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Al-Ghraiybah T, Lago L, Fernandez R, Sim J. Effects of the nursing practice environment, nurse staffing, patient surveillance and escalation of care on patient mortality: A multi-source quantitative study. Int J Nurs Stud 2024; 156:104777. [PMID: 38772288 DOI: 10.1016/j.ijnurstu.2024.104777] [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: 04/12/2023] [Revised: 03/08/2024] [Accepted: 04/13/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND A favourable nursing practice environment and adequate nurse staffing have been linked to reduced patient mortality. However, the contribution of nursing care processes such as patient surveillance and escalation of care, on patient mortality is not well understood. OBJECTIVE The aim of this study was to investigate the effect of the nursing practice environment, nurse staffing, missed care related to patient surveillance and escalation of care on 30-day inpatient mortality. DESIGN A multi-source quantitative study including a cross-sectional survey of nurses, and retrospective data extracted from an audit of medical and admission records. SETTING(S) A large tertiary teaching hospital (600 beds) in metropolitan Sydney, Australia. METHODS Data on the nursing practice environment, nurse staffing and missed care were obtained from the nursing survey. Patient deterioration data and patient outcome data were collected from the medical and admission records respectively. Logistic regression models were used to examine the association between the nursing practice environment, patient deterioration and 30-day inpatient mortality accounting for clustering of episodes within patients using generalised estimating equations. RESULTS Surveys were completed by 304 nurses (84.5 % female, mean age 34.4 years, 93.4 % Registered Nurses) from 16 wards. Patient deterioration data was collected for 30,011 patient deterioration events and 63,847 admitted patient episodes of care. Each additional patient per nurse (OR = 1.22, 95 % CI = 1.04-1.43) and the presence of increased missed care for patient surveillance (OR = 1.13, 95 % CI = 1.03-1.23) were associated with higher risk of 30-day inpatient mortality. The use of a clinical emergency response system reduced the risk of mortality (OR = 0.82, 95 % CI = 0.76-0.89). A sub-group analysis excluding aged care units identified a 38 % increase in 30-day inpatient mortality for each additional patient per nurse (OR = 1.38, 95 % CI = 1.15-1.65). The nursing practice environment was also significantly associated with mortality (OR = 0.79, 95 % CI: 0.72-0.88) when aged care wards were excluded. CONCLUSIONS Patient mortality can be reduced by increasing nurse staffing levels and improving the nursing practice environment. Nurses play a pivotal role in patient safety and improving nursing care processes to minimise missed care related to patient surveillance and ensuring timely clinical review for deteriorating patients reduces inpatient mortality. TWEETABLE ABSTRACT Patient mortality can be reduced by improving the nursing practice environment & increasing the number of nurses so that nurses have more time to monitor patients. Investing in nurses results in lower mortality and better outcomes. #PatientSafety #NurseStaffing #WorkEnvironment #Mortality.
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Affiliation(s)
- Tamer Al-Ghraiybah
- School of Nursing, University of Wollongong, Northfields Ave, Wollongong, Australia; School of Nursing & Midwifery, Faculty of Health, University of Technology Sydney, Australia.
| | - Luise Lago
- Centre for Health Research Illawarra Shoalhaven Population, Innovation Campus, University of Wollongong, Australia.
| | - Ritin Fernandez
- School of Nursing and Midwifery, University of Newcastle, Newcastle, Australia.
| | - Jenny Sim
- School of Nursing, University of Wollongong, Northfields Ave, Wollongong, Australia; School of Nursing and Midwifery, University of Newcastle, Newcastle, Australia; School of Nursing, Midwifery & Paramedicine, Australian Catholic University, North Sydney, Australia.
