Developing and evaluating the success of a family activated medical emergency team: a quality improvement report

Physician Work-Personal Intersection: A Scoping Review of Terms, Definitions, and Measures

PURPOSE

A substantial body of evidence describes the multidimensional relationship between the intersection of physicians' work and personal lives and health care quality and costs, workforce sustainability, and workplace safety culture. However, there is no clear consensus on the terms, definitions, or measures used in physician work-personal intersection (WPI) research. In this scoping review, the authors aimed to describe the terms and definitions used by researchers to describe physician WPI, summarize the measurement tools used, and formulate a conceptual model of WPI that can inform future research.

METHOD

The authors searched PubMed, CINAHL, Scopus, and Web of Science for studies that investigated U.S. practicing physicians' WPI and measured WPI as an outcome from January 1990 to March 2022. The authors applied thematic analysis to all WPI terms, definitions, and survey questions or prompts in the included studies to create a conceptual model of physician WPI.

RESULTS

Ultimately, 102 studies were included in the final analysis. The most commonly used WPI terms were work-life balance, work-life integration, and work-home or work-life conflict(s). There was no consistency in the definition of any terms across studies. There was heterogeneity in the way WPI was measured, and only 8 (7.8%) studies used a validated measurement tool. The authors identified 6 key driver domains of WPI: work and personal demands; colleague and institutional support and resources; personal identity, roles, health, and values; work schedule and flexibility; partner and family support; and personal and professional strategies.

CONCLUSIONS

The authors found significant variability in the terms, definitions, and measures used to study physician WPI. They offer a conceptual model of the WPI construct that can be used to more consistently study physician WPI in the future. Future work should further investigate the validity of this model and generate consensus around WPI terms, definitions, and measures.

Impact of Rapid Response Teams on Pediatric Care: An Interrupted Time Series Analysis of Unplanned PICU Admissions and Cardiac Arrests

Pediatric rapid response teams (RRTs) are expected to significantly lower pediatric mortality in healthcare settings. This study evaluates RRTs' effectiveness in decreasing cardiac arrests and unexpected Pediatric Intensive Care Unit (PICU) admissions. A quasi-experimental study (2014-2017) at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, involved 3261 pediatric inpatients, split into pre-intervention (1604) and post-intervention (1657) groups. Baseline pediatric warning scores and monthly data on admissions, transfers, arrests, and mortality were analyzed pre- and post-intervention. Statistical methods including bootstrapping, segmented regression, and a Zero-Inflation Poisson model were employed to ensure a comprehensive evaluation of the intervention's impact. RRT was activated 471 times, primarily for respiratory distress (29.30%), sepsis (22.30%), clinical anxiety (13.80%), and hematological abnormalities (6.7%). Family concerns triggered 0.1% of activations. Post-RRT implementation, unplanned PICU admissions significantly reduced (RR = 0.552, 95% CI 0.485-0.628, p < 0.0001), and non-ICU cardiac arrests were eliminated (RR = 0). Patient care improvement was notable, with a -9.61 coefficient for PICU admissions (95% CI: -12.65 to -6.57, p < 0.001) and a -1.641 coefficient for non-ICU cardiac arrests (95% CI: -2.22 to -1.06, p < 0.001). Sensitivity analysis showed mixed results for PICU admissions, while zero-inflation Poisson analysis confirmed a reduction in non-ICU arrests. The deployment of pediatric RRTs is associated with fewer unexpected PICU admissions and non-ICU cardiopulmonary arrests, indicating improved PICU management. Further research using robust scientific methods is necessary to conclusively determine RRTs' clinical benefits.

Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU: 2023

RATIONALE

Clinical deterioration of patients hospitalized outside the ICU is a source of potentially reversible morbidity and mortality. To address this, some acute care hospitals have implemented systems aimed at detecting and responding to such patients.

OBJECTIVES

To provide evidence-based recommendations for hospital clinicians and administrators to optimize recognition and response to clinical deterioration in non-ICU patients.

PANEL DESIGN

The 25-member panel included representatives from medicine, nursing, respiratory therapy, pharmacy, patient/family partners, and clinician-methodologists with expertise in developing evidence-based Clinical Practice Guidelines.

METHODS

We generated actionable questions using the Population, Intervention, Control, and Outcomes (PICO) format and performed a systematic review of the literature to identify and synthesize the best available evidence. We used the Grading of Recommendations Assessment, Development, and Evaluation Approach to determine certainty in the evidence and to formulate recommendations and good practice statements (GPSs).

RESULTS

The panel issued 10 statements on recognizing and responding to non-ICU patients with critical illness. Healthcare personnel and institutions should ensure that all vital sign acquisition is timely and accurate (GPS). We make no recommendation on the use of continuous vital sign monitoring among unselected patients. We suggest focused education for bedside clinicians in signs of clinical deterioration, and we also suggest that patient/family/care partners' concerns be included in decisions to obtain additional opinions and help (both conditional recommendations). We recommend hospital-wide deployment of a rapid response team or medical emergency team (RRT/MET) with explicit activation criteria (strong recommendation). We make no recommendation about RRT/MET professional composition or inclusion of palliative care members on the responding team but suggest that the skill set of responders should include eliciting patients' goals of care (conditional recommendation). Finally, quality improvement processes should be part of a rapid response system.

CONCLUSIONS

The panel provided guidance to inform clinicians and administrators on effective processes to improve the care of patients at-risk for developing critical illness outside the ICU.

Executive Summary: Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU

RATIONALE

Clinical deterioration of patients hospitalized outside the ICU is a source of potentially reversible morbidity and mortality. To address this, some acute care facilities have implemented systems aimed at detecting and responding to such patients.

OBJECTIVES

To provide evidence-based recommendations for hospital clinicians and administrators to optimize recognition and response to clinical deterioration in non-ICU patients.

PANEL DESIGN

The 25-member panel included representatives from medicine, nursing, respiratory therapy, pharmacy, patient/family partners, and clinician-methodologists with expertise in developing evidence-based clinical practice guidelines.

METHODS

We generated actionable questions using the Population, Intervention, Control, and Outcomes format and performed a systematic review of the literature to identify and synthesize the best available evidence. We used the Grading of Recommendations Assessment, Development, and Evaluation approach to determine certainty in the evidence and to formulate recommendations and good practice statements (GPSs).

