Recognising and responding to deteriorating patients: what difference do national standards make?

A theoretical framework for identifying sociocultural factors that influence nurses' compliance with early warning systems for acute clinical deterioration: A cross-sectional survey

BACKGROUND

Systematic adoption of early warning systems in healthcare settings is dependent on the optimal and reliable application by the user. Psychosocial issues and hospital culture influence clinicians' patient safety behaviours.

OBJECTIVE

(i) To examine the sociocultural factors that influence nurses' EWS compliance behaviours, using a theory driven behavioural model and (ii) to propose a conceptual model of sociocultural factors for EWS compliance behaviour.

DESIGN

A cross-sectional survey.

SETTING

Nurses employed in public hospitals across Queensland, Australia.

PARTICIPANTS

Using convenience and snowball sampling techniques eligible nurses accessed a dedicated web site and survey containing closed and open-ended questions. 291 nurses from 60 hospitals completed the survey.

METHODS

Quantitative data were analysed using ANOVA or t-tests to test differences in means. A series of path models based on the theory were conducted to develop a new model. Directed or theory driven content analysis informed qualitative data analysis.

RESULTS

Nurses report high levels of previous compliance behaviour and strong intentions to continue complying in the future (M=4.7; SD 0.48). Individual compliance attitudes (β 0.29, p<.05), perceived value of escalation (β 0.24, p<.05) and perceived ease or difficulty complying with documentation (β -0.31, p<.05) were statistically significant, predicting 24% of variation in compliance behaviour. Positive personal charting beliefs (β 0.14, p<.05) and subjective norms both explain higher behavioural intent indirectly through personal attitudes. High ratings of peer charting beliefs indirectly explain attitudes through subjective norms (β 0.20, p<.05). Perceptions of control over one's clinical actions (β -0.24, p<.05) and early warning system training (β -0.17, p<.05) directly contributed to fewer difficulties complying with documentation requirements. Prior difficulties when escalating care (β -0.31, p<.05) directly influenced the perceived value of escalating.

CONCLUSIONS

The developed theory-based conceptual model identified sociocultural variables that inform compliance behaviour (documenting and escalation protocols). The model highlights areas of clinical judgement, education, interprofessional trust, workplace norms and cultural factors that directly or indirectly influence nurses' intention to comply with EWS protocols. Extending our understanding of the sociocultural and system wide factors that hamper nurses' use of EWSs and professional accountability has the potential to improve the compliance behaviour of staff and subsequently enhance the safety climate attitudes of hospitals.

TWEETABLE ABSTRACT

A newly developed model reports nurse's personal attitudes, peer influence, perceived difficulties encountered documenting and escalation beliefs all predict early warning system compliance behaviour.

Pre-medical emergency team activations - Patient characteristics, outcomes and predictors of deterioration

BACKGROUND

Pre-medical emergency team (MET) calls are an increasingly common tier of Rapid Response Systems, but the epidemiology of patients who trigger a Pre-MET is not well understoof.

OBJECTIVES

This study aims to examine the epidemiology and outcomes of patients who trigger a pre-MET activation and identify risk factors for further deterioration.

METHODS

This is a retrospective cohort study of pre-MET activations in a university-affiliated metropolitan hospital in Australia, between 13 April 2021 and 4 October 2021. A multivariable regression model was used to identify variables associated with further deterioration, defined as a MET call or Code Blue within 24 h of pre-MET activation.

RESULTS

From a total of 39 664 admissions, there were 7823 pre-MET activations (197.2 per 1000 admissions). Compared to inpatients that did not trigger a pre-MET, the patients were older (68.8 vs 53.8 years, p < 0.001), were more likely to be male (51.0 vs 47.6%, p < 0.001), had an emergency admission (70.1% vs 53.3%, p < 0.001), and were under a medical specialty (63.7 vs 54.9%, p < 0.001). They had a longer hospital length of stay (5.6 vs 0.4 d, p < 0.001) and higher in-hospital mortality (3.4% vs 1.0%, p < 0.001). A pre-MET was more likely to progress to a MET call or Code Blue if it was activated for fever, cardiovascular, neurological, renal, or respiratory criteria (p < 0.001), if the patient was under a paediatric team (p = 0.018), or if there had been a MET call or Code Blue prior to the pre-MET activation (p < 0.001).

