Indicators of patient deterioration in poorly resourced private hospitals: Which vital sign to watch? A retrospective case-control study

BACKGROUND

Patient vital signs are a measure of wellness if monitored regularly and accurately. Staff shortages in poorly resourced regional hospitals often result in inadequate patient monitoring, putting patients at risk of undetected deterioration.

OBJECTIVE

This study aims to explore the pattern and completeness of vital sign monitoring and the contribution of each vital sign in predicting clinical deterioration events in resource-poor regional/rural hospitals.

METHOD

Using a retrospective case-control study design, we compared 24 h of vital sign data from deteriorating and nondeteriorating patients from two poorly-resourced regional hospitals. Descriptive statistics, t-tests, and analysis of variance are used to compare patient-monitoring frequency and completeness. The contribution of each vital sign in predicting patient deterioration was determined using the Area Under the Receiver Operator Characteristic curve and binary logistical regression analysis.

RESULTS

Deteriorating patients were monitored more frequently (9.58 [7.02] times) in the 24-h period than nondeteriorating patients (4.93 [2.66] times). However, the completeness of vital sign documentation was higher in nondeteriorating (85.2%) than in deteriorating patients (57.7%). Body temperature was the most frequently omitted vital sign. Patient deterioration was positively linked to the frequency of abnormal vital signs and the number of abnormal vital signs per set (Area Under the Receiver Operator Characteristic curve: 0.872 and 0.867, respectively). No single vital sign strongly predicts patient outcomes. However, a supplementary oxygen value of >3 L/min and a heart rate of >139 beats/min were the best predictors of patient deterioration.

CONCLUSION

Given the poor resourcing and often geographical remoteness of small regional hospitals, it is prudent that the nursing staff are made aware of the vital signs that best indicate deterioration for the cohort of patients in their care. Tachycardic patients on supplementary oxygen are at high risk of deterioration.

Contextual determinants impacting final year nursing students' emergency team communication during deteriorating patient simulations: A grounded theory study

BACKGROUND

Ability to focus on development of students' team communication and non-technical skills may be reduced in content saturated nursing curricula. Even when communication and simulation-based education is provided, students' utilisation of non-technical skills remains challenging. Although simulation is a recognised means to learn communication skills, little is known about nursing students' team communication in simulated settings.

OBJECTIVE

To understand the process by which final year undergraduate nursing students communicate in simulated team emergencies.

DESIGN

Using constructivist grounded theory, data was collected using semi-structured interviews and student observations and analysed using constant comparative analysis.

SETTING

Simulation laboratories in one university nursing school in Australia.

PARTICIPANTS

21 final year nursing students in seven teams.

METHODS

Data were gathered from interviews and video observations of final year nursing students during simulated team emergencies.

RESULTS

Interview data and observations of video-recordings revealed contextual determinants that influence communication within teams: the simulation context, the student context and the team context. Team member characteristics, such as cultural and linguistic background, life experiences, gender and age, the ability to shift from leadership to followership as well as environmental factors such as mask wearing and simulation fidelity, contributed to uncertainty in communicating that nursing team effectiveness.

CONCLUSIONS

Improvement of contextual conditions necessitates implementation of supportive strategies. These include development of educational initiatives, and further research in experiential learning as a modality for learners to experience team communication. Further, simulation context, student context and team context are important considerations. Meeting clinical communication learning needs of students allows better preparation to care for deteriorating patients as graduates.

Development and evaluation of a sepsis simulation with undergraduate nursing students

BACKGROUND

In 2016, the Centers for Disease Control found that more than 1.5 million people develop sepsis each year and about 250,000 Americans die from it. Early identification and treatment of sepsis can decrease mortality and morbidity, yet studies have shown student nurses are not prepared to rescue deteriorating patients.

METHOD

The purpose of this pilot study was to create and test a response to rescue simulation for use with undergraduate nursing students. The simulation depicted a patient deteriorating from sepsis. The Martinez Sepsis Competency Evaluation Tool (MSCET) developed to rate student behaviors during the simulation. Promoting Excellence and Reflective Learning in Simulation (PEARLS) debriefing model was used post simulation.

RESULTS

The overall content validity of the MSCET was 0.88. Each item that scored a I-CVI of 0.78 or less were revised. The total percentage of behaviors met was 68 %. The inter-rater reliability of the MSCET conciseness was 0.47 (X = 67.508, df = 48, p ≤ .05).

CONCLUSION

The results indicate the simulation based experience was effective in preparing students to care for patients with early signs of sepsis. Students were complimentary about the experience, and preliminary data on the MSCET psychometrics were positive. Limitations of the study and recommendations for further revision of the simulation were made.

The patient experience of a medical emergency team review: A convergent mixed-methods study

AIMS

The aim of this study was to explore clinician-patient engagement during, and patient experience of, medical emergency team (MET) reviews.

DESIGN

This study involved a convergent mixed-methods design.

METHODS

This three-phase study was conducted at two hospitals of one Australian health service. Reviews by the MET were observed for clinician-patient engagement behaviours; medical records were audited to confirm patient demographics and clinical characteristics; and patients who received a MET review were interviewed. Quantitative data were analysed using descriptive statistics, and thematic analysis of qualitative interview data was conducted.

RESULTS

In total, 26 MET reviews were observed for 22 patients (median age = 81.5 years and 68.2% females). Between 8 and 13 clinicians and other staff members were present during each review, with a total of 209 clinicians present during the 26 reviews. Clinicians were not observed to speak directly or indirectly to the patient about their care in 38.5% (n = 10/26) of the MET reviews, and 58.3% (n = 56/96) of interventions were performed without explanation. Four themes were identified from the interviews: An unexpected event; A lack of understanding; In good hands, and What happens next?

CONCLUSION

Clinician-patient engagement was infrequent during and after MET reviews. Patients experienced surprise from the sudden arrival of clinicians in their room and had poor levels of understanding about the review. However, most patients felt supported and safe. MET reviews are frequent safety-critical events, and this study identified the patient experience of these events. Clinicians should be aware that patients expressed they were surprised and shocked by the review and that an explanation of what was being done by the clinical team was rarely offered. These findings can be used to inform strategies to improve their patient-engagement behaviours and patient-centred care.

Frontline Nurses' clinical judgment in recognizing, understanding, and responding to patient deterioration: A qualitative study

BACKGROUND

Early warning systems and rapid response teams have been widely implemented in hospitals worldwide to facilitate early recognition and response to patient deterioration. Unfortunately, evidence suggests that these interventions have made little impact on unexpected cardiac or respiratory arrest, hospital mortality, unplanned admission to intensive care units, or hospital length of stay. These programs depend on nurses recognizing at risk patients and initiating a timely response. Although physiologic abnormalities commonly precede serious adverse events, nurses often fail to recognize or respond effectively. Clinical judgment is a critical component in the effective response to deterioration, yet little is known about factors that influence nurses' clinical judgment in these situations. Noticing, interpreting, and responding are aspects of clinical judgment and are essential to preventing further patient deterioration and serious adverse events.

