The Impact of Implementation of Family-Initiated Escalation of Care for the Deteriorating Patient in Hospital: A Systematic Review

Intensive Care Unit Without Walls

Critical illness is a continuum with different phases and trajectories. The "Intensive Care Unit (ICU) without walls" concept refers to a model whereby care is adjusted in response to the patient's needs, priorities, and preferences at each stage from detection, escalation, early decision making, treatment and organ support, followed by recovery and rehabilitation, within which all healthcare staff, and the patient are equal partners. The rapid response system incorporates monitoring and alerting tools, a multidisciplinary critical care outreach team and care bundles, supported with education and training, analytical and governance functions, which combine to optimise outcomes of critically ill patients, independent of location.

Understanding the enablers and barriers to implementing a patient-led escalation system: a qualitative study

BACKGROUND

The management of acute deterioration following surgery remains highly variable. Patients and families can play an important role in identifying early signs of deterioration but effective contribution to escalation of care can be practically difficult to achieve. This paper reports the enablers and barriers to the implementation of patient-led escalation systems found during a process evaluation of a quality improvement programme Rescue for Emergency Surgery Patients Observed to uNdergo acute Deterioration (RESPOND).

METHODS

The research used ethnographic methods, including over 100 hours of observations on surgical units in three English hospitals in order to understand the everyday context of care. Observations focused on the coordination of activities such as handovers and how rescue featured as part of this. We also conducted 27 interviews with a range of clinical and managerial staff and patients. We employed a thematic analysis approach, combined with a theoretically focused implementation coding framework, based on Normalisation Process Theory.

RESULTS

We found that organisational infrastructural support in the form of a leadership support and clinical care outreach teams with capacity were enablers in implementing the patient-led escalation system. Barriers to implementation included making changes to professional practice without discussing the value and legitimacy of operationalising patient concerns, and ensuring equity of use. We found that organisational work is needed to overcome patient fears about disrupting social and cultural norms.

CONCLUSIONS

This paper reveals the need for infrastructural support to facilitate the implementation of a patient-led escalation system, and leadership support to normalise the everyday process of involving patients and families in escalation. This type of system may not achieve its goals without properly understanding and addressing the concerns of both nurses and patients.

Listen to me, I really am sick! Patient and family narratives of clinical deterioration before and during rapid response system intervention

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.

Risk factors associated with escalation of care in a quaternary academic hospital at home program

BACKGROUND

Hospital-at-home has become a more recognized way to care for patients requiring inpatient hospitalization. At times, these patients may require escalation of care (transfer from home back to the brick-and mortar (BAM) hospital for ongoing hospitalization care needs), a process that has not been extensively studied.

OBJECTIVE

To evaluate what patient factors contribute to escalations of care in the hospital-at-home delivery model.

DESIGNS, SETTINGS, AND PARTICIPANTS

We conducted a retrospective review of all patients admitted to Mayo Clinic's Advanced Care at Home (ACH) program from January 1, 2022 to December 31, 2022.

INTERVENTION

None.

MAIN OUTCOMES AND MEASURES

Patient information was collected via electronic health record including demographic, socioeconomic, and clinical status. The primary outcome was the of occurrence of an escalation.

RESULTS

A total of 904 patients were included, of whom 80 (8.8%) required an escalation of care. In multivariable analysis, risk of an escalation was significantly higher for patients who were married or had a life partner (HR: 1.82, 95% CI: 1.05-3.23, p = .033) for patients admitted with procedure-related disorders (HR: 2.61, 95% CI: 1.35-5.05, p = .005) and patients with an increased mortality risk score (HR [per each 1-category increase] = 1.86, 95% CI: 1.39-2.50, p < .001).

Parents' Trigger Tool for Children with Medical Complexity - PAT-CMC: Development of a recognition tool for clinical deterioration at home

AIM

To develop a trigger tool for parents and lay caregivers of children with medical complexity (CMC) at home and to validate its content.

DESIGN

This was a multi-method study, using qualitative data, a Delphi method and a concept mapping approach.

