Early warning systems and rapid response to the deteriorating patient in hospital: A realist evaluation

Why vital signs observations are delayed and interrupted on acute hospital wards: A multisite observational study

BACKGROUND

Vital signs monitoring is key to identifying deteriorating hospital patients. However, adherence to monitoring protocols is limited, with observations frequently missed or delayed. Previous studies of interruptions and delays to vital signs observations have been descriptive, with none attempting to conceptualise the types of tasks that are prioritised over vital signs observations.

OBJECTIVE

This paper aims to explore how nursing teams perform vital sign observations on acute hospital wards and conceptualises which types of work delay or interrupt them.

DESIGN

Non-participant observational study.

SETTING(S)

Four hospitals in the south of England.

METHODS

Eligible adult wards (surgical and medical) within each hospital were randomly sampled for inclusion. Four sets of two-hour daytime observation sessions were undertaken on each ward. Two observers recorded structured and unstructured observations (open comments, field notes) on a tablet with adapted QI Tool software. We collected data over 128 h, including 715 sets of vital signs observations and 1127 interruptions. We undertook a qualitative content analysis of interruptions and delays to planned vital signs observations using both structured and unstructured observations.

RESULTS

We identified eight reasons why vital signs were delayed or interrupted: fixed routines, staff availability, bundled care, proximity-related activities, collaborative care, patient inaccessible or unavailable, requests for or responses to time-critical activities, or limited context available. We propose a new concept of 'temporal status.' Flexible care (vital signs observations, 'bundled care' and 'proximity-related care') has a low temporal status so is delayed in favour of higher temporal status activities (fixed routines and time-critical care).

CONCLUSIONS

Our findings could explain why vital signs taken early in the morning and evening are least likely to be postponed, as there may be fewer competing tasks with a higher temporal status at these times. Our work also challenges binary conceptualisations of interruptions as 'beneficial' or 'detrimental', recognising the complexity of nursing care decisions on a moment-by-moment basis. Our new framework suggests the lower temporal status of vital signs observations (and other flexible care) means they are delayed by higher temporal status tasks during daytime shifts in acute hospitals, regardless of their clinical priority.

REGISTRATION

10863045, ISRCTN (6/8/2019).

Ward-Based Staff Perspectives on Their Preparedness to Recognize Patient Deterioration: An Interpretive Description Study

BACKGROUND

Despite an overall decline in serious adverse events in hospitalized patients, approximately one third of inpatient mortality continues to relate to adverse events impacting patients on general wards. The preparedness of nurses, midwives, and nursing assistants (collectively referred to as ward-based staff) to recognize patient deterioration is therefore seen as critical.

PURPOSE

The aim of this study was to explore ward-based staff perspectives regarding their preparedness to recognize patient deterioration.

METHODS

An interpretive description approach was utilized to interview 16 participants from a single-center regional hospital. The participants included nurses, midwives, and nursing assistants who worked exclusively on wards. The participants were purposely selected to complete semistructured interviews. Data were analyzed using a six-step thematic analysis, and the study followed the Standards for Reporting Qualitative Research checklist.

RESULTS

Three main themes (with subthemes) were identified: (a) feeling prepared (experience, intuitive awareness, early warning systems), (b) promoting preparedness (multimodal education, debriefing, collegial support), and (c) being unprepared (undergraduate education, knowledge deficit, staffing related concerns, psychological response to incident, unforeseen barriers).

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

The findings suggest strategies for increasing knowledge and confidence in all ward-based staff, allowing them to feel better prepared to recognize clinical deterioration. Moreover, based on the results, ward-based staff strongly perceive experience, clinical shortfalls in undergraduate education, collegial support networks, mentorship, psychological response to incidents, and multimodal education to be key contributors to preparedness.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

FINDINGS

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

CONCLUSION

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

A Process-Based Standardization of an Intraoperative Escalation Protocol in Anesthesiology

Prompt recognition and management of critical events is pivotal for the provision of safe anesthetic care. This requires a well-functioning team that focuses on effective communication, timely decision-making, and escalation of potential complications. We believe that variation in bedside care leads to "near-misses," adverse outcomes, and serious safety events (SSEs). The principles of an escalation culture have been used successfully in other highly reliable industries such as aviation, military, and manufacturing. We discuss here the introduction of a unique and compelling thought-process for developing an intraoperative escalation protocol that is specifically tailored for our institution. Inspired by a critical intraoperative event, this departmental protocol was developed based on an analysis of multispecialty literature and expert opinion to decrease the incidence of SSEs. It includes a stepwise approach and incorporates patient-specific information to guide team members who encounter dynamic clinical situations. The implementation of the protocol has facilitated continuous quality improvement through iterative education, improving communication, and enhancing decision-making. Concurrently, we have plans to incorporate technology and electronic decision support tools to enhance real-time communication, monitor performance, and foster a culture of safety.

The impact of mandated use early warning system tools on the development of nurses' higher-order thinking: A systematic review

AIM

Ascertain the impact of mandated use of early warning systems (EWSs) on the development of registered nurses' higher-order thinking.

DESIGN

A systematic literature review was conducted, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and checklist (Page et al., 2021).

DATA SOURCES

CINAHL, Medline, Embase, PyscInfo.

REVIEW METHODS

Eligible articles were quality appraised using the MMAT tool. Data extraction was conducted independently by four reviewers. Three investigators thematically analysed the data.

RESULTS

Our review found that EWSs can support or suppress the development of nurses' higher-order thinking. EWS supports the development of higher-order thinking in two ways; by confirming nurses' subjective clinical assessment of patients and/or by providing a rationale for the escalation of care. Of note, more experienced nurses expressed their view that junior nurses are inhibited from developing effective higher-order thinking due to reliance on the tool.