OBJECTIVE

To describe medical-surgical nurses' perceptions of factors that influenced their clinical judgment in situations of patient deterioration.

DESIGN

A qualitative descriptive design using individual, semi-structured interviews. Tanner's Clinical Judgment Model served as the framework for interview questions and data analysis.

PARTICIPANTS

A purposive sample of 20 medical-surgical registered nurses were recruited from 10 adult medical-surgical units at an academic medical center hospital in the United States.

METHODS

Telephone interviews occurred between March and July 2018. A directed approach to content analysis was used to code the transcribed data and identify themes.

RESULTS

Eight themes related to each aspect of clinical judgment emerged from the analysis: Knowing the patient, Experience matters, Lots of small points where the system can fail, Making sense of the data, Something doesn't go together, Caught in the middle, Culture of teamwork, and Increased nursing workload. An overarching theme was Nurses' keen sense of responsibility. Findings revealed that factors within the nurse, the patient, and the work environment influence each component of noticing, interpreting, and initiating an effective response to deteriorating patients.

CONCLUSIONS

Findings have implications for health care systems regarding interventions to support timely recognition and response to deterioration. Nurses' clinical judgment and factors that influence each aspect (noticing, interpreting, and responding) should be a key consideration in organizational efforts to improve the overall response to patient deterioration. Research is needed to enhance understanding of the contextual factors that impact nurses' clinical judgment to inform interventions to support timely recognition and response.

Workload involved in vital signs-based monitoring & responding to deteriorating patients: A single site experience from a regional New Zealand hospital

Objective

This study aimed to quantify the workload involved in patient monitoring by vital signs and early warning scores (EWS), and the time spent by a rapid response team locally known as the Patient-at-Risk (PaR) team in responding to deteriorating patients.

Methods

The workload involved in the measurement and the documentation of vital signs and EWS was quantified by time and motion study using electronic stopwatch application in 167 complete sets of vital signs observations taken by nursing staff on general hospital wards at Taranaki Base Hospital, New Plymouth, New Zealand. The workload involved in responding to deteriorating patients was measured by the PaR team in real-time and recorded in an electronic logbook specifically designed for this purpose. Dependent variables were studied using analysis of variance (ANOVA), post hoc Tukey, Kruskal Wallis test, Mann-Whitney test and correlation tests.

Results

The mean time to measure and record a complete set of vital signs including interruptions was 4:18 (95% CI: 4:07–4:28) minutes. After excluding interruptions, the mean time taken to measure and record a set of vital signs was 3:24 (95% CI: 3:15–3:33) minutes. We found no statistical difference between the observer, location of the patient, staff characteristics or experience and patient characteristics. PaR nurses' mean time to provide rapid response was 47:36 (95% CI: 44:57–50:15) minutes. Significantly more time was spent on patients having severe degrees of deterioration (higher EWS) < 0.001. No statistical difference was observed between ward specialty, and nursing shifts.

Conclusions

Patient monitoring and response to deterioration consumed considerable time. Time spent in monitoring was not affected by independent and random factors studied; however, time spent on the response was greater when patients had higher degrees of deterioration.

Characterizing rescue performance in a tertiary care medical center: a systems approach to provide management decision support

Background

Allocation of limited resources to improve quality, patient safety, and outcomes is a decision-making challenge health care leaders face every day. While much valuable health care management research has concentrated on administrative data analysis, this approach often falls short of providing actionable information essential for effective management of specific system implementations and complex systems. This comprehensive performance analysis of a hospital-wide system illustrates application of various analysis approaches to support understanding specific system behaviors and identify leverage points for improvement. The study focuses on performance of a hospital rescue system supporting early recognition and response to patient deterioration, which is essential to reduce preventable inpatient deaths.

Methods

Retrospective analysis of tertiary care hospital inpatient and rescue data was conducted using a systems analysis approach to characterize: patient demographics; rescue activation types and locations; temporal patterns of activation; and associations of patient factors, including complications, with post-rescue care disposition and outcomes.

Results

Increases in bedside consultations (20% per year) were found with increased rescue activations during periods of resource limitations and changes (e.g., shift changes, weekends). Cardiac arrest, respiratory failure, and sepsis complications present the highest risk for rescue and death. Distributions of incidence of rescue and death by day of patient stay may suggest opportunities for earlier recognition.

Conclusions

Specific findings highlight the potential of using rescue-related risk and targeted resource deployment strategies to improve early detection of deterioration. The approach and methods applied can be used by other institutions to understand performance and allow rational incremental improvements to complex care delivery systems.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06855-w.

The impact of web-based and face-to-face simulation education programs on nurses' response to patient deterioration: A multi-site interrupted time series study

BACKGROUND

Nurses' response to patient deterioration in acute hospital wards is a priority issue. Simulation education programs improve nurses' knowledge and confidence, but the translation into better care is largely unknown for both web based (WB) and face to face (F2F) simulation programs.

AIM

To measure the impact of simulation education on nurses' response to patient deterioration in acute medical ward settings, and to compare the impact of WB and F2F versions.

DESIGN

An interrupted time series, non-randomised trial across four medical wards in Victoria, Australia. Wards were allocated to either web-based or face-to-face versions of the same simulation program, FIRST2ACT. Interrupted time series measurement for six fortnights both before and after the intervention were used to measure and compare responses to deterioration. Responses to patient deterioration were extracted from medical records and grouped into outcomes for escalation (e.g. initiation of clinical review), assessment and observation (e.g. increased recording of vital signs, conscious state and pain scores) and clinical interventions (e.g. oxygen administration).

RESULTS

126 nurses (89%) participated across the four wards. 946 patient records (506 in the F2F; 440 in the WB group) were included in analyses. There were significant and sustained improvements between pre and post samples in outcomes for escalation (13.0% to 28.8%; p = 0.000) and assessment and observation (conscious state recorded increased from 91.1% to 100%; p = 0.000, and pain score recorded increased from 97.8% to 99.8%; p = 0.000). There were no differences between the web-based and face-to-face groups except in appropriate oxygen application which increased by 7.7% in the F2F group and decreased by 11.8% in the WB group (p = 0.046).

CONCLUSIONS

There was a significant improvement in nurses' response to patient deterioration following both versions of simulation, indicating that both have a role to play in supporting nurses' response to patient deterioration.

The pilot, proof of concept REMOTE-COVID trial: remote monitoring use in suspected cases of COVID-19 (SARS-CoV 2)

BACKGROUND

SARS-CoV-2 has ever-increasing attributed deaths. Vital sign trends are routinely used to monitor patients with changes in these parameters preceding an adverse event. Wearable sensors can measure vital signs continuously and remotely, outside of hospital facilities, recognising early clinical deterioration. We aim to determine the feasibility & acceptability of remote monitoring systems for quarantined individuals in a hotel suspected of COVID-19.