METHODS

A three-round electronic Delphi was performed from December 2021 to April 2022 with a panel of 23 expert parents and 30 healthcare providers, supplemented by a preliminary qualitative exploration of children's signs of deterioration and three consensus meetings to develop the PArents' Trigger Tool for Children with Medical Complexity (PAT-CMC). Cognitive interviews with parents were performed to assess the comprehensiveness and comprehensibility of the tool. The COREQ checklist, the COSMIN guidelines and the CREDES guidelines guided the reporting respectively of the qualitative study, the development and content validity of the trigger tool and the Delphi study.

RESULTS

The PAT-CMC was developed and its content validated to recognize clinical deterioration at home. The tool consists of 7 main clusters of items: Breathing, Heart, Devices, Behaviour, Neuro-Muscular, Nutrition/Hydration and Other Concerns. A total of 23 triggers of deterioration were included and related to two recommendations for escalation of care, using a traffic light coding system.

CONCLUSION

Priority indicators of clinical deterioration of CMC were identified and integrated into a validated trigger tool designed for parents or other lay caregivers at home, to recognize signs of acute severe illness and initiate healthcare interventions.

IMPACT

The PAT-CMC was developed to guide families in recognizing signs of deterioration in CMC and has potential for initiating an early escalation of care. This tool may also be useful to support education provided by healthcare providers to families before hospital discharge.

PATIENT OR PUBLIC CONTRIBUTION

Parents of CMC were directly involved in the selection of relevant indicators of children's clinical deterioration and the development of the trigger tool. They were not involved in the design, conducting, reporting or dissemination plans of this research.

Opinions of Nurses and Physicians on a Patient, Family, and Visitor Activated Rapid Response System in Use Across Two Hospital Settings

BACKGROUND

Early detection of deterioration of hospitalized patients with timely intervention improves outcomes in the hospital. Patients, family members, and visitors (consumers) at the patient's bedside who are familiar with the patient's condition may play a critical role in detecting early patient deterioration. The authors sought to understand clinicians' views on consumer reporting of patient deterioration through an established hospital consumer-initiated escalation-of-care system.

METHODS

A convenience sample of new graduate-level to senior-level nurses and physicians from two hospitals in South Australia was administered a paper survey containing six open-ended questions. Data were analyzed with a matrix-style framework and six steps of thematic analysis.

RESULTS

A total of 244 clinicians-198 nurses and 46 physicians-provided their views on the consumer-initiated escalation-of-care system. Six major themes and subthemes emerged from the responses indicating that (1) clinicians were supportive of consumer reporting and felt that consumers were ideally positioned to recognize deterioration early and raise concerns about it; (2) management support was required for consumer escalation processes to be effective; (3) clinicians' workload could possibly increase or decrease from consumer escalation; (4) education of consumers and staff on escalation protocol is a requirement for success; (5) there is need to build consumer confidence to speak up; and (6) there is a need to address barriers to consumer escalation.

CONCLUSION

Clinicians were supportive of consumers acting as first reporters of patient deterioration. Use of interactive, encouraging communication skills with consumers was recognized as critical. Annual updating of clinicians on consumer reporting of deterioration was also recommended.

Impact of Rapid Response Teams on Pediatric Care: An Interrupted Time Series Analysis of Unplanned PICU Admissions and Cardiac Arrests