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Bohingamu Mudiyanselage S, Considine J, Hutchinson AM, Mitchell I, Mohebbi M, Watts JJ, Bucknall TK. An economic evaluation of the Prioritising Responses Of Nurses To deteriorating patient Observations (PRONTO) clinical trial. Resuscitation 2024; 201:110272. [PMID: 38866230 DOI: 10.1016/j.resuscitation.2024.110272] [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: 03/19/2024] [Revised: 05/26/2024] [Accepted: 06/05/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND Early recognition and response to clinical deterioration reduce the frequency of in-hospital cardiac arrests, mortality, and unplanned intensive care unit (ICU) admissions. This study aimed to investigate the impact of the Prioritising Responses Of Nurses To deteriorating patient Observations (PRONTO) intervention on hospital costs and patient length of stay (LOS). METHOD The PRONTO cluster randomised control trial was conducted to improve nurses' responses to patients with abnormal vital signs. Hospital data were collected pre-intervention (T0) at 6 months (T1) and 12 months (T2) post-intervention. The economic evaluation involved a cost-consequence analysis from the hospital's perspective. Generalised estimating equations were used to estimate the parameters for regression models of the difference in costs and LOS between study groups and time points. RESULTS Hospital admission data for 6065 patients (intervention group, 3102; control group, 2963) were collected from four hospitals for T0, T1 and T2. The intervention cost was 69.61 A$ per admitted patient, including the additional intervention training for nurses and associated labour costs. The results showed cost savings and a shorter LOS in the intervention group between T0 - T1 and T0 - T2 (cost differences T0 - T1: -364 (95% CI -3,782; 3049) A$ and T0 - T2: -1,710 (95% CI -5,162; 1,742) A$; and LOS differences T0 - T1: -1.10 (95% CI -2.44; 0.24) days and T0 & T2: -2.18 (95% CI -3.53; -0.82) days). CONCLUSION The results of the economic analysis demonstrated that the PRONTO intervention improved nurses' responses to patients with abnormal vital signs and significantly reduced hospital LOS by two days at 12 months in the intervention group compared to baseline. From the hospital's perspective, savings from reduced hospitalisations offset the costs of implementing PRONTO.
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Affiliation(s)
- Shalika Bohingamu Mudiyanselage
- School of Health and Social Development, Deakin Health Economics, Institute for Health Transformation, Faculty of Health, Deakin University, Geelong, Victoria, Australia.
| | - Julie Considine
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Faculty of Health, Deakin University, Geelong, Victoria, Australia; Centre for Quality and Patient Safety Research - Eastern Health Partnership, Eastern Health, Box Hill, Victoria, Australia
| | - Alison M Hutchinson
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Faculty of Health, Deakin University, Geelong, Victoria, Australia; Barwon Health, Geelong, Victoria, Australia
| | - Imogen Mitchell
- Australian National University College of Health and Medicine, Canberra, Australian Capital Territory, Australia; Research and Academic Partnerships, Canberra Health Services, Canberra, Australian Capital Territory, Australia
| | - Mohammadreza Mohebbi
- Faculty of Health, Biostatistics Unit, Deakin University, Geelong, Victoria, Australia
| | - Jennifer J Watts
- School of Health and Social Development, Deakin Health Economics, Institute for Health Transformation, Faculty of Health, Deakin University, Geelong, Victoria, Australia
| | - Tracey K Bucknall
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Faculty of Health, Deakin University, Geelong, Victoria, Australia; Alfred Health, Melbourne, Victoria, Australia
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Bucknall TK, Guinane J, McCormack B, Jones D, Buist M, Hutchinson AM. Listen to me, I really am sick! Patient and family narratives of clinical deterioration before and during rapid response system intervention. J Clin Nurs 2024. [PMID: 38822476 DOI: 10.1111/jocn.17310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 05/08/2024] [Accepted: 05/21/2024] [Indexed: 06/03/2024]
Abstract
AIM To explore patient and family narratives about their recognition and response to clinical deterioration and their interactions with clinicians prior to and during Medical Emergency Team (MET) activations in hospital. BACKGROUND Research on clinical deterioration has mostly focused on clinicians' roles. Although patients and families can identify subtle cues of early deterioration, little research has focused on their experience of recognising, speaking up and communicating with clinicians during this period of instability. DESIGN A narrative inquiry. METHODS Using narrative interviewing techniques, 33 adult patients and 14 family members of patients, who had received a MET call, in one private and one public academic teaching hospital in Melbourne, Australia were interviewed. Narrative analysis was conducted on the data. RESULTS The core story of help seeking for recognition and response by clinicians to patient deterioration yielded four subplots: (1) identifying deterioration, recognition that something was not right and different from earlier; (2) voicing concerns to their nurse or by family members on their behalf; (3) being heard, desiring a response acknowledging the legitimacy of their concerns; and (4) once concerns were expressed, there was an expectation of and trust in clinicians to act on the concerns and manage the situation. CONCLUSION Clinical deterioration results in an additional burden for hospitalised patients and families to speak up, seek help and resolve their concerns. Educating patients and families on what to be concerned about and when to notify staff requires a close partnership with clinicians. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE Clinicians must create an environment that enables patients and families to speak up. They must be alert to both subjective and objective information, to acknowledge and to act on the information accordingly. REPORTING METHOD The consolidated criteria for reporting qualitative research (COREQ) guidelines were used for reporting. PATIENT OR PUBLIC CONTRIBUTION The consumer researcher was involved in design, data analysis and publication preparation.
