Strengthening the afferent limb of rapid response systems: an educational intervention using web-based learning for early recognition and responding to deteriorating patients

Educational Interventions for Rapid Response Team Members: A Narrative Literature Review

BACKGROUND

Research continues to be conducted on rapid response systems as patient outcomes associated with rapid response team activations are still not consistently showing benefit. One particular area of focus that is a growing area is the literature regarding training and education for individual team members of the rapid response team.

OBJECTIVE

The purpose of this narrative review was to describe the current literature regarding educational interventions for rapid response team members.

METHODS

This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. To be included in the narrative review, studies needed to be reporting on educational interventional research for rapid response team members of the efferent limb. No studies were excluded based upon study design or publication years.

RESULTS

This narrative review included 6 studies. Four studies assessed outcomes associated with rapid response team members, and 2 of the studies assessed patient outcomes associated with implementing education routinely for rapid response teams. All studies found a positive impact of implementing educational interventions.

DISCUSSION

Our narrative review found that limited research has been conducted in the area of educational interventions for rapid response team members, and of the articles identified, most did not assess patient-associated outcomes. The findings demonstrate that this area of research is in its early stages, and further work is needed to identify what content should be provided in the education and what educational methodologies should be employed, and to continue to assess patient health outcomes associated with educational interventions for rapid response team members.

The effectiveness of education strategies for nurses to recognise and manage clinical deterioration: A systematic review

OBJECTIVES

To identify, critically appraise and synthesise evidence on the efficacy of education strategies for nurses to recognise and manage clinical deterioration, as well as provide recommendations for standardised educational programmes.

DESIGN

A systematic review of quantitative studies.

METHODS

Quantitative studies published in English between 1 January 2010 and 14 February 2022 were chosen from nine databases. Studies were included if they reported education strategies for nurses to recognise and manage clinical deterioration. The quality appraisal was performed using the Quality Assessment Tool for Quantitative Studies, developed by the Effective Public Health Practice Project. The data were extracted and the findings were integrated into a narrative synthesis.

RESULTS

Altogether, 37 studies published in 39 eligible papers were included in this review, encompassing 3632 nurses. Most education strategies were determined to be effective, and outcome measures can be divided into three types: nurse outcomes; system outcomes; and patient outcomes. The education strategies could be divided into simulation and non-simulation interventions, and six interventions were in-situ simulations. Retention of knowledge and skills during the follow-up after education was determined in nine studies, with the longest follow-up interval totalling 12 months.

CONCLUSIONS

Education strategies can improve nurses' ability and practice to recognise and manage clinical deterioration. Simulation combined with a structured prebrief and debrief design can be viewed as a routine simulation procedure. Regular in-situ education determined long-term efficacy in response to clinical deterioration, and future studies can use an education framework to guide regular education practice and focus more on nurses' practice and patient outcomes.

The role of language barriers on efficacy of rapid response teams

OBJECTIVES

Rapid response (RR) systems are associated with decreased hospital mortality. Systemic biases and inequities can negatively impact RR outcomes. Language barriers between patients and providers are associated with worse outcomes, but it is unknown if language barriers are associated with RR outcomes.

METHODS

We analyzed all adult hospitalized patients who experienced a RR over one year (January 2020 to December 2020) at a tertiary care academic medical center. We used an objective scoring system to establish disease severity at the time of the event. We then compared disease severity and outcomes for patients who are primary language Spanish (PLS) and primary language English (PLE) using both univariable and multivariable analyses.

RESULTS

Of 1133 patients, 42 identified as PLS and 1091 as PLE. In multivariable analyses, PLS patients had significantly higher disease severity scores, as measured by deterioration index score (8.2, p = 0.021) at the time of their rapid responses. PLS patients also had 18.5% increase in length of stay (LOS) after RRs and this disparity was not mitigated when controlling for disease severity at the time of RRs. PLS was not a significant predictor for hospital mortality after RRs.

CONCLUSIONS

Our study found that PLS patients had increased disease severity at the time of RRs and increased LOS after RRs. However, the disparity in LOS was not mitigated when controlling for disease severity at the time of RRs. These findings suggest that language barriers may cause both delays in activation of RR systems, as well as the care provided during and after RRs.

Desktop Virtual Reality Versus Face-to-Face Simulation for Team-Training on Stress Levels and Performance in Clinical Deterioration: a Randomised Controlled Trial

BACKGROUND

Simulation-based education can equip healthcare providers with the ability to respond to and manage stressors associated with rapidly deteriorating patient situations. However, little is known about the benefits of using virtual reality (VR) for this purpose.