METHODS

A pilot, proof-of-concept, feasibility trial was conducted in engineered hotels near London airports (May-June 2020). Individuals arriving to London with mild suspected COVID-19 symptoms requiring quarantine, as recommended by Public Health England, or healthcare professionals with COVID-19 symptoms unable to isolate at home were eligible. The SensiumVitals™ patch, measuring temperature, heart & respiratory rates, was applied on arrival for the duration of their stay. Alerts were generated when pre-established thresholds were breeched; trained nursing staff could consequently intervene.

RESULTS

Fourteen individuals (M = 7, F = 7) were recruited; the mean age was 34.9 (SD 11) years. Mean length of stay was 3 (SD 1.8) days. In total, 10 vital alerts were generated across 4 participants, resulting in telephone contact, reassurance, or adjustment of the sensor. No individuals required hospitalisation or virtual general practitioner review.

DISCUSSION

This proof-of-concept trial demonstrated the feasibility of a rapidly implemented model of healthcare delivery through remote monitoring during a pandemic at a hotel, acting as an extension to a healthcare trust. Benefits included reduced viral exposure to healthcare staff, with recognition of clinical deterioration through ambulatory, continuous, remote monitoring using a discrete wearable sensor.

CONCLUSION

Remote monitoring systems can be applied to hotels to deliver healthcare safely in individuals suspected of COVID-19. Further work is required to evaluate this model on a larger scale.

TRIAL REGISTRATION

Clinical trials registration information: ClinicalTrials.gov Identifier: NCT04337489 (07/04/2020).

Design of the pilot, proof of concept REMOTE-COVID trial: remote monitoring use in suspected cases of COVID-19 (SARS-CoV-2)

Background

The outbreak of SARS-CoV-2 (coronavirus, COVID-19), declared a pandemic by the World Health Organization (WHO), is a global health problem with ever-increasing attributed deaths. Vital sign trends are routinely used to monitor patients with changes in these parameters often preceding an adverse event. Wearable sensors can measure vital signs continuously (e.g. heart rate, respiratory rate, temperature) remotely and can be utilised to recognise early clinical deterioration.

Methods

We describe the protocol for a pilot, proof-of-concept, observational study to be conducted in an engineered hotel near London airports, UK. The study is set to continue for the duration of the pandemic. Individuals arriving to London with mild symptoms suggestive of COVID-19 or returning from high-risk areas requiring quarantine, as recommended by the Public Health England, or healthcare professionals with symptoms suggestive of COVID-19 unable to isolate at home will be eligible for a wearable patch to be applied for the duration of their stay. Notifications will be generated should deterioration be detected through the sensor and displayed on a central monitoring hub viewed by nursing staff, allowing for trend deterioration to be noted. The primary objective is to determine the feasibility of remote monitoring systems in detecting clinical deterioration for quarantined individuals in a hotel.

Discussion

This trial should prove the feasibility of a rapidly implemented model of healthcare delivery through remote monitoring during a global pandemic at a hotel, acting as an extension to a healthcare trust. Potential benefits would include reducing infection risk of COVID-19 to healthcare staff, with earlier recognition of clinical deterioration through ambulatory, continuous, remote monitoring using a discrete wearable sensor. We hope our results can power future, robust randomised trials.

Trial registration

ClinicalTrials.gov Identifier: NCT04337489.

Demonstrating the consequences of learning missingness patterns in early warning systems for preventative health care: A novel simulation and solution

When using tree-based methods to develop predictive analytics and early warning systems for preventive healthcare, it is important to use an appropriate imputation method to prevent learning the missingness pattern. To demonstrate this, we developed a novel simulation that generated synthetic electronic health record data using a variational autoencoder with a custom loss function, which took into account the high missing rate of electronic health data. We showed that when tree-based methods learn missingness patterns (correlated with adverse events) in electronic health record data, this leads to decreased performance if the system is used in a new setting that has different missingness patterns. Performance is worst in this scenario when the missing rate between those with and without an adverse event is the greatest. We found that randomized and Bayesian regression imputation methods mitigate the issue of learning the missingness pattern for tree-based methods. We used this information to build a novel early warning system for predicting patient deterioration in general wards and telemetry units: PICTURE (Predicting Intensive Care Transfers and other UnfoReseen Events). To develop, tune, and test PICTURE, we used labs and vital signs from electronic health records of adult patients over four years (n = 133,089 encounters). We analyzed primary outcomes of unplanned intensive care unit transfer, emergency vasoactive medication administration, cardiac arrest, and death. We compared PICTURE with existing early warning systems and logistic regression at multiple levels of granularity. When analyzing PICTURE on the testing set using all observations within a hospital encounter (event rate = 3.4%), PICTURE had an area under the receiver operating characteristic curve (AUROC) of 0.83 and an adjusted (event rate = 4%) area under the precision-recall curve (AUPR) of 0.27, while the next best tested method-regularized logistic regression-had an AUROC of 0.80 and an adjusted AUPR of 0.22. To ensure system interpretability, we applied a state-of-the-art prediction explainer that provided a ranked list of features contributing most to the prediction. Though it is currently difficult to compare machine learning-based early warning systems, a rudimentary comparison with published scores demonstrated that PICTURE is on par with state-of-the-art machine learning systems. To facilitate more robust comparisons and development of early warning systems in the future, we have released our variational autoencoder's code and weights so researchers can (a) test their models on data similar to our institution and (b) make their own synthetic datasets.

Evaluation of nurses' experiences of a post education program promoting recognition and response to patient deterioration: Phase 2, clinical coach support in practice

Front-line nurses providing around the clock care are pivotal to the identification, recognition, and response to patient deterioration. However, there is growing evidence that patient deterioration indicators are poorly managed and not escalated to rapid response teams (RRTs), contributing to adverse outcomes. Access to effective educational programs has been cited as vital in optimising nurses' recognition and response to deteriorating patients. Several studies evaluated educational programs, but have not explored nurses' experiences of engaging in patient deterioration events post attendance. Participants in a multimodal education program (DeTER) were invited to attend a series of focus groups three months post workshop as phase two of an overall study. A convenience sample of 22 acute care nurses was recruited. A qualitative descriptive design incorporating focus groups and thematic analysis was used to evaluate participants' experiences of engaging with the RRT during patient deterioration events and whether clinical coach support in practice influenced their recognition and response. Four themes were identified within the data, categorised as enhanced confidence, effective communication, supportive culture, and early response. The importance of an educational model using multimodal strategies, underpinned by coach support and guidance post workshop, was clearly demonstrated to optimise nurses' management of patient deterioration events.

Assessing validity evidence for a serious game dedicated to patient clinical deterioration and communication

Background

A serious game (SG) is a useful tool for nurse training. The objectives of this study were to assess validity evidence of a new SG designed to improve nurses’ ability to detect patient clinical deterioration.

