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Le Lagadec MD, Dwyer T, Browne M. Indicators of patient deterioration in poorly resourced private hospitals: Which vital sign to watch? A retrospective case-control study. Aust Crit Care 2024; 37:461-467. [PMID: 37391286 DOI: 10.1016/j.aucc.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 05/26/2023] [Accepted: 05/27/2023] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND Patient vital signs are a measure of wellness if monitored regularly and accurately. Staff shortages in poorly resourced regional hospitals often result in inadequate patient monitoring, putting patients at risk of undetected deterioration. OBJECTIVE This study aims to explore the pattern and completeness of vital sign monitoring and the contribution of each vital sign in predicting clinical deterioration events in resource-poor regional/rural hospitals. METHOD Using a retrospective case-control study design, we compared 24 h of vital sign data from deteriorating and nondeteriorating patients from two poorly-resourced regional hospitals. Descriptive statistics, t-tests, and analysis of variance are used to compare patient-monitoring frequency and completeness. The contribution of each vital sign in predicting patient deterioration was determined using the Area Under the Receiver Operator Characteristic curve and binary logistical regression analysis. RESULTS Deteriorating patients were monitored more frequently (9.58 [7.02] times) in the 24-h period than nondeteriorating patients (4.93 [2.66] times). However, the completeness of vital sign documentation was higher in nondeteriorating (85.2%) than in deteriorating patients (57.7%). Body temperature was the most frequently omitted vital sign. Patient deterioration was positively linked to the frequency of abnormal vital signs and the number of abnormal vital signs per set (Area Under the Receiver Operator Characteristic curve: 0.872 and 0.867, respectively). No single vital sign strongly predicts patient outcomes. However, a supplementary oxygen value of >3 L/min and a heart rate of >139 beats/min were the best predictors of patient deterioration. CONCLUSION Given the poor resourcing and often geographical remoteness of small regional hospitals, it is prudent that the nursing staff are made aware of the vital signs that best indicate deterioration for the cohort of patients in their care. Tachycardic patients on supplementary oxygen are at high risk of deterioration.
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Affiliation(s)
- Marie Danielle Le Lagadec
- School of Nursing, Midwifery and Social Sciences, Central Queensland, University, 6 University Dr, Branyan, Bundaberg, Queensland, 4670, Australia.
| | - Trudy Dwyer
- School of Nursing, Midwifery and Social Sciences, Central Queensland, University, 554-700 Yaamba Rd, Norman Gardens Rockhampton, Queensland, 4701, Australia.
| | - Matthew Browne
- School of Health, Medical and Applied Sciences Central Queensland, University, 6 University Dr, Branyan, Bundaberg Queensland, 4670, Australia.
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Doyon O, Raymond L. Surveillance and patient safety in nursing research: A bibliometric analysis from 1993 to 2023. J Adv Nurs 2024; 80:777-788. [PMID: 37458320 DOI: 10.1111/jan.15793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/20/2023] [Accepted: 07/03/2023] [Indexed: 07/29/2023]
Abstract
AIMS To identify and characterize the thematic foci, structure and evolution of nursing research on surveillance and patient safety. DESIGN Bibliometric analysis. METHODS Bibliometric methods were employed to analyse 1145 articles, using Bibliometrix and VOSviewer software. DATA SOURCE The Scopus bibliographic database was searched on April 7, 2023. RESULTS A keyword co-occurrence analysis found the most frequently occurring keywords to be: patient safety, nursing, nurses, adverse events, monitoring, critical care, quality improvement, vital signs, safety, alarm fatigue, education, nursing care, surveillance, clinical alarms, failure to rescue, evidence-based practice, acute care, clinical deterioration, communication, intensive care. Network mapping, clustering and time-tracking of the keywords revealed the focal themes, structure and evolution of the research field. CONCLUSION By assessing critical areas of the nursing research field, this study extends and enriches the current discourse on surveillance and patient safety for nursing researchers and practitioners. Critical challenges still have to be met by nurses, however, including the failure to rescue deteriorating patients. Further knowledge and understanding of surveillance and patient safety must be successfully translated from research to practice. IMPLICATIONS FOR THE PROFESSION This study highlights the gaps in nursing knowledge with regard to surveillance and patient safety and encourages nursing professionals to turn to evidence-based surveillance practices. IMPACT In addressing the problem of surveillance and its effect on patient safety, this study found that, in most clinical care settings, preventing failures to rescue and adverse patient outcomes still remains a challenge for the nursing profession. This study should have an impact on nursing academics' future research themes and on nursing professionals' future clinical practices. REPORTING METHOD Relevant EQUATOR guidelines have been adhered to by employing recognized bibliometric reporting methods.
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Affiliation(s)
- Odette Doyon
- Université du Québec à Trois-Rivières, Trois-Rivières, Quebec, Canada
| | - Louis Raymond
- Université du Québec à Trois-Rivières, Trois-Rivières, Quebec, Canada
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3
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Honarmand K, Wax RS, Penoyer D, Lighthall G, Danesh V, Rochwerg B, Cheatham ML, Davis DP, DeVita M, Downar J, Edelson D, Fox-Robichaud A, Fujitani S, Fuller RM, Haskell H, Inada-Kim M, Jones D, Kumar A, Olsen KM, Rowley DD, Welch J, Baldisseri MR, Kellett J, Knowles H, Shipley JK, Kolb P, Wax SP, Hecht JD, Sebat F. Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU: 2023. Crit Care Med 2024; 52:314-330. [PMID: 38240510 DOI: 10.1097/ccm.0000000000006072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
RATIONALE Clinical deterioration of patients hospitalized outside the ICU is a source of potentially reversible morbidity and mortality. To address this, some acute care hospitals have implemented systems aimed at detecting and responding to such patients. OBJECTIVES To provide evidence-based recommendations for hospital clinicians and administrators to optimize recognition and response to clinical deterioration in non-ICU patients. PANEL DESIGN The 25-member panel included representatives from medicine, nursing, respiratory therapy, pharmacy, patient/family partners, and clinician-methodologists with expertise in developing evidence-based Clinical Practice Guidelines. METHODS We generated actionable questions using the Population, Intervention, Control, and Outcomes (PICO) format and performed a systematic review of the literature to identify and synthesize the best available evidence. We used the Grading of Recommendations Assessment, Development, and Evaluation Approach to determine certainty in the evidence and to formulate recommendations and good practice statements (GPSs). RESULTS The panel issued 10 statements on recognizing and responding to non-ICU patients with critical illness. Healthcare personnel and institutions should ensure that all vital sign acquisition is timely and accurate (GPS). We make no recommendation on the use of continuous vital sign monitoring among unselected patients. We suggest focused education for bedside clinicians in signs of clinical deterioration, and we also suggest that patient/family/care partners' concerns be included in decisions to obtain additional opinions and help (both conditional recommendations). We recommend hospital-wide deployment of a rapid response team or medical emergency team (RRT/MET) with explicit activation criteria (strong recommendation). We make no recommendation about RRT/MET professional composition or inclusion of palliative care members on the responding team but suggest that the skill set of responders should include eliciting patients' goals of care (conditional recommendation). Finally, quality improvement processes should be part of a rapid response system. CONCLUSIONS The panel provided guidance to inform clinicians and administrators on effective processes to improve the care of patients at-risk for developing critical illness outside the ICU.
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Affiliation(s)
- Kimia Honarmand
- Division of Critical Care, Department of Medicine, Mackenzie Health, Vaughan, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Randy S Wax
- Department of Critical Care Medicine, Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
- Department of Critical Care, Lakeridge Health, Oshawa, ON, Canada
| | - Daleen Penoyer
- Center for Nursing Research and Advanced Nursing Practice, Orlando Health, Orlando, FL
| | - Geoffery Lighthall
- Department of Anesthesia, Pain, and Perioperative Medicine, Stanford University School of Medicine, Palo Alto, CA
- Veterans Affairs Medical Center, Palo Alto, CA
| | - Valerie Danesh
- Center for Applied Health Research, Baylor Scott and White Health, Dallas, TX
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, Mackenzie Health, Vaughan, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Michael L Cheatham
- Division of Surgical Education, Orlando Regional Medical Center, Orlando, FL
| | | | - Michael DeVita
- Columbia Vagelos College of Physicians and Surgeons, Department of Medicine Harlem Hospital Medical Center, New York City, NY
| | - James Downar
- Division of Critical Care, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Dana Edelson
- Division of Internal Medicine, Department of Medicine, University of Chicago Medical Center, Chicago, IL
| | - Alison Fox-Robichaud
- Division of Critical Care, Department of Internal Medicine, Thrombosis and Atherosclerosis Research Institute, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Shigeki Fujitani
- Division of Critical Care, Department of Emergency Medicine, Saint Marianna University, Kawasaki, Japan
| | - Raeann M Fuller
- Division of Trauma and Critical Care, Department of Emergency Medicine, Advocate Condell Medical Center, Libertyville, IL
| | | | - Matthew Inada-Kim
- Department of Acute Medicine, Hampshire Hospitals NHS Foundation Trust and University of Southampton, Southampton, United Kingdom
| | - Daryl Jones
- Division of Surgery, Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Anand Kumar
- Division of Critical Care, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Keith M Olsen
- University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE
| | - Daniel D Rowley
- Respiratory Therapy Services, University of Virginia Medical Center, Charlottesville, VA
| | - John Welch
- Critical Care Unit, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Marie R Baldisseri
- Department of Critical Care, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - John Kellett
- Department of Emergency Medicine, University of Southern Denmark, Odense, Denmark
| | - Heidi Knowles
- Department of Emergency Medicine, John Peter Smith Health Network, Fort Worth, TX
| | - Jonathan K Shipley
- Division of Critical Care, Vanderbilt University Medical Center, Nashville, TN
| | - Philipp Kolb
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Family Medicine, Dalhousie University, Halifax, ON, Canada
| | - Sophie P Wax
- Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
| | - Jonathan D Hecht
- School of Nursing, The University of Texas at Austin, Austin, TX
| | - Frank Sebat
- Division of Internal Medicine, Mercy Medical Center, Redding, CA
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4
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Honarmand K, Wax RS, Penoyer D, Lighthall G, Danesh V, Rochwerg B, Cheatham ML, Davis DP, DeVita M, Downar J, Edelson D, Fox-Robichaud A, Fujitani S, Fuller RM, Haskell H, Inada-Kim M, Jones D, Kumar A, Olsen KM, Rowley DD, Welch J, Baldisseri MR, Kellett J, Knowles H, Shipley JK, Kolb P, Wax SP, Hecht JD, Sebat F. Executive Summary: Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU. Crit Care Med 2024; 52:307-313. [PMID: 38240509 DOI: 10.1097/ccm.0000000000006071] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
RATIONALE Clinical deterioration of patients hospitalized outside the ICU is a source of potentially reversible morbidity and mortality. To address this, some acute care facilities have implemented systems aimed at detecting and responding to such patients. OBJECTIVES To provide evidence-based recommendations for hospital clinicians and administrators to optimize recognition and response to clinical deterioration in non-ICU patients. PANEL DESIGN The 25-member panel included representatives from medicine, nursing, respiratory therapy, pharmacy, patient/family partners, and clinician-methodologists with expertise in developing evidence-based clinical practice guidelines. METHODS We generated actionable questions using the Population, Intervention, Control, and Outcomes format and performed a systematic review of the literature to identify and synthesize the best available evidence. We used the Grading of Recommendations Assessment, Development, and Evaluation approach to determine certainty in the evidence and to formulate recommendations and good practice statements (GPSs). RESULTS The panel issued 10 statements on recognizing and responding to non-ICU patients with critical illness. Healthcare personnel and institutions should ensure that all vital sign acquisition is timely and accurate (GPS). We make no recommendation on the use of continuous vital sign monitoring among "unselected" patients due to the absence of data regarding the benefit and the potential harms of false positive alarms, the risk of alarm fatigue, and cost. We suggest focused education for bedside clinicians in signs of clinical deterioration, and we also suggest that patient/family/care partners' concerns be included in decisions to obtain additional opinions and help (both conditional recommendations). We recommend hospital-wide deployment of a rapid response team or medical emergency team (RRT/MET) with explicit activation criteria (strong recommendation). We make no recommendation about RRT/MET professional composition or inclusion of palliative care members on the responding team but suggest that the skill set of responders should include eliciting patients' goals of care (conditional recommendation). Finally, quality improvement processes should be part of a rapid response system (GPS). CONCLUSIONS The panel provided guidance to inform clinicians and administrators on effective processes to improve the care of patients at-risk for developing critical illness outside the ICU.