CONCLUSION

EWSs facilitate early identification of clinical deterioration in hospitalised patients. The impact of EWSs on the development of nurses' higher-order thinking is under-explored. We found that EWSs can support and suppress nurses' higher-order thinking. EWS as a supportive factor reinforces the development of nurses' heuristics, the mental shortcuts experienced clinicians call on when interpreting their subjective clinical assessment of patients. Conversely, EWS as a suppressive factor inhibits the development of nurses' higher-order thinking and heuristics, restricting the development of muscle memory regarding similar presentations they may encounter in the future. Clinicians' ability to refine and expand on their catalogue of heuristics is important as it endorses the future provision of safe and effective care for patients who present with similar physiological signs and symptoms.

IMPACT

This research impacts health services and education providers as EWS and nurses' development of higher-order thinking skills are essential aspects of delivering safe, quality care.

NO PATIENT OR PUBLIC CONTRIBUTION

This is a systematic review, and therefore, comprises no contribution from patients or the public.

Findings from a decade of experience following implementation of a Rapid Response System into an Asian hospital

Aim

Rapid response systems (RRS) are present in many acute hospitals in western nations but are not widely adopted in Asia. The influence of healthcare culture and the effect of implementing an RRS over time are infrequently reported. We describe the introduction a RRS into a Singaporean hospital and the barriers encountered. The efferent limb activation rates, cardiac arrest rates and unplanned intensive care unit (ICU) admissions are trended over eleven years.

Methods

We conducted a retrospective observational study using prospectively collected data derived from administrative and Medical Emergency Team (MET) databases.

Results

The RRS used a MET with a single parameter track and trigger and physician led efferent limb. Barriers encountered included clinical leadership buy-in, assembling and equipping the efferent team, maintaining a non-punitive mindset, improving accessibility to MET and communicating the impact of the MET. Over an 11-year period with 488,252 hospital admissions, MET activation rates increased from 1.6/1000 admissions (2009) to 14.1/1000 admissions (2019). Code blue activations and unplanned ICU admission rates decreased from 2.9 to 1.7 and from 8.8 to 2.0/1000 admissions, respectively over the 11 years. There were associations between increasing MET activation rate and reduction in code blue activations (p = 0.013) and unplanned medical ICU admission rates (p = 0.001).

Conclusion

Implementing, sustaining and continued improvement of an RRS in Singapore is possible despite challenges encountered. With increasing activation rates over a decade, there were reductions in cardiac arrest rates and unplanned medical ICU admissions.

How do nurses use early warning system vital signs observation charts in rural, remote and regional health care facilities: A scoping review

INTRODUCTION

Physiological signs of clinical deterioration are known to occur in the hours preceding a serious adverse event. As a result, track and trigger systems known as early warning systems (EWS) were introduced and routinely implemented as patient observation tools to trigger an alert in the presence of abnormal vital signs.

OBJECTIVE

The objective aimed to explore the literature pertaining to EWS and their utilisation in rural, remote and regional health care facilities.

DESIGN

The Arksey and O'Malley's methodological framework was used to guide the scoping review. Only studies reporting on rural, remote and regional health care settings were included. All four authors participated in the screening, data extraction and analysis process.

FINDINGS

Our search strategy yielded 3869 peer-reviewed articles published between 2012 and 2022, with six studies ultimately included. Collectively, the studies included in this scoping review examined the complex interaction between patient vital signs observation charts and recognition of patient deterioration.

DISCUSSION

Whilst rural, remote and regional clinicians use EWS to recognise and respond to clinical deterioration, noncompliance dilutes the tool's effectiveness. This overarching finding is informed by three contributing factors: documentation, communication and challenges specific to the rural context.

CONCLUSION

The success of EWS relies on accurate documentation and effective communication within the interdisciplinary team to support appropriate responses to clinical patient decline. More research is required to understand the nuances and complexities of rural and remote nursing and to address challenges associated with the use of EWS in rural health care settings.

Early warning scores and trigger recommendations must be used with care in older home nursing care patients: Results from an observational study

AIMS

To explore modified early warning scores (MEWSs) and deviating vital signs among older home nursing care patients to determine whether the MEWS trigger recommendations were adhered to in cases of where registered nurses (RNs) suspected acute functional decline.

DESIGN

Prospective observational study with a descriptive, explorative design.

METHODS

Participants were included from April 2018 to February 2019. Demographic, health-related and clinical data were collected over a 3-month period.

RESULTS

In all, 135 older patients participated. Median MEWS (n = 444) was 1 (interquartile range (IQR) 1-2). Frequently deviating vital signs were respiratory (88.8%) and heart rate (15.3%). Median habitual MEWS (n = 51) was 1 (IQR 0-1). Deviating vital signs were respiratory (72.5%) and heart rate (19.6%). A significant difference between habitual MEWS and MEWS recorded in cases of suspected functional decline was found (p = 0.002). MEWS' trigger recommendations were adhered to in 68.9% of all MEWS measurements.

Exploration of Ward-Based Nurses' Perspectives on Their Preparedness to Recognize Clinical Deterioration: A Scoping Review

BACKGROUND

Despite initiatives in the early recognition of clinical deterioration, the incidence of failure to recognize clinical deterioration in patients continues to occur contributing to the ongoing rise of in-hospital mortality and morbidity.

OBJECTIVE

The aim of the study was to explore and appraise the research evidence that related to ward-based nurses' preparedness to recognize the clinically deteriorating patient.

METHODS

A scoping review was undertaken as this approach enabled the researchers to investigate the breadth of the available evidence through broad inclusion criteria. A comprehensive database search was conducted through the Cochrane Library; Cumulative Index to Nursing and Allied Health Literature; MEDLINE; ProQuest; PubMed; and Wiley Online Library. Each article was critically appraised and analyzed using a critical appraisal tool and thematic analysis, respectively. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews checklist.

RESULTS

Twelve primary sources of literature met the eligibility criteria. Through thematic analyses 6 primary themes were identified: implication of experience on preparedness; interprofessional and intraprofessional relationships; knowledge of calling criteria, process and procedures; requirement for a supportive system and culture; existence of hierarchy within healthcare impacting care; and clinical deterioration as an education opportunity.

CONCLUSIONS

This review identified central issues that impacted on ward-based nurses' preparedness. Further development of collaborative, supportive professional relationships across-and-within disciplines is needed. Effective use of clinical deterioration situations as educational opportunities would also assist nurses' preparedness through skill and knowledge development. However, more research evidence will be needed because of the limited data available on the topic.

