Use of the pre-medical emergency team tier of rapid response systems: A scoping Review

'White lies and safety nets': The perceptions of nurses on the use of early warning systems and the development of higher-order thinking skills

BACKGROUND

Algorithmic tools such as early warning systems (EWSs) have been embedded into clinical practice globally to facilitate the early recognition of patient deterioration and to guide the escalation of care. Concerns have been raised that the mandated use of these EWS tools may impact the development of nurses' higher-order thinking. However, the relationship between EWS tools and the development of higher-order thinking is poorly understood.

OBJECTIVES

This paper provides the qualitative results of a larger study that sought to explore the impact of EWS tools on the development of nurses' higher-order thinking. The objective of this component of the study was to ascertain the thoughts and perceptions of nurses on the use of EWSs and how this related to the development of higher-order thinking skills.

METHODS

A mixed-method, concurrent study design was used to explore the concept of the development of nurses' higher-order thinking in the context of EWS tools. The qualitative responses from a Qualtrics survey were thematically analysed and presented.

FINDINGS

Two major themes were uncovered: White Lies and Safety Nets. Our analysis of the data suggested that some nurses amend their documentation practice to accommodate the EWS's escalation process, uncovering a view that the tool did not account for clinical reasoning. Parallel to this, some nurses found that these systems supported clinical decision-making and helped to build confidence, thus acting as a safety net for their practice.

CONCLUSION

Reliance on EWSs can both hinder and/or support the development of higher-order thinking. Early warning systems are useful tools in ensuring patient safety but should be used in conjunction with nurses' higher-order thinking.

Acute care nurses' decisions to recognise and respond to patient improvement: A qualitative study

AIM

To explore and describe acute care nurses' decisions to recognise and respond to improvement in patients' clinical states as they occurred in the real-world clinical environment.

DESIGN

A descriptive study.

METHODS

Nine medical and eleven surgical nurses in a large Australian metropolitan hospital were individually observed during nurse-patient interactions and followed up in interview to describe their reasoning and clinical judgements behind observed decisions. Verbal description of observations and interviews were recorded and transcribed. Reflexive thematic analysis was used to analyse the data.

RESULTS

The three themes constructed from the data were as follows: nurses checking in; nurses reaching judgements about improvements; and nurses deciding on the best person to respond. Acute care nurses made targeted assessment decisions based on predicted safety risks related to improvement in clinical states. Subjective and objective cues were used to assess for and make judgements about patient improvement. Acute care nurses' judgment of patient safety and a desire to promote patient centred care guided their decisions to select the appropriate person to manage improvement.

CONCLUSIONS

The outcomes of this research have demonstrated that the proven safety benefits of acute care nurses' decision making in response to deterioration extend to improvement in patients' clinical states. In response to improvement, acute care nurses' decisions protect patients from harm and promote recovery.

IMPLICATIONS FOR PATIENT CARE

Early recognition and response to improvement enable acute care nurses to protect patients from risks of unnecessary treatment and promote recovery.

IMPACT

This study makes explicit nurses' essential safety role in recognising and responding to improvement in patients' clinical states. Healthcare policy and education must reflect the equal importance of assessment for and management of deterioration and improvement to ensure patients are protected and provided with safe care.

Realist synthesis of a rapid response system in managing mental state deterioration in acute hospital settings

Mental state deterioration in patients poses significant challenges in healthcare, potentially resulting in adverse outcomes for patients and continued reliance on restrictive interventions. Implementing evidence-based approaches such as a rapid response system that prioritises early identification and intervention can effectively manage adverse outcomes. However, little is known regarding the effectiveness of these interventions. The objective of this synthesis was to test and refine initial programme theories by synthesising evidence to understand what works, for whom and under what circumstances. Based on the realist synthesis methodology, we searched EMBASE, CINAHL, MEDLINE, the Cochrane Library and grey literature for evidence to inform contexts, mechanisms and outcomes on the functioning of a rapid response model. We identified 28 relevant sources encompassing peer-reviewed journal articles and grey literature. This synthesis identified three important elements that contribute to the effectiveness of a rapid response system for managing mental state deterioration: care processes, therapeutic practices and organisational support. Essential elements include improving confidence and clinical skills through training, timely assessment and intervention, teamwork, communication and the creation of governance structures for monitoring and evaluation. To ensure the effectiveness, an organisation must adopt a comprehensive approach that incorporates organisational support, resource allocation, training, clear communication channels and commitment to continuous quality improvement. However, implementing interventions within a complex healthcare system requires thoughtful consideration of the organisational culture and governance structures. By taking a comprehensive and holistic approach to improvement initiatives, organisations can strive to achieve optimal outcomes in managing mental state deterioration and improving patient care.

