Clinical user experiences of observation and response charts: focus group findings of using a new format chart incorporating a track and trigger system

Development of an enhanced scoring system to predict ICU readmission or in-hospital death within 24 hours using routine patient data from two NHS Foundation Trusts

RATIONALE

Intensive care units (ICUs) admit the most severely ill patients. Once these patients are discharged from the ICU to a step-down ward, they continue to have their vital signs monitored by nursing staff, with Early Warning Score (EWS) systems being used to identify those at risk of deterioration.

OBJECTIVES

We report the development and validation of an enhanced continuous scoring system for predicting adverse events, which combines vital signs measured routinely on acute care wards (as used by most EWS systems) with a risk score of a future adverse event calculated on discharge from the ICU.

DESIGN

A modified Delphi process identified candidate variables commonly available in electronic records as the basis for a 'static' score of the patient's condition immediately after discharge from the ICU. L1-regularised logistic regression was used to estimate the in-hospital risk of future adverse event. We then constructed a model of physiological normality using vital sign data from the day of hospital discharge. This is combined with the static score and used continuously to quantify and update the patient's risk of deterioration throughout their hospital stay.

SETTING

Data from two National Health Service Foundation Trusts (UK) were used to develop and (externally) validate the model.

PARTICIPANTS

A total of 12 394 vital sign measurements were acquired from 273 patients after ICU discharge for the development set, and 4831 from 136 patients in the validation cohort.

RESULTS

Outcome validation of our model yielded an area under the receiver operating characteristic curve of 0.724 for predicting ICU readmission or in-hospital death within 24 hours. It showed an improved performance with respect to other competitive risk scoring systems, including the National EWS (0.653).

CONCLUSIONS

We showed that a scoring system incorporating data from a patient's stay in the ICU has better performance than commonly used EWS systems based on vital signs alone.

TRIAL REGISTRATION NUMBER

ISRCTN32008295.

How to co-design a prototype of a clinical practice tool: a framework with practical guidance and a case study

Clinical tools for use in practice-such as medicine reconciliation charts, diagnosis support tools and track-and-trigger charts-are endemic in healthcare, but relatively little attention is given to how to optimise their design. User-centred design approaches and co-design principles offer potential for improving usability and acceptability of clinical tools, but limited practical guidance is currently available. We propose a framework (FRamework for co-dESign of Clinical practice tOols or 'FRESCO') offering practical guidance based on user-centred methods and co-design principles, organised in five steps: (1) establish a multidisciplinary advisory group; (2) develop initial drafts of the prototype; (3) conduct think-aloud usability evaluations; (4) test in clinical simulations; (5) generate a final prototype informed by workshops. We applied the framework in a case study to support co-design of a prototype track-and-trigger chart for detecting and responding to possible fetal deterioration during labour. This started with establishing an advisory group of 22 members with varied expertise. Two initial draft prototypes were developed-one based on a version produced by national bodies, and the other with similar content but designed using human factors principles. Think-aloud usability evaluations of these prototypes were conducted with 15 professionals, and the findings used to inform co-design of an improved draft prototype. This was tested with 52 maternity professionals from five maternity units through clinical simulations. Analysis of these simulations and six workshops were used to co-design the final prototype to the point of readiness for large-scale testing. By codifying existing methods and principles into a single framework, FRESCO supported mobilisation of the expertise and ingenuity of diverse stakeholders to co-design a prototype track-and-trigger chart in an area of pressing service need. Subject to further evaluation, the framework has potential for application beyond the area of clinical practice in which it was applied.

Epidemiology of in-hospital cardiac arrest patients admitted to the intensive care unit in Australia: a retrospective observational study

BACKGROUND

In-hospital cardiac arrest (IHCA) affects approximately 3000 patients annually in Australia. Introduction of the National Standard for Deteriorating Patients in 2011 was associated with reduced IHCA-related intensive care unit (ICU) admissions and reduced in-hospital mortality of such patients.

AIMS

To assess whether the reduction in IHCA-related ICU admissions from hospital wards seen following the implementation of the national standard (baseline period 2013-2014) was sustained over the follow-up period (2015-2019) in Australia.

METHODS

A multi-centre retrospective cohort study to compare the characteristics and outcomes of IHCA admitted to the ICU between baseline and follow-up periods. The primary outcome was the proportion of patients admitted to ICU from the ward following IHCA. Secondary outcomes included ICU and hospital mortality of IHCA-related ICU admissions. Data were analysed using hierarchical multivariable logistic regression.

RESULTS

The proportion of cardiac arrest-related admissions from the ward was lower in the follow-up period when compared to baseline (4.1 vs 3.8%; P = 0.04). Such patients had lower illness severity and were more likely to have limitations of medical treatment at admission. However, after adjustment for severity of illness, the likelihood of being admitted to ICU following cardiac arrest on the ward increased in the follow-up period (odds ratio (OR) 1.13 (1.05-1.22); P = 0.001). Hospital mortality was lower in the follow-up period (50.3 vs 46.3%; P = 0.02), but after adjustment the likelihood of death did not differ between the periods (OR 1.0 (0.86-1.17); P = 0.98).