RESULTS

The panel issued 10 statements on recognizing and responding to non-ICU patients with critical illness. Healthcare personnel and institutions should ensure that all vital sign acquisition is timely and accurate (GPS). We make no recommendation on the use of continuous vital sign monitoring among "unselected" patients due to the absence of data regarding the benefit and the potential harms of false positive alarms, the risk of alarm fatigue, and cost. We suggest focused education for bedside clinicians in signs of clinical deterioration, and we also suggest that patient/family/care partners' concerns be included in decisions to obtain additional opinions and help (both conditional recommendations). We recommend hospital-wide deployment of a rapid response team or medical emergency team (RRT/MET) with explicit activation criteria (strong recommendation). We make no recommendation about RRT/MET professional composition or inclusion of palliative care members on the responding team but suggest that the skill set of responders should include eliciting patients' goals of care (conditional recommendation). Finally, quality improvement processes should be part of a rapid response system (GPS).

CONCLUSIONS

The panel provided guidance to inform clinicians and administrators on effective processes to improve the care of patients at-risk for developing critical illness outside the ICU.

How do we detect and respond to clinical deterioration in hospitalized children? Results of the Pediatric Care BefOre Deterioration Events (CODE) survey

Systems to detect and respond to deteriorating hospitalized children are common despite little evidence supporting best practices. Our objective was to describe systems to detect/respond to deteriorating hospitalized children at Pediatric Resuscitation Quality Collaborative (pediRES-Q) institutions. We performed a cross-sectional survey of pediRES-Q leaders. Questionnaire design utilized expert validation and cognitive interviews. Thirty centers (88%) responded. Most (93%) used ≥1 system to detect deterioration: most commonly, early warning scores (83%), watcher lists (55%), and proactive surveillance teams (31%). Most (90%) had a team to respond to deteriorating patients and the majority of teams could be activated by clinician or family concerns. Most institutions (90%) collect relevant data, including number of rapid responses (88%), arrests outside intensive care units (100%), and serious safety events (88%). In conclusion, most pediRES-Q institutions utilize systems to detect/respond to deteriorating hospitalized children. Heterogeneity exists among programs. Rigorous evaluation is needed to identify best practices.

Call 4 Concern: the impact of a patient-and-relative-activated service

The aim of this project was to introduce and evaluate the Call 4 Concern© (C4C) service, which provides patients and relatives with direct access to critical care outreach services (CCOS). This allows patients and relatives an additional platform to raise concerns related to the clinical condition and facilitate early recognition of a deteriorating patient. The introduction of Call 4 Concern at a district general hospital was inspired by the Royal Berkshire Hospital, where staff have been pioneering the service in the UK since 2009. They were able to demonstrate the potential to prevent clinical deterioration and improve the patients' and relatives' experiences. The project was originally inspired by the Condition H(elp) system in the USA, which was set up following the death of an 18-month-old child who died of preventable causes. Similar tragic cases in the USA and the UK have prompted campaigning by affected families, resulting in the widespread adoption of comparable services. The project was rolled out in the authors' trust for all adult inpatients. There was a 2-week implementation phase to raise awareness. Between 22 February 2022 and 22 February 2023, the CCOS team received 39 C4C referrals, representing approximately 2.13% of the total CCOS activity. Clinical deterioration of a patient was prevented in at least three cases, alongside overwhelming positive feedback from service users.

Parent Experiences with the Process of Sharing Inpatient Safety Concerns for Children with Medical Complexity: A Qualitative Analysis

OBJECTIVE

To describe the process of identifying and reporting inpatient safety concerns from the perspective of parents of children with medical complexity (CMC).

METHODS

We conducted a secondary analysis of qualitative data from semi-structured interviews with 31 English and Spanish-speaking parents of CMC at two tertiary children's hospitals. Interviews lasted 45-60 minutes and were audio-recorded, translated, and transcribed. Three researchers inductively and deductively coded transcripts using an iteratively refined codebook with validation by a fourth researcher. Thematic analysis was used to develop a conceptual model of the process of inpatient parent safety reporting.

RESULTS

We identified four steps illustrating the process of inpatient parent safety concern reporting 1) parent recognizing concern, 2) parent reporting concern, 3) staff/hospital response continuum, and 4) parent feelings of validation/invalidation. Many parents endorsed that they were the first to catch a safety concern and were identified as unique reporters of safety information. Parents typically described reporting their concerns verbally and in real-time to the person they felt could quickly remedy the situation. There was a spectrum of validation. Some parents reported their concerns were not acknowledged and addressed, which led them to feel overlooked, disregarded, or judged. Others reported their concerns were acknowledged and addressed, resulting in parents feeling heard and seen and often leading to changes in clinical care.

CONCLUSIONS

Parents described a multi-step process of reporting safety concerns during hospitalization and a spectrum of staff response and validation. These findings can inform family-centered interventions that support safety concern reporting in the inpatient setting.

Life on the Frontlines: Caregiver Experience of Pediatric Cerebrospinal Shunt Malfunction

BACKGROUND

We aimed to characterize the caregiver experience in the detection and evaluation of pediatric cerebrospinal shunt malfunction.

METHODS

In this descriptive qualitative study, we recruited English-speaking caregivers of children aged five years or less in collaboration with a stakeholder organization. Semistructured interviews were completed; content targeted the caregiver experience of shunt malfunction. Interviews were audio-recorded, transcribed, and deidentified. Qualitative data were analyzed using a conventional content analysis approach.

RESULTS

We enrolled 20 caregivers (n = 20 mothers). The median child age at the time of the interview was 2.8 years; about half (n = 11) were born prematurely and the majority (n = 15) had shunts placed at age less than six months. Caregiver experiences of shunt malfunction were grouped into three major themes: (1) my error could be life or death: the high stakes of shunt malfunction and the ambiguity of malfunction symptoms exacerbated baseline caregiver vigilance; (2) finding and engaging people who can help: hurdles during malfunction evaluation included locating trusted clinicians and advocating for parental intuition; and (3) how the shunt defines our family: caregivers described evolving expertise and modifications made to everyday life due to the threat of malfunction.

CONCLUSIONS

In this study, caregivers highlighted the challenges associated with recognizing shunt malfunction, accessing necessary treatment, and the impact of their child's shunt on family life. Future work should leverage these findings to inform counseling about shunt malfunction, develop interventions to better support families in shunt malfunction identification, and educate medical providers.

Paediatric family activation rapid response (FARR) in tertiary healthcare organisations: Protocol for an online, multi-lingual, application (app) intervention development study

INTRODUCTION

At least 85% of unplanned admissions to critical care wards for children and young people (CYP) are associated with clinical deterioration. CYP and their families play an integral role in the recognition of deterioration. The Paediatric Critical Care Outreach Team (PCCOT) supports the reduction of avoidable harm through earlier recognition and treatment of the deteriorating child, acting as a welcome conduit between the multiprofessional teams, helping ensure that CYP gets the right care, at the right time and in the right place. This positions PCCOT well to respond to families who call for help as part of family activation.