OBJECTIVE

To compare between desktop VR and face-to-face simulation in stress responses and performance outcomes of a team-based simulation training in managing clinical deterioration.

DESIGN

A randomised controlled study METHOD: The study was conducted on 120 medical and nursing students working in interprofessional teams. The teams were randomly assigned to participate in a 2-h simulation using either the desktop VR or face-to-face simulation with simulated patient (SP). Biophysiological stress response, psychological stress, and confidence levels were measured before and after the simulation. Performance outcomes were evaluated after the simulation using a deteriorating patient scenario.

RESULTS

The systolic blood pressure and psychological stress response were significantly increased among participants in VR and SP groups; however, no significant differences were found between the groups. There was also no significant difference in confidence and performance outcomes between participants in the VR and SP groups for both medical and  nursing students. Although the psychological stress response was negatively correlated (r = -0.43; p < 0.01) with confidence levels, there was no association between stress response and performance score.

CONCLUSION

Despite being less immersive, the desktop VR was capable of inducing psychological and physiological stress responses by placing emotional, social, and cognitive demands on learners. Additionally, by ensuring close alignment between the simulation tasks and the clinical tasks (i.e. functional fidelity), the desktop VR may provide similar performance outcomes as conventional simulation training. This evidence is timely given the rise in the use of virtual learning platforms to facilitate training during the COVID-19 pandemic where face-to-face training may not be feasible.

TRIAL REGISTRATION

The study was registered at ClinicalTrials.gov NCT04330924.

Simulation-Based Mastery Learning to Facilitate Transition to Nursing Practice

BACKGROUND

Simulation-based mastery learning (SBML) was developed and implemented to facilitate nursing students' transition to clinical practice.

PURPOSE

To evaluate nursing students' perspectives on the impact of SBML on their transition to clinical practice.

METHOD

A descriptive qualitative study using focus group discussions was conducted with final-year nursing students who had completed their clinical practicum and SBML.

RESULTS

Three themes emerged: authenticity of simulations, whereby students were able to draw some parallels between their simulations and clinical experiences; self-efficacy in clinical practice, which was gained through deliberate practice; and application of cognitive tools, which provided mental frameworks to guide clinical performances.

CONCLUSION

This study highlights the need to ensure the fidelity of the simulations to achieve authentic experiences, provide deliberate practice to develop self-efficacy, and use cognitive tools for mental model formation to create a high-quality SBML program to foster better transfer of simulation learning to real-life setting.

Virtual Simulation to Enhance Clinical Reasoning in Nursing: A Systematic Review and Meta-analysis

Background

The COVID-19 pandemic has given rise to more virtual simulation training. This study aimed to review the effectiveness of virtual simulations and their design features in developing clinical reasoning skills among nurses and nursing students.

Method

A systematic search in CINAHL, PubMed, Cochrane Library, Embase, ProQuest, PsycINFO, and Scopus was conducted. The PRISMA guidelines, Cochrane's risk of bias, and GRADE was used to assess the articles. Meta-analyses and random-effects meta-regression were performed.

Results

The search retrieved 11,105 articles, and 12 randomized controlled trials (RCTs) were included. Meta-analysis demonstrated a significant improvement in clinical reasoning based on applied knowledge and clinical performance among learners in the virtual simulation group compared with the control group. Meta-regression did not identify any significant covariates. Subgroup analyses revealed that virtual simulations with patient management contents, using multiple scenarios with nonimmersive experiences, conducted more than 30-minutes and postscenario feedback were more effective.

Conclusions

Virtual simulations can improve clinical reasoning skill. This study may inform nurse educators on how virtual simulation should be designed to optimize the development of clinical reasoning.

Transfer of Clinical Decision-Making-Related Learning Outcomes Following Simulation-Based Education in Nursing and Medicine: A Scoping Review

PURPOSE

Simulation is often depicted as an effective tool for clinical decision-making education. Yet, there is a paucity of data regarding transfer of learning related to clinical decision-making following simulation-based education. The authors conducted a scoping review to map the literature regarding transfer of clinical decision-making learning outcomes following simulation-based education in nursing or medicine.