Nurses' and Physicians' Ideas on Initiatives for Effective Use of the Early Warning Score: A Participatory Study

Ineffective use of the early warning score (EWS) can compromise recognition and response to patients' deteriorating condition. This study explores nurses' and physicians' ideas on initiatives for supporting the effective use of the EWS in a hospital setting. Participatory workshops were conducted, and data were analyzed using content analysis. Ideas generated for integrating new functions into the EWS protocol to facilitate effective use are described. Also recommended was that all users receive training and an update on how to use the EWS score to support acceptance and confidence using the protocol and thereby increase adherence to the EWS. Further research is needed on the efficiency of incorporating nurses' clinical judgment in the EWS protocol within different specialties and the effect on adherence to the tool.

A realist evaluation to identify targets to improve the organization of compression therapy for deep venous thrombosis- and chronic venous disease patients

Background

Although compression therapy is well established for patients with deep venous thrombosis (DVT) and chronic venous disease (CVD), considerable variation exists in its organization in clinical practice which may impact patient outcomes. The current study aims to deepen our understanding of the main drivers of the complex care organization for compression therapy and to identify targets for improvement.

Methods

This realist evaluation includes a mixed-method design consisting of semi-structured interviews with patients and health care professionals involved in compression therapy (n = 30), stakeholder meetings (n = 2) and surveys (n = 114). Data were collected to create the content of context-mechanism-outcome-configurations (CMOcs) important in compression therapy. Based on these CMOcs, targets for improvement to optimize the organization of compression care were identified.

Results

We identified overarching context factors and mechanisms targeting four optimal outcomes for the organization of compression therapy: selecting initial compression therapy types that support patient’s self-reliance (1), evidence based selection of elastic compression stocking type and class (2), patient-based selection of assistive devices (3), individualizing treatment duration for DVT patients (4a) and providing follow-up for CVD patients (4b). We found that increasing health care professionals’ knowledge of compression therapy, the availability of unambiguous protocols and guidelines, increasing patient involvement (and if applicable their informal care giver) in the decision making process, the accessible availability of resources, and increasing interdisciplinary consultation enhanced desirable outcomes. These targets triggered mechanisms such as increased health care professionals’ willingness, confidence and motivation to provide patient-based care and increased patients’ self-confidence and self-efficacy.

Conclusions

This study provides a detailed insight into what needs to be in place to optimize compression care and identified five main targets for improvement.

Factors influencing nursing students' ability to recognise and respond to simulated patient deterioration: A scoping review

AIM

The aim of this scoping review was to identify empirical literature on simulation used to develop undergraduate nursing student's clinical assessment skills to recognise and respond to patient deterioration.

BACKGROUND

Early recognition and response to clinical deterioration is necessary to ensure the best outcome for the patient. Undergraduate nursing students have limited exposure to deteriorating patient situations, therefore simulation is widely implemented in nursing courses to address this educational need. It is imperative to identify the simulation modalities and features that best optimise student learning.

DESIGN

Scoping review using the Joanna Briggs Institute scoping reviews methodology and the Arksey and O'Malley framework.

REVIEW METHODS

Seven health databases were searched electronically for relevant literature and complemented with hand searching for additional relevant sources. A total of 344 potential articles were identified from the seven databases: Cumulative Index to Nursing and Allied Health Literature (n = 234); PubMed (n = 16); Medline (n = 51); Scopus (n = 21); Embase (n = 3); American Psychological Association PsychInfo (n = 13); and JBI (n = 6). After applying inclusion and exclusion criteria, 15 research articles were included in the review.

RESULTS

Most research on clinical deterioration simulation was quantitative (n = 12), two were qualitative and one used a mixed method approach. Findings included a lack of situational awareness, distractors causing incomplete patient assessment and failure to recognise deterioration. Repeated simulation showed positive results.

CONCLUSIONS

Findings of this review suggest students lack situational awareness, perform incomplete assessment and fixate on single cues rather than an entire clinical picture. The use of a variety of simulation modalities was effective in improving student performance. Repeated practice within a single simulated learning experience, was shown to improve performance and situational awareness. This approach to simulation is under-researched in nursing and needs further exploration.

Development and psychometric evaluation of the Attitudes Towards Recognising Early and Noticeable Deterioration (ATREND) scale

AIMS AND OBJECTIVES

To develop and evaluate the psychometric properties of an instrument that measures nurses' Attitudes Towards Recognising Early and Noticeable Deterioration (ATREND).

BACKGROUND

General ward nurses play an important role in recognising patient deterioration. However, their attitudes towards early recognition of clinical deterioration have not been adequately explored due to the lack of a valid and reliable scale.

DESIGN

An instrument development and validation study.

METHODS

A three-phase structure that followed the STROBE checklist was used: (1) item generation, (2) content and face validity assessment and (3) psychometric properties evaluation. The scale items were developed based on a comprehensive literature review and content validity assessment by 15 international experts from five countries. The psychometric properties of the ATREND scale were tested on 434 registered nurses, with retest evaluations (n = 100) at two hospitals. Exploratory and confirmatory factor analyses were used to examine the factor structure of the scale. The scale was also evaluated for its internal consistency, test-retest reliability and convergent validity.

RESULTS

The scale's content validity was 0.95. A 3-factor solution was identified from the final 11 items: (1) beliefs about importance of patient observation, (2) use of broader patient assessment skills and (3) confidence in recognising clinical deterioration. The internal consistency reliability of the scale was supported with an acceptable Cronbach's alpha value of 0.745. Test-retest reliability of the scale was excellent, with an intraclass correlation coefficient of 0.825. The ATREND scale shows evidence of good convergent validity.

CONCLUSION

The final 11-item ATREND scale demonstrates adequate initial evidence of reliability and validity for use in acute ward settings.

RELEVANCE TO CLINICAL PRACTICE

Nursing educators and clinicians may use this scale to assess ward nurses' attitudes and practices towards early recognition of clinical deterioration and then enhance their competencies and behaviours in the recognition of clinical deterioration.