AIM

This protocol details the methods and process of developing a family activation rapid response online application.

METHODS

This is a single-centre, sequential, multiple methods study design. Firstly, a systematic review of the international literature on rapid response interventions in paediatric family activation was conducted. Findings from the review aimed to inform the content for next stages; interviews/ focus groups and experience-based co-design (EBCD) workshops.

PARTICIPANTS

parents / caregivers whose children have been discharged or admitted to an acute care hospital and healthcare professionals who care for paediatric patients (CYP). During interviews and workshops participants' opinion, views and input will be sort on designing a family activation rapid response online-app, detailing content, aesthetics, broad functionality and multi-lingual aspects. Further areas of discussions include; who will use the app, access, appropriate language and terminology for use. A suitable app development company will be identified and will be part of the stakeholders present at workshops. Data obtained will be used to develop a multi-lingual paediatric family activation rapid response web based application prototype.

ETHICS AND DISSEMINATION

Full ethical approval was received from the Wales Research Ethics Committee 2. Cardiff; REC reference: 22/WA/0174. The findings will be made available to all stakeholders.

Paediatric family activated rapid response interventions; qualitative systematic review

BACKGROUND

Failure to recognise deterioration early which results in patient death, is considered failure to rescue and it is identified as one of the leading causes of harm to patients. It is recognised that patients and their families can often recognise changes within the child's condition before healthcare professionals. To mitigate the risk of failure to rescue and promote early intervention, family-activated rapid response systems are becoming widely acknowledged and accepted as part of family integrated care.

OBJECTIVE

To identify current family-activated rapid response interventions in hospitalised paediatric patients and understand mechanisms by which family activation works.

METHODS

A narrative systematic review of published studies was conducted. Seven online databases; AMED, CINHAL, EMBASE, EMCARE, HMIC, JBI, and Medline were searched for potentially relevant papers. The critical appraisal skills programme tool was used to assess methodological rigor and validity of included studies.

RESULTS

Six studies met the predefined inclusion criteria. Five telephone family activation interventions were identified; Call for Help, medical emergency-teams, Condition HELP, rapid response teams, and family initiated rapid response. Principles underpinning all interventions were founded on a principal of granting families access to a process to escalate concerns to hospital emergency teams. Identified interventions outcomes and mechanisms include; patient safety, empowerment of families, partnership working/ family centred care, effective communication and better patient outcomes. Interventions lacked multi-lingual options.

CONCLUSION

Family activation rapid response system are fundamental to family integrated care and enhancing patient safety. Underlying principles and concepts in delivering interventions are transferable across global healthcare system.

Family Safety Reporting in Medically Complex Children: Parent, Staff, and Leader Perspectives

BACKGROUND AND OBJECTIVES

Despite compelling evidence that patients and families report valid and unique safety information, particularly for children with medical complexity (CMC), hospitals typically do not proactively solicit patient or family concerns about patient safety. We sought to understand parent, staff, and hospital leader perspectives about family safety reporting in CMC to inform future interventions.

METHODS

This qualitative study was conducted at 2 tertiary care children's hospitals with dedicated inpatient complex care services. A research team conducted approximately 60-minute semistructured, individual interviews with English and Spanish-speaking parents of CMC, physicians, nurses, and hospital leaders. Audio-recorded interviews were translated, transcribed, and verified. Two researchers coded data inductively and deductively developed and iteratively refined the codebook with validation by a third researcher. Thematic analysis allowed for identification of emerging themes.

RESULTS

We interviewed 80 participants (34 parents, 19 nurses and allied health professionals, 11 physicians, and 16 hospital leaders). Four themes related to family safety reporting were identified: (1) unclear, nontransparent, and variable existing processes, (2) a continuum of staff and leadership buy-in, (3) a family decision-making calculus about whether to report, and (4) misaligned staff and parent priorities and expectations. We also identified potential strategies for engaging families and staff in family reporting.

CONCLUSIONS

Although parents were deemed experts about their children, buy-in about the value of family safety reporting among staff and leaders varied, staff and parent priorities and expectations were misaligned, and family decision-making around reporting was complex. Strategies to address these areas can inform design of family safety reporting interventions attuned to all stakeholder groups.

Development and Validation of an Evaluation Tool of Consumers' Knowledge and Confidence to Report Patient Deterioration in Hospitals

OBJECTIVES

Studies have shown that many preventable hospital deaths may be reduced through early reporting of deterioration by patients and their visitors to health professionals. Engagement of patients and families for safer health care was recommended by the World Health Organization. As no validated tool was identified, the objective of the study was to develop and validate a tool to measure the impact of messages contained in self-developed educational materials on consumers' knowledge and confidence to report patient deterioration.

METHODS

A tool was created using consumer-based input. A test-retest methodology was used 2 weeks apart, using 37 participants sourced from consumer groups. Fourteen 5-point Likert scale questionnaire items were categorized into knowledge and confidence components to identify the impact of the materials in both of these areas.

RESULTS

Test-retest reliability confirmed 10 of the 14 proposed questionnaire items (4 knowledge items and 6 confidence) had at least moderate κ agreement ranging from 0.42 to 0.69 and an intraclass correlation coefficient of 0.66. An exploratory factor analysis of the 10 remaining items indicated a 2-factor solution had the best interpretability accounting for 96.9% of variability. The Cronbach α and factor loadings for the factors, knowledge, and confidence suggested an acceptable level of reliability and validity.

CONCLUSIONS

The study confirms our tool for assessment of educational materials to be a reliable, context-specific, and validated instrument. The tool is an appropriate instrument to assess the effectiveness of educational materials in public awareness campaigns that focus on consumer reporting of patient deterioration within hospitals.

Can Routinely Collected, Patient-Reported Wellness Predict National Early Warning Scores? A Multilevel Modeling Approach

OBJECTIVE

Measures exist to improve early recognition of and response to deteriorating patients in hospital. However, management of critical illness remains a problem globally; in the United Kingdom, 7% of the deaths reported to National Reporting and Learning System from acute hospitals in 2015 related to failure to recognize or respond to deterioration. The current study explored whether routinely recording patient-reported wellness is associated with objective measures of physiology to support early recognition of hospitalized deteriorating patients.

METHODS

A prospective observation study design was used. Nurses on four inpatient wards were invited to participate and record patient-reported wellness during every routine observation (where possible) using an electronic observation system. Linear multilevel modeling was used to examine the relationship between patient-reported wellness, and national early warning scores (NEWS), and whether patient-reported wellness predicted subsequent NEWS.