CONCLUSION

After adjustment for the severity of illness, the likelihood of being admitted to ICU after IHCA slightly increased in the follow-up period.

Clinicians' use and perceptions of the pre-medical emergency team tier of one rapid response system: A mixed-methods study

BACKGROUND

The pre-medical emergency team (pre-MET) tier of rapid response systems facilitates early recognition and treatment of deteriorating ward patients using ward-based clinicians before a MET review is needed. However, there is growing concern that the pre-MET tier is inconsistently used.

OBJECTIVE

This study aimed to explore clinicians' use of the pre-MET tier.

METHODS

A sequential mixed-methods design was used. Participants were clinicians (nurses, allied health, doctors) caring for patients on two wards of one Australian hospital. Observations and medical record audits were conducted to identify pre-MET events and examine clinicians' use of the pre-MET tier as per hospital policy. Clinician interviews expanded on understandings gained from observation data. Descriptive and thematic analyses were performed.

RESULTS

Observations identified 27 pre-MET events for 24 patients that involved 37 clinicians (nurses = 24, speech pathologist = 1, doctors = 12). Nurses initiated assessments or interventions for 92.6% (n = 25/27) of pre-MET events; however, only 51.9% (n = 14/27) of pre-MET events were escalated to doctors. Doctors attended pre-MET reviews for 64.3% (n = 9/14) of escalated pre-MET events. Median time between escalation of care and in-person pre-MET review was 30 min (interquartile range: 8-36). Policy-specified clinical documentation was partially completed for 35.7% (n = 5/14) of escalated pre-MET events. Thirty-two interviews with 29 clinicians (nurses = 18, physiotherapists = 4, doctors = 7) culminated in three themes: Early Deterioration on a Spectrum, A Safety Net, and Demands Versus Resources.

CONCLUSIONS

There were multiple gaps between pre-MET policy and clinicians' use of the pre-MET tier. To optimise use of the pre-MET tier, pre-MET policy must be critically reviewed and system-based barriers to recognising and responding to pre-MET deterioration addressed.

We Are Not There Yet: A Qualitative System Probing Study of a Hospital Rapid Response System

OBJECTIVES

The capability of a hospital's rapid response system (RRS) depends on various factors to reduce in-hospital cardiac arrests and mortality. Through system probing, this qualitative study targeted a more comprehensive understanding of how healthcare professionals manage the complexities of RRS in daily practice as well as identifying its challenges.

METHODS

We observed RRS through in situ simulations in 2 wards and conducted the debriefings as focus group interviews. By arranging a separate focus group interview, we included the perspectives of intensive care unit personnel.

RESULTS

Healthcare professionals appreciated the standardized use of the National Early Warning Score, when combined with clinical knowledge and experience, structured communication, and interprofessional collaboration. However, we identified salient challenges in RRS, for example, unwanted variation in recognition competence, and inconsistent routines in education and documentation. Furthermore, we found that a lack of interprofessional trust, different understandings of RRS protocol, and signs of low psychological safety in the wards disrupted collaboration. To help remedy identified challenges, healthcare professionals requested shared arenas for learning, such as in situ simulation training.

CONCLUSIONS

Through system probing, we described the inner workings of RRS and revealed the challenges that require more attention. Healthcare professionals depend on structured RRS education, training, and resources to operate such a system. In this study, they request interventions like in situ simulation training as an interprofessional educational arena to improve patient care. This is a relevant field for further research. The Consolidated Criteria for Reporting Qualitative Studies Checklist was followed to ensure rigor in the study.

Factors that influence hospital nurses' escalation of patient care in response to their early warning score: A qualitative evidence synthesis

BACKGROUND

The Early Warning Score (EWS) is a validated tool that has improved patient outcomes internationally. This scoring system is used within the hospital setting to identify potentially deteriorating patients, thus expediting referral to appropriate medical personnel. It is increasingly recognised that there are other influencing factors along with EWS, which impact on nurses' decisions to escalate care.

AIM

The aim of this review was to identify and synthesise data from qualitative studies, which examined factors influencing nurses' escalation of care in response to patients' EWS.

METHODS

The systematic search strategy and eligibility criteria were guided by the SPIDER (Sample Phenomenon of Interest Design Evaluation Type of Research) framework. Eleven databases and five grey literature databases were searched. Titles and abstracts were independently screened in line with pre-established inclusion and exclusion criteria using the cloud-based platform, Rayyan. The selected studies underwent quality appraisal using CASP (Critical Appraisal Skills Programme, 2017, https://www.casp-uk.net/casp-toolschecklists) and subsequently synthesised using Thomas and Harden's thematic analysis approach. GRADE-CERQual (Grading of Recommendations Assessment Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research) was used to assess confidence in results. The EQUATOR listed guideline ENTREQ (Tong et al., 2012, BMC Medical Research Methodology, 12) was used to synthesise and report findings.