A realist model for home visitation program evaluation

Increased attention on home visitation as a strategy to reduce child maltreatment and increased funding to support home visitation programs has led to their rapid and widespread adoption in the United States and internationally. The rapid adoption of home visitation programs has occurred without an adequate understanding of the underlying mechanisms of influence on child maltreatment. Consequently, there is a lack of consistency in structures and processes across programs. The variability in structures and processes within and across programs has contributed to the inconsistent findings related to the effectiveness of home visitation as a strategy to constrain child maltreatment. Identifying the underlying mechanisms that are facilitating or constraining program success or failure is essential for informing policy and practice. We propose the use of realist theory to identify the underlying mechanisms of home visitation programs. While realist theory has been used broadly in the social sciences, its uptake in nursing has been slow. Despite its limited use in nursing, realism's primary function, seeking to identify the underlying mechanisms in complex social programs, makes it suitable for investigating many complex phenomena that are of interest to nurse scientists. Here we discuss the theoretical foundations for home visitation programs, the recent evidence for program effectiveness, significant home visitation program components, and we propose a realist model for home visitation program evaluation that may aid in identifying how, for whom, and under what conditions home visitation programs work when these programs are implemented to address child maltreatment.

Factors Associated With Care Trajectory Following Acute Functional Decline in Older Home Nursing Care Patients: A Prospective Observational Study

Health policies and previous research highlight the importance of early identification and treatment of clinical deterioration in older patients to prevent frailty, higher levels of care, and mortality. This study explores older home nursing care patients’ care trajectories and factors associated with clinical response (type and level of intervention) from the health care services, final level of community care and death within 3 months after an incidence of acute functional decline. This observational study with a prospective, descriptive design includes a sample of 135 older home nursing care patients with acute functional decline. Demographic, health-related, and clinical characteristics were analyzed and prediction models for care trajectories were fitted using Bayesian generalized mixed models. Age ranged from 65 to 100, with a median age of 85. Hospital admission were registered for 13.33% ( T1) and 8.77% ( T2) of the participants. Nine patients (6.7%) were transferred to a higher level of community care, and 11 patients (8.1%) died. Frequent transitions between levels of care characterized care trajectories for patients experiencing more severe functional decline. Age, living in a private home, and increased Modified Early Warning Scores (MEWS) were associated with level of clinical responses throughout the care trajectory. Living in a private home was associated with the patients’ final level of community care. Female gender, hospital admission, and increased MEWS scores were associated with death. Health care personnel must be vigilant when MEWS scores rise even slightly, as this might be an indication of acute functional decline with possible increased risk of mortality.

Improving In-Hospital Patient Rescue: What Are Studies on Early Warning Scores Missing? A Scoping Review

OBJECTIVES

Administrative and clinical efforts to improve hospital mortality and intensive care utilization commonly focus on patient rescue, where deteriorating patients are systematically identified and intervened upon. Patient rescue is known to depend on hospital context inclusive of technologic environment, structural features, and hospital organizational behavioral features. With widespread adoption of electronic medical records, early warning score (EWS) systems, which assign points to clinical data elements, are increasingly promoted as a tool for timely patient rescue by referencing their prediction of patient deterioration. We describe the extent to which EWS intervention studies describe the hospital environment of the intervention-details that would be critical for hospital leaders attempting to determine the real-world utility of EWSs in their own hospitals.

DATA SOURCES

We searched CINAHL, PubMed, and Scopus databases for English language EWS implementation research published between 2009 and 2021 in adult medical-surgical inpatients.

STUDY SELECTION

Studies including pediatric, obstetric, psychiatric, prehospital, outpatient, step-down, or ICU patients were excluded.

DATA EXTRACTION

Two investigators independently reviewed titles/abstracts for eligibility based on prespecified exclusion criteria.

DATA SYNTHESIS

We identified 1,434 studies for title/abstract screening. In all, 352 studies underwent full-text review and 21 studies were summarized. The 21 studies (18 before-and-after, three randomized trials) detailed 1,107,883 patients across 54 hospitals. Twelve reported the staff composition of an EWS response team. Ten reported the proportion of surgical patients. One reported nursing ratios; none reported intensive care staffing with in-house critical-care physicians. None measured changes in bed utilization or availability. While 16 qualitatively described resources for education/technologic implementation, none estimated costs. None described workforce composition such as team stability or culture of safety in the hospitals.

CONCLUSIONS

Despite hundreds of EWS-related publications, most do not report details of hospital context that would inform decisions about real-world EWS adoption. To make informed decisions about whether EWS implementation improves hospital quality, decision-makers may require alternatives such as peer networks and implementation pilots nested within local health systems.

Ambivalence in nurses' use of the early warning score: A focussed ethnography in a hospital setting

AIM

This study describes and explores the influences in registered nurses' use of early warning scores to support clinical decisions in a hospital setting.

DESIGN

A focussed ethnography allowed for the investigation of registered nurses' clinical practices in two wards in a Danish University Hospital. The study adhered to the 'Standards for Reporting Qualitative Research'.

METHODS

Participant observation and ethnographic interviews were conducted from March 2019 to August 2019. Ten registered nurses were observed and interviewed, and four physicians were interviewed. Data were analysed using LeCompte and Schensul's ethnographic analysis.

FINDINGS

The findings show the registered nurses' ambivalence towards the early warning score as a decision support system. Early warning score monitoring created a space for registered nurses to identify and initiate optimized care. However, when early warning scores contradicted registered nurses' clinical judgments, the latter were given priority in decisions even though elevated scores were not always accounted for in the situation. Moreover, we found unspoken expectations in the collaboration between physicians and registered nurses, which influenced the registered nurses' workloads and decisions regarding early warning scores.

CONCLUSION

Registered nurses' clinical judgment is essential to clinical decisions on the care and safety of patients if used combined with the early warning score. Interprofessional collaboration between registered nurses and physicians about the early warning score is challenged. Future research may address this challenge to explore how it should be operated as a collaboration tool.

