | - Amitava Banerjee
- Institute of Health Informatics, University College London, London, UK
- Department of Cardiology, University College London Hospitals NHS Trust, London, UK
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13
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Dall'Ora C, Saville C, Rubbo B, Turner L, Jones J, Griffiths P. Nurse staffing levels and patient outcomes: A systematic review of longitudinal studies. Int J Nurs Stud 2022; 134:104311. [DOI: 10.1016/j.ijnurstu.2022.104311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 05/04/2022] [Accepted: 06/09/2022] [Indexed: 02/08/2023]
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Elliott M, Endacott R. The clinical neglect of vital signs' assessment: an emerging patient safety issue? Contemp Nurse 2022; 58:249-252. [PMID: 35924342 DOI: 10.1080/10376178.2022.2109494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Vital signs assessment is a critical component of acute clinical care. Despite this, research has consistently found that the assessment of these signs is often neglected in clinical practice. This paper highlights three recent cases in the media where the neglect of vital signs assessment resulted in patient mortality. RESULTS Recent media reports highlighted the potentially devastating consequences of vital signs not being rigorously assessed including avoidable death. The public needs to be confident they will receive safe, quality health care when admitted to hospital. CONCLUSION The neglect of vital signs assessment places patients at risk of poor outcomes. Early detection of clinical deterioration via the assessment of vital signs facilitates prompt medical intervention. Factors contributing to the neglect of vital signs assessment need to be identified and corrective action taken to improve the safety of clinical care.
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Affiliation(s)
- Malcolm Elliott
- Senior Lecturer, Monash Nursing & Midwifery, Monash University, Melbourne, Australia
| | - Ruth Endacott
- Professor, Monash Nursing & Midwifery, Monash University, Melbourne, Australia
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15
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Campagna S, Conti A, Clari M, Basso I, Sciannameo V, Di Giulio P, Dimonte V. Factors Associated With Missed Nursing Care in Nursing Homes: A Multicentre Cross-sectional Study. Int J Health Policy Manag 2022; 11:1334-1341. [PMID: 33949814 PMCID: PMC9808324 DOI: 10.34172/ijhpm.2021.23] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 03/13/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Despite its association with patient safety, few studies on missed nursing care have been conducted in nursing homes. We aimed to describe individual and environmental factors in a sample of registered nurses (RNs) reporting missed nursing care in nursing homes, and to explore the association between these factors and missed nursing care. METHODS In the present, multicentre cross-sectional study, 217 RNs from 43 nursing homes in Northern Italy reported all episodes of missed nursing care (ie, any aspect of required care that was omitted or delayed) that occurred in the 20 most dependent residents (according to RNs' judgement; 860 residents in total) over 3 consecutive days. Multilevel multivariable logistic regression models were used to test possible explanatory factors of missed nursing care (individual, work-related, organisational, and work environment factors), which were entered in a step-wise manner. RESULTS Younger RNs (P=.026), freelance RNs (P=.046), RNs with a permanent contract (P=.035), and those working in publicly-owned nursing homes reported more episodes of missed nursing care (P<.012). Public ownership (odds ratio [OR]=9.88; 95% CI 2.22-44.03; P=.003), a higher proportion of residents with severe clinical conditions (OR=2.45; 95% CI 1.12-5.37; P=.025), a lower proportion of RNs (OR=2.24; 95% CI 1.10-4.54; P=.026), and perceived lack of time to care for residents (OR=2.33; 95% CI 1.04-5.26; P=.041) were statistically significantly associated with missed nursing care. CONCLUSION Factors associated with missed nursing care are similar in hospitals and nursing homes, and include heavy workload and perceived lack of time for care. Because missed nursing care in nursing homes represents tasks performed specifically by RNs, missed nursing care in this setting should be measured in terms of these tasks. An optimal skill mix is crucial to guarantee not only comfort and basic care for nursing home residents, but also good outcomes for residents with severe clinical conditions.