RESULTS

A significant positive relationship was found between patient-reported wellness and NEWS recorded at the next observation while controlling for baseline NEWS (β = 0.180, P = 0.033). A significant positive relationship between patient-reported wellness and NEWS (β = 0.229, P = 0.005) recorded during an observation 24 hours later while controlling for baseline NEWS was also found. Patient-reported wellness added to the predictive model for subsequent NEWS.

CONCLUSIONS

The preliminary findings suggest that patient-reported wellness may predict subsequent improvement or decline in their condition as indicated by objective measurements of physiology (NEWS). Routinely recording patient-reported wellness during observation shows promise for supporting the early recognition of clinical deterioration in practice, although confirmation in larger-scale studies is required.

You're Worried, We're Listening: Online Testing of the Effectiveness of Education Materials to Improve Consumer Knowledge and Confidence in Reporting Patient Deterioration

OBJECTIVES

Early identification of patient deterioration in hospital is important to reduce mortality, avoidable morbidity, length of stay, and associated healthcare costs. By closely observing physical and behavioral changes, deteriorating patients are more likely to be identified. Patients and family at the bedside can play an important role in reporting deterioration if made aware of how to do so. Therefore, the objective of this study was to undertake an online evaluation of educational materials designed to improve consumers' knowledge and confidence to report patient deterioration.

METHODS

A convenience sample was used to recruit community-based participants for an online survey. A self-designed validated instrument was used to undertake a preintervention and postintervention test involving 3 types of educational materials. Quantitative data were analyzed with Wilcoxon signed rank test to compare participants' knowledge and confidence before and after exposure to the intervention. Conventional content analyses examined responses on key messages and recommendations to improve the educational materials.

RESULTS

A total of 84 respondents completed both prequestionnaires and postquestionnaires. After exposure to the education materials, analyses confirmed that knowledge and confidence scores were significantly higher than baseline measures. Content analyses indicated a clear understanding of the key messages presented in the materials. Four main recommendations were made regarding the education materials.

CONCLUSIONS

Participants readily identified the key messages in the educational materials and demonstrated increased knowledge and confidence to report concerns about deterioration. Further research is required to determine the efficacy of the educational materials in relation to consumer behavior.

[Adult advanced life support]

These European Resuscitation Council Advanced Life Support guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the prevention of and ALS treatments for both in-hospital cardiac arrest and out-of-hospital cardiac arrest.

European Resuscitation Council Guidelines 2021: Adult advanced life support

These European Resuscitation Council Advanced Life Support guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the prevention of and ALS treatments for both in-hospital cardiac arrest and out-of-hospital cardiac arrest.

Clinical and organizational risk factors for mortality during deterioration events among pediatric oncology patients in Latin America: A multicenter prospective cohort

BACKGROUND

Hospitalized pediatric hematology-oncology (PHO) patients have frequent clinical deterioration events (CDE) requiring intensive care unit (ICU) admission, particularly in resource-limited settings. The objective of this study was to describe CDEs in hospitalized PHO patients in Latin America and to identify event-level and center-level risk factors for mortality.

METHODS

In 2017, the authors implemented a prospective registry of CDEs, defined as unplanned transfers to a higher level of care, use of ICU-level interventions on the floor, or nonpalliative floor deaths, in 16 PHO centers in 10 countries. PHO hospital admissions and hospital inpatient days were also reported. This study analyzes the first year of registry data (June 2017 to May 2018).

RESULTS

Among 16 centers, 553 CDEs were reported in PHO patients during 11,536 admissions and 119,414 inpatient days (4.63 per 1000 inpatient days). Event mortality was 29% (1.33 per 1000 inpatient days) but ranged widely across centers (11%-79% or 0.36-5.80 per 1000 inpatient days). Significant risk factors for event mortality included requiring any ICU-level intervention on the floor and not being transferred to a higher level of care. Events with organ dysfunction, a higher severity of illness, and a requirement for ICU intervention had higher mortality. In center-level analysis, hospitals with a higher volume of PHO patients, less floor use of ICU intervention, lower severity of illness on transfer, and lower rates of floor cardiopulmonary arrest had lower event mortality.

CONCLUSIONS

Hospitalized PHO patients who experience CDEs in resource-limited settings frequently require floor-based ICU interventions and have high mortality. Modifiable hospital practices around the escalation of care for these high-risk patients may contribute to poor outcomes. Earlier recognition of critical illness and timely ICU transfer may improve survival in hospitalized children with cancer.

Patient and family involvement in escalating concerns about clinical deterioration in acute adult wards: A qualitative systematic review

BACKGROUND

Despite international standards for recognition and response to deterioration, warning signs are not always identified by staff on acute hospital wards. Patient and family-initiated escalation of care schemes have shown some benefit in assisting early recognition, but are not widely used in many clinical practice areas.

OBJECTIVES

To explore (a) patients' and relatives' experiences of acute deterioration and (b) patients', relatives' and healthcare professionals' perceptions of the barriers or facilitators to patient and family-initiated escalation of care in acute adult hospital wards.

METHODS

We conducted a qualitative review using Cochrane methodology. Two reviewers independently screened studies, extracted data, and appraised the quality using a qualitative critical appraisal tool. Findings were analysed using thematic synthesis and confidence in findings was assessed using GRADE-CERQual.

SEARCH STRATEGY

MEDLINE, CINAHL, EMBASE, PsychINFO databases and grey literature from 2005 to August 2019.

INCLUSION CRITERIA

Any research design that had a qualitative element and focused on adult patients' and relatives' experiences of deterioration and perceptions of escalating care.

RESULTS

We included five studies representing 120 participants and assessed the certainty of evidence as moderate using GRADE-CERQual. Findings indicated that a number of patients/relatives have the ability to detect acute deterioration, however, various factors act as both barriers and facilitators to being heard. These include personal factors, perceptions of role, quality of relationships with healthcare staff, and organisational factors. Theoretical understanding suggests that patient and relative involvement in escalation is dependent on both inherent capabilities and the factors that influence empowerment.

CONCLUSION

This review highlights that patient and family escalation of care interventions need to be designed with the aim of improving patient/relative-clinician collaboration and the sharing of responsibility.

RELEVANCE TO PRACTICE

These factors need to be addressed to promote more active partnerships when designing and implementing patient and family-initiated escalation of care interventions.

Diurnal Variation in Medical Emergency Team Calls at a Tertiary Care Children's Hospital

Medical emergency teams (METs) bring critical care expertise to the bedsides of hospital ward patients who may be deteriorating. Diurnal variation in MET activation rates may identify inconsistencies in the detection of patients needing intervention. We aimed to determine whether such variation exists at our tertiary care children's hospital.

Methods

In this retrospective cohort study, we collected data including date and time of MET and disposition following MET for all inpatients at Cincinnati Children's Hospital Medical Center with a MET call between January 2008 and May 2014. The analysis compared the MET rate between days and nights, weekdays and weekends, and before and after nursing shift change.