METHOD

Based on the Joanna Briggs Institute methodology, the authors searched 5 databases (CINAHL, ERIC, MEDLINE, PsycINFO, and Web of Science) in May 2020 for quantitative studies in which the clinical decision-making performance of nursing and medical students or professionals was assessed following simulation-based education. Data items were extracted and coded. Codes were organized and hierarchized into patterns to describe conceptualizations and conditions of transfer, as well as learning outcomes related to clinical decision-making and assessment methods.

RESULTS

From 5,969 unique records, 61 articles were included. Only 7 studies (11%) assessed transfer to clinical practice. In the remaining 54 studies (89%), transfer was exclusively assessed in simulations that often included one or more variations in simulation features (e.g., scenarios, modalities, duration, and learner roles; 50, 82%). Learners' clinical decision-making, including data gathering, cue recognition, diagnoses, and/or management of clinical issues, was assessed using checklists, rubrics, and/or nontechnical skills ratings.

CONCLUSIONS

Research on simulation-based education has focused disproportionately on the transfer of learning from one simulation to another, and little evidence exists regarding transfer to clinical practice. The heterogeneity in conditions of transfer observed represents a substantial challenge in evaluating the effect of simulation-based education. The findings suggest that 3 dimensions of clinical decision-making performance are amenable to assessment-execution, accuracy, and speed-and that simulation-based learning related to clinical decision-making is predominantly understood as a gain in generalizable skills that can be easily applied from one context to another.

Using an early warning score for nurse shift patient handover: Before-and-after study

PURPOSE

This study aimed to examine the impact of using an early warning score for shift patient handover on nurse and patient outcomes.

METHODS

A before-and-after study was conducted with nurses and patients in three general wards in a tertiary teaching hospital. A short-time nurse education on the National Early Warning Score 2 and the use of a checklist for score calculation were performed from June 4, 2019 to June 30, 2019. Outcomes of nurse response (safety competency, handover quality, teamwork, safety climate, and documentation of vital signs and clinical concerns), patient response (deterioration occurrence post-admission, hospitalization length, and discharge status), and adverse events (mortality, cardiopulmonary arrest, and unplanned intensive care unit admission) were measured using questionnaires and medical record reviews. Data from 89 nurses and 388 patients were analyzed.

RESULTS

Regarding nurse outcomes, handover quality (p <.001), teamwork (p = .004), safety climate (p = .018), and recordings of vital signs (p = .047) and clinical concerns (p = .008) increased after early warning score use. However, no significant change in the safety competency scores was observed. Regarding patient outcomes, there were no significant changes in the occurrence of deterioration, hospitalization length, discharge status, and occurrence of adverse events between pre-and-post intervention.

CONCLUSION

Despite no significant changes in patient outcomes, using a simple, evidence-based early warning score for patient handover enhanced socio-cultural factors for patient safety, with improved patient monitoring. The findings provide evidence that supports the active implementation of an early warning score to improve patient safety.

Effect of simulation-based teaching on nursing skill performance: a systematic review and meta-analysis

Objective

To summarize and produce aggregated evidence on the effect of simulation-based teaching on skill performance in the nursing profession. Simulation is an active learning strategy involving the use of various resources to assimilate the real situation. It enables learners to improve their skills and knowledge in a coordinated environment.

Methods

Systematic literature search of original research articles was carried out through Google Scholar, Medline, and Cochrane Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. Studies conducted on simulation-based teaching and skill performance among nursing students or clinical nursing staff from 2010 to 2019, and published in the English language, were included in this study. Methodological quality was assessed by Joanna Briggs Institute, and the risk of bias was also assessed by Cochrane risk of bias and the risk of bias assessment tool for non-randomized studies (ROBINS-I) checklists.

Results

Initially, 638 titles were obtained from 3 sources, and 24 original studies with 2209 study participants were taken for the final analysis. Of the total studies, 14 (58.3%) used single group prep post design, 7 (29.1%) used high fidelity simulator (HFS), and 7 (29.1%) used a virtual simulator (VS). Twenty (83.3%) studies reported improved skill performance following simulation-based teaching. Simulation-based teaching improves skill performance among types of groups (single or double), study regions, high fidelity (HF), low fidelity (LF), and standard patient (SP) users. But the effect over virtual and medium fidelity simulators was not statistically significant. Overall, simulation-based teaching improves the skill performance score among the experimental group (d = 1.01, 95% confidence interval [CI] [0.69–1.33], Z = 6.18, P < 0.01, 93.9%). Significant heterogeneity and publication bias were observed during the pooled analysis.