Pediatric rapid response teams (RRTs) are expected to significantly lower pediatric mortality in healthcare settings. This study evaluates RRTs' effectiveness in decreasing cardiac arrests and unexpected Pediatric Intensive Care Unit (PICU) admissions. A quasi-experimental study (2014-2017) at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, involved 3261 pediatric inpatients, split into pre-intervention (1604) and post-intervention (1657) groups. Baseline pediatric warning scores and monthly data on admissions, transfers, arrests, and mortality were analyzed pre- and post-intervention. Statistical methods including bootstrapping, segmented regression, and a Zero-Inflation Poisson model were employed to ensure a comprehensive evaluation of the intervention's impact. RRT was activated 471 times, primarily for respiratory distress (29.30%), sepsis (22.30%), clinical anxiety (13.80%), and hematological abnormalities (6.7%). Family concerns triggered 0.1% of activations. Post-RRT implementation, unplanned PICU admissions significantly reduced (RR = 0.552, 95% CI 0.485-0.628, p < 0.0001), and non-ICU cardiac arrests were eliminated (RR = 0). Patient care improvement was notable, with a -9.61 coefficient for PICU admissions (95% CI: -12.65 to -6.57, p < 0.001) and a -1.641 coefficient for non-ICU cardiac arrests (95% CI: -2.22 to -1.06, p < 0.001). Sensitivity analysis showed mixed results for PICU admissions, while zero-inflation Poisson analysis confirmed a reduction in non-ICU arrests. The deployment of pediatric RRTs is associated with fewer unexpected PICU admissions and non-ICU cardiopulmonary arrests, indicating improved PICU management. Further research using robust scientific methods is necessary to conclusively determine RRTs' clinical benefits.

Hospital Testing of the Effectiveness of Co-Designed Educational Materials to Improve Patient and Visitor Knowledge and Confidence in Reporting Patient Deterioration

BACKGROUND

Co-designed educational materials could significantly improve the likelihood of patients and visitors (consumers) escalating care through hospital systems. The objective was to investigate patients' and visitors' knowledge and confidence in recognizing and reporting patient deterioration in hospitals before and after exposure to educational materials.

METHODS

A multimethod design involved a convenience sample of patients and visitors at a South Australian hospital. Knowledge and confidence of participants to report patient deterioration was assessed using a validated questionnaire. Baseline group was surveyed, and a second group was surveyed after exposure to a poster and on-hold message relating to consumer-initiated escalation-of-care. Nominal data were examined using chi-square analysis, and ordinal data using the Mann-Whitney U test. Open-ended questions were examined using thematic analysis.

RESULTS

A total of 407 participants completed the study, 203 undertook the baseline survey, and 204 the postintervention survey. Respondents exposed to the educational materials reported significantly higher recognition of responsibility to report concerns about patient deterioration compared to controls (86.3% vs. 73.1%; p = 0.007). Respondents exposed to the educational materials also had better ability to identify signs that a patient was becoming sicker compared to controls (77.5% vs. 71.3%, p = 0.012). Four overarching themes emerged from the questions: patient/visitor understanding of key messages, patient/visitor recognition of deterioration, patient/visitor response to deterioration and patient/visitor recommendations.

CONCLUSION

Following educational interventions, patients and visitors report improved awareness of their role in recognizing and responding to clinical deterioration. They advise additional active interventions and caution that the materials should accommodate language, cultural, and disability needs.

Night-time detection and response in relation to deteriorating inpatients: A scoping review

BACKGROUND

Although detection and response to clinical deterioration have been studied, the range and nature of studies focused on night-time clinical setting remain unclear.

AIM

This study aimed to identify and map existing research and findings concerning night-time detection and response to deteriorating inpatients in usual care or research settings.

STUDY DESIGN

A scoping review method was used. PubMed, CINAHL, Web of Science, and Ichushi-Web databases were systematically searched. We included studies focusing on night-time detection and response to clinical deterioration.

RESULTS

Twenty-eight studies were included. These studies were organized into five categories: night-time medical emergency team or rapid response team (MET/RRT) response, night-time observation using the early warning score (EWS), available resources for physicians' practice, continuous monitoring of specific parameters, and screening for night-time clinical deterioration. The first three categories were related to interventional measures in usual care settings, and relevant findings mainly demonstrated the actual situation and challenges of night-time practice. The final two categories were related to the interventions in the research settings and included innovative interventions to identify at-risk or deteriorating patients.

CONCLUSIONS

Systematic interventional measures, such as MET/RRT and EWS, could have been sub-optimally performed at night. Innovations in monitoring technologies or implementation of predictive models could be helpful in improving the detection of night-time deterioration.