Methods

The SG (LabForGames Warning) was developed through interaction between clinical and pedagogical experts and one developer. For the game study, consenting nurses were divided into three groups: nursing students (pre-graduate) (group S), recently graduated nurses (graduated < 2 years before the study) (group R) and expert nurses (graduated > 4 years before the study and working in an ICU) (group E). Each volunteer played three cases of the game (haemorrhage, brain trauma and obstructed intestinal tract). The validity evidence was assessed following Messick’s framework: content, response process (questionnaire, observational analysis), internal structure, relations to other variables (by scoring each case and measuring playing time) and consequences (a posteriori analysis).

Results

The content validity was supported by the game design produced by clinical, pedagogical and interprofessional experts in accordance with the French nurse training curriculum, literature review and pilot testing. Seventy-one nurses participated in the study: S (n = 25), R (n = 25) and E (n = 21). The content validity in all three cases was highly valued by group E. The response process evidence was supported by good security control. There was no significant difference in the three groups’ high rating of the game’s realism, satisfaction and educational value. All participants stated that their knowledge of the different steps of the clinical reasoning process had improved. Regarding the internal structure, the factor analysis showed a common source of variance between the steps of the clinical reasoning process and communication or the situational awareness errors made predominantly by students. No statistical difference was observed between groups regarding scores and playing time. A posteriori analysis of the results of final examinations assessing study-related topics found no significant difference between group S participants and students who did not participate in the study.

Conclusion

While it appears that this SG cannot be used for summative assessment (score validity undemonstrated), it is positively valued as an educational tool.

Trial registration

ClinicalTrials.gov ID: NCT03092440

Nurses' judgments of patient risk of deterioration at change-of-shift handoff: Agreement between nurses and comparison with early warning scores

BACKGROUND

Nurses begin forming judgments regarding patients' clinical stability during change-of-shift handoffs.

OBJECTIVES

To examine the agreement between incoming and outgoing nurses' judgments of deterioration risk following handoff and compare these judgments to commonly used early warning scores (MEWS, NEWS, ViEWS).

METHODS

Following handoffs on three medical/surgical units, nurses completed the Patient Acuity Rating. Nurse ratings were compared with computed early warning scores based on clinical data. In follow-up interviews, nurses were invited to describe their experiences of using the rating scale.

RESULTS

Sixty-two nurses carried out 444 handoffs for 158 patients. While the agreement between incoming and outgoing nurses was fair, correlations with early warning scores were low. Nurses struggled with predicting risk and used their impressions of differential risk across all the patients to whom they had been assigned to arrive at their ratings.

CONCLUSION

Nurses shared information that influenced their clinical judgments at handoff; not all of these cues may necessarily be captured in early warning scores.

The association between nurse staffing levels and a failure to respond to patients with deranged physiology: A retrospective observational study in the UK

BACKGROUND

Responding to abnormalities in patients' vital signs is a fundamental aspect of nursing. However, failure to respond to patient deterioration is common and often leads to adverse patient outcomes. This study aimed to determine the association between Registered Nurse (RN) and Nursing Assistant (NA) staffing levels and the failure to respond promptly to patients' abnormal physiology.

METHODS

This retrospective, observational study used routinely collected patients' vital signs and administrative data, including nursing staffing, from 32 general wards of an acute hospital in England between April 2012 and March 2015. Mixed-effects binomial regression was used to model the relationship between nurse staffing, measured as 'Hours per Patient Day' (HPPD), and a composite primary outcome representing failure to respond for patients with National Early Warning Score (NEWS) values ≥ 6 and ≥ 7.

RESULTS

There were 189,123 NEWS values ≥ 6 and 114,504 NEWS values ≥ 7, affecting 28,098 patients. For patients with NEWS values ≥ 7, failure to respond was significantly associated with levels of RN HPPD ((IRR 0.98, 95% CI 0.96-0.99, p = 0.0001) but not NA HPPD (((IRR 0.99, 95%CI 0.96-1.01, p = 0.238). For patients with NEWS values ≥ 6, no such relationship existed.

CONCLUSIONS

RN, but not NA, staffing levels influence the rates of failure to respond for patients with the most abnormal vital signs (NEWS values ≥ 7). These findings offer a possible explanation for the increasingly reported association between low RN staffing and an increased risk of patient death during a hospital admission.

A good idea badly implemented? Revised National Early Warning Score 2 in community settings

The revised National Early Warning Score (NEWS2), a tool used to measure acute deterioration in hospital, has been introduced in acute NHS hospitals and ambulance services. Community nurses report that when they call 999 requesting an ambulance to take a person to hospital, they are asked to provide a NEWS score. They report that when the NEWS score is high, ambulance staff prioritise the call. The NEWS score is being introduced in the community by default. This article will outline how the NEWS score is calculated, its uses and limitations and asks if the NEWS score accurately measures acute deterioration in people living in the community and predicts the need for referral to accident and emergency services.

The response to patient deterioration in the UK National Health Service - A survey of acute hospital policies

BACKGROUND

The assessment of acute-illness severity in adult non-pregnant patients in the United Kingdom is based on early warning score (EWS) values that determine the urgency and nature of the response to patient deterioration. This study aimed to describe, and identify variations in, the expected clinical response outlined in 'deteriorating patient' policies/guidelines in acute NHS hospitals.

METHODS

A copy of the local 'deteriorating patient' policy/guideline was requested from 152 hospitals. Each was analysed against pre-determined areas of interest, e.g., minimum expected vital sign observations frequency, expected response and expected staff response times.

RESULTS

In the 55 responding hospitals (36.2%), the documented structure and process of the response to deterioration varied considerably. All hospitals used a 12-hourly minimum vital signs measurement frequency. Thereafter, for a low-risk patient, the minimum frequency varied from '6-12 hourly' to 'hourly'. Frequencies were higher for higher risk categories. Expected escalation responses were highly individualised between hospitals. Other than repeat observations, only nine (16.4%) documents described specific clinical actions for ward staff to consider/perform whilst awaiting responding personnel. Maximum permitted response times for medium-risk and high-risk patients varied widely, even when based on the same EWS. Only 33/55 documents (60%) gave clear instructions regarding who to contact 'out of hours'.

CONCLUSIONS

The 'deteriorating patient' policies of the hospitals studied varied in their contents and often omitted precise instructions for staff. We recommend that individual hospitals review these documents, and that research and/or consensus are used to develop a national algorithm regarding the response to patient deterioration.

Repeated vital sign measurements in the emergency department predict patient deterioration within 72 hours: a prospective observational study

BACKGROUND

More than one in five patients presenting to the emergency department (ED) with (suspected) infection or sepsis deteriorate within 72 h from admission. Surprisingly little is known about vital signs in relation to deterioration, especially in the ED. The aim of our study was to determine whether repeated vital sign measurements in the ED can differentiate between patients who will deteriorate within 72 h and patients who will not deteriorate.