CONCLUSION

Pre-MET activations affect almost 20% of hospital admissions and are associated with a higher risk of mortality. Certain characteristics may predict further deterioration to a MET call or Code Blue, suggesting the potential for early intervention via clinical decision support systems.

In-hospital outcomes among older medical inpatients admitted to aged care wards after activation of a 2-tier rapid response system

BACKGROUND

The outcomes of rapid response systems (RRS) are poorly established in older people. We examined the outcomes in older inpatients at a tertiary hospital that uses a 2-tier RRS, including the outcomes of each tier.

METHODS

The 2-tier RRS comprised the clinical review call (CRC) (tier one) and the medical emergency team call (MET) (tier two). We compared the outcomes in four configurations of MET and CRC (MET with CRC; MET without CRC; CRC without MET; neither MET nor CRC). The primary outcome was in-hospital death, and secondary outcomes were length of stay (LOS) and new residential facility placement. Statistical analyses were carried out using Fisher's exact tests, Kruskal-Wallis tests, and logistic regression.

RESULTS

A total of 433 METs and 1,395 CRCs occurred among 3,910 consecutive admissions of mean age 84 years. The effect of a MET on death was unaffected by the occurrence of a CRC. The rates of death for MET ± CRC, and CRC without MET, were 30.5% and 18.5%, respectively. Patients having one or more MET ± CRC (adjusted odds ratio [aOR] 4.04, 95% confidence interval [CI] 2.96-5.52), and those having one or more CRC without MET (aOR 2.22, 95% CI 1.68-2.93), were more likely to die in adjusted analysis. Patients who required a MET ± CRC were more likely to be placed in a high-care residential facility (aOR 1.52, 95% CI 1.03-2.24), as were patients who required a CRC without MET (aOR 1.61, 95% CI 1.22-2.14). The LOS of patients who required a MET ± CRC, and CRC without MET, was longer than that of patients who required neither (P < 0.001).

CONCLUSIONS

Both MET and CRC were associated with increased likelihood of death and new residential facility placement, after adjusting for factors such as age, comorbidity, and frailty. These data are important for patient prognostication, discussions on goals of care, and discharge planning. The high death rate of patients requiring a CRC (without a MET) has not been previously reported, and may suggest that CRCs among older inpatients should be expediated and attended by senior medical personnel.

Evaluation of the effectiveness of an eLearning program in the nursing observation and assessment of acute surgical patients: A naturalistic observational study

AIM/OBJECTIVE

The aim of this study was to evaluate the effectiveness of an eLearn program in changing surgical nurses' approach to clinical assessment.

BACKGROUND

Nurses need to have the knowledge and skills to recognise and respond to changes in patients' physiological condition in a timely manner. A private health service in Melbourne, Australia developed an online (eLearn) program highlighting the importance of clinical assessment and provided nurses with an overview of the Airway,Breathing, Circulation, Disability, Exposures ('ABCDE') approach.

DESIGN

A before and after study design that involved naturalistic observation of nurse-patient interactions and nurses' performing patient clinical assessments was undertaken on two surgical wards.

METHODS

The intervention ward nurses received standard education and exposure to the eLearning program. The comparison ward nurses received standard workplace education on patient assessment. The nurses were observed from May to August 2018.

RESULTS

Following completion of the eLearn, intervention ward nurses were observed to spend more time with their patients conducting clinical assessment. On both wards, not all nurses performed comprehensive ABCDE assessment and there was variability associated with the sequencing of ABCDE assessment.

CONCLUSIONS

This study provides some evidence that completion of an eLearn can change clinical practice, however the intensity of the intervention was insufficient to achieve optimal practice in the conduct of clinical assessments.