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Affiliation(s)
- Sara Campagna
- Department of Public Health and Pediatrics, University of Torino, Torino, Italy
| | - Alessio Conti
- Department of Public Health and Pediatrics, University of Torino, Torino, Italy
| | - Marco Clari
- Department of Public Health and Pediatrics, University of Torino, Torino, Italy
| | - Ines Basso
- Department of Public Health and Pediatrics, University of Torino, Torino, Italy
| | - Veronica Sciannameo
- Unit of Biostatistics, Epidemiology and Public Health, University of Padova, Padua, Italy
| | - Paola Di Giulio
- Department of Public Health and Pediatrics, University of Torino, Torino, Italy
| | - Valerio Dimonte
- Department of Public Health and Pediatrics, University of Torino, Torino, Italy
- Città della Salute e della Scienza di Torino University Hospital, Torino, Italy
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Gawronski O, Biagioli V, Dall'oglio I, Cecchetti C, Ferro F, Tiozzo E, Raponi M. Attitudes and practices towards vital signs monitoring on paediatric wards: Cross-validation of the Ped-V scale. J Pediatr Nurs 2022; 65:98-107. [PMID: 35410733 DOI: 10.1016/j.pedn.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 02/15/2022] [Accepted: 03/21/2022] [Indexed: 11/16/2022]
Abstract
PURPOSE To develop and psychometrically test an instrument measuring the attitudes and practices towards vital signs (VS) monitoring in nurses caring for children on paediatric wards (Ped-V scale). DESIGN AND METHODS This is a multicentre cross-validation study with a cross-sectional design. The Ped-V scale was developed by adapting the V-scale to the paediatric context and administered to a convenience sample of clinical nurses working in paediatric wards from January to May 2020. The content validity of the Ped-V scale was evaluated by a group of 10 experts. The psychometric properties of the scale were tested through Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA). RESULTS Overall, 10 Italian hospitals participated in the study, and 640 questionnaires were completed (87% female). At EFA a 30-item version of the scale and four factors emerged. This solution was confirmed at CFA: F1) 'Inaccuracy of VS monitoring and workload'; F2) 'Clinical competence and communication'; F3) 'Standardization and protocol adherence'; F4) 'Misconceptions about key indicators'. Cronbach's alpha ranged between 0.63 and 0.85. CONCLUSIONS The Ped-V scale is valid and reliable for use in the paediatric context to identify barriers concerning nurses' self-efficacy, competences, and knowledge of clinical indicators of paediatric critical deterioration, attitudes towards accuracy, standardization, communication to senior team members and the appropriate use of technology in paediatric VS monitoring. PRACTICE IMPLICATIONS The Ped-V scale may assist in identifying gaps in nurses' attitudes and devising strategies to change nurses' beliefs, knowledge, skills and decreasing individual, local cultural or organizational barriers towards VS monitoring.
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Affiliation(s)
- Orsola Gawronski
- Professional Development, Continuing Education and Research Service, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio 4, 00165 Rome, Italy.
| | - Valentina Biagioli
- Professional Development, Continuing Education and Research Service, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio 4, 00165 Rome, Italy.
| | - Immacolata Dall'oglio
- Professional Development, Continuing Education and Research Service, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio 4, 00165 Rome, Italy.
| | - Corrado Cecchetti
- Pediatric Intensive Care Unit, Department of Critical Care, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio 4, 00165 Rome, Italy.
| | - Federico Ferro
- Professional Development, Continuing Education and Research Service, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio 4, 00165 Rome, Italy
| | - Emanuela Tiozzo
- Professional Development, Continuing Education and Research Service, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio 4, 00165 Rome, Italy.
| | - Massimiliano Raponi
- Medical Directorate, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio 4, 00165 Rome, Italy.