METHODS

We performed a prospective observational study in patients presenting with (suspected) infection or sepsis to the ED of our tertiary care teaching hospital. Vital signs (heart rate, mean arterial pressure (MAP), respiratory rate and body temperature) were measured in 30-min intervals during the first 3 h in the ED. Primary outcome was patient deterioration within 72 h from admission, defined as the development of acute kidney injury, liver failure, respiratory failure, intensive care unit admission or in-hospital mortality. We performed a logistic regression analysis using a base model including age, gender and comorbidities. Thereafter, we performed separate logistic regression analyses for each vital sign using the value at admission, the change over time and its variability. For each analysis, the odds ratios (OR) and area under the receiver operator curve (AUC) were calculated.

RESULTS

In total 106 (29.5%) of the 359 patients deteriorated within 72 h from admission. Within this timeframe, 18.3% of the patients with infection and 32.9% of the patients with sepsis at ED presentation deteriorated. Associated with deterioration were: age (OR: 1.02), history of diabetes (OR: 1.90), heart rate (OR: 1.01), MAP (OR: 0.96) and respiratory rate (OR: 1.05) at admission, changes over time of MAP (OR: 1.04) and respiratory rate (OR: 1.44) as well as the variability of the MAP (OR: 1.06). Repeated measurements of heart rate and body temperature were not associated with deterioration.

CONCLUSIONS

Repeated vital sign measurements in the ED are better at identifying patients at risk for deterioration within 72 h from admission than single vital sign measurements at ED admission.

Nursing students' educational experience in regional Australia: Reflections on acute events. A qualitative review of clinical incidents

Concerns have been expressed relating to healthcare professionals' ability to manage deteriorating patients. Whilst on placement nursing students are exposed to a range of behaviours and role models that may influence their future practice. We aimed to identify events that impact upon the practice and preparedness of Australian undergraduate nursing students in the management of deteriorating patients. Methods included a Generic Qualitative Research design reviewing 224 reflective reports on clinical events submitted by 92 final year nursing students. Forty (40) patient deterioration events were identified and subjected to detailed coding and thematic analysis. A range of events impacted upon students' practice and preparation. Five themes and 15 subthemes were identified including 'Communication' - the need for adequate handover and documentation; 'Teamwork' - demonstrating the positive impact on patient outcomes; 'Workload' - the negative effects of high staff/patient ratios; 'Clinical judgement/knowledge' - the need for adequate preparation of staff for safe clinical settings; and negative outcomes relating to 'Attention Deficits'. In conclusion Australian nursing students experience a range of practice behaviours from exemplary leadership, to careless individual practices and a 'failure to rescue' deteriorating patients. Clinical experiences have a profound influence on students with potential positive and negative effects on future practice.

The educational impact of web-based and face-to-face patient deterioration simulation programs: An interventional trial

BACKGROUND

There are international concerns relating to the management of patient deterioration. The "failure to rescue" literature identifies that nursing staff miss cues of deterioration and often fail to call for assistance. Simulation-based educational approaches may improve nurses' recognition and management of patient deterioration.

OBJECTIVES

To investigate the educational impact of the First2Act web-based (WB) and face-to-face (F2F) simulation programs.

DESIGN & SETTING

A mixed methods interventional cohort trial with nursing staff from four Australian hospitals.

PARTICIPANTS

Nursing staff working in four public and private hospital medical wards in the State of Victoria.

METHODS

In 2016, ward nursing staff (n = 74) from a public and private hospital completed three F2F laboratory-based team simulations with a patient actor in teams of three. 56 nursing staff from another public and private hospital individually completed a three-scenario WB simulation program (First2ActWeb) [A 91% participation rate]. Validated tools were used to measure knowledge (multi-choice questionnaire), competence (check-list of actions) and confidence (self-rated) before and after the intervention.

RESULTS

Both WB and F2F participants' knowledge, competence and confidence increased significantly after training (p ≤0.001). Skill performance for the WB group increased significantly from 61% to 74% (p ≤ 0.05) and correlated significantly with post-test knowledge (p = 0.014). No change was seen in the F2F groups' performance scores. Course evaluations were positive with median ratings of 4/5 (WB) and 5/5 (F2F). The F2F program received significantly more positive evaluations than the WB program (p < 0.05), particularly with regard to quality of feedback.

CONCLUSION

WB and F2F simulation are effective education strategies with both programs demonstrating positive learning outcomes. WB programs increase ease of access to training whilst F2F enable the development of tactile hands on skills and teamwork. A combined blended learning education strategy is recommended to enhance competence and patient safety.

The effectiveness of virtual simulation in improving student nurses' knowledge and performance during patient deterioration: A pre and post test design

BACKGROUND

Preparing nursing students to perform competently in complex emergency situations, such as during rapid patient deterioration, is challenging. Students' active engagement in such scenarios cannot be ensured, due to the unexpected nature of such infrequent events. Many students may consequently not experience and integrate the management of patient deterioration into their knowledge and practical competency by the end of their studies, making them unprepared to manage such situations as practicing nurses. This study investigated the effectiveness of virtual simulation in improving performance during rapid patient deterioration.

OBJECTIVE

To investigate the effectiveness of virtual simulation in improving student nurses' knowledge and performance during rapid patient deterioration.

DESIGN

A pre- and post-test design was used.

SETTING

Nursing students at a university in Malta were invited to participate in a virtual simulation program named FIRST²ACTWeb™, using their own computer devices.

PARTICIPANTS

A total of 166 (response rate=50%) second and third year diploma and degree nursing students participated in the study.

METHODS

The simulation included three scenarios (Cardiac-Shock-Respiratory) portraying deteriorating patients. Performance feedback was provided at the end of each scenario. Students completed pre- and post-scenario knowledge tests and performance during each scenario was recorded automatically on a database.

RESULTS

Findings showed a significant improvement in the students' post-scenario knowledge (z=-6.506, p<0.001). Highest mean performance scores were obtained in the last scenario (M=19.7, median: 20.0, s.d. 3.41) indicating a learning effect. Knowledge was not a predictor of students' performance in the scenarios.

CONCLUSIONS

This study supports virtual simulation as an effective learning tool for pre-registration nursing students in different programs. Simulation improves both knowledge about and performance during patient deterioration. Virtual simulation of rare events should be a key component of undergraduate nurse education, to prepare students to manage complex situations as practicing nurses.

Nurses' experiences of managing patient deterioration following a post-registration education programme: A critical incident analysis study

The aim of this study was to explore nurses' experiences assessing and managing deteriorating patients in practice following completion of a relevant post-registration education programme. Recognising the increasing acuity of ward patients, nurses are faced with patients who are at an increased risk of deterioration. Patients who are acutely ill or deteriorating often exhibit periods of physiological deterioration; however there is evidence illustrating that these clinical changes are frequently missed, misinterpreted or mismanaged in practice. In order to prepare nurses to competently assess and manage the deteriorating patient, education as a care initiative is offered to develop the knowledge and skills required. A qualitative study using critical incident analysis was conducted to acquire narrative data from nurses, describing their clinical practice experiences of patient deterioration. Thematic analysis was used to analyse the data. Findings revealed improvements in nurses' abilities to recognise patient deterioration, greater application of the evidence base and an increase in confidence and assertiveness. There was some evidence of applying the knowledge and skills learned, however equally some nurses indicated that they remained ill-prepared to apply the skills in practice.