RESULTS

Eighteen studies from seven countries including 235 nurses were identified. Following synthesis, four analytical themes were generated with eighteen derived consequent findings. The four themes identified were as follows: 1) Marrying nurses' clinical judgement with EWS 2) SMART communication 3) EWS Protocol: Blessing and a Curse 5) Hospital Domain.

CONCLUSION

Nurses strive to find balance by simultaneously navigating within the boundaries of both the EWS protocol and the hospital domain. They view the EWS as a valid essential component in the system but one that does not give a definitive answer and absolute direction. They value the protocols' ability to identify deteriorating patients and convey the seriousness of a situation to their multidisciplinary colleagues but also find it somewhat restrictive and frustrating and wish to have credence given to their own intuition and clinical judgement.

Clinical Sign-Based Rapid Response Team Call Criteria for Identifying Patients Requiring Intensive Care Management in Japan

Background and Objectives: For effective function of the rapid response system (RRS), prompt identification of patients at a high risk of cardiac arrest and RRS activation without hesitation are important. This study aimed to identify clinical factors that increase the risk of intensive care unit (ICU) transfer and cardiac arrest to identify patients who are likely to develop serious conditions requiring ICU management and appropriate RRS activation in Japan. Materials and Methods: We performed a single-center, case control study among patients requiring a rapid response team (RRT) call from 2017 to 2020. We extracted the demographic data, vital parameters, blood oxygen saturation (SpO₂) and the fraction of inspired oxygen (FiO₂) from the medical records at the time of RRT call. The patients were divided into two groups to identify clinical signs that correlated with the progression of clinical deterioration. Patient characteristics in the two groups were compared using statistical tests based on the distribution. Receiver operating characteristic (ROC) curve analysis was used to identify the appropriate cut-off values of vital parameters or FiO₂ that showed a significant difference between-group. Multivariate logistic regression analysis was used to identify patient factors that were predictive of RRS necessity. Results: We analyzed the data of 65 patients who met our hospital’s RRT call criteria. Among the clinical signs in RRT call criteria, respiratory rate (RR) (p < 0.01) and the needed FiO₂ were significantly increased (p < 0.01) in patients with severe disease course. ROC curve analysis revealed RR and needed FiO₂ cut-off values of 25.5 breaths/min and 30%. The odds ratio for the progression of clinical deterioration was 40.5 times higher with the combination of RR ≥ 26 breaths/min and needed FiO₂ ≥ 30%. Conclusions: The combined use of RR ≥ 26 breaths/min and needed FiO₂ ≥ 30% might be valid for identifying patients requiring intensive care management.

Could standing orders have a place? A phenomenological exploration of experienced ward-based registered nurses' views on the escalation protocol for patient deterioration

AIMS AND OBJECTIVES

To explore experienced ward-based Registered Nurses' views on the potential use of standing orders, prior to the escalation protocol, for patient deterioration.

BACKGROUND

Ward based nurses are required to follow set steps of the escalation protocol. The introduction of standing order policies would allow nurses to intervene earlier when deterioration was first detected.

DESIGN

Hermeneutic Phenomenology.

METHODS

Ten experienced ward-based RNs were recruited. Semi-structured interviews were conducted, with the data subjected to thematic analysis. Diekelmann's framework was used to analyse the texts, seeking the highest level of hermeneutic analysis namely, a constitutive pattern. COREQ guidelines were utilised.

RESULTS

Four main themes emerged: (1) Ambiguity in perception: the escalation protocol; (2) Observations within acceptable parameters, but the patient is deteriorating; (3) Paradoxes of escalation: well laid out protocol, but hard to escalate; (4) We could intervene with standing orders, but are we permitted? The constitutive pattern namely, Dualism in Perception related to the dissonance conveyed by participants regarding the escalation protocol.

CONCLUSIONS

Notwithstanding the benefits of the escalation protocol for junior staff, the RNs offered critique of the established escalation practices and the restrictive role of the protocol. Another aspect of the protocol, that is 'worried criterion' was viewed positively. The participants expressed a desire to apply nurse-driven standing orders, to enable them to intervene earlier for patient deterioration.

RELEVANCE TO CLINICAL PRACTICE

Organisations should consider new policies introducing standing orders for implementation by experienced RNs. The engagement of experienced ward-based nurses in forming 'patient at-risk teams' could assist organisations to deal with cases of clinical deterioration prior to activation of the escalation of care protocol.

Adherence to the bedside paediatric early warning system (BedsidePEWS) in a pediatric tertiary care hospital

Background

The aim of this study is to describe the adherence to the Bedside Pediatric Early Warning System (BedsidePEWS) escalation protocol in children admitted to hospital wards in a large tertiary care children’s hospital in Italy.