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Affiliation(s)
- Kimia Honarmand
- Division of Critical Care, Department of Medicine, Mackenzie Health, Vaughan, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Randy S Wax
- Department of Critical Care Medicine, Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
- Department of Critical Care, Lakeridge Health, Oshawa, ON, Canada
| | - Daleen Penoyer
- Center for Nursing Research and Advanced Nursing Practice, Orlando Health, Orlando, FL
| | - Geoffery Lighthall
- Department of Anesthesia, Pain, and Perioperative Medicine, Stanford University School of Medicine, Palo Alto, CA
- Veterans Affairs Medical Center, Palo Alto, CA
| | - Valerie Danesh
- Center for Applied Health Research, Baylor Scott and White Health, Dallas, TX
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, Mackenzie Health, Vaughan, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Michael L Cheatham
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL
| | | | - Michael DeVita
- Columbia Vagelos College of Physicians and Surgeons, Department of Medicine Harlem Hospital Medical Center, New York City, NY
| | - James Downar
- Division of Critical Care, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Dana Edelson
- Division of Internal Medicine, Department of Medicine, University of Chicago Medical Center, Chicago, IL
| | - Alison Fox-Robichaud
- Division of Critical Care, Department of Internal Medicine, Thrombosis and Atherosclerosis Research Institute, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Shigeki Fujitani
- Division of Critical Care, Department of Emergency Medicine, Saint Marianna University, Kawasaki, Japan
| | - Raeann M Fuller
- Division of Trauma and Critical Care, Department of Emergency Medicine, Advocate Condell Medical Center, Libertyville, IL
| | | | - Matthew Inada-Kim
- Department of Acute Medicine, Hampshire Hospitals NHS Foundation Trust and University of Southampton, Southampton, United Kingdom
| | - Daryl Jones
- Division of Surgery, Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Anand Kumar
- Division of Critical Care, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Keith M Olsen
- University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE
| | - Daniel D Rowley
- Respiratory Therapy Services, University of Virginia Medical Center, Charlottesville, VA
| | - John Welch
- Critical Care Unit, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Marie R Baldisseri
- Department of Critical Care, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - John Kellett
- Department of Emergency Medicine, University of Southern Denmark, Odense, Denmark
| | - Heidi Knowles
- Department of Emergency Medicine, John Peter Smith Health Network, Fort Worth, TX
| | - Jonathan K Shipley
- Division of Critical Care, Vanderbilt University Medical Center, Nashville, TN
| | - Philipp Kolb
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Family Medicine, Dalhousie University, Halifax, NS, Canada
| | - Sophie P Wax
- Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
| | - Jonathan D Hecht
- School of Nursing, The University of Texas at Austin, Austin, TX
| | - Frank Sebat
- Division of Internal Medicine, Mercy Medical Center, Redding, CA
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Snarskis C, Banerjee A, Franklin A, Weavind L. Systems of Care Delivery and Optimization in the Postoperative Care Wards. Anesthesiol Clin 2023; 41:875-886. [PMID: 37838390 DOI: 10.1016/j.anclin.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
A third of all patients are at risk for a serious adverse event, including death, in the first month after undergoing a major surgery. Most of these events will occur within 24 hours of the operation but are unlikely to occur in the operating room or postanesthesia care unit. Most opioid-induced respiratory depression events in the postoperative period resulted in death (55%) or anoxic brain injury (22%). A future state of mature artificial intelligence and machine learning will improve situational awareness of acute clinical deterioration, minimize alert fatigue, and facilitate early intervention to minimize poor outcomes.
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Affiliation(s)
- Connor Snarskis
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Arna Banerjee
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Andrew Franklin
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Liza Weavind
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA.
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6
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Benson B, Belle A, Lee S, Bassin BS, Medlin RP, Sjoding MW, Ward KR. Prediction of episode of hemodynamic instability using an electrocardiogram based analytic: a retrospective cohort study. BMC Anesthesiol 2023; 23:324. [PMID: 37737164 PMCID: PMC10515416 DOI: 10.1186/s12871-023-02283-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 09/14/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Predicting the onset of hemodynamic instability before it occurs remains a sought-after goal in acute and critical care medicine. Technologies that allow for this may assist clinicians in preventing episodes of hemodynamic instability (EHI). We tested a novel noninvasive technology, the Analytic for Hemodynamic Instability-Predictive Indicator (AHI-PI), which analyzes a single lead of electrocardiogram (ECG) and extracts heart rate variability and morphologic waveform features to predict an EHI prior to its occurrence. METHODS Retrospective cohort study at a quaternary care academic health system using data from hospitalized adult patients between August 2019 and April 2020 undergoing continuous ECG monitoring with intermittent noninvasive blood pressure (NIBP) or with continuous intraarterial pressure (IAP) monitoring. RESULTS AHI-PI's low and high-risk indications were compared with the presence of EHI in the future as indicated by vital signs (heart rate > 100 beats/min with a systolic blood pressure < 90 mmHg or a mean arterial blood pressure of < 70 mmHg). 4,633 patients were analyzed (3,961 undergoing NIBP monitoring, 672 with continuous IAP monitoring). 692 patients had an EHI (380 undergoing NIBP, 312 undergoing IAP). For IAP patients, the sensitivity and specificity of AHI-PI to predict EHI was 89.7% and 78.3% with a positive and negative predictive value of 33.7% and 98.4% respectively. For NIBP patients, AHI-PI had a sensitivity and specificity of 86.3% and 80.5% with a positive and negative predictive value of 11.7% and 99.5% respectively. Both groups performed with an AUC of 0.87. AHI-PI predicted EHI in both groups with a median lead time of 1.1 h (average lead time of 3.7 h for IAP group, 2.9 h for NIBP group). CONCLUSIONS AHI-PI predicted EHIs with high sensitivity and specificity and within clinically significant time windows that may allow for intervention. Performance was similar in patients undergoing NIBP and IAP monitoring.
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Affiliation(s)
- Bryce Benson
- Fifth Eye Inc, 110 Miller Avenue, Suite 300, Ann Arbor, MI, 48104, USA
| | - Ashwin Belle
- Fifth Eye Inc, 110 Miller Avenue, Suite 300, Ann Arbor, MI, 48104, USA
| | - Sooin Lee
- Fifth Eye Inc, 110 Miller Avenue, Suite 300, Ann Arbor, MI, 48104, USA
| | - Benjamin S Bassin
- Department of Emergency Medicine, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI, 48109-5301, USA
- Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, NCRC 10-A103 2800 Plymouth Road, Ann Arbor, MI, 48109, USA
| | - Richard P Medlin
- Department of Emergency Medicine, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI, 48109-5301, USA
- Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, NCRC 10-A103 2800 Plymouth Road, Ann Arbor, MI, 48109, USA
| | - Michael W Sjoding
- Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, NCRC 10-A103 2800 Plymouth Road, Ann Arbor, MI, 48109, USA
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI, 48109-5642, USA
| | - Kevin R Ward
- Department of Emergency Medicine, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI, 48109-5301, USA.
- Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, NCRC 10-A103 2800 Plymouth Road, Ann Arbor, MI, 48109, USA.
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7
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Jones D. The medical emergency team - current status and future directions: a perspective for acute care physicians. Intern Med J 2023; 53:888-891. [PMID: 37349279 DOI: 10.1111/imj.16118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 03/28/2023] [Indexed: 06/24/2023]
Affiliation(s)
- Daryl Jones
- Intensive Care Unit, Austin Hospital, Melbourne, Victoria, Australia
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Liu Q, Zheng X, Xu L, Chen Q, Zhou F, Peng L. The effectiveness of education strategies for nurses to recognise and manage clinical deterioration: A systematic review. NURSE EDUCATION TODAY 2023; 126:105838. [PMID: 37172445 DOI: 10.1016/j.nedt.2023.105838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 04/14/2023] [Accepted: 04/30/2023] [Indexed: 05/15/2023]
Abstract
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.
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Affiliation(s)
- Qingqing Liu
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University, Changsha, Hunan, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China; Xiangya School of Nursing, Central South University, Changsha, Hunan, China
| | - Xilin Zheng
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University, Changsha, Hunan, China; Xiangya School of Nursing, Central South University, Changsha, Hunan, China
| | - Laiyu Xu
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University, Changsha, Hunan, China; Xiangya School of Nursing, Central South University, Changsha, Hunan, China
| | - Qirong Chen
- Xiangya School of Nursing, Central South University, Changsha, Hunan, China; Xiangya Center for Evidence-based Nursing Practice and Healthcare Innovation: A JBI Affiliated Group, Changsha, Hunan, China
| | - Fangyi Zhou
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University, Changsha, Hunan, China; Emergency Department, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Lingli Peng
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University, Changsha, Hunan, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China; Orthopedics Department, Xiangya Hospital, Central South University, Changsha, Hunan, China.
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9
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O'Connell A, Flabouris A, Edwards S, Thompson CH. Tiered escalation response systems in practice: A post hoc analysis examining the workload implications. CRIT CARE RESUSC 2023; 25:47-52. [PMID: 37876991 PMCID: PMC10581276 DOI: 10.1016/j.ccrj.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
Objective Many rapid response systems now have multiple tiers of escalation in addition to the traditional single tier of a medical emergency team. Given that the benefit to patient outcomes of this change is unclear, we sought to investigate the workload implications of a multitiered system, including the impact of trigger modification. Design The study design incorporated a post hoc analysis using a matched case-control dataset. Setting The study setting was an acute, adult tertiary referral hospital. Participants Cases that had an adverse event (cardiac arrest or unanticipated intensive care unit admission) or a rapid response team (RRT) call participated in the study. Controls were matched by age, gender, ward and time of year, and no adverse event or RRT call. Participants were admitted between May 2014 and April 2015. Main outcome measures The main outcome measure were the number of reviews, triggers, and modifications across three tiers of escalation; a nurse review, a multidisciplinary review (MDT-admitting medical team review), and an RRT call. Results There were 321 cases and 321 controls. Overall, there were 1948 nurse triggers, of which 1431 (73.5%) were in cases and 517 (26.5%) in controls, 798 MDT triggers (660 [82.7%] in cases and 138 [17.3%] in controls), and 379 RRT triggers (351 [92.6%] in cases and 28 [7.4%] in controls). Per patient per 24 h, there were 3.03 nurse, 1.24 MDT, and 0.59 RRT triggers. Accounting for modifications, this reduced to 2.17, 0.88, and 0.42, respectively. The proportion of triggers that were modified, so as not to trigger a review, was similar across all the tiers, being 28.6% of nurse, 29.6% of MDT, and 28.2% of RRT triggers. Per patient per 24 h, there were 0.61 nurse reviews, 0.52 MDT reviews, and 0.08 RRT reviews. Conclusions Lower-tier triggers were more prevalent, and modifications were common. Modifications significantly mitigated the escalation workload across all tiers of a multitiered system.
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Affiliation(s)
- Alice O'Connell
- Consultant, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Arthas Flabouris
- Consultant, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Suzanne Edwards
- Statistician, Adelaide Health Technology Assessment, School of Public Health, The University of Adelaide, South Australia, Australia
| | - Campbell H. Thompson
- Consultant, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
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10
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Chambers S, Spooner A, Parker C, Jack L, Schnitker L, Beattie E, Yates P, MacAndrew M. Clinical indicators of acute deterioration in persons who reside in residential aged care facilities: A rapid review. J Nurs Scholarsh 2023; 55:365-377. [PMID: 36264005 PMCID: PMC10092821 DOI: 10.1111/jnu.12819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 07/29/2022] [Accepted: 09/14/2022] [Indexed: 01/04/2023]
Abstract
PURPOSE To identify the clinical indicators of acute deterioration in residents and the factors that influence residential aged care facility staff's identification of these. DESIGN Rapid review and narrative synthesis. METHODS The WHO and Cochrane Rapid Review Methods Group recommendations guided the review processes. CINAHL, Medline, PubMed, and the Cochrane Library were searched from 2000 to January 2022. Data related to clinical indicators of deterioration were categorized using the Airway, Breathing, Circulation, Disability, Exposure assessment framework, and factors influencing detection were grouped as consumer (resident and family), aged care workforce, and organization factors. RESULTS Twenty publications were included of which 14 informed clinical indicators; nine highlighted factors that influence staff's identification of these and three informed both. Included article were collectively below moderate quality. Most clinical indicators were grouped into the 'Disability' category with altered level of consciousness, behavior, and pain identified most frequently. Few studies reported more traditional indicators of deterioration used in the general population - changes in vital signs. The most common factors influencing the detection of acute deterioration were organizational and workforce-related including resource, knowledge, and confidence deficits. CONCLUSION Findings suggest subtle changes in resident's health status, rather than focusing primarily on physiologic parameters used in early warning tools for acute care settings, should be recognized and considered in the design of early warning tools for residential aged care facilities. CLINICAL RELEVANCE Early warning tools sensitive to the unique needs of residents and support for aged care facility staff are recommended to improve the capacity of aged care facility care staff to identify and manage acute deterioration early to avoid hospitalization.
