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

Purpose

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

Data sources

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

Study selection

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

Data extraction

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

Results of data synthesis

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

Conclusion

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

Attitudes of emergency department physicians and nurses toward implementation of an early warning score to identify critically ill patients: qualitative explanations for failed implementation

BACKGROUND

Sepsis, a common, time-sensitive condition, is sometimes not identified at emergency department (ED) triage. The use of early warning scores has been shown to improve sepsis-related screening in other settings.

OBJECTIVES

Our objective was to elucidate nurse and physician perceptions with the Hamilton Early Warning Score (HEWS) in combination with the Canadian Triage Acuity Scale.

METHOD

Semi-structured interviews were conducted with nurses, resident physicians and attending physicians to explore perceived feasibility, utility, comfort, barriers, successes, opportunities and accuracy. A constructivist grounded theory approach was used. Transcripts were coded into thematic coding trees.

RESULTS

The twelve participants did not value the HEWS in the ED because they felt it was not helpful in identifying critically ill patients. We identified five themes; knowledge of sepsis and HEWS, utility of HEWS in emergency triage, utility of HEWS at the bedside, utility in communicating acuity and deterioration, and feasibility and accuracy of data collection. We also found 9 barriers and 7 enablers to the use of early warning score in the ED.

CONCLUSIONS

In our emergency departments, we identified potential barriers to implementation of an early warning score. A pre-existing expertise and lexicon related to critically ill patients lessens the perceived utility of an EWS in the ED. Understanding these cultural barriers needs to be addressed through change theory and implementation science.

Inter-rater reliability in the Paediatric Observation Priority Score (POPS)

OBJECTIVE

The primary objective of this study was to determine the level of inter-rater reliability between nursing staff for the Paediatric Observation Priority Score (POPS).

DESIGN

Retrospective observational study.

SETTING

Single-centre paediatric emergency department.

PARTICIPANTS

12 participants from a convenience sample of 21 nursing staff.

INTERVENTIONS

Participants were shown video footage of three pre-recorded paediatric assessments and asked to record their own POPS for each child. The participants were blinded to the original, in-person POPS. Further data were gathered in the form of a questionnaire to determine the level of training and experience the candidate had using the POPS score prior to undertaking this study.

MAIN OUTCOME MEASURES

Inter-rater reliability among participants scoring of the POPS.

RESULTS

Overall kappa value for case 1 was 0.74 (95% CI 0.605 to 0.865), case 2 was 1 (perfect agreement) and case 3 was 0.66 (95% CI 0.58 to 0.744).

CONCLUSION

This study suggests there is good inter-rater reliability between different nurses' use of POPS in assessing sick children in the emergency department.

Clinical deterioration: A concept analysis

AIMS AND OBJECTIVES

To present a concept analysis of clinical deterioration and introduce an operational definition.

BACKGROUND

Hospitalised patients who endure cardiopulmonary arrest and unplanned intensive care unit admissions often exhibit physiological signs preceding these events. Clinical deterioration not promptly recognised can result in increased patient morbidity and mortality. A barrier to recognising and responding to clinical deterioration stems from practice variations among healthcare clinicians.

DESIGN

Concept analysis.

METHODS

Eight-step method of concept analysis proposed by Walker and Avant.

RESULTS

Defining attributes include dynamic state, decompensation and objective and subjective determination. Antecedents identified include clinical state, susceptibility, pathogenesis and adverse event. Increased mortality, resuscitation, implementation of higher level of care and prolonged hospital admission were the consequences identified. Defining attributes, antecedents and consequences identified led to an operational definition of clinical deterioration as a dynamic state experienced by a patient compromising hemodynamic stability, marked by physiological decompensation accompanied by subjective or objective findings.

CONCLUSIONS

Clinical deterioration is a key contributor to inpatient mortality, and its recognition is often underpinned by contextual factors and practice variances. Variation in the uniformity of the concept of clinical deterioration causes a gap in knowledge and necessitated clarification of this phenomenon for nursing research and practice.

RELEVANCE TO CLINICAL PRACTICE

Identifying and intervening on clinical deterioration plays a vital role in the inpatient setting demonstrated by the dynamic nature of a patients' condition during hospitalisation. It is anticipated that this concept analysis on clinical deterioration will contribute to further identification of clinically modifiable risk factors and accompanying interventions to prevent clinical deterioration in the inpatient setting.

Dynamic and Personalized Risk Forecast in Step-Down Units. Implications for Monitoring Paradigms

RATIONALE

Cardiorespiratory insufficiency (CRI) is a term applied to the manifestations of loss of normal cardiorespiratory reserve and portends a bad outcome. CRI occurs commonly in hospitalized patients, but its risk escalation patterns are unexplored.