IMPACT

The study adds knowledge to the evidence base of registered nurses' use of early warning score and the advantages and challenges associated with the use of these scoring systems. The study may provide valuable knowledge for the future development of policies or implementation strategies.

Early warning systems and rapid response systems for the prevention of patient deterioration on acute adult hospital wards

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.

Triggers and Interventions of Patients Who Require Medical Emergency Team Reviews: A Cross-Sectional Analysis of Single Versus Multiple Reviews

BACKGROUND

Medical emergency teams constitute part of the escalation protocol of early warning systems in many hospitals. The literature indicates that medical emergency teams may reduce hospital mortality and cardiac arrest. A greater understanding of pathways of patients who experience multiple medical emergency team reviews will inform clinical decision-making.

OBJECTIVES

To explore differences between patients who require a single medical emergency team review and those who require multiple reviews, and to identify any differences between patients who were reviewed only once during admission and patients who required multiple reviews.

METHODS

Data for this retrospective cross-sectional review, including demographic data, call triggers, outcomes, and interventions, were routinely collected from January 2013 through December 2015. The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) collaborative's cross-sectional studies checklist (version 4).

RESULTS

Of 54 787 admitted patients, 1274 (2%) required a call to a medical emergency team; of those, 260 patients (20%) needed multiple calls. Patients requiring multiple calls demonstrated higher mortality (odds ratio, 1.49 [95% CI, 1.12-1.98]). A logistic regression model identified surgical patients and those receiving antibiotics and respiratory interventions at the first medical emergency team review as being more likely to require multiple reviews. Patients transferred to a higher level of care after the first review were less likely to require another review.

CONCLUSIONS

Patients requiring multiple medical emergency team reviews have higher mortality. Surgical patients have a higher risk of requiring multiple reviews. Hospitals need to include more details on surgical patients when auditing medical emergency team activation.

Human factors in escalating acute ward care: a qualitative evidence synthesis

Background

Identifying how human factors affect clinical staff recognition and managment of the deteriorating ward patient may inform process improvements. We systematically reviewed the literature to identify (1) how human factors affect ward care escalation (2) gaps in the current literature and (3) critique literature methodologies.

Methods

We undertook a Qualitative Evidence Synthesis of care escalation studies. We searched MEDLINE, EMBASE and CINHAL from inception to September 2019. We used the Critical Appraisal Skills Programme and the Grading of Recommendations Assessment-Development and Evaluation and Confidence in Evidence from Reviews of Qualitative Research tool to assess study quality.

Results

Our search identified 24 studies meeting the inclusion criteria. Confidence in findings was moderate (20 studies) to high (4 studies). In 16 studies, the ability to recognise changes in the patient’s condition (soft signals), including skin colour/temperature, respiratory pattern, blood loss, personality change, patient complaint and fatigue, improved the ability to escalate patients. Soft signals were detected through patient assessment (looking/listening/feeling) and not Early Warning Scores (eight studies). In contrast, 13 studies found a high workload and low staffing levels reduced staff’s ability to detect patient deterioration and escalate care. In eight studies quantifiable deterioration evidence (Early Warning Scores) facilitated escalation communication, particularly when referrer/referee were unfamiliar. Conversely, escalating concerning non-triggering patients was challenging but achieved by some clinical staff (three studies). Team decision making facilitated the clinical escalation (six studies).

Conclusions

Early Warning Scores have clinical benefits but can sometimes impede escalation in patients not meeting the threshold. Staff use other factors (soft signals) not captured in Early Warning Scores to escalate care. The literature supports strategies that improve the escalation process such as good patient assessment skills.

PROSPERO registration number

CRD42018104745.

Risk of acute deterioration and care complexity individual factors associated with health outcomes in hospitalised patients with COVID-19: a multicentre cohort study

BACKGROUND

Evidence about the impact of systematic nursing surveillance on risk of acute deterioration of patients with COVID-19 and the effects of care complexity factors on inpatient outcomes is scarce. The aim of this study was to determine the association between acute deterioration risk, care complexity factors and unfavourable outcomes in hospitalised patients with COVID-19.

METHODS

A multicentre cohort study was conducted from 1 to 31 March 2020 at seven hospitals in Catalonia. All adult patients with COVID-19 admitted to hospitals and with a complete minimum data set were recruited retrospectively. Patients were classified based on the presence or absence of a composite unfavourable outcome (in-hospital mortality and adverse events). The main measures included risk of acute deterioration (as measured using the VIDA early warning system) and care complexity factors. All data were obtained blinded from electronic health records. Multivariate logistic analysis was performed to identify the VIDA score and complexity factors associated with unfavourable outcomes.

RESULTS

Out of a total of 1176 patients with COVID-19, 506 (43%) experienced an unfavourable outcome during hospitalisation. The frequency of unfavourable outcomes rose with increasing risk of acute deterioration as measured by the VIDA score. Risk factors independently associated with unfavourable outcomes were chronic underlying disease (OR: 1.90, 95% CI 1.32 to 2.72; p<0.001), mental status impairment (OR: 2.31, 95% CI 1.45 to 23.66; p<0.001), length of hospital stay (OR: 1.16, 95% CI 1.11 to 1.21; p<0.001) and high risk of acute deterioration (OR: 4.32, 95% CI 2.83 to 6.60; p<0.001). High-tech hospital admission was a protective factor against unfavourable outcomes (OR: 0.57, 95% CI 0.36 to 0.89; p=0.01).

CONCLUSION

The systematic nursing surveillance of the status and evolution of COVID-19 inpatients, including the careful monitoring of acute deterioration risk and care complexity factors, may help reduce deleterious health outcomes in COVID-19 inpatients.

Update on early warning scores

Early warning scores (EWS) have the objective to provide a preventive approach for detecting those patients in general wards at risk of deterioration before it begins. Well implemented and combined with a tiered response, the EWS expect to be a relevant tool for patient safety. Most of the evidence for their use has been published for the general EWS. Their strengths, such as objectivity and systematic response, health provider training, universal applicability and automatization potential need to be highlighted to counterbalance the weakness and limitations that have also been described. The near future will probably increase availability of EWS, reliability and predictive value through the spread and acceptability of continuous monitoring in general ward, its integration in decision support algorithms with automatic alerts and the elaboration of temporal vital signs patterns that will finally allow to perform a personal modelling depending on individual patient characteristics.