RELEVANCE TO CLINICAL PRACTICE

This review provides a compilation of current evidence regarding night-time practice concerning patient deterioration. However, a lack of understanding exists on specific and effective practices regarding timely action for deteriorating patients at night.

The predictive value of the modified early warning score for admission to the intensive care unit in patients with a hematologic malignancy - A multicenter observational study

OBJECTIVES

The modified early warning score (MEWS) is used to detect clinical deterioration of hospitalized patients. We aimed to investigate the predictive value of MEWS and derived quick Sequential Organ Failure Assessment (qSOFA) scores for intensive care unit admission in patients with a hematologic malignancy admitted to the ward.

DESIGN

Retrospective, observational study in two Dutch university hospitals.

SETTING

Data from adult patients with a hematologic malignancy, admitted to the ward over a 2-year period, were extracted from electronic patient files.

MAIN OUTCOME MEASURES

Intensive care admission.

RESULTS

We included 395 patients with 736 hospital admissions; 2% (n = 15) of admissions resulted in admission to the intensive care unit. A higher MEWS (OR 1.5; 95 %CI 1.3-1.80) and qSOFA (OR 4.4; 95 %CI 2.1-9.3) were associated with admission. Using restricted cubic splines, a rise in the probability of admission for a MEWS ≥ 6 was observed. The AUC of MEWS for predicting admission was 0.830, the AUC of qSOFA was 0.752. MEWS was indicative for intensive care unit admission two days before admission.

CONCLUSIONS

MEWS was a sensitive predictor of ICU admission in patients with a hematologic malignancy, superior to qSOFA. Future studies should confirm cut-off values and identify potential additional characteristics, to further enhance identification of critically ill hemato-oncology patients.

IMPLICATIONS FOR CLINICAL PRACTICE

The Modified Early Warning Score (MEWS) can be used as a tool for healthcare providers to monitor clinical deterioration and predict the need for intensive care unit admission in patients with a hematologic malignancy. Yet, consistent application and potential reevaluation of current thresholds is crucial. This will enable bedside nurses to more effectively identify patients needing adjunctive care, facilitating timely interventions and improved outcome.

ICU without borders

Critical illness is a continuum, but patient care is often fragmented. Value-based critical care focuses on the overall health of the patient, not on an episode of care. The "ICU without borders" model incorporates a concept where members of the critical care team are involved in the management of patients from the onset of critical illness until recovery and beyond. In this paper, we summarise the potential benefits and challenges to patients, families, staff and the wider healthcare system and list some essential requirements, including a tight governance framework, advanced technologies, investment and trust. We also argue that "ICU without borders" should be viewed as a bi-directional model, allowing extended visiting hours, giving patients and families direct access to experienced critical care staff and offering mutual aid when needed.

A practical approach to establishing a critical care outreach service: An expert panel research design

BACKGROUND

For over two decades, nurse-led critical care outreach services have improved the recognition, response, and management of deteriorating patients in general hospital wards, yet variation in terms, design, implementation, and evaluation of such services continue. For those establishing a critical care outreach service, these factors make the literature difficult to interpret and translate to the real-world setting.

AIM

The aim of this study was to provide a practical approach to establishing a critical care outreach service in the hospital setting.

METHOD

An international expert panel of clinicians, managers, and academics with experience in implementing, developing, operationalising, educating, and evaluating critical care outreach services collaborated to synthesise evidence, experience, and clinical judgment to develop a practical approach for those establishing a critical care outreach service. A rapid review of the literature identified publications relevant to the study. A modified Delphi technique was used to achieve expert panel consensus particularly in areas where insufficient published literature or ambiguities existed.

FINDINGS

There were 502 publications sourced from the rapid review, of which 104 were relevant and reviewed. Using the modified Delphi technique, the expert panel identified five key components needed to establish a critical care outreach service: (i) approaches to service delivery, (ii) education and training, (iii) organisational engagement, (iv) clinical governance, and (v) monitoring and evaluation.