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Noë B, Bullock A, Frankish J, Turner LD. Temporal patterns in vital sign recording within and across general hospital wards. Resusc Plus 2022; 10:100247. [PMID: 35620181 PMCID: PMC9127396 DOI: 10.1016/j.resplu.2022.100247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 04/05/2022] [Accepted: 04/30/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction The use of mobile devices on hospital wards to record patient vital signs and Early Warning Scores provides opportunity for secondary analysis of the data collected. This research investigated how such analysis can contribute to the understanding of the complexities of managing clinical care in hospital environments. Methods The influence of ward type and the distribution of patient observation intervals was evaluated in relation to the timing of vital signs observation patterns in data collected from eight adult in-patient wards over a 12-month period. Actual and projected observation times were compared across patients with higher and lower National Early Warning Scores (NEWS). Results Both ward type and the distribution of patient observation intervals were significant predictors of temporal observation patterns. Observation patterns showed evidence of grouping of observation recordings. This was, however, not found for observations of patients with higher NEWS scores (3 or more). Conclusions Secondary analysis of vital signs observation data can reveal insights into how ward operate. The patterns of observation recordings within a ward are a reflection of ward type and the distribution of patient observation intervals. The grouping of observation recordings of patients with low NEWS (<3) result in late or early observations to fit activity peaks characteristic of the ward culture.
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Affiliation(s)
- Beryl Noë
- School of Computer Science and Informatics, Cardiff University, UK
- Corresponding author.
| | - Alison Bullock
- Cardiff Unit for Research and Evaluation in Medical and Dental Education, School of Social Sciences, Cardiff University, UK
| | - John Frankish
- Informatics Directorate, Aneurin Bevan University Health Board, UK
| | - Liam D. Turner
- School of Computer Science and Informatics, Cardiff University, UK
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18
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Winter V, Dietermann K, Schneider U, Schreyögg J. Nurse staffing and patient-perceived quality of nursing care: a cross-sectional analysis of survey and administrative data in German hospitals. BMJ Open 2021; 11:e051133. [PMID: 34753760 PMCID: PMC8578983 DOI: 10.1136/bmjopen-2021-051133] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To examine the impact of nurse staffing on patient-perceived quality of nursing care. We differentiate nurse staffing levels and nursing skill mix as two facets of nurse staffing and use a multidimensional instrument for patient-perceived quality of nursing care. We investigate non-linear and interaction effects. SETTING The study setting was 3458 hospital units in 1017 hospitals in Germany. PARTICIPANTS We contacted 212 554 patients discharged from non-paediatric, non-intensive and non-psychiatric hospital units who stayed at least two nights in the hospital between January and October 2019. Of those, 30 174 responded, yielding a response rate of 14.2%. Our sample included only those patients. After excluding extreme values for our nurse staffing variables and removing observations with missing values, our final sample comprised 28 136 patients ranging from 18 to 97 years of age (average: 61.12 years) who had been discharged from 3458 distinct hospital units in 1017 hospitals. PRIMARY AND SECONDARY OUTCOME MEASURES Patient-perceived quality of nursing care (general nursing care, guidance provided by nurses, and patient loyalty to the hospital). RESULTS For all three dimensions of patient-perceived quality of nursing care, we found that they significantly decreased as (1) nurse staffing levels decreased (with decreasing marginal effects) and (2) the proportion of assistant nurses in a hospital unit increased. The association between nurse staffing levels and quality of nursing care was more pronounced among patients who were less clinically complex, were admitted to smaller hospitals or were admitted to medical units. CONCLUSIONS Our results indicate that, in addition to nurse staffing levels, nursing skill mix is crucial for providing the best possible quality of nursing care from the patient perspective and both should be considered when designing policies such as minimum staffing regulations to improve the quality of nursing care in hospitals.