Results

The number of METs per hour varied throughout the day. More METs were called during the day than at night (0.7 calls/shift ± 0.95 vs 0.6 ± 0.9, P < 0.001). There were also more METs per day on weekdays than weekends (1.4 ± 1 calls/d vs 1.2 ± 1, P < 0.001). Daytime METs were more likely to lead to transfer to the intensive care unit or operating room than those called at night (61.9% vs. 52.9%, P < 0.001). MET activation rates did not differ significantly in the 2 hours before nursing shift change compared to the 2 hours after.

Conclusions

At our large tertiary care children's hospital, there are both diurnal variations and variations across weekdays versus weekends in the MET activation rate. This difference may indicate variations in our ability to detect deteriorating patients on the wards and be further studied.

Acute clinical deterioration and consumer escalation in the hospital setting: A literature review

BACKGROUND

Consumer escalation systems that allow patients and/or their family/carers to escalate concerns about clinical deterioration have been proposed as a way of enhancing patient safety. However, evidence to guide implementation or to support system effectiveness remains unclear.

AIM

To critically evaluate the current evidence surrounding consumer escalation within the context of clinical deterioration to identify the strengths, weaknesses and gaps in existing knowledge, essential themes, and directions for further investigation.

METHOD

Database searches were conducted within Cumulative Index of Nursing and Allied Health Literature, PubMed, and the Cochrane Library for articles directly relating to consumer escalation systems published, in English, within the previous 10 year-period. Titles and abstracts were screened and relevant full-text articles included. Content was examined to identify breadth of knowledge, essential themes, and the effectiveness of current systems.

RESULTS

27 articles, containing a mixture of both quantitative and qualitative findings, were identified. Within the context of limitations in the overall depth and quality of current evidence, four key areas (relating to consumer understanding and awareness of clinical deterioration, confidence and ability to escalate concerns, education, and staff attitudes) were identified as potentially critical to the foundation, functioning, and success of consumer escalation systems. Consumer escalation processes may contribute positive effects beyond mortality rates; however, an agreed method of assessing effectiveness remains undetermined.

CONCLUSIONS

The ability of consumer escalation processes to achieve their underlying goals is still to be adequately assessed. Further research is required to inform how to best implement, support and optimise consumer escalation systems.

The Parent Role in Advocating for a Deteriorating Child: A Qualitative Study

BACKGROUND AND OBJECTIVES

Families of children with medical complexity are experts on their child's baseline behavior and temperament and may recognize changes in their hospitalized child's health before clinicians. Our objective was to develop a comprehensive understanding of how families identify and communicate their child's deteriorating health with the hospital-based health care team.

METHODS

In this qualitative study, our multidisciplinary team recruited family members of hospitalized children with neurologic impairment. Interviews, conducted in the hospital, were audio recorded, deidentified, and transcribed. By using inductive thematic analysis, each transcript was independently coded by 3 or 4 team members. Members met regularly to reach consensus on coding decisions. Patterns observed were organized into themes and subthemes.

RESULTS

Participants included 28 family members of 26 hospitalized children 9 months to 17 years of age. Children had a mean of 9 hospitalizations in the previous 3 years. Analysis resulted in 6 themes. First, families often reported their child "writes his own book," meaning the child's illness narrative rarely conformed to textbooks. Second, families developed informal, learned pathways to navigate the inpatient system. Third, families stressed the importance of advocacy. Fourth, families self-identified as "not your typical parents" and discussed how they learned their roles as part of the care team. Fifth, medical culture often did not support partnership. Finally, families noted they are often "running on empty" from stress, fear, and lack of sleep.

CONCLUSIONS

Families of children with medical complexity employ mature, experience-based pathways to identify deteriorating health. Existing communication structures in the hospital are poorly equipped to incorporate families' expertise.

Frequency and Types of Patient-Reported Errors in Electronic Health Record Ambulatory Care Notes

Importance

As health information transparency increases, patients more often seek their health data. More than 44 million patients in the US can now readily access their ambulatory visit notes online, and the practice is increasing abroad. Few studies have assessed documentation errors that patients identify in their notes and how these may inform patient engagement and safety strategies.

Objective

To assess the frequency and types of errors identified by patients who read open ambulatory visit notes.

Design, Setting, and Participants

In this survey study, a total of 136 815 patients at 3 US health care organizations with open notes, including 79 academic and community ambulatory care practices, received invitations to an online survey from June 5 to October 20, 2017. Patients who had at least 1 ambulatory note and had logged onto the portal at least once in the past 12 months were included. Data analysis was performed from July 3, 2018, to April 27, 2020.

Exposures

Access to ambulatory care open notes through patient portals for up to 7 years (2010-2017).

Main Outcomes and Measures

Proportion of patients reporting a mistake and how serious they perceived the mistake to be, factors associated with finding errors characterized by patients as serious, and categories of patient-reported errors.

Results

Of 136 815 patients who received survey invitations, 29 656 (21.7%) responded and 22 889 patients (mean [SD] age, 55.16 [15.96] years; 14 447 [63.1%] female; 18 301 [80.0%] white) read 1 or more notes in the past 12 months and completed error questions. Of these patients, 4830 (21.1%) reported a perceived mistake and 2043 (42.3%) reported that the mistake was serious (somewhat serious: 1563 [32.4%]; very serious: 480 [9.9%]). In multivariable analysis, female patients (relative risk [RR], 1.79; 95% CI, 1.72-1.85), more educated patients (RR, 1.38; 95% CI, 1.29-1.48), sicker patients (RR, 1.89; 95% CI, 1.84-1.94), those aged 45 to 64 years (RR, 2.23; 95% CI, 2.06-2.42), those 65 years or older (RR, 2.00; 95% CI, 1.73-2.32), and those who read more than 1 note (2-3 notes: RR, 1.82; 95% CI, 1.34-2.47; ≥4 notes: RR, 3.09; 95% CI, 2.02-4.73) were more likely to report a mistake that they found to be serious compared with their reference groups. After categorization of patient-reported very serious mistakes, those specifically mentioning the word diagnosis or describing a specific error in current or past diagnoses were most common (98 of 356 [27.5%]), followed by inaccurate medical history (85 of 356 [23.9%]), medications or allergies (50 of 356 [14.0%]), and tests, procedures, or results (30 of 356 [8.4%]). A total of 23 (6.5%) reflected notes reportedly written on the wrong patient. Of 433 very serious errors, 255 (58.9%) included at least 1 perceived error potentially associated with the diagnostic process (eg, history, physical examination, tests, referrals, and communication).