Methods

This is a retrospective observational chart review. Data on the frequency and accuracy of BedsidePEWS score calculations, escalation of patient observations, monitoring and medical reviews were recorded.

Two research nurses performed weekly visits to the hospital wards to collect data on BedsidePEWS scores, medical reviews, type of monitoring and vital signs recorded. Data were described through means or medians according to the distribution. Inferences were calculated either with Chi-square, Student’s t test or Wilcoxon-Mann–Whitney test, as appropriate (P < 0.05 considered as significant).

Results

A total of 522 Vital Signs (VS) and score calculations [BedsidePEWS documentation events, (DE)] on 177 patient clinical records were observed from 13 hospital inpatient wards. Frequency of BedsidePEWS DE occurred < 3 times per day in 33 % of the observations. Adherence to the BedsidePEWS documentation frequency according to the hospital protocol was observed in 54 % of all patients; in children with chronic health conditions (CHC) it was significantly lower than children admitted for acute medical conditions (47 % vs. 69 %, P = 0.006). The BedsidePEWS score was correctly calculated and documented in 84 % of the BedsidePEWS DE. Patients in a 0–2 BedsidePEWS score range were all reviewed at least once a day by a physician. Only 50 % of the patients in the 5–6 score range were reviewed within 4 h and 42 % of the patients with a score ≥ 7 within 2 h.

Conclusions

Escalation of patient observations, monitoring and medical reviews matching the BedsidePEWS is still suboptimal. Children with CHC are at higher risk of lower compliance. Impact of adherence to predefined response algorithms on patient outcomes should be further explored.

Modifications to medical emergency team activation criteria and implications for patient safety: A point prevalence study

BACKGROUND

Medical emergency team (MET) activation criteria are sometimes modified to minimise unnecessary MET calls in patients who have chronic physiological derangements, have limitation of medical treatment orders in place, or have recently received treatment for clinical deterioration. However, the safety implications of modifying MET activation criteria are poorly understood.

OBJECTIVES

The aim of the study was to examine the safety of modifying MET activation criteria. Specifically, we aimed to examine the frequency and nature of modifications to MET activation criteria and compare characteristics and outcomes of patients with and without modifications to MET activation criteria.

METHODS

This was a point prevalence study using a retrospective medical record audit. Patients admitted to 14 wards on November 7, 2018, at two acute-care hospitals of one health service in Melbourne, Australia, were included (N = 430). Data were analysed using descriptive and inferential statistics. The main outcome measures included frequency and nature of modifications to MET activation criteria on a specified date, MET calls, intensive care unit admission, in-hospital cardiac arrest, and in-hospital death.

RESULTS

Amongst 430 inpatients, there were 30 modifications to MET activation criteria in 26 (6.0%) patients. All modifications were intended to trigger METs at more extreme levels of physiological derangement. Most modifications pertained to tachypnoea (26.7%; n = 8/30) and bradycardia (23.3%; n = 7/30). Patients with modifications were more likely to have documented physiological deterioration that fulfilled MET (47.8%, n = 11; p < 0.001) or pre-MET (87.0%, n = 20; p < 0.001) criteria in the preceding 24-h period than patients without modifications. Of patients with modifications, none were admitted to an intensive care unit, had a cardiac arrest, or died in the hospital. There were no differences in hospital length of stay or discharge destination between patients with and without modifications.

CONCLUSIONS

In this point prevalence study, modifications to MET activation criteria were infrequent and not associated with negative patient safety outcomes.

Why do healthcare professionals fail to escalate as per the early warning system (EWS) protocol? A qualitative evidence synthesis of the barriers and facilitators of escalation

Background

Early warning systems (EWSs) are used to assist clinical judgment in the detection of acute deterioration to avoid or reduce adverse events including unanticipated cardiopulmonary arrest, admission to the intensive care unit and death. Sometimes healthcare professionals (HCPs) do not trigger the alarm and escalate for help according to the EWS protocol and it is unclear why this is the case. The aim of this qualitative evidence synthesis was to answer the question ‘why do HCPs fail to escalate care according to EWS protocols?’ The findings will inform the update of the National Clinical Effectiveness Committee (NCEC) National Clinical Guideline No. 1 Irish National Early Warning System (INEWS).

Methods

A systematic search of the published and grey literature was conducted (until February 2018). Data extraction and quality appraisal were conducted by two reviewers independently using standardised data extraction forms and quality appraisal tools. A thematic synthesis was conducted by two reviewers of the qualitative studies included and categorised into the barriers and facilitators of escalation. GRADE CERQual was used to assess the certainty of the evidence.