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Affiliation(s)
- Vera Winter
- Schumpeter School of Business and Economics, University of Wuppertal, Wuppertal, Germany
- Hamburg Center for Health Economics, University of Hamburg, Hamburg, Germany
| | - Karina Dietermann
- Hamburg Center for Health Economics, University of Hamburg, Hamburg, Germany
| | | | - Jonas Schreyögg
- Hamburg Center for Health Economics, University of Hamburg, Hamburg, Germany
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19
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Saar L, Unbeck M, Bachnick S, Gehri B, Simon M. Exploring omissions in nursing care using retrospective chart review: An observational study. Int J Nurs Stud 2021; 122:104009. [PMID: 34298321 DOI: 10.1016/j.ijnurstu.2021.104009] [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: 11/22/2020] [Revised: 05/30/2021] [Accepted: 06/16/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Omissions in nursing care can compromise patient safety. To date, this phenomenon has been investigated almost exclusively via nurse surveys. However, such surveys restrict the range of activities which can be assessed for omissions, and patient level analysis. As an alternative, retrospective chart review methodology has been used successfully in other research fields, but not yet for omitted nursing care. OBJECTIVES To describe characteristics and frequency of omitted nursing care using a retrospective chart review methodology. DESIGN, SETTING AND PARTICIPANTS Observational single center study in two German neurological inpatient units. A random sample of 100 patient admissions was used. METHODS A structured chart review protocol to detect nursing omissions was developed and applied. The full range of expected nursing care activities were assessed regarding the importance of documenting them and whether they had been fully or partially omitted. Vital sign measurements were assessed regarding both the measurement target number and the number of measurements recorded. RESULTS In total, 1885 activities-a mean of 19 per patient-were identified. Of the reviewed activities, 52% (n = 971) were fully or partially omitted. Patients experienced between one and 22 omitted nursing care activities during their hospital stay (8-84% of expected care activities). Ranging from 6% to 100% some activities were more commonly omitted than others during admission. The most frequently omitted nursing activity was giving emotional care (88%, n = 66); the least frequently omitted was teaching (10%, n = 29). Vital signs were recorded only 50% (n = 141) of the targeted number of times. CONCLUSIONS Using a retrospective chart review protocol to identify omissions in nursing care allows the assessment of a broad range of nursing activities. Additionally, this is the first-time patient-level data on a broad range of activities have been analyzed. The newly developed chart review methodology can complement established survey methods and provide a new perspective on the phenomenon of omitted nursing care.
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Affiliation(s)
- Lili Saar
- Department of Neurology, Universitätsklinik Freiburg, Breisacherstrasse 64, Freiburg im Breisgau D-79106, Germany.
| | - Maria Unbeck
- School of Health and Welfare, Dalarna University, Falun SE-791 88, Sweden; Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm SE-171 77, Sweden.
| | - Stefanie Bachnick
- Institute of Nursing Science (INS), Department Public Health (DPH), Faculty of Medicine, University of Basel, Bernoullistrasse 28, CH-4056 Basel, Switzerland; Department of Nursing Science, University of Applied Sciences (hsg Bochum), Bochum, Germany.
| | - Beatrice Gehri
- Institute of Nursing Science (INS), Department Public Health (DPH), Faculty of Medicine, University of Basel, Bernoullistrasse 28, CH-4056 Basel, Switzerland; Department of Psychiatry, University Hospital Basel, University of Basel, Basel CH- 4002, Switzerland.
| | - Michael Simon
- Institute of Nursing Science (INS), Department Public Health (DPH), Faculty of Medicine, University of Basel, Bernoullistrasse 28, CH-4056 Basel, Switzerland; Department of Nursing, Nursing Research Unit, Inselspital Bern University Hospital, Bern 3010, Switzerland.