Conclusions and Relevance

In this study, patients who read ambulatory notes online perceived mistakes, a substantial proportion of which they found to be serious. Older and sicker patients were twice as likely to report a serious error compared with younger and healthier patients, indicating important safety and quality implications. Sharing notes with patients may help engage them to improve record accuracy and health care safety together with practitioners.

Nursing Surveillance for Deterioration in Pediatric Patients: An Integrative Review

PROBLEM

Adverse events occur in up to 19% of pediatric hospitalized patients, often associated with delays in recognition or treatment. While early detection is recognized as a primary determinant of recovery from deterioration, most research has focused on profiling patient risk and testing interventions, and less on factors that impact surveillance efficacy. This integrative review explored actions and factors that influence the quality of pediatric nursing surveillance.

ELIGIBILITY CRITERIA

Original research on nursing surveillance, escalation of care, or cardiopulmonary deterioration in hospitalized pediatric patients in non-critical environments, published in English in peer reviewed journals.

SAMPLE

Twenty-four studies from a literature search within the databases of CINAHL, PubMed, and Web of Science were evaluated and synthesized using a socio-technical systems theory framework. Study quality was assessed using The Mixed Methods Appraisal Tool.

RESULTS

Assessment, documentation, decision-making, intervening and communicating were identified as activities associated with surveillance of deterioration. Factors that influenced nurses' detection of deterioration were patient acuity, nurse education, experience, expertise and confidence, staffing, standardized assessment and communication tools, availability of emergency services, team composition and opportunities for multidisciplinary care planning.

CONCLUSIONS

Research provides insight into some aspects of nursing surveillance but does not adequately explore factors that affect clinical data interpretation and synthesis, and role integration between nurse and parents, and nurse and other clinicians on surveillance of clinical stability.

IMPLICATIONS

Research is needed to enhance understanding of the contextual factors that impact nursing surveillance to inform intervention design to support nurses' timely recognition and mitigation of clinical deterioration.

Getting to the Heart of the Matter: A Triage Model to Improve Utilization of Cardiology Consultative Services

Objective

Patient and Methods

Results

Conclusion

Severe illness getting noticed sooner - SIGNS-for-Kids: developing an illness recognition tool to connect home and hospital

Background

Delays to definitive treatment for time-sensitive acute paediatric illnesses continue to be a cause of death and disability in the Canadian healthcare system. Our aim was to develop the SIGNS-for-Kids illness recognition tool to empower parents and other community caregivers to recognise the signs and symptoms of severe illness in infants and children. The goal of the tool is improved detection and reduced time to treatment of acute conditions that require emergent medical attention.

Methods

A single-day consensus workshop consisting of a 17-member panel of parents and multidisciplinary healthcare experts with content expertise and/or experience managing children with severe acute illnesses was held. An a priori agreement of ≥85% was planned for the final iteration SIGNS-for-Kids tool elements by the end of the workshop.

Results

One hundred percent consensus was achieved on a five-item tool distilled from 20 initial items at the beginning of the consensus workshop. The final items included four child-based items consisting of: (1) behaviour, (2) breathing, (3) skin, and (4) fluids, and one context-based item and (5) response to rescue treatments.

Conclusions

Specific cues of urgent child illness were identified as part of this initial development phase. These cues were integrated into a comprehensive tool designed for parents and other lay caregivers to recognise the signs of serious acute illness and initiate medical attention in an undifferentiated population of infants and children. Future validation and optimisation of the tool are planned.

Optimising paediatric afferent component early warning systems: a hermeneutic systematic literature review and model development

OBJECTIVE

To identify the core components of successful early warning systems for detecting and initiating action in response to clinical deterioration in paediatric inpatients.

METHODS

A hermeneutic systematic literature review informed by translational mobilisation theory and normalisation process theory was used to synthesise 82 studies of paediatric and adult early warning systems and interventions to support the detection of clinical deterioration and escalation of care. This method, which is designed to develop understanding, enabled the development of a propositional model of an optimal afferent component early warning system.

RESULTS

Detecting deterioration and initiating action in response to clinical deterioration in paediatric inpatients involves several challenges, and the potential failure points in early warning systems are well documented. Track and trigger tools (TTT) are commonly used and have value in supporting key mechanisms of action but depend on certain preconditions for successful integration into practice. Several supplementary interventions have been proposed to improve the effectiveness of early warning systems but there is limited evidence to recommend their wider use, due to the weight and quality of the evidence; the extent to which systems are conditioned by the local clinical context; and the need to attend to system component relationships, which do not work in isolation. While it was not possible to make empirical recommendations for practice, the review methodology generated theoretical inferences about the core components of an optimal system for early warning systems. These are presented as a propositional model conceptualised as three subsystems: detection, planning and action.

CONCLUSIONS

There is a growing consensus of the need to think beyond TTTs in improving action to detect and respond to clinical deterioration. Clinical teams wishing to improve early warning systems can use the model to consider systematically the constellation of factors necessary to support detection, planning and action and consider how these arrangements can be implemented in their local context.

PROSPERO REGISTRATION NUMBER

CRD42015015326.

Parent escalation of care for the deteriorating child in hospital: A health-care improvement study

OBJECTIVE

To evaluate the implementation of an intervention for parents to escalate care if concerned about their child's clinical condition.

DESIGN

Mixed-methods health-care improvement approach guided by the Theoretical Domains Framework.

METHODS

Implementation of the 'Calling for Help' (C4H) intervention was informed by previously identified barriers and facilitators. Evaluation involved audit, review of clinical deterioration incidents, interviews and focus groups.

SETTING

Australian specialist paediatric hospital.

PARTICIPANTS

Convenience sample of 75 parents from inpatient areas during the audit, interviews with ten parents who had expressed concern about their child's clinical condition; five focus groups with 35 ward nurses.

MAIN OUTCOME MEASURES

Parent awareness and utilization of C4H, parent and nurse views of factors influencing implementation.

RESULTS

Parent awareness of C4H improved to 35% (25/75). Parent concern was documented prior to 21/174 (12%) clinical deterioration events. All interviewed parents and nurses who participated in focus groups were positive about C4H. Parents preferred to be informed about C4H by nurses, but nurses described this as time-consuming and selectively chose parents who they believed would benefit most. Parents and nurses described frustrations with and trepidation in escalating care. Nurses had used C4H to expedite urgent medical review.

CONCLUSIONS

There was an improvement in the level of parent awareness of C4H, which was viewed positively by parents and nurses alike. To achieve a high level of parent awareness in a sustainable way, a multifaceted approach is required. Further strategies will be required for parents to feel confident enough to use C4H and to address interprofessional communication barriers.