Patient outcomes following medical emergency team review on general wards: Development of predictive models

AIM

To develop and internally validate risk prediction models for subsequent clinical deterioration, unplanned ICU admission and death among ward patients following medical emergency team (MET) review.

DESIGN

A retrospective cohort study of 1500 patients who remained on a general ward following MET review at an Australian quaternary hospital.

METHOD

Logistic regression was used to model (1) subsequent MET review within 48 h, (2) unplanned ICU admission within 48 h and (3) hospital mortality. Models included demographic, clinical and illness severity variables. Model performance was evaluated using discrimination and calibration with optimism-corrected bootstrapped estimates. Findings are reported using the TRIPOD guideline for multivariable prediction models for prognosis or diagnosis. There was no patient or public involvement in the development and conduct of this study.

RESULTS

Within 48 h of index MET review, 8.3% (n = 125) of patients had a subsequent MET review, 7.2% (n = 108) had an unplanned ICU admission and in-hospital mortality was 16% (n = 240). From clinically preselected predictors, models retained age, sex, comorbidity, resuscitation limitation, acuity-dependency profile, MET activation triggers and whether the patient was within 24 h of hospital admission, ICU discharge or surgery. Models for subsequent MET review, unplanned ICU admission, and death had adequate accuracy in development and bootstrapped validation samples.

CONCLUSION

Patients requiring MET review demonstrate complex clinical characteristics and the majority remain on the ward after review for deterioration. A risk score could be used to identify patients at risk of poor outcomes after MET review and support general ward clinical decision-making.

RELEVANCE TO CLINICAL PRACTICE

Our risk calculator estimates risk for patient outcomes following MET review using clinical data available at the bedside. Future validation and implementation could support evidence-informed team communication and patient placement decisions.

Improving the pre-medical emergency team: the case for a behavioural theoretical lens

There is mounting evidence that the pre-medical emergency team (pre-MET) of rapid response systems is underutilised in clinical practice due to suboptimal structures and processes and resource constraints. In this perspective article, we argue for examining the pre-MET through a 'Behaviour Change Wheel' lens to improve the pre-MET and maximise the associated patient safety benefits. Using pre-MET communication practices as an example, we illustrate the value of the COM-B model, where clinicians' 'capability', 'opportunity', and 'motivation' drive 'behaviour'. Optimising clinicians' behaviours and establishing failsafe rapid response systems is a complex undertaking; however, examining clinicians' behaviours through the COM-B model enables reframing barriers and facilitators to develop multifaceted and coordinated solutions that are behaviourally and theoretically based. The COM-B model is recommended to clinical governance leaders and health services researchers to explore the underlying causes of behaviour and successfully enact change in the design, implementation, and use of the pre-MET to improve patient safety.

Medical Emergency Team call within 24 h of medical admission with a focus on sepsis: a retrospective review

BACKGROUND AND AIMS

Clinical deterioration within the first 24 h of patient admission triggering a Medical Emergency Team (MET) call is a common occurrence. A greater understanding of these events, with a focus on the recognition and management of sepsis, could lead to quality improvement interventions.

METHODS

A retrospective observational review of general and subspecialty medical admissions triggering a MET call within 24 h of admission at a quaternary Australian hospital.

RESULTS

2648 MET calls occurred (47.9/1000 admissions), 527 (20% of total MET events, 9.5/1000 admissions) within 24 h of admission, with the trigger more likely to be hypotension (odds ratio: 1.5, P = 0.0013). There were 263 MET calls to 217 individual medical patients within 24 h of admission, of which 84 (38.7%) were admitted with suspected infection, 69% of which fulfilled sepsis criteria. Of these, 36.2% received antimicrobial therapy within the recommended timeframe and 39.6% received antibiotics in line with hospital guidelines. Sepsis was initially missed in 11% of patients. Afferent limb failure occurred in 29% of patients with 40.5% experiencing a failure of the ward-based response to deterioration prior to MET call. Median hospital length of stay was increased in patients admitted with suspected infection (7 vs 5 days, P = 0.015) and in those with sepsis not receiving antimicrobial therapy within guideline timeframes (9 vs 4 days, P = 0.017).

CONCLUSION

There is a significant opportunity to improve care for patients who trigger a MET within 24 h of admission. This study supports the implementation of a hospital sepsis management guideline.