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20
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Dall'Ora C, Griffiths P, Hope J, Briggs J, Jeremy J, Gerry S, Redfern OC. How long do nursing staff take to measure and record patients' vital signs observations in hospital? A time-and-motion study. Int J Nurs Stud 2021; 118:103921. [PMID: 33812297 PMCID: PMC8249906 DOI: 10.1016/j.ijnurstu.2021.103921] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/16/2021] [Accepted: 02/24/2021] [Indexed: 01/13/2023]
Abstract
Introduction Monitoring vital signs in hospital is an important part of safe patient care. However, there are no robust estimates of the workload it generates for nursing staff. This makes it difficult to plan adequate staffing to ensure current monitoring protocols can be delivered. Objective To estimate the time taken to measure and record one set of patient's vital signs; and to identify factors associated with the time required to measure and record one set of patient's vital signs. Methods We undertook a time-and-motion study of 16 acute medical or surgical wards across four hospitals in England. Two trained observers followed a standard operating procedure to record the time taken to measure and record vital signs. We used mixed-effects models to estimate the mean time using whole vital signs rounds, which included equipment preparation, time spent taking vital signs at the bedside, vital signs documentation, and equipment storing. We tested whether our estimates were influenced by nurse, ward and hospital factors. Results After excluding non-vital signs related interruptions, dividing the length of a vital signs round by the number of vital signs assessments in that round yielded an estimated time per vital signs set of 5 min and 1 second (95% Confidence Interval (CI) = 4:39–5:24). If interruptions within the round were included, the estimated time was 6:26 (95% CI = 6:01–6:50). If only time taking each patient's vital signs at the bedside was considered, after excluding non-vital signs related interruptions, the estimated time was 3:45 (95% CI = 3:32–3:58). We found no substantial differences by hospital, ward or nurse characteristics, despite different systems for recording vital signs being used across the hospitals. Discussion The time taken to observe and record a patient's vital signs is considerable, so changes to recommended assessment frequency could have major workload implications. Variation in estimates derived from previous studies may, in part, arise from a lack of clarity about what was included in the reported times. We found no evidence that nurses save time when using electronic vital signs recording, or that the grade of staff measuring the vital signs influenced the time taken. Conclusions Measuring and recording vital signs is time consuming and the impact of interruptions and preparation away from the bedside is considerable. When considering the nursing workload around vital signs assessment, no assumption of relative efficiency should be made if different technologies or staff groups are deployed.
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Affiliation(s)
- Chiara Dall'Ora
- School of Health Sciences, University of Southampton, Highfield Campus, Southampton SO17 1BJ, United Kingdom; Applied Research Collaboration Wessex, University of Southampton, Southampton, United Kingdom.
| | - Peter Griffiths
- School of Health Sciences, University of Southampton, Highfield Campus, Southampton SO17 1BJ, United Kingdom; Applied Research Collaboration Wessex, University of Southampton, Southampton, United Kingdom; Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, United States.
| | - Joanna Hope
- School of Health Sciences, University of Southampton, Highfield Campus, Southampton SO17 1BJ, United Kingdom; Applied Research Collaboration Wessex, University of Southampton, Southampton, United Kingdom.
| | - Jim Briggs
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, United Kingdom.
| | - Jones Jeremy
- School of Health Sciences, University of Southampton, Highfield Campus, Southampton SO17 1BJ, United Kingdom.
| | - Stephen Gerry
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, United Kingdom.
| | - Oliver C Redfern
- Critical Care Research Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom.