Conclusions

Simulation did improve skill performance among the intervention groups, but the conclusion is uncertain due to the significant heterogeneity. The large extent of difference among original research has necessitated the development of well-defined assessment methods for skills and standardized simulation set-up for proper assessment of their effects.

British and Finnish nurses' attitudes, practice, and knowledge on deteriorating patient in-service education: A study in two acute hospitals

AIM

The aim was to assess both nurses' attitudes about in-service education, and the impact had by attending in-service education on nurses' management and knowledge of deteriorating patients.

BACKGROUND

In-service education cannot reach its best potential outcomes without strong leadership. Nurse managers are in a position of adopting leadership styles and creating conditions for enhancing the in-service education outcomes.

DESIGN

We conducted a comparative cross-sectional study between British and Finnish nurses (N = 180; United Kingdom: n = 86; Finland: n = 94).

METHODS

A modified "Rapid Response Team Survey" was used in data collection. A sample of medical and surgical registered nurses were recruited from acute care hospitals. Self-reporting, self-reflection, and case-scenarios were used to assess nurses' attitudes, practice, and knowledge. Data were analyzed by Mann-Whitney-U and Chi-square tests.

RESULTS

Nurses' views on education programs were positive; however, low confidence, delays caused by hospital culture, and fear of criticism remained barriers to post education management of deteriorating patients. Nurses' self-reflection on their management of deteriorating patients indicates that 20-25% of deteriorating patients are missed.

CONCLUSION

Nurse managers should promote a no-blame culture, mitigate unnecessary hospital culture and routines, and facilitate in-service education focusing on identification and management of deteriorating patients, simultaneously improving nurses' confidence.

Barriers and enablers of recognition and response to deteriorating patients in the acute hospital setting: A theory-driven interview study using the Theoretical Domains Framework

AIM

To explore barriers and enablers of recognition and response to signs of patient deterioration by nursing staff in an acute hospital.

DESIGN

A theory-driven interview study underpinned by the Theoretical Domains Framework of behaviour change.

METHODS

Between 07/01/2019 and 18/12/2019 a purposive sample of registered nurses and healthcare assistants was recruited to participate in a semi-structured (audio-recorded) interview, to explore the determinants of seven specified behaviours of the afferent limb. Anonymised transcripts were deductively coded (using the 14 Theoretical Domains Framework domains as coding categories) and then extracts within each domain were inductively analysed to synthesise belief statements and themes. Prioritisation criteria from published literature were applied.

RESULTS

Thirty-two semi-structured interviews were conducted. From 1,888 quotes, 184 belief statements and 66 themes were synthesised. One hundred and forty-six belief statements, represented by 58 themes, met prioritisation criteria. Nine domains of the Theoretical Domains Framework were of high importance: Knowledge; Social, Professional Role and Identity; Beliefs about Consequences; Reinforcement; Intentions; Goals; Memory, Attention and Decision Processes; Environment, Context and Resources and Social Influences.

CONCLUSIONS

Barriers and enablers most likely to impact on nursing staff afferent limb behaviour were identified in nine domains of the Theoretical Domains Framework.

Evaluation of a blended learning approach to developing specialty-nursing practice. An exploratory descriptive qualitative study

BACKGROUND

An ageing population and a transitioning workforce is creating demands on healthcare workforces. Clinical and procedural knowledge deficits cause anxieties in new and experienced nurses alike when integrating into new teams. Overcoming these boundaries can be achieved with Introductory programs. These develop knowledge, technical skills and non-technical skills. Investigating nurses drive to undertake such programs, and the benefits they perceive for themselves, will help to tailor future programs.

OBJECTIVES

To explore post-registration nurses' motivations for undertaking an introductory program that utilised a blended learning methodology. Identifying changes in participants understanding and clinical behaviours.

METHODS

An exploratory descriptive qualitative study design was used to evaluate the Introduction to Specialty Practice (ISP) program that is run by a large private healthcare provider in Melbourne, Australia. The health service includes eight campuses and four intensive care units across the group. Twelve participants from a mixture of critical care and acute care clinical areas were consented. They were interviewed using a semi-structured questionnaire. Responses were transcribed verbatim and thematic analysis of the transcripts then occurred.

RESULTS

The study demonstrated intrinsic and extrinsic factors influenced participant's desires to undertake this program. Three major themes were evident: 1) that caring without knowledge was daunting, 2) that participants needed to create a clinical and professional identity and 3) that participant's perspective on their delivery of care improved, along with their professional aptitude.