Patient- and relative-activated critical care outreach: a 7-year service review

Five years following the introduction of a whole-hospital, 24-hour critical care outreach (CCO) service, an additional service was introduced that enabled patients and their families to directly call the CCO team if they had concerns that were not being acknowledged by the patient's clinical team. The aim of this review was to report on 7 years of patient and family referrals using quantitative and free text data extracted from the CCO referral database. Information on demographics, frequency, nature and reason for the referrals have been reported that highlight the feasibility of such a service, and the potential to prevent patient deterioration. By tapping into the rich source of information from family concerns, future hospital services could be designed that could not only have an impact on patient outcome, but also positively influence the quality of the patient experience.

Family-Initiated Pediatric Rapid Response: Characteristics, Impetus, and Outcomes

BRIEF DESCRIPTION

Family-initiated rapid response (FIRR) empowers families to express concern and seek care from specialized response teams. We studied FIRRs that occurred in a pediatric tertiary hospital over a 3-year period. The main aims were to describe the characteristics and outcomes of FIRRs and compare them with clinician-activated RRs (C-RRs). Of the 1,906 RRs events reviewed, 49 (2.6%) were FIRRs. All FIRRs had appropriate clinical triggers with the most common being uncontrolled pain. Chronic conditions and previous admissions were present in 61%. More than half of FIRRs had a vital sign change that should have qualified C-RR activation. Seventy-six percent FIRRs needed at least one or more interventions. Twenty-seven percent of FIRRs needed transfer to intensive care unit compared with 60% transfer rate for C-RRs.

PURPOSE OF SUBMISSION/RELEVANCE TO HEALTHCARE QUALITY

Family-initiated rapid response events were activated for legitimate concerns and frequently needed clinical interventions. Enhanced information and awareness of FIRR can improve utilization of the system and enhance family satisfaction, patient safety, and outcomes. Disseminating the information on FIRR and the importance of family involvement will improve the care of children and empower family members.

Patient and family-initiated escalation of care: a qualitative systematic review protocol

BACKGROUND

Despite the introduction of rapid response systems and early warning scores, clinical deterioration that is not recognised or responded to early enough prevails in acute care areas. One intervention that aims to address this issue and that is gaining increased attention is patient- and family-initiated escalation of care schemes. Existing systematic review evidence to date has tended to focus on identifying the impact or effectiveness of these schemes in practice. However, they have not tended to focus on qualitative evidence to consider the experience of deterioration and the factors that may promote or hinder engagement with these schemes in the practice setting. This systematic review will address this gap. The aim of this review is to explore patients', relatives' and healthcare professionals' experiences of deterioration and their perceptions of the barriers or facilitators to patient and family-initiated escalation of care in acute adult hospital wards.

METHODS

We will search Medline, CINAHL, Embase and PsycINFO databases using free-text and MESH terms relating to deterioration, family-initiated rapid response, families, patients, healthcare staff, hospital and experiences. We will search grey literature and reference lists of included studies for further published and unpublished literature. All studies with a qualitative design or method will be included. Two reviewers will independently assess studies for eligibility, extract data and appraise the quality of included studies. Data will be synthesised using a thematic synthesis approach, and findings will be presented narratively.

DISCUSSION

Patient- and family-initiated escalation of care schemes have been developed and implemented in several countries including the United States, the United Kingdom and Australia, but there is limited evidence regarding patients' or families' perceptions of deterioration or the barriers and facilitators to using these schemes in practice, particularly in acute adult areas. This systematic review will provide evidence for the development of a patient and family escalation of care scheme that can be tested in a feasibility study.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018106952.

Consumers' perspectives on their involvement in recognizing and responding to patient deterioration-Developing a model for consumer reporting

BACKGROUND

Adverse events occur in health care. Detection and reporting of deterioration therefore have a critical role to play. Patient and family member (consumer) involvement in patient safety has gained powerful support amongst global policymakers. Few studies, with none taking a rigorous qualitative approach, have drawn upon consumers' experiences to establish their preferences in consumer reporting of patient deterioration programmes.

OBJECTIVE

To explore consumers' experiences of previous reporting of patient deterioration; their preferred educational strategies on this role and recommended pathways in a consumer reporting of patient deterioration model.

DESIGN, SETTING AND PARTICIPANTS

An interpretive, qualitative research design was utilized. Nine focus group interviews were undertaken across Adelaide, capital city of South Australia. Interviews were audio-taped, transcribed and analysed thematically. Twenty-six adults described, then reflected, on previous experiences of reporting patient deterioration.

RESULTS

Overarching themes incorporated consumers' experiences and patient/family education. Three themes emerged in relation to consumers' experiences: feelings, thoughts and actions. Five themes arose on educating consumers: content, timing, format, information providers and information recipients. The consumers' deep reflections on their past reporting experiences led to the development of a new model for consumer reporting of patient deterioration.

CONCLUSIONS

Consumers' views on ways to improve consumer reporting of patient deterioration processes emerged. These improvements include structured educational programmes for staff advocating open health-care professional/consumer communication, educational materials developed and tested with English-speaking and culturally and linguistically diverse consumers and a model with three consumer reporting pathways.

Speaking up about care concerns in the ICU: patient and family experiences, attitudes and perceived barriers

BACKGROUND

Little is known about patient/family comfort voicing care concerns in real time, especially in the intensive care unit (ICU) where stakes are high and time is compressed. Experts advocate patient and family engagement in safety, which will require that patients/families be able to voice concerns. Data on patient/family attitudes and experiences regarding speaking up are sparse, and mostly include reporting events retrospectively, rather than pre-emptively, to try to prevent harm. We aimed to (1) assess patient/family comfort speaking up about common ICU concerns; (2) identify patient/family-perceived barriers to speaking up; and (3) explore factors associated with patient/family comfort speaking up.

METHODS

In collaboration with patients/families, we developed a survey to evaluate speaking up attitudes and behaviours. We surveyed current ICU families in person at an urban US academic medical centre, supplemented with a larger national internet sample of individuals with prior ICU experience.

RESULTS

105/125 (84%) of current families and 1050 internet panel participants with ICU history completed the surveys. Among the current ICU families, 50%-70% expressed hesitancy to voice concerns about possible mistakes, mismatched care goals, confusing/conflicting information and inadequate hand hygiene. Results among prior ICU participants were similar. Half of all respondents reported at least one barrier to voicing concerns, most commonly not wanting to be a 'troublemaker', 'team is too busy' or 'I don't know how'. Older, female participants and those with personal or family employment in healthcare were more likely to report comfort speaking up.

CONCLUSION

Speaking up may be challenging for ICU patients/families. Patient/family education about how to speak up and assurance that raising concerns will not create 'trouble' may help promote open discussions about care concerns and possible errors in the ICU.