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21
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Ede J, Petrinic T, Westgate V, Darbyshire J, Endacott R, Watkinson PJ. Human factors in escalating acute ward care: a qualitative evidence synthesis. BMJ Open Qual 2021; 10:bmjoq-2020-001145. [PMID: 33637554 PMCID: PMC7919590 DOI: 10.1136/bmjoq-2020-001145] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 01/07/2021] [Accepted: 02/04/2021] [Indexed: 11/07/2022] Open
Abstract
Background Identifying how human factors affect clinical staff recognition and managment of the deteriorating ward patient may inform process improvements. We systematically reviewed the literature to identify (1) how human factors affect ward care escalation (2) gaps in the current literature and (3) critique literature methodologies. Methods We undertook a Qualitative Evidence Synthesis of care escalation studies. We searched MEDLINE, EMBASE and CINHAL from inception to September 2019. We used the Critical Appraisal Skills Programme and the Grading of Recommendations Assessment-Development and Evaluation and Confidence in Evidence from Reviews of Qualitative Research tool to assess study quality. Results Our search identified 24 studies meeting the inclusion criteria. Confidence in findings was moderate (20 studies) to high (4 studies). In 16 studies, the ability to recognise changes in the patient’s condition (soft signals), including skin colour/temperature, respiratory pattern, blood loss, personality change, patient complaint and fatigue, improved the ability to escalate patients. Soft signals were detected through patient assessment (looking/listening/feeling) and not Early Warning Scores (eight studies). In contrast, 13 studies found a high workload and low staffing levels reduced staff’s ability to detect patient deterioration and escalate care. In eight studies quantifiable deterioration evidence (Early Warning Scores) facilitated escalation communication, particularly when referrer/referee were unfamiliar. Conversely, escalating concerning non-triggering patients was challenging but achieved by some clinical staff (three studies). Team decision making facilitated the clinical escalation (six studies). Conclusions Early Warning Scores have clinical benefits but can sometimes impede escalation in patients not meeting the threshold. Staff use other factors (soft signals) not captured in Early Warning Scores to escalate care. The literature supports strategies that improve the escalation process such as good patient assessment skills. PROSPERO registration number CRD42018104745.
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Affiliation(s)
- Jody Ede
- Adult Intensive Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK .,Plymouth University, Plymouth, UK
| | - Tatjana Petrinic
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Verity Westgate
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Julie Darbyshire
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Ruth Endacott
- Plymouth University, Plymouth, UK.,School of Nursing & Midwifery, Monash University, Clayton, Victoria, Australia
| | - Peter J Watkinson
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, Oxfordshire, UK
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22
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Fogg C, Bridges J, Meredith P, Spice C, Field L, Culliford D, Griffiths P. The association between ward staffing levels, mortality and hospital readmission in older hospitalised adults, according to presence of cognitive impairment: a retrospective cohort study. Age Ageing 2021; 50:431-439. [PMID: 32970798 DOI: 10.1093/ageing/afaa133] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Lower nurse staffing levels are associated with increased hospital mortality. Older patients with cognitive impairments (CI) have higher mortality rates than similar patients without CI and may be additionally vulnerable to low staffing. OBJECTIVES To explore associations between registered nurse (RN) and nursing assistant (NA) staffing levels, mortality and readmission in older patients admitted to general medical/surgical wards. RESEARCH DESIGN Retrospective cohort. PARTICIPANTS All unscheduled admissions to an English hospital of people aged ≥75 with cognitive screening over 14 months. MEASURES The exposure was defined as deviation in staffing hours from the ward daily mean, averaged across the patient stay. Outcomes were mortality in hospital/within 30 days of discharge and 30-day re-admission. Analyses were stratified by CI. RESULTS 12,544 admissions were included. Patients with CI (33.2%) were exposed to similar levels of staffing as those without. An additional 0.5 RN hours per day was associated with 10% reduction in the odds of death overall (odds ratio 0.90 [95% CI 0.84-0.97]): 15% in patients with CI (OR 0.85 [0.74-0.98]) and 7% in patients without (OR 0.93 [0.85-1.02]). An additional 0.5 NA hours per day was associated with a 15% increase in mortality in patients with no impairment. Readmissions decreased by 6% for an additional 0.5 RN hours in patients with CI. CONCLUSIONS Although exposure to low staffing was similar, the impact on mortality and readmission for patients with CI was greater. Increased mortality with higher NA staffing in patients without CI needs exploration.