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Affiliation(s)
- Shirley Chambers
- School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Amy Spooner
- School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Christina Parker
- School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Leanne Jack
- School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia.,School of Nursing, Midwifery and Social Sciences, Central Queensland University, Brisbane, Queensland, Australia
| | - Linda Schnitker
- School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia.,Bolton Clarke, Kelvin Grove, Queensland, Australia
| | - Elizabeth Beattie
- School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia.,Dementia Collaborative Research Centre, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Patsy Yates
- Faculty of Health, Office of the Executive Dean, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Margaret MacAndrew
- School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia.,Dementia Collaborative Research Centre, Queensland University of Technology, Brisbane, Queensland, Australia
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11
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Schmitzberger FF, Hall AE, Hughes ME, Belle A, Benson B, Ward KR, Bassin BS. Detection of Hemodynamic Status Using an Analytic Based on an Electrocardiogram Lead Waveform. Crit Care Explor 2022; 4:e0693. [PMID: 35620767 PMCID: PMC9116956 DOI: 10.1097/cce.0000000000000693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Delayed identification of hemodynamic deterioration remains a persistent issue for in-hospital patient care. Clinicians continue to rely on vital signs associated with tachycardia and hypotension to identify hemodynamically unstable patients. A novel, noninvasive technology, the Analytic for Hemodynamic Instability (AHI), uses only the continuous electrocardiogram (ECG) signal from a typical hospital multiparameter telemetry monitor to monitor hemodynamics. The intent of this study was to determine if AHI is able to predict hemodynamic instability without the need for continuous direct measurement of blood pressure. DESIGN Retrospective cohort study. SETTING Single quaternary care academic health system in Michigan. PATIENTS Hospitalized adult patients between November 2019 and February 2020 undergoing continuous ECG and intra-arterial blood pressure monitoring in an intensive care setting. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One million two hundred fifty-two thousand seven hundred forty-two 5-minute windows of the analytic output were analyzed from 597 consecutive adult patients. AHI outputs were compared with vital sign indications of hemodynamic instability (heart rate > 100 beats/min, systolic blood pressure < 90 mm Hg, and shock index of > 1) in the same window. The observed sensitivity and specificity of AHI were 96.9% and 79.0%, respectively, with an area under the curve (AUC) of 0.90 for heart rate and systolic blood pressure. For the shock index analysis, AHI's sensitivity was 72.0% and specificity was 80.3% with an AUC of 0.81. CONCLUSIONS The AHI-derived hemodynamic status appropriately detected the various gold standard indications of hemodynamic instability (hypotension, tachycardia and hypotension, and shock index > 1). AHI may provide continuous dynamic hemodynamic monitoring capabilities in patients who traditionally have intermittent static vital sign measurements.
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Affiliation(s)
| | - Ashley E Hall
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, MI
| | - Morgan E Hughes
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, MI
| | | | | | - Kevin R Ward
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, MI
- Department of Emergency Medicine, Division of Critical Care, Michigan Medicine, Ann Arbor, MI
- Max Harry Weil Institute for Critical Care Research and Innovation, Michigan Medicine, Ann Arbor, MI
| | - Benjamin S Bassin
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, MI
- Department of Emergency Medicine, Division of Critical Care, Michigan Medicine, Ann Arbor, MI
- Max Harry Weil Institute for Critical Care Research and Innovation, Michigan Medicine, Ann Arbor, MI
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12
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Burke C, Conway Y. Factors that influence hospital nurses' escalation of patient care in response to their early warning score: A qualitative evidence synthesis. J Clin Nurs 2022; 32:1885-1934. [PMID: 35338540 DOI: 10.1111/jocn.16233] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 01/18/2022] [Accepted: 01/19/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The Early Warning Score (EWS) is a validated tool that has improved patient outcomes internationally. This scoring system is used within the hospital setting to identify potentially deteriorating patients, thus expediting referral to appropriate medical personnel. It is increasingly recognised that there are other influencing factors along with EWS, which impact on nurses' decisions to escalate care. AIM The aim of this review was to identify and synthesise data from qualitative studies, which examined factors influencing nurses' escalation of care in response to patients' EWS. METHODS The systematic search strategy and eligibility criteria were guided by the SPIDER (Sample Phenomenon of Interest Design Evaluation Type of Research) framework. Eleven databases and five grey literature databases were searched. Titles and abstracts were independently screened in line with pre-established inclusion and exclusion criteria using the cloud-based platform, Rayyan. The selected studies underwent quality appraisal using CASP (Critical Appraisal Skills Programme, 2017, https://www.casp-uk.net/casp-toolschecklists) and subsequently synthesised using Thomas and Harden's thematic analysis approach. GRADE-CERQual (Grading of Recommendations Assessment Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research) was used to assess confidence in results. The EQUATOR listed guideline ENTREQ (Tong et al., 2012, BMC Medical Research Methodology, 12) was used to synthesise and report findings. RESULTS Eighteen studies from seven countries including 235 nurses were identified. Following synthesis, four analytical themes were generated with eighteen derived consequent findings. The four themes identified were as follows: 1) Marrying nurses' clinical judgement with EWS 2) SMART communication 3) EWS Protocol: Blessing and a Curse 5) Hospital Domain. CONCLUSION Nurses strive to find balance by simultaneously navigating within the boundaries of both the EWS protocol and the hospital domain. They view the EWS as a valid essential component in the system but one that does not give a definitive answer and absolute direction. They value the protocols' ability to identify deteriorating patients and convey the seriousness of a situation to their multidisciplinary colleagues but also find it somewhat restrictive and frustrating and wish to have credence given to their own intuition and clinical judgement.
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Affiliation(s)
- Catherine Burke
- St Johns Hospital Urgent Care Center St Johns Hospital St Johns Square, Limerick, Ireland
| | - Yvonne Conway
- Department of Nursing, Health Sciences and Integrated Care, Galway Mayo Institute of Technology, Galway, Ireland
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13
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Bunting J, de Klerk M. Strategies to Improve Compliance with Clinical Nursing Documentation Guidelines in the Acute Hospital Setting: A Systematic Review and Analysis. SAGE Open Nurs 2022; 8:23779608221075165. [PMID: 35620302 PMCID: PMC9127672 DOI: 10.1177/23779608221075165] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 12/24/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction This systematic review attempts to answer the following question - which strategies to improve clinical nursing documentation have been most effective in the acute hospital setting? Methods A keyword search for relevant studies was conducted in CINAHL and Medline in May 2019 and October 2020.Studies were appraised using the Joanna Briggs Institute (JBI) critical appraisal for quasi-experimental studies. The studies were graded for level of evidence according to GRADE principles.The data collected in each study were added to a Summary of Data (SOD) spreadsheet. Pre intervention and a post intervention percentage compliance scores were calculated for each study where possible i.e. (mean score/possible total score) × (100/1). A percentage change in compliance for each study was calculated by subtracting the pre intervention score from the post intervention score. The change in compliance score and the post intervention compliance score were both added to the SOD and used as a basis for comparison between the studies. Each study was analyzed thematically in terms of the intervention strategies used. Compliance rates and the interventions used were compared to determine if any strategies were effective in achieving a meaningful improvement in compliance. Results Seventy six full text articles were reviewed for this systematic review. Fifty seven of the studies were before and after studies and 66 were conducted in western countries. Publishing dates for the studies ranged from 1991 to 2020.Eleven studies included documentation audits with personal feedback as one of the strategies used to improve nursing documentation. Ten of these studies achieved a post intervention compliance rate ≥ 70%. Conclusion Notwithstanding the limitations of this study, it may be that documentation audit with personal feedback, when combined with other context specific strategies, is a reliable method for gaining meaningful improvements in clinical nursing documentation. The level of evidence is very low and further research is required.
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Affiliation(s)
- Jeanette Bunting
- Joondalup Health Campus Librarian, Joondalup, Western Australia,
Australia
| | - Melissa de Klerk
- Joondalup Health Campus Library
Technician, Joondalup, Western Australia, Australia
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14
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McGaughey J, Fergusson DA, Van Bogaert P, Rose L. Early warning systems and rapid response systems for the prevention of patient deterioration on acute adult hospital wards. Cochrane Database Syst Rev 2021; 11:CD005529. [PMID: 34808700 PMCID: PMC8608437 DOI: 10.1002/14651858.cd005529.pub3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Early warning systems (EWS) and rapid response systems (RRS) have been implemented internationally in acute hospitals to facilitate early recognition, referral and response to patient deterioration as a solution to address suboptimal ward-based care. EWS and RRS facilitate healthcare decision-making using checklists and provide structure to organisational practices through governance and clinical audit. However, it is unclear whether these systems improve patient outcomes. This is the first update of a previously published (2007) Cochrane Review. OBJECTIVES To determine the effect of EWS and RRS implementation on adults who deteriorate on acute hospital wards compared to people receiving hospital care without EWS and RRS in place. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and two trial registers on 28 March 2019. We subsequently ran a MEDLINE update on 15 May 2020 that identified no further studies. We checked references of included studies, conducted citation searching, and contacted experts and critical care organisations. SELECTION CRITERIA We included randomised trials, non-randomised studies, controlled before-after (CBA) studies, and interrupted time series (ITS) designs measuring our outcomes of interest following implementation of EWS and RRS in acute hospital wards compared to ward settings without EWS and RRS. DATA COLLECTION AND ANALYSIS Two review authors independently checked studies for inclusion, extracted data and assessed methodological quality using standard Cochrane and Effective Practice and Organisation of Care (EPOC) Group methods. Where possible, we standardised data to rates per 1000 admissions; and calculated risk differences and 95% confidence intervals (CI) using the Newcombe and Altman method. We reanalysed three CBA studies as ITS designs using segmented regression analysis with Newey-West autocorrelation adjusted standard errors with lag of order 1. We assessed the certainty of evidence using the GRADE approach. MAIN RESULTS We included four randomised trials (455,226 participants) and seven non-randomised studies (210,905 participants reported in three studies). All 11 studies implemented an intervention comprising an EWS and RRS conducted in high- or middle-income countries. Participants were admitted to 282 acute hospitals. We were unable to perform meta-analyses due to clinical and methodological heterogeneity across studies. Randomised trials were assessed as high risk of bias due to lack of blinding participants and personnel across all studies. Risk of bias for non-randomised studies was critical (three studies) due to high risk of confounding and unclear risk of bias due to no reporting of deviation from protocol or serious (four studies) but not critical due to use of statistical methods to control for some but not all baseline confounders. Where possible we presented original study data which reported the adjusted relative effect given these were appropriately adjusted for design and participant characteristics. We compared outcomes of randomised and non-randomised studies reported them separately to determine which studies contributed to the overall certainty of evidence. We reported findings from key comparisons. Hospital mortality Randomised trials provided low-certainty evidence that an EWS and RRS intervention may result in little or no difference in hospital mortality (4 studies, 455,226 participants; results not pooled). The evidence on hospital mortality from three non-randomised studies was of very low certainty (210,905 participants). Composite outcome (unexpected cardiac arrests, unplanned ICU admissions and death) One randomised study showed that an EWS and RRS intervention probably results in no difference in this composite outcome (adjusted odds ratio (aOR) 0.98, 95% CI 0.83 to 1.16; 364,094 participants; moderate-certainty evidence). One non-randomised study suggests that implementation of an EWS and RRS intervention may slightly reduce this composite outcome (aOR 0.85, 95% CI 0.72 to 0.99; 57,858 participants; low-certainty evidence). Unplanned ICU admissions Randomised trials provided low-certainty evidence that an EWS and RRS intervention may result in little or no difference in unplanned ICU admissions (3 studies, 452,434 participants; results not pooled). The evidence from one non-randomised study is of very low certainty (aOR 0.88, 95% CI 0.75 to 1.02; 57,858 participants). ICU readmissions No studies reported this outcome. Length of hospital stay Randomised trials provided low-certainty evidence that an EWS and RRS intervention may have little or no effect on hospital length of stay (2 studies, 21,417 participants; results not pooled). Adverse events (unexpected cardiac or respiratory arrest) Randomised trials provided low-certainty evidence that an EWS and RRS intervention may result in little or no difference in adverse events (3 studies, 452,434 participants; results not pooled). The evidence on adverse events from three non-randomised studies (210,905 participants) is very uncertain. AUTHORS' CONCLUSIONS Given the low-to-very low certainty evidence for all outcomes from non-randomised studies, we have drawn our conclusions from the randomised evidence. This evidence provides low-certainty evidence that EWS and RRS may lead to little or no difference in hospital mortality, unplanned ICU admissions, length of hospital stay or adverse events; and moderate-certainty evidence of little to no difference on composite outcome. The evidence from this review update highlights the diversity in outcome selection and poor methodological quality of most studies investigating EWS and RRS. As a result, no strong recommendations can be made regarding the effectiveness of EWS and RRS based on the evidence currently available. There is a need for development of a patient-informed core outcome set comprising clear and consistent definitions and recommendations for measurement as well as EWS and RRS interventions conforming to a standard to facilitate meaningful comparison and future meta-analyses.
