Improving patient's intensive care admission through multidisciplinary simulation-based crisis resource management: A qualitative study

AIM

To explore nurses' and physicians' experiences of simulation-based training in a crisis resource management quality improvement intervention on intensive care admission.

BACKGROUND

Quantitative studies have documented that staffs' non-technical skills are improved after simulation-based training in crisis resource management interventions. Experienced-based consensus led to development of a quality improvement intervention based on principles of crisis resource management and tested in simulation-based training to enhance staffs' non-technical skills. However, the impact on staff is unexplored, leaving little understanding of the relationship between simulation-based training in crisis resource management interventions and changes in non-technical skills.

DESIGN

A qualitative study with a hermeneutical approach.

METHODS

Data consisted of semi-structured interviews with physicians (n = 5) and nurses (n = 15) with maximum variation in work experience. Data were collected 3 months after implementation and analysed using thematic analysis. The COREQ guideline was applied.

RESULTS

The analysis revealed three themes: prioritising core clinical activities and patient centredness; transition into practice; and reflection on patient safety. These themes reflected staff's experiences of the intervention and implementation process, which evolved through prioritising core clinical activities that facilitated the transition into clinical practice and staff's reflection on patient safety.

CONCLUSIONS

Prioritising core clinical activities were facilitated by clear communication, predefined roles and better teamwork. Transition into practice stimulated professional growth through feedback. Reflection on patient safety created a new understanding on how a new structure of intensive care admission could be implemented. Collectively, this indicated a joint understanding of admissions.

IMPLICATIONS FOR PRACTICE

Findings enables health care professionals to understand how the intervention can contribute to improve quality of care in management of intensive care admission. Improving non-technical skills are vital in high-quality admissions, which supported a structured process and a collaborative professional standard of admissions.

PATIENT AND PUBLIC CONTRIBUTION

None.

Rapid response teams-how and who? A protocol for a randomised clinical trial evaluating the composition of the efferent limb of the rapid response system

BACKGROUND

Many patients experiencing deterioration have documented deviation of vital signs prior to the deterioration event. Increasing focus on these patients led to the rapid response systems and their configuration with afferent and efferent limbs. The two most prevalent team constellations in the efferent limb are the medical emergency team (MET), usually led by a doctor, and the critical care outreach team (CCOT), usually led by a nurse. The two constellations have not previously been examined in a comparative clinical trial.

METHODS

This is a single centre non-inferiority randomised controlled trial of MET vs CCOT. All patients will be randomised at the time of the call. The intervention group will be the critical care outreach team. The primary outcome is mortality at 30 days and the occurrence of serious adverse events. All patients will be followed for 90 days. We aim to detect or reject a change of 7% in mortality whilst accepting a type I error of 5 and type II error of 20, using a sample size of maximum of 2000 individual patients.

DISCUSSION

There is evidence supporting a benefit for the patient when using rapid response systems; however, earlier randomised studies are marked by cross-contamination and selection bias. Previous studies have primarily examined the effect of RRS on hospital cardiac arrests (IHCA) and mortality. Our study will be examining the effect on intensive care unit admissions as well as the ICHA and mortality.

CONCLUSION

This study may highlight potential benefits of specific configurations of rapid response systems and their impact on safety outcomes.

Test-Retest Reliability of an Experienced Global Trigger Tool Review Team

OBJECTIVES

During a comprehensive patient safety program at a 550-bed regional hospital in the Capital Region of Denmark, we observed an unexpected and unexplained doubling of the median patient harm rate from 56 to 109 harms per 1000 patient days measured by the Institute for Healthcare Improvement Global Trigger Tool (GTT). Meanwhile, other measures of patient safety, including hospital standardized mortality ratio, were stable or improving. Moreover, the review team was very experienced and stable during this period. Thus, we hypothesized that the increase in harm rate was not a true reflection of increased risk of patient harm but the result of the team getting better at identifying harms during GTT reviews.

METHODS

We examined the ability of the GTT review team to reproduce the rate of harm of two separate periods in the same hospital: period 1 (January-June 2010) and period 2 (October 2011-March 2012). For each period, we examined two samples: the original sample that was drawn and used for the ongoing monitoring of harm at the hospital during the safety campaign and a second that we drew and analyzed for this study.

RESULTS

We found increased harm rates both between review 1 and review 2 and between period 1 and period 2. The increase was solely in category E, minor temporary harm.