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Affiliation(s)
- Carole Fogg
- Research and Development, Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Cosham, Hampshire PO6 3LY, UK
- National Institute of Health Research Collaboration for Leadership in Applied Health Research and Care / Applied Research Centre (NIHR CLAHRC / ARC) Wessex, Hampshire SO16 7NP, UK
- School of Health Sciences, Faculty of Environmental and Life Sciences University of Southampton, Hampshire SO17 1BJ, UK
| | - Jackie Bridges
- National Institute of Health Research Collaboration for Leadership in Applied Health Research and Care / Applied Research Centre (NIHR CLAHRC / ARC) Wessex, Hampshire SO16 7NP, UK
- School of Health Sciences, Faculty of Environmental and Life Sciences University of Southampton, Hampshire SO17 1BJ, UK
| | - Paul Meredith
- Research and Development, Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Cosham, Hampshire PO6 3LY, UK
| | - Claire Spice
- Department of Medicine for Older People, Rehabilitation and Stroke, Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital Cosham, Hampshire PO6 3LY, UK
| | - Linda Field
- Department of Medicine for Older People, Rehabilitation and Stroke, Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital Cosham, Hampshire PO6 3LY, UK
| | - David Culliford
- National Institute of Health Research Collaboration for Leadership in Applied Health Research and Care / Applied Research Centre (NIHR CLAHRC / ARC) Wessex, Hampshire SO16 7NP, UK
| | - Peter Griffiths
- National Institute of Health Research Collaboration for Leadership in Applied Health Research and Care / Applied Research Centre (NIHR CLAHRC / ARC) Wessex, Hampshire SO16 7NP, UK
- School of Health Sciences, Faculty of Environmental and Life Sciences University of Southampton, Hampshire SO17 1BJ, UK
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23
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Recio-Saucedo A, Smith GB, Redfern O, Maruotti A, Griffiths P. Observational study of the relationship between nurse staffing levels and compliance with mandatory nutritional assessments in hospital. J Hum Nutr Diet 2021; 34:679-686. [PMID: 33406321 DOI: 10.1111/jhn.12847] [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: 06/26/2020] [Revised: 08/24/2020] [Accepted: 10/30/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND In the UK, it is recommended that hospital patients have their nutritional status assessed within 24 h of admission using the Malnutrition Universal Screening Tool (MUST). The present study aimed to examine the association between nurse staffing levels and missed nutritional status assessments. METHODS A single-centre, retrospective, observational study was employed using routinely collected MUST assessments from 32 general adult hospital wards over 2 years, matched to ward nurse staffing levels. We used mixed-effects logistic regression to control for ward characteristics and patient factors. RESULTS Of 43 451 instances where staffing levels could be linked to a patient for whom an assessment was due, 21.4% had no MUST score recorded within 24 h of admission. Missed assessments varied between wards (8-100%). There was no overall association between registered nurse staffing levels and missed assessments; although higher admissions per registered nurse were associated with more missed assessments [odds ratio (OR) = 1.09, P = 0.005]. Higher healthcare assistant staffing was associated with lower rates of missed assessments (OR = 0.80, P < 0.001). There was a significant interaction between registered nurses and healthcare assistants staffing levels (OR = 0.97, P = 0.011). CONCLUSIONS Despite a written hospital policy requiring a nutritional assessment within 24 h of admission, missed assessments were common. The observed results show that compliance with the policy for routine MUST assessments within 24 h of hospital admission is sensitive to staffing levels and workload. This has implications for planning nurse staffing.