Patient and family involvement in escalating concerns about clinical deterioration in acute adult wards: A qualitative systematic review

BACKGROUND

Despite international standards for recognition and response to deterioration, warning signs are not always identified by staff on acute hospital wards. Patient and family-initiated escalation of care schemes have shown some benefit in assisting early recognition, but are not widely used in many clinical practice areas.

OBJECTIVES

To explore (a) patients' and relatives' experiences of acute deterioration and (b) patients', relatives' and healthcare professionals' perceptions of the barriers or facilitators to patient and family-initiated escalation of care in acute adult hospital wards.

METHODS

We conducted a qualitative review using Cochrane methodology. Two reviewers independently screened studies, extracted data, and appraised the quality using a qualitative critical appraisal tool. Findings were analysed using thematic synthesis and confidence in findings was assessed using GRADE-CERQual.

SEARCH STRATEGY

MEDLINE, CINAHL, EMBASE, PsychINFO databases and grey literature from 2005 to August 2019.

INCLUSION CRITERIA

Any research design that had a qualitative element and focused on adult patients' and relatives' experiences of deterioration and perceptions of escalating care.

RESULTS

We included five studies representing 120 participants and assessed the certainty of evidence as moderate using GRADE-CERQual. Findings indicated that a number of patients/relatives have the ability to detect acute deterioration, however, various factors act as both barriers and facilitators to being heard. These include personal factors, perceptions of role, quality of relationships with healthcare staff, and organisational factors. Theoretical understanding suggests that patient and relative involvement in escalation is dependent on both inherent capabilities and the factors that influence empowerment.

CONCLUSION

This review highlights that patient and family escalation of care interventions need to be designed with the aim of improving patient/relative-clinician collaboration and the sharing of responsibility.

RELEVANCE TO PRACTICE

These factors need to be addressed to promote more active partnerships when designing and implementing patient and family-initiated escalation of care interventions.

What works, for whom and under what circumstances? Using realist methodology to evaluate complex interventions in nursing: A scoping review

BACKGROUND

The Medical Research Council's (MRC) framework recommends basing every evaluation of a complex intervention on a theory that explains WHY an intervention works instead of focusing exclusively on the identification IF an intervention works. Theory-based evaluation approaches such as realist evaluations are promising in this respect. The aim of this scoping review is to examine current scientific literature with regard to the use of realist methodology in studies that evaluate complex nursing interventions. We also seek to answer the question whether realist evaluation studies of complex nursing interventions are embedded in the Medical Research Council's framework.

METHODS

A systematic database search in MEDLINE and CINAHL supplemented with snowballing techniques and a hand search in relevant nursing journals were performed between January and February 2018 and updated in July 2019. Both authors independently screened the title / abstract of studies that were initially identified and appraised the full texts if inclusion criteria were fulfilled. Inclusion criteria were the explicit use of realist methodology and a focus on the development or evaluation of complex nursing interventions. Results were summarized narratively.

RESULTS

A total of 28 articles from 22 studies, published between 2010 and 2019, were included. The majority of the studies included originate in the UK. Realist methodology was used by a variety of nursing disciplines, including midwifery, community / public health, critical care, palliative care, gerontological nursing, psychiatric nursing / mental health, and infection control. Study designs included case studies and realist reviews; two studies were conducted alongside a randomized controlled trial. All studies included used more than one method to develop their results; the majority of methods were qualitative by nature. Thirteen of the studies included aimed to develop a theory about what works, for whom and under what circumstances regarding the investigated complex nursing intervention. One study was clearly embedded in the Medical Research Council's framework.

CONCLUSION

Realist evaluation broadens the methodologies that have traditionally been used in nursing. Conceptual clarity on its principal tenets is still needed, as well as the methods used to assess them. Nursing scientists should be more critical when using novel methodology and contribute to academic debates about limitations. Embedding realist evaluations into the Medical Research Council's framework is in its infancy in nursing and needs more contributions in order to develop a common academic position within the profession. Tweetable abstract Realist methodology in nursing - review of the use, methods, limitations and embedding into the Medical Research Council's framework.

Clarity, confidence and complexity: Learning from mental health nurses' experiences of events involving physiological deterioration of consumers in acute inpatient mental health settings

AIMS AND OBJECTIVE

To capture the experiences of nurses in relation to the acutely physiologically deteriorating consumer.

BACKGROUND

Improving the physical health care of consumers with mental illness has been widely adopted as a priority for mental health nursing. Much of the effort thus far has focused on routine screening, prevention and treatment of common comorbidities including cardiovascular disease, diabetes mellitus and cancer. There has been less focus on the acutely physiologically deteriorating consumer in the mental health setting. Further study is warranted since this issue poses a set of highly complex challenges for nurses within the inpatient setting.

METHOD

An exploratory, descriptive study was employed using focus groups to gather narrative data, which was then subject to qualitative analysis. Eleven mental health inpatient wards within a local health district in Sydney, Australia, were studied, comprising ward-based nurses (n = 64) and nurse unit managers (n = 8). This paper follows the COREQ guidelines for reporting qualitative health research.

RESULTS

Qualitative data analysis revealed three themes central to the nurses' experience: (a) lack of clarity (subthemes: procedures and leadership accountability); (b) confidence in the workforce (subthemes: knowledge and skills, training needs, relevant experience, collaboration with emergency and medical teams, stigmatising attitudes); and (c) complexity (subthemes: complexity as the new norm and suitability of the mental health environment).

CONCLUSION

The themes found in this study can be used to guide and inform healthcare policy, protocols, education and processes around building a more confident nurse workforce for the acutely physiologically deteriorating consumer.

RELEVANCE TO CLINICAL PRACTICE

Findings provide a rich data set for the generation of measurement tools and protocols to guide physical health care and evaluate performance.