CONCLUSIONS

The very experienced GTT team could not reproduce harm rates found in earlier reviews. We conclude that GTT in its present form is not a reliable measure of harm rate over time.

Adjusting Early Warning Score by clinical assessment: a study protocol for a Danish cluster-randomised, multicentre study of an Individual Early Warning Score (I-EWS)

INTRODUCTION

Track and trigger systems (TTSs) based on vital signs are implemented in hospitals worldwide to identify patients with clinical deterioration. TTSs may provide prognostic information but do not actively include clinical assessment, and their impact on severe adverse events remain uncertain. The demand for prospective, multicentre studies to demonstrate the effectiveness of TTSs has grown the last decade. Individual Early Warning Score (I-EWS) is a newly developed TTS with an aggregated score based on vital signs that can be adjusted according to the clinical assessment of the patient. The objective is to compare I-EWS with the existing National Early Warning Score (NEWS) algorithm regarding clinical outcomes and use of resources.

METHOD AND ANALYSIS

In a prospective, multicentre, cluster-randomised, crossover, non-inferiority study. Eight hospitals are randomised to use either NEWS in combination with the Capital Region of Denmark NEWS Override System (CROS) or implement I-EWS for 6.5 months, followed by a crossover. Based on their clinical assessment, the nursing staff can adjust the aggregated score with a maximum of -4 or +6 points. We expect to include 150 000 unique patients. The primary endpoint is all-cause mortality at 30 days. Coprimary endpoint is the average number of times per day a patient is NEWS/I-EWS-scored, and secondary outcomes are all-cause mortality at 48 hours and at 7 days as well as length of stay.

ETHICS AND DISSEMINATION

The study was presented for the Regional Ethics committee who decided that no formal approval was needed according to Danish law (J.no. 1701733). The I-EWS study is a large prospective, randomised multicentre study that investigates the effect of integrating a clinical assessment performed by the nursing staff in a TTS, in a head-to-head comparison with the internationally used NEWS with the opportunity to use CROS.

TRIAL REGISTRATION NUMBER

NCT03690128.

[Review of Early Warning Score in preventing sudden critical illness and death]

Early Warning Score (EWS) are used extensively to identify patients at risk of deterioration during hospital admission. The validation of EWS has primarily focused on investigating predictive validity, i.e. the association between EWS and severe adverse events. Few studies have tested, whether EWS work in the clinical setting, and if it prevents severe adverse events from occurring. Many of these studies have methodological limitations, and their clinical relevance could be questioned. Currently, there is limited evidence to support, that the implementation of EWS reduces the occurrence of severe adverse events.

Experiences with global trigger tool reviews in five Danish hospitals: an implementation study

OBJECTIVES

To describe experiences with the implementation of global trigger tool (GTT) reviews in five Danish hospitals and to suggest ways to improve the performance of GTT review teams.

DESIGN

Retrospective observational study.

SETTING

The measurement and monitoring of harms are crucial to campaigns to improve the safety of patients. Increasingly, teams use the GTT to review patient records and measure harms in English and non-English-speaking countries. Meanwhile, it is not clear as to how the method performs in such diverse settings.

PARTICIPANTS

Review teams from five Danish pilot hospitals of the national Danish Safer Hospital Programme.

PRIMARY AND SECONDARY OUTCOME MEASURES

We collected harm rates, background and anecdotal information and reported patient safety incidents (PSIs) from five pilot hospitals currently participating in the Danish Safer Hospital Programme. Experienced reviewers categorised harms by type. We plotted harm rates as run-charts and applied rules for the detection of patterns of non-random variation.

RESULTS

The hospitals differed in size but had similar patient populations and activity. PSIs varied between 3 and 12 per 1000 patient-days. The average harm rate for all hospitals was 60 per 1000 patient-days ranging from 34 to 84. The percentage of harmed patients was 25 and ranged from 18 to 33. Overall, 96% of harms were temporary. Infections, pressure ulcers procedure-related and gastrointestinal problems were common. Teams reported differences in training and review procedures such as the role of the secondary reviewer.

CONCLUSIONS

We found substantial variation in harm rates. Differences in training, review procedures and documentation in patient records probably contributed to these variations. Training reviewers as teams, specifying the roles of the different reviewers, training records and a database for findings of reviews may improve the application of the GTT.