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Affiliation(s)
- Jennifer McGaughey
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Peter Van Bogaert
- Nursing and Midwifery Sciences, Centre for Research and Innovation in Care, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
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15
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Badr MN, Khalil NS, Mukhtar AM. Effect of National Early Warning Scoring System Implementation on Cardiopulmonary Arrest, Unplanned ICU Admission, Emergency Surgery, and Acute Kidney Injury in an Emergency Hospital, Egypt. J Multidiscip Healthc 2021; 14:1431-1442. [PMID: 34163171 PMCID: PMC8214550 DOI: 10.2147/jmdh.s312395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 05/14/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose To evaluate the effect of national early warning scoring system (NEWS) implementation in identifying patients at risk of clinical deterioration at an emergency hospital. Background Early warning score has been developed to facilitate early detection of deterioration by categorizing a patients’ severity of illness and prompting nursing staff to request a medical review at specific trigger points. Patients and Methods A prospective, control/intervention groups’, quasi-experimental design was utilized. A sample of 364 adult patients were admitted to the inpatient unit at an emergency hospital for six months. The patients were divided into a study group (174 patients) and a control group (190 patients). All study patients were followed up to either death or hospital discharge before and after implementing a new observation chart. The patients’ outcomes were compared and analyzed between both groups. Results In the intervention period, compared to the control period, a significant reduction was seen in the number of cardiopulmonary arrest (4.7% vs 1.1%, p = 0.046), unplanned ICU admission (5.3% vs 1.7%, p = 0.049), emergency surgery (6.3% vs 0%, p = 0.001), acute kidney injury (6.8% vs 1.1%, p = 0.006). As well, there was a significant increase in the number of patients receiving medical reviews following clinical deterioration in terms of escalation plan (3.2% vs 26.4%, p = <0.001). Conclusion The implementation of NEWS was associated with a significant improvement in patients’ outcomes in hospital wards, increases in the frequency of vital signs measurements, and an increase in the number of medical reviews following clinical instability. ![]()
Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/RD-H4EINULQ
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Affiliation(s)
- Mohamed Naeem Badr
- Critical Care and Emergency Nursing, Faculty of Nursing, Cairo University, Cairo, Egypt
| | - Nahla Shaaban Khalil
- Critical Care and Emergency Nursing, Faculty of Nursing, Cairo University, Cairo, Egypt
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16
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Bhatnagar M, Sirohi N, Dubey AB. Prediction of hospital outcome in emergency medical admissions using modified early warning score (MEWS): Indian experience. J Family Med Prim Care 2021; 10:192-198. [PMID: 34017725 PMCID: PMC8132807 DOI: 10.4103/jfmpc.jfmpc_1426_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 09/17/2020] [Accepted: 10/12/2020] [Indexed: 12/14/2022] Open
Abstract
Objective: To evaluate the applicability of modified early warning (MEWS) Score for prediction of hospital outcomes of medical emergency patients. Design: Prospective hospital based observational study. Setting: A tertiary care level medicine emergency unit in a medical college of North India. Study Population: 300 Patients admitted in medicine emergency. Method: Patients of both sexes of age more than 18 years who were admitted in medical emergency unit at MMIMSR, Ambala were evaluated. Patients who were in cardiac arrest at arrival and those who died within the first 24 hours were excluded and 300 patients were included. Modified Early Warning Score based on physiological parameters was recorded at admission for each patient and monitored over the next 24 hours in the emergency unit. Hospital outcome of the patient in terms of mortality, need for critical care, prolonged stay and uneventful discharge were recorded and correlated with MEWS scores over the first 24 hours in the emergency unit. Receiver Operating Characteristic (ROC) curves was generated to evaluate the utility of MEWS as a tool to predict patient outcome in medical emergency setting. Result: Of the 300 patients studied, the mean age of patients was 49 years, and the majority of the patients were male (61%). A MEWS Score of >5 at 24 hours of admission was associated significantly with in-hospital mortality of patients (p < 0.0001). The ROC (Receiver Operator Characteristic) curve revealed that in those patients who had a 24 hours MEWS >/= 5, the area under curve was (AUC) = 0.9. (95% CI: 0.95-0.98). Thus, MEWS was an effective predictor of in hospital mortality with sensitivity (78%) and specificity (94%). Conclusion: MEWS, a scoring system based on easily recordable physiological parameters can be used as an effective tool to triage and monitor patients in medical emergency units, to identify patients who are at greater risk of clinical deterioration and need close monitoring or early transfer for critical care or other timely interventions. Thus, application of MEWS in medical emergency units can be a useful tool to improve patient care, ensure optimal utilization of resources and prevent inappropriate discharge or neglect of sick patients.
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Affiliation(s)
- Mini Bhatnagar
- Department of General Medicine, MMIMSR, Mullana, Haryana, India
| | - Nikita Sirohi
- Department of Medicine, MMIMSR, Mullana, Haryana, India
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17
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Connell CJ, Endacott R, Cooper S. The prevalence and management of deteriorating patients in an Australian emergency department. Australas Emerg Care 2020; 24:112-120. [PMID: 32917577 DOI: 10.1016/j.auec.2020.07.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 07/22/2020] [Accepted: 07/30/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Complex human and system factors impact the effectiveness of Rapid Response Systems (RRS). Emergency Department (ED) specific RRS are relatively new and the factors associated with their effectiveness are largely unknown. This study describes the period prevalence of deterioration and characteristics of care for deteriorating patients in an Australia ED and examine relationships between system factors and escalation of care. METHODS A retrospective medical record audit of all patients presenting to an Australian ED in two weeks. RESULTS Period prevalence of deterioration was 10.08% (n=269). Failure to escalate care occurred in nearly half (n=52, 47.3%) of the patients requiring a response (n=110). Appropriate escalation practices were associated with where the patient was being cared for (p=0.01), and the competence level of the person documenting deterioration (p=0.005). Intermediate competence level nurses were nine times more likely to escalate care than novices and experts (p=0.005). While there was variance in escalation practice related to system factors, these associations were not statistically significant. CONCLUSION The safety of deteriorating ED patients may be improved by informing care based on the escalation practices of staff with intermediate ED experience and competence levels.
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Affiliation(s)
- Clifford J Connell
- Monash Nursing and Midwifery, Monash University, PO Box 527, Frankston, VIC 3199, Australia.
| | - Ruth Endacott
- Monash Nursing and Midwifery, Monash University, PO Box 527, Frankston, VIC 3199, Australia; School of Nursing and Midwifery, University of Plymouth, Drake Circus, Plymouth PL4 8AA, United Kingdom.
| | - Simon Cooper
- School of Nursing and Health Professions, Federation University, Gippsland Campus, Churchill, VIC 3842, Australia.
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18
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O'Connell A, Flabouris A, Thompson CH. Optimising the response to acute clinical deterioration: the role of observation and response charts. Intern Med J 2020; 50:790-797. [DOI: 10.1111/imj.14444] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 07/04/2019] [Accepted: 07/30/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Alice O'Connell
- General and Acute MedicineRoyal Adelaide Hospital and University of Adelaide Adelaide South Australia Australia
| | - Arthas Flabouris
- Intensive Care UnitRoyal Adelaide Hospital and University of Adelaide Adelaide South Australia Australia
| | - Campbell H. Thompson
- General and Acute MedicineRoyal Adelaide Hospital and University of Adelaide Adelaide South Australia Australia
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19
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Evaluation of nurses' experiences of a post education program promoting recognition and response to patient deterioration: Phase 2, clinical coach support in practice. Nurse Educ Pract 2020; 46:102835. [PMID: 32778370 DOI: 10.1016/j.nepr.2020.102835] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 11/19/2019] [Accepted: 07/02/2020] [Indexed: 11/23/2022]
Abstract
Front-line nurses providing around the clock care are pivotal to the identification, recognition, and response to patient deterioration. However, there is growing evidence that patient deterioration indicators are poorly managed and not escalated to rapid response teams (RRTs), contributing to adverse outcomes. Access to effective educational programs has been cited as vital in optimising nurses' recognition and response to deteriorating patients. Several studies evaluated educational programs, but have not explored nurses' experiences of engaging in patient deterioration events post attendance. Participants in a multimodal education program (DeTER) were invited to attend a series of focus groups three months post workshop as phase two of an overall study. A convenience sample of 22 acute care nurses was recruited. A qualitative descriptive design incorporating focus groups and thematic analysis was used to evaluate participants' experiences of engaging with the RRT during patient deterioration events and whether clinical coach support in practice influenced their recognition and response. Four themes were identified within the data, categorised as enhanced confidence, effective communication, supportive culture, and early response. The importance of an educational model using multimodal strategies, underpinned by coach support and guidance post workshop, was clearly demonstrated to optimise nurses' management of patient deterioration events.
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20
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The Modified Early Warning Score as a Predictive Tool During Unplanned Surgical Intensive Care Unit Admission. Ochsner J 2020; 20:176-181. [PMID: 32612472 PMCID: PMC7310184 DOI: 10.31486/toj.19.0057] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background: The Modified Early Warning Score (MEWS) has been proposed to warn healthcare providers of potentially serious adverse events. We evaluated this scoring system during unplanned escalation of care in hospitalized surgical patients during a 1-year period. Methods: Following institutional review board approval, all consecutive, unplanned surgical admissions into the surgical intensive care unit (SICU) during 2016 were entered into this study. MEWS and patient demographics during bedside evaluation for SICU admission were extracted from electronic medical records. Logistic regression was used to analyze the association of MEWS with the incidence of future mortality. P values were set at <0.01 for statistical significance. Results: In this series of 263 consecutive patients, the incidence of mortality following unplanned escalation of care was 29.3% (confidence interval [CI] 24.1% to 35.0%), ranging from 22% to 57%, with all positive MEWS values. The association of MEWS with future mortality was not statistically significant (P=0.0107). A misclassification rate of 0.29 (CI 0.24 to 0.35) was observed with this association. Conclusion: MEWS provided no clinical benefit as an early warning system, as mortality was elevated throughout the MEWS scale in this clinical setting. The high misclassification rate indicates MEWS does not provide discriminatory support for patients at risk for mortality.
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21
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Sun L, Joshi M, Khan SN, Ashrafian H, Darzi A. Clinical impact of multi-parameter continuous non-invasive monitoring in hospital wards: a systematic review and meta-analysis. J R Soc Med 2020; 113:217-224. [PMID: 32521195 PMCID: PMC7439595 DOI: 10.1177/0141076820925436] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 04/21/2020] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE Delayed response to clinical deterioration as a result of intermittent vital sign monitoring is a cause of preventable morbidity and mortality. This review focuses on the clinical impact of multi-parameter continuous non-invasive monitoring of vital signs (CoNiM) in non-intensive care unit patients. DESIGN Systematic review and meta-analysis of primary studies. Embase, MEDLINE, HMIC, PsycINFO and Cochrane were searched from April 1964 to 18 June 2019 with no language restriction. SETTING The search was limited to hospitalised, non-intensive care unit adult patients who had two or more vital signs continuously monitored. PARTICIPANTS All primary studies that evaluated the clinical impact of using multi-parameter CoNiM in adult hospital wards outside of the intensive care unit. MAIN OUTCOME MEASURES Clinical impact of multi-parameter CoNiM. RESULTS This systematic review identified 14 relevant studies from 3846 search results. Five studies were classified as Group A - associations found between measured vital signs and clinical parameters. Nine studies were classified as Group B - comparison between clinical outcomes of patients with and without multi-parameter CoNiM. Vital signs data from CoNiM were found to associate with type of presenting complaint, level of renal function and incidence of major clinical events. CoNiM also assisted in diagnosis by differentiating between patients with acute heart failure, stroke and sepsis (with sub-clustering of septic patients). In the meta-analysis, patients on multi-parameter CoNiM had a 39% decrease in risk of mortality (risk ratio [RR] 0.61; 95% confidence interval [95% CI] -0.39-0.95) when compared to patients with regular intermittent monitoring. There was a trend of reduced intensive care unit transfer (RR 0.86; 95% CI -0.67-1.11) and reduced rapid response team activation (RR 0.61; 95% CI 0.26-1.43). A trend towards reduced hospital length of stay was also found using weighted mean difference (WMD -3.32 days; 95% CI -8.82-2.19 days). CONCLUSION There is evidence of clinical benefit in implementing CoNiM in non-intensive care unit patients. This review supports the use of multi-parameter CoNiM outside of intensive care unit with further large-scale RCTs required to further affirm clinical impact.