Hospital nurses' professional accountability while using the National Early Warning Score: A qualitative study with a hermeneutic design

AIM

To explore general hospital ward nurses' experiences with the National Early Warning Score and to determine its impacts on their professionalism.

BACKGROUND

The National Early Warning Score has broad appeal; it is a patient safety initiative designed to ensure early identification of and response to deteriorating patients in hospitals. However, it is still unclear how the tool impacts nurses' professionalism.

METHODS

A qualitative study with a hermeneutic design was conducted in autumn 2017; the study consisted of semi-structured, in-depth interviews with 14 hospital nurses. The data were analysed thematically to understand and interpret the nurses' experiences. Methods are reported using COREQ guidelines (see Appendix S1).

RESULTS

The study examined nurses' experience with the National Early Warning Score and its perceived impact on their professionalism. Four themes were identified: (a) the National Early Warning Score and clinical judgement in patient assessment, (b) responding to the National Early Warning Score standard, (c) involving the professional community and (d) adjusting the tool.

CONCLUSION

The National Early Warning Score may impact nurses' professionalism in diverse ways. Nurses are aware of the importance of incorporating all of their professional competence, comprising clinical judgement, discretion and accountability, with the National Early Warning Score to accurately assess patients' conditions. Findings indicated that the National Early Warning Score was beneficial to nurses' professional practice; however, accountability to this standard alone does not ensure quality care and patient safety.

RELEVANCE TO CLINICAL PRACTICE

A greater understanding of the role of nurses' professional accountability when using the National Early Warning Score is needed to improve practice and ensure patient safety.

How do nurses use early warning scoring systems to detect and act on patient deterioration to ensure patient safety? A scoping review

BACKGROUND

Despite widespread adoption of rapid response systems and the use of various early warning scoring systems, the detection of patient deterioration remains suboptimal, leading to the development of potentially avoidable serious adverse events. Why this occurs has been the focus of many investigations, but the complexities around advancing understanding that leads to effective actions are less evident.

OBJECTIVE

To better understand medical/surgical nurses use of early warning scoring systems.

DESIGN

A five-step process was used in this scoping review including: identify the research question; search and identify the relevant studies; selecting relevant studies; charting the data; and collate, summarize and report the results. The PRISMA extension for scoping reviews was used to guide this scoping review.

DATA SOURCES

In August 2018 a literature search was performed using the following medical subject headings: physiological, clinical deterioration, and the expanders early warning score, system, nurse attitudes, with Boolean operators in Ovid MEDLINE, CINAHL, and EMBASE databases.

REVIEW METHODS

Extracted data included study aims, key findings, afferent/efferent focus and rapid response team description. Effective practice and organisation of care taxonomy guided data synthesis, before a thematic analysis was performed.

RESULTS

Of 120 unique articles, 23 were included in the scoping review (11 qualitative, 8 quantitative and 4 mixed methods studies). Fifteen studies focused on the afferent limb of the rapid response system whilst eight focused on both the afferent and efferent limbs. In the effective practice and organisation of care taxonomy twenty-two studies met criteria for quality and safety improvements while nineteen met criteria for referral, outreach and teams. Three themes, Inconsistent activation of the rapid response team; Barriers to following early warning scoring system algorithms; and Overreliance on scores emerged.

CONCLUSION

Nurses aim to use early warning score systems to detect deterioration and ensure patient safety, however cultures, confidence and past experiences impact on rates of afferent limb failure globally. Simple to follow algorithms used in track and trigger charts are likely difficult for nurses to adhere to due to heavy workloads and challenges in getting medical officers to review within recommended time frames. Nurses rely heavily on the scores generated by early warning score systems but should aim to follow algorithms better and undertake holistic physical assessments to detect deterioration earlier and ensure patient safety is not compromised.

Patient and family-initiated escalation of care: a qualitative systematic review protocol

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.

Determining acute nurse staffing: a hermeneutic review of an evolving science

BACKGROUND

Calculating nurse staffing in the acute hospital has become a key issue but solutions appear distant. Community, mental health and areas such as learning disability nursing have attracted less attention and remain intractable. This review aims to examine current approaches to the issue across many disciplines.

DESIGN

The approach taken is iterative and in the form of a hermeneutic review. 769 pieces of evidence were reviewed from across disciplines such as nursing, medicine, engineering, statistics, population science, computer science and mathematics where hospital nurse staffing was the subject of the study.

RESULTS

A number of themes emerged. The first iteration showed the predominance of unit base approaches (eg, nurse numbers, ratios, activity and workload) and the second was the development of methodologies. Subsequent iterations examined issues such as demand, safety, nurse education, turnover, patient outcomes, patient or staff satisfaction, workload and activity. The majority of studies examined (n=767) demonstrated some association between staffing (units or type/skill) and various factors such as staff or patient satisfaction, working conditions, safety parameters, outcomes complexity of work achieved, work left undone or other factors. Many potential areas such as operational safety research were not utilised.

CONCLUSION

Although the relationship between staffing in acute care and factors such as units, safety or workload is complex, the evidence suggests an interdependent relationship which should only be dismissed with caution. The nature of these relationships should be further examined in order to determine nurse staffing. The body of knowledge appears substantial and complex yet appears to have little impact on policy.

How do nurses use the early warning score in their practice? A case study from an acute medical unit

AIMS AND OBJECTIVES

This study aimed to describe how nurses use the early warning score (EWS) in an acute medical ward and their compliance with the EWS and explore their views and experiences of the EWS.

BACKGROUND

early warning score systems have been implemented in response to upward trends in mortality rates. Nurses play a central role in the use of EWS systems. However, barriers to their use have been identified and include behavioural, cultural and organisational approaches to adherence. Improvement strategies including education and training and electronic devices have assisted in compliance with the system.

DESIGN

A holistic single descriptive case study design was used.

METHODS

Data triangulation was used including non-participant observation, semi-structured interviews with nurses and document analysis. Nurses were observed using EWS and were subsequently interviewed. Data analysis was guided by systematic text condensation (STC), an approach underpinned by Giorgi's phenomenological method, where meaning units and themes are identified. The study adhered to the consolidated criteria for reporting qualitative research (COREQ) guidelines.