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Affiliation(s)
- Tracey K Bucknall
- School of Nursing & Midwifery, Deakin University, Geelong, Victoria, Australia
- Alfred Health, Melbourne, Victoria, Australia
- Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
| | - Jessica Guinane
- School of Nursing & Midwifery, Deakin University, Geelong, Victoria, Australia
| | - Brendan McCormack
- Division of Nursing, Paramedic Science, Occupational Therapy and Arts Therapies, Queen Margaret University, Edinburgh, UK
- Faculty of Medicine and Health, The Susan Wakil School of Nursing and Midwifery, University of Sydney, Sydney, New South Wales, Australia
| | - Daryl Jones
- Austin Health, Melbourne, Victoria, Australia
- Department of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
| | - Michael Buist
- School of Medicine, University of Tasmania, Tasmania, Australia
| | - Alison M Hutchinson
- School of Nursing & Midwifery, Deakin University, Geelong, Victoria, Australia
- Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
- Barwon Health, Geelong, Victoria, Australia
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Smith D, Aitken LM. Rethinking the problem of clinically deteriorating patients: Time for theory-informed solutions. Aust Crit Care 2023; 36:925-927. [PMID: 37716883 DOI: 10.1016/j.aucc.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 09/02/2023] [Indexed: 09/18/2023] Open
Affiliation(s)
- Duncan Smith
- City, University of London, School of Health & Psychological Sciences, Northampton Square, London, EC1V 0HB, UK; Patient Emergency Response & Resuscitation Team (PERRT), University College London Hospitals NHS Foundation Trust, Euston Road, London, NW1 2BU, UK.
| | - Leanne M Aitken
- City, University of London, School of Health & Psychological Sciences, Northampton Square, London, EC1V 0HB, UK; School of Nursing and Midwifery, Griffith University, Nathan, QLD, 4111, Australia.
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Clinicians' attitudes towards escalation and management of deteriorating patients: A cross-sectional study. Aust Crit Care 2022; 36:320-326. [PMID: 35490110 DOI: 10.1016/j.aucc.2022.03.004] [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: 11/15/2021] [Revised: 02/23/2022] [Accepted: 03/01/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Internationally, rapid response systems have been implemented to recognise and categorise hospital patients at risk of deterioration. Whilst rapid response systems have been implemented with a varying amount of success, there remains ongoing concern about the lack of improvement in the escalation, and management of the deteriorating patient. It also remains unclear why some clinicians fail to escalate concerns for the deteriorating patient. OBJECTIVE The objective of this study was to explore clinicians' attitudes towards the escalation, and management of the deteriorating patient. METHODS A cross-sectional online survey of conveniently sampled clinicians from the acute care sector in a regional health district in Australia was conducted. The Clinicians' Attitudes towards Responding and Escalating care of Deteriorating patients scale, was used to explore attitudes towards the escalation and management of the deteriorating patient. RESULTS Survey responses were received from medical officers (n = 43), nurses (n = 677), allied health clinicians (n = 60), and students (n = 57). Years of experience was significantly associated with more confidence responding to deteriorating patients (p < .001) and significantly less fears about escalating care (p < .001). Nurses (M = 4.16, SD = .57) and students (M = 4.11, SD = .55) in general had significantly greater positive beliefs that the rapid response system would support them to respond to the deteriorating patient than allied health (M = 3.67, SD = .64) and medical (M = 3.87, SD = .54) clinicians, whilst nurses and medical clinicians had significantly less fear about escalating care and greater confidence in responding to deteriorating patients than allied health clinicians and healthcare students (p < .001). CONCLUSION Nurses and medical officers have less fear to escalate care and greater confidence responding to the deteriorating patient than allied health clinicians and students. Whilst the majority of participants had positive perceptions towards the rapid response system, those with less experience lacked the confidence to escalate care and respond to the deteriorating patient.
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Roasio A, Costanzo E, Bergesio G, Bosso S, Longu S, Zapparoli F, Bertocchini S, Forno G, Fogliati A, Novelli MT. Impact of the Proactive Rounding Team on Rapid Response System During COVID-19 Pandemic: A Retrospective Study From an Italian Medical Center. Cureus 2022; 14:e24432. [PMID: 35637817 PMCID: PMC9128792 DOI: 10.7759/cureus.24432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2022] [Indexed: 11/05/2022] Open
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