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Affiliation(s)
- Lin Sun
- Department of Surgery and Cancer,
Imperial
College London, London SW7 2AZ, UK
| | - Meera Joshi
- Department of Surgery and Cancer,
Imperial
College London, London SW7 2AZ, UK
| | - Sadia N Khan
- West Middlesex University Hospital,
Isleworth TW7 6AF, UK
| | - Hutan Ashrafian
- Department of Surgery and Cancer,
Imperial
College London, London SW7 2AZ, UK
| | - Ara Darzi
- Department of Surgery and Cancer,
Imperial
College London, London SW7 2AZ, UK
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22
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McKinney A, Fitzsimons D, Blackwood B, White M, McGaughey J. Co‐design of a patient and family‐initiated escalation of care intervention to detect and refer patient deterioration: Research protocol. J Adv Nurs 2020; 76:1803-1811. [DOI: 10.1111/jan.14365] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 02/29/2020] [Accepted: 03/16/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Aidín McKinney
- School of Nursing & Midwifery Queen’s University BelfastMedical Biology CentreBelfast UK
| | - Donna Fitzsimons
- School of Nursing & Midwifery Queen’s University BelfastMedical Biology CentreBelfast UK
| | - Bronagh Blackwood
- Wellcome‐Wolfson Institute for Experimental Medicine School of Medicine, Dentistry and Biomedical Sciences Queen’s University Belfast Belfast UK
| | - Mark White
- Department of Research, Innovation and Graduate Studies Waterford Institute of Technology, Research, Innovation & Graduate Studies Waterford Ireland
| | - Jennifer McGaughey
- School of Nursing & Midwifery Queen’s University BelfastMedical Biology CentreBelfast UK
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Loftus TJ, Tighe PJ, Filiberto AC, Balch J, Upchurch GR, Rashidi P, Bihorac A. Opportunities for machine learning to improve surgical ward safety. Am J Surg 2020; 220:905-913. [PMID: 32127174 DOI: 10.1016/j.amjsurg.2020.02.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 02/09/2020] [Accepted: 02/14/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Delayed recognition of decompensation and failure-to-rescue on surgical wards are major sources of preventable harm. This review assimilates and critically evaluates available evidence and identifies opportunities to improve surgical ward safety. DATA SOURCES Fifty-eight articles from Cochrane Library, EMBASE, and PubMed databases were included. CONCLUSIONS Only 15-20% of patients suffering ward arrest survive. In most cases, subtle signs of instability often occur prior to critical illness and arrest, and underlying pathology is reversible. Coarse risk assessments lead to under-triage of high-risk patients to wards, where surveillance for complications depends on time-consuming manual review of health records, infrequent patient assessments, prediction models that lack accuracy and autonomy, and biased, error-prone decision-making. Streaming electronic heath record data, wearable continuous monitors, and recent advances in deep learning and reinforcement learning can promote efficient and accurate risk assessments, earlier recognition of instability, and better decisions regarding diagnosis and treatment of reversible underlying pathology.
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Affiliation(s)
- Tyler J Loftus
- Department of Surgery, University of Florida Health, Gainesville, FL, USA
| | - Patrick J Tighe
- Departments of Anesthesiology, Orthopedics, and Information Systems/Operations Management, University of Florida Health, Gainesville, FL, USA
| | - Amanda C Filiberto
- Department of Surgery, University of Florida Health, Gainesville, FL, USA
| | - Jeremy Balch
- Department of Surgery, University of Florida Health, Gainesville, FL, USA
| | - Gilbert R Upchurch
- Department of Surgery, University of Florida Health, Gainesville, FL, USA
| | - Parisa Rashidi
- Departments of Biomedical Engineering, Computer and Information Science and Engineering, and Electrical and Computer Engineering, University of Florida, Gainesville, FL, USA; Precision and Intelligence in Medicine, Department of Medicine, University of Florida Health, Gainesville, FL, USA
| | - Azra Bihorac
- Precision and Intelligence in Medicine, Department of Medicine, University of Florida Health, Gainesville, FL, USA; Department of Medicine, University of Florida Health, Gainesville, FL, USA.
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24
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What Do We Do After the Pilot Is Done? Implementation of a Hospital Early Warning System at Scale. Jt Comm J Qual Patient Saf 2020; 46:207-216. [PMID: 32085952 DOI: 10.1016/j.jcjq.2020.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 01/15/2020] [Accepted: 01/16/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Adults who deteriorate outside the ICU have high mortality. Most rapid response systems (RRSs) have employed manual detection processes that rapid response teams (RRTs) use to identify patients at risk. This project piloted the use of an automated early warning system (EWS), based on a very large database, that provides RRTs with 12 hours lead time to mount a response. Results from a 2-hospital pilot were encouraging, so leadership decided to deploy the Advance Alert Monitor (AAM) program in 19 more hospitals. CHALLENGE How can one deploy an RRS using an automated EWS at scale? SOLUTION EWS displays were removed from frontline clinicians' hospital electronic dashboards, and a Virtual Quality Team (VQT) RN was interposed between the EWS and the RRT. VQT RNs monitor the EWS remotely-when alerts are issued, they conduct a preliminary chart review and contact hospital RRT RNs. VQT and RRT RNs review the cases jointly. The RRT RNs then consult with hospitalists regarding clinical rescue and/or palliative care workflows. Subsequently, VQT RNs monitor patient charts, ensuring adherence to RRS practice standards. To enable this process, the project team developed a governance structure, clinical workflows, palliative care workflows, and documentation standards. RESULTS The AAM Program now functions in 21 Kaiser Permanente Northern California hospitals. VQT RNs monitor EWS alerts 24 hours a day, 7 days a week. The AAM Program handles ∼16,000 alerts per year. Its implementation has resulted in standardization of RRT staffing, clinical rescue workflows, and in-hospital palliative care.
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25
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Parker MW, Carroll M, Bolser B, Ballinger J, Brewington J, Campanella S, Davis-Sandfoss A, Tucker K, Brady PW. Implementation of a Communication Bundle for High-Risk Patients. Hosp Pediatr 2019; 7:523-529. [PMID: 28851754 DOI: 10.1542/hpeds.2016-0170] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Interventions that facilitate early identification and management of hospitalized pediatric patients who are at risk for deterioration are associated with decreased mortality. In our large pediatric hospital with a history of success in decreasing unrecognized deterioration, patients at higher risk of deterioration are termed "watchers." Because communication errors often contribute to unrecognized deterioration, clear and timely communication of watcher status to all team members and contingency planning was desired. OBJECTIVES Increase the percentage of eligible watchers with a complete communication, teamwork, and planning bundle within 2 hours of identification from 28% to 80%. METHODS Watchers admitted to Hospital Medicine on 2 targeted units were eligible. Stakeholders were educated to facilitate ownership. Daily data analysis enabled real-time failure identification. Automated physician notification provided reminders for timely communication. RESULTS The percentage of watchers with a complete situation awareness bundle within 2 hours increased from 28% to 81% and was sustained for more than 2 years. There was no change in rates of rapid response team calls or ICU transfers on our intervention units, but these both increased throughout the hospital. Education facilitated modest improvement, with marked improvements and sustainment through use of technology. CONCLUSIONS A novel bundle that included contingency planning and communication expectations was created to improve situation awareness for watchers. Multidisciplinary engagement and use of automated technology facilitated by an electronic health record helped implement and sustain bundle adherence.
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Affiliation(s)
| | - Matthew Carroll
- Division of Hospital Medicine, Cook Children's Medical Center, Fort Worth, Texas
| | | | | | | | - Suzanne Campanella
- Rollins School of Public Health, Emory University, Atlanta, Georgia; and
| | | | | | - Patrick W Brady
- Divisions of Hospital Medicine.,James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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26
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Clinical deterioration of ward patients in the presence of antecedents: A systematic review and narrative synthesis. Aust Crit Care 2019; 32:411-420. [DOI: 10.1016/j.aucc.2018.06.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 05/01/2018] [Accepted: 06/04/2018] [Indexed: 11/20/2022] Open
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27
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Buist N, Webster CS. Simulation Training to Improve the Ability of First-Year Doctors to Assess and Manage Deteriorating Patients: a Systematic Review and Meta-analysis. MEDICAL SCIENCE EDUCATOR 2019; 29:749-761. [PMID: 34457539 PMCID: PMC8368756 DOI: 10.1007/s40670-019-00755-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Many simulation courses now exist which aim to prepare first-year doctors for the task of assessing and managing potentially deteriorating patients. Despite the substantial resources required, the degree to which participants benefit from such courses, and which aspects of the simulation training are optimal for learning, remains unclear. A systematic literature search was undertaken across seven electronic databases. Inclusion criteria were that the intervention must be a simulation of a deteriorating patient scenario that would likely be experienced by first-year doctors, and that participants being first-year doctors or in their final year of medical school. Studies reporting quantitative benefits of simulation on participants' knowledge and simulator performance underwent meta-analyses. The search returned 1444 articles, of which 48 met inclusion criteria. All studies showed a benefit of simulation training, but outcomes were largely limited to self-rated or objective tests of knowledge, or simulator performance. The meta-analysis demonstrated that simulation improved participant performance by 16% as assessed by structured observation of a simulated scenario, and participant knowledge by 7% as assessed by written assessments. A mixed-methods analysis found conflicting evidence about which aspects of simulation were optimal for learning. The results of the review indicate that simulation is an important tool to improve first-year doctors' confidence, knowledge and simulator performance with regard to assessment and management of a potentially deteriorating patient. Future research should now seek to clarify the extent to which these improvements translate into clinical practice, and which aspects of simulation are best suited to achieve this.
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Affiliation(s)
- Nicholas Buist
- Department of Emergency Medicine, Whangarei Hospital, Northland District Health Board, Maunu Rd, Private Bag 9742, Whangarei, 0110 New Zealand
| | - Craig S. Webster
- Centre for Medical and Health Sciences Education and Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
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Al-Kalaldeh M, Suleiman K, Abu-Shahroor L, Al-Mawajdah H. The impact of introducing the Modified Early Warning Score ‘MEWS’ on emergency nurses’ perceived role and self-efficacy: A quasi-experimental study. Int Emerg Nurs 2019; 45:25-30. [DOI: 10.1016/j.ienj.2019.03.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 03/25/2019] [Accepted: 03/27/2019] [Indexed: 11/25/2022]
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29
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Haegdorens F, Monsieurs KG, De Meester K, Van Bogaert P. An intervention including the national early warning score improves patient monitoring practice and reduces mortality: A cluster randomized controlled trial. J Adv Nurs 2019; 75:1996-2005. [DOI: 10.1111/jan.14034] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 01/28/2019] [Accepted: 02/07/2019] [Indexed: 01/27/2023]
Affiliation(s)
- Filip Haegdorens
- Centre for Research and Innovation in Care (CRIC), Department of Nursing and Midwifery Sciences University of Antwerp Wilrijk Belgium
| | - Koenraad G. Monsieurs
- Department of Emergency Medicine Antwerp University Hospital, University of Antwerp Edegem Belgium
| | - Koen De Meester
- Centre for Research and Innovation in Care (CRIC), Department of Nursing and Midwifery Sciences University of Antwerp Wilrijk Belgium
| | - Peter Van Bogaert
- Centre for Research and Innovation in Care (CRIC), Department of Nursing and Midwifery Sciences University of Antwerp Wilrijk Belgium
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30
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Bunkenborg G, Smith‐Hansen L, Poulsen I. Implementing mandatory early warning scoring impacts nurses’ practice of documenting free text notes. J Clin Nurs 2019; 28:2990-3000. [DOI: 10.1111/jocn.14870] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 02/13/2019] [Accepted: 03/23/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Gitte Bunkenborg
- Department of Anesthesiology Copenhagen University Hospital Hvidovre Denmark
- Department of Anesthesiology Holbaek Hospital, part of Copenhagen University Hospital Holbaek Denmark
| | - Lars Smith‐Hansen
- Clinical Research Center Copenhagen University Hospital Hvidovre Denmark
| | - Ingrid Poulsen
- Research Unit on Brain Injury Rehabilitation Copenhagen (RUBRIC) Department of Neurorehabilitation, Traumatic Brain Injury Copenhagen University Hospital Rigshospitalet Denmark
- Section of Nursing Science, Health Aarhus University Aarhus Denmark
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31
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Le Lagadec MD, Dwyer T, Browne M. The efficacy of twelve early warning systems for potential use in regional medical facilities in Queensland, Australia. Aust Crit Care 2019; 33:47-53. [PMID: 30979578 DOI: 10.1016/j.aucc.2019.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 02/05/2019] [Accepted: 03/06/2019] [Indexed: 10/27/2022] Open
Abstract
AIM Early warning system (EWS) validation studies are conducted predominantly in tertiary metropolitan facilities and are not necessarily applicable to regional hospitals. This study evaluates 12 EWSs for use in regional subcritical hospitals. METHOD This is a retrospective case-control study of patients who experienced severe adverse events (SAEs) in two regional private hospitals. Vital signs collected over 72 h preceding the SAE were applied to 12 EWSs representing three classes of EWSs. The EWS area under the receiver operator characteristic curve (AUROC), sensitivity, specificity, and number of alerts were calculated. RESULTS Data from 159 index and 172 control patients showed no significant differences in demographics, length of stay, and level of comorbidities. Only half of index patients achieved a medical emergency alert threshold score. On average, index patients triggered alerts 20.06 (22.67) hours preceding the SAE and alerted 2.25 (3.87) times over 72 h. The AUROC ranged from 0.628 to 0.747, with a single-parameter EWS having the lowest AUROC and an aggregated weighted EWS, the highest. The sensitivity of the EWS ranges from 0.359 to 0.692. The specificity was greater than 0.9 for all the EWSs tested. CONCLUSIONS Based on the EWS sensitivity and AUROC, there is a lack of conclusive evidence of the efficacy of the 12 EWSs tested. However, because the adoption of the EWS in Australian hospitals is mandatory, the implementation of an aggregated weighted EWS, such as Compass, should be considered in subcritical regional private hospitals. Given that only half of SAE achieved an EWS medical alert threshold score, it is important that good clinical judgement be used with EWS.