CONCLUSION

Maintaining currency with knowledge, skills, and technological developments is crucial for nurses to consistently deliver high-level care. The demands that nurses' face within their clinical areas affects their intention to stay within the workforce and their ability to deliver care. Introductory programs that utilise blended learning strategies have a role to play in enabling nurses to create their professional identity, find their position in clinical teams, and meet the requirements of organisations.

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.

Nursing Students' Knowledge, Competence and Attitudes towards Vital Signs Monitoring during Clinical Practice

AIM AND OBJECTIVE

This study assessed the perceived knowledge and competence, and the attitude of Saudi nursing students towards vital signs monitoring for detecting patient deterioration during clinical rotation. It also examined the predictors of students' attitudes.

BACKGROUND

One of the most important uses of vital signs monitoring is the early detection of deterioration. Vital signs monitoring is one of the most frequently assigned tasks to students during clinical rotation. However, the attitudes of nursing students towards vital signs monitoring for detecting clinical deterioration remain unexplored.

DESIGN

Quantitative, cross-sectional design.

METHOD

A convenience sample of 529 baccalaureate nursing students in two universities in Saudi Arabia was surveyed using the V-scale from October 2019-December 2019. A multivariate multiple regression was implemented to examine the multivariate effect of the predictor variables on the five subscales of the V-scale. This study adhered to the STROBE checklist.

RESULTS

The overall attitudes of the students towards VS monitoring can be interpreted as poor to modest. The highest mean was reported in the subscale 'communication'. The subscales 'workload', 'key indicators' and 'technology' received low mean scores. The university, age, gender, academic year level and perceived knowledge had significant multivariate effects on the five subscales of the V-scale.

CONCLUSIONS

The Saudi nursing students had poor attitudes towards vital signs monitoring, specifically towards the use of technology in vital signs monitoring, the workload associated with vital signs monitoring and vital signs as key indicators of patient deterioration.

RELEVANCE TO CLINICAL PRACTICE

The findings reveal the need to improve the curricular content and training of nursing students regarding vital signs and the physiological indicators of clinical deterioration. This study also identified areas that require improvement to ensure positive attitudes among students.

The fifth vital sign? Nurse worry predicts inpatient deterioration within 24 hours

Introduction

Identification of hospitalized patients with suddenly unfavorable clinical course remains challenging. Models using objective data elements from the electronic health record may miss important sources of information available to nurses.

Methods

We recorded nurses’ perception of patient potential for deterioration in 2 medical and 2 surgical adult hospital units using a 5-point score at the start of the shift (the Worry Factor [WF]), and any time a change or an increase was noted by the nurse. Cases were evaluated by three reviewers. Intensive care unit (ICU) transfers were also tracked.

Results

31 159 patient-shifts were recorded for 3185 unique patients during 3551 hospitalizations, with 169 total outcome events. Out of 492 potential deterioration events identified, 380 (77%) were confirmed by reviewers as true deterioration events. Likelihood ratios for ICU transfer were 17.8 (15.2–20.9) in the 24 hours following a WF > 2, and 40.4 (27.1–60.1) following a WF > 3. Accuracy rates were significantly higher in nurses with over a year of experience (68% vs 79%, P = 0.04). The area under the receiver operator characteristic curve (AUROC) was 0.92 for the prediction of ICU transfer within 24 hours.

Discussion

This is a higher accuracy than most published early warning scores.

Conclusion

Nurses’ pattern recognition and sense of worry can provide important information for the detection of acute physiological deterioration and should be included in the electronic medical record.

How actionable are staff behaviours specified in policy documents? A document analysis of protocols for managing deteriorating patients

BACKGROUND

To optimise care of deteriorating patients, healthcare organisations have implemented rapid response systems including an "afferent" and "efferent" limb. Afferent limb behaviours include monitoring vital signs and escalating care. To strengthen afferent limb behaviour and reduce adverse patient outcomes, the National Early Warning Score was implemented in the UK. There are no published reports of how National Early Warning Score guidance has translated into trust-level deteriorating patient policy and whether these documents provide clear, actionable statements guiding staff.

AIM

To identify how deteriorating patient policy documents provide "actionable" behavioural instruction for staff, responsible for actioning the afferent limb of the rapid response system.

DESIGN

A structured content analysis of a national guideline and local policies using a behaviour specification framework.