OBJECTIVES

To describe the dynamic and personal character of CRI risk evolution observed through continuous vital sign monitoring of individual step-down unit patients.

METHODS

Using a machine learning model, we estimated risk trends for CRI (defined as exceedance of vital sign stability thresholds) for each of 1,971 admissions (1,880 unique patients) to a 24-bed adult surgical trauma step-down unit at an urban teaching hospital in Pittsburgh, Pennsylvania using continuously recorded vital signs from standard bedside monitors. We compared and contrasted risk trends during initial 4-hour periods after step-down unit admission, and again during the 4 hours immediately before the CRI event, between cases (ever had a CRI) and control subjects (never had a CRI). We further explored heterogeneity of risk escalation patterns during the 4 hours before CRI among cases, comparing personalized to nonpersonalized risk.

MEASUREMENTS AND MAIN RESULTS

Estimated risk was significantly higher for cases (918) than control subjects (1,053; P ≤ 0.001) during the initial 4-hour stable periods. Among cases, the aggregated nonpersonalized risk trend increased 2 hours before the CRI, whereas the personalized risk trend became significantly different from control subjects 90 minutes ahead. We further discovered several unique phenotypes of risk escalation patterns among cases for nonpersonalized (14.6% persistently high risk, 18.6% early onset, 66.8% late onset) and personalized risk (7.7% persistently high risk, 8.9% early onset, 83.4% late onset).

CONCLUSIONS

Insights from this proof-of-concept analysis may guide design of dynamic and personalized monitoring systems that predict CRI, taking into account the triage and real-time monitoring utility of vital signs. These monitoring systems may prove useful in the dynamic allocation of technological and clinical personnel resources in acute care hospitals.

Derivation and validation of a universal vital assessment (UVA) score: a tool for predicting mortality in adult hospitalised patients in sub-Saharan Africa

Background

Critical illness is a leading cause of morbidity and mortality in sub-Saharan Africa (SSA). Identifying patients with the highest risk of death could help with resource allocation and clinical decision making. Accordingly, we derived and validated a universal vital assessment (UVA) score for use in SSA.

Methods

We pooled data from hospital-based cohort studies conducted in six countries in SSA spanning the years 2009–2015. We derived and internally validated a UVA score using decision trees and linear regression and compared its performance with the modified early warning score (MEWS) and the quick sepsis-related organ failure assessment (qSOFA) score.

Results

Of 5573 patients included in the analysis, 2829 (50.8%) were female, the median (IQR) age was 36 (27–49) years, 2122 (38.1%) were HIV-infected and 996 (17.3%) died in-hospital. The UVA score included points for temperature, heart and respiratory rates, systolic blood pressure, oxygen saturation, Glasgow Coma Scale score and HIV serostatus, and had an area under the receiver operating characteristic curve (AUC) of 0.77 (95% CI 0.75 to 0.79), which outperformed MEWS (AUC 0.70 (95% CI 0.67 to 0.71)) and qSOFA (AUC 0.69 (95% CI 0.67 to 0.72)).

Conclusion

We identified predictors of in-hospital mortality irrespective of the underlying condition(s) in a large population of hospitalised patients in SSA and derived and internally validated a UVA score to assist clinicians in risk-stratifying patients for in-hospital mortality. The UVA score could help improve patient triage in resource-limited environments and serve as a standard for mortality risk in future studies.

A ward-based time study of paper and electronic documentation for recording vital sign observations

OBJECTIVE

To investigate time differences in recording observations and an early warning score using traditional paper charts and a novel e-Obs system in clinical practice.

METHODS

Researchers observed the process of recording observations and early warning scores across 3 wards in 2 university teaching hospitals immediately before and after introduction of the e-Obs system. The process of recording observations included both measurement and documentation of vital signs. Interruptions were timed and subtracted from the measured process duration. Multilevel modeling was used to compensate for potential confounding factors.

RESULTS

In all, 577 nurse events were observed (281 paper, 296 e-Obs). The geometric mean time to take a complete set of vital signs was 215 s (95% confidence interval [CI], 177 s-262 s) on paper, and 150 s (95% CI, 130 s-172 s) electronically. The treatment effect ratio was 0.70 (95% CI, 0.57-0.85, P  < .001). The treatment effect ratio in ward 1 was 0.37 (95% CI, 0.26-0.53), in ward 2 was 0.98 (95% CI, 0.70-1.38), and in ward 3 was 0.93 (95% CI, 0.66-1.33).