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Affiliation(s)
| | - Trudy Dwyer
- CQUniversity Australia, Building 18/G.06 Rockhampton, Bruce Highway, Rockhampton Qld, 4702 Australia.
| | - Matthew Browne
- CQUniversity Australia, University Drive, Building 8/G.47 Bundaberg, Branyan Australia, Qld, 4670, Australia.
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32
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McKinney A, Fitzsimons D, Blackwood B, McGaughey J. Patient and family-initiated escalation of care: a qualitative systematic review protocol. Syst Rev 2019; 8:91. [PMID: 30967158 PMCID: PMC6454605 DOI: 10.1186/s13643-019-1010-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 03/29/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite the introduction of rapid response systems and early warning scores, clinical deterioration that is not recognised or responded to early enough prevails in acute care areas. One intervention that aims to address this issue and that is gaining increased attention is patient- and family-initiated escalation of care schemes. Existing systematic review evidence to date has tended to focus on identifying the impact or effectiveness of these schemes in practice. However, they have not tended to focus on qualitative evidence to consider the experience of deterioration and the factors that may promote or hinder engagement with these schemes in the practice setting. This systematic review will address this gap. The aim of this review is to explore patients', relatives' and healthcare professionals' experiences of deterioration and their perceptions of the barriers or facilitators to patient and family-initiated escalation of care in acute adult hospital wards. METHODS We will search Medline, CINAHL, Embase and PsycINFO databases using free-text and MESH terms relating to deterioration, family-initiated rapid response, families, patients, healthcare staff, hospital and experiences. We will search grey literature and reference lists of included studies for further published and unpublished literature. All studies with a qualitative design or method will be included. Two reviewers will independently assess studies for eligibility, extract data and appraise the quality of included studies. Data will be synthesised using a thematic synthesis approach, and findings will be presented narratively. DISCUSSION Patient- and family-initiated escalation of care schemes have been developed and implemented in several countries including the United States, the United Kingdom and Australia, but there is limited evidence regarding patients' or families' perceptions of deterioration or the barriers and facilitators to using these schemes in practice, particularly in acute adult areas. This systematic review will provide evidence for the development of a patient and family escalation of care scheme that can be tested in a feasibility study. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018106952.
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Affiliation(s)
- Aidín McKinney
- School of Nursing and Midwifery, Queen’s University Belfast, 97 Lisburn Road, Belfast, BT9 7BL Northern Ireland
| | - Donna Fitzsimons
- School of Nursing and Midwifery, Queen’s University Belfast, 97 Lisburn Road, Belfast, BT9 7BL Northern Ireland
| | - Bronagh Blackwood
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Wellcome-Wolfson Institute for Health Sciences, 97 Lisburn Rd, Belfast, BT9 7BL Northern Ireland
| | - Jennifer McGaughey
- School of Nursing and Midwifery, Queen’s University Belfast, 97 Lisburn Road, Belfast, BT9 7BL Northern Ireland
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Bunkenborg G, Poulsen I, Samuelson K, Ladelund S, Akeson J. Bedside vital parameters that indicate early deterioration. Int J Health Care Qual Assur 2019; 32:262-272. [DOI: 10.1108/ijhcqa-10-2017-0206] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Purpose
The purpose of this paper is to determine associations between initially recorded deviations in individual bedside vital parameters that contribute to total Modified Early Warning Score (MEWS) levels 2 or 3 and further clinical deterioration (MEWS level=4).
Design/methodology/approach
This was a prospective study in which 27,504 vital parameter values, corresponding to a total MEWS level⩾2, belonging to 1,315 adult medical and surgical inpatient patients admitted to a 90-bed study setting at a university hospital, were subjected to binary logistic and COX regression analyses to determine associations between vital parameter values initially corresponding to total MEWS levels 2 or 3 and later deterioration to total MEWS level ⩾4, and to evaluate corresponding time intervals.
Findings
Respiratory rate, heart rate and patient age were significantly (p=0.012, p<0.001 and p=0.028, respectively) associated with further deterioration from a total MEWS level 2, and the heart rate also (p=0.009) from a total MEWS level 3. Within 24 h from the initially recorded total MEWS levels 2 or 3, 8 and 17 percent of patients, respectively, deteriorated to a total MEWS level=4. Patients initially scoring MEWS 2 had a 27 percent 30-day mortality rate if they later scored MEWS level=4, and 8.7 percent if they did not.
Practical implications
It is important to observe all patients closely, but especially elderly patients, if total MEWS levels 2 or 3 are tachypnoea and/or tachycardia related.
Originality/value
Findings might contribute to patient safety by facilitating appropriate clinical and organizational decisions on adequate time spans for early warning scoring in general ward patients.
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Cornish L, Hill A, Horswill MS, Becker SI, Watson MO. Eye-tracking reveals how observation chart design features affect the detection of patient deterioration: An experimental study. APPLIED ERGONOMICS 2019; 75:230-242. [PMID: 30509531 DOI: 10.1016/j.apergo.2018.10.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 10/09/2018] [Accepted: 10/14/2018] [Indexed: 06/09/2023]
Abstract
Particular design features intended to improve usability - including graphically displayed observations and integrated colour-based scoring-systems - have been shown to increase the speed and accuracy with which users of hospital observation charts detect abnormal patient observations. We used eye-tracking to evaluate two potential cognitive mechanisms underlying these effects. Novice chart-users completed a series of experimental trials in which they viewed patient data presented on one of three observation chart designs (varied within-subjects), and indicated which observation was abnormal (or that none were). A chart that incorporated both graphically displayed observations and an integrated colour-based scoring-system yielded faster, more accurate responses and fewer, shorter fixations than a graphical chart without a colour-based scoring-system. The latter, in turn, yielded the same advantages over a tabular chart (which incorporated neither design feature). These results suggest that both colour-based scoring-systems and graphically displayed observations improve search efficiency and reduce the cognitive resources required to process vital sign data.
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Affiliation(s)
- Lillian Cornish
- School of Psychology, The University of Queensland, St Lucia, Brisbane, Queensland, 4072, Australia
| | - Andrew Hill
- School of Psychology, The University of Queensland, St Lucia, Brisbane, Queensland, 4072, Australia; Clinical Skills Development Service, Metro North Hospital and Health Service, Herston, Brisbane, Queensland, 4006, Australia.
| | - Mark S Horswill
- School of Psychology, The University of Queensland, St Lucia, Brisbane, Queensland, 4072, Australia
| | - Stefanie I Becker
- School of Psychology, The University of Queensland, St Lucia, Brisbane, Queensland, 4072, Australia
| | - Marcus O Watson
- School of Psychology, The University of Queensland, St Lucia, Brisbane, Queensland, 4072, Australia; Clinical Skills Development Service, Metro North Hospital and Health Service, Herston, Brisbane, Queensland, 4006, Australia; School of Medicine, The University of Queensland, Herston, Brisbane, Queensland, 4006, Australia
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35
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Izmailova ES, McLean IL, Bhatia G, Hather G, Cantor M, Merberg D, Perakslis ED, Benko C, Wagner JA. Evaluation of Wearable Digital Devices in a Phase I Clinical Trial. Clin Transl Sci 2019; 12:247-256. [PMID: 30635980 PMCID: PMC6510458 DOI: 10.1111/cts.12602] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 10/26/2018] [Indexed: 01/22/2023] Open
Abstract
We assessed the performance of two US Food and Drug Administration (FDA) 510(k)‐cleared wearable digital devices and the operational feasibility of deploying them to augment data collection in a 10‐day residential phase I clinical trial. The Phillips Actiwatch Spectrum Pro (Actiwatch) was used to assess mobility and sleep, and the Vitalconnect HealthPatch MD (HealthPatch) was used for monitoring heart rate (HR), respiratory rate (RR), and surface skin temperature (ST). We measured data collection rates, compared device readouts with anticipated readings and conventional in‐clinic measures, investigated data limitations, and assessed user acceptability. Six of nine study participants consented; completeness of data collection was adequate (> 90% for four of six subjects). A good correlation was observed between the HealthPatch device derived and in‐clinic measures for HR (Pearson r = 0.71; P = 2.2e‐16) but this was poor for RR (r = 0.08; P = 0.44) and ST (r = 0.14; P = 0.14). Manual review of electrocardiogram strips recorded during reported episodes of tachycardia > 180 beats/min showed that these were artefacts. The HealthPatch was judged to be not fit‐for‐purpose because of artefacts and the need for time‐consuming manual review. The Actiwatch device was suitable for monitoring mobility, collecting derived sleep data, and facilitating the interpretation of vital sign data. These results suggest the need for fit‐for‐purpose evaluation of wearable devices prior to their deployment in drug development studies.
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Affiliation(s)
- Elena S Izmailova
- Takeda Pharmaceuticals International, Inc., Cambridge, Massachusetts, USA
| | - Ian L McLean
- Takeda Pharmaceuticals International, Inc., Cambridge, Massachusetts, USA
| | | | - Greg Hather
- Takeda Pharmaceuticals International, Inc., Cambridge, Massachusetts, USA
| | | | - David Merberg
- Takeda Pharmaceuticals International, Inc., Cambridge, Massachusetts, USA
| | - Eric D Perakslis
- Takeda Pharmaceuticals International, Inc., Cambridge, Massachusetts, USA
| | | | - John A Wagner
- Takeda Pharmaceuticals International, Inc., Cambridge, Massachusetts, USA
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Hogan H, Hutchings A, Wulff J, Carver C, Holdsworth E, Welch J, Harrison D, Black N. Interventions to reduce mortality from in-hospital cardiac arrest: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BackgroundUnchecked 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.ObjectiveTo determine how interventions aimed at identification and management of deteriorating patients are associated with IHCA rates and outcomes.DesignA 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).SettingEnglish hospitals participating in the NCAA audit.ParticipantsNHS staff (approximately 300) and patients (13 million).InterventionsEducation, track-and-trigger systems (TTSs), standardised handover tools and outreach teams.Main outcome measuresIHCA rates, survival and hospital-wide mortality.Data sourcesNCAA, Hospital Episode Statistics, Office for National Statistics Mortality Statistics.MethodsA 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).ResultsAcross 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.LimitationsThe 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.ConclusionsStandardisation 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 workTo 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.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Helen Hogan
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Andrew Hutchings
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Jerome Wulff
- Intensive Care National Audit & Research Centre, London, UK
| | - Catherine Carver
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Elizabeth Holdsworth
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - John Welch
- Critical Care Outreach, University College London Hospitals NHS Foundation Trust, London, UK
| | - David Harrison
- Intensive Care National Audit & Research Centre, London, UK
| | - Nick Black
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
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Middleton S, McElduff P, Drury P, D’Este C, Cadilhac DA, Dale S, Grimshaw JM, Ward J, Quinn C, Cheung NW, Levi C. Vital sign monitoring following stroke associated with 90-day independence: A secondary analysis of the QASC cluster randomized trial. Int J Nurs Stud 2019; 89:72-79. [DOI: 10.1016/j.ijnurstu.2018.09.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 09/21/2018] [Accepted: 09/21/2018] [Indexed: 01/04/2023]
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Griffiths P, Ball J, Bloor K, Böhning D, Briggs J, Dall’Ora C, Iongh AD, Jones J, Kovacs C, Maruotti A, Meredith P, Prytherch D, Saucedo AR, Redfern O, Schmidt P, Sinden N, Smith G. Nurse staffing levels, missed vital signs and mortality in hospitals: retrospective longitudinal observational study. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06380] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background
Low nurse staffing levels are associated with adverse patient outcomes from hospital care, but the causal relationship is unclear. Limited capacity to observe patients has been hypothesised as a causal mechanism.