RESULTS

Three themes with associated meaning units were found. Protocol Adherence vs. Clinical Judgement addresses nurses' knowledge, skill and experience and patient assessment. Parameter Adjustment and Escalation included parameters not being adjusted or reviewed, junior doctors not being authorised to set parameters and escalation. The final theme Culture highlighted a task-driven approach and deficient communication processes.

CONCLUSION

This study highlights the need for ongoing training, behavioural change and a cultural shift by healthcare professionals and organisations to ensure adherence with EWS escalation protocols.

RELEVANCE TO CLINICAL PRACTICE

Improvements in education and training into recognition, management and communication of a deteriorating patient are required. Also, a cultural shift is needed to improve compliance and adherence with EWS practice. The potential use of electronic data should be explored.

Investigating the discriminative value of Early Warning Scores in patients with respiratory disease using a retrospective cohort analysis of admissions to Nottingham University Hospitals Trust over a 2-year period

OBJECTIVE

Early Warning Scores (EWSs) are used to monitor patients for signs of imminent deterioration. Although used in respiratory disease, EWSs have not been well studied in this population, despite the underlying cardiopulmonary pathophysiology often present. We examined the performance of two scoring systems in patients with respiratory disease.

DESIGN

Retrospective cohort analysis of vital signs observations of all patients admitted to a respiratory unit over a 2-year period. Scores were linked to outcome data to establish the performance of the National EWS (NEWS) compared results to a locally adapted EWS.

SETTING

Nottingham University Hospitals National Health Service Trust respiratory wards. Data were collected from an integrated electronic observation and task allocation system employing a local EWS, also generating mandatory referrals to clinical staff at set scoring thresholds.

OUTCOME MEASURES

Projected workload, and sensitivity and specificity of the scores in predicting mortality based on outcome within 24 hours of a score being recorded.

RESULTS

8812 individual patient episodes occurred during the study period. Overall, mortality was 5.9%. Applying NEWS retrospectively (vs local EWS) generated an eightfold increase in mandatory escalations, but had higher sensitivity in predicting mortality at the protocol cut points.

CONCLUSIONS

This study highlights issues surrounding use of scoring systems in patients with respiratory disease. NEWS demonstrated higher sensitivity for predicting death within 24 hours, offset by reduced specificity. The consequent workload generated may compromise the ability of the clinical team to respond to patients needing immediate input. The locally adapted EWS has higher specificity but lower sensitivity. Statistical evaluation suggests this may lead to missed opportunities for intervention, however, this does not account for clinical concern independent of the scores, nor ability to respond to alerts based on workload. Further research into the role of warning scores and the impact of chronic pathophysiology is urgently needed.

Implementation of a whole of hospital sepsis clinical pathway in a cancer hospital: impact on sepsis management, outcomes and costs

Infection and sepsis are common problems in cancer management affecting up to 45% of patients and are associated with significant morbidity, mortality and healthcare utilisation.

Objective

To develop and implement a whole of hospital clinical pathway for the management of sepsis (SP) in a specialised cancer hospital and to measure the impact on patient outcomes and healthcare utilisation.

Methods

A multidisciplinary sepsis working party was established. Process mapping of practices for recognition and management of sepsis was undertaken across all clinical areas. A clinical pathway document that supported nurse-initiated sepsis care, prompt antibiotic and fluid resuscitation was implemented. Process and outcome measures for patients with sepsis were collected preimplementation (April-December 2012), postimplementation cohorts (April-December 2013), and from January to December 2014.

Results

323 patients were evaluated (111 preimplementation, 212 postimplementation). More patients with sepsis had lactate measured (75.0% vs 17.2%) and appropriate first dose antibiotic (90.1% vs 76.1%) (all p<0.05). Time to antibiotics was halved (55 vs 110 min, p<0.05). Patients with sepsis had lower rates of intensive care unit admission (17.1% vs 35.5%), postsepsis length of stay (7.5 vs 9.9 days), and sepsis-related mortality (5.0% vs 16.2%) (all p<0.05). Mean total hospital admission costs were lower in the SP cohort, with a significant difference in admission costs between historical and SP non-surgical groups of $A8363 (95% CI 81.02 to 16645.32, p=0.048) per patient on the pathway. A second cohort of 449 patients with sepsis from January to December 2014 demonstrated sustained improvement.

Conclusions

The SP was associated with significant improvement in patient outcomes and reduced costs. The SP has been sustained since 2013, and has been successfully implemented in another hospital with further implementations underway in Victoria.

Enhanced early warning system impact on nursing practice: A phenomenological study

AIM

To determine how an enhanced early warning system has an impact on nursing practice.

BACKGROUND

Early warning systems score physiologic measures and alert nurses to subtle changes in patient condition. Critics of early warning systems have expressed concern that nurses would rely on a score rather than assessment skills and critical thinking to determine the need for intervention. Enhancing early warning systems with innovative technology is still in its infancy, so the impact of an enhanced early warning system on nursing behaviours or practice has not yet been studied.

DESIGN

Phenomenological design.

METHODS

Scripted, semistructured interviews were conducted in September 2015 with 25 medical/surgical nurses who used the enhanced early warning system. Data were analysed using thematic analysis techniques (coding and bracketing). Emerging themes were examined for relationships and a model describing the enhanced early warning system experience was developed.

FINDINGS

Nurses identified awareness leading to investigation and ease of prioritization as the enhanced early warning system's most important impact on their nursing practice. There was also an impact on organizational culture, with nurses reporting improved communication, increased collaboration, increased accountability and proactive responses to early changes in patient condition.

CONCLUSIONS

Rather than hinder critical thinking, as many early warning systems' critics claim, nurses in this study found that the enhanced early warning system increased their awareness of changes in a patient's condition, resulting in earlier response and reassessment times. It also had an impact on the organization by improving communication and collaboration and supporting a culture of proactive rather than reactive response to early signs of deterioration.