DISCUSSION

Introduction of an e-Obs system was associated with a statistically significant reduction in overall time to measure and document vital signs electronically compared to paper documentation. The reductions in time varied among wards and were of clinical significance on only 1 of 3 wards studied.

CONCLUSION

Our results suggest that introduction of an e-Obs system could lower nursing workload as well as increase documentation quality.

Can the prehospital National Early Warning Score identify patients most at risk from subsequent deterioration?

INTRODUCTION

The National Early Warning Score (NEWS) aids the early recognition of those at risk of becoming critically ill. NEWS has been recommended for use by ambulance services, but very little work has been undertaken to date to determine its suitability. This paper examines whether a prehospital NEWS derived from ambulance service clinical observations is associated with the hospital ED disposition.

METHODS

Prehospital NEWS was retrospectively calculated from the ambulance service clinical records of 287 patients who were treated by the ambulance service and transported to hospital. In this cohort study, derived NEWS scores were compared with ED disposition data and patients were categorised into the following groups depending on their outcome: discharged from ED, admitted to a ward, admitted to intensive therapy unit (ITU) or died.

RESULTS

Prehospital NEWS-based ambulance service clinical observations were significantly associated with discharge disposition groups (p<0.001), with scores escalating in line with increasing severity of outcome. Patients who died or were admitted to ITU had higher scores than those admitted to a ward or discharged from ED (mean NEWS 7.2 and 7.5 vs 2.6 and 1.7, respectively), and in turn those who were admitted to a ward had higher pre-hospital NEWS than those who were discharged (2.6 vs 1.7).

CONCLUSION

Our findings suggest that the NEWS could successfully be used by ambulance services to identify patients most at risk from subsequent deterioration. The implementation of this early warning system has the potential to support ambulance clinician decision making, providing an additional tool to identify and appropriately escalate care for acutely unwell patients.

Daily surveillance with early warning scores help predicthospital mortality in medical wards

BACKGROUND/AIM

To analyze the potency of a modified early warning score (EWS) to help predict hospital mortality when used for surveillance in nonacute medical wards.

MATERIALS AND METHODS

Patients in internal medicine wards were prospectively recruited. First, highest, and last scores; and mean daily score recordings and values were recorded. Nurses calculated scores for each patient upon admission and every 4 h. The last score was the score before death, discharge, or transfer to another ward. The highest scores in total and for each single parameter were used for analysis.

RESULTS

Fifty-nine percent of 182 recruited patients had recordings eligible for data analysis. Patients admitted from the emergency room had higher mortality rates than patients admitted from outpatient clinics (15% vs. 1.5%; P = 0.01) as well as patients whose first (40% vs. 4.9%; P = 0.033) and highest scores (18.8% vs. 1.3%; P = 0.003) were equal to or more than 3. The first recorded EWS was not predictive for mortality while the maximum score during the admission period was.

CONCLUSION

This study underlines the fact that each physiological variable of EWS may not have the same weight in determining the outcome.

Early warning score predicts acute mortality in stroke patients

OBJECTIVES

Clinical deterioration and death among patients with acute stroke are often preceded by detrimental changes in physiological parameters. Systematic and effective tools to identify patients at risk of deterioration early enough to intervene are therefore needed. The aim of the study was to investigate whether the aggregate weighted track and trigger system early warning score (EWS) can be used as a simple observational tool to identify patients at risk and predict mortality in a population of patients with acute stroke.

MATERIALS AND METHODS

Patients admitted with acute stroke at the Copenhagen University Hospital, Nordsjaellands Hospital, Denmark, from May to September 2012 were enrolled in a retrospective cohort study (n = 274). Vital signs were measured immediately after admission and consistently during the hospitalization period. Based on the vital signs, a single composite EWS was calculated. Death within 30 days was used as outcome. Area under the receiver operating characteristics curve (AUROC) and a Kaplan-Meier curve were computed to examine the prognostic validity of EWS.

RESULTS

A total of 24 patients (8.8%) died within 30 days. The prognostic performance was high for both the EWS at admission (AUROC 0.856; 95% CI 0.760-0.951; P-value < 0.001) and the maximal EWS measured (AUROC 0.949; 95% CI 0.919-0.980; P-value < 0.001). Mortality rates were lowest for admission EWS 0-1 (2%) and highest for admission EWS ≥ 5 (63%).

CONCLUSIONS

Early warning score is a simple and valid tool for identifying patients at risk of dying after acute stroke. Readily available physiological parameters are converted to a single score, which can guide both nurses and physicians in clinical decision making and resource allocation.