Objectives
This study determines whether or not adverse outcomes are more likely to occur after patients experience low nurse staffing levels, and whether or not missed vital signs observations mediate any relationship.
Design
Retrospective longitudinal observational study. Multilevel/hierarchical mixed-effects regression models were used to explore the association between registered nurse (RN) and health-care assistant (HCA) staffing levels and outcomes, controlling for ward and patient factors.
Setting and participants
A total of 138,133 admissions to 32 general adult wards of an acute hospital from 2012 to 2015.
Main outcomes
Death in hospital, adverse event (death, cardiac arrest or unplanned intensive care unit admission), length of stay and missed vital signs observations.
Data sources
Patient administration system, cardiac arrest database, eRoster, temporary staff bookings and the Vitalpac system (System C Healthcare Ltd, Maidstone, Kent; formerly The Learning Clinic Limited) for observations.
Results
Over the first 5 days of stay, each additional hour of RN care was associated with a 3% reduction in the hazard of death [hazard ratio (HR) 0.97, 95% confidence interval (CI) 0.94 to 1.0]. Days on which the HCA staffing level fell below the mean were associated with an increased hazard of death (HR 1.04, 95% CI 1.02 to 1.07), but the hazard of death increased as cumulative staffing exposures varied from the mean in either direction. Higher levels of temporary staffing were associated with increased mortality. Adverse events and length of stay were reduced with higher RN staffing. Overall, 16% of observations were missed. Higher RN staffing was associated with fewer missed observations in high-acuity patients (incidence rate ratio 0.98, 95% CI 0.97 to 0.99), whereas the overall rate of missed observations was related to overall care hours (RN + HCA) but not to skill mix. The relationship between low RN staffing and mortality was mediated by missed observations, but other relationships between staffing and mortality were not. Changing average skill mix and staffing levels to the levels planned by the Trust, involving an increase of 0.32 RN hours per patient day (HPPD) and a similar decrease in HCA HPPD, would be associated with reduced mortality, an increase in staffing costs of £28 per patient and a saving of £0.52 per patient per hospital stay, after accounting for the value of reduced stays.
Limitations
This was an observational study in a single site. Evidence of cause is not definitive. Variation in staffing could be influenced by variation in the assessed need for staff. Our economic analysis did not consider quality or length of life.
Conclusions
Higher RN staffing levels are associated with lower mortality, and this study provides evidence of a causal mechanism. There may be several causal pathways and the absolute rate of missed observations cannot be used to guide staffing decisions. Increases in nursing skill mix may be cost-effective for improving patient safety.
Future work
More evidence is required to validate approaches to setting staffing levels. Other aspects of missed nursing care should be explored using objective data. The implications of findings about both costs and temporary staffing need further exploration.
Trial registration
This study is registered as ISRCTN17930973.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 6, No. 38. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Peter Griffiths
- Health Sciences, University of Southampton, Southampton, UK
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, Southampton, UK
| | - Jane Ball
- Health Sciences, University of Southampton, Southampton, UK
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, Southampton, UK
| | - Karen Bloor
- Health Sciences, University of York, York, UK
| | - Dankmar Böhning
- Mathematical Sciences, University of Southampton, Southampton, UK
| | - Jim Briggs
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, UK
| | - Chiara Dall’Ora
- Health Sciences, University of Southampton, Southampton, UK
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, Southampton, UK
| | - Anya De Iongh
- Independent lay researcher c/o National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care, Southampton, UK
| | - Jeremy Jones
- Health Sciences, University of Southampton, Southampton, UK
| | - Caroline Kovacs
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, UK
| | | | - Paul Meredith
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, Southampton, UK
- Clinical Outcomes Research Group, Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth, UK
| | - David Prytherch
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, Southampton, UK
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, UK
- Clinical Outcomes Research Group, Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth, UK
| | - Alejandra Recio Saucedo
- Health Sciences, University of Southampton, Southampton, UK
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, Southampton, UK
| | - Oliver Redfern
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, UK
| | - Paul Schmidt
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, Southampton, UK
- Clinical Outcomes Research Group, Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth, UK
| | - Nicola Sinden
- Clinical Outcomes Research Group, Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth, UK
| | - Gary Smith
- Health and Social Sciences, Bournemouth University, Bournemouth, UK
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Mohammed Iddrisu S, Considine J, Hutchinson A. Frequency, nature and timing of clinical deterioration in the early postoperative period. J Clin Nurs 2018; 27:3544-3553. [DOI: 10.1111/jocn.14611] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 06/01/2018] [Accepted: 06/25/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Suad Mohammed Iddrisu
- School of Nursing and Midwifery; Deakin University; Geelong Vic. Australia
- Intensive Care Unit; The Northern Hospital; Epping Vic. Australia
- Intensive Care Unit; Box Hill Hospital; Box Hill Vic. Australia
| | - Julie Considine
- School of Nursing and Midwifery; Deakin University; Geelong Vic. Australia
- Centre for Quality and Patient Safety Research; Eastern Health Partnership; Deakin University; Box Hill Vic. Australia
| | - Anastasia Hutchinson
- School of Nursing and Midwifery; Deakin University; Geelong Vic. Australia
- Centre for Quality and Patient Safety Research; Epworth HealthCare Partnership Health Partnership and Northern Health Partnership; Deakin University; Box Hill Vic. Australia
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The introduction of a rapid response system in acute hospitals: A pragmatic stepped wedge cluster randomised controlled trial. Resuscitation 2018; 129:127-134. [DOI: 10.1016/j.resuscitation.2018.04.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 03/23/2018] [Accepted: 04/14/2018] [Indexed: 12/21/2022]
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Al-Thubaity D, Williamson S, Leavey R, Tume LN. Newly qualified Saudi nurses' ability to recognize the deteriorating child in hospital. Nurs Crit Care 2018; 24:263-267. [PMID: 30004156 DOI: 10.1111/nicc.12356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 04/08/2018] [Accepted: 04/20/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND It is recognized that nurses' failure to recognize and respond promptly to deterioration in children's physiological status can result in increased morbidity and mortality. AIM The aim of this study was to explore the ability of Saudi-educated, newly qualified nurses, working in paediatric wards, to recognize children's deterioration. METHODS A pilot study was carried out to assess nurses' responses to three clinical vignettes (deteriorating child, improving child and ambiguous scenarios). The nurses' ability to make a correct identification was captured using a 'Think Aloud' approach and quantified using a visual analogue scale. RESULTS Twenty-seven nurses in two geographical regions in Saudi Arabia participated. Only half the nurses (51·8%) correctly identified the deteriorating child vignette. Of those who could not, 37% were unsure and 11% responded incorrectly. No nurses correctly identified all three vignettes, and four nurses (15%) responded incorrectly to all vignettes. CONCLUSIONS The recognition of the deteriorating child is complex, and even in non-stressful simulated scenarios using vignettes, many newly qualified nurses working with children failed to recognize clear signs of deterioration. A focused (culturally specific) educational intervention is being developed to target this, taking into account Saudi nurses' perceived education and training needs. RELEVANCE TO CLINICAL PRACTICE Newly qualified nurses working in paediatric wards frequently find it difficult to identify the deteriorating child.
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42
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Connolly F, Byrne D, Lydon S, Walsh C, O'Connor P. Barriers and facilitators related to the implementation of a physiological track and trigger system: A systematic review of the qualitative evidence. Int J Qual Health Care 2018; 29:973-980. [PMID: 29177409 DOI: 10.1093/intqhc/mzx148] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 10/25/2017] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Fergal Connolly
- Discipline of General Practice, School of Medicine, National University of Ireland, Galway, Co. Galway, Ireland.,Irish Centre for Applied Patient Safety and Simulation, National University of Ireland, Galway, Co. Galway, Ireland
| | - Dara Byrne
- Irish Centre for Applied Patient Safety and Simulation, National University of Ireland, Galway, Co. Galway, Ireland.,School of Medicine, National University of Ireland, Galway, Co. Galway, Ireland
| | - Sinéad Lydon
- Irish Centre for Applied Patient Safety and Simulation, National University of Ireland, Galway, Co. Galway, Ireland.,School of Medicine, National University of Ireland, Galway, Co. Galway, Ireland
| | - Chloe Walsh
- Discipline of General Practice, School of Medicine, National University of Ireland, Galway, Co. Galway, Ireland.,Irish Centre for Applied Patient Safety and Simulation, National University of Ireland, Galway, Co. Galway, Ireland
| | - Paul O'Connor
- Discipline of General Practice, School of Medicine, National University of Ireland, Galway, Co. Galway, Ireland.,Irish Centre for Applied Patient Safety and Simulation, National University of Ireland, Galway, Co. Galway, Ireland
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The impact of a multimodal education strategy (the DeTER program) on nurses' recognition and response to deteriorating patients. Nurse Educ Pract 2018; 31:130-135. [PMID: 29879637 DOI: 10.1016/j.nepr.2018.05.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 01/22/2018] [Accepted: 05/21/2018] [Indexed: 11/21/2022]
Abstract
Nurses are ideally positioned to recognise and respond to patient deterioration. However, premonitory signs of patient deterioration are often overlooked, not managed, or not communicated in a timely fashion. Education programs aimed at improving nurses' technical and non-technical skills have been developed, however, the outcomes of these educational strategies remain unclear. A quasi-experimental time series design was used in this study to evaluate the impact of a multi-modal education program (DeTER) on acute care nurses' technical and non-technical skill development and recognition and response to patient deterioration. Participants were asked to complete a survey on four occasions: one month prior to commencement of the DeTER program, immediately prior and post workshop attendance and two-three months' post workshop completion. Pre-intervention, data were collected on participants' demographic profile and their responses to the Clinical Emergency Recognition and Response Survey designed by (Buckley and Gordon, 2011). Post intervention these data were collected again and, in addition, respondents were asked to report on their recent experiences of deteriorating patients and report on their confidence in managing these incidents. Sixty staff consented to participate in the study and all completed the surveys at time 2 and 3. In total 32 staff (45%) responded at all time points. Participants included registered nurses (n = 51; 85%), and enrolled nurses (n = 9; 15%), on average they had worked for 10.4 years (sd = 11.1). Participants rated patient advocacy and assertiveness skills as the most useful aspects of the workshop. Recognition and response to deteriorating patients by ward nurses is a multifaceted process influenced by many factors. Our study supports the importance of multimodal educational strategies in sustaining changes to ward nurses' technical and non-technical skills over time.
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Haig S, Day EA. Here's the NEWS from Belgium…. Resuscitation 2018; 129:A9-A10. [PMID: 29803704 DOI: 10.1016/j.resuscitation.2018.05.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 05/13/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Stephen Haig
- Great Western Hospitals NHS Foundation Trust, United Kingdom.
| | - E A Day
- Great Western Hospitals NHS Foundation Trust, United Kingdom
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A Systematic Review of Early Warning Systems’ Effects on Nurses’ Clinical Performance and Adverse Events Among Deteriorating Ward Patients. J Patient Saf 2018; 16:e104-e113. [DOI: 10.1097/pts.0000000000000492] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Hope J, Recio-Saucedo A, Fogg C, Griffiths P, Smith GB, Westwood G, Schmidt PE. A fundamental conflict of care: Nurses' accounts of balancing patients' sleep with taking vital sign observations at night. J Clin Nurs 2018; 27:1860-1871. [PMID: 29266489 PMCID: PMC6001445 DOI: 10.1111/jocn.14234] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2017] [Indexed: 11/29/2022]
Abstract
Aims and objectives To explore why adherence to vital sign observations scheduled by an early warning score protocol reduces at night. Background Regular vital sign observations can reduce avoidable deterioration in hospital. early warning score protocols set the frequency of these observations by the severity of a patient's condition. Vital sign observations are taken less frequently at night, even with an early warning score in place, but no literature has explored why. Design A qualitative interpretative design informed this study. Methods Seventeen semi‐structured interviews with nursing staff working on wards with varying levels of adherence to scheduled vital sign observations. A thematic analysis approach was used. Results At night, nursing teams found it difficult to balance the competing care goals of supporting sleep with taking vital sign observations. The night‐time frequency of these observations was determined by clinical judgement, ward‐level expectations of observation timing and the risk of disturbing other patients. Patients with COPD or dementia could be under‐monitored, while patients nearing the end of life could be over‐monitored. Conclusion In this study, we found an early warning score algorithm focused on deterioration prevention did not account for long‐term management or palliative care trajectories. Nurses were therefore less inclined to wake such patients to take vital sign observations at night. However, the perception of widespread exceptions and lack of evidence regarding optimum frequency risks delegitimising the early warning score approach. This may pose a risk to patient safety, particularly patients with dementia or chronic conditions. Relevance to clinical practice Nurses should document exceptions and discuss these with the wider team. Hospitals should monitor why vital sign observations are missed at night, identify which groups are under‐monitored and provide guidance on prioritising competing expectations. early warning score protocols should take account of different care trajectories.