CONCLUSION

An expert panel research design successfully synthesised evidence, experience, and clinical judgement to provide a practical approach for those establishing a critical care outreach service. This method of research will likely be valuable in other areas of practice where terms are used interchangeably, and the literature is diverse and lacking a single approach to practice.

Acute clinical deterioration and consumer escalation: The understanding and perceptions of hospital staff

Introduction

Consumer escalation systems allow patients and families to escalate concerns about acute clinical deterioration. Hospital staff can impact upon the success of this process. As part of evaluation processes within a Local Health Network, where a consumer escalation system was introduced in accordance with National requirements, we sought to explore clinicians’ understanding and perceptions of consumer escalation.

Methods

Voluntary and anonymous staff surveys pre, and post, system introduction. Quantitative data was analysed using descriptive statistics, chi-square independence, and non-parametric independent samples median tests. Qualitative data was evaluated using content analysis and cross-referenced with quantitative responses.

Results

Respondent’s (pre: 215; post: 89) area of work varied significantly between survey periods. Most agreed that patients/families have a sound knowledge of a patient’s typical health status (pre: 192/215 (89.3%); post 82/88 (93.2%)) and that patients/families should be encouraged to escalate concerns of deterioration to ward staff (pre: 209/212 (98.6%); post: 85/89 (95.5%)). Respondent perceptions of patient/family ability to recognise clinical deterioration varied. Staff agreement towards local response expectations decreased as the degree of clinical requirement increased. Staff concerns of increased workloads (pre: 90/214 (42.1%); post 12/72 (16.7%), p<0.001) and conflict generation (pre: 71/213 (33.3%); post: 7/71 (9.9%), p = 0.001) decreased significantly following system introduction. However, clinician perceptions of positive system effects also decreased (patient-staff rapport pre: 163/213 (76.5%); post: 38/72 (52.8%), p = 0.001; patient centred care pre: 188/214 (87.9%); post: 53/72 (73.6%), p = 0.012; patient safety pre: 173/214 (80.8%); post: 49/72 (68.1%), p = 0.077). Only 53% of respondents (pre: 112/213 (52.6%); post: 48/88 (54.5%)) perceived that patient/family have sufficient confidence to escalate concerns.

Conclusion

Consumer escalation systems require staff support. Staff perceptions may indicate, and act as, barriers to the operation of consumer escalation processes. Further exploration in identifying and managing staff barriers is crucial to the success of consumer escalation.

Aboriginal perspectives on recognising clinical deterioration in their child and communicating concerns to clinicians

AIMS AND OBJECTIVES

To explore the perspectives of family members of Aboriginal children about a) their involvement in recognising clinical deterioration in a hospital setting and b) the effectiveness of a poster designed to promote family involvement.

BACKGROUND

To assist in the early recognition and response to clinical deterioration for hospitalised children, many escalation of care processes now include family involvement. Little is currently known about the perspectives of Australian Aboriginal families in recognising deterioration in their child and raising the alarm, or if current escalation of care systems meet the needs of Aboriginal families.

DESIGN

Qualitative pragmatist approach using semi-structured interviews.

METHODS

Seven interviews were conducted with five mothers and two grandmothers of Aboriginal children who were inpatients at a children's hospital. Thematic analysis was undertaken.

FINDINGS

Two themes were identified: Theme one was: Family role in recognising and responding to clinical deterioration, with two subthemes of knowing when to worry and communicating concerns. Participants reported that some families needed more knowledge to recognise clinical deterioration. Communication barriers between families and clinicians were identified. Theme two was: Effective visual communication with three subthemes of linguistic clarity, visual appeal and content.

CONCLUSIONS

Additional strategies are needed to promote effective communication between clinicians and families of Aboriginal children in hospital. Posters were considered effective, particularly if including a cultural connection, images and simplified language.

PRACTICE IMPLICATIONS

These insights provide important information for health professionals and health service managers to be aware that additional communication strategies are required to support Aboriginal family involvement in recognising clinical deterioration and escalation of care.