METHODS

Local deteriorating patient policies were obtained. Statements of behaviour were extracted from policies; coded using a behaviour specification framework: Target, Action, Context, Timing and Actor and scored for specificity (1 = present, nonspecific; 2 = present, specific). Frequencies and proportions of statements containing elements of the Target, Action, Context, Timing and Actor framework were summarised descriptively. Reporting was guided by the COREQ checklist.

RESULTS

There were more statements related to monitoring than escalation behaviour (65% vs 35%). Despite high levels of clear specification of the action (94%) and the target of the behaviour (74%), context, timing and actor were poorly specified (37%, 37% and 33%).

CONCLUSION

Delay in escalating deteriorating patients is associated with adverse outcomes. Some delay could be addressed by writing local protocols with greater behavioural specificity, to facilitate actionability.

RELEVANCE TO CLINICAL PRACTICE

Numerous clinical staff are required for an effective response to patient deterioration. To mitigate role confusion, local policy writers should provide clear specification of the actor. As the behaviours are time-sensitive, clear specification of the time frame may increase actionability of policy statements for clinical staff.

Interventions to reduce mortality from in-hospital cardiac arrest: a mixed-methods study

Background

Unchecked patient deterioration can lead to in-hospital cardiac arrest (IHCA) and avoidable death. The National Cardiac Arrest Audit (NCAA) has found fourfold variation in IHCA rates and survival between English hospitals. Key to reducing IHCA is both the identification of patients at risk of deterioration and prompt response. A range of targeted interventions have been introduced but implementation varies between hospitals. These differences are likely to contribute to the observed variation between and within hospitals over time.

Objective

To determine how interventions aimed at identification and management of deteriorating patients are associated with IHCA rates and outcomes.

Design

A mixed-methods study involving a systematic literature review, semistructured interviews with 60 NHS staff, an organisational survey in 171 hospitals and interrupted time series and difference-in-difference analyses (106 hospitals).

Setting

English hospitals participating in the NCAA audit.

Participants

NHS staff (approximately 300) and patients (13 million).

Interventions

Education, track-and-trigger systems (TTSs), standardised handover tools and outreach teams.

Main outcome measures

IHCA rates, survival and hospital-wide mortality.

Data sources

NCAA, Hospital Episode Statistics, Office for National Statistics Mortality Statistics.

Methods

A literature review and qualitative interviews were used to design an organisational survey that determined how interventions have been implemented in practice and across time. Associations between variations in services and IHCA rates and survival were determined using cross-sectional, interrupted time series and difference-in-difference analyses over the index study period (2009/10 to 2014/15).

Results

Across NCAA hospitals, IHCAs fell by 6.4% per year and survival increased by 5% per year, with hospital mortality decreasing by a similar amount. A national, standard TTS [the National Early Warning Score (NEWS)], introduced in 2012, was adopted by 70% of hospitals by 2015. By 2015, one-third of hospitals had converted from paper-based TTSs to electronic TTSs, and there had been an increase in the number of hospitals with an outreach team and an increase in the number with a team available at all times. The extent of variation in the uses of educational courses and structured handover tools was limited, with 90% of hospitals reporting use of standardised communication tools, such as situation, background, assessment and recommendation, in 2015. Introduction of the NEWS was associated with an additional 8.4% decrease in IHCA rates and, separately, a conversion from paper to electronic TTS use was associated with an additional 7.6% decrease. However, there was no associated change in IHCA survival or hospital mortality. Outreach teams were not associated with a change in IHCA rates, survival or hospital mortality. A sensitivity analysis restricted to ward-based IHCAs did not alter the findings but did identify an association between increased outreach team intensity in 2015 and IHCA survival.

Limitations

The organisational survey was not able to explore all aspects of the interventions and the contextual factors that influenced them. Changes over time were dependent on respondents’ recall.

Conclusions

Standardisation of TTSs and introduction of electronic TTSs are associated with a reduction in IHCAs. The apparent lack of impact of outreach teams may reflect their mode of introduction, that their effect is through providing support for implementation of TTS or that the organisation of the response to deterioration is not critical, as long as it is timely. Their role in end-of-life decision-making may account for the observed association with IHCA survival.

Future work

To assess the potential impact of outreach teams at hospital level and patient level, and to establish which component of the TTS has the greatest effect on outcomes.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Evaluating the validity and reliability of the V-scale instrument (Turkish version) used to determine nurses' attitudes towards vital sign monitoring

AIM

The aim of this study was to determine the validity and reliability of the Turkish version of the V-scale, which measures nurses' attitudes towards vital signs monitoring in the detection of clinical deterioration.