No more pediatric code blues on the floor: evolution of pediatric rapid response teams and situational awareness plans

Reducing or eliminating code blues that occur on the inpatient, noncritical care units of children's hospitals is a challenging yet achievable goal. The mechanism to accomplish this involves several levels of effort. The implementation of effective pediatric rapid response teams is a well identified part of the process. Rapid response teams can allow for appropriate clinical interventions for deteriorating patients and may ultimately result in a reduction in hospital-wide mortality as well as efficient transfer to the pediatric intensive care unit (PICU) when necessary. The timely deployment of rapid response teams is dependent upon the appropriate recognition of patients at risk for deterioration. This recognition can be optimized by relying on assessments as simple as utilization of parental intuition to those as complex as big data models which utilize multiple predictor variables extracted from the electronic medical record. Ultimately, the goal to proactively identify patients at risk of deterioration may allow for prevention of clinical decline via appropriate and timely interventions, and if unsuccessful at that level, may allow for improved outcomes via optimized resuscitation care in the PICU.

Employing the arts for knowledge production and translation: Visualizing new possibilities for women speaking up about safety concerns in maternity

OBJECTIVES

This project used animated film to translate research findings into accessible health information aimed at enabling women to speak up and secure professional help for serious safety concerns during pregnancy and after birth. We tested as proof of concept our use of the arts both as product (knowledge production) and process (enabling involvement).

BACKGROUND

Emergencies during pregnancy and birth, while unusual, can develop rapidly and unexpectedly, with catastrophic consequences. Women's tacit knowledge of changes in their condition is an important resource to aid early detection, but women can worry about the legitimacy of their concerns and struggle to get these taken seriously by staff.

DESIGN

Arts-based knowledge translation. A user group of women who had experienced complications in the perinatal period (n = 34) helped us develop and pilot test the animation. Obstetricians and midwives (15), clinical leads (3) and user group representatives (8) helped with the design and testing.

FINDINGS

The consultation process, script and storyboard enabled active interaction with the evidence, meaningful engagement with stakeholders and new understandings about securing help for perinatal complications. The method enabled us to address gender stereotypes and social norms about speaking up and embed a social script for women within the animation, to help structure their help seeking. While for some women, there was an emotional burden, the majority were glad to have been part of the animation's development and felt it had enabled their voices to be heard.

CONCLUSION

This project has demonstrated the benefits of arts-science collaborations for meaningful co-production and effective translation of research evidence.

Is there a role for patients and their relatives in escalating clinical deterioration in hospital? A systematic review

BACKGROUND

Measures exist to improve early recognition of, and response to, deteriorating patients in hospital. However, deteriorating patients continue to go unrecognized. To address this, interventions have been developed that invite patients and relatives to escalate patient deterioration to a rapid response team (RRT).

OBJECTIVE

To systematically review articles that describe these interventions and investigate their effectiveness at reducing preventable deterioration.

SEARCH STRATEGY

Following PRISMA guidelines, four electronic databases and two web search engines were searched to identify literature investigating patient and relative led escalation.

INCLUSION CRITERIA

Articles investigating the implementation or use of systems involving patients and relatives in the detection of clinical patient deterioration and escalation of patient care to address any clinical or non-clinical outcomes were included. Articles' eligibility was validated by a second reviewer (20%).

DATA EXTRACTION

Data were extracted according to pre-defined criteria.

DATA SYNTHESIS

Narrative synthesis was applied to included studies.

MAIN RESULTS

Nine empirical studies and 36 grey literature articles were included in the review. Limited studies were conducted to establish the clinical effectiveness of patient and relative led escalation. Instead, studies investigated the impact of this intervention on health-care staff and available resources. Although appropriate, this reflects the infancy of research in this area. Patients and relatives did not overwhelm resources by activating the RRT. However, they did activate it to address concerns unrelated to patient deterioration.

CONCLUSIONS

Activating a RRT may not be the most appropriate or cost-effective method of resolving non-life-threatening concerns.

Improving Recruitment and Retention Rates in a Randomized Controlled Trial

High recruitment and retention rates in randomized controlled trials are essential to ensure validity and broad generalizability. We used quality improvement methods, including run charts and intervention cycles, to achieve and sustain high recruitment and retention rates during the Hospital-To-Home Outcomes randomized controlled trial. This study is examining the effects of a single nurse-led home health care visit after discharge for an acute pediatric hospitalization. A total of 1500 participants were enrolled in the 15-month study period. For study recruitment, we assessed the percentage of patients who enrolled in the study among those randomly selected to approach (goal ≥50%) and the percentage of patients who refused to enroll from those randomly selected to approach (goal ≤30%). For intervention completion, we examined the percentage of patients who completed the home visit intervention among those randomized to receive the intervention (goal ≥95%) were examined. Follow-up rates were tracked as the percentage of patients who completed the 14-day follow-up telephone survey (goal ≥95%). The study goals for 2 of the 4 metrics were met and sustained, with statistically significant improvements over time in 3 metrics. The median enrollment rate increased from 50% to 59%, and the median refusal rate decreased from 37% to 32%. The median intervention completion rate remained unchanged at 88%. The 14-day follow-up completion median rate increased from 94% to 96%. These results indicate that quality improvement methods can be used within the scope of a large research study to achieve and sustain high recruitment and retention rates.

Explanation and elaboration of the SQUIRE (Standards for Quality Improvement Reporting Excellence) Guidelines, V.2.0: examples of SQUIRE elements in the healthcare improvement literature

Since its publication in 2008, SQUIRE (Standards for Quality Improvement Reporting Excellence) has contributed to the completeness and transparency of reporting of quality improvement work, providing guidance to authors and reviewers of reports on healthcare improvement work. In the interim, enormous growth has occurred in understanding factors that influence the success, and failure, of healthcare improvement efforts. Progress has been particularly strong in three areas: the understanding of the theoretical basis for improvement work; the impact of contextual factors on outcomes; and the development of methodologies for studying improvement work. Consequently, there is now a need to revise the original publication guidelines. To reflect the breadth of knowledge and experience in the field, we solicited input from a wide variety of authors, editors and improvement professionals during the guideline revision process. This Explanation and Elaboration document (E&E) is a companion to the revised SQUIRE guidelines, SQUIRE 2.0. The product of collaboration by an international and interprofessional group of authors, this document provides examples from the published literature, and an explanation of how each reflects the intent of a specific item in SQUIRE. The purpose of the guidelines is to assist authors in writing clearly, precisely and completely about systematic efforts to improve the quality, safety and value of healthcare services. Authors can explore the SQUIRE statement, this E&E and related documents in detail at http://www.squire-statement.org.