Accuracy of Bedside Paediatric Early Warning System (BedsidePEWS) in a Pediatric Stem Cell Transplant Unit

Hospital mortality in children who undergo stem cell transplant (SCT) is high. Early warning scores aim at identifying deteriorating patients and at preventing adverse outcomes. The bedside pediatric early warning system (BedsidePEWS) is a pediatric early warning score based on 7 clinical indicators, ranging from 0 (all indicators within normal ranges for age) to 26. The aim of this case-control study was to assess the performance of BedsidePEWS in identifying clinical deterioration events among children admitted to an SCT unit. Cases were defined as clinical deterioration events; controls were all the other patients hospitalized on the same ward at the time of case occurrence. BedsidePEWS was retrospectively measured at 4-hour intervals in cases and controls 24 hours before an event (T4-T24). We studied 19 cases and 80 controls. The score significantly increased in cases from a median of 4 at T24 to a median of 14 at T4. The proportion of correctly classified cases and controls was >90% since T8. The area under the curve receiver operating characteristic was 0.9. BedsidePEWS is an accurate screening tool to predict clinical deterioration in SCT patients.

Validation of pediatric early warning score in pediatric emergency department

BACKGROUND

One of the most important functions of the emergency department (ED) is to assess patient status. Only one, the pediatric early warning score (PEWS), has been designed for ED with acceptable validity, but it has never been validated in Thailand. The objective of this study was to validate PEWS in predicting hospitalization in children visiting the ED.

METHODS

During the initial phase, two triage nurses performed blind scoring (in order to determine inter-rater reliability using kappa statistics) for the first 30 patients who presented to the ED at Ramathibodi Hospital between March and May 2014 and who were aged < 15 years. The second phase then consisted of validation and involved 1136 patients. Patients who presented with trauma, psychiatric, dental and surgical concerns were excluded. Validity of the scoring system in predicting admission was assessed using area under the receiver operating characteristics (ROC) curve (AUC), sensitivity, and specificity, positive predictive value (PPV) and negative predictive value (NPV).

RESULTS

Phase I demonstrated good inter-rater reliability (kappa = 0.75). In phase II, of the total group of 1136 patients, 168 patients (14.8%) were admitted: 162 to the general ward and six to the intensive care unit (ICU) during the study period. AUC for predicting overall, ICU, and general ward admission were 0.73 (95%CI: 0.68-0.77), 0.98 (95%CI: 0.96-1) and 0.71 (95%CI: 0.66-0.75), respectively. The sensitivity and specificity in predicting overall admission with a cut-off of PEWS ≥ 1 was 78% and 60%, respectively (PPV, 28%; NPV, 95%). Sensitivity and specificity in predicting ICU admission with the cut-off PEWS ≥ 3 was 100% and 91%, respectively (PPV, 5%; NPV, 100%). Using the cut-off PEWS ≥ 1, sensitivity and specificity in predicting ward admission were 77% and 59%, respectively (PPV, 24%; NPV, 94%).

CONCLUSION

PEWS can be helpful in assessing patient status in pediatric ED with acceptable validity and can serve as a potentially excellent screening tool for prediction of ICU admission.

Development of heart and respiratory rate percentile curves for hospitalized children

OBJECTIVE

To develop and validate heart and respiratory rate percentile curves for hospitalized children and compare their vital sign distributions to textbook reference ranges and pediatric early warning score (EWS) parameters.

METHODS

For this cross-sectional study, we used 6 months of nurse-documented heart and respiratory rates from the electronic records of 14,014 children on general medical and surgical wards at 2 tertiary-care children's hospitals. We developed percentile curves using generalized additive models for location, scale, and shape with 67% of the patients and validated the curves with the remaining 33%. We then determined the proportion of observations that deviated from textbook reference ranges and EWS parameters.

RESULTS

We used 116,383 heart rate and 116,383 respiratory rate values to develop and validate the percentile curves. Up to 54% of heart rate observations and up to 40% of respiratory rate observations in our sample were outside textbook reference ranges. Up to 38% of heart rate observations and up to 30% of respiratory rate observations in our sample would have resulted in increased EWSs.

CONCLUSIONS

A high proportion of vital signs among hospitalized children would be considered out of range according to existing reference ranges and pediatric EWSs. The percentiles we derived may serve as useful references for clinicians and could be used to inform the development of evidence-based vital sign parameters for physiologic monitor alarms, inpatient electronic health record vital sign alerts, medical emergency team calling criteria, and EWSs.