Contribution of a reflective debriefing to nursing students' clinical judgment in patient deterioration simulations: A mixed-methods study

BACKGROUND

While reflection is a hallmark of debriefing, there is little understanding of how it contributes to nursing students' clinical judgment.

OBJECTIVES

The aim of this study was to describe how nursing students perceived that the Reflective dEbriefing after a PatieNt Deterioration simulation (REsPoND) fostered learning and how it contributed to their clinical judgment in patient deterioration simulations.

DESIGN

A sequential explanatory mixed-methods study.

PARTICIPANTS

Nineteen students who showed the greatest clinical judgment score variation in a randomized controlled trial of the effectiveness of REsPoND.

METHODS

Students participated in interviews on their learning experience in REsPoND. Data were subjected to thematic analysis and themes were contrasted according to students' score variations.

RESULTS

Through guided exchanges with their peers, students configured a causes-observations-interventions framework that embodied their understanding of the patient's situation. They evaluated their own simulation performance based on that framework. The contribution of REsPoND to students' clinical judgment differed depending on (1) the value placed on the review of the simulation through a systematic assessment approach; (2) their focus on anticipating the situation or on performing in the simulation; and (3) their preference for who participated more in debriefing.

CONCLUSION

Clinical judgment might be improved when a systematic assessment approach is used to structure debriefing. The relationship between reflection and self-assessment during debriefing remains to be disentangled.

Scoping review: The use of early warning systems for the identification of in-hospital patients at risk of deterioration

INTRODUCTION

Early warning systems (EWS) were developed as a means of alerting medical staff to patient clinical decline. Since 85% of severe adverse events are preceded by abnormal physiological signs, the patient bed-side vital signs observation chart has emerged as an EWS tool to help staff identify and quantify deteriorating patients. There are three broad categories of patient observation chart EWS: single or multiple parameter systems; aggregated weighted scoring systems; or combinations of single or multiple parameter and aggregated weighted scoring systems.

OBJECTIVE

This scoping review is an overview of quantitative studies and systematic reviews examining the efficiency of the adult EWS charts in the recognition of in-hospital patient deterioration.

METHOD

A broad search was undertaken of peer-reviewed publications, official government websites and databases housing research theses, using combinations of keywords and phrases.

DATA SOURCES

CINAHL with full text; MedLine, PsycINFO, MasterFILE Premier, GreenFILE and ScienceDirect. Also, the Cochrane Library database, Department of Health government websites and Ethos, ProQuest and Trove databases were searched.

EXCLUSIONS

Paediatric, obstetric and intensive care studies, studies undertaken at the point of hospital admission or pre-admission, non-English publications and editorials.

RESULTS

Five hundred and sixty five publications, government documents, reports and theses were located of which 91 were considered and 21 were included in the scoping review. Of the 21 publications eight studies compared the efficacy of various EWS and 13 publications validated specific EWS.

CONCLUSIONS

There is low level quantitative evidence that EWS improve patient outcomes and strong anecdotal evidence that they augment the ability of the clinical staff to recognise and respond to patient decline, thus reducing the incidence of severe adverse events. Although aggregated weighted scoring systems are most frequently used, the efficiency of the specific EWS appears to be dependent on the patient cohort, facilities available and staff training and attitude. While the review demonstrates support for EWS, researchers caution that given the contribution of human factors to the EWS decision-making process, patient EWS charts alone cannot replace good clinical judgment.

The effectiveness of education in the recognition and management of deteriorating patients: A systematic review

BACKGROUND

Survival from in-hospital cardiac arrest is poor. Clinical features, including abnormal vital signs, often indicate patient deterioration prior to severe adverse events. Early warning systems and rapid response teams are commonly used to assist the health profession in the identification and management of the deteriorating patient. Education programs are widely used in the implementation of these systems. The effectiveness of the education is unknown.

AIM

The aims of this study were to identify: (i) the evidence supporting educational effectiveness in the recognition and management of the deteriorating patient and (ii) outcome measures used to evaluate educational effectiveness.

METHODS

A mixed methods systematic review of the literature was conducted using studies published between 2002 and 2014. Included studies were assessed for quality and data were synthesized thematically, while original data are presented in tabular form.

RESULTS

Twenty-three studies were included in the review. Most educational programs were found to be effective reporting significant positive impacts upon learners, patient outcomes and organisational systems. Outcome measures related to: i learners, for example knowledge and performance, ii systems, including activation and responses of rapid response teams, and iii patients, including patient length of stay and adverse events. All but one of the programs used blended teaching with >87% including medium to high fidelity simulation. In situ simulation was employed in two of the interventions. The median program time was eight hours. The longest program lasted 44h however one of the most educationally effective programs was based upon a 40min simulation program.

CONCLUSION

Educational interventions designed to improve the recognition and management of patient deterioration can improve learner outcomes when they incorporate medium to high-fidelity simulation. High-fidelity simulation has demonstrated effectiveness when delivered in brief sessions lasting only forty minutes. In situ simulation has demonstrated sustained positive impact upon the real world implementation of rapid response systems. Outcome measures should include knowledge and skill developments but there are important benefits in understanding patient outcomes.

Testing nursing students' clinical judgment in a patient deterioration simulation scenario: Development of a situation awareness instrument

BACKGROUND

Situation awareness may be used to operationalize nursing students' clinical judgment of patient deterioration simulation scenarios.

OBJECTIVES

To develop and test an instrument to measure bachelor-level nursing students' situation awareness in a patient deterioration simulation scenario, using the Situation Awareness Global Assessment Technique (SAGAT).

DESIGN

Instrument development and validation.

SETTINGS

A faculty of nursing of a French-Canadian university.

PARTICIPANTS

15 critical care experts and 234 bachelor-level nursing students from a critical care course.

METHODS

The queries were developed from evidence and guidelines regarding nurses' assessment and response to patient deterioration and an inventory of nursing diagnosis. After expert content validation, the instrument was administered to three cohorts of nursing students in a high-fidelity simulation with a scenario of hypovolemic hemorrhagic shock. Difficulty, discrimination, and fidelity indices were computed. The impact of the instrument on student's performance was assessed with a post-simulation survey.

RESULTS

The instrument comprised 31 queries, which obtained high content validity indices. Most showed satisfying difficulty, discrimination, and fidelity properties. Inadequate properties of the queries may be explained by the content of the simulation scenario, the assessment practices of nursing students, and their reliance on medical assistance. Students perceived that completing the instrument helped them realize what they forgot to assess in the simulation.

CONCLUSIONS

This instrument appears as a promising research tool, although it still needs to be tested with other populations and in other patient deterioration simulation scenarios.