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Affiliation(s)
- Joanna Hope
- Faculty of Health Sciences, University of Southampton, National Institute for Health Research (NIHR) Collaboration for Applied Health Research and Care (CLAHRC) Wessex, Southampton, UK
| | - Alejandra Recio-Saucedo
- Faculty of Health Sciences, University of Southampton, National Institute for Health Research (NIHR) Collaboration for Applied Health Research and Care (CLAHRC) Wessex, Southampton, UK
| | - Carole Fogg
- School of Health Sciences and Social Work, University of Portsmouth, Portsmouth, National Institute for Health Research (NIHR) Collaboration for Applied Health Research and Care (CLAHRC) Wessex, Southampton, UK.,Portsmouth Hospitals NHS Trust, Research and Innovation, Queen Alexandra Hospital, Cosham, Portsmouth, National Institute for Health Research (NIHR) Collaboration for Applied Health Research and Care (CLAHRC) Wessex, Southampton, UK
| | - Peter Griffiths
- Faculty of Health Sciences, University of Southampton, National Institute for Health Research (NIHR) Collaboration for Applied Health Research and Care (CLAHRC) Wessex, Southampton, UK
| | - Gary B Smith
- Centre of Postgraduate Medical Research & Education (CoPMRE), Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, Dorset, UK
| | - Greta Westwood
- Faculty of Health Sciences, Clinical Academic Facility, The QUaD Building, Queen Alexandra Hospital, University of Southampton, Portsmouth, National Institute for Health Research (NIHR) Collaboration for Applied Health Research and Care (CLAHRC) Wessex, Southampton, UK
| | - Paul E Schmidt
- Medical Assessment Unit, Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth, National Institute for Health Research (NIHR) Collaboration for Applied Health Research and Care (CLAHRC) Wessex, Southampton, UK
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Reed MJ, McGrath M, Black PL, Lewis S, McCann C, Whiting S, O’Brien R, Grant A, Harrison B, Skyrme L, Odam M. Detection of physiological deterioration by the SNAP40 wearable device compared to standard monitoring devices in the emergency department: the SNAP40-ED study. Diagn Progn Res 2018; 2:18. [PMID: 31093566 PMCID: PMC6460837 DOI: 10.1186/s41512-018-0040-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 07/09/2018] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In recent years, there has been increasing focus on the earlier detection of deterioration in the clinical condition of hospital patients with the aim of instigating earlier treatment to reverse this deterioration and prevent adverse outcomes. This is especially important in the ED, a dynamic environment with large volumes of undifferentiated patients, which carries inherent patient risk. SNAP40 is an innovative medical-grade device that can be worn on the upper arm that continuously monitors patients' vital signs including relative changes in systolic blood pressure, respiratory rate, heart rate, movement, blood oxygen saturation and temperature. It uses automated risk analysis to potentially allow clinical staff to easily and quickly identify high-risk patients. The aim of this study is to investigate whether the SNAP40 device is able to identify deterioration in the vital sign physiology of an ED patient earlier than current standard monitoring and observation charting techniques. METHODS/DESIGN Single centre, teaching hospital ED open label, prospective, observational cohort study recruiting 250 high acuity participants aged 16 years or over presenting to the ED. Participants will be approached and enrolled in the ED and after consent will have the SNAP40 wearable monitoring device attached which will be used alongside standard care monitoring. Participants will be observed throughout their time in the ED. Any SNAP40 device alarm, standard monitoring alarms or standard practice vital sign observations indicating a deterioration in a patient's vital sign physiology (defined as an increase in NEWS score) will be recorded. Primary outcome is time to detection of deterioration. Secondary outcomes include staff time spent performing observations and responding to standard monitoring alarms, clinical escalation of care when deterioration is detected and participants and staff rating of experience of both SNAP40 and current monitoring. DISCUSSION The SNAP40-ED study aims to recruit 250 patients. It will be the first study to compare the ability of a novel ambulatory monitoring device to detect deterioration compared to standard care in the ED. It may allow the earlier detection of deterioration in the clinical condition of ED patients and therefore earlier treatment to reverse this deterioration and prevent adverse outcomes. TRIAL REGISTRATION NCT03179267 ClinicalTrials.gov. Registered on June 17, 2017.
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Affiliation(s)
- Matthew J. Reed
- 0000 0001 0709 1919grid.418716.dEmergency Medicine Research Group Edinburgh (EMERGE), Department of Emergency Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA UK
- 0000 0004 1936 7988grid.4305.2Acute Care Group, Usher Institute of Population Health Sciences and Informatics, College of Medicine and Veterinary Medicine, University of Edinburgh, Nine Edinburgh BioQuarter, 9 Little France Road, Edinburgh, EH16 4UX UK
- 0000 0001 0709 1919grid.418716.dEmergency Department, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA UK
| | - Megan McGrath
- 0000 0001 0709 1919grid.418716.dEmergency Medicine Research Group Edinburgh (EMERGE), Department of Emergency Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA UK
| | - Polly L. Black
- 0000 0001 0709 1919grid.418716.dEmergency Medicine Research Group Edinburgh (EMERGE), Department of Emergency Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA UK
| | - Steff Lewis
- Edinburgh Clinical Trials Unit and Centre for Population Health Sciences, Usher Institute of Population Health Sciences and Informatics, Nine Edinburgh BioQuarter, 9 Little France Road, Edinburgh, EH16 4UX UK
| | | | | | - Rachel O’Brien
- 0000 0001 0709 1919grid.418716.dEmergency Medicine Research Group Edinburgh (EMERGE), Department of Emergency Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA UK
| | - Alison Grant
- 0000 0001 0709 1919grid.418716.dEmergency Medicine Research Group Edinburgh (EMERGE), Department of Emergency Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA UK
| | - Beth Harrison
- 0000 0001 0709 1919grid.418716.dEmergency Medicine Research Group Edinburgh (EMERGE), Department of Emergency Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA UK
| | - Laura Skyrme
- 0000 0001 0709 1919grid.418716.dEmergency Medicine Research Group Edinburgh (EMERGE), Department of Emergency Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA UK
| | - Miranda Odam
- 0000 0001 0709 1919grid.418716.dEmergency Medicine Research Group Edinburgh (EMERGE), Department of Emergency Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA UK
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Abstract
OBJECTIVE This study aimed to explore the impact of a human factors intervention bundle on the quality of ward-based surgical care in a UK hospital. SUMMARY OF BACKGROUND DATA Improving the culture of a surgical team is a difficult task. Engagement with stakeholders before intervention is key. Studies have shown that appropriate supervision can enhance surgical ward safety. METHODS A pre-post intervention study was conducted. The intervention bundle consisted of twice-daily attending ward rounds, a "chief resident of the week" available at all times on the ward, an escalation of care protocol and team contact cards. Twenty-seven junior and senior surgeons completed validated questionnaires assessing supervision, escalation of care, and safety culture pre and post-intervention along with interviews to further explore the impact of the intervention. Patient outcomes pre and postintervention were also analyzed. RESULTS Questionnaires revealed significant improvements in supervision postintervention (senior median pre 5 vs post 7, P = 0.002 and junior 4 vs 6, P = 0.039) and senior surgeon approachability (junior 5 vs 6, P = 0.047). Both groups agreed that they would feel safer as a patient in their hospital postintervention (senior 3 vs 4.5, P = 0.021 and junior 3 vs 4, P = 0.034). The interviews confirmed that the safety culture of the department had improved. There were no differences in inpatient mortality, cardiac arrest, reoperation, or readmission rates pre and postintervention. CONCLUSION Improving supervision and introducing clear protocols can improve safety culture on the surgical ward. Future work should evaluate the effect these measures have on patient outcomes in multiple institutions.
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Wuytack F, Meskell P, Conway A, McDaid F, Santesso N, Hickey FG, Gillespie P, Raymakers AJN, Smith V, Devane D. The effectiveness of physiologically based early warning or track and trigger systems after triage in adult patients presenting to emergency departments: a systematic review. BMC Emerg Med 2017; 17:38. [PMID: 29212452 PMCID: PMC5719672 DOI: 10.1186/s12873-017-0148-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 11/21/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Changes to physiological parameters precede deterioration of ill patients. Early warning and track and trigger systems (TTS) use routine physiological measurements with pre-specified thresholds to identify deteriorating patients and trigger appropriate and timely escalation of care. Patients presenting to the emergency department (ED) are undiagnosed, undifferentiated and of varying acuity, yet the effectiveness and cost-effectiveness of using early warning systems and TTS in this setting is unclear. We aimed to systematically review the evidence on the use, development/validation, clinical effectiveness and cost-effectiveness of physiologically based early warning systems and TTS for the detection of deterioration in adult patients presenting to EDs. METHODS We searched for any study design in scientific databases and grey literature resources up to March 2016. Two reviewers independently screened results and conducted quality assessment. One reviewer extracted data with independent verification of 50% by a second reviewer. Only information available in English was included. Due to the heterogeneity of reporting across studies, results were synthesised narratively and in evidence tables. RESULTS We identified 6397 citations of which 47 studies and 1 clinical trial registration were included. Although early warning systems are increasingly used in EDs, compliance varies. One non-randomised controlled trial found that using an early warning system in the ED may lead to a change in patient management but may not reduce adverse events; however, this is uncertain, considering the very low quality of evidence. Twenty-eight different early warning systems were developed/validated in 36 studies. There is relatively good evidence on the predictive ability of certain early warning systems on mortality and ICU/hospital admission. No health economic data were identified. CONCLUSIONS Early warning systems seem to predict adverse outcomes in adult patients of varying acuity presenting to the ED but there is a lack of high quality comparative studies to examine the effect of using early warning systems on patient outcomes. Such studies should include health economics assessments.
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Affiliation(s)
- Francesca Wuytack
- School of Nursing & Midwifery, National University of Ireland Galway, Galway, County Galway, Ireland
| | - Pauline Meskell
- School of Nursing & Midwifery, National University of Ireland Galway, Galway, County Galway, Ireland
| | - Aislinn Conway
- Health Research Board Trials Methodology Research Network, Galway, Ireland
| | - Fiona McDaid
- Nurse Lead, National Emergency Medicine Programme/Clinical Nurse Manager, Emergency Department, Naas General Hospital, Naas, County Kildare Ireland
| | - Nancy Santesso
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St. W., HSC-2C15, Hamilton, ON L8S 4K1 Canada
| | | | - Paddy Gillespie
- Health Economics & Policy Analysis Centre (HEPAC), School of Business & Economics, National University of Ireland Galway, Galway, County Galway, Ireland
| | - Adam J. N. Raymakers
- Health Economics & Policy Analysis Centre (HEPAC), School of Business & Economics, National University of Ireland Galway, Galway, County Galway, Ireland
| | - Valerie Smith
- School of Nursing & Midwifery, National University of Ireland Galway, Galway, County Galway, Ireland
| | - Declan Devane
- School of Nursing & Midwifery, National University of Ireland Galway, Galway, County Galway, Ireland
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50
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McGaughey J, O'Halloran P, Porter S, Blackwood B. Early warning systems and rapid response to the deteriorating patient in hospital: A systematic realist review. J Adv Nurs 2017; 73:2877-2891. [DOI: 10.1111/jan.13398] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Jennifer McGaughey
- School of Nursing & Midwifery; Medical Biology Centre; Queen's University Belfast; Belfast UK
| | - Peter O'Halloran
- School of Nursing & Midwifery; Queen's University of Belfast; Belfast UK
| | - Sam Porter
- Department of Social Sciences and Social Work; Bournemouth University; Poole UK
| | - Bronagh Blackwood
- School of Medicine, Dentistry & Biomedical Sciences; Centre for Experimental Medicine; Queen's University Belfast; Belfast UK
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