Breaches of pre-medical emergency team call criteria in an Australian hospital

Objectives and outcomes

To evaluate the 24hrs before medical emergency team (MET) calls to examine: 1) the frequency, nature, and timing of pre-MET criteria breaches; 2) differences in characteristics and outcomes between patients who did and didn't experience pre-MET breaches.

Design

Retrospective observational study November 2020-June 2021.

Setting

Tertiary referral Australian hospital.

Participants

Adults (≥18 years) experiencing MET calls.

Results

Breaches in pre-MET criteria occurred prior to 1886/2255 (83.6%) MET calls, and 1038/1281 (81.0%) of the first MET calls. Patients with pre-MET breaches were older (median [IQR] 72 [57-81] vs 66 [56-77] yrs), more likely to be admitted from home (87.8% vs 81.9%) and via the emergency department (73.0% vs 50.2%), but less likely to be for full resuscitation after (67.3% vs 76.5%) the MET. The three most common pre-MET breaches were low SpO2 (48.0%), high pulse rate (39.8%), and low systolic blood pressure (29.0%) which were present for a median (IQR) of 15.4 (7.5-20.8), 13.2 (4.3-21.0), and 12.6 (3.5-20.1) hrs before the MET call, respectively. Patients with pre-MET breaches were more likely to need intensive care admission within 24 h (15.6 vs 11.9%), have repeat MET calls (33.3 vs 24.7%), and die in hospital (15.8 vs 9.9%).

Conclusions

Four-fifths of MET calls were preceded by pre-MET criteria breaches, which were present for many hours. Such patients were older, had more limits of treatment, and experienced worse outcomes. There is a need to improve goals of care documentation and pre-MET management of clinical deterioration.

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.

The illness severity of ward remaining patients reviewed by the medical emergency team: A retrospective cohort study

BACKGROUND

Although progress has been made in identifying and responding to acutely deteriorating ward patients, judgements about the level of care required for patients after medical emergency team review are complex, rarely including a formal assessment of illness severity. This challenges staff and resource management practices and patient safety.

OBJECTIVE

This study sought to quantify the illness severity of ward patients after medical emergency team review.

RESEARCH DESIGN AND SETTING

This retrospective cohort study examined the clinical records of 1500 randomly sampled adult ward patients following medical emergency team review at a metropolitan tertiary hospital. Outcome measures were the derivation of patient acuity and dependency scores using sequential organ failure assessment and nursing activities score instruments. Findings are reported using the STROBE guideline for cohort studies.

NO PATIENT OR PUBLIC CONTRIBUTION

No direct patient contact was made during the data collection and analysis phases of the study.

RESULTS

Patients were male (52.6%), unplanned (73.9%) medical admissions (57.5%), median age of 67 years. The median sequential organ failure assessment score was 4% and 20% of patients demonstrated multiple organ system failure requiring non typical monitoring and coordination arrangements for at least 24 h. The median nursing activities score was 86% suggestive of a near 1:1 nurse-to-patient ratio. More than half of all patients required enhanced levels of assistance with mobilization (58.8%) and hygiene (53.9%) activities.

CONCLUSIONS

Patients who remain on the ward following medical emergency team review had complex combinations of organ dysfunction, with levels of dependency similar to those found in intensive care units. This has implications for ward and patient safety and continuity of care arrangements.

RELEVANCE TO CLINICAL PRACTICE

Profiling illness severity at the conclusion of the medical emergency team review may help determine the need for special resource and staffing arrangements or placement within the ward environment.

Exploring interdisciplinary communication pathways for escalating pre-medical emergency team deterioration: a mixed-methods study

Objective To explore clinicians' use and perceptions of interdisciplinary communication pathways for escalating care within the pre-medical emergency team (pre-MET) tier of rapid response systems. Method A sequential mixed-methods study was conducted using observations and interviews. Participants were clinicians (nurses, allied health, doctors) caring for orthopaedic and general medicine patients at one hospital. Descriptive and thematic analyses were conducted. Results Escalation practices were observed for 13 of 27 pre-MET events. Leading communication methods for escalating pre-MET events were alphanumeric pagers (61.5%) and in-person discussions (30.8%). Seven escalated pre-MET events led to bedside pre-MET reviews by doctors. Clinician interviews (n  = 29) culminated in two themes: challenges in escalation of care, and navigating information gaps. Clinicians reported deficiencies in communication methods for escalating care that hindered interdisciplinary communication and clinical decision-making pertaining to pre-MET deterioration. Conclusion Policy-defined escalation pathways were inconsistently utilised for pre-MET deterioration. Available communication methods for escalating pre-MET events inadequately fulfilled clinicians' needs. Variable perceptions of escalation pathways illuminated a lack of of a shared mental model about clinicians' roles and responsibilities. To optimise timely and appropriate management of patient deterioration, communication infrastructure and interdisciplinary collaboration must be enhanced.