Results

Eighteen studies incorporating a variety of HCPs across seven countries were included. The barriers and facilitators to the escalation of care according to EWS protocols were developed into five overarching themes: Governance, Rapid Response Team (RRT) Response, Professional Boundaries, Clinical Experience, and EWS parameters. Barriers to escalation included: Lack of Standardisation, Resources, Lack of accountability, RRT behaviours, Fear, Hierarchy, Increased Conflict, Over confidence, Lack of confidence, and Patient variability. Facilitators included: Accountability, Standardisation, Resources, RRT behaviours, Expertise, Additional support, License to escalate, Bridge across boundaries, Clinical confidence, empowerment, Clinical judgment, and a tool for detecting deterioration. These are all individual yet inter-related barriers and facilitators to escalation.

Conclusions

The findings of this qualitative evidence synthesis provide insight into the real world experience of HCPs when using EWSs. This in turn has the potential to inform policy-makers and HCPs as well as hospital management about emergency response system-related issues in practice and the changes needed to address barriers and facilitators and improve patient safety and quality of care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00403-9.

Escalation triggers and expected responses in obstetric early warning systems used in UK consultant-led maternity units

Background

The use of obstetric early warning systems (OEWS) are recommended as an adjunct to reduce maternal morbidity and mortality. The aim of this review was to document the variation in OEWS trigger thresholds and the quality of information included within accompanying escalation protocols.

Methods

A review of OEWS charts and escalation policies across consultant-led maternity units in the UK (n = 147) was conducted. OEWS charts were analysed for variation in the values of physiological parameters triggering different levels of clinical escalation. Relevant data within the escalation protocols were also searched for: urgency of clinical response; seniority of responder; frequency of on-going clinical monitoring; and clinical setting recommended for on-going care.

Results

The values of physiological parameters triggering specific clinical responses varied significantly between OEWS. Only 99 OEWS charts (67.3%) had an escalation protocol as part of the chart. For 29 charts (19.7%), the only escalation information included was generic, for example to “contact a doctor if triggers”. Only 76 (51.7%) charts detailed the required seniority of responder, 37 (25.2%) the frequency for on-going clinical monitoring, eight (5.4%) the urgency of clinical response and two (1.4%) the recommended clinical setting for on-going care.

Conclusion

The observed variations in the trigger thresholds used in OEWS charts and the quality of information included within the accompanying escalation protocols is likely to lead to suboptimal detection and response to clinical deterioration during pregnancy and the post-partum period. The development of a national OEWS and escalation protocol would help to standardise care across obstetric units.

The development and psychometric evaluation of the Clinicians' Attitudes towards Responding and Escalating care of Deteriorating patients scale

BACKGROUND

Validated measures of ward nurses' safety cultures in relation to escalations of care in deteriorating patients are lacking.

OBJECTIVES

This study aimed to develop and evaluate the psychometric properties of the Clinicians' Attitudes towards Responding and Escalating care of Deteriorating patients (CARED) scale for use among ward nurses.

METHODS

The study was conducted in two phases: scale development and psychometric evaluation. The scale items were developed based on a systematic literature review, informant interviews, and expert reviews (n = 15). The reliability and validity of the scale were examined by administering the scale to 617 registered nurses with retest evaluations (n = 60). The factor structure of the CARED scale was examined in a split-half analysis with exploratory and confirmatory factor analyses. The internal consistency, test-retest reliability, convergent validity, and known-group validity of the scale were also analysed.

RESULTS

A high overall content validity index of 0.95 was obtained from the validations of 15 international experts from seven countries. A three-factor solution was identified from the final 22 items: 'beliefs about rapid response system', 'fears about escalating care', and 'perceived confidence in responding to deteriorating patients'. The internal consistency reliability of the scale was supported with a good Cronbach's alpha value of 0.86 and a Spearman-Brown split-half coefficient of 0.87. An excellent test-retest reliability was demonstrated, with an intraclass correlation coefficient of 0.92. The convergent validity of the scale was supported with an existing validated scale. The CARED scale also demonstrated abilities to discriminate differences among the sample characteristics.

CONCLUSIONS

The final 22-item CARED scale was tested to be a reliable and valid scale in the Singaporean setting. The scale may be used in other settings to review hospitals' rapid response systems and to identify strategies to support ward nurses in the process of escalating care in deteriorating ward patients.

Introducing the National Early Warning Score - A qualitative study of hospital nurses' perceptions and reactions

AIM

The aim of this study was to explore hospital nurses' perceptions and reactions to the National Early Warning Score during an introduction programme.

DESIGN

A qualitative case study approach with participatory observations was used for this study.

METHODS

In total, nine seminars and 23 simulation sessions attended by nurses were observed. An activity theory system analysis was applied to interpret the material.

RESULTS

The findings revealed four tensions related to the working context: (a) tension between using a standardized tool and relying on clinical judgement (the tool could be either an aid or a barrier to patient assessment); (b) tension in the community of practice (the tool could be beneficial or increase stress and anxiety); (c) tension related to rules and compliance (the tool could be perceived as optional or compulsory); and (d) tension related to the division of labour (nurses feared more work).