METHODS

This validity and reliability study was conducted at a tertiary hospital in Ankara, Turkey, in 2016. A total of 169 ward nurses participated in the study. Exploratory factor analysis, Cronbach's alpha coefficient, and the intraclass correlation coefficient were used to determine the validity and reliability of the scale.

RESULTS

A 5-factor, 16-item scale explained 60.823% of the total variance according to the validity analysis. Our version matched the original scale in terms of the number of items and factor structure. Cronbach's alpha coefficient of the Turkish version of the V-scale was 0.764. The test-retest reliability results were 0.855 for the overall intraclass correlation coefficient, and the t-test result was P > 0.05.

CONCLUSION

The V-scale is a reliable and valid instrument to measure Turkish nurses' attitudes towards vital signs monitoring in the detection of clinical deterioration.

Development and psychometric testing of a Clinical Reasoning Evaluation Simulation Tool (CREST) for assessing nursing students' abilities to recognize and respond to clinical deterioration

BACKGROUND

The development of clinical reasoning skills in recognising and responding to clinical deterioration is essential in pre-registration nursing education. Simulation has been increasingly used by educators to develop this skill.

OBJECTIVE

To develop and evaluate the psychometric properties of a Clinical Reasoning Evaluation Simulation Tool (CREST) for measuring clinical reasoning skills in recognising and responding to clinical deterioration in a simulated environment.

DESIGN

A scale development with psychometric testing and mixed methods study.

PARTICIPANTS/SETTINGS

Nursing students and academic staff were recruited at a university.

METHOD

A three-phase prospective study was conducted. Phase 1 involved the development and content validation of the CREST; Phase 2 included the psychometric testing of the tool with 15 second-year and 15 third-year nursing students who undertook the simulation-based assessment; Phase 3 involved the usability testing of the tool with nine academic staff through a survey questionnaire and focus group discussion.

RESULTS

A 10-item CREST was developed based on a model of clinical reasoning. A content validity of 0.93 was obtained from the validation of 15 international experts. The construct validity was supported as the third-year students demonstrated significantly higher (p<0.001) clinical reasoning scores than the second-year students. The concurrent validity was also supported with significant positive correlations between global rating scores and almost all subscale scores, and the total scores. The predictive validity was supported with an existing tool. The internal consistency was high with a Cronbach's alpha of 0.92. A high inter-rater reliability was demonstrated with an intraclass correlation coefficient of 0.88. The usability of the tool was rated positively by the nurse educators but the need to ease the scoring process was highlighted.

CONCLUSIONS

A valid and reliable tool was developed to measure the effectiveness of simulation in developing clinical reasoning skills for recognising and responding to clinical deterioration.

Nurses' experiences of managing patient deterioration following a post-registration education programme: A critical incident analysis study

The aim of this study was to explore nurses' experiences assessing and managing deteriorating patients in practice following completion of a relevant post-registration education programme. Recognising the increasing acuity of ward patients, nurses are faced with patients who are at an increased risk of deterioration. Patients who are acutely ill or deteriorating often exhibit periods of physiological deterioration; however there is evidence illustrating that these clinical changes are frequently missed, misinterpreted or mismanaged in practice. In order to prepare nurses to competently assess and manage the deteriorating patient, education as a care initiative is offered to develop the knowledge and skills required. A qualitative study using critical incident analysis was conducted to acquire narrative data from nurses, describing their clinical practice experiences of patient deterioration. Thematic analysis was used to analyse the data. Findings revealed improvements in nurses' abilities to recognise patient deterioration, greater application of the evidence base and an increase in confidence and assertiveness. There was some evidence of applying the knowledge and skills learned, however equally some nurses indicated that they remained ill-prepared to apply the skills in practice.

The Effectiveness of Simulation on Recognizing and Managing Clinical Deterioration: Meta-Analyses

The purpose of these meta-analyses was to quantitatively synthesize the effectiveness of simulation on student nurses’ and registered nurses’ ability to recognize and manage clinical deterioration in the acute care setting. A search of the literature resulted in 22 reports and 19 studies meeting inclusion criteria. Four random-effects analyses were conducted to examine two-group posttest and single-group pre–posttest intervention effect sizes for knowledge and performance. A total of 41 effect sizes were calculated from the data extracted. The standardized mean difference ( d) for two-group posttest knowledge was d = 0.964 ( p = .001) and for performance was d = 1.382 ( p ≤ .001). The standardized mean difference for single-group pre–posttest knowledge was d = 1.231 ( p ≤ .001) and performance was d = 1.610 ( p ≤ .001). Findings indicate that simulation-based interventions have a positive effect on knowledge and performance. As simulation is increasingly used as a teaching modality in nursing, further research should aim to test standardized simulation-based education programs.