Use of pager devices in New Zealand public hospitals as a critical communication tool: Barriers & way forward

OBJECTIVES

The aim of this study was to analyse the current use, identify challenges and barriers and propose a way forward for the use of the pager devices in the in-hospital communications.

METHODS

Initially, 447 studies were identified through database searching. After checking against the eligibility, 39 studies were included. Full-text records were retrieved and reviewed by two authors. After excluding unrelated studies and duplicate records, a total of 12 articles were selected for the final review.

RESULTS

The use of pagers often lacks standardisation, content, format, urgency level, and clarity within the message. Some studies reported that medical staff preferred in-person interactions with consults instead of communicating over the phone or pagers. Productive communication can reduce the turnaround time by up to 50%. The key challenges are; (1) data security and privacy, (2) timely acknowledgement of received communication, (3) lack of two-way communications causing issues in critical care situations and (4) there is no standard process for the in-hospital communications.

CONCLUSION

We found that the clinicians' age, experience, speciality and preferences greatly matter and influence the selection of tools and technology in healthcare. With revolutionary advances in technology, smartphones have inevitably become beneficial to healthcare, owing to multiple instant messaging applications (apps) that can streamline encrypted clinical communication between medical teams and could be safely used for in-hospital communications.

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.

Frequency and nature of medical emergency team afferent limb failure in patients with documented vital sign abnormalities: A retrospective point prevalence study

BACKGROUND

Medical emergency team (MET) afferent limb failure is the presence of MET triggers and the absence of a documented MET call.

OBJECTIVES

The aim of this study was to measure and understand the frequency and nature of MET afferent limb failure in patients with documented vital sign abnormalities in an Australian major teaching hospital.

METHODS

A retrospective point prevalence study was conducted at a 600-bed teaching hospital in Melbourne, Australia. Data were collected for all adult inpatients (aged ≥18 years) on 13 wards (three general medicine, three surgical, and seven specialist wards) during a randomly selected 24-h period. Data were extracted from the electronic medical record.

RESULTS

There were 357 patients included in the study, with a median age of 72 y. Of the 9716 vital sign measures extracted, 0.9% fulfilled patient-specific MET activation criteria. There were 93 MET triggers documented in 36 patients: 25 patients experienced MET afferent limb failure. The major issues related to MET afferent limb failure were MET trigger modification processes, resolution of vital sign abnormalities, alternative escalation of care, and limitations of medical treatment orders without specific modifications to MET triggers.

CONCLUSIONS

Mandating MET activation for one aberrant vital sign at a single point in time warrants further assessment: lack of timely vital sign resolution may be a more appropriate trigger for MET calls and should be formally tested in future research. The frequency and effectiveness of alternative escalation pathways and local management of patients with MET triggers also warrant further investigation.

Safe transfer of pediatric patients from hematopoietic stem cell transplant unit into the pediatric intensive care unit: views of nurses and physicians

Sufficient communication between hematopoietic stem cell transplantation (HSCT) and pediatric intensive care unit (PICU) teams is pivotal for a successful advanced support in the PICU for HSCT-related complications. We evaluated perceived communication and barriers between both teams with the aim of providing recommendations for improvement. In this cross-sectional survey, a self-designed online questionnaire was distributed among ESPNIC and EBMT members. Data were analyzed using descriptive statistics. Over half of HSCT respondents employed a transfer indication protocol and patient assessment tool, but less structured checklist prior to patient transfer. Nearly all PICU respondents perceived this checklist as improvement for communication. Most HSCT and PICU physicians have daily rounds upon patient transfer while this is mostly missing between nursing teams. Half of both HSCT and PICU nurses indicated that HSCT training for PICU nurses could improve communication and patient transfer. Most respondents indicated that structured meetings between HSCT and PICU nurses could improve communication. Overall there is good communication between HSCT and PICU units, although barriers were noted between members of both teams. Based on our findings, we recommend use of a structured and specific checklist by HSCT teams, HSCT training for PICU personnel, and structured meetings between HSCT and PICU nurses.

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

AIMS AND OBJECTIVES

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

BACKGROUND

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

DESIGN

Hermeneutic Phenomenology.

METHODS

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

RESULTS

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

CONCLUSIONS

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

RELEVANCE TO CLINICAL PRACTICE

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