Standard instruction versus simulation: Educating registered nurses in the early recognition of patient deterioration in paediatric critical care

Identifying and stabilising deterioration in a child with significant clinical compromise is both a challenging and necessary role of the paediatric critical care nurse. Within adult critical care research, high fidelity patient simulation (HFPS) has been shown to positively impact learner outcomes regarding identification and management of a deteriorating patient; however, there is a paucity of evidence examining the use of HFPS in paediatric nursing education. The aim of this study was to investigate the effect of HFPS on nurses' self-efficacy and knowledge for recognising and managing paediatric deterioration. Further, participants' perceptions of the learning experiences specific to the identification and management of a deteriorating child were also explored. Registered nurses working in a tertiary-referral paediatric critical care unit were recruited for this quasi-experimental study. Using a pre-test/post-test control-group design, participants were assigned to one of two learning experiences: HFPS or standard instruction. Following the learning experience, nurses were also invited to participate in semi-structured interviews. 30 nurses participated in the study (control n=15, experiment n=15). Participants in the HFPS intervention were most likely to demonstrate an increase in both perceived self-efficacy (p=<0.01) and knowledge (p=<0.01). No statistically significant change was observed in control group scores. The mean difference in self-efficacy gain score between the two groups was 5.67 score units higher for the experiment group compared to the control. HFPS also yielded higher follow-up knowledge scores (p=0.01) compared to standard instruction. Ten nurses participated in semi-structured interviews. Thematic analysis of the interview data identified four themes: self-awareness, hands-on learning, teamwork, and maximising learning. The results of this study suggest that HFPS can positively influence nurses' self-efficacy and knowledge test scores specific to the recognition and management of paediatric deterioration.

Comparison of standardized patients with high-fidelity simulators for managing stress and improving performance in clinical deterioration: A mixed methods study

BACKGROUND

The use of standardized patients in deteriorating patient simulations adds realism that can be valuable for preparing nurse trainees for stress and enhancing their performance during actual patient deterioration. Emotional engagement resulting from increased fidelity can provide additional stress for student nurses with limited exposure to real patients. To determine the presence of increased stress with the standardized patient modality, this study compared the use of standardized patients (SP) with the use of high-fidelity simulators (HFS) during deteriorating patient simulations. Performance in managing deteriorating patients was also compared. It also explored student nurses' insights on the use of standardized patients and patient simulators in deteriorating patient simulations as preparation for clinical placement.

METHODS

Fifty-seven student nurses participated in a randomized controlled design study with pre- and post-tests to evaluate stress and performance in deteriorating patient simulations. Performance was assessed using the Rescuing A Patient in Deteriorating Situations (RAPIDS) rating tool. Stress was measured using salivary alpha-amylase levels. Fourteen participants who joined the randomized controlled component then participated in focus group discussions that elicited their insights on SP use in patient deterioration simulations.

RESULTS

Analysis of covariance (ANCOVA) results showed no significant difference (p=0.744) between the performance scores of the SP and HFS groups in managing deteriorating patients. Amylase levels were also not significantly different (p=0.317) between the two groups. Stress in simulation, awareness of patient interactions, and realism were the main themes that resulted from the thematic analysis.

CONCLUSIONS

Performance and stress in deteriorating patient simulations with standardized patients did not vary from similar simulations using high-fidelity patient simulators. Data from focus group interviews, however, suggested that the use of standardized patients was perceived to be valuable in preparing students for actual patient deterioration management.

A trial of e-simulation of sudden patient deterioration (FIRST2ACT WEB) on student learning

BACKGROUND

High-fidelity simulation pedagogy is of increasing importance in health professional education; however, face-to-face simulation programs are resource intensive and impractical to implement across large numbers of students.

OBJECTIVES

To investigate undergraduate nursing students' theoretical and applied learning in response to the e-simulation program-FIRST2ACT WEBTM, and explore predictors of virtual clinical performance.

DESIGN AND SETTING

Multi-center trial of FIRST2ACT WEBTM accessible to students in five Australian universities and colleges, across 8 campuses.

PARTICIPANTS

A population of 489 final-year nursing students in programs of study leading to license to practice.

METHODS

Participants proceeded through three phases: (i) pre-simulation-briefing and assessment of clinical knowledge and experience; (ii) e-simulation-three interactive e-simulation clinical scenarios which included video recordings of patients with deteriorating conditions, interactive clinical tasks, pop up responses to tasks, and timed performance; and (iii) post-simulation feedback and evaluation. Descriptive statistics were followed by bivariate analysis to detect any associations, which were further tested using standard regression analysis.

RESULTS

Of 409 students who commenced the program (83% response rate), 367 undergraduate nursing students completed the web-based program in its entirety, yielding a completion rate of 89.7%; 38.1% of students achieved passing clinical performance across three scenarios, and the proportion achieving passing clinical knowledge increased from 78.15% pre-simulation to 91.6% post-simulation. Knowledge was the main independent predictor of clinical performance in responding to a virtual deteriorating patient R(2)=0.090, F(7, 352)=4.962, p<0.001.

DISCUSSION

The use of web-based technology allows simulation activities to be accessible to a large number of participants and completion rates indicate that 'Net Generation' nursing students were highly engaged with this mode of learning.

CONCLUSION

The web-based e-simulation program FIRST2ACTTM effectively enhanced knowledge, virtual clinical performance, and self-assessed knowledge, skills, confidence, and competence in final-year nursing students.

Development of a post-simulation debriefing intervention to prepare nurses and nursing students to care for deteriorating patients

To provide optimal care, nurses need to be prepared to recognize signs and symptoms of patient deterioration so they can obtain assistance from appropriate respondents and initiate rescue interventions when needed. In this paper, we describe the development of a post-simulation educational intervention aimed at improving nurses' and nursing students' recognition and response to patient deterioration. This intervention takes the form of a debriefing after a simulated patient deterioration experience. Following the Medical Research Council's guidance on complex interventions, we reviewed empirical studies of existing educational interventions for content, teaching strategies, and outcomes, as well as for frameworks, theoretical underpinnings, and rationale. Based on those results, we reviewed theoretical literature (Tanner's clinical judgment model and Dewey's theory of experiential learning) that might inform our understanding of our intervention's intended effect (learning outcomes) and of the mechanisms by which the intervention could lead to it. Integrating results from the empirical and theoretical phases helped us define the new intervention's rationale and develop its components according to relevant standards of best practices. The resulting educational intervention, REsPoND, consists in a reflective debriefing after a patient deterioration simulation. It will be tested in an upcoming mixed methods study.

Defining patient deterioration through acute care and intensive care nurses' perspectives

AIM

To explore the variations between acute care and intensive care nurses' understanding of patient deterioration according to their use of this term in published literature.

BACKGROUND

Evidence suggests that nurses on wards do not always recognize and act upon patient deterioration appropriately. Even if resources exist to call for intensive care nurses' help, acute care nurses use them infrequently and the problem of unattended patient deterioration remains.

DESIGN

Dimensional analysis was used as a framework to analyze papers retrieved in a nursing-focused database.

METHOD

A thematic analysis of 34 papers (2002-2012) depicting acute care and intensive care unit nurses' perspectives on patient deterioration was conducted.