Strategies for successful implementation and permanent maintenance of a rapid response system

Rapid response systems (RRSs) have been introduced to intervene with patients experiencing non-code medical emergencies and operate widely around the world. An RRS has four components: an afferent limb, an efferent limb, quality improvement, and administration. A proper triggering system, a hospital culture that embraces the RRS from the afferent limb, experienced primary responders, and dedicated physicians from the efferent limb are key for successful implementation. After initial implementation, quality improvement through objective outcome measures and self-evaluation are crucial, which lead to a better outcome when this process is well performed. Furthermore, better outcomes lead to more investment, which is essential for effective development of the system. The RRS is successfully maintained when these four components are closely interconnected.

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.

Acute clinical deterioration and consumer escalation in the hospital setting: A literature review

BACKGROUND

Consumer escalation systems that allow patients and/or their family/carers to escalate concerns about clinical deterioration have been proposed as a way of enhancing patient safety. However, evidence to guide implementation or to support system effectiveness remains unclear.

AIM

To critically evaluate the current evidence surrounding consumer escalation within the context of clinical deterioration to identify the strengths, weaknesses and gaps in existing knowledge, essential themes, and directions for further investigation.

METHOD

Database searches were conducted within Cumulative Index of Nursing and Allied Health Literature, PubMed, and the Cochrane Library for articles directly relating to consumer escalation systems published, in English, within the previous 10 year-period. Titles and abstracts were screened and relevant full-text articles included. Content was examined to identify breadth of knowledge, essential themes, and the effectiveness of current systems.

RESULTS

27 articles, containing a mixture of both quantitative and qualitative findings, were identified. Within the context of limitations in the overall depth and quality of current evidence, four key areas (relating to consumer understanding and awareness of clinical deterioration, confidence and ability to escalate concerns, education, and staff attitudes) were identified as potentially critical to the foundation, functioning, and success of consumer escalation systems. Consumer escalation processes may contribute positive effects beyond mortality rates; however, an agreed method of assessing effectiveness remains undetermined.

CONCLUSIONS

The ability of consumer escalation processes to achieve their underlying goals is still to be adequately assessed. Further research is required to inform how to best implement, support and optimise consumer escalation systems.

Severe illness getting noticed sooner - SIGNS-for-Kids: developing an illness recognition tool to connect home and hospital

Background

Delays to definitive treatment for time-sensitive acute paediatric illnesses continue to be a cause of death and disability in the Canadian healthcare system. Our aim was to develop the SIGNS-for-Kids illness recognition tool to empower parents and other community caregivers to recognise the signs and symptoms of severe illness in infants and children. The goal of the tool is improved detection and reduced time to treatment of acute conditions that require emergent medical attention.

Methods

A single-day consensus workshop consisting of a 17-member panel of parents and multidisciplinary healthcare experts with content expertise and/or experience managing children with severe acute illnesses was held. An a priori agreement of ≥85% was planned for the final iteration SIGNS-for-Kids tool elements by the end of the workshop.

Results

One hundred percent consensus was achieved on a five-item tool distilled from 20 initial items at the beginning of the consensus workshop. The final items included four child-based items consisting of: (1) behaviour, (2) breathing, (3) skin, and (4) fluids, and one context-based item and (5) response to rescue treatments.

Conclusions

Specific cues of urgent child illness were identified as part of this initial development phase. These cues were integrated into a comprehensive tool designed for parents and other lay caregivers to recognise the signs of serious acute illness and initiate medical attention in an undifferentiated population of infants and children. Future validation and optimisation of the tool are planned.

Parent escalation of care for the deteriorating child in hospital: A health-care improvement study

OBJECTIVE

To evaluate the implementation of an intervention for parents to escalate care if concerned about their child's clinical condition.

DESIGN

Mixed-methods health-care improvement approach guided by the Theoretical Domains Framework.