Review of systems for recognising and responding to clinical deterioration in Singapore hospitals: a nationwide cross-sectional study

INTRODUCTION

The Rapid Response System for recognising and responding to clinically deteriorating patients has been progressively implemented in acute care hospitals across the globe. This study sought to review the implementation of this system in acute public hospitals in Singapore.

METHODS

A cross-sectional study using a face-to-face survey questionnaire was conducted.

RESULTS

Five out of seven invited hospitals completed the questionnaire and rated the Rapid Response System as either high priority or essential, and indicated its importance over other patient safety indicators. Sensitivity and specificity of the triggering criteria and non-adherence to the escalation protocol were highlighted issues. Only two hospitals had a dedicated response team for providing emergency help to deteriorating ward patients. Limited manpower resources, unclear roles between the primary and response teams, and the potential deskilling of ward staff were reported barriers that inhibited the uptake of a response team. All hospitals had a committee that oversaw its system operation, provided training to ward staff, and used information technology to support the implementation.

CONCLUSION

A variety of approaches have been taken to support the system of recognising and responding to clinical deterioration. This calls for a national approach to enable the standardisation of clinical processes, sharing of educational resources and multi-site evaluation.

Using the National Early Warning Score (NEWS) outside acute hospital settings: a qualitative study of staff experiences in the West of England

OBJECTIVES

Early warning scores were developed to improve recognition of clinical deterioration in acute hospital settings. In England, the National Early Warning Score (NEWS) is increasingly being recommended at a national level for use outside such settings. In 2015, the West of England Academic Health Science Network supported the roll-out of NEWS across a range of non-acute-hospital healthcare sectors. Research on the use of NEWS outside acute hospitals is limited. The objective of this study was to explore staff experiences of using NEWS in these new settings.

DESIGN

Thematic analysis of qualitative semi-structured interviews with purposefully sampled healthcare staff.

SETTING

West of England healthcare settings where NEWS was being used outside acute hospitals-primary care, ambulance, referral management, community and mental health services.

PARTICIPANTS

Twenty-five healthcare staff interviewed from primary care (9), ambulance (3), referral management/acute interface (5), community (4) and mental health services (3), and service commissioning (1).

RESULTS

Participants reported that NEWS could support clinical decision-making around escalation of care, and provide a clear means of communicating clinical acuity between clinicians and across different healthcare organisations. Challenges with implementing NEWS varied-in primary care, clinicians had to select patients for NEWS and adopt different methods of clinical assessment, whereas for paramedics it fitted well with usual clinical practice and was used for all patients. In community services and mental health, modifications were 'needed' to make the tool relevant to some patient populations.

CONCLUSIONS

This study demonstrated that while NEWS can work for staff outside acute hospital settings, the potential for routine clinical practice to accommodate NEWS in such settings varied. A tailored approach to implementation in different settings, incorporating guidance supported by further research on the use of NEWS with specific patient groups in community settings, may be beneficial, and enhance staff confidence in the tool.

Barriers and facilitators related to the implementation of a physiological track and trigger system: A systematic review of the qualitative evidence

Purpose

To identify the barriers to, and facilitators of, the implementation of physiological track and trigger systems (PTTSs), perceived by healthcare workers, through a systematic review of the extant qualitative literature.

Data sources

Searches were performed in PUBMED, CINAHL, PsycInfo, Embase and Web of Science. The reference lists of included studies were also screened.

Study selection

The electronic searches yielded 2727 papers. After removing duplicates, and further screening, a total of 10 papers were determined to meet the inclusion criteria and were reviewed.

Data extraction

A deductive content analysis approach was taken to organizing and analysing the data. A framework consisting of two overarching dimensions ('User-related changes required to implement PTTSs effectively' and 'Factors that affect user-related changes'), 5 themes (staff perceptions of PTTSs and patient safety, workflow adjustment, PTTS, implementation process and local context) and 14 sub themes was used to classify the barriers and facilitators to the implementation of PTTSs.

Results of data synthesis

Successful implementation of a PTTS must address the social context in which it is to be implemented by ensuring that the users believe that the system is effective and benefits patient care. The users must feel invested in the PTTS and its use must be supported by training to ensure that all healthcare workers, senior and junior, understand their role in using the system.

Conclusion

PTTSs can improve patient safety and quality of care. However, there is a need for a robust implementation strategy or the benefits of PTTSs will not be realized.

Factors influencing the quality of vital sign data in electronic health records: A qualitative study

AIMS AND OBJECTIVES

To investigate reasons for inadequate documentation of vital signs in an electronic health record.

BACKGROUND

Monitoring vital signs is crucial to detecting and responding to patient deterioration. The ways in which vital signs are documented in electronic health records have received limited attention in the research literature. A previous study revealed that vital signs in an electronic health record were incomplete and inconsistent.