FINDINGS

No explicit definition of patient deterioration was retrieved in the papers. There are variations between acute care and intensive care unit nurses' accounts of this concept, particularly regarding the validity of patient deterioration indicators. Contextual factors, processes and consequences are also explored.

CONCLUSIONS

From the perspectives of acute care and intensive care nurses, patient deterioration can be defined as an evolving, predictable and symptomatic process of worsening physiology towards critical illness. Contextual factors relating to acute care units (ACU) appear as barriers to optimal care of the deteriorating patient. This work can be considered as a first effort in modelling the concept of patient deterioration, which could be specific to ACU.

RELEVANCE TO CLINICAL PRACTICE

The findings suggest that it might be relevant to include subjective indicators of patient deterioration in track and trigger systems and educational efforts. Contextual factors impacting care for the deteriorating patient could be addressed in further attempts to deal with this issue.

Undergraduate nursing students' performance in recognising and responding to sudden patient deterioration in high psychological fidelity simulated environments: an Australian multi-centre study

BACKGROUND

Early recognition and situation awareness of sudden patient deterioration, a timely appropriate clinical response, and teamwork are critical to patient outcomes. High fidelity simulated environments provide the opportunity for undergraduate nursing students to develop and refine recognition and response skills.

OBJECTIVES

This paper reports the quantitative findings of the first phase of a larger program of ongoing research: Feedback Incorporating Review and Simulation Techniques to Act on Clinical Trends (FIRST2ACTTM). It specifically aims to identify the characteristics that may predict primary outcome measures of clinical performance, teamwork and situation awareness in the management of deteriorating patients.

DESIGN

Mixed-method multi-centre study.

SETTING

High fidelity simulated acute clinical environment in three Australian universities.

PARTICIPANTS

A convenience sample of 97 final year nursing students enrolled in an undergraduate Bachelor of Nursing or combined Bachelor of Nursing degree were included in the study.

METHOD

In groups of three, participants proceeded through three phases: (i) pre-briefing and completion of a multi-choice question test, (ii) three video-recorded simulated clinical scenarios where actors substituted real patients with deteriorating conditions, and (iii) post-scenario debriefing. Clinical performance, teamwork and situation awareness were evaluated, using a validated standard checklist (OSCE), Team Emergency Assessment Measure (TEAM) score sheet and Situation Awareness Global Assessment Technique (SAGAT). A Modified Angoff technique was used to establish cut points for clinical performance.

RESULTS

Student teams engaged in 97 simulation experiences across the three scenarios and achieved a level of clinical performance consistent with the experts' identified pass level point in only 9 (1%) of the simulation experiences. Knowledge was significantly associated with overall teamwork (p=.034), overall situation awareness (p=.05) and clinical performance in two of the three scenarios (p=.032 cardiac and p=.006 shock). Situation awareness scores of scenario team leaders were low overall, with an average total score of 41%.

CONCLUSIONS

Final year undergraduate nursing students may have difficulty recognising and responding appropriately to patient deterioration. Improving pre-requisite knowledge, rehearsal of first response and team management strategies need to be a key component of undergraduate nursing students' education and ought to specifically address clinical performance, teamwork and situation awareness.

An integrated educational model for continuing nurse education

AIM

This paper reports on the development and evaluation of an integrated clinical learning model to inform ongoing education for surgical nurses. The research aim was to evaluate the effectiveness of implementing a Respiratory Skills Update (ReSKU) education program, in the context of organisational utility, on improving surgical nurses' practice in the area of respiratory assessment.

BACKGROUND

Continuous development and integration of technological innovations and research in the healthcare environment mandate the need for continuing education for nurses. Despite an increased worldwide emphasis on this, there is scant empirical evidence of program effectiveness.

METHODS

A quasi experimental pre test, post test non-equivalent control group design evaluated the impact of the ReSKU program on surgical nurses' clinical practice. The 2008 study was conducted in a 400 bed regional referral public hospital and was consistent with contemporary educational approaches using multi-modal, interactive teaching strategies.

FINDINGS

The study demonstrated statistically significant differences between groups regarding reported use of respiratory skills, three months after ReSKU program attendance. Between group data analysis indicated that the intervention group's reported beliefs and attitudes pertaining to subscale descriptors showed statistically significant differences in three of the six subscales.

CONCLUSION

The construct of critical thinking in the clinical context, combined with clinical reasoning and purposeful reflection, was a powerful educational strategy to enhance competency and capability in clinicians.

Creating a culture of safety by coaching clinicians to competence

Contemporary discussions of nursing knowledge, skill, patient safety and the associated ongoing education are usually combined with the term competence. Ensuring patient safety is considered a fundamental tenet of clinical competence together with the ability to problem solve, think critically and anticipate variables which may impact on patient care outcomes. Nurses are ideally positioned to identify, analyse and act on deteriorating patients, near-misses and potential adverse events. The absence of competency may lead to errors resulting in serious consequences for the patient. Gaining and maintaining competence are especially important in a climate of rapid evidence availability and regular changes in procedures, systems and products. Quality and safety issues predominate highlighting a clear need for closer inter-professional collaboration between education and clinical units. Educators and coaches are ideally placed to role model positive leadership and resilience to develop capability and competence. With contemporary guidance and support from educators and coaches, nurses can participate in life-long learning to create and enhance a culture of safety. The added challenge for nurse educators is to modernise, rationalise and integrate education delivery systems to improve clinical learning. Investing in evidence-based, contemporary education assists in building a capable, resilient and competent workforce focused on patient safety.

Defining clinical deterioration

OBJECTIVES

To review literature reporting adverse events and physiological instability in order to develop frameworks that describe and define clinical deterioration in hospitalised patients.

METHODS

Literature review of publications from 1960 to August 2012. Conception and refinement of models to describe clinical deterioration based on prevailing themes that developed chronologically in adverse event literature.

RESULTS

We propose four frameworks or models that define clinical deterioration and discuss the utility of each. Early attempts used retrospective chart review and focussed on the end result of deterioration (adverse events) and iatrogenesis. Subsequent models were also retrospective, but used discrete complications (e.g. sepsis, cardiac arrest) to define deterioration, had a more clinical focus, and identified the concept of antecedent physiological instability. Current models for defining clinical deterioration are based on the presence of abnormalities in vital signs and other clinical observations and attempt to prospectively assist clinicians in predicting subsequent risk. However, use of deranged vital signs in isolation does not consider important patient-, disease-, or system-related factors that are known to adversely affect the outcome of hospitalised patients. These include pre-morbid function, frailty, extent and severity of co-morbidity, nature of presenting illness, delays in responding to deterioration and institution of treatment, and patient response to therapy.

CONCLUSION

There is a need to develop multiple-variable models for deteriorating ward patients similar to those used in intensive care units. Such models may assist clinician education, prospective and real-time patient risk stratification, and guide quality improvement initiatives that prevent and improve response to clinical deterioration.