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Affiliation(s)
- A Recio-Saucedo
- NIHR Collaboration for Leadership in Applied Heath Research and Care (Wessex, University of Southampton, Southampton, UK
| | - G B Smith
- Faculty of Health and Social Sciences, University of Bournemouth, Bournemouth, UK
| | - O Redfern
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, UK
| | - A Maruotti
- Dipartimento di Scienze Economiche, Libera Universita Maria Santissima Assunta, Roma, Italy
| | - P Griffiths
- NIHR Collaboration for Leadership in Applied Heath Research and Care (Wessex, University of Southampton, Southampton, UK
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24
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Kostakis I, Smith GB, Prytherch D, Meredith P, Price C, Chauhan A. Impact of the coronavirus pandemic on the patterns of vital signs recording and staff compliance with expected monitoring schedules on general wards. Resuscitation 2020; 158:30-38. [PMID: 33221355 PMCID: PMC7676313 DOI: 10.1016/j.resuscitation.2020.11.014] [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: 08/07/2020] [Revised: 10/19/2020] [Accepted: 11/09/2020] [Indexed: 11/23/2022]
Abstract
Introduction Coronavirus disease 2019 (COVID-19) placed increased burdens on National Health Service hospitals and necessitated significant adjustments to their structures and processes. This research investigated if and how these changes affected the patterns of vital sign recording and staff compliance with expected monitoring schedules on general wards. Methods We compared the pattern of vital signs and early warning score (EWS) data collected from admissions to a single hospital during the initial phase of the COVID-19 pandemic with those in three control periods from 2018, 2019 and 2020. Main outcome measures were weekly and monthly hospital admissions; daily and hourly patterns of recorded vital signs and EWS values; time to next observation and; proportions of ‘on time’, ‘late’ and ‘missed’ vital signs observations sets. Results There were large falls in admissions at the beginning of the COVID-19 era. Admissions were older, more unwell on admission and throughout their stay, more often required supplementary oxygen, spent longer in hospital and had a higher in-hospital mortality compared to one or more of the control periods. More daily observation sets were performed during the COVID-19 era than in the control periods. However, there was no clear evidence that COVID-19 affected the pattern of vital signs collection across the 24-h period or the week. Conclusions The increased burdens of the COVID-19 pandemic, and the alterations in healthcare structures and processes necessary to respond to it, did not adversely affect the hospitals’ ability to monitor patients under its care and to comply with expected monitoring schedules.
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Affiliation(s)
- Ina Kostakis
- Centre for Healthcare Modelling & Informatics, University of Portsmouth, Portsmouth, UK
| | - Gary B Smith
- Centre of Postgraduate Medical Research & Education (CoPMRE), Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, UK.
| | - David Prytherch
- Centre for Healthcare Modelling & Informatics, University of Portsmouth, Portsmouth, UK
| | - Paul Meredith
- Research & Innovation Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Connor Price
- Centre for Healthcare Modelling & Informatics, University of Portsmouth, Portsmouth, UK
| | - Anoop Chauhan
- Director of Research and Innovation and Consultant Respiratory Physician, Portsmouth Hospitals University NHS Trust, Professor of Respiratory Medicine, University of Portsmouth, Portsmouth, UK
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25
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Abstract
Supplemental Digital Content is available in the text. Objectives: Early detection of subacute potentially catastrophic illnesses using available data is a clinical imperative, and scores that report risk of imminent events in real time abound. Patients deteriorate for a variety of reasons, and it is unlikely that a single predictor such as an abnormal National Early Warning Score will detect all of them equally well. The objective of this study was to test the idea that the diversity of reasons for clinical deterioration leading to ICU transfer mandates multiple targeted predictive models. Design: Individual chart review to determine the clinical reason for ICU transfer; determination of relative risks of individual vital signs, laboratory tests and cardiorespiratory monitoring measures for prediction of each clinical reason for ICU transfer; and logistic regression modeling for the outcome of ICU transfer for a specific clinical reason. Setting: Cardiac medical-surgical ward; tertiary care academic hospital. Patients: Eight-thousand one-hundred eleven adult patients, 457 of whom were transferred to an ICU for clinical deterioration. Interventions: None. Measurements and Main Results: We calculated the contributing relative risks of individual vital signs, laboratory tests and cardiorespiratory monitoring measures for prediction of each clinical reason for ICU transfer, and used logistic regression modeling to calculate receiver operating characteristic areas and relative risks for the outcome of ICU transfer for a specific clinical reason. The reasons for clinical deterioration leading to ICU transfer were varied, as were their predictors. For example, the three most common reasons—respiratory instability, infection and suspected sepsis, and heart failure requiring escalated therapy—had distinct signatures of illness. Statistical models trained to target-specific reasons for ICU transfer performed better than one model targeting combined events. Conclusions: A single predictive model for clinical deterioration does not perform as well as having multiple models trained for the individual specific clinical events leading to ICU transfer.
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26
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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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