DESIGN

Qualitative study.

METHODS

Qualitative study. Data were collected by observing (68 hr) and interviewing nurses (n = 11) and doctors (n = 3), and analysed by thematic analysis to examine processes for measuring, documenting and retrieving vital signs in four clinical settings in a 353-bed hospital.

RESULTS

We identified two central reasons for inadequate vital sign documentation. First, there was an absence of firm guidelines for observing patients' vital signs, resulting in inconsistencies in the ways vital signs were recorded. Second, there was a lack of adequate facilities in the electronic health record for recording vital signs. This led to poor presentation of vital signs in the electronic health record and to staff creating paper "workarounds."

CONCLUSIONS

This study demonstrated inadequate routines and poor facilities for vital sign documentation in an electronic health record, and makes an important contribution to knowledge by identifying problems and barriers that may occur. Further, it has demonstrated the need for improved facilities for electronic documentation of vital signs.

RELEVANCE TO CLINICAL PRACTICE

Patient safety may have been compromised because of poor presentation of vital signs. Thus, our results emphasised the need for standardised routines for monitoring patients. In addition, designers should consult the clinical end-users to optimise facilities for electronic documentation of vital signs. This could have a positive impact on clinical practice and thus improve patient safety.

Comparison of the Between the Flags calling criteria to the MEWS, NEWS and the electronic Cardiac Arrest Risk Triage (eCART) score for the identification of deteriorating ward patients

INTRODUCTION

Traditionally, paper based observation charts have been used to identify deteriorating patients, with emerging recent electronic medical records allowing electronic algorithms to risk stratify and help direct the response to deterioration.

OBJECTIVE(S)

We sought to compare the Between the Flags (BTF) calling criteria to the Modified Early Warning Score (MEWS), National Early Warning Score (NEWS) and electronic Cardiac Arrest Risk Triage (eCART) score.

DESIGN AND PARTICIPANTS

Multicenter retrospective analysis of electronic health record data from all patients admitted to five US hospitals from November 2008-August 2013.

MAIN OUTCOME MEASURES

Cardiac arrest, ICU transfer or death within 24h of a score RESULTS: Overall accuracy was highest for eCART, with an AUC of 0.801 (95% CI 0.799-0.802), followed by NEWS, MEWS and BTF respectively (0.718 [0.716-0.720]; 0.698 [0.696-0.700]; 0.663 [0.661-0.664]). BTF criteria had a high risk (Red Zone) specificity of 95.0% and a moderate risk (Yellow Zone) specificity of 27.5%, which corresponded to MEWS thresholds of >=4 and >=2, NEWS thresholds of >=5 and >=2, and eCART thresholds of >=12 and >=4, respectively. At those thresholds, eCART caught 22 more adverse events per 10,000 patients than BTF using the moderate risk criteria and 13 more using high risk criteria, while MEWS and NEWS identified the same or fewer.

CONCLUSION(S)

An electronically generated eCART score was more accurate than commonly used paper based observation tools for predicting the composite outcome of in-hospital cardiac arrest, ICU transfer and death within 24h of observation. The outcomes of this analysis lend weight for a move towards an algorithm based electronic risk identification tool for deteriorating patients to ensure earlier detection and prevent adverse events in the hospital.

Midwives' experiences of performing maternal observations and escalating concerns: a focus group study

BACKGROUND

For the past decade, Maternal Mortality Reports, published in the United Kingdom every three years, have consistently raised concerns about maternal observations in maternity care. The reports identify that observations are not being done, not being completed fully, are not recorded on Early Warning Score systems, and/or are not escalated appropriately. This has resulted in delays in referral, intervention and increases the risk of maternal morbidity or mortality. However there has been little exploration of the possible reasons for non-completion of maternal observations.

METHODS

The aim of this study was to explore midwives' experiences of performing maternal observations and escalating concerns in rural and urban maternity settings in the West Midlands of England. A qualitative design involving a series of six focus groups with midwives and Supervisors of Midwives was employed to investigate the facilitators of, and barriers to the completion of maternal observations.

RESULTS

Eighteen Midwives and 8 Supervisors of Midwives participated in a total of 6 focus groups. Three key themes emerged from the data: (1) Organisation of Maternal Observations (including delegation of tasks to Midwifery Support Workers, variation in their training, the care model used e.g. one to one care, and staffing issues); (2) Prioritisation of Maternal Observations (including the role of professional judgement and concerns expressed by midwives that they did not feel equipped to care for women with complex clinical needs; and (3) Negotiated Escalation (including the inappropriate response from senior staff to use of Modified Early Warning Score systems, and the emotional impact of escalation).