METHODS

Implementation of the 'Calling for Help' (C4H) intervention was informed by previously identified barriers and facilitators. Evaluation involved audit, review of clinical deterioration incidents, interviews and focus groups.

SETTING

Australian specialist paediatric hospital.

PARTICIPANTS

Convenience sample of 75 parents from inpatient areas during the audit, interviews with ten parents who had expressed concern about their child's clinical condition; five focus groups with 35 ward nurses.

MAIN OUTCOME MEASURES

Parent awareness and utilization of C4H, parent and nurse views of factors influencing implementation.

RESULTS

Parent awareness of C4H improved to 35% (25/75). Parent concern was documented prior to 21/174 (12%) clinical deterioration events. All interviewed parents and nurses who participated in focus groups were positive about C4H. Parents preferred to be informed about C4H by nurses, but nurses described this as time-consuming and selectively chose parents who they believed would benefit most. Parents and nurses described frustrations with and trepidation in escalating care. Nurses had used C4H to expedite urgent medical review.

CONCLUSIONS

There was an improvement in the level of parent awareness of C4H, which was viewed positively by parents and nurses alike. To achieve a high level of parent awareness in a sustainable way, a multifaceted approach is required. Further strategies will be required for parents to feel confident enough to use C4H and to address interprofessional communication barriers.

Involving patients in recognising clinical deterioration in hospital using the Patient Wellness Questionnaire: A mixed-methods study

Background

Measures exist to improve early recognition of, and response to deteriorating patients in hospital. Despite these, 7% of the deaths reported to the National Reporting and Learning System from acute hospitals in 2015 related to a failure to recognise or respond to deterioration. Interventions have been developed that allow patients and relatives to escalate patient deterioration to a critical care outreach team. However, there is not a strong evidence base for the clinical effectiveness of these interventions, or patients' ability to recognise deterioration.

Aims

The aims of this study were as follows. (a) To identify methods of involving patients in recognising deterioration in hospital, generated by health professionals. (b) To develop and evaluate an identified method of patient involvement in practice, and explore its feasibility and acceptability from the perspectives of patients.

Methods

The study used a mixed-methods design. A measure to capture patient-reported wellness during observation was developed (Patient Wellness Questionnaire) through focus group discussion with health professionals and patients, and piloted on inpatient wards.

Results

There was limited uptake where patients were asked to record ratings of their wellness using the Patient Wellness Questionnaire themselves. However, where the researcher asked patients about their wellness using the Patient Wellness Questionnaire and recorded their responses during observation, this was acceptable to most patients.

Conclusions

This study has developed a measure that can be used to routinely collect patient-reported wellness during observation in hospital and may potentially improve early detection of deterioration.

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.

Consumers' perspectives on their involvement in recognizing and responding to patient deterioration-Developing a model for consumer reporting

BACKGROUND

Adverse events occur in health care. Detection and reporting of deterioration therefore have a critical role to play. Patient and family member (consumer) involvement in patient safety has gained powerful support amongst global policymakers. Few studies, with none taking a rigorous qualitative approach, have drawn upon consumers' experiences to establish their preferences in consumer reporting of patient deterioration programmes.

OBJECTIVE

To explore consumers' experiences of previous reporting of patient deterioration; their preferred educational strategies on this role and recommended pathways in a consumer reporting of patient deterioration model.

DESIGN, SETTING AND PARTICIPANTS

An interpretive, qualitative research design was utilized. Nine focus group interviews were undertaken across Adelaide, capital city of South Australia. Interviews were audio-taped, transcribed and analysed thematically. Twenty-six adults described, then reflected, on previous experiences of reporting patient deterioration.

RESULTS

Overarching themes incorporated consumers' experiences and patient/family education. Three themes emerged in relation to consumers' experiences: feelings, thoughts and actions. Five themes arose on educating consumers: content, timing, format, information providers and information recipients. The consumers' deep reflections on their past reporting experiences led to the development of a new model for consumer reporting of patient deterioration.