Diurnal variation in the performance of rapid response systems: the role of critical care services-a review article

The type of medical review before an adverse event influences patient outcome. Delays in the up-transfer of patients requiring intensive care are associated with higher mortality rates. Timely detection and response to a deteriorating patient constitute an important function of the rapid response system (RRS). The activation of the RRS for at-risk patients constitutes the system’s afferent limb. Afferent limb failure (ALF), an important performance measure of rapid response systems, constitutes a failure to activate a rapid response team (RRT) despite criteria for calling an RRT.

There are diurnal variations in hospital staffing levels, the performance of rapid response systems and patient outcomes. Fewer ward-based nursing staff at night may contribute to ALF. The diurnal variability in RRS activity is greater in unmonitored units than it is in monitored units for events that should result in a call for an RRT. RRT events include a significant abnormality in either the pulse rate, blood pressure, conscious state or respiratory rate. There is also diurnal variation in RRT summoning rates, with most activations occurring during the day. The reasons for this variation are mostly speculative, but the failure of the afferent limb of RRT activation, particularly at night, may be a factor.

The term “circadian variation/rhythm” applies to physiological variations over a 24-h cycle. In contrast, diurnal variation applies more accurately to extrinsic systems. Circadian rhythm has been demonstrated in a multitude of bodily functions and disease states.

For example, there is an association between disrupted circadian rhythms and abnormal vital parameters such as anomalous blood pressure, irregular pulse rate, aberrant endothelial function, myocardial infarction, stroke, sleep-disordered breathing and its long-term consequences of hypertension, heart failure and cognitive impairment. Therefore, diurnal variation in patient outcomes may be extrinsic, and more easily modifiable, or related to the circadian variation inherent in human physiology. Importantly, diurnal variations in the implementation and performance of the RRS, as gauged by ALF, the RRT response to clinical deterioration and any variations in quality and quantity of patient monitoring have not been fully explored across a diverse group of hospitals.

Effectiveness of a Web-Based Simulation in Improving Nurses' Workplace Practice With Deteriorating Ward Patients: A Pre- and Postintervention Study

Background

Nurses play an important role in detecting patients with clinical deterioration. However, the problem of nurses failing to trigger deteriorating ward patients still persists despite the implementation of a patient safety initiative, the Rapid Response System. A Web-based simulation was developed to enhance nurses’ role in recognizing and responding to deteriorating patients. While studies have evaluated the effectiveness of the Web-based simulation on nurses’ clinical performance in a simulated environment, no study has examined its impact on nurses’ actual practice in the clinical setting.

Objective

The objective of this study was to evaluate the impact of Web-based simulation on nurses' recognition of and response to deteriorating patients in clinical settings. The outcomes were measured across all levels of Kirkpatrick’s 4-level evaluation model with clinical outcome on triggering rates of deteriorating patients as the primary outcome measure.

Methods

A before-and-after study was conducted on two general wards at an acute care tertiary hospital over a 14-month period. All nurses from the two study wards who undertook the Web-based simulation as part of their continuing nursing education were invited to complete questionnaires at various time points to measure their motivational reaction, knowledge, and perceived transfer of learning. Clinical records on cases triggered by ward nurses from the two study wards were evaluated for frequency and types of triggers over a period of 6 months pre- and 6 months postintervention.

Results

The number of deteriorating patients triggered by ward nurses in a medical general ward increased significantly (P<.001) from pre- (84/937, 8.96%) to postintervention (91/624, 14.58%). The nurses reported positively on the transfer of learning (mean 3.89, SD 0.49) from the Web-based simulation to clinical practice. A significant increase (P<.001) on knowledge posttest score from pretest score was also reported. The nurses also perceived positively their motivation (mean 3.78, SD 0.56) to engage in the Web-based simulation.

Conclusions

This study provides evidence on the effectiveness of Web-based simulation in improving nursing practice when recognizing and responding to deteriorating patients. This educational tool could be implemented by nurse educators worldwide to address the educational needs of a large group of hospital nurses responsible for patients in clinical deterioration.