CONCLUSIONS

A number of organisational and cultural barriers exist to the completion of maternal observations and the escalation of concerns. In order to address these the following actions are recommended: standardised training for Midwifery Support Workers, review of training of midwives to ensure it addresses the increasing complexity of the maternal population, identification and agreement regarding the organisation of maternal observations among staff, an emphasis on increasing the priority placed on maternal observations in all clinical settings, and clarification and reinforcement of escalation procedures for both midwives and senior clinicians.

A newly designed observation and response chart's effect upon adverse inpatient outcomes and rapid response team activity

BACKGROUND

Adverse inpatient events may diminish with earlier response to clinical deterioration. Observation and response charts with a tiered escalation response are recommended for use.

AIMS

To examine the impact of an observation and response chart and altered calling criteria on rapid response team (RRT) calls, cardiac arrests and intensive care unit (ICU) admissions from the ward and hospital deaths.

METHODS

Linked administrative and clinical data from an Australian, adult tertiary hospital for August 2007 to June 2013 (pre-chart) and July 2013 to December 2014 (post-chart) and analysed using interrupted time series analysis.

RESULTS

Pre-chart RRT calls were increasing by 1.7 calls per 10 000 hospital admissions per month, whilst ICU admissions from the ward, deaths and cardiac arrests were decreasing by 0.3, 0.25 and 0.079 per 10 000 admissions per month respectively. Immediately upon chart introduction, the RRT call rate increased by 82% (66-98% CI; P < 0.01), the ward admissions to ICU rate increased by 41% (14-67% CI; P < 0.01) and the rates of deaths and cardiac arrests did not change. In the post chart period, both the pre-chart increasing trend in the rate of RRT and decreasing trend in the rate of ICU admissions changed significantly to become constant. The pre chart trends in the cardiac arrest rate and hospital mortality did not change.

CONCLUSION

Observation and response charts increased RRT and ICU workload without improving cardiac arrest rate or mortality. Future chart evaluation should identify features beneficial to patient outcomes and refine those that consume critical care resources that are not associated with improved patient outcomes.

Accuracy and Efficiency of Recording Pediatric Early Warning Scores Using an Electronic Physiological Surveillance System Compared With Traditional Paper-Based Documentation

Pediatric Early Warning Scores are advocated to assist health professionals to identify early signs of serious illness or deterioration in hospitalized children. Scores are derived from the weighting applied to recorded vital signs and clinical observations reflecting deviation from a predetermined "norm." Higher aggregate scores trigger an escalation in care aimed at preventing critical deterioration. Process errors made while recording these data, including plotting or calculation errors, have the potential to impede the reliability of the score. To test this hypothesis, we conducted a controlled study of documentation using five clinical vignettes. We measured the accuracy of vital sign recording, score calculation, and time taken to complete documentation using a handheld electronic physiological surveillance system, VitalPAC Pediatric, compared with traditional paper-based charts. We explored the user acceptability of both methods using a Web-based survey. Twenty-three staff participated in the controlled study. The electronic physiological surveillance system improved the accuracy of vital sign recording, 98.5% versus 85.6%, P < .02, Pediatric Early Warning Score calculation, 94.6% versus 55.7%, P < .02, and saved time, 68 versus 98 seconds, compared with paper-based documentation, P < .002. Twenty-nine staff completed the Web-based survey. They perceived that the electronic physiological surveillance system offered safety benefits by reducing human error while providing instant visibility of recorded data to the entire clinical team.

Observation chart design features affect the detection of patient deterioration: a systematic experimental evaluation

AIM

To systematically evaluate the impact of several design features on chart-users' detection of patient deterioration on observation charts with early-warning scoring-systems.

BACKGROUND

Research has shown that observation chart design affects the speed and accuracy with which abnormal observations are detected. However, little is known about the contribution of individual design features to these effects.

DESIGN

A 2 × 2 × 2 × 2 mixed factorial design, with data-recording format (drawn dots vs. written numbers), scoring-system integration (integrated colour-based system vs. non-integrated tabular system) and scoring-row placement (grouped vs. separate) varied within-participants and scores (present vs. absent) varied between-participants by random assignment.

METHODS

205 novice chart-users, tested between March 2011-March 2014, completed 64 trials where they saw real patient data presented on an observation chart. Each participant saw eight cases (four containing abnormal observations) on each of eight designs (which represented a factorial combination of the within-participants variables). On each trial, they assessed whether any of the observations were physiologically abnormal, or whether all observations were normal. Response times and error rates were recorded for each design.

RESULTS

Participants responded faster (scores present and absent) and made fewer errors (scores absent) using drawn-dot (vs. written-number) observations and an integrated colour-based (vs. non-integrated tabular) scoring-system. Participants responded faster using grouped (vs. separate) scoring-rows when scores were absent, but separate scoring-rows when scores were present.

CONCLUSION

Our findings suggest that several individual design features can affect novice chart-users' ability to detect patient deterioration. More broadly, the study further demonstrates the need to evaluate chart designs empirically.