CONCLUSIONS

Consumers' views on ways to improve consumer reporting of patient deterioration processes emerged. These improvements include structured educational programmes for staff advocating open health-care professional/consumer communication, educational materials developed and tested with English-speaking and culturally and linguistically diverse consumers and a model with three consumer reporting pathways.

Patient and/or family activated rapid response service: Patients' perceptions of deterioration and need for a service

BACKGROUND

Patient and/or family activated escalation may improve care to deteriorating patients. However, limited literature describes patients' and families' experience of deterioration and what barriers might restrict call activation.

OBJECTIVE

This study explored patients' and families' experiences of acute ward deterioration, their perception of a need for a patient and/or family activated escalation service and barriers that may prevent them from using it.

DESIGN

Using a qualitative cross sectional research design and a co-design approach, data were collected using face-to-face semi-structured interviews, field notes and reflective journaling. Between December 2015 and February 2016, purposeful sampling recruited 41 adult ward patients and family who either experienced a recent Medical Emergency team (MET) or Patient at Risk team (PART) escalation, or no recent MET or PART escalation.

FINDINGS

Themes included: (1) patient awareness of their illness and deterioration, 2) the importance of returning to their normal lives, (3) reassurance on arrival of the PART and MET, (4) beliefs held to prevent use of such a service, and (5) support for a patient and/or family activated escalation service.

CONCLUSION

Most participants supported a patient and/or family activated escalation service, however barriers may prevent some patients from using it.

Barriers and facilitators to implementing a process to enable parent escalation of care for the deteriorating child in hospital

OBJECTIVE

To identify barriers and facilitators to implementing a parent escalation of care process: Calling for Help (C4H).

DESIGN

Audits, semi-structured interviews and focus groups guided by the Theoretical Domains Framework.

SETTING

Australian paediatric hospital where a parent escalation of care process was introduced in the previous 6 months.

PARTICIPANTS

Four children, 13 parents, 91 nurses and doctors including Medical Emergency Team (MET) members.

MAIN OUTCOME MEASURES

Parent awareness and involvement in escalating care and factors impacting implementation of C4H.

RESULTS

Two audits identified low level of parent awareness (16/88, 19% and 5/85, 6%). Parent involvement in escalation of care was documented in 11/62 (18%) events. The main facilitators included uniformly positive views that C4H was in the child's best interest, acknowledgement that parents had skills to recognize deterioration and would take action. C4H was considered to add to patient safety and being reviewed by the MET was a patient benefit. Key barriers were the low level of awareness, doubt about parent capabilities, concern about parents' information overload, anticipated overuse of resources, staff unease about possible repercussions and anticipated difficulty for parents to question staff with potential negative effects on parent-staff relationships. Overall C4H presents a challenge to traditional hospital hierarchy and culture.

CONCLUSIONS

Although there was a low level of awareness about C4H in practice, there was in-principle support for the concept. Initial strategies had primarily targeted policy change without taking into account the need for practice and organizational behaviour changes. Using a theoretical approach to identify key factors will enable a targeted approach to implementation.

The nursing assessment of infants with bronchiolitis

Bronchiolitis is the leading cause of morbidity and hospitalization in infants under the age of one year. Supportive treatments and regular assessment remain the mainstay of care for infants admitted to hospital. Nurses play an important role in the assessment of infants with bronchiolitis; however, this is not well described in the literature and consequently little is known about what strategies nurses employ in assessing infants with bronchiolitis. The aim of this study was to explore bronchiolitis assessment in the context of nursing practice. A naturalistic inquiry study was undertaken using think aloud and retrospective probing data collection methods. The results revealed that the information gathered by nurses in their assessment of infants with bronchiolitis was varied and the process of acquiring and evaluating this information was multifaceted and holistic in nature. A close partnership between the nurse and mother was identified, and the mother's expert knowledge and ability to identify subtle changes in the infant's clinical condition over time was essential to the assessment process. The assessment partnership with families provides nurses with the most comprehensive and holistic view of the infant's clinical condition and vital assessment information could be